+

VA HEALTHCARE: SCANDAL, GREATNESS AND BACK AGAIN

Key lessons learned, and relevance to the NHS

Ashish K. Jha, MD, MPHDecember 2, 2014Twitter: @ashishkjha

+Goals

Basic background on the VA

The VA story for change

VA as a model for improvement Decentralization of decision making Performance measurement Health Information Technology Visionary leadership

What went wrong?

How the VA can turn things around

+History of the VA

Continental Congress of 1776 Authorizes pensions for disability in the

revolutionary war

Veterans Administration established 1930

Department of Veterans Affairs in 1989 Achieves cabinet level status

+The VA

6 million patients receive at least some care in the VA

Out of 26 million living veterans in the U.S.

Who is eligible for VA care? Service-connected (service-related health

conditions) Prisoners of War or recipients of the Purple Heart Poor (for a family of 4, <$35K in annual income)

+Who receives care in the VA system?

They are old: 40% are > 65 years old

They are poor: 70% have annual incomes <$26,000 Median family income in US is $51,000

They are generally sick: Compared to age-matched Americans, they have

3 additional non-Mental Health Diagnoses 1 additional Mental Health Diagnosis

+VA Facilities: Some Basics

1400 Sites of Care 153 Medical Centers 768 Community-based outpatient clinics 135 Nursing Homes

254,000 employees 19,000 doctors (about 3% of all physicians) 50,000 nurses

+VA Background

Perceptions of poor quality Widely depicted as having poor quality doctors,

nurses Long wait times High mortality rates

Congress considered closing VA hospitals

Mid-1990s: Transformation is launched Decentralization Data collection and feedback Performance measurement Accountability Electronic Information Systems

+VA Transformation: Element #1

Decentralization

Nation split into 22 regions based on referral

patterns

Each region had a director who was given a budget

All major clinical decisions were to be made locally

+The VA

+VA Transformation: Element #2

Performance measurement & accountability

Key quality metrics chosen based on clinical priority

Targets set in Washington DC with input from clinicians

Contracts with local leadership, salary tied to performance

Peer-pressure and competition

+VA Transformation: Element #3

Data collection / feedback

Independent outside entity collects quality data

Data reported back to facility every 3 months

Opportunities for review, correction of errors, etc.

+VA Transformation: Element #4

Health Information Technology

Electronic Health Record rolled out across the VA

Computerized physician order entry a priority

Clinical Decision Support such as clinical

reminders

+The Impact of VA Transformation

Source: Jha et al., NEJM 2003

Preventive Care 1995 2000 p-value

Mammography 64% 90% <0.001

Influenza vaccine 28% 78% <0.001

Pneumococcal vaccine 27% 81% <0.001

Colon cancer screen 33% 68% <0.001

Cervical cancer screen 62% 93% <0.001

Preventive Care 1995 2000 p-value

Mammography 64% 90% <0.001

Influenza vaccine 28% 78% <0.001

Pneumococcal vaccine 27% 81% <0.001

Colon cancer screen 33% 68% <0.001

Cervical cancer screen 62% 93% <0.001

+The Impact of VA Transformation

Chronic Care 1995 2000

Diabetes: Annual HbA1c

51% 94%

Diabetes: Eye exam 48% 67%

Hypertension Control 25% 46%

Source: Jha et al., NEJM 2003

Chronic Care 1995 2000

Diabetes: Annual HbA1c

51% 94%

Diabetes: Eye exam 48% 67%

Hypertension Control 25% 46%

+VA versus Traditional Medicare

VA

2000

Medicare

2000-2001

Prevention

Mammography 90% 77%

Influenza vaccine 78% 71%

Pneumococcal vaccine

81% 64%

Diabetes

Annual Hb A1c 94% 70%

Annual eye exam 67% 74%

Bi-annual Lipid screen

89% 60%

Source: Jha et al., NEJM 2003

VA

2000

Medicare

2000-2001

Prevention

Mammography 90% 77%

Influenza vaccine 78% 71%

Pneumococcal vaccine

81% 64%

Diabetes

Annual Hb A1c 94% 70%

Annual eye exam 67% 74%

Bi-annual Lipid screen

89% 60%

+VA versus Traditional Medicare

VA

2000

Medicare

2000-2001

Acute Myocardial Infarction

Aspirin within 24 hours

93% 84%

Aspirin at discharge 98% 84%

ß-blocker at discharge

95% 78%

CHF

Smoking cessation 62% 38%

Ejection fraction checked

94% 71%

ACE-I if EF < 40% 93% 66%

Source: Jha et al., NEJM 2003

+VA versus U.S.: Ambulatory Care

VA

2007

BRFSS/HEDIS

2006

Prevention

Mammography 86% 80%

Influenza vaccine 72% 70%

Pneumococcal vaccine

90% 67%

DiabetesAnnual HbA1c 97% 88%

Annual Eye Exam 85% 62%

+VA versus U.S.: Inpatient Care

VA

2007

U.S.

2007

Acute MIASA within 24 hours 97% 93%

ß-blocker at discharge

98% 92%

CHFACE-I if EF <40% 89% 82%

Smoking Cessation 93% 83%

Pneumonia

Pneumococcal Vaccine

96% 71%

Antibiotics within 4 hours

81% 80%

+Lessons from the VA

Reform must encompass multiple actions at once

Any single activity likely inadequate

Focus on high value conditions, prevention, safety

Critical for ensuring patient trust in the system

Hold senior managers accountable

Focus on a robust information system

+And the VA declared victory….

“Best Care Anywhere”

“High quality VA is the model for the nation”

And so on

And yet….

+

+What went wrong?

Culture of satisfaction with success“Best Care Anywhere”

InsularityMost of the leadership from within the VA

+What went wrong?

If performance measurement works, then… Mid-1990s: 20-25 measures Mid-2000s: 150+ measures 2010: 250+ measures

Bureaucratic bloat: 2000: 800 central office staff 2012: 11,000 central office staff

+And the evidence was building

Anecodotes about PMs leading to bad care

Stories about data falsification

Concerns about transparency and openness

+VA versus U.S.: Readmissions

AMI 3

0-da

y re

adm

ission

rate

CHF 30

-day

read

miss

ion

rate

Pneu

mon

ia 3

0-da

y re

adm

ission

rate

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

20.4%25.1%

19.1%19.8%24.6%

18.5%

VA (2011)U.S. (2011)

+So what’s the big lesson?

+It isn’t about the what…but how

Performance measures are powerful But wrong measures can be a distraction

Incentives can change behavior, and culture critical But powerful incentives, in wrong culture, create

gaming

Information technology is an enabler IT can be manipulated and used to hide bad

actions

+How does the VA recover?

By placing competence over ideology

Focusing on what matters Limit the number of performance measures Focus on outputs, not inputs

Health of the population Be more creative with IT Focus less on # of doctors, nurses

Bring in more people from the outside

Openness and transparencySunshine is the best disinfectant

+Final thoughts

Reform is never a one step processOne is never done

Failures are part of the processIf you aren’t failing, you aren’t trying

Keep the eyes on the prize Focus on what matters And try to focus on only what matters

+The End

Thank you

Happy to take questions