Restoring trust in VA health care

In their Perspective article, published online in the New England Journal of Medicine, authors Kenneth W. Kizer and Ashish K. Jha provide new insights into the causes behind the VA's decline in safe, effective, patient-centered care and propose several first steps to help restore trust in the system.

Both physicians are among few who can provide an insider's view of challenges within the VA health-care system. Kizer served as undersecretary for health in the Department of Veterans Affairs from 1994 through 1999 and is credited with fundamentally transforming the system -- an effort widely viewed as the largest and most successful health-care turnaround in U.S. history. He is now director of the UC Davis Institute for Population Health Improvement and a distinguished professor at the UC Davis School of Medicine and Betty Irene Moore School of Nursing. Jha is a professor of Health Policy at the Harvard School of Public Health and a practicing general internist at the Boston VA Medical Center and the Brigham and Women's Hospital in Boston.

"Inadequate numbers of primary care providers, aged facilities, overly complicated scheduling processes and other difficult challenges have thwarted the VA's efforts to meet soaring demand for services," the authors stated in the article. "For years, it has been no secret that the VA's front lines of care delivery are understaffed for the needs.

"And though there can be no excuse for falsifying data, we believe that VA leadership created a toxic milieu when it imposed an unrealistic performance standard and placed high priority on meeting it in the face of these difficult challenges. They further compounded the situation by using a severely flawed wait-time monitoring system and expressing a 'no excuses' management attitude," they wrote.

The authors specifically identified three major causes of the decline in superior quality of care that became the hallmark of VA health care in the late 1990s:

• An unfocused performance-measurement program, which changed from having about two dozen credible quality measures in the 1990s to hundreds used today that make it difficult to know which performance initiatives are truly important.
• A shift from local facilities and regional-network managers bearing responsibility for the day-to-day operations to meet clearly articulated performance goals to an increasingly centralized control of care delivery and associated increased bureaucracy. For example, the Veteran Health Administration's central office grew from about 800 in the late 1990s to nearly 11,000 in 2012. (VHA is the sub-cabinet agency within the Department of Veterans Affairs that runs the VA health care system.)
• Increasing organizational insularity, with less and less engagement with private-sector health-care providers in recent years and limited participation in national public reporting programs such as Hospital Compare and the Leapfrog Group to assess patient safety.

To start the process of returning the VA to its previous level of delivering superior quality of care, Kizer and Jha suggest the following next steps:

• Ensure all veterans on wait lists are screened and triaged for care as quickly as possible.
• Refocus the performance management system on fewer measures that directly address what is most important to patients and clinicians. VA's recent development of the Strategic Analytics for Improvement and Learning dashboard is a "good start," the authors state.
• Design a new access strategy based on the concept of a "continuous healing relationship" that draws on modern information and advanced communication technologies to facilitate caregiver-patient connectivity 24/7/365.
• Engage more with private-sector health-care organizations and the general public by participating fully in performance reporting forums, expanding learning and improvement partnerships with private-sector providers, and making performance data broadly available.

The authors conclude, importantly, that the VA employs "an army of highly dedicated clinicians and administrators who are deeply committed to providing high-quality care to veterans" and that the agency's problems can be fixed if new leadership helps them succeed.