Improving Quality of Care

In its 2001 report Crossing the Quality Chasm, the Institute of Medicine called for systematic reform to address shortfalls in U.S. health care quality. Recommended reforms included developing medical informatics infrastructure, a performance tracking system, and methods to ensure provider and manager accountability. The Department of Veterans Affairs (VA), the country’s largest health care provider, has been recognized as a leader in improving the quality of health care. Beginning in the early 1990s, the VA established system-wide quality improvement initiatives, many of which model the changes the Institute of Medicine would later recommend.

How does the VA measure up against other U.S. health care providers? To address this question, RAND researchers compared the medical records of VA patients with a national sample and evaluated how effectively health care is delivered to each group. Their findings:

• VA patients received about two-thirds of the care recommended by national standards, compared with about half in the national sample.
• Among chronic care patients, VA patients received about 70 percent of recommended care, compared with about 60 percent in the national sample.
• For preventive care, the difference was greater: VA patients received about 65 percent of recommended care, while patients in the national sample received 20 percent less.
• VA patients received consistently better care across the board, including screening, diagnosis, treatment, and follow-up.
• Quality of care for acute conditions — a performance area the VA did not measure — was similar for the two populations.
• The greatest differences between the VA and the national sample were for indicators where the VA was actively measuring performance and for indicators related to those on which performance was measured.

VA Delivers Higher Quality of Care

Using indicators from RAND’s Quality Assessment Tools system, RAND researchers analyzed the medical records of 596 VA patients and 992 non-VA patients from across the country. The patients were randomly selected males aged 35 and older. Based on 294 health indicators in 15 categories of care, they found that overall, VA patients were more likely than patients in the national sample to receive recommended care. In particular, the VA patients received significantly better care for depression, diabetes, hyperlipidemia, and hypertension. The VA also performed consistently better across the spectrum of care, including screening, diagnosis, treatment, and follow-up. The only exception to the pattern of better care in VA facilities was care for acute conditions, for which the two samples were similar.

VA Changes Helped Improve Performance

The VA has been making significant strides in implementing technologies and systems to improve care. Its sophisticated electronic medical record system allows instant communication among providers across the country and reminds providers of patients’ clinical needs. VA leadership has also established a quality measurement program that holds regional managers accountable for essential processes in preventive care and in the management of common chronic conditions.

Performance Measurement Plays an Important Role

How does performance measurement affect actual performance in health care delivery? To answer this question, the researchers conducted another analysis focused solely on the health indicators that matched the performance measures used by the VA. They found that VA patients had a substantially greater chance of receiving the indicated care for these health conditions than did patients in the national sample. They also observed that performance measurement has a “spillover effect” that influences care: VA patients were more likely than patients in the national sample to receive recommended care for conditions related to those on which performance is measured. For example, VA outperformed the national sample on administering influenza vaccinations, a process on which the system tracks performance. However, it also outpaced the national sample on other, related immunization and preventive care processes that are not measured. This provides strong evidence that, if one tracks quality, it will improve not only in the area tracked but overall as well.

These Results Have Important Implications

The implications of this study go far beyond differences in quality of care between the VA and other health care systems. The research shows that it is possible to improve quality of care and that specific improvement initiatives play an important role. First, health care leaders must embrace and implement information technology systems that support coordinated health care. Second, they should adopt monitoring systems that measure performance and hold managers accountable for providing recommended care. If other health care providers followed the VA’s lead, it would be a major step toward improving the quality of care across the U.S. health care system.