Health System TransformationRobert A. Petzel, M.D. | Under Secretary for Health

Budget…………………........................................…..$50 Billion

Medical centers………………………………………………..153

Outpatient clinics……………………………………..………850

Unique patients treated…………………………….…6 Million

Outpatient visits……………................................….78 Million

Employees………………………………………………...250,000

Physicians………………...................................….….....19,000

Nurses (RN)………………………………………….…..…45,000

Nurse Practitioners………………………………..….……3,500

Veterans Health Administration

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A vision for change

Structural re-organisation

Decentralisation

Evidence-based medicine

Performance measures

Performance management

Electronic medical record

Integration

What drove the change?

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The Veterans Health Administration is a comprehensive, integrated health care

system that provides excellence in health care value, defined by quality, cost,

access and satisfaction. An organisation characterised by accountability and being

an employee of choice.

The Transformation Vision1996

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• 1995: Creating VISNs

• Objective to transform from a ‘hospital system’ to a ‘health system’

• From ‘safety net’ to ‘health promotion and disease prevention’

21 Veterans Integrated Service Networks in 1998

VISNs are the Funding & Accountability Unit in VA

I J 2002

N ANUARY

W ERE INTEGRATED AND

RENAMED

VISN 13 14

VISN 23

S AND

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Decrease BDOC by 19%

Increase ambulatory surgery by 20%

Chronic disease index

Prevention index

Implement 12 new clinical practice guidelines

Sample performance measures 1997

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Outpatient visits vs BDOC

3.63.73.83.94.04.14.24.34.44.54.6

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FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10

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Outpatient Visits vs BDOC

Outpatient Visits (millions) Bed Days of Care (millions)

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Clinical IndicatorVA Average

2009 (1)

VA Average

2008 (1)

HEDIS Commercial

2008 (2)

HEDIS Medicare

2008 (2)

HEDIS Medicaid

2008 (2)

HEDIS 90th Percentile (All)

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Breast Cancer Screening 87% 87% 70% 68% 51% 77%

Cervical Cancer Screening 92% 92% 80% n/a 66% 86%Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Control

(<100 mg/dL) 67% 66% 60% 57% 40% 69%

Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Screening 96% 94% 89% 89% 80% 92%

Colorectal Cancer Screening 80% 79% 59% 53% n/a 67%

Comprehensive Diabetes Care - Blood Pressure Control (<140/90) 80% 78% 66% 60% 57% 73%

Comprehensive Diabetes Care - Eye Exams 88% 86% 57% 61% 53% 70%

Comprehensive Diabetes Care - HbA1c Testing 98% 97% 89% 88% 81% 93%

Comprehensive Diabetes Care - LDL-C Controlled (LDL-C<100 mg/dL) 69% 68% 46% 49% 34% 53%

Comprehensive Diabetes Care - LDL-C Screening 96% 95% 85% 86% 74% 88%

Comprehensive Diabetes Care - Medical Attention for Nephropathy 95% 93% 82% 88% 77% 88%

Comprehensive Diabetes Care - Poor HbA1c Control 16% 16% 28% 29% 45% 20%

Controlling High Blood Pressure - Total 77% 75% 63% 59% 56% 72%

Flu Shots for Adults (50-64) 69% 69% 50% n/a n/a 58%Medical Assistance with Smoking Cessation -

Advising Smokers To Quit (3) 96% 89% 77% n/a 69% 83%Medical Assistance with Smoking Cessation -

Discussing Medications (3) 90% 84% 54% n/a 41% 63%

Medical Assistance with Smoking Cessation -

Discussing Strategies (3) 96% 92% 50% n/a 41% 58%

Flu Shots for Adults (65 and older) (4) (5) 83% 84% n/a 71% n/a n/aImmunizations: pneumococcal, (note patients

age groups) (4) (5) 95% (all ages) 94% (all ages) n/a 67% n/a n/a

External Comparisons for 2008/2009

SOURCE: Office of Quality and Performance Updated 11-12-09

* Due to population differences, and methodology variations not all HEDIS measures are comparable to VA measures - therefore this is not a comprehensive list of indicators but this comparison does contain those indicators that are closely aligned in content and methodology.

1) VA comparison data is obtained by abstracting medical record data using similar methodologies to matched HEDIS methodologies. There are noted differences in eligibility and exclusions for end of life care.

6) Data obtained from Quality Compass, a tool available through NCQA (www.ncqa.org)

2) HEDIS Data was obtained from the 2009 "State of Health Care Quality Report" available on the NCQA website: www.ncqa.org

3) HEDIS is obtained by survey, VA is obtained by medical record abstraction

4) BRFSS reports are available on the CDC website: www.cdc.gov

5) BRFSS (survey) scores are median scores. VA Scores are averages obtained by medical record abstraction

Patient satisfaction

2001 2002 2003 2004 2005 2006 2007 2008 2009

VHA inpatients 82 81 81 84 83 84 83 85 84

VHA outpatients 79 79 80 83 80 82 83 81 83

Private sector hospitals 68 70 73 76 71 74 77 75 77

NM = Not Measured Source: http://www.theacsi.org

VHA has led private sector health care in patient satisfaction.

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Electronic Health Record

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• Information– 1 in 7 hospital admissions occurs because care

providers do not have access to previous medical records*

– 12% of physician orders are not executed as written*– 20% of laboratory tests are requested because previous

studies are not accessible*– 1 in 6.5 hospitalisations are complicated by drug error

• 1 in 20 outpatient prescriptions

*PITAC (President’s Information Technology Advisory Committee, 2004)

Why is IT a central strategy?Healthcare in the U.S., presents multiple challenges

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Transformation 2010

Vision

VHA will continue to be the benchmark of excellence and value in healthcare and benefits by providing exemplary services

that are both patient-centered and evidence-based.

This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery

and continuous improvement.

It will emphasise prevention and population health and contribute to the nation’s well-being through education,

research and service in national emergencies.

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Transformational initiatives

Patient-aligned care teams – PACT

Telemedicine

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PACT

Patient

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Teams

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‘Changing the paradigm from episodic care to longitudinal engagement’

-Robert Jesse, MD

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Patient-centered

Team care

Continuous improvement

Evidence-based, data driven

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12 principles of patient-centered care

Honor the veteran’s expectations of safe, high-quality, accessible care.

Enhance the quality of human interactions and therapeutic alliances.

Solicit and respect the veteran’s values, preferences and needs.

Systemise the co-ordination, continuity and integration of care.

Empower veterans through information and education.

Incorporate nutritional, cultural and nurturing aspects of food.

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12 principles of patient-centered carecontinued

Provide for physical comfort and pain management.

Ensure emotional and spiritual support.

Encourage involvement of family and friends.

Ensure that architectural layout and design are conductive to health and healing.

Introduce creative arts into the healing environment.

Support and sustain an engaged workforce as key to providing patient-centered care.

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Team care

Everyone is on a team

Team members are peers

Collaboration

Culture of respect

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Continuous improvement

Data

Methodology

Time

Empowerment

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Data-driven and evidence-based

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Data at point of care about cost, quality, access and satisfaction

Practice to the evidence

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Patient-aligned care teams

• PACT offers diverse methods of accessing health care:• personal visits• group clinics• telephone conversations• secure messaging through My HealtheVet• web access• telehealth

PACT: Enhanced Access to Care

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Patient-aligned care teams

• PACT co-operates with veterans to plan their overall health with focus on:

• personal relationships• patient preferences• open communication and sharing of information• team delivery of holistic care• co-ordination across specialties and settings of care• quality and safety improvements.

PACT: Co-ordinated care (cont.)

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PACT Compass

Panel management

Access

Continuity

Co-ordination

Satisfaction

Outcomes

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PACT Compass

Continuity

• Provider: % visits with assigned PCP

• Team: % visits with team• ED visit rate

Patient engagement and satisfaction

• SHEP scores (selected)• Patient complaints (Patient

Advocate)• My HealtheVet enrollment• % IPA

• Employee satisfaction scores

Panel management

• Panel size• Panel capacity• Teamlet staff• Staff turnover rate• PCMM Team setup

Access•Desired date appointments•same day•within 7 days•within 14 days

•Third next available•No-show rate•Telephone access data•Group clinic encounters•Telephone clinic encounters

Co-ordination• Admission rate• Specialty referral rates• Pt contacted within 2 days of

discharge• Consult tracking

Clinical improvement• Clinical indicators (selected)• Admission rates• ED visit rates• Panel case mix

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Transparency

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ASPIRE

• Used to track each VAMC’s progress toward meeting the goals that VA aspires to achieve over the next few years (eg: no hospital-acquired infections)

• Includes 50 metrics

• Examples: MRSA, VAP, CLAB infection rates, hospital-acquired pressure ulcers, incorrect surgery, risk adjusted, standardised mortality rates for AMI, CHF, pneumonia and all cause re-admission rates

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LinKS

• Used to identify the performance of each VAMC in relation to all other VAMCs

• Contains 45 process and outcomes metrics

• Examples: Standardised mortality ratios for acute care (30 day) and ICU (in hospital & 30 day), and surgery (30 day), AMI, CHF, and pneumonia patients; risk adjusted re-admission rates (AMI, CHF and pneumonia); all cause re-admission rates, ambulatory care sensitive condition hospitalisations, hospital-acquired infections, etc

(Linking Knowledge and Systems)

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Telemedicine

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Telehealth

• Telemedicine:• dermatology• ophthalmology• cardiology• pathology• mental health

• Telehome Health• eICU

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Telehealth

• Home telehealth• 50,000 unique patients in FY 2010

• Telemedicine• FY 2010

• 73,000 unique patients• 165,000 encounters

• Mental health• 100,500 unique patients over a four year period

• Teleretinal imaging• 155,780 encounters in FY 2010

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What drives the change?

A vision for change

Structural re-organisation

Decentralisation

Evidence-based medicine

Performance measures

Performance management

Electronic medical record

Integration

Constancy of purpose

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