VA health care quality: The road to recovery

"We are not your father's VA," Jonathan B. Perlin, MD, PhD, who until recently headed the Dept. of Veterans Affairs health system, was fond of saying about today's department.

For decades, the quality of care in the VA health system was considered woefully sub-par. Enrollees complained of shoddy facilities, uncaring medical professionals and neglectful treatment. Its reputation suffered from such accounts as Oliver Stone's 1989 film "Born on the Fourth of July," which depicted the paralyzed protagonist's VA hospital setting as squalid and decaying.

Veterans, physicians and other experts tell a different story today. By many accounts, the quality-of-care picture at the more than 150 hospitals and nearly 900 outpatient clinics has changed dramatically since the mid-1990s. What was once the subject of embarrassment and ridicule is now held up as a model for health systems.

With its new reputation for having some of the best treatment available anywhere, the veterans system has been in high demand in recent years, said Martin F. Conatser, American Legion national commander. This demand, combined with the large influx of new Iraq and Afghanistan veterans, has strained the system's capabilities and led to access problems for new enrollees and long-time patients. "It's been a victim of its own success," Conatser said.

Investigators have found that veterans are having trouble enrolling in the system and receiving timely care once they do. Veterans, physicians and lawmakers have joined the chorus calling for major reforms to address an antiquated disability assessment process, staffing shortages and bureaucratic barriers to care.

But for those who can get it, the level of care can match or exceed most anything veterans could receive in the private sector or elsewhere in the government. A 2004 study by Steven M. Asch, MD, found that 12 VA health care systems provided a higher level of care nearly across the board when compared with patient care in 12 non-VA settings. Although no statistical differences were found in acute care, VA patients received significantly better chronic and preventive care than did non-VA patients, and better care through the spectrum of treatment from diagnosis to follow-up. Dr. Asch is a researcher with the VA Greater Los Angeles Health Care System.

Another study, led in 2003 by Ashish K. Jha, MD, MPH, an assistant professor of health policy at the Harvard School of Public Health, found that the VA reforms of the mid-1990s quickly improved quality. By 2000, the veterans system was outperforming Medicare in 12 out of 13 process measures after achieving double-digit percentage point gains in nearly every category since 1995.

The VA takes pride not only in its basic care but also in providing a level of specialized care that veterans cannot receive elsewhere. This care is being tested as more veterans return from Iraq and Afghanistan with complex injuries that would have killed most patients in prior conflicts.

One way the department has adapted is by establishing polytrauma rehabilitation centers. The four current centers, with a fifth under construction, treat some of the most severely wounded veterans with the aim of later transitioning them to one of 21 polytrauma network sites or to other less intensive care settings closer to home. So far, the four centers have treated nearly 400 severely wounded veterans from the wars, with roughly two-thirds of the patients having massive injuries from improvised explosive devices.

The great advantage of these centers is that they can take care of patients' multiple severe injuries in a single setting, said Barbara Sigford, MD, PhD, the Minneapolis Polytrauma Rehabilitation Center's director.

A veteran with traumatic brain injury, burns and a broken back, for instance, can receive top-notch, coordinated care for all three traumas without ever having to travel to another facility, she said. The centers employ the latest in rehabilitation technology. The department established the centers in 2005 largely in response to the significant rates of wounded returning with traumatic brain injuries. Before assuming their current titles, all four facilities had been established as TBI lead centers in 1992.

Patients give high marks to the care they receive at VA facilities, from the vaunted polytrauma centers down to the smallest outpatient clinic.

In a survey released last year by the American Customer Satisfaction Index, veterans rated their care 91 out of 100. The American Legion's Conatser says his organization reviews care at many VA facilities every year and consistently rates it as outstanding.

Continuing a quality tradition

VA physicians, administrators and other professionals have no intention of resting on their laurels, said Barbara B. Fleming, MD, PhD, the VA's chief quality and performance officer. They see their mission as continuing the course toward even higher quality care that was charted in a radical transformation more than a decade ago.

In 1994, Kenneth W. Kizer, MD, MPH, became the VA's top doctor and promptly set to work fixing what many considered a badly broken system. An emergency medicine physician who had received high marks for his work overhauling California's health system as its top official, he helped set into motion reforms that many experts credit with making the VA the quality beacon it is today.

He moved the system away from its traditional focus on inpatient care. Dr. Kizer established hundreds of outpatient clinics to provide most of veterans' basic health care needs. Before 1994, only 10% of VA enrollees had a primary care physician, Dr. Kizer said. By 1998, more than 80% did.

He also eliminated an organizational structure in which individual medical centers essentially operated independently of each other. By organizing the centers into 22 Veterans Integrated Service Networks that draft their own budgets and compete with each other for funding, the VA introduced a new culture based on quality improvement.

Since then, regional managers and medical professionals working under them have been judged based on a set of clinical quality measures, the results of which are publicized throughout the department. Doctors and others who excel in certain areas receive bonuses, making the VA one of the first health systems to use a pay-for-performance model.

To better coordinate care for a highly mobile patient population and to measure quality, Dr. Kizer pushed the department to develop a universal electronic medical record system, VistA. It is hailed as a model for public and private health plans.

Not all of Dr. Kizer's reforms were initially embraced by VA physicians and others, but they proved to be the right changes to make, he said. "I said that if we couldn't show that it could be just as good or better than the care in the private sector, then why should it exist? That wasn't necessarily a popular thing to say at the time."

Today, most initial skeptics have come around to the reforms and helped prove that they worked, said James P. Bagian, MD, VA chief patient safety officer. The national patient safety center he directs, another legacy of Dr. Kizer, has succeeded in doing what many thought impossible. VA physicians, nurses and others voluntarily report medical errors or close calls with the assurance that the information will be used to help prevent future occurrences -- not to punish the medical professionals involved.

Challenges of a new war

The VA has stumbled on occasion, as the system deals with new wars and new patients.

Despite having such resources as the polytrauma rehabilitation centers, the VA is still working to ramp up the quality of its specialized treatment for traumatic brain injury patients, amid criticism that it is not as good as it should be.

Although the department is often well ahead of the curve on many clinical issues, it did not predict at the start of the wars in Iraq and Afghanistan that it would be receiving so many TBI patients, said Margaret E. O'Kane, president of the National Committee for Quality Assurance, which ranks health plans based on quality measures.

"This issue kind of sneaked up on them, and they weren't prepared," she said.

One VA report estimated that about 6% of returning Iraq and Afghanistan veterans suffer from TBI, but veterans advocacy groups say that figure is too low. Some estimates put the total portion of combat troops who will sustain these brain injuries at as high as 20%, meaning some 300,000 veterans could end up experiencing the medical consequences. Although military health officials estimate that about seven in 10 TBI cases are mild and generally resolve on their own, the others could have lasting effects.

Posttraumatic stress disorder and other mental health issues that particularly affect veterans also are proving to be ongoing challenges for the VA. The department reported that it has already treated more than 50,000 cases of PTSD from the wars, but veterans groups warned that the actual number of those impacted is much higher.

The department recently made a concerted attempt to catch more cases by ordering that all returning combat veterans be screened for PTSD, in addition to TBI that might have escaped earlier detection. An Army report released last month, however, finds that many cases of the disorder do not emerge for three to six months after a veteran has returned from the war.

Last month, President Bush responded to the criticism by signing into law a veterans suicide prevention bill that requires more mental health training for VA staff and more counselors at department facilities.

The VA and the military have launched outreach efforts aimed at educating private practice physicians on the need to conduct mental illness screens on veterans who may have fallen through the cracks. The improvements have not been good enough for some advocacy groups. Veterans for Common Sense and Veterans United for Truth have filed a lawsuit against the department on behalf of their members. It seeks damages for what they deem failure to provide appropriate mental health care and disability payments. The groups expect a decision in the case this spring.

The VA facilities are not in as good condition as they should be, Dr. Kizer said. The average building is more than 50 years old, and some are sorely in need of renovations or updates, he said. An internal investigation of 1,400 VA facilities in March found that about 90% of the roughly 1,000 problems identified were relatively minor, but the report added that several of the more serious issues qualified as patient safety concerns. Several mental health facilities, for instance, were found to have bathroom fixtures that could make it easy for a patient to commit suicide.

Patient care concerns also have surfaced. The VA has launched several investigations into questionable patient outcomes. The latest one, regarding a spike in surgical deaths earlier this year at Marion (Ill.) VA Medical Center, is pending. The department has suspended three physicians' privileges while it investigates.

When the VA encounters a situation that goes against its reputation for the highest quality care, it moves quickly, said chief quality officer Dr. Fleming. "When a problem is identified, the response is immediate."