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Strategic Analytics for Improvement and Learning (SAIL) Value Model Measure Definitions

Acute admission reviews met criteria

The UM hospital admission review is a screening to determine the appropriateness of admission to a specific level of care. This review is typically performed within 24 hours following the admission, or no later than the first business day following the admission. Nationally-approved, standardized, objective, evidence-based criteria must be used to determine the clinical appropriateness of admission to specific levels of care. SAIL report percent of acute admission reviews met InterQual criteria for medicine, surgery, and neurology, excluding observation stays and mental health. The rate is calculated as # Acute Admission Reviews Met / # Acute Admission Reviews, adjusted for facility complexity peer group average. A higher value is preferred.

Acute care 30-day standardized mortality ratio (SMR30)

The acute care 30-day SMR is the actual number of patients admitted to acute care wards who died within 30 days of hospital admission divided by the sum of the expected deaths of all acute care ward patients using the risk adjusted mortality model that predicts death at 30 days. The SMR30 included in this report is a rolling 12-month measure.

SMR30 (ratio) = number of observed deaths within 30 days of admission / number of expected deaths within 30 days of admission

Acute care in-hospital standardized mortality ratio (SMR)

The in-hospital SMR is the actual number of deaths within 1 day of hospital discharge for patients who were admitted to acute care wards divided by sum of the expected deaths determined using the risk adjusted mortality model for patients admitted to acute care wards. This measure is calculated for patients who have at least one acute care ward stay. A difference between in-hospital SMR and the 30-day SMR suggests that acute care discharge practices might be influencing the numbers (e.g., availability or lack of long-term acute care facilities or palliative care facilities). The SMR included in this report uses rolling 12 month data.

SMR (ratio) = number of observed in-hospital deaths / number of expected in-hospital deaths

The reference value of both SMR and SMR30 is 1.00. A value of 1.20 suggests 20% more deaths occurred than were expected. Similarly, a value of 0.80 indicates 20% fewer deaths than expected. A lower value and a value less than 1.00 is preferred. 

Acute care risk adjusted length of stay (LOS)

We calculate the risk adjusted length of stay by first estimate a length of stay index, measured as the sum of the actual length of stay divided by the sum of the expected length of stay for a hospital. The risk adjusted length of stay is then calculated by multiplying the length of stay index by the grand mean length of stay for all VA hospitals.

A lower risk adjusted average length of stay generally suggests a more efficient consumption of hospital resources and reduced risk to patients.

Acute continued stay reviews met criteria

The continued stay review is a screening performed during a patient’s hospitalization to determine the appropriateness of continuation of the patient’s stay at a specified level of care. Continued stay reviews are concurrent reviews performed daily (i.e., each day following admission), or no later than the first business day following other than normal duty hours, throughout the patient's acute care hospital stay. SAIL reports percent of acute admission reviews met InterQual criteria for medicine, surgery, and neurology, excluding mental health and observation stays. The rate is calculated as # Acute Continued Stay Reviews Met / # Acute Continued Stay Reviews, adjusted for facility complexity peer group average. A higher value is preferred.

All cause hospital-wide 30-day readmission rate

Readmission following hospitalization is costly and often preventable. To provide a broader assessment of quality of care at hospitals, in addition to disease specific Risk Standardized Readmission Rate, CMS has developed a hospital-wide readmission (HWR) measure for all conditions. The HWR measure reported on SAIL adapted and improved upon CMS HWR method to model basing on unplanned readmissions within 30 days of hospital discharge for all conditions among adult patients 18 and older. Risk adjusters include those used by CMS (comorbidity, discharge diagnosis group (AHRQ CCS) and age) and other risk factors identified through literature (patient demographics, social determinants, predicted medical resource utilization and hospitalization characteristics). This measure is presented as a single summary score derived from the results of five models (patient cohorts): Medicine, Surgery/Gynecology, Cardiorespiratory, Cardiovascular, and Neurology. A lower value is preferred than a higher value.

Ambulatory care sensitive condition (ACSC) hospitalizations

Hospitalizations due to ambulatory care-sensitive conditions (ACSCs) such as hypertension and pneumonia are preventable if ambulatory care is provided in a timely and effective manner. Studies show that effective primary care is associated with fewer ACSC-related hospitalizations. For this reason, the rate of ACSC hospitalizations is accepted as an indicator of access and quality of primary care.

ACSC hospitalizations reported on SAIL is a risk adjusted rate of ACSC hospitalizations per 1000 patients, measured as the Observed to Expected ratio (actual number of hospitalizations due to ACSC divided by the predicted number of hospitalizations due to ACSC) multiplied by the VA national rate per 1000 patients. 

Best Places to Work

The Best Places to Work score is an annual ranking of U.S. government agencies using data from the Federal Employee Viewpoint Survey (FEVS). It is a composite score ranging from 0-100 points and is calculated by the Partnership for Public Service.

In 2013, the AES started collecting the same Best Places to Work survey measures used in the FEVS. These AES measures are then calculated by the Partnership for Public Service to derive Best Places to Work scores across VA at network/area, facility/office, and workgroup levels.

Both FEVS and AES Best Places to Work scores are measured using three items with the calculation based on the weighted percentage of positive responses (0-100%) of “Very Satisfied/Satisfied” or “Strongly Agree/Agree” to:

  • Overall Satisfaction: Considering everything, how satisfied are you with your job?
  • Organization Satisfaction: Considering everything, how satisfied are you with your organization?
  • Organizational Commitment: I recommend my organization as a good place to work.

To find FEVS Best Places to Work scores for VA, other federal agencies, and the private sector, please visit: http://bestplacestowork.org.

A higher score indicates a higher level of satisfaction for the work place.

Call center answer speed

It is VHA policy that telephone services for clinical care must be made available to all veterans receiving care at VHA facilities and that these services include 24/7 telephone access to clinical staff trained to provide health care advice and information. All primary care practice sites with more than 5,000 active primary care patients and all VISN and Regional Call Centers must implement call management software to collect measures on their performance.

Call center responsiveness assess the average number of seconds in response to calls to call centers, measured as:

Average speed of response = Sum(Answer speed * Call volume) / Sum(Call volume)

Quality improvement goal is for the average speed to answer at less than or equal to 30 seconds combined at the facility level for all call center types.

Capacity

Physician Capacity Report gives administrators a dashboard look at overall productivity and capacity at their facility across all specialties. It contains a single view with information on the overall facility picture including access, productivity, capacity, fee, MD staffing and support staffing numbers.
Capacity reported is measured as the % Increase in Current Physician Capacity, prepared basing on physician productivity. It presents the percentage increase in the productivity measure from the current year baseline for the selected facility to grow to the MCG average productivity across all specialties. The percent increase is calculated as

Capacity = Potential Additional Physician Capacity (RVUs) / Current Physician Workload (RVUs) * 100

Potential additional physician capacity is the sum across all specialties of the potential additional physician capacity in the Physician Capacity Report. Potential Physician Capacity is calculated when Productivity is less than the Average Productivity by Specialty and MCG Complexity.

Potential Physicain Capacity = (Average Productivity by MCG - Productivity * Total MD FTE

Physician capacity is not calculated for sites with above average productivity for their MCG. For Capacity, a lower value is preferred than a higher value.

CMS 30-day risk standardized mortality rate: Acute Myocardial Infarction (AMI RSMR)

CMS measures AMI RSMR as the ratio of the number of predicted deaths within 30 days of hospital admission in AMI patients to the expected number of deaths within 30-day of hospital admission in AMI patients, multiplied by the national unadjusted 30-day mortality rate. The predicted deaths are adjusted for patient and facility characteristics, while the expected deaths are adjusted for patient characteristics only.

CMS 30-day risk standardized mortality rate – Congestive Heart Failure (CHF RSMR)

CMS measures CHF RSMR as the ratio of the number of predicted deaths within 30 days of hospital admission in CHF patients to the expected number of deaths within 30-day of hospital admission in CHF patients, multiplied by the national unadjusted 30-day mortality rate. The predicted deaths are adjusted for patient and facility characteristics, while the expected deaths are adjusted for patient characteristics only.

CMS 30-day risk standardized mortality rate – Pneumonia (Pneumonia RSMR)

CMS measures Pneumonia RSMR as the ratio of the number of predicted deaths within 30 days of hospital admission in pneumonia patients to the expected number of deaths within 30-day of hospital
admission in pneumonia patients, multiplied by the national unadjusted 30-day mortality rate. The predicted deaths are adjusted for patient and facility characteristics, while the expected deaths are adjusted for patient characteristics only.

30-day mortality rates are widely used to indicate effectiveness of hospital care by looking beyond immediate inpatient outcomes and assessing longer term of patient survival. A lower value indicates lower mortality and thus is preferred.

CMS 30-day risk standardized readmission rate – Acute Myocardial Infarction (AMI RSRR)

CMS measures AMI RSRR as the ratio of the number of predicted readmissions within 30 days of discharge in AMI patients to the expected number of readmissions within 30-day of hospital discharge in AMI patients, multiplied by the national unadjusted 30-day readmission rate. The predicted readmissions are adjusted for patient and facility characteristics, while the expected readmissions are adjusted for patient characteristics only.

CMS 30-day risk standardized readmission rate – Congestive Heart Failure (CHF RSRR)

CMS measures CHF RSRR as the ratio of the number of predicted readmissions within 30 days of discharge in CHF patients to the expected number of readmissions within 30-day of hospital discharge in CHF patients, multiplied by the national unadjusted 30-day readmission rate. The predicted readmissions are adjusted for patient and facility characteristics, while the expected readmissions are adjusted for patient characteristics only.

CMS 30-day risk standardized readmission rate – Pneumonia (Pneumonia RSRR)

CMS measures Pneumonia RSRR as the ratio of the number of predicted readmissions within 30 days of discharge in Pneumonia patients to the expected number of readmissions within 30-day of hospital discharge in Pneumonia patients, multiplied by the national unadjusted 30-day readmission rate. The predicted readmissions are adjusted for patient and facility characteristics, while the expected readmissions are adjusted for patient characteristics only.

30-day readmission rates are widely used to indicate effectiveness of hospital care by looking at care delivered in hospital or post discharge that may have contributed to stability and recovery once a patient leaves hospital. A lower value indicates lower readmission rate and thus is preferred.

Comprehensiveness (PCMH Survey)

Data for these measures are collected through the Consumer Assessment of Healthcare Providers and Systems Survey for Patient-Centered Medical Homes (CAHPS PCMH) survey. The survey instrument was developed by the National Committee for Quality Assurance (NCQA) and the CAHPS Consortium, which was sponsored by the Agency for Healthcare Research and Quality (AHRQ), to capture consumer and patient perspectives on healthcare quality. This report focuses on key measures of the patient-centered medical homes experience including access to care, communications with providers, office staff support, comprehensiveness of adult behavioral services, support provided for self-management, discussion of medication decisions, patient's overall rating of the provider, and follow-up on test results.

For the Comprehensiveness composite, patients are asked whether their providers pay attention to their mental or emotional health on a scale of Yes and No. A facility’s item score is calculated as the percentage of responses that fall in the top category (Yes). The Comprehensiveness composite score is calculated as the average of the facility’s scores on the items. A higher value is preferred than a lower value.

Days waited for an appointment for urgent care (PCMH Survey)

Data for this measure are collected through the Consumer Assessment of Healthcare Providers and Systems Survey for Patient-Centered Medical Homes (CAHPS PCMH) survey. The survey instrument was developed by the National Committee for Quality Assurance (NCQA) and the CAHPS Consortium, which was sponsored by the Agency for Healthcare Research and Quality (AHRQ), to capture consumer and patient perspectives on healthcare quality. This report focuses on key measures of the patient-centered medical homes experience including access to care, communications with providers, office staff support, comprehensiveness of adult behavioral services, support provided for self-management, discussion of medication decisions, patient's overall rating of the provider, and follow-up on test results. Patients are asked the number of days they waited for an appointment for urgent care on a scale of Same Day, 1 Day, 2 to 3 Days, 4 to 7 Days, and More Than 7 Days. A facility’s item score is calculated as the percentage of responses that fall in the top two categories (Same Day, 1 Day). A higher value is preferred than a lower value.

Efficiency

For each medical center, clinical and administrative cost efficiency is measured by using Stochastic Frontier Analysis (SFA). SFA is a well-validated approach in assessing operational efficiency with quality of care taken into account. The modeling principle is to estimate the optimal cost (given quality of care) after controlling for risks or confounding factors such as hospital characteristics, and separating random factors that are not under managers’ control from true managerial inefficiency.

Based on the optimal cost, an efficiency score is derived for each facility; an efficiency score of 1.00 is most efficient, and values greater than 1.00 are associated with increasing inefficiency. SFA efficiency measurement is a macro model that does not provide ‘actionable’ information for VISNs and facilities to use. The Efficiency Opportunity Grid (EOG) includes numerous models that correlate with SFA efficiency thereby providing ‘actionable’ areas for VISNs and facilities to target.

Healthcare associated infections (HAI)

CDC defines healthcare associated infections are infections caused by a wide variety of common and unusual bacteria, fungi and viruses during the course of receiving medical care. The SAIL model measures four types of HAIs reported by medical centers to IPEC:
  • Central line associated bloodstream infection (CLAB)
  • Catheter associated urinary tract infection (CAUTI)
  • Ventilator associated events (VAE)
  • Methicillin-Resistant Staphylococcus aureus (MRSA)
CLAB and CAUTI are reported as infections per 1000 device days, VAE as events per 1000 device days, and MRSA as infections per 1000 bed days. For all HAIs, a lower rate is preferred than a higher rate.

Healthcare Effectiveness Data and Information Set (HEDIS)

HEDIS is a widely used set of outpatient performance measures. The measures allow consumers to compare health plan performance to other plans and to national or regional benchmarks.

HEDIS is one component of the National Committee for Quality Assurance’s (NCQA) accreditation process. The Centers for Medicare and Medicaid Services requires hospitals and health systems (e.g., HMOs) to submit HEDIS data and report the measures in the CMS Hospital Compare.

The HEDIS Performance Measure is a combined composite (HED90) that averages five outpatient VHA composite measure scores: Behavioral Health Screening (bh90), Diabetes (dmg90), Ischemic Heart Disease (ihd90), Prevention (prv90) and Tobacco (smg90). Each composite (bh90, dmg90, ihd90, prv90, smg90) is calculated as the weighted numerator divided by the weighted denominator. The five composite domains contribute equally to the HED90 score because they are considered equally important to quality care. A higher value in HED90 score is preferred rather than a lower value.

Mental Health Domain

Mental health domain monitors three perspectives or domains important to the delivery of mental health care: population coverage, continuity of care and experience of care. Each of the composites consists of multiple measures. SAIL benchmarks VISNs and facilities on the over mental health domain. A higher mental health domain score is preferred than a lower score.

ORYX®

ORYX is an initiative introduced by Join Commission in 1997 that integrates patient outcomes of inpatient care and other performance measure data into accreditation process. Organizations seeking accreditation contract with a performance measurement system are required to submit ORYX data to the Joint Commission.

Starting FY15Q4, the ORYX Performance Measure is a combined composite (ORYX90) that averages three inpatient VHA composite measure scores: Global Measures (gm90), Hospital Based Inpatient Psychiatric Services (hbips90), and Stroke (stk90). Each composite (gm90, hbips90, stk90) is calculated using the opportunities model which assumes that each Veteran needs and has the opportunity to receive one or more processes of care, but not all Veterans need the same care. This model summarizes the proportion of appropriate care that is delivered. The three composite domains contribute equally to the ORYX90 score because they are considered equally important to quality care. At facilities where all three service lines/patient populations are not represented, each available composite remains equally weighted; however, the proportion of the attributed weight is greater (e.g., if a site only has two composites, each contributes 50 percent to the ORYX90 combined composite). While the resulting model has some inherent biases, it performed the best when tested and its simplicity facilitates drill down and the identification of performance improvement opportunities. A higher ORYX90 score is preferred than a lower score.

Patient safety index (PSI)

Patient Safety Index is derived from a set of patient safety indicators developed by the Agency for Healthcare Research and Quality (AHRQ). These indicators provide information on potential in-hospital complications and adverse events following surgeries, procedures and childbirth.

The SAIL Value Model includes 10 patient safety indicators to derive an overall Index value. For each indicator, we calculate the number of actual events and divided it by the expected number of events, given the risk of having an event for each patient. These ratios are then averaged to derive an Index score. The 10 patient safety indicators included in the SAIL Values Model are:

• Pressure ulcer (PSI 3)
• Death among surgical inpatients with serious, treatable complications (PSI 4)
• Iatrogenic pneumothorax (PSI 6)
• Central venous catheter-related blood stream infections (PSI 7)
• Perioperative hemorrhage or hematoma (PSI 9)
• Postoperative physiologic and metabolic derangement (PSI 10)
• Postoperative respiratory failure (PSI 11)
• Perioperative pulmonary embolism or deep vein thrombosis (PSI 12)
• Postoperative sepsis (PSI 13)
• Postoperative wound dehiscence (PSI 14)

A lower PSI index score is preferred than a higher score.

Patient satisfaction (HCAHPS)

Patient satisfaction data is extracted from the SHEP Inpatient survey, basing on the HCAHPS survey to measure patients’ perspectives on hospital care. The CAHPS Hospital Survey is endorsed by the National Quality Forum, an organization established to standardize health care quality measurement and reporting, in 2005.

The SAIL Value Model uses a question measuring overall patient satisfaction with hospital care: “Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?” A facility’s HCAHPS score is measured as the percentage of patients responded 9 and 10. A higher HCAHPS score is preferred than a lower score.

Preventable in-hospital complications

Preventable in-hospital complications are conditions that arise after hospital admission. These conditions are potentially preventable if health care are delivered appropriately. The SAIL model tracks 7 preventable in-hospital complications that have been either endorsed by the National Quality Forum or extensively examined in large national studies. These conditions are identified using secondary diagnoses following algorithm published in the literature. These include 1 surgical condition and 6 medical conditions.

Surgical:
  • Wound infection
Medical:
  • Hospital acquired pneumonia
  • Shock or cardiac arrest
  • Upper gastrointestinal bleeding
  • Hospital acquired sepsis
  • Deep vein thrombosis
  • Central nervous system complications
SAIL measures preventable in-hospital complication as the observed number of hospitalizations with occurrence of any of the seven complications divided by the expected number of hospitalizations with occurrence of any of the seven complications. A lower value is preferred than a higher value.

Rating of primary care providers

Data for this measure is collected through the Consumer Assessment of Healthcare Providers and Systems Survey for Patient-Centered Medical Homes (CAHPS PCMH) survey. The survey instrument was developed by the National Committee for Quality Assurance (NCQA) and the CAHPS Consortium, which was sponsored by the Agency for Healthcare Research and Quality (AHRQ), to capture consumer and patient perspectives on healthcare quality. This report focuses on key measures of the patient-centered medical homes experience including access to care, communications with providers, office staff support, comprehensiveness of adult behavioral services, support provided for self-management, discussion of medication decisions, patient's overall rating of the provider, and follow-up on test results. Patients are asked to rate their primary care provider on a scale from 0 to 10, with 0 as the worst provider possible and 10 the best provider possible. A facility’s score is calculated as the percentage of responses that fall in the top two categories (9, 10). A higher value is preferred than a lower value.

Rating of specialty care providers

Administration of Specialty care survey began in May 2015. The FY 2015 survey instrument was based on CAHPS Clinician and Group (CG) Visit survey (2.0) which asks about patients’ experience during their recent visit. Beginning FY2016, the specialty care survey was modified to CAHPS CG version 3.0 which assess patients’ experiences in the last 6 months. Results are aggregated for all specialty care clinics. Patients are asked to rate their specialty care provider on a scale from 0 to 10, with 0 as the worst specialist possible and 10 the best specialist possible. A facility’s score is calculated as the percentage of responses that fall in the top two categories (9, 10). A higher value is preferred than a lower value.

Registered nurse turnover rate

The registered nurse RN turnover rate measures losses of RNs, a key indicator in Magnet Journey, Joint Commission performance monitor, as well as other national and local reports. SAIL measures losses due to termination and voluntary separation. A lower turnover rate is preferred than a higher rate.

Telephone abandonment rate

It is VHA policy that telephone services for clinical care must be made available to all veterans receiving care at VHA facilities and that these services include 24/7 telephone access to clinical staff trained to provide health care advice and information. All primary care practice sites with more than 5,000 active primary care patients and all VISN and Regional Call Centers must implement call management software to collect measures on their performance.

Telephone abandonment rate is defined as the percentage of calls coming into a telephone system that are terminated by the persons originating the call before being answered by a staff person. To allow comparison across VA, Call Centers collect abandonment rate for all calls coming into the Call Center, without excluding calls abandoned within a specified timeframe such as the first 15 or 30 seconds. Abandonment rate is measured as

Abandonment rate = Sum(Abandoned calls) / Sum(Call volume)

Average abandonment rate = Sum(Abandoned rate * call volume) / Sum(Call volume)

Quality improvement goal is for the average abandonment rate at less than or equal to 5% combined at the facility level for all call center types.

Timeliness in getting appointments, care and information (PCMH Access composite)

Data for these measures are collected through the Consumer Assessment of Healthcare Providers and Systems Survey for Patient-Centered Medical Homes (CAHPS PCMH) survey. The survey instrument was developed by the National Committee for Quality Assurance (NCQA) and the CAHPS Consortium, which was sponsored by the Agency for Healthcare Research and Quality (AHRQ), to capture consumer and patient perspectives on healthcare quality. This report focuses on key measures of the patient-centered medical homes experience including access to care, communications with providers, office staff support, comprehensiveness of adult behavioral services, support provided for self-management, discussion of medication decisions, patient's overall rating of the provider, and follow-up on test results. Patients are asked to rate their experience with getting timely appointments, care and information on a scale of Never, Sometimes, Usually, and Always. A facility’s item score is calculated as the percentage of responses that fall in the top category (Always). The Access composite score is calculated as the average of the facility’s scores on the items. A higher value is preferred than a lower value.

Timeliness in getting Specialty Care urgent care and routine care appointments (SC Access composite)

Data for these measures are collected through Specialty Care survey. Administration of Specialty care survey began in May 2015. The FY 2015 survey instrument was based on CAHPS Clinician and Group
(CG) Visit survey (2.0) which asks about patients’ experience during their recent visit. Beginning FY2016, the specialty care survey was modified to CAHPS CG version 3.0 which assess patients’ experiences in the last 6 months. The specific questions asked patients to rate their experience with getting timely appointments, care and information on a scale of Never, Sometimes, Usually, and Always. A facility’s item score is calculated as the percentage of responses that fall in the top category (Always). The Access composite score is calculated as the average of the facility’s scores on the items. A higher value is preferred than a lower value.

Wait time for completed appointments

Wait time measures are designed to help reduce the number of appointments with long waits. The report identifies all completed appointments and the associated wait times in the selected timeframes beginning in FY14. SAIL reports three (3) new patient completed appointment wait time measures:

  • % New Patient Primary Care appointments completed within 30 days of Preferred Date
  • % New Patient Specialty Care appointments completed within 30 days of Preferred Date
  • % New Patient Mental Health appointments completed within 30 days of Preferred Date