Fiscal Year 2004 Performance and Accountability Report Published November 15, 2004
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FY 2004 Obligation ($ in Millions) |
% of Total VA Resources |
Strategic Goal 3: Honor and serve veterans in life and memorialize them in death for their sacrifices on behalf of the Nation. |
$23,293 |
33.3% |
Objective |
Performance Results
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3.1 Provide high-quality, reliable, accessible, timely, and efficient health care that maximizes the health and functional status for all enrolled veterans, with special focus on veterans with service-connected conditions, those unable to defray the cost, and those statutorily eligible for care. |
- Increased to 77 percent the score on the Clinical Practice Guidelines Index (goal was 70 percent)
- Increased to 88 percent the score on the Prevention Index II (goal was 82 percent)
- Increased the percent of primary care appointments scheduled within 30 days of the desired date to 94 percent (goal was 93 percent)
- Increased the percent of specialist appointments scheduled within 30 days of the desired date to 93 percent (goal was 90 percent)
- Maintained a score of 74 percent of patients rating VA health care service as "very good" or "excellent" for inpatients (goal was 70 percent); achieved a score of 72 percent for outpatients (goal was 72 percent)
- Increased to 29,631 the non-institutional long-term care average daily census (goal was 29,631)
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$17,568 |
25.1% |
Performance
In FY 2004 the Department made good progress toward meeting Objective 3.1 by improving the quality of VA health care and making this high-quality care more easily accessible to veterans. Our two most important measures (Clinical Practice Guidelines Index and Prevention Index II) of health care quality focus on the degree to which we follow nationally recognized guidelines and standards of care that the medical literature has proven to be directly linked to improved health outcomes for patients. Both the Clinical Practice Guidelines Index score of 77 percent and the Prevention Index II score of 88 percent represent performance levels in excess of our performance goals. At the same time that the quality of VA health care continued to reach new heights, the Department made excellent progress in making this care more readily accessible to veterans. For both primary care (94 percent of appointments scheduled within 30 days of the desired date) and specialty care appointments (93 percent of appointments scheduled within 30 days of the desired date), we exceeded our performance goals and moved closer to our ultimate performance level of an average waiting time of 30 days for appointments. Our improvements in quality and timeliness of health care delivery contributed to high percentages of the share of patients who rated VA health care as very good or excellent. In the face of a declining, but aging veteran population, VA is expanding access to non-institutional forms of long-term care with an emphasis on community-based and in-home care. During FY 2004, the Department increased access to non-institutional long-term care (as expressed by the average daily census). All of these performance achievements were accomplished while treating 2.4 percent more patients (5.1 million) in FY 2004 than in FY 2003.
Program Assessment Rating Tool (PART) Evaluation
During the development of the FY 2005 budget, the Administration conducted a PART evaluation of the medical care program that relates to the accomplishment of Objective 3.1. This assessment reviewed the combined effectiveness of the legislative and executive branches in designing and implementing the many aspects of the medical care program. The PART evaluation for the medical care program resulted in a rating of "Adequate," an improvement from the FY 2004 budget year PART rating of "Results Not Demonstrated." The improvement in the PART evaluation of the medical care program resulted from several factors, including VA's sharpening its focus on providing timely, high-quality health care to our highest priority veterans-those with service-connected disabled conditions, veterans with lower incomes, and those with special health care needs.
Major Management Challenges
The major management challenges related to this objective are the same as those for Objective 1.1.
Program Evaluations
An independent evaluation of VA's cardiac care program was completed in 2003. The study found that heart patients treated at VA hospitals have consistently higher mortality rates than patients of similar age and in roughly similar health who are treated at non-VA institutions. A larger proportion of the veterans die in the first month after suffering a heart attack, and a larger proportion of the survivors die over the next 3 years. The program evaluation also found that VA patients undergo cardiac catheterization-a key step in assessing the seriousness of a person's heart disease-less often than patients treated in non-VA hospitals. In addition, VA patients have only about one-half the likelihood of undergoing angioplasty or bypass surgery, two procedures that can often extend life.
A blue ribbon panel of national experts was commissioned to oversee the quality improvements for VA's cardiac care program. Among the expected changes are the following: stricter adherence to national clinical guidelines, hiring more cardiologists, upgrading catheterization lab equipment, reconfiguring access to cardiac care (including expansion of community services), providing reimbursements for emergency care provided in non-VA settings, and conducting additional clinical research to discover the causal effects of VA's higher mortality statistics. All VA hospitals were required to provide detailed plans on how they intended to improve the quality of care at their facility.
The Department has started an independent evaluation of VA's oncology program, and a contract has been awarded. The program evaluation will focus on lung, colorectal, prostate, hematologic, and breast cancers. The results of the program evaluation will help VA determine how well it is meeting the oncology program goals and objectives and will provide a comparison of how VA is performing compared to the private sector. Patient-centered outcomes have been developed for each of the patient populations along a continuum of care from prevention - through screening, diagnosis, treatment, and palliative care. Additional research questions will focus on utilization, availability of services, access, pain management, quality of contracted care, costs, and enrollment in clinical trials. This evaluation is expected to be contracted to a firm in partnership with a university school of public health or medicine. The study will take approximately 2 years to complete.
New Policies and Procedures
Several new policies and procedures have been recently implemented that are related to Objective 3.1. Many others are either currently ongoing or are planned for the near future. For example, VA is:
- Continuing to lead the practice of patient safety initiatives through the establishment of an environment of nonpunitive reporting and by aggregating and disseminating information for improved safety performance.
- Implementing technology strategies to provide care in the least restrictive environments in order to allow patients and families maximum participation in disease management and health maintenance.
- Applying information technology and other technologies such as telehealth to streamline administrative, business, and care delivery processes in order to improve care provider and patient interface, minimize wait times, and reduce the incidence of errors.
- Implementing pay policies and human resource management practices to facilitate hiring and retaining sufficient health care workers to meet capacity demands across the full continuum of care.
- Creating the appropriate balance between demand and capacity through health care enrollment policies.
- Improving and enhancing home care services and developing an assisted living strategy, including partnering with community organizations.
- Continuing to work closely with DoD and other Federal agencies in such areas as interoperable computerized patient health data, improved data on insurance coverage, and enrollment and eligibility information in order to further the use of resources.
Objective 3.1 - Key Performance Goal: Achieve 70 percent on the Clinical Practice Guidelines Index
Clinical Practice Guidelines Index
2003 |
70% |
2004 Actual |
77%* |
2004 Plan |
70% |
2005 Plan |
71% |
Strategic Target |
80% |
* Actual data through June 2004. Final data will be available in November 2004. |
Description, Importance, and Results
One of VHA's primary quality measures is the Clinical Practice Guidelines Index, a composite measure comprised of the evidence and outcomes-based measures for high-prevalence and high-risk diseases that have significant impact on overall health status. The index is comprised of various indicators from several clinical practice guidelines including: ischemic heart disease, pneumonia, hypertension, heart failure, diabetes mellitus, major depressive disorder, substance abuse, and tobacco use cessation. The percent compliance is an average of the separate indicators. To ensure the highest quality of care possible, VHA systematically measures and communicates the outcomes and quality of care. This index reflects a change from those individual indicators that have shown sustained improvement over time and adds new indicators that allow VHA to be transformative in its drive to continuously improve care. We have achieved a score of 77 percent on the index as of June 2004. VA has continued to improve compliance on the index each year.
Management and Policy Issues
VA's primary strategies to achieve this performance goal include promoting timely and equitable access to health care; continuously improving the quality and safety of health care; emphasizing patient-centered care, especially for our most vulnerable patients; proactively inviting and acting on complaints and suggestions; and equipping patients and staff with practical health information. We will identify high-quality evidence-based medical care and will use interactive technology strategies to provide care in the least restrictive environments to allow patients and families maximum participation in disease management and health maintenance. VA will continue to implement the HealtheVet initiative with automated practice guidelines, clinical reminders, and care management tools to support shared decision-making and patient empowerment. Finally, VA will continue working with DoD to implement and refine clinical practice guidelines.
Data Quality
Please refer to the Key Measures Data Table.
Objective 3.1 - Key Performance Goal: Achieve 82 percent on the Prevention Index II.
Prevention Index II
2001 |
80% |
2002 |
82% |
2003 |
83% |
2004 Actual |
88%* |
2004 Plan |
82% |
2005 Plan |
84% |
Strategic Target |
85% |
* Actual data through June 2004. Final data will be available in November 2004. |
Description, Importance, and Results
One of VHA's primary quality measures is the Prevention Index (PI) II, a composite measure comprised of the interventions that help to improve the overall health status of veterans through early detection of certain common diseases or health factors. The PI II Index includes nationally recognized primary prevention and early detection recommendations for nine diseases or health factors that significantly determine health outcomes including: rate of immunizations for influenza and pneumococcal pneumonia and screening for tobacco consumption, alcohol abuse, breast cancer, cervical cancer, colorectal cancer, prostate cancer education, and cholesterol levels. To ensure the highest quality of care possible, VHA systematically measures and communicates the outcomes and quality of care. This index reflects a change from those individual indicators that have shown sustained improvement over time and adds new indicators that allow VHA to be transformative in its drive to continuously improve care. We have achieved a score of 88 percent on the Prevention Index II as of June 2004. VA has continued to improve compliance on the index each year.
Management and Policy Issues
VA's primary strategies to achieve this performance goal include promoting timely and equitable access to health care; continuously improving the quality and safety of health care; emphasizing patient-centered care, especially for our most vulnerable patients; proactively inviting and acting on complaints and suggestions; and equipping patients and staff with practical health information. We will identify high-quality evidence-based medical care. We will lead the advancement of knowledge and the practice of patient safety initiatives through the establishment of an environment of nonpunitive reporting and through aggregating and disseminating information for improved safety performance. VA ensures the consistent delivery of health care by implementing standard measures for the provision of preventive care. The prevention measure includes several indicators that allow comparison of VA and private health care outcomes.
Data Quality
Please refer to the Key Measures Data Table.
Objective 3.1 - Key Performance Goal: Achieve 93 percent of primary care appointments scheduled within 30 days of desired date.
Percent of Primary Care Appointments Scheduled within 30 Days of Desired Date
2001 |
87% |
2002 |
89% |
2003 |
93% |
2004 Actual |
94%* |
2004 Plan |
93% |
2005 Plan |
93% |
Strategic Target |
90% |
* Actual data through June 2004. Final data will be available in November 2004. |
Description, Importance, and Results
VHA is working to improve access to clinic appointments and timeliness of service. Through the Advanced Clinic Access initiative, we continue efforts to develop ways to reduce waiting times for appointments in primary care and key specialty clinics nationwide. Past experience in measuring access has led to the development of a number of new access measures including this one that will provide even more detail regarding waiting times for new patients and for specialty clinic appointments. This measure tracks the time between when the primary care appointment request is made (entered into the computer) and the date for which the appointment is actually scheduled. The percent is calculated using the numerator - appointments scheduled within 30 days of desired date (includes both new and established patient experiences) - and the denominator - all appointments in primary care clinics posted in the scheduling software during the review period. We have achieved a score of 94 percent of primary care appointments scheduled within 30 days of desired date as of June 2004. VA has continued to improve access to primary care each year.
Management and Policy Issues
VA's primary strategies to achieve this performance goal include promoting timely and equitable access to health care; continuously improving the quality and safety of health care; emphasizing patient-centered care, especially for our most vulnerable patients; proactively inviting and acting on complaints and suggestions; and equipping patients and staff with practical health information. VHA will continue to redesign health care systems to streamline work and promulgate improved health care practices. Strategies similar to those developed by the Institute for Health Care Improvement, such as open access and group visits, with workload management in all specialties will be implemented. VA will implement pay policies and HR practices to facilitate hiring and retaining a sufficient number of health care workers to meet capacity demands across the full continuum of care. Balance between demand and capacity will be achieved through enrollment policies. VA will work with state agencies, especially in long-term care services, to reduce the redundancies and gaps in veterans' services.
Data Quality
Please refer to the Key Measures Data Table.
Objective 3.1 - Key Performance Goal: Achieve 90 percent of specialty care appointments scheduled within 30 days of desired date.
Percent of Specialist Appointments Scheduled within 30 Days of Desired Date
2001 |
84% |
2002 |
86% |
2003 |
89% |
2004 Actual |
93%* |
2004 Plan |
90% |
2005 Plan |
90% |
Strategic Target |
90% |
* Actual data through June 2004. Final data will be available in November 2004. |
Description, Importance, and Results
VHA is working to improve access to clinic appointments and timeliness of service. Through the Advanced Clinic Access initiative, we continue efforts to develop ways to reduce waiting times for appointments in primary care and key specialty clinics nationwide. Past experience in measuring access has led to the development of a number of new access measures including this one that will provide even more detail regarding waiting times for new and established patients for specialty clinic appointments. This measure tracks the number of days between when the specialty appointment request is made (entered into the computer) and the date for which the appointment is actually scheduled. This includes both new and established specialty care patients. The percent is calculated using the numerator - all appointments scheduled within 30 days of desired date - and the denominator - all appointments posted in the scheduling software during the review period in selected high volume/key specialty clinics. We have achieved a score of 93 percent of selected specialty care appointments scheduled within 30 days of desired date as of June 2004. VA has continued to improve access to specialty care each year.
Management and Policy Issues
VA's primary strategies to achieve this performance goal include promoting timely and equitable access to health care; continuously improving the quality and safety of health care; emphasizing patient-centered care, especially for our most vulnerable patients; proactively inviting and acting on complaints and suggestions; and equipping patients and staff with practical health information. VHA will continue to redesign health care systems to streamline work and promulgate improved health care practices. Strategies similar to those developed by the Institute for Health Care Improvement, such as open access and group visits, with workload management in all specialties will be implemented. VA will implement pay policies and HR practices to facilitate hiring and retaining a sufficient number of health care workers to meet capacity demands across the full continuum of care. Balance between demand and capacity will be achieved through enrollment policies. VA will work with state agencies, especially in long-term care services, to reduce the redundancies and gaps in veterans' services.
Data Quality
Please refer to the Key Measures Data Table.
Objective 3.1 - Key Performance Goal: Achieve patient satisfaction rating of 70 percent for inpatient and 72 percent for outpatient
Percent of Patients Who Rate VA Health Care Service as Very Good or Excellent
|
Inpatient |
Outpatient |
2000 |
66% |
64% |
2001 |
64% |
65% |
2002 |
70% |
71% |
2003 |
74% |
73% |
2004 Actual |
74%* |
72%* |
2004 Plan |
70% |
72% |
2005 Plan |
71% |
73% |
Strategic Target |
72% |
72% |
* Actual data through March 2004. Final data will be available in November 2004. |
Description, Importance, and Results
VA relies on periodic feedback obtained through surveys as to the level of veterans' satisfaction with service. VHA's Office of Quality and Performance, Performance Analysis Center for Excellence, conducts national satisfaction surveys that allow VHA to better understand and meet patient expectations. The monthly surveys target the dimensions of care that concern veterans the most. The survey consists of a sample of inpatients and outpatients who respond to the question, "Overall, how would you rate your quality of care?" The satisfaction rating includes those patients who respond "very good" or "excellent." We have achieved a score of 74 percent for inpatient satisfaction and 72 percent for outpatient satisfaction through March.
Management and Policy Issues
VA's primary strategies to achieve this performance goal include promoting timely and equitable access to health care; continuously improving the quality and safety of health care; emphasizing patient-centered care, especially for our most vulnerable patients; proactively inviting and acting on complaints and suggestions; and equipping patients and staff with practical health information. VA has implemented "service-recovery" with standardized patient satisfaction surveys with real-time results and data aggregation and reporting. VHA will continue to strive to improve patient satisfaction in all areas of service. Surveys are sent to patients who have received care in both inpatient and outpatient settings. Veteran satisfaction will continue to be benchmarked to other large organizations. The inpatient and outpatient survey, the Survey of Health Expectations of Patients, incorporates a sample methodology that allows for monthly data collection with quarterly (outpatient) and semi-annually (inpatient) reporting functions. The VA health care environment will be characterized by courteous and coordinated patient-focused services. VHA will continually assess and improve patients' perceptions of their health care.
Data Quality
Please refer to the Key Measures Data Table.
Objective 3.1 - Key Performance Goal: Increase to 29,631 the average daily census in long-term care in non-institutional settings.
Increase Non-institutional Long-Term Care as Expressed by Average Daily Census
2002 |
24,126 |
2003 |
24,413 |
2004 Actual |
29,631* |
2004 Plan |
29,631 |
2005 Plan |
36,524 |
Strategic Target |
35,271 |
* Estimated actual. Final data will be available in November 2004. |
Description, Importance, and Results
This measure concerns the average daily census (ADC) of veterans enrolled in home and community-based care programs (Home-Based Primary Care, Contract Home Health Care, Adult Day Health Care (VA and Contract), Care Coordination and Homemaker/Home Health Aide Services). In June 2002, VHA published a comprehensive policy document on oversight of Community Nursing Homes (CNHs) that established a national standard for annual reviews of CNHs and monthly visits by VA staff to patients in these homes. This is being certified at a national level. VHA implemented a 25-point plan to further refine its oversight efforts of the community nursing home programs in FY 2004. VA has continued to increase the number of long-term care patients in noninstitutional settings each year.
Management and Policy Issues
VA's primary strategies to achieve this performance goal include promoting timely and equitable access to health care; continuously improving the quality and safety of health care; emphasizing patient-centered care, especially for our most vulnerable patients; proactively inviting and acting on complaints and suggestions; and equipping patients and staff with practical health information. VHA will improve and enhance home care services and continue to refine an assisted living strategy including partnering with community organizations. We will promote the use of care management to facilitate care in the least restrictive and most efficient setting possible. In the face of a declining, but aging veteran population, VA will expand access to long-term care alternatives to institutional care with an emphasis on community-based and in-home care. VA is in the process of establishing a Care Coordination program in every VISN that will allow many veterans to be monitored in their home. The success of achieving this performance goal will partially depend on the availability of community resources that can provide long-term care.
Data Quality
Please refer to the Key Measures Data Table.
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