Published on February 20, 2014
Healthcare Executive Circle 6 February 2014 Health Quality Journey US Department of Veterans Affairs James B. Peake, M.D. Lieutenant General, USA (Ret) 6th Secretary of Veterans Affairs President, CGI Federal CGI
LONG & WINDING THE ROAD TO A QUALITY HEALTH SYSTEM
VA Major Business Lines FY12 Total VA Funding: $127 Billion National Cemetery Administration (NCA) •Memorials & Burials • Headstones & Markers • National Shrines • State Grants 4 Veterans Benefits Administration (VBA) • • • • • • Life Insurance Home Mortgage Education (G.I. Bill) Comp & Pension Vocational Rehab Employment Services Veterans Health Administration (VHA) • • • • • • • Primary/Specialty Care Long-Term Care Rehabilitative Care Health Promotion Mental Health Services Prosthetics Services Medical Research
Two GREAT Systems Two GREAT Missions HEALTH & FIT RETURN TO DUTY SPECIALIZED RECOVERY LONG TERM REHAB MILITARY HEALTH SYSTEM DEPT OF DEFENSE VETERANS HEALTH ADMIN DEPT OF VETERANS AFFAIRS
FY 2012 End-of-Year Totals Enrollees…………………………….…..…8.76 Million Unique Patients Treated……………........6.33 Million Outpatient Visits…………………………................83.6 Million Outpatient Surgeries…………………………………….292,500 Inpatient Admissions………………………………….…703,500 Lab Tests (Inpatient & Outpatient)…………....…268.3 Million Prescriptions Dispensed (30-Day Equivalent)…..266.2 Million Source: FY 2012 End-of-Year Pocket Card Prosthetic Services Performed………..…………..14.5 Million 7
VA’s Health Care Expertise VA is one of the largest civilian employers in the federal government and one of the largest health care employers in the world. 277,000+ Total VHA Employees 84,000+ Veteran Employees 21,000+ Physicians 67,000+ Nurses* 8 *Includes registered nurses, licensed practical nurses and licensed vocational nurses.
HARVARD . . . TO . . . CBO PREVENTION WELLNESS SURGICAL CARE PATIENT SATISFACTION EQUALITY OF CARE TECHNOLOGY INNOVATION January 2007
Hospital System to Health System In 1996, VA began the creation of Veterans Integrated Service Networks (VISNs). • 152 Medical Centers •990 Outpatient Clinics 821 Community-Based 152 Hospital-Based 11 Mobile 6 Independent • 300 Vet Centers • 70 Mobile Vet Centers • 102 Domiciliary Residential Rehabilitation Programs • 134 Community Living Centers 14 Source: FY 2012 End-of-Year Pocket Card
N Engl J Med 2003; 348:2218-2227, May 29, 2003
Community Based Outpatient Clinics (Cbocs) Shift To Ambulatory And Primary CareWith Mental HealthAugmented With Telemedicine The VA Southeast Network proudly serves veterans in the tri-state area which includes Alabama, Georgia, and South Carolina.
HOM E T O WN S
WOMEN’S HEALTH CLINIC
Better Access, Better Care Before After Hospital System Health System “Kizer had cut more than half of the 52,000 hospital beds in order to open 300 new community clinics, helping the agency treat 700,000 more Only patients.” Hospitals Vet Centers Hospitals Outpatient Clinics Mobile Clinics 20 Mobile Vet Centers My HealtheVet
PATIENT CENTERED MEDICAL HOME Continuity Through Team-based Care Patient Access to Care Care Management and Coordination Patient Partnership
Patient Centered Medical Home Patient Aligned Care Teams
The Evolution of VistA • 1977 – ANSI Standardization of MUMPS • 1977-78 – CASS – Computer Assisted System Staff • 1979-81 – Underground in the VA • 1981-82 Becoming “Legal” • Decentralized Hospital Computer Program – DHCP ‘82 VistA ‘94 24
VistA Value . Open Source Confidential 25
2009 VHA Quality and Safety Metrics Metric 2009 2008 Benchmark Unadjusted Mortality Acute Care 2.3% 3.0% No national benchmark; 2008 Kaiser-P study = 4.5% Unadjusted Mortality ICU 8.0% 8.0% No national number- 2008 Kaiser-P study = 8.9% (other studies up to 20% mortality) Catheter Line Associated Bacteremia (CLAB) 1.7/ 1000 Line days 2.15/ 1000 line days No national benchmark; recent Nosocomial Infections Survey. Rate approx. 1.8-2% Ventilator Associated Pneumonia (VAP) 2.46/1000 Vent days 3.42/ 1000 Vent days No benchmark; in Q1 2004, VHA = 8.8/1000 vent days (72% decrease) MRSA infections – Acute Care 0.37/ 1000 Bed days No Data No benchmark; in Oct 2007, VHA=0.53/1000 days (32% decrease) MRSA Infections – ICU 0.61/ 1000 Bed days No Data No benchmark; in Oct 2007, VHA=1.82/1000 days (67% decrease) MRSA Screening – ICU/ Acute Care 94%/ 93% No Data None 68% 57% Literature: approx 30-40% 76.3% 68.0% Literature: approx 30-40% 4.21 days 4.39 days DVT prevention (high risk, nonoperative, acute care) ICU non-operative DVT prevention Acute care Length of Stay Medicare average approx 4.9 days Areas in Green highlight substantial improvement 26
The Value Continues 2012 VA Average Percent (1) Clinical Indicator DELTA HEDIS 2011 (2) Commercial Medicare Medicaid 2012 (6) 2011 (6) 2010 (6) (7) (7) Breast Cancer Screening 87 85 87 71 69 50 Cervical Cancer Screening 93 93 94 77 n/a 67 Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Control (<100 mg/dL) 70 71 69 59 57 42 Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Screening 96 96 96 88 89 82 Colorectal Cancer Screening 82 82 82 62 60 n/a Comprehensive Diabetes Care - Blood Pressure Control (<140/90) 80 81 82 66 63 61 Comprehensive Diabetes Care - Eye Exams 90 90 91 57 66 53 98 99 90 91 83 Comprehensive Diabetes Care - HbA1c Testing Comprehensive Diabetes Care - LDL-C Controlled (LDL-C<100 mg/dL) 68 69 70 48 53 35 Comprehensive Diabetes Care - LDL-C Screening 97 97 97 85 88 75 Comprehensive Diabetes Care - Medical Attention for Nephropathy 95 95 96 84 90 78 Comprehensive Diabetes Care - Poor HbA1c Control (8) 19 17 15 28 27 43 Controlling High Blood Pressure - Total 77 78 79 65 64 57 Medical Assistance with Smoking Cessation - Advising Smokers To Quit 3 96 97 97 77 n/a 76 94 94 94 53 n/a 44 96 97 97 48 n/a 40 Flu Shots for Adults (50-64) 3 65 65 71 53 na n/a Flu Shots for Adults (65 and older) 3, 4, 5 76 79 82 n/a 69 n/a Immunizations: Pneumococcal 3,4, 5 93 94 95 n/a 69 n/a Medical Assistance with Smoking Cessation - Discussing Medications Medical Assistance with Smoking Cessation - Discussing Strategies 3 SOURCE: Office of Analytics and Business Intelligence Updated 11/28/2012 RAW % 16 16 23% 21% 11 19% 8 9% 20 14 33 8 32% 21% 58% 9% 20 42% 12 11 (9) 12 14% 13% -32% 18% 19 25% 41 77% 48 12 7 24 100% 23% 10% 35% (7)
Power of Information Knowledge Data Act Decisively TIME What we don’t know WILL hurt us!
State of the Union Address “…By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care”
The award cites VA's collaboration with the Department of Defense (DoD) on electronic medical records for patients receiving care from both departments. American Council For Technology . . . Excellence.Gov Award
System of Systems System of Systems PARADIGM SHIFT NTE GRAT ED FR O M C ON US T O THE F OXH OLE . . . INTEGRATED FROM FOX HOLE TO CONUS TO& E TO& E TDA TDA Res erv ee Res erv JJOINT OINT CARE IN THE AIR GERM ANY VA 68W/ 18D CO NU S B ASE AO In Theater Health Services Medical Centers, Scientific Expertise Forward Surgical Tm
WW II / Korea •Geriatric Care •End Of Life Vietnam Era •End Professional Life • Latent Medical Issues OIF / OEF •Early in Professional Life •Young Families •Reintegrating
Rich 85-Year Research History The groundbreaking achievements of VA researchers— 60% of whom also provide direct patient care—have resulted in 3 Nobel Prizes, 6 Lasker Awards, and numerous other distinctions. 36
Million Veteran Program (MVP) VA is partnering with Veterans to learn more about how genes affect health by establishing a program where Veterans can volunteer to link their DNA with their health information. Over the next 5 to 7 years, the MVP database is expected to develop new knowledge that may eventually lead to better treatments and preventive measures for many diseases, including common illnesses such as heart disease, diabetes, and cancer. 37
Veterans Give High Marks to VA Pharmacies J.D. Power and Associates, a firm specializing in consumer surveys, recognized VA’s Consolidated Mail Outpatient Pharmacy as “Among the Best” mail order systems in the country in 2009, 2010, 2011 and 2012. VA ships 460,000 prescriptions to Veterans every workday. 38
Evolution of Bar Code Medication Administration (BCMA) within the Department of Veterans Affairs. Coyle GA, Heinen M. Abstract The Department of Veterans Affairs Medical Center implemented Bar Code Medication Administration (BCMA) between 1999 and 2000 in 161 Medical Centers or Health Systems….Nurses have moved from manual to electronic medication documentation … A marked decrease in medication administration errors is a result of implementing BCMA. Nurse Admin Q. 2005 Jan-Mar;29(1):32-8
PATIENT’S HOME Adam Darkins
Increasing Access to Care via Telehealth Since FY 2009, Telehealth funding has increased by 368% to $334.8M. In 2012, VA’s Telehealth programs: • Provided care to half a million Veterans • Provided 1,429,424 episodes of care • Supported 42,699 patients to live independently in their own homes, instead of long-term institutional care 41
My HealtheVet A personal My HealtheVet account provides Veterans with 24/7 online access to a variety of tools to manage their health care. Communicate View with Participating Appointments and Patient Aligned Health Information Care Team Members 44 Refill Prescriptions Download and Share Personal Health Record
Expanding On-the-Go Resources The “PTSD Coach” mobile app is one of the first in a series of VA and DoD jointly-designed resources to help Servicemembers and Veterans manage their readjustment challenges and get anonymous assistance. 90,000 Downloads via + iTunes and Android Market 45
Simulated Learning VA is expanding simulated learning programs so training can be held in a safe and protective environment. This provides practitioners the opportunity to master skills, practice protocols, learn systems-based practices, apply critical decision making, and promote improved team communications and function. 47
American College of Surgeons 2001 National Surgical Quality Improvement Program (NSQIP) 1994 Today: 9 of VA top 10 of 1991 to 2006: thehospitals: America’s • 47 percent drop World Report U.S. News & in postoperative mortality Best Hospitals participate in ACS • 43 percent drop in morbidity rates. NSQIP National VA Surgical Risk Study (NVASRS) 1991 - 1993
Recognition Continues 51 2012 The Joint Commission Accreditation & Top Performers Award. All VA medical centers are accredited by The Joint Commission. In addition, The Joint Commission recognized nineteen medical centers as Top Performers on Key Quality Measures. 2012 ATA President’s Award for Innovation. The VA/DoD Post-traumatic Stress Disorder (PTSD) coach mobile application marked its first anniversary with receipt of an award for innovation in the advancement of telemedicine from the American Telemedicine Association. 2012 Fed Innovation of the Year Award. FedScoop honored the VA Blue Button initiative with an award that celebrates a new innovation that increases accessibility to a federal service and allows citizens to more easily interact with government. 2011 Innovations in American Government Award. Harvard University selected VHA’s IntegratedEthics program, a program which handles ethic issues affecting VHA patients, as one of the “Top 25 Programs” in the 2011 Innovations in American Government Award competition. 2011 Global Vision Award. The National Hospice Foundation presented its Global Vision Award to VHA for its groundbreaking efforts to improve end-of-life care for all Veterans through the We Honor Veterans Campaign.
JOURNEY Hospitals to Health System In-Patient to Ambulatory CBOCs to PACTs Ambulatory to Home Home to Personal Devices Technology Adoption Quality Measurement Information Ubiquity
The VA Quality Journey… Still Evolving… Still Changing… It Must .. And So Must YOURS
Health Quality Journey US Department of Veterans Affairs THANK YOU Healthcare Executive Circle
Calcification Inhibitors in CKD and Dialysis Patients
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