+ VA H EALTHCARE : SCANDAL, GREATNESS AND BACK AGAIN Key lessons learned, and relevance to the NHS Ashish K. Jha, MD, MPH December 2, 2014

+ Goals Basic background on the VA The VA story for change VA as a model for improvement Decentralization of decision making Performance measurement Health Information Technology Visionary leadership What went wrong? How the VA can turn things around

+ History of the VA Continental Congress of 1776 Authorizes pensions for disability in the revolutionary war Veterans Administration established 1930 Department of Veterans Affairs in 1989 Achieves cabinet level status

+ The VA 6 million patients receive at least some care in the VA Out of 26 million living veterans in the U.S. Who is eligible for VA care? Service-connected (service-related health conditions) Prisoners of War or recipients of the Purple Heart Poor (for a family of 4, <$35K in annual income)

+ Who receives care in the VA system? They are old: 40% are > 65 years old They are poor: 70% have annual incomes <$26,000 Median family income in US is $51,000 They are generally sick: Compared to age-matched Americans, they have 3 additional non-Mental Health Diagnoses 1 additional Mental Health Diagnosis

+ VA Facilities: Some Basics 1400 Sites of Care 153 Medical Centers 768 Community-based outpatient clinics 135 Nursing Homes 254,000 employees 19,000 doctors (about 3% of all physicians) 50,000 nurses

+ VA Background Perceptions of poor quality Widely depicted as having poor quality doctors, nurses Long wait times High mortality rates Congress considered closing VA hospitals Mid-1990s: Transformation is launched Decentralization Data collection and feedback Performance measurement Accountability Electronic Information Systems

+ VA Transformation: Element #1 Decentralization Nation split into 22 regions based on referral patterns Each region had a director who was given a budget All major clinical decisions were to be made locally

+ The VA

+ VA Transformation: Element #2 Performance measurement & accountability Key quality metrics chosen based on clinical priority Targets set in Washington DC with input from clinicians Contracts with local leadership, salary tied to performance Peer-pressure and competition

+ VA Transformation: Element #3 Data collection / feedback Independent outside entity collects quality data Data reported back to facility every 3 months Opportunities for review, correction of errors, etc.

+ VA Transformation: Element #4 Health Information Technology Electronic Health Record rolled out across the VA Computerized physician order entry a priority Clinical Decision Support such as clinical reminders

+ The Impact of VA Transformation Source: Jha et al., NEJM 2003 Preventive Care p-value Mammography 64%90%<0.001 Influenza vaccine 28%78%<0.001 Pneumococcal vaccine 27%81%<0.001 Colon cancer screen 33%68%<0.001 Cervical cancer screen 62%93%<0.001 Preventive Care p-value Mammography 64%90%<0.001 Influenza vaccine 28%78%<0.001 Pneumococcal vaccine 27%81%<0.001 Colon cancer screen 33%68%<0.001 Cervical cancer screen 62%93%<0.001

+ The Impact of VA Transformation Chronic Care Diabetes: Annual HbA1c51%94% Diabetes: Eye exam48%67% Hypertension Control25%46% Source: Jha et al., NEJM 2003 Chronic Care Diabetes: Annual HbA1c51%94% Diabetes: Eye exam48%67% Hypertension Control25%46%

+ VA versus Traditional Medicare VA 2000 Medicare Prevention Mammography90%77% Influenza vaccine78%71% Pneumococcal vaccine 81%64% Diabetes Annual Hb A1c94%70% Annual eye exam67%74% Bi-annual Lipid screen89%60% Source: Jha et al., NEJM 2003 VA 2000 Medicare Prevention Mammography90%77% Influenza vaccine78%71% Pneumococcal vaccine 81%64% Diabetes Annual Hb A1c94%70% Annual eye exam67%74% Bi-annual Lipid screen89%60%

+ VA versus Traditional Medicare VA 2000 Medicare Acute Myocardial Infarction Aspirin within 24 hours 93%84% Aspirin at discharge 98%84% ß-blocker at discharge 95%78% CHF Smoking cessation 62%38% Ejection fraction checked 94%71% ACE-I if EF < 40% 93%66% Source: Jha et al., NEJM 2003

+ VA versus U.S.: Ambulatory Care VA 2007 BRFSS/HEDIS 2006 Prevention Mammography 86%80% Influenza vaccine 72%70% Pneumococcal vaccine 90%67% Diabetes Annual HbA1c 97%88% Annual Eye Exam 85%62%

+ VA versus U.S.: Inpatient Care VA 2007 U.S Acute MI ASA within 24 hours 97%93% ß-blocker at discharge 98%92% CHF ACE-I if EF <40% 89%82% Smoking Cessation 93%83% Pneumonia Pneumococcal Vaccine 96%71% Antibiotics within 4 hours 81%80%

+ Lessons from the VA Reform must encompass multiple actions at once Any single activity likely inadequate Focus on high value conditions, prevention, safety Critical for ensuring patient trust in the system Hold senior managers accountable Focus on a robust information system

+ And the VA declared victory…. “Best Care Anywhere” “High quality VA is the model for the nation” And so on And yet….

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+ What went wrong? Culture of satisfaction with success “Best Care Anywhere” Insularity Most of the leadership from within the VA

+ What went wrong? If performance measurement works, then… Mid-1990s: measures Mid-2000s: 150+ measures 2010: 250+ measures Bureaucratic bloat: 2000: 800 central office staff 2012: 11,000 central office staff

+ And the evidence was building Anecodotes about PMs leading to bad care Stories about data falsification Concerns about transparency and openness

+ VA versus U.S.: Readmissions

+ So what’s the big lesson?

+ It isn’t about the what…but how Performance measures are powerful But wrong measures can be a distraction Incentives can change behavior, and culture critical But powerful incentives, in wrong culture, create gaming Information technology is an enabler IT can be manipulated and used to hide bad actions

+ How does the VA recover? By placing competence over ideology Focusing on what matters Limit the number of performance measures Focus on outputs, not inputs Health of the population Be more creative with IT Focus less on # of doctors, nurses Bring in more people from the outside Openness and transparency Sunshine is the best disinfectant

+ Final thoughts Reform is never a one step process One is never done Failures are part of the process If you aren’t failing, you aren’t trying Keep the eyes on the prize Focus on what matters And try to focus on only what matters

+ The End Thank you Happy to take questions