1. 1 Wins, Losses, Errors and Ties Quality Improvement in the VA 1994 to 2004 Lisa V. Rubenstein, MD, MSPH

2. 2 Overview: The VA As a National Demonstration Project  How has VA care changed, 1994 – 2004? (Rubenstein)  What is the evidence for improvement?  Primary care (Yano)  Computerization (Doebbeling)  Cardiovascular disease (Petersen)  Overall quality measures (Asch)  Commentary (Brook)

3. 3 The VA Before 1994  Primary care was illegal  Most outpatient care in specialty and walk- in clinics (“triage”)  System resources concentrated in northern academic centers  Quality of care complaints from veterans and congress common  Roosevelt Commission

4. 4 VA Health Services Research/Clinical Partnership  VA HSR investment 1970’s--  Centers of Excellence and Resource Centers  HSR-based initiatives  Resources matched to patients (VERA)  Primary care initiative  Computer medical record  Performance monitoring  Quality Enhancement and Research Initiative (QUERI)

5. 5 Computer Medical Record  Implementation of the computer medical record –Reminders –Regional data warehouses –Clinician order entry –Computer medical record (CPRS) –Healthe Vet will be interactive with patients –Cost accounting system

6. 6 Performance Measures  Medical Center and VISN Directors Paid for Performance since 1995  Office of Quality and Performance –Patient satisfaction surveys (Picker- Commonwealth) –Medical record review (External Peer Review Program)