# Presentation: 772446

## Using Performance Measurement to Create an Organizational Culture of Quality

- Lynnette Nilan, RN MN EdD(c)
- Director, Performance Management
- Office of Quality and Performance
- Veterans Health Administration

## Background – VHA Performance Measurement

- 1994 – criticism of inconsistent healthcare quality and economic efficiency
- In era of ‘balanced budget’ was the VHA worth receiving the taxpayer dollar
- Heartfelt mission to care for nation’s veterans

## Driving Change

-  It is believed the improvement gained will, over time, become institutionalized.

## Goals of Performance Measurement

- Decrease variation in practices & increase possibility for achieving consistent outcomes across the organization
- PROVE quality and efficacy of care delivery
- Continuous Improvement

## Characteristics

- Consistent with the VA & VHA Strategic Plan
- Grounded  in ‘evidence-based’ medical practice or management theory
- Explicit accountability for performance

## Supports Strategic Plan

- Provides balanced approach
- Organized around ‘Domains of Value’
- Quality of Care
- Access to Care
- Patient Functional Status
- Cost of Care
- Patient Satisfaction
- Building Healthy Communities

## Supports Strategic Plan

- Plus – Employer of Choice
- High Performance Development Model
- Succession Planning/Diversity
- Employee education
- Employee Satisfaction (including occupational health and stress/violence in the workplace)

## Setting Annual Targets 

- Drive for excellence goals are set against what has already been achieved, not just the “average”
- Use of comparative data
- Normative sources, e.g US Healthy People 2010 Goals, “Society” recommendations, etc

## Implementation Strategies (ECF)

- Think Globally, Act Locally
- Outline of expectations
- Performance Plan
- Technical Manual
- Abstraction - Collection logic
- Frequent, accurate and useful feedback at all levels of the organization
- Individual patient report
- Aggregate results – exit conference
- Timely Network and Facility reports

## Implementation Strategies (cont.)

- Devise mechanisms that promote a systematic change in processes of care delivery and business operations – Prevent gaming
- Non-replacement sampling where possible
- Non-acceptance of care given after pull list date
- Where possible, devise management reports/patient locators
- Build in quality –
- Electronic medical record
- Electronic “Administrative” abstraction/collection
- Use clinical reminders / electronic entry & capture

## Implementation Strategies (cont.)

- National committee responsible for development of annual plan and approval of all ‘measures’
- _Performance Management Work Group_
- Membership consists of field based clinicians and administrators
- Template for Indicator development
- Criteria for ‘levels’ of indicators
- Information only, supporting indicator or measure
- Criteria for selection/de-selection of a measure

## Dissemination of Information

-   Distribution through Email groups and Web
- Performance Plan
- Technical manual (s)
- Criteria set questions
- Reports
- FAQ
-   Monthly PM conference call
-   Quarterly meetings with Network Quality                             Management Officers

## Explicit Accountability for Performance

- Vision/commitment of leadership
- Willingness to set high standards
- Willingness to ‘look’ bad (at first!!)
- Accountability
- Sometimes uncomfortable
- Unquestionably helpful
- Has speeded process

## Accountability Continuum

- Accountability Continuum

- From: “The Accountability Revolution” by Mark Samuel

## Committed to the success of:

- Entitlement – “no true commitment”
- Individual  - MY JOB
- Work Unit – MY TEAM
- Cross-Functional –OUR TEAMS
- Organizational – OUR ORGANIZATION

- From: “The Accountability Revolution” by Mark Samuel

## Accountability

- Accountability involves each individual in the organization regardless of position or function.  We all must keep our commitments to perform, our agreements to sustain effective team relationships, and our level of effort given to support others when support is requested or required.

## The confidence that we can count on each other during rough times is what helps us get through the rough times.

- Accountability

## Results

## Slide 19

**Notes:**
Another Publication: 
 “Hospital Use and Survival among Veterans Affairs Beneficiaries”
  Ashton, C.M., et al, N. Eng. J. Med., October 23, 2003

 Rates of urgent care visits fell by 35 percent
  No increase in Medicare-reimbursed non-VA hospital care by veterans eligible for both VA care and Medicare
  The survival rates were essentially unchanged over the study period. 

## British Medical Journal   Dec 2003

## VA's Performance Compared to Non VA

|   |  |   |   |   |   |   |
| --- | --- | --- | --- | --- | --- | --- |
|   | CLINICAL PERFORMANCE INDICATOR | VA FY 2004 Qtr4 (1) | HEDIS (2)   Commercial 2003 | HEDIS (2)           Medicare 2003 | HEDIS (2)              Medicaid 2003 |   |
|   | Breast cancer screening | 84% | 75% | 74% | 56% |   |
|   | Cervical cancer screening  | 90% | 82% | Not Reported | 64% |   |
|   | Colorectal cancer screening | 74% | 47% | 50% | Not Reported |   |
|   | LDL Cholesterol < 100 after AMI, PTCA, CABG | Not Reported (3) | 48% | 50% | 27% |   |
|   | LDL Cholesterol < 130 after AMI, PTCA, CABG | Not Reported (3) | 65% | 67% | 39% |   |
|   | Beta blocker on discharge after AMI | 98% | 94% | 93% | 84% |   |
|   | Diabetes: HgbA1c done past year | 95% | 85% | 88% | 75% |   |
|   | Diabetes: Poor control HbA1c > 9.0% (lower is better) | 16% | 32% | 24% | 49% |   |
|   | Diabetes: Cholesterol (LDL-C) Screening | 96% | 88% | 91% | 76% |   |
|   | Diabetes: Cholesterol (LDL-C) controlled (<100)  | 55% | 35% | 42% | 28% |   |
|   | Diabetes: Cholesterol (LDL-C) controlled (<130)  | 80% | 60% | 68% | 48% |   |
|   | Diabetes: Eye Exam   | 76% | 49% | 65% | 45% |   |
|   | Diabetes: Renal Exam   | 69% | 48% | 54% | 44% |   |
|   | Hypertension: BP <= 140/90 most recent visit  | 76% | 62% | 61% | 59% |   |
|   | Follow-up after Hospitalization for Mental Illness (30 days) | 77% (4) | 74% | 60% | 56% |   |
|   | CLINICAL PERFORMANCE INDICATOR | VA FY 2004 | HEDIS (2)   Commercial 2003 | HEDIS (2)           Medicare 2003 | BRFSS (5) 2003 |   |
|   | Immunizations: influenza, (note patients age groups) (6) | 81%                                  (65 and older) | 48%                                (50-64) | 75%                          (65 and older) | 70%                                    (65 and older) |   |
|   | Immunizations: pneumococcal, patients 65 and older (6) | 92% | Not Reported | Not Reported | 65% |   |

|   |
| --- |

**VA's Performance Compared to Non VA**

- From Closing the Gap . . .To Leading the Pack

## VHA ORYX Quality Report Comparisons – April 2005

## OQP Web for Information

- _[http://vaww.oqp.med.va.gov](http://vaww.oqp.med.va.gov/)__ _

- Reports
- CPG
- Tech Manual
- Plans
- Minutes
- Q&A

## In summary

- Take the first step....Life Is Not a Randomized Controlled Trial...
- Coordinate and communicate through all levels of the organization
- Work as a team

## Questions?

## Back to Work!