# Presentation: 045181

## High Performance Healthcare:Mission, Strategy, & Measurement

**Jonathan B. Perlin, MD, PhD, MSHA, FACP**
- Chief Quality and Performance Officer
- 	&
**Thomas J. Hogan**
- Director, Management Support Office
- Veterans Health Administration
- Department of Veterans Affairs

*OPM Strategic Compensation Conference*
*August, 2001*

## “High Performance Organizations”

**HPO’s are outcomes oriented.  The *****desired outcomes are****** ******clearly delineated*****, and the organization actively and *****continuously assesses its performance***** based on outcomes.  In addition, HPO’s *****are customer-focused*****.**

- Michael Edmond, MD, MPH,
*ACPE Click;*9/2000:www.acpe.org/Click/

## . . . Abraham Lincoln

**. . . Abraham Lincoln**

**To Care for Him Who Shall Have Borne the Battle , and for His Widow , and His Orphan . . .**

- Mission

## Mission Assumptions

_*Effective*_ in serving Veterans health & social needs
- Multiple Stakeholders including:
- Executive & Legislative Branches of Federal Government
- Veteran Service Organizations
- Community (including govt), Healthcare Community, Business (Academic) Partners
- Fellow Employees

**   ****VHA  STRATEGIC TARGETS &**
**      ****PERFORMANCE MEASURES**

## Mission drives strategy
Strategy drives measures 
Measures drive change

- Strategy drives measures
- Measures drive change

- Mission Guides Strategy:Strategic Goal Areas

## Strategic Realities:Planning Assumptions

- Good Management ( and Resource Constraints ) Compel Difficult Questions
- Compel Accountability for Performance and VALUE
- Is VA Care Valuable?
- Does VA Provide Quality? Satisfaction? Access? Safety?
- Is Care Cost-Effective?
- Is there ( Unacceptable ) Variability?
- How would we know ( prove ) these things?
- How do we measure and manage to create and demonstrate (Health Care) VALUE?

- In God We Trust

- All Others Bring Data

## Value   =    QUALITY 

**Value  **** ****=   **_** QUALITY**__** **_
-         **Cost**

- Challenge:  Create Value
- For Veterans and America

**Value  **** ****=   **_** OUTCOMES**__** **_
-         **Cost**

## Measuring VAlueWhere the Rubber Hits the Road

- VHA “Domains-of-Value” = Strategic Goal Areas
- Quality
- Access
- Community Health

- Satisfaction
- Functional Status
- Cost-Effectiveness

- Provide _*consistently*_ reliable, accessible, satisfying, high-quality care which maximizes functional status, is cost-effective and fosters healthy communities . . .

**Challenge:  To Create & Communicate VALUE**
**Value = **_** **__**Access + Technical + Functional + Satisfaction + Community Health**__** **_
-   Cost

## Variation Also Occurs at the Facility, Clinic & Practitioner Level

-  after DA Burnett, ©UHC, 1995

**Positive Variation**

**Negative Variation**

## Variation Also Occurs at the Facility, Clinic & Practitioner Level

-  after DA Burnett, ©UHC, 1995

**Reasonable Expectation**

**Unfortunate Experience**

## Variation Also Occurs at the Facility, Clinic & Practitioner Level

-  after DA Burnett, ©UHC, 1995

**Justifiable**

**Unjustifiable**

## Variation Also Occurs at the Facility, Clinic & Practitioner Level

-  after DA Burnett, ©UHC, 1995

**How do we capture and**
**systematize *****best practices*****?**

**How do we drive these practices**
**to be more like those above?**

**How do we know **
**– ****throughout VHA – **
**how we’re doing?**

## What’s Wrong With Variation?

- Not All Variation is Positive
- Inconsistent Quality
- Inconsistent Cost (Efficiency)
- Inconsistent Access
- Inconsistent Satisfaction
- Inconsistent Outcomes reflect inconsistent processes
- Sub-optimal outcomes reflect sub-optimal processes
- A.K.A.  *The Quality Chasm*

## So, Who is VA, VHA?Veterans Health Administration

- Agency of the Department of Veterans Affairs
- Veterans Benefits Administration
- National Cemetery Administration
- Almost 4 million patients, ~ 5 million enrollees
- ~ 1,300 Sites-of-Care, including > 170 medical centers or hospitals, > 600 clinics, long-term care, domiciliaries, home-care programs
- ~ $21 Billion budget (flat at ~ $19B from 1995 - 1999)
- 180,000 FTEE (~15,000 MD , 30,000 RN)
- Affiliations with 107 Academic Health Systems
- 60% US health professionals with some training in VA
- Separate $1B Research Budget; focus on human DZ / HSR

##  A “New VA?”
... Back to the Data

*** ******A “New VA?”***
***... ******Back to the Data***

- Quality   Access   Satisfaction

- Functional Status    Efficiency   Community Health

## Vaccine Cuts Pneumonia Risk in High-Risk PatientsArchives of Internal Medicine 1999;159:2437-2442Dr. Kristin Nichol, VAMC / Minneapolis 

- 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine.
- VAMC study of 1,900 elderly patients with chronic lung disease; **2/3** vaccinated against pneumonia.
- Pneumococcal vaccination:
- 43% reduction in hospitalizations for pneumonia and influenza, and a 29% reduction in the risk of death.
- Pneumonia and Influenza vaccination:
- 72% reduction in hospitalizations for these two diseases and an   82% reduction in deaths from all causes.
- Pneumococcal vaccination saved an average of $294 per vaccine recipient over the 2-year period.

## Pneumococcal Vaccination Rates

- * Iowa: Petersen, *Med Care* 1999;37:502-9. >65/ch dz

## Slide 19

## Quality:Influenza Vaccination Rates

## Quality:  Gender / Age Approp CareBreast CA   &  Cervical CA Screen

## Quality:Diabetes Measures

- Sawin CT, Walder DJ, Bross DS, Pogach LM, “Diabetes process and outcome measures in the VHA,” *Diabetes Care*, 1999

- Age-Standardized Amputation Rates have decreased 12% . . . And may be National Benchmark

## Survival after MISoumerai SB  "Adverse Outcomes of Underuse of Beta Blockers in Elderly Survivors of Acute Myocardial Infarction," JAMA 1997; 277(2):115-21 

**Elderly patients who receive beta blockers following a heart attack are 43 percent less likely to die in the first 2 years** following the attack than patients who do not receive this drug, according to a new study funded by the Agency for Health Care Policy and Research (AHCPR), published in the January 8 issue of *The Journal of the American Medical Association* (JAMA).
- The study found that patients who receive beta blockers are **rehospitalized for heart ailments 22 percent less often** than those who do not get beta blockers. However, **only 21 percent of eligible patients receive beta blocker therapy**.
- Researchers found that these patients were almost three times as likely to receive a new prescription for a calcium channel blocker than for a beta blocker after their AMI. Eligible patients receiving calcium channel blockers instead of beta blockers doubled their risk of death.

## Beta Blocker following AMIin VHA Medical Centers

- AHCPR: Soumerai *et al. JAMA* 1997;277(2):115-21
- Non-Govt:  Krumholz HM *et al. Ann Int Med* 1999;131(9):648-54

- Improved Provision of
- Beta Blockers Has Saved
- Over 500 Lives since 1996

## What others are saying:Teaching Status & Cardiac Care

- Allison JJ *et al*, *JAMA* 2000;284:1256-1262

## What others are saying:Teaching Status & Cardiac Care

- What others are saying:Teaching Status & Cardiac Care

## NSQIP:  National Surgery Quality Improvement Program

## Chronic Disease Index:1996 - 1999

## Prevention Index

## Access:  Geographic

*Supporting Better Primary Care*

## Slide 31

## Satisfaction:Progress & Opportunity ...

- 2000:  79 of 100 on external American Customer Satisfaction Index (Univ. of Michigan) Outpt Care
- 2001:  82/100 Inpatient & 83/100 Pharmacy
- Significantly better than private health sector average of 68
- Loyalty Score of 90 and Customer Service Score of 87 were healthcare benchmarks!
- National VA data:  Opportunity for improvement
- Priority Areas Identified: Access, Coordination of Care, Health Information, Pain Management

## A New VA:  New Strategies... Outcomes Don’t Just Happen

- Outcomes Can & Should Be Specified
- Linking Mission & Vision with Measurement & Management of Outcomes
- Identify Variability
- Assess opportunity  ( negative variation )
- Risk (“delta” between current and ideal) – “IOM Quality Chasm”
- Prioritize (e.g. volume, other significant factors)
- Identify and Implement “Best Practices”
- Spectrum of Outcomes, Spectrum of Measures
-  Measures  provide “Tension” - Accountability for Outcomes

## Challenge:  Identify Needs, Set Direction, Measure Performance & Articulate Outcomes

- Kaplan & Norton
- Concept of balanced perspective
- Link of Goals with Measures
- Real World: Perspectives don’t operate in isolation

## Not Necessarily Pretty, But Pretty Effective

**VALUES, GOALS, STRATEGIES                  ******

**Performance Measures            ******

## Changing the Paradigm:
From HR to Management Support
________________
Thomas J. Hogan
Director, Management Support
Veterans Health Administration

***Changing the Paradigm:***
***From HR to Management Support***
***________________***
***Thomas J. Hogan***
***Director, Management Support***
***Veterans Health Administration***

## When You Think VA,Think VAlue for Veterans

- When You Think VA,Think ***VA***lue for Veterans

**IMPROVING ACCESS**

**BENCHMARK OUTCOMES in**

** ****PREVENTIVE HEALTH**

** ****DISEASE TREATMENT**

** ****CUSTOMER SATISFACTION**

**LEADING PATIENT SAFETY **