IN THIS ISSUE

Invited Commentary . . . . . . . . . . . . . . . . . 1

Response. . . . . . . . . . . . . . . . . . . . . . . . . . 3

Best Practices . . . . . . . . . . . . . . . . . . . . . . 4

Organization Profile . . . . . . . . . . . . . . . . .6

New Initiatives. . . . . . . . . . . . . . . . . . . . . .7

A Publication of the VA Office of Research & Development, Health Services Research & Development Service,

Management Decision and Research Center, in conjunction with the Association for Health Services Research

I DIRECTOR’S LETTER NVITED COMMENTARY

One of the keys to doing high

quality health services research is

to have a dedicated cadre of experienced investigators in the field

with knowledge of the VA. We

are fortunate in HSR&D in that

our previous director, Dr. Daniel

Deykin, recognized this and initiated the HSR&D Career Development Program for clinicians.

This is a unique opportunity for

young men and women interested

in a research career to apply for a

three-year mentorship program

in which their entire salaries are

paid by VA Headquarters. It is

expected that 75 percent of their

time will be devoted to research. 

Of the initial eight individuals

funded in 1989, seven are still

with the VA, and all eight have

received merit reviewed funding.

The one person who left is now

Director of the Division of General

Internal Medicine at a major medical school and is responsible for

staffing the affiliate VA. All have

moved into leadership positions in

the VA and/or their universities.

Since then, an additional 50 clinicians have been accepted into the

program. 

This has been a highly successful program that has helped us

build a health services research

capacity in the VA. Unfortunately,

although the program is open to all

clinicians, very few non-physicians

have applied. It is my hope that in

the future, other clinicians will take

advantage of this unique opportunity.

I especially would like to see more

nurses, social workers and clinical

psychologists apply, although all

clinicians are welcome to apply. 

Each new awardee brings a fresh

insight and outlook to patient care.

I expect that their research will

reflect these perspectives and that

they, too, will become leaders in the

VHA.

John G. Demakis, M.D.

Director

continued on page 2

About the National VA Surgical

Quality Improvement Program

By Jennifer Daley, M.D., Co-chair, National VA Surgical Quality

Improvement Program and Staff Physician, Brockton/West Roxbury

Veterans Affairs Medical Center

Overview 

The National VA Surgical Quality

Improvement Program (NSQIP)

was created and implemented to

extend the methods, analysis and

reporting developed in the National

VA Surgical Risk Study (NVASRS).

The program was implemented in

1994 to provide reliable, valid, and

comparative information about surgical outcomes among the 123

VAMCs performing major surgery.

Since its implementation, the

NSQIP has been endorsed by clinicians and managers in the Veterans

Health Administration (VHA) as one

means of assessing the quality of

surgical care for veterans. 

Prospectively collected preoperative patient risk factors; key intraoperative process information; and

postoperative 30-day mortality, 30-

day morbidity and length of stay are

collected on 95,000 to 100,000 major

operations annually. Volume of

major surgery and risk-adjusted 30-

day morbidity and mortality rates

and observed-to-expected ratios are

available for a six-year period for the

forty-four VAMCs that participated

in the NVASRS. This information is

available for four years for the

remaining VAMCs that joined the

NSQIP in January 1994. 

Since 1987, the Center for

Continuous Improvement in Cardiac

Surgery (CCICS) at the Denver

VAMC has developed and used similar risk adjustment models for cardiac surgery. The CCICS reports

on risk-adjusted outcomes (morbidity, mortality and length of stay)

biannually to the 42 VAMCs performing open heart surgery in

VHA. Risk adjustment models for

the most common major surgeries

are also available (e.g., partial 

colectomy, total hip arthroplasty,

non-ruptured abdominal aortic

aneurysm, coronary artery bypass

graft.)

■ Why adjust for patient risk/

severity of illness in comparing

surgical outcomes?

The fundamental premise in studying comparative outcomes of health

care delivery is that patients’ health

status after medical treatment is a

reflection of the process of care they

receive. In comparing postsurgical

mortality and morbidity rates, the

assumption is that surgical services

with low rates of death and complications have better processes and

structures of care than surgical services with higher rates. Clinicians

recognize, however, that some surgical services may operate on patients

who are sicker. Not to account for

differences in how sick patients are

before surgery may unfairly disadFORUM

VA HEALTH SERVICES RESEARCH & DEVELOPMENT NOVEMBER 1998
2

vantage those surgical services with

sicker patients.

The NSQIP has developed 

methods for adjusting for how sick

patients are before major surgery

and provides post operative morbidity and mortality rates adjusted for

patient risk and severity of illness.

In 1997, the NSQIP identified 11

surgical services with 30-day postoperative mortality rates that were significantly lower than the VHA

average and 13 surgical services with

mortality rates that were significantly higher than the VHA average.

Sixty-four percent of these surgical

services would have been misclassified as high or low outliers if risk

adjustment had not been applied.

■ What risk adjustment methods are used?

The National VA Surgical Risk

Study developed highly predictive

risk adjustment models based on

accepted statistical methods of risk

adjustment for all major surgery

and eight surgical subspecialties

(general surgery, vascular surgery,

orthopedics, neurosurgery, plastic

surgery, non-cardiac thoracic

surgery and otolaryngology). The

risk adjustment models developed

for each of these surgical subspecialties have excellent predictive validity and have remained remarkably

stable for the past seven years.

■ What has been the outcome

of the NSQIP?

Since the inception of the NVASRS

and the NSQIP, the volume of

major surgery performed in VHA

has remained approximately the

same, while the average complexity

of major surgery has declined slightly. The average risk factor profiles

of the veterans undergoing major

surgery have remained remarkably

similar. Since 1991, the 30-day

mortality rate after major surgery

has decreased from 3.1 percent to

2.8 percent, a 9.6 percent decline in

30-day mortality. 

An even more dramatic decline in

the incidence of postoperative morbidity has been observed. Between

January 1994 and September 1997,

I NVITED COMMENTARY

the number of patients undergoing

major surgery in the NSQIP who

experienced one or more of 20 

predefined postoperative complications has decreased from 14.8 percent to 10.3 percent, a 30 percent

decline. Improvements in postoperative morbidity and mortality rates

after major surgery in VHA have

occurred at the same time that the

median postoperative length of stay

in VAMCs has declined by five days

between 1991 and 1997. 

Better surgical and anesthesia

techniques, improved supervision of

residents in surgical training, and

improvements in technology and

equipment all contributed to

improvements in surgical care. 

■ Do surgical services with

lower-than-expected riskadjusted morbidity and mortality rates have better quality of

care?

Although many are willing to accept

the answer to this question as “yes”,

others require additional evidence.

The NAVSRS conducted site visits to

20 VAMC surgical services, 10 with

higher-than-expected risk-adjusted

mortality and complication rates and

10 that were lower than expected.

Site visitors reviewed structure and

process of care on each service and

rated the technology and equipment

and overall quality of care better on

those services with better-thanexpected outcomes. They found that

the surgical services with better-thanexpected outcomes had higher levels

of formal and informal communication among surgeons, nurses and

anesthesiologists in the administration of the surgical service, as well as

in the direct care of patients. They

used protocols, practice guidelines or

care maps in the care of routine surgical cases more often than surgical services with worse-than-expected

outcomes. 

Using trained surgeon reviewers,

the NVASRS also reviewed 1100

charts of patients from surgical services with better- and worse-thanexpected outcomes and found that

patients with a low probability of

dying preoperatively, who subsequently died, were much more likely

to have had substandard process of

care as rated by the surgeon reviewers. Lastly, surgical services with

better-than-expected risk-adjusted

mortality and morbidity outcomes

are more likely to have better

patient satisfaction scores among

surgical patients as rated by the

National Customer Feedback

Center and the Picker survey.

■ What has contributed to the

success of the National VA

Surgical Quality Improvement

Program?

First, NSQIP has had access to a consistent surgical scheduling module

and operating room log in every

VAMC to identify all operations performed in operating rooms throughout the country and to create and use

a dedicated risk assessment and outcome module into which all the surgical nurse reviewers enter the same

data. Uniform software updates

insure uniform data collection. 

After completion of data collection,

the appropriate data fields are electronically transferred to the data

coordinating center for further cleaning and analysis.

Second, the presence of a trained

clinical nurse with experience in

clinical practice, data collection and

quality assurance has insured a very

high level of clinical credibility, reliability and validity of the data collected for analysis in the NSQIP.

The nurse reviewers are highly

motivated to maintain the integrity

T he NSQIP has developed methods for adjusting for how sick patients

are before major surgery

and provides post operative morbidity and mortality rates adjusted for

patient risk and severity of

illness. 
3

of the NSQIP database, as well as

their collaborative relationships

with the Chiefs of Surgery and surgical, anesthesia and other nursing

staffs of each surgical service. Many

of the nurse reviewers are very

active in the Surgical Service and 

in hospital quality improvement

activities.

Finally, the NSQIP has enjoyed the

support of senior surgeons and

administrative managers in VHA.

The original impetus for the creation

of the NVASRS came from senior surgeons who recognized that their

proactive involvement in developing

prospective data collection systems

and state-of-the-art risk adjustment

methods leading to reliable and credible reports of risk-adjusted outcomes,

was crucial in establishing the quality

of surgical care in VHA.

In addition, the Executive

Committee of the NSQIP is a peer

group of chiefs of surgery with assistance from other senior clinical managers and methodologists who work

together to assess the quality of surgical care in VHA. 

During the initial years of the

NVASRS and NSQIP, senior administrative managers in VA Central

Office (Clinical Services, Quality

Management, and Health Services

Research and Development) collaborated to provide support for the program. Since the restructuring of the

VHA into the Veterans Integrated

Service Networks in 1995-1996, the

NSQIP has also enjoyed the support

of the network directors and chief

medical officers in the 22 networks.

■ What’s next in the NSQIP?

Two major initiative are underway. First, the NSQIP is conducting a pilot study collecting

pre- and postoperative functional

status measures in veterans

undergoing major surgery in urology and orthopedics in 14

VAMCs. Second, the NSQIP is

collaborating with four affiliated

academic health centers to implement the NSQIP to provide 

comparison data from non-VA

hospitals performing major

surgery.

I NVITED COMMENTARY

Response

By Rodney A. Hayward, MD., Director, VA Center for Practice Management 

& Outcomes Research, Ann Arbor VAMC

Since HCFA began publishing risk-adjusted hospital mortality rates in the mid1980s, controversy has abounded regarding their value and merits as a quality measure. The NSQIP is an excellent example of a collaborative and constructive quality

improvement initiative. NSQIP encouraged surgical centers to inspect their practices and learn from each other. Although it is difficult to sort out potential confounding when making pre/post intervention comparisons, the introduction of the

NSQIP was associated with a substantial decrease in mortality rates without a

change in patient severity scores. 

Several key factors aided NSQIP’s success. First, strong clinical leadership 

from the field supported by an experienced research team helped assure both the

project’s quality and credibility. Second, NSQIP’s leadership developed and implemented detailed casemix-adjustment. Third, and perhaps most importantly, the 

project emphasized improving care, not sanction or blame. 

However, caution is critical in all profiling enterprises, even one as commendable

as NSQIP. Misunderstanding and misuse of profiles can waste precious health care

resources and potentially do harm. NSQIP has produced evidence that surgical hospital mortality rates are associated with quality, but this evidence is not conclusive.

The results could be confounded by associated hospital factors, and the lack of correlation between hospitals’ mortality rates and their complication rates is difficult to

reconcile. Still, demonstrating that mortality rates are associated with quality is not

the same as demonstrating that hospital mortality rates are an accurate measure of

an individual hospital’s quality. 

We know little about the reliability of mortality rates as a measure of a hospital’s

quality. If used as a screening test, this may not be a problem. However, for making

individual classifications and decisions, we need much greater diagnostic accuracy

than we do for determining whether someone is simply at higher than average risk.

Simulation models by Timothy Hofer, a VA HSR&D Career Development

Awardee, suggest that surgical mortality rates could possibly be sensitive to specific

measures of quality, but that casemix-adjustment would have to be excellent, and

quality differences between facilities would have to be large (Medical Care, 1996).

These mathematical simulations also suggest that validating the accuracy of surgical

mortality rates for classifying individual hospitals would be extremely difficult and

that disease-specific mortality rates for medical conditions (i.e., stroke, heart attacks,

pneumonia) are unlikely to be accurate quality measures under any circumstances. 

A further argument in support of the cooperative approach is that a punitive

approach may result in harm to veterans even if the measures are accurate. Indeed,

if surgeons can predict surgical risk above and beyond the formal casemix system,

hand-picking their cases, even to the detriment of patient care, would be a rational,

although undesirable gaming strategy. 

NSQIP demonstrates how a cooperative approach can take advantage of the

VHA’s national health care network and facilitate quality improvement. Further

efforts in quality improvement will often best be focused on improving compliance

with processes of care that are proven to affect outcomes (i.e., appropriate use of

thrombolytics and control of hypertension) rather than relying upon measurement

of outcomes directly. However, it is critical that our quality improvement efforts be

directed at improving important aspects of care that will have a tangible impact on

veterans’ health and well-being.

■ How to get more information about the NSQIP

The NSQIP publishes a newsletter biannually. For more information, or to receive a list of

publications of the National VA

Surgical Quality Improvement

Program,call Jeannette Spencer,

R.N., National Clinical Coordinator, National VA Surgical

Quality Improvement Program

(Chairman’s Office); Brockton/

West Roxbury VAMC; tel 617/

323-7700, x6740. 
4

The management of a surgical service is quite a complex undertaking.

Consider that a surgical service

comprises several components —

patient care units, operating room,

recovery room, and surgical intensive care unit (SICU) — among

which patients are transferred following admission for a surgical procedure. Also, a surgical service

requires close collaboration among

different professional groups, namely surgeons, anesthesiologists, and

nurses. The complexity of managing a service can be even greater if

staff members are involved in training aspiring surgeons. Given such

complexity, how can surgical services be managed most effectively? 

HSR&D Studies 44 Largest

Surgical Services

A study sponsored by VA’s HSR&D

provides some answers to this question. The study grew out of the

National VA Surgical Quality

Improvement Program (see article

on page 1). Study participants were

the 44 largest VA surgical services

(all of which are involved in graduate medical education). 

There were two primary data collection activities: (1) a survey of surgical staff at each participating site,

and (2) site visits to 20 of the 44

participating sites (the ten with the

highest and the ten with the lowest

risk-adjusted morbidity or mortality

rates). The study team used the

survey and site visit data to assess

the relationship between surgical

outcomes and different patterns or

approaches to coordinating surgical

staff. 

The team was particularly interested in learning to what extent

surgical services combined personal

interaction (which involves staff

coordination through one-to-one

and group communication) and

standardization (which involves

coordination through planning and

programming work activities in

advance of actually performing the

work). From a theoretical perspective, standardization is best suited

for coordination of routine work

activities while personal interaction

is necessary for work activities that

are non-routine and thus uncertain. 

Study Shows Combination of

Coordination Practices

Produce Better Outcomes

Overall, study results indicated that

the surgical services that used a

variety of both personal and standardized coordination practices had

better outcomes. Through the site

visits, the study team identified

some examples of highly effective

and/or innovative practices for coordinating surgical staff. 

Personal Approaches. With

respect to personal approaches, the

surgical services with the best outcomes were more likely than their

counterparts to emphasize interdisciplinary collaboration for handling

administrative and patient care

activities. 

A common coordination practice

among high performing surgical services was a regular meeting of the

leaders of the surgical service —

chief of surgery, chief of anesthesia

and nurse manager responsible for

the surgical service. The meetings

were often conducted as strategy

sessions with discussions focusing

on future staffing requirements,

equipment and space needs, and

tactics for strengthening the interaction of surgical staff. Such meetings were rare among the other

surgical services that the site team

visited. When meetings were held,

they were more likely to be ad hoc,

usually in response to a problem or

crisis after it had already occurred. 

At the level of patient care, the

high performing surgical services

used a variety of mechanisms to

promote personal interaction among

surgeons, anesthesiologists and

nurses. Such mechanisms included

interdisciplinary rounds, where surgeons and nurses conducted patient

rounds together. One surgeon who

was interviewed for the study commented that interdisciplinary

rounds provided opportunities “for

a more complete exchange of clinical

information.” 

Two of the high performing surgical services also emphasized teamwork by assigning each operating

room nurse to a surgical subspecialty. The nurses worked primarily

with the surgeons of the subspecialty to which they were assigned.

Surgeons commented that working

with the same nurses on a regular

basis “promoted efficiency and

trust”, nurses referred to benefits

such as “enhanced professionalism

and stronger skill development.” 

High-performing surgical services

were also adept at supervising the

activities of surgical staff through

personal coordination approaches.

For example, some of these services

had an “operating room czar,” an

individual who had ultimate responsibility and authority for coordinating the operating room schedule. 

The individual who was in this

position at one of the surgical services that the study team visited

was, by training, a nurse with a

master’s degree in business administration. Because she reported

Best Practices for Surgical Services

By Gary J. Young, J.D., Ph.D. and Martin P. Charns, D.B.A.

O verall, study results

indicated that the surgical

services that used a variety

of both personal and standardized coordination

practices had better 

outcomes.
5

directly to the hospital’s chief of

staff, her authority over scheduling

matters was formalized in the hospital’s organizational structure.

The praises of having someone in

this role were sung by many of the

surgical staff with whom we spoke.

One attending surgeon commented:

“Before [she] took over, there was

some degree of confusion and dissension about whose case would be

taken next. She developed a set of

scheduling rules for the O.R. and

enforces these rules fairly and effectively. Her addition to the O.R. has

really helped to reduce unnecessary

delays in surgery.”

Standardization. With respect to

standardization, the high-performing surgical services were typically

farther along than the other surgical services in the development and

implementation of clinical pathways

and protocols. Indeed, high performers were much more likely than

the other surgical services to make

pathway development a priority.

For example, the study team visited

one high performer and found that

the walls of the office of the chief of

surgery to be adorned with numerous charts depicting completed

pathways and pathways under

development. The charts identified

the individuals who were responsible for developing each pathway and

the expected completion times for

preliminary and final products. 

Role of Training and

Education. High performers also

emphasized training and education

to standardize the skills of their

staff. In particular, the study team

observed that high performers were

more likely than their counterparts

to use clinical nurse specialists for

developing the skills of nurses at

the patients’ bedside. Almost all of

the higher performers that the

study team visited had a clinical

nurse specialist dedicated to the

SICU, whereas several of the other

surgical services had either never

had a clinical nurse specialist, or

lost the one they did have, to staff

cutbacks.

Conclusion

From the study team’s perspective,

the most distinctive characteristic of

the high performers was the way

they often combined personal and

standardized approaches to coordinate surgical staff. For example, at

one high performer the staff had

developed a protocol to assist nurses

in identifying patients at risk for

pressure sores. The protocol is a

form of standardization. When atrisk patients were identified, nurses

would then schedule a patient care

conference — often with the

attending surgeon, resident responsible for the patient, and consulting

physician from the department of

medicine — to discuss appropriate

prevention strategies such as ordering a special bed. 

Although it has been commonly

believed that standardization

improves efficiency but is antagonistic to effectiveness in professional

settings, this study and several others have found that standardization

combined with personal approaches

to coordination contributes to effectiveness.

The results of this surgical study

are reported in three separate publications. For further information

please email Gary Young at gary.

young@med.va.gov or call 617/278-

4433.

Health Services Research at the Interface is

Theme of 1999 HSR&D Annual Meeting

The VA HSR&D 17th Annual Meeting, Health Services Research at the

Interface, will be held in Washington, D.C., February 24-26, 1999. The

meeting will bring together researchers, clinicians, and policymakers,

interested in exploring new methods to improve health. As in previous

years, the program will feature invited speakers, competitively selected

oral and poster presentations, workshops, and exhibits. Throughout

the conference, attendees will be encouraged to articulate the linkages

between scientific activities, VA policy development, and clinical service

delivery.

A call for abstracts along with registration material was issued in

September. Individuals who are interested in presenting special interest groups or workshops should contact W. Edgar Cockrell,

Administrative Officer, Center for Heath Services Research in Primary

Care, VA Medical Center, 508 Fulton Street, Durham, NC 27705; or 

tel 919/286-6936; FTS 700/671-6936; fax 919/416-5836.

For more information regarding registration or hotel accomodations,

please call Karen Hickey, HSR&D Special Projects Office, VA Maryland

Health Care System, Perry Point, MD at FTS 700/956-5448, tel

410/642-1018, fax 410/642-1095; e-mail Rainelle.Holcomb@med.va.gov.

Ashton Appointed

New Director of

Houston HSR&D

Carol M. Ashton, M.D., is the

newly appointed Director of the

Houston Center for Quality of

Care and Utilization Studies.

After eight years as Associate

Director at the center, one of 11

VA HSR&D Field Centers of

Excellence, Carol succeeds outgoing Director Nelda P. Wray, M.D.,

who was recently appointed to

lead the new Section of Health

Services Research in the

Department of Medicine at

Baylor. Ashton also holds positions as general internist at the

Houston VA Medical Center and

Associate Professor of Medicine at

Baylor.
6

On July 1, 1998, the Department of

Veterans Affairs (VA) established the

VA Information Resource Center

(VIREC) to serve VA and non-VA

researchers. The Center, funded

through the VA’s HSR&D Service, is

located within Hines VA Hospital and

co-directed by Dr. Denise Hynes and

Ms. Diane Cowper. 

VIREC’s mission is to work with

researchers to expand the current

VA information infrastructure as

they seek to use the databases to

address research issues that ultimately serve the needs of the VA

patient population. VIREC’s six

objectives are to:

■ update the current database

Resource Guides and the library of

SAS program shells;

■ develop user manuals for new and

other important data systems as they

come on-line and to develop a network of VA data experts/consultants

for each of the relevant databases;

■ provide ongoing evaluation to scientific review boards on the feasibility of VA database needs and

strategies in proposed HSR&D and

CSP studies;

■ provide liaison between HSR&D,

CIO and, as appropriate, represent

HSR&D on data system development

projects such as data modeling teams

for the National Patient Care Database;

■ develop a data consulting service

to facilitate access and interpretation of VA data; and

■ provide a means to evaluate data

reliability and validity of current

databases used extensively in health

services research. 

VIREC’s Four Service Lines

There are four primary service lines

within VIREC to coordinate key

functions — Customer Service,

Website, Dissemination and

Promotion, and Research:

Customer Service. This service

line deals directly with telephone,

O RGANIZATION PROFILE

fax, E-mail and Internet inquiries.

Staff currently is developing

inquiry action protocols to promote

timely and appropriate responses

and/or referrals to customers. The

customer service staff primarily is

responsible for developing and

maintaining the Data Consulting

Referral List and for coordinating

dissemination and feedback on customer and needs assessment surveys, and database updates. 

Website. The Website team primarily deals with the design and

updating of the Website to meet

the needs of VIREC and its customers. Responsibilities include

designing a “user-friendly” site

with internal and external site

links as needed. Website staff is

working with the research staff to

develop a customer needs and satisfaction survey on-line and with customer service staff to coordinate

timely responses to on-line

inquiries and documentation. The

Website recently was activated and

can be accessed at www.virec.

research.med.va.gov.

Dissemination and Promotion.

This service line deals with information dissemination at research,

trade, and VA sponsored seminars

and meetings. Other responsibilities include the development of

manuscripts on the VIREC for the

lay and professional press and to

increase the awareness about

VIREC to the health services

research community.

Research. Research staff is

responsible for database documentation and updates, developing

strategies for providing technical

support to review panels, and reliability and validation studies of

databases. Specifically, research

staff currently is working on the

following major projects.

■ Decision Support System

The Decision Support System

(DSS) is a new VHA database that

provides integrated clinical and

financial data to help managers

make informed decisions. As it is

imperative that research investigators and managers understand and

have access to DSS, the creation of

a DSS Resource Guide is a top priority for VIREC research staff. 

■ National Patient Care Database

The reorganization of patient data

into an integrated National Patient

Care Database (NPCD) is an ongoing activity at the Austin Automation Center (AAC). Thus far, the

outpatient segments are the sole

components of the NPCD with the

inpatient data scheduled to be

migrated into the database in

October, 1998. Once the NPCD is

complete, a resource guide is being

developed by VIREC research staff

to aid customers through the system.

■ Resource Guides

The Databases Resource Guides,

i.e., the “Blue Books” developed by

Drs. Ralph Swindle, Martha Beattie

and colleagues, filled a gap in the

VA Research community. Resource

Guides for the Patient Treatment

File (PTF), the Outpatient Clinic

File (OPC), Costing Data and

Decentralized Hospital Computing

Program (DHCP) enhanced the

ability to access data, provided a

training tool for new programming

staff and investigators, documented

variable names and code lists, provided a history of variable changes

to the contents of the databases,

and provided step-by-step processes

for uploading and downloading

data. VIREC will update and distribute this valuable resource. 

Affiliations

The VIREC’s primary affiliation is

with the HSR&D Center of

Excellence, the Midwest Center for

Health Services and Policy Research

and the Cooperative Studies

Program Coordinating Center, both

located at Hines VA Hospital. The

VIREC also has an academic affiliaVA Establishes New Information Resource Center

continued on page 8
7

The VHA’s Quality Enhancement

Research Initiative (QUERI) was

launched this past summer. In July

the Research and Methodology

(R&M) Committee of QUERI

reviewed the strategic plans of six

QUERI Executive Committees—

Ischemic Heart Disease, Chronic

Heart Failure, Stroke, Substance

Abuse, HIV/AIDS and Mental

Health (including Depression and

schizophrenia). Then in September,

they reviewed the strategic plans of

the remaining four QUERI Executive Committees— Diabetes,

Spinal Cord Injury, Prostate

Disease and Cancer. A series of

research solicitations for each of the

QUERIs will address major gaps in

our knowledge about improving the

quality of care for patients with

each of the diseases/conditions. 

Solicitations for Investigator

Initiated Research and Service

Directed Research projects will be

distributed to the field in October

and November. Proposals will be

due by February 5, reviewed in

March and funded April 1, 1999.

The R&M committee also

approved several rapid response initiatives that will be done by the coordinating centers of the respective

QUERIs. These will obtain base line

data on best practices, address database issues, etc., to enable future

larger scale studies. Each strategic

N EW INITIATIVES

plan was the result of painstaking

work by members of the respective

Executive Committees. Each committee is comprised of knowledgeable

VHA clinicians and researchers with

expertise in epidemiology, statistics,

and methods for measuring riskadjusted patient outcomes. Each

QUERI is based at an existing

research Center of Excellence and

includes a Clinical Coordinator and a

Research Coordinator.

Cross-cutting Issues Among

QUERI Groups

There are several crosscutting

issues that pertain to all QUERI

groups. Such issues as how to

implement best practices (e.g., clinical guidelines), how to measure

patient outcomes and how to measure cost-effectiveness of interventions are common to all groups.

Another important issue is how to

manage change, both clinical and

organizational. There also are database problems — how to add variables, and how to improve reliability

and validity of existing databases

and registries. 

Finally, how can we systematize

quality improvement in VHA? 

If we look at each of the QUERI

groups as isolated and free standing, we will lose an important

opportunity. Our task is not just

to improve quality of care in heart

disease, diabetes, and SCI, but to

look at quality improvement as a

total systems issue. VHA must

develop a structure that will encourage continuous quality improvement in all areas of health care.

Exactly what structure is required

is not known, but we do know that

it will not be cheap or easy.

In order to address these crosscutting issues, a meeting of all

QUERI coordinators, members of

the R&M Committee, key managers

in Headquarters, and network representatives has been scheduled.

Many of the QUERI projects will

create more work in VHA facilities,

and by addressing these crosscutting issues, we hope to contribute to

the discussion of how to systematize quality improvement. 

The Need for A Structure to

Manage Quality

Dr. Peter Goldschmidt was asked

by Congress to evaluate the VHA’s

quality management program. The

resulting report stated “The central problem with the VA’s QM 

program appears to be a lack of

mechanisms to manage QM. As the

largest integrated health care delivery system in the nation, the VA

has the opportunity to demonstrate

what can be done to manage QM.

Without a proper structure, the VA

will always struggle to show that it

is doing enough and that what it is

doing is worthwhile.” 

The VHA is already a leader in

many areas of quality improvement, most notably the National

Surgical Quality Improvement

Program (NSQIP). This successful

program developed a structure in

the field that included a new computerized surgical database and

extra support staff that was translated into lower national surgical

mortality and complication rates

even though patient severity

remained constant. 

The VHA’s challenge is to develop

a structure for quality improvement

that will not only improve care for

surgical patients and patients with

the QUERI conditions but will

improve care for all VHA patients.

QUERI is envisioned as a partnership among clinicians, researchers

and managers. Hopefully, the collaborative structure and systematic

approach incorporated into QUERI

will move VHA to a new paradigm

for translating research results into

improved quality of care, and documented better patient outcomes.

QUERI Off And Running

By John G. Demakis, M.D. 

T he VHA’s challenge is

to develop a structure for

quality improvement that

will not only improve care

for surgical patients and

patients with the QUERI

conditions, but will improve

care for all VHA patients. 
tion with the Institute for Health

Services Research and Policy Studies

at Northwestern University,

Evanston, Illinois.

Information

For additional information about

VIREC, please contact Joseph D.

Kubal, Center Manager, Hines VA

Hospital (151V), P.O. Box 5000,

Hines, IL 60141-5000; tel 708/216-

2413; fax 708/216-2415; e-mail

virec@research.hines.med.va.gov.

8

Martin P. Charns, D.B.A., Editor-in-Chief

Wendy G. Valentine, M.H.A., Editor

Geraldine McGlynn, M.Ed., Co-editor

ADVISORY COMMITTEE

Carol M. Ashton, M.D., M.P.H., VA HSR&D

Center of Excellence, Houston

John G. Demakis, M.D., Director, VA HSR&D

Rodney A. Hayward, M.D., VA HSR&D

Center of Excellence, Ann Arbor

David H. Law, M.D., VA Medical Center, 

Bay Pines, FL

Shirley Meehan, M.B.A., Ph.D., VA HSR&D

Alan S. Perry, VA Medical Center, Roseburg

Robert M. Roswell, M.D., VA Network #8,

Birmingham

Forum is a Publication of the VA Office of Research &

Developemnt, Health Services Research & Development

Service, Management Decision and Research Center, in

conjunction with the Association for Health Services

Research.

F O R U M

Organization Profile

continued from page 6

VA Seeks Director, Midwest Center for Health

Services & Policy Research

The VA Great Lakes Health Care System Edward Hines, Jr. VA

Hospital, Hines, IL is recruiting for a Director for the Midwest Center

for Health Services & Policy Research (MCHSPR). MCHSPR is made up

of an interdisciplinary group of researchers, with a total staff of 27 and a

budget of $7 million in core and grant funding. 

Candidates must have either an M.D. or Ph.D. with excellent leadership, research credentials and administrative skills to direct a premier

health services research program with a national reputation. 

Qualified candidates should submit a letter of interest, curriculum

vitae and a list of five references by November 30, 1998 to: Chair,

MCHSPR Director Search Committee, P.O. Box 1041, Hines, IL 60141.

A candidate will be selected no later than December 31, 1998. U.S.

Citizenship required. The VA is an equal opportunity employer.

HSR&D Solicitations

There are a number of on-going and new HSR&D solicitations and more

soon to emerge from the Quality Enhancement Research Initiative (QUERI).

The list below was last updated October 30th.

QUERI solicitations thus far include: 

Investigator-Initiated Research (IIR) and Service Directed Research (SDR)

in: Chronic Heart Failure, HIV/AIDS, and Substance Abuse. SDRs in:

Ischemic Heart Disease and Mental Health. IIRs for Diabetes and for cross-cutting

issues in Clinical Guideline Implementation and Patient Centered Outcomes.

Other active solicitations include:

IIRs: Major IIR Priorities for FY 1998 (includes Access, Managed Care,

Ethnic/Cultural Issues, Gender Issues, Guideline Implementation), CrossCutting Issues in Telemedicine, Patient Safety, Patient-Centered Care, and

Interdisciplinary Studies of Rehabilitation Outcomes. Other solicitations:

Health Economics Research Support Center; Centers of Excellence in

Tobacco Use and Treatment Outcomes Research (TUTOR); HSR&D/VISN

Collaborative Health Services Research Projects. 

For information about these solicitations and proposal requirements please

visit our web site at www.va.gov/resdev/hsr-sols.htm, call our Fax on Demand

server at 617/278-4492 and follow voice prompts or contact the HSR&D

Headquarters offices at, HSR&D Service (124), Department of Veterans

Affairs, 810 Vermont Avenue, NW, Washington, DC 20420, Phone 202/273-8287.