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VA’s Performance Measurement Makeover

Former New York Yankees’ catcher Yogi Berra, famous for his amusing observations about life, once reputedly said, “You’ve got to be careful if you don’t know where you’re going—because you might not get there.” As nonsensical as Yogi’s comment may seem, it underscores an important point about providing veterans with the best possible health care: in order to know where we are going, we first need to know where we are.

That’s what makes VA’s performance management system so important. The system helps us understand our successes, identify gaps in our care or management processes, and build improvements to enable us to provide veterans with “the best care anywhere.”

Turning Point for Measurement System

Although the current performance measurement system has served VA well, we are at a turning point. The Executive Career Field (ECF) plan for 2008 is the beginning of a new use of performance measurement. In 1995, when measures became a formalized part of the ECF plan by which all Senior Executives in the Veterans Health Administration are evaluated, all VA performance measures were simultaneously part of the ECF plan. Measures flowed through a Performance Management Work Group where vote counts determined their fate. Those votes were sometimes swayed by views of the ideal number of measures, not just the intrinsic properties of the new measure which was up for consideration.

Of VA’s four missions: patient care, education, research, and emergency management, I believe that patient care is by far the most important. Therefore, it is critical we assess our performance in delivering patient care by collecting data on broad and comprehensive measures covering the core areas of care we provide. We have turned a key corner in measurement with the development, this year, of both a comprehensive set of Health Systems Indicators and an ECF plan that is a subset of Health Systems Indicators. The Health Systems Indicators are a library of measures that cover, with breadth and depth, the care that we provide to our veterans. We are liberated from the “too few, too many” dilemma that existed when all performance measures were included in the ECF plan. Now we can ask the only performance question that really matters: How are we doing in taking care of our veterans?

Patients’ perceptions, as measured by the Survey of Healthcare Experiences of Patients, allow us to add a rich patient-centered dimension to what we learn about the care we provide and also allow us to shape that care to meet the needs of patients. Both dimensions, measuring clinical care and asking our patients about their care, are critical.

In some cases, there are disconnects (such as the fact that patients’ perceptions of the clinical quality of care delivered does not correlate with the clinical quality we measure). However, we learn and improve by addressing both key components—as well as the factors that lead to the lack of connection between the two.

The 2008 ECF plan will address a more select and limited set of measures. It will include a new category that we refer to as transformational measures, an expanded set of measures that reflect the efficiency of the care we provide, and core competencies that we deem essential for our senior executives. We know our staff, clinicians and non-clinicians alike, want to do the right thing for our veterans. We do not believe that a measure must be in the ECF plan in order for us to improve our care. But we do know that presence in the plan is a powerful driver. This led to the development of Mission Critical Measures (measures designated as “must achieve” for this system of care) as part of the ECF plan.

Many new items are part of our new measurement system. The breadth and depth of our measures, and continual monitoring of them through a library of Health System Indicators, allow us to maintain continual readiness. If we see a key measure trending in the wrong direction, we act immediately: first through alerts to the field; then by adding the measure back to the plan; and, finally, by developing quality improvement initiatives around the measure. Transformational measures provide us with stretch goals in key areas where we have opportunities for improvement.

An External Benchmarking Opportunity

This year, we have formalized the concept of external comparisons. While we desire to provide great care because of our deep and passionate commitment to achieving excellence, the perception of VHA’s quality is important to our very existence. In the past, one of the challenges to external perceptions of quality was the charge by detractors that VA both developed our own measures and compared ourselves to ourselves—resulting in a lack of credibility. The statute that established the National Quality Forum (NQF) required federal entities such as ours to use NQF-endorsed measures. An August 2006 Executive Order further mandated use of measures developed by external entities, such as the Ambulatory Quality Alliance and the National Committee for Quality Assurance (NCQA).

This year, the quality measures in the ECF plan will be those of the Healthcare Effectiveness Data and Information Set (HEDIS), and ORYX measures that have been developed and given face validity as a result of the work of multiple bodies, including the NCQA, the American Medical Association, the Joint Commission, the Centers for Medicare and Medicaid Services, and the final arbiter, the NQF. Therefore, it will no longer be possible to challenge that we do well on measures only when we can create them ourselves. We gladly accept the challenge of comparing ourselves on measures that have been externally developed and widely used. This also gives VHA a valuable external benchmarking opportunity, and we do well when given that opportunity.

These measures and all measures are population- based. None are intended to guide treatments of individual patients. Making sure that this message is clear for clinicians is the ongoing challenge of measurement, not just for the VA, but for all who develop and use health care performance measures. No VA measures will be dropped; instead they will remain in the library of Health Systems Indicators so that our clinicians continue to receive a refined and granular look at the care they provide to patients.

As our knowledge about how to measure clinical performance expands, and our library of measures grows, we also face the challenge of narrowing our focus to areas of critical importance, and the ability to shift that focus in response to new knowledge and events. As Yogi also supposedly said, “You can observe a lot by watching.”