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VA's Performance Management Work Group

As Dr. Kussman points out in his lead commentary, the VA's performance measurement system—with over 100 performance measures in the areas of access, satisfaction, cost, and quality—has served VA well. In 1995, VA first incorporated performance measures in the Executive Career Field (ECF) performance contract, an annual plan that establishes standards against which both central office and VISN leaders are evaluated. ECF contracts ensure accountability for both administrative and clinical performance measures and are developed collaboratively by central management and field leaders.

These performance contracts form the basis for quarterly management reviews, and incorporate modest management incentives. Results are also reported broadly within the VA and externally to key stakeholders including Congress, the Office of Management and Budget, and advocacy groups. Linking performance measures to these contracts results in personal accountability throughout the system. The Performance Management Work Group is central to this process. The work group has four key responsibilities:

Engage in regular and systematic planning for measurement;

Perform annual review of existing network trends;

Consider non-VA comparator system trends; and,

Oversee the development of the annual ECF performance plan.

This last responsibility involves a multi-step process, which begins with the work group integrating the priorities it receives from the Under Secretary for Health and other central and local VA leaders. The work group then convenes to identify measurement priorities and to assure measurement initiatives are developed, and approves proof of concept proposals from subject matter experts. The work group must also maintain a clear set of criteria for measurement approval and retirement, and, ultimately, identify and incorporate proposed performance measures into the next year's performance plan. The 2008 ECF plan emphasizes greater personal accountability by utilizing a streamlined set of performance measures, including new measures aimed at the efficiency of care provided to veterans, and also core competencies expected of senior leaders.

The recent adoption of a new VA national performance measure for thiazide diuretic use illustrates the rigorous process by which new measures are vetted by the work group. Despite evidence-based guidelines which favor thiazide diuretics among patients with uncomplicated hypertension, use of these drugs remains low. National hypertension management guidelines such as the Joint National Committee (JNC) 7 and the VA/DoD Hypertension Clinical Practice Guidelines recommend thiazide use for most patients in accordance with the results of the ALLHAT study. However, review of published pharmacy utilization data both in VA and in the private sector strongly suggests that hypertension guidelines are not followed for most patients. The work group approved inclusion of a pilot measure for diuretic use, which eventually led to adoption of the new performance measure for diuretic use in 2007.

Comprised of central and field leaders, and including both administrators and clinicians, the work group is co-chaired by Barbara Fleming, M.D., Ph.D., and Jim Roseborough, FACHE. The efforts of the group result in performance contracts that are recommended to the Under Secretary for Health and represent the collaborative efforts of central and field leadership, and reflect both administrative and clinical priorities.