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VHA Transformation Challenges and Lessons

As Dr. Tuchschmidt affirmed, VHA is undertaking a major transformation aimed at creating a comprehensive array of interlinked, technologically advanced services centered on Veteran needs and preferences, with VHA's infrastructure of primary care practices serving as the hub. Termed Patient Aligned Care Teams (PACT) and initiated in early 2010, this reorganization envisions both a higher quality of primary care and integration of specialized care into the primary care setting. To accomplish these goals, PACT aims to push VHA's already advanced technologies and staff training capabilities to new levels.

The magnitude of the PACT reorganization is staggering. Unlike non-VHA examples of primary care redesign, PACT engages an entire highly developed national system, with participants located in hundreds of local primary care practices, in over a hundred different medical systems, and in more than twenty administrative regions. PACT changes are occurring in sites that are reluctant or enthusiastic, urban or rural, academic or non-academic. These diverse participants must build PACT into established and sometimes rigid clinical, information system, financial, and human resource functions. In this context, VHA's highly developed technological and human infrastructure is both a resource and a barrier to change.

Changes of the magnitude being undertaken in VHA PACT have been termed disruptive innovations by Clayton Christensen and other organizational theorists.1 Provision of self-serve gasoline or ATM technology, for example, increased customer access, decreased costs, and drove major reorganization of the respective industries. Disruptions such as these occur when gaps between needs preferences and offered services or products are too large to allow linear change. In health care, successful disruptive innovation would reduce costs, increase access, and place a greater share of health care tools and technology in the hands of patients. In accomplishing these goals, the innovation would also reduce morbidity and mortality disparities; focus medical workforce training and evaluation on competency and performance; make waste reduction a core cultural value; and clearly define and articulate rights and responsibilities of providers and patients.2 PACT goals are thus in-line with disruptive innovation principles.

The motivations in VHA for undertaking disruptive innovation are compelling. First, VHA exists in order to be "the best care anywhere" for Veterans. As Dr. Tuchschmidt points out, we have yet to fully exploit the enormous VHA system capabilities, especially in terms of optimal responsiveness to Veteran needs and preferences. Another is flattening or slight deterioration in VHA primary care quality and satisfaction in recent years. Most care provided to most patients is either primary care or accessed through primary care—unsatisfactory primary care is a major threat to the system's viability. Finally, the opportunities for improving VHA's primary care models and the threats from not achieving it are occurring within a broader context of upcoming increases in both affordable insurance choices for Veterans and in federal budget constraints.

VHA's ability to undertake disruptive innovation has already been demonstrated. Prior to 1994, the VHA system was a natural experiment in providing access to specialty and hospital care, but not to primary care, because federal regulations prohibited the system from delivering primary care. This hospital-centric care configuration was typical of safety net systems of the time. While specialty care was often high quality, access to general care, even for serious symptoms, was a major problem. The rapid bottom-up and top-down reorganization of the VHA system to correct these problems (beginning around 1990 prior to legalization of VHA primary care and extending through the next decade) was both disruptive and highly productive.3, 4

PACT implementation shares some, but not all, features of the 1990's reorganization. First, in the earlier reorganization, the large resources freed up by reducing preventable hospital admissions were available for building primary care. Currently, VHA rates of preventable hospitalization, such as for ambulatory care sensitive conditions, are low. Second, the models of the 1990s were preliminarily built and tested from the bottom up prior to full system implementation; PACT lacks this level of prior bottom up development. Third, the prior reorganization could achieve improvements even when it did not deliver full biopsychosocial care to vulnerable patients. For PACT, these patients may provide the largest remaining opportunities for improvement. Overcoming these challenges will require ongoing bottom-up local innovation, as well as top-down guidance, but can lead the way to better, more efficient, and more patient-centered health care models for the 21st century.

  1. Christensen C.M. "Disruptive Innovation: Can Health Care Learn from Other Industries? A Conversation with Clayton M. Christensen. Interview by Mark D. Smith." Health Affairs 2007; 26(3):w288-95.
  2. Brook R.H. "Disruption and Innovation in Health Care." Journal of the American Medical Association, 302(13):1465-6.
  3. Yano E.M. et al. "The Evolution of Changes in Primary Care Delivery Underlying the Veterans Health Administration's Quality Transformation." American Journal of Public Health 2007; 97(12):2151-9.
  4. Rubenstein L.V. et al. "Evaluation of the VA's Pilot Program in Institutional Reorganization Toward Primary and Ambulatory Care: Part II, A Study of Organizational Stresses and Dynamics." Academic Medicine 1996;71(7): 784-92.

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