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FORUM - Translating research into quality health care for Veterans

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The "access" crisis that engulfed VA last year spurred significant changes in VA health care. Changes included increases in Veterans' access to care, improvements in clinic scheduling practices, and new leadership. At a recent Congressional budget hearing, Secretary McDonald reported the following outcome measures: 7 million more VA clinic appointments this year, a 44 percent increase in VA care in the community, increases in net staffing by more than 12,000, increases in the number of primary care exam rooms, and increases in provider productivity. These outcomes reflect the traditional structural approach to measuring access. What they also reflect, however, is a missed opportunity to reinforce a multi—dimensional conceptualization that includes both "actual and perceived" access to care as defined in the 2010 VA State of the Art (SOTA) Conference on Access.

Over—reliance on the structure of VA health care, such as wait time metrics, distracts us from measuring patient—perceived access from a broader conceptual foundation that includes geographical, temporal, financial, cultural, and digital dimensions.1 Some, but not all aspects of these access dimensions are addressed by the Survey of Healthcare Experience of Patients (SHEP), the single most important VA program to systematically assess patient perceptions of health care. Questions about the "ease of access to routine and urgent care" form the basis for key agency metrics tied to the Agency Performance Plan. During the early days of the VA access crisis, we observed that results from these standard access questions were already available and indicated wide variability across VA facilities in patient perceptions of access to care. We also observed that lower access scores correlated with longer wait times. We should have been listening to the voice of our Veterans via the SHEP survey results rather than a singular dimensional focus on wait time metrics.

The SHEP program, managed by the Office of Performance Management within the Office of Analytics and Business Intelligence (OABI), was initiated in fiscal year (FY) 2002 in an effort to create standardized survey instruments administered monthly to assess ambulatory and inpatient care. We adopted the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey methodology in FY09 when we launched two flagship surveys: 1) an outpatient survey which was later transitioned to the Patient Centered Medical Home (PCMH) survey that specifically focused on primary care; and 2) a hospital CAHPS survey of inpatient medical and surgical services. These instruments provided a standardized, validated, and tested mechanism for assessing patient experiences with health care that are used to systematically evaluate VA hospital performance. These surveys are supported in the public domain by the CAHPS Consortium, Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid Services, and National Committee for Quality Assurance. Although SHEP deployed the standardized CAHPS surveys, the access questions were limited and did not evaluate the full scope of services used by Veterans.

SHEP was awarded additional resources to significantly expand the inventory of surveys to more comprehensively assess Veteran access to care. Award of these additional resources was prompted by the widespread recognition that clinic appointment wait times were inadequate measures of access to care. This year we are introducing the following new surveys, multiple survey modalities, and new analytic reports designed to measure access to—and experience with—a wide range of VA health care services, including VA care in the community.

PCMH Survey Addition of Specialty Care Item—Set. For those Veterans who responded to the PCMH survey and who also had an encounter with a specialist, they are asked additional questions about the ease of getting specialty care appointments and the Overall Rating of Specialists. Data collection began in October and facility—level results are being reported to the field.

VA Specialty Care Survey. Veterans with visits to high volume specialty care clinics are sent a specific specialty care survey that includes questions about ease of access to VA specialty care clinics, overall rating of VA specialist, and CAHPS domains such as communication and coordination of care. The survey utilizes more timely and effective modes of survey administration including email invites, an online survey (mobile device enabled), and traditional mail—mode administration. Data collection began in May and results will be available in late August.

VA Care in the Community. This survey will address the requirements of the Choice Act by evaluating Veteran perceptions of access to—and experiences with—all VA care in the community. The survey addresses experience with both choice care and traditional fee care. Just as with the Specialty Care Survey, multiple modes of administration will be utilized in implementing this survey. Extensive focus group work was completed to support the development of this survey to be launched in late FY15.

New Enrollee Survey. This survey will address Veteran experiences with initial enrollment and access to first clinic appointments. Extensive focus group work was recently completed to support the development of this survey with an anticipated early fall launch.

Finally, we have established a Veteran Insights Panel composed of over 3,200 Veterans that are representative of users of VA health care. We are engaging panel members in direct discussions about important themes and issues. We interact with the panel through email notification and a special access website (mobile device enabled). We are engaged in real time feedback via live chat discussion, qualitative and quantitative surveys, and survey development and testing. The panel can be engaged collaboratively with operational program offices and researchers to prompt direct discussions with our Veterans.

Measurement of access is complex because the understanding and definition of access mean different things to different people. We need to embrace a patient—centered view of access that encompasses both the structure of our health care system and the preferences of our Veterans. We need help from the research community to better understand what is most important to our Veterans so that we can systematically assess how well the system is performing to meet those needs. Our commitment of providing accessibility to high quality care for our Veterans deserves no less.

1. Fortney JC, et al. "A Re—conceptualization of Access for 21st Century Healthcare," Journal of General Internal Medicine November 2011; 26 (Suppl 2):639—47.

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