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Director's Letter

David Atkins, M.D., M.P.H., Director, HSR&D

The crisis of the past year for VA over access will likely become an organizational case study about how not to use performance measures to drive system performance in a complex system. The problem of access was not a secret to VA leadership—while satisfaction with VA care was generally equal or above that of private systems, many facilities struggled to provide timely care especially for certain hard-to-recruit specialties, and especially in places where the growth of the Veteran population had outpaced staffing increases. In efforts to focus attention on access and improve performance, VA made numerous errors: it chose the wrong measure (wait times for appointments rather than a more comprehensive patient-centered measure of access), set a uniform and unrealistic target (two weeks, without regard to capacity to meet that target), and tied performance to executive bonuses. The result was that in many facilities, lower level employees felt pressure to report misleading numbers. The irony was that VA had actually adopted many innovations over the past five years to improve access to care, but their success was not necessarily measured in shorter clinic wait times. Initiatives like video-telehealth, secure messaging, MyHealtheVet, SCAN-ECHO, and e-consult all improved the means by which patients, especially rural Veterans, could access their care team or engage the expertise of specialists.

The access crisis was a manifestation of deeper challenges for VA. The series of outside assessments of VA care that were commissioned as part of the Choice Act have recently been delivered to VA and a summary report integrating the separate findings has been made public. 1

Among the many shortcomings it calls out, the report highlights a lack of strategic vision and systems thinking as a fundamental failing, reflected in a tendency to tackle each issue as an isolated problem without thinking of its relation to the entire system. The greatest contribution of research in helping VA respond will be to examine and test the multiple system effects of different solutions being offered to improve access. While timely access is essential, it cannot be viewed alone without considering its relation to other important VA goals: high quality of care; coordination and communication across sites of care; sustainable costs to both the Veteran and VA; a robust mission of education, training, and research; and most importantly, an improved patient experience. There is enough work to keep many researchers busy while VA continues to address access and works to carry out a new transformation.

David Atkins, MD, MPH, Director, HSR&D

1. CMS Alliance to Modernize Healthcare. Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs. Volume 1: Integrated Report. September 1, 2015. The report may be accessed at


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