VA's reorganization of care presaged the IoM Quality Chasm report by having already launched internal restructuring, including changes in delivery models, adoption of new technologies, and implementation of new management strategies. In the aggregate, these organizational changes have been found to be associated with substantial gains in VA quality over time and in comparison to Medicare. Yet remarkably little is known about the discrete changes in VA facilities that specifically contributed to these gains or the contextual factors that affected the ability of local facilities to deploy changes needed to accommodate reorganization policies and practice changes. The overarching goal of this study was to use unique data sources to provide an empirically tested substrate for informing evidence-based management, practice and policy for the next wave of VA transformational initiatives and to foster translation of VA's successes to core administrative and clinical practice knowledge to other health care systems, organizations and health plans.
Our research objective was therefore to evaluate the organizational and contextual determinants of VA's quality transformation. As a result, we had three aims:
Aim #1: To evaluate the organizational changes associated with VA performance over VA's reorganization.
Aim #2: To determine the area contextual factors that may have influenced organizational changes over the course of the VA's reorganization and accompanying performance.
Aim #3: To use expert panel methods to integrate and apply findings to produce evidence-based management guidelines in support of ongoing VA quality improvement and translation of lessons to other health care settings.
To accomplish Aims #1-2, we merged and analyzed data from three national VA organizational surveys, 5 years of VA performance data, matched patient-level covariates and area contextual characteristics. For Aim #3, we convened an expert panel comprised of national, network and facility VA leaders using a modified Delphi process to critically review/synthesize results from Aims #1-2 to develop evidence-based management guidelines.
We documented the wide array of longitudinal organizational changes that served as the foundation of VA's quality transformation, demonstrating early advances in staffing, policy development and practice arrangements. However, we also found significant rescissions in policy and procedures that backtracked early gains supporting primary care delivery by 1999. Yet, early investment in primary care staffing and practice arrangements yielded important dividends for the trajectory of organizational change and post-reorganization performance when sustained. We also found that contextual factors (e.g., urban/rural location, primary care shortage area, size) had substantial impacts on local structural/process changes and ultimately performance.
Our findings reflect the challenges and successes behind the VA Journey for Change of the mid-1990s, enabled by an unusual level of concordance of mission and vision from the highest levels of VA to the everyday work of frontline clinicians and managers. Some of the changes accomplished during 1993-96 were deconstructed during 1996-99, raising issues about how to sustain initiatives and create enduring new ways of doing business. We anticipate that the lessons from the previous quality transformation have important implications for the medical home and cultural transformations currently underway.
External Links for this Project
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