Correspondence

The Quality of Care in the Veterans Affairs Health Care System

N Engl J Med 2003; 349:1093-1094September 11, 2003

Article

To the Editor:

In their article on the effect of the transformation of the Veterans Affairs (VA) health care system on the quality of care, Jha et al. (May 29 issue)1 describe some of the changes in the VA system that led to remarkable improvements in quality. Patient care also benefited from computerized physician-order entry, implementation of an electronic medical record system, pharmaceutical software, bar-code–based administration of medication, adoption of clinical pathways and guidelines, computerized alerts, clinical reminders, and immediate access to remote patient data.

Perhaps Medicare and commercial health insurance carriers could follow the path the VA system took to improve, but there are several caveats. Support for the reporting and monitoring of quality can be costly; the VA system is more likely than others to reap the benefit, since there is little migration of patients out of the system as compared with managed-care systems. Even well-intentioned efforts to improve quality can move too rapidly, with too many measures, some of which may prove to be irrelevant. Finally, cynicism on the part of clinicians is a risk when the documentation of quality is perceived to be the goal.

Edward L. Arsura, M.D.
Melinda Lewis, R.N.
Salem Veterans Affairs Medical Center, Salem, VA 24153
edward.arsura@med.va.gov

1 References

1. 1

   Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med 2003;348:2218-2227
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Asura and Ms. Lewis make important points about the many factors contributing to the transformation of VA care. Certainly, Medicare and others may face additional challenges if they try to introduce some of the changes that contributed to the VA's success, and the VA's long-term responsibility for some groups of patients does cause its leadership to consider investments that pay off over a period of years. However, given the widespread evidence of deficiencies in quality,1 we believe that all health care provider organizations should engage in ongoing monitoring of quality, despite its expense. Support for the measurement and reporting of quality seems to be increasing as consumers, employers, and other groups express more interest in these data,2 and forms of technology such as electronic medical records can facilitate the generation of data on quality at lower cost by improving documentation and making data retrieval easier.

We agree that quality-improvement initiatives run the risk of creating too many indicators and losing the support of clinicians. For that reason, we would suggest emphasizing such initiatives as the list of safety and process measures issued by the National Quality Forum, and reports on outcomes should focus on high-priority clinical arenas in which untoward outcomes are common. In the VA system, quality-improvement initiatives are developed by identifying evidence-based performance measures and ensuring the involvement by clinicians in the design and implementation of improvement programs.

Ashish K. Jha, M.D.
Jonathan B. Perlin, M.D., Ph.D.
Veterans Health Administration, Washington, DC 20420

R. Adams Dudley, M.D., M.B.A.
Institute for Health Policy Studies, San Francisco, CA 94118
adudley@itsa.ucsf.edu

2 References

1. 1

   Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001. JAMA 2003;289:305-312[Erratum, JAMA 2003;289:2649.]
   CrossRef | Web of Science | Medline

2. 2

   Mehrotra A, Bodenheimer T, Dudley RA. Employers' efforts to measure and improve hospital quality: determinants of success. Health Aff (Millwood) 2003;22:60-71
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   David R. Snydman. (2007) Prevention of Catheter-Related Bloodstream Infections: Looking to the Department of Veterans Affairs Health Care System for Guidance. Mayo Clinic Proceedings 82:6, 665
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2. 2

   D. R. Snydman. (2007) Prevention of Catheter-Related Bloodstream Infections: Looking to the Department of Veterans Affairs Health Care System for Guidance. Mayo Clinic Proceedings 82:6, 665-665
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3. 3

   Ronald T. Ackermann, Paris Roach, David G. Marrero. (2004) Good Diabetes Care. Medical Care 42:2, 99-101
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