BACKGROUND/RATIONALE:
At the heart of the Institute of Medicine's "Crossing the Quality Chasm" was the need to address the improvement of quality of care through major changes in how health care is organized. Their central tenet was that only through significant, sustained and innovative efforts to reorganize the health care system were substantive gains in quality of care and health outcomes possible. VA's reorganization of care presaged this report by having already launched significant internal restructuring of the care delivery system, including changes in delivery models (e.g., primary care teams, service lines) and adoption of new technologies (e.g., CPRS) and management strategies (e.g., reminders, guideline implementation, performance audit/feedback). While these organizational changes in the aggregate have been found to be associated with substantial gains in VA quality over time and in comparison to Medicare, relatively little is known about the discrete organizational characteristics in VA facilities that have specifically contributed to these changes and which structural features will foster ongoing quality improvement. The need for identifying the organizational influences on quality is all the more important given recent research that indicates that structural differences in how care is organized may explain a greater proportion of the variance in performance than that explained by patient factors alone.
OBJECTIVE(S):
Our objectives are to collaboratively develop a VA clinical practice system assessment survey that meets the combined operational and research needs of the VA Office of Quality & Performance (OQP) and HSR&D investigators by measuring organizational traits of VA facilities that may be associated with performance, including fixed and mutable characteristics that will support the design and adaptation of future quality improvement (QI) policies, practices and interventions. Two key aims will guide the organizational assessment: (1) the ability to benchmark VA health care organizational characteristics with those of non-VA health care settings, plans, and organizations, and (2) the ability to examine time trends in organizational change based on previous VA organizational survey data.
METHODS:
Using a participatory, multi-method approach, we developed, pilot tested, administered the first part of the survey series (Chief of Staff and Primary Care modules) and to adapt the Primary Care (PC) module for web-administration to a random sample of Community-Based Outpatient Clinics (CBOCs). To develop the organizational survey, we reviewed the published literature, integrate expert opinion and cull organizational measures from an array of existing survey tools; content finalization was achieved through iterative review, priority-setting and pilot testing to assure a field-worthy instrument that minimizes response burden while maximizing information yield. Key informants were identified and selected on the basis of the knowledge/familiarity of each individual VA facility (e.g., Chief of Staff, Primary Care Director). The unit of analysis is each geographically distinct site of care, including all VA medical centers and large community-based outpatient clinics (e.g., those serving 4,000+ patients and delivering 20,000+ visits/year) based on VA Outpatient Clinic file data queries. Field preparation and survey administration activities relied on the tailored design method and build on extensive prior experience fielding similar surveys in VA. Data will be 100% double-entered using detailed question-by-question specifications, followed by data reduction, scale development and basic survey analysis.
FINDINGS/RESULTS:
The Chief of Staff Module was fielded in May 2006 through September 2006 with an 86% response rate. The Primary Care Module will be administered in Fall 2006.
IMPACT:
Understanding structural variations and their links to quality of care will help inform the design of more effective QI policies and practices and enable improved "fit" of QI interventions to individual VA facilities. Ultimately, evaluation of the organizational influences on quality of care in VA settings will foster evidence-based practice changes that will have substantial potential for improving the quality of chronic disease and preventive care, as well as veterans' ratings of the quality of care they receive in VA facilities.
PUBLICATIONS:
Journal Articles
- Jackson GL, Yano EM, Edelman D, Krein SL, Ibrahim MA, Carey TS, Lee SY, Hartmann KE, Dudley TK, Weinberger M. Veterans Affairs primary care organizational characteristics associated with better diabetes control. American Journal of Managed Care. 2005; 11(4): 225-37.
