STATEMENT OF
DENIS J. FITZGERALD, MD, MHA
NETWORK DIRECTOR (VISN 1)
VA NEW ENGLAND HEALTHCARE SYSTEM
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE SUBCOMMITTEE ON HUMAN RESOURCES
OF THE
HOUSE COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT

September 25, 1998

Chairman and members of the Committee, I appreciate the opportunity to appear before you today. I look forward to discussing not only the high quality of care delivered in the New England Healthcare System (VANEHS) and how we measure it, but also any related issues about which you may have received expressions of concern. In addition, I would be pleased to address how we plan to maintain the quality of care within our VISN as our new "integrated" structure continues to evolve.

VISN 1, the VA New England Healthcare System (VANEHS), includes nine Medical Centers located in the six New England states: Vermont, New Hampshire, Maine, Connecticut, Rhode Island and Massachusetts. Most of these Medical Centers have significant, longstanding affiliations with some of the most prominent Medical Schools in this Country. These include Harvard, Yale, Brown, Dartmouth, Boston University, Tufts, and the Universities of Massachusetts, Connecticut and Vermont Medical Schools. Our programs and personnel provide the full spectrum of healthcare services from outpatient primary care to complex tertiary and quaternary care. Among these services are many special programs such as Spinal Cord Injury, Open Heart Surgery, Domiciliary care, Compensated Work Therapy, Blind Rehabilitation and a model program for addressing the needs of Homeless veterans, to name but a few.

VANEHS is charged with providing services to veterans in diverse geographic locations which span the spectrum from the densely populated urban centers of Boston and West Haven to the sparsely populated rural areas of Maine, Vermont and New Hampshire. In addition, from a demographic and socio-economic perspective, the health of New England veterans parallels similar non-veteran cohorts within the general population. As a result, the clinical care expectations and delivery system challenges facing VISN 1 represent a cross section of American healthcare and bring together all of the issues found in different regions throughout the VA. In addition, despite projections and studies that conclude that there is a decreasing number of veterans within New England, the overall workload has not declined considerably in the past few years. Our VISN, in fact, has experienced an increase in the number of outpatient visits and the overall number of veterans being served.

After an extensive study and evaluation in October 1995, Congress approved implementation of the Veterans Health Administration reorganization plan. As with all changes undertaken by VHA, the purpose of the reorganization was, and is, to improve the overall well being of those veterans who seek our help. The VA New England Healthcare System (VANEHS), VISN 1, is accomplishing this mission by placing the veteran - our patient - at the center of all we do and by rethinking, redesigning and realigning VA assets to meet patient needs in the most effective and efficient manner within available resources. Under this construct, the Network is responsible for and entrusted with the development, maintenance and performance of the necessary systems, protocols and guidelines that will ensure comparable clinical care of consistent high quality across the Network and that will add value to every patient encounter.

Through the development of network service lines and the application of performance measures and clinical guidelines, VANEHS management is creating the systems of care and the medical environment necessary to ensure that high quality care is available and practiced universally throughout the network. Our extensive involvement in professional education and clinical research, when linked with our close affiliation with numerous prestigious Medical Schools, further contributes to the quality and richness of the practice environment found throughout Network 1. The result is that in VISN 1, clinical interactions are coordinated and managed across the continuum to meet measurable best practice standards and prospectively negotiated outcome expectations.

Operationally, "value" is defined as achieving an optimal balance among three critical, yet dynamic, parameters: clinical and functional outcomes; patient satisfaction and service; and costs. Where clinical and functional outcome parameters are not yet available, process and / or structural quality measures are used. Ultimately, as our Network evolves and matures, all clinical and administrative decisions will focus on patient need and be designed to add value to each patient - caregiver interaction. The result will be measurably better clinical and functional patient outcomes, greater patient and professional satisfaction, and lower operational costs …the right care, in the right place, at the right time, and at the right cost.

Clearly, to accomplish our approved mission and vision requires a significant shift in the VAMC's traditional approach to providing services. To facilitate that transformation and to integrate the existing health service programs and the capacity of the divisions into a coordinated, regional network that meets the needs of veterans in local markets, the VISN introduced several network-wide systems.

STANDARDIZATION OF HEALTH CARE

To help standardize the delivery of healthcare throughout VISN 1 and to expedite the transition to ambulatory care and outpatient services, an ambulatory service line was developed. This service line, and the others, which will follow, ensures that veterans receive comparable care of consistently high quality across the Network. In addition, the Network has instituted 23 clinical practice guidelines and protocols which foster better clinical outcomes, greater patient satisfaction, and lower costs.

OUTREACH

To reach out to the veteran population, to become a more friendly and convenient provider, and to improve patient access, the Network has provided guidance and funding for the establishment of several Community-Based Outpatient Clinics (CBOCs) located in veteran population centers that are distant from existing VA facilities. Among the newly activated CBOCs in VISN 1 are Portsmouth, NH; Hyannis, Lynn, Haverhill, and Framingham, MA; Waterbury and Stamford, CT; Bennington, VT; and Rumford, ME. Additional CBOCs are in the planning stages and will continue to be placed in local communities when there is a demonstrated need for such services. As a supplement to these permanent clinic sites, the Network encourages and incentivizes the provision of screening clinics and health fairs at a variety of locations across New England to better serve our veteran population.

TRANSPORTATION AND REFERRALS

For those patients who require referral to another VA medical center, the Network has coordinated, enhanced and formalized an interfacility transportation system. This system is designed to ease the burden and inconvenience for the veteran when a referral cannot be avoided. It enables veterans to go to their local VA medical site and be transported by the VA to the VA referral destination and then be returned when their appointment or treatment has concluded. The transportation system also provides for the regular and timely transfer of lab samples, supplies, mail and other packages that must be moved between medical centers. In addition, the system enables us to move healthcare providers to the patient when that is appropriate. Several specialists currently travel from Boston and White River Junction to provide outpatient clinics at the Bedford, Brockton, and Manchester sites and from Brockton and Providence to provide services at the Hyannis site. This system facilitates the veteran's ability to receive specialty care at their local VA and minimizes the number of veterans who have to travel to a referral hospital for their care. Interfacility cooperation of this type will continue to be coordinated and encouraged by the Network.

When it is not practical for VA staff to travel to the patients, each Division is encouraged to explore the possibility of providing services locally through contracts or sharing agreements with local providers. Our goal is to provide as much care as possible in the local area, consistent with best clinical practices. Examples of Network-guided innovative approaches to improve local access include: the agreement between Newington and the University of Connecticut to provide ambulatory specialty care, ambulatory and inpatient surgery, and medical hospitalization; and the agreement between community providers at three MRI sites and a radiation therapy site and VAMC Togus to provide those services to the Maine veterans. However, this approach must be balanced with our obligation to use available resources in the most effective and cost efficient manner to provide the most care for the most veterans.

INFORMATION TECHNOLOGY

The standardization and appropriate application of advanced information technology has made possible the convenient access to an enhanced quality of care in rural areas and the improved coordination and continuum of care. We have implemented telemedicine and teleradiology systems that allow physicians from remote locations to transmit images of patients or x-rays to specialists at major VA facilities in VISN 1 to assist with the diagnostic and therapeutic process. This offers the patient another mechanism to receive care in the local community while still having access to highly specialized expertise that would not previously have been available without traveling to a tertiary care medical center.

In addition, our telephone systems now allow veteran access to VA medical centers and professional staff 24 hours a day. Using clinically determined protocols, veteran health questions and needs can often be satisfied immediately. Use of this telephone system is often effective in obviating the need for a visit; in providing helpful healthcare information; in improving patient compliance with treatment regimes; and in preventing potential problems.

Recently, the VISN concluded a telephone based pilot study that offers disease-specific information. Designed to educate and involve the patient in his or her treatment decisions, this program is available at three sites, 24 hours per day. If data analysis proves that the program adds value to our patient users, we will expand the program to all sites in VISN 1.

As an integrated healthcare system serving a defined veteran population, we must provide our clinical staff with the ability to access patient information as needed. To that end, we have significantly upgraded our information systems to facilitate the sharing of complete, accurate information about any patient among all VA Medical Centers in VISN 1. This expedites the consult, referral and feedback process to ensure each patient’s care is managed appropriately by his primary care team and all pertinent information is available to any provider involved in the care of the patient.

As a result of the system and process changes discussed above, veterans in New England will benefit by the availability of more primary care and specialty outpatient services in all VISN 1 facilities. A standard package of basic benefits and services will be available at all sites. The full range of services from basic primary care to highly specialized tertiary services will be available within the VISN. Improved communication and referral procedures between hospitals will facilitate patient treatment and movement along the continuum of care. Better coordination of all transportation systems and clinical appointment scheduling will improve access for veterans and eliminate unnecessary delays in obtaining care. In addition, coordination with local community providers, in circumstances when VANEHS cannot provide services, will help expand the availability of care at the local level. Finally, the continued establishment of CBOCs throughout the Network will substantially improve local access to care for a significant number of veterans. In sum, these changes are helping to move VISN 1 toward our goal of providing veterans with the right care, in the right place, at the right time, and at the right cost.

As we implement these network-wide systems, process and system improvements, uniform quality criteria, standards of care, practice guidelines, performance measures and outcome monitors are applied. The ability to impose consistent procedures across a network of hospitals is one of the major benefits of the new VISN organizational structure.

Prior to the activation of the Networks, each VA facility operated to a significant extent in isolation from other VA Medical Centers. Standards of care and quality monitors were often developed or interpreted locally and they often relied on different databases from one facility to the next. While each facility had a systematic approach to measuring and monitoring the quality of care being provided, it was difficult to make comparisons among facilities or review performance without understanding the sources and definitions of the information being reviewed. This diminished the reliability of many reports that were collected at the national level.

Consequently, in light of this situation, we initially relied on each Medical Center to monitor and report on the quality of care they provided. In addition to these internal systems, we looked to VISN level reviews and external reviewers such as the External Peer Review Program, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Office of the Medical Inspector, the Inspector General, and site visits by Veteran Service Organizations to validate the quality of care being provided at VISN 1 Medical Centers.

Based on our goal of providing comparable, high quality care throughout the VISN, we began the process of developing and implementing uniform criteria, definitions, standards, databases, and other measures to ensure consistency of care and quality across the VISN. Quality has been the major focus of our initiatives since the VISN was formed in 1995. This emphasis on quality and consistency extends beyond the Networks to VHA at the national level. By establishing and applying national standards, performance measures, quality monitors, outcome indicators, and healthcare industry benchmarks to all VISNs, the VHA has demonstrated its commitment to improving quality within the "new VA". All VISNs have been assigned performance standards they are expected to meet on an annual basis. In Fiscal Year 1997, VISN 1 was rated second among all 22 VISNs in overall performance. For the first three quarters in FY 1998 VISN 1 is currently at or above the national average for most performance measures and is again near the top of the list for all VISNs.

The above achievement is the result of significant time and effort being devoted to improving our performance. We implemented a process that involves weekly conference calls, periodic network-wide meetings, and regular feedback of current performance data to all facilities in VISN 1. This ensures continuous attention to quality issues and provides numerous opportunities for addressing concerns, sharing ideas, offering suggestions, recommending solutions to problems, and discussing general information related to quality.

More specifically, the VISN 1 value scorecard of clinical and functional outcome measures includes the following outcome results:

• From The Cohort Based Analysis of Utilization and Survival Rates across VA Healthcare between 1992 - 1996: the early year results from this study reveal that VISN 1 is consistently a high outlier in inpatient and outpatient resource use. The latest data (1996) reveals that over the period studied VISN 1 has shown substantial improvement in resource use while maintaining among the lowest mortality rates in the Nation. The results of this study provided the rationale for our first 18 Network clinical practice guidelines.

• From The 1997 National Health Outcomes Study: This study which was conducted by the VA Health Systems Research and Development Organization used a SF36 patient evaluation instrument to determine the outcomes of care as perceived by veterans. More specifically, this tool measures veterans' perceptions of their functional level post treatment. Overall, the study concluded that VISN 1 functional outcomes were among the best in the Nation. VISN 1 was the leader in the area of Mental Health and was among the top quartile in functional outcomes in Medicine and Surgery.
• From The National Surgical Quality Improvement Program (NSQIP): This study demonstrates that surgical care provided in VISN 1 meets or exceeds quality standards.

Process quality indicators include elements of the Chronic Disease Index (CDI) and the Preventive Index (PI):

• From the Performance Measures, CDI, and PI: During the first three quarters of 1998, VISN 1 continued to make significant improvements in the overall CDI and PI and remained at or above the VA national percentage score in both areas. Significant gains were made in the elements of hypertension and obesity monitoring within the CDI and tobacco use and immunization parameters in the PI.
• From the Veterans Health Survey from the National Center for Health Promotion (1997 - 1998): This study indicates that between 1997 and 1998 VISN 1 significantly improved in 24 out of the 28 measured parameters and met or exceeded the National VA score in 23 of 28 indicators. Currently, VISN 1 meets or exceeds 61% of the 28 VA goals for the year 2000. These measurements are an indicator of our veterans' understanding of and participation in their preventative, disease monitoring and treatment programs. This represents an independent validation of the VISN's performance on the CDI and PI from the patient's perspective.

In addition to the above national outcome studies and process measures, there are structural measures of quality that support our contention that the quality of care provided in VISN 1 is very high. In 1997, the JCAHO conducted triennial surveys at all VA Medical Centers in VISN 1. The JCAHO is a nationally recognized healthcare accrediting body that surveys most hospitals throughout the country. Their standards and survey results are considered to be the benchmarks for the healthcare industry and are accepted as indicators of the quality of care provided by those institutions it surveys. In VISN 1, all nine VA Medical Centers received three-year accreditation with scores that exceeded the national average for private sector hospitals. In addition, each VA Medical Center in VISN 1 demonstrated improvement in its score from the previous survey and the Providence and VA Connecticut facilities received "Accreditation with Commendation". This is an honor bestowed on very few hospitals and is indicative of excellent care and conformance to high quality structure and process standards. Several other VISN 1 facilities came close to receiving accreditation with commendation as well. We are currently in the midst of preparing for another survey in which the JCAHO will evaluate us as a Network. This is a pilot program in VHA and we are one of only two VISNs selected to participate in the JCAHO process.

Aside from the technical and clinical measures of quality care, patient satisfaction is an important indicator of the quality of care being provided. The timeliness of service and patients’ satisfaction with the care they receive is measured nationally through patient satisfaction surveys.

Entry into the VA system of care begins with the establishment of eligibility. This process often requires completion of a Compensation and Pension examination. The national standard for processing such requests for C&P exams is 35 days. VISN 1 is currently exceeding this standard by completing these exams within 28 days on average. In addition, 98.9% of the exams we conduct are determined to be sufficient to meet the needs of the reviewers. This exceeds the VA standard of 98% and is very close to the exceptional level of performance, which is 99%. In fact, only two of seven Medical Centers that provide these exams in VISN 1 are below the 99% level.

As a VISN, we have been very successful in improving our ability to provide prosthetic devices to eligible veterans in a timely fashion as well. In FY 1998 for the first three quarters only 0.6% of all orders were delayed by more than five days. The VA standard calls for less than 2% delayed orders. Other measures of timeliness related to the issuance of prosthetic devices are monitored as well. Average Appointment Waiting Times for several clinics that specifically serve veterans who may be in need of prosthetic appliances are monitored nationally. In four of the five clinics, waiting times in VISN 1 are significantly less than the national average waiting times. In the fifth clinic our average waiting time is less than one day longer than the national average.

With regard to patient satisfaction, we are very proud of our performance as measured by patient surveys conducted at the national level on a random sample of outpatients. For the past two years, VISN 1 has received excellent scores in the six categories that are measured: Access, Preferences, Education, Emotional Support, Coordination, and Courtesy. In fact, our scores in each category and our overall score exceed the VA national averages by more than two standard deviations. We are at the top of all VISNs in the area of patient satisfaction based on these results.

In order to maintain the level of achievement we have experienced to date, we must continue the various activities we have described above. We must also supplement existing programs with new initiatives that will enhance quality of care throughout the VISN. Some of the initiatives that have already been developed include the following:

• Hired a full-time physician to serve as the Quality Management Officer for VISN 1.
• Reorganized the performance improvement efforts into a Quality Management Improvement Council (QMIC) with representation from all Medical Centers.
• Developed a model Patient Safety Policy and a Patient Safety Handbook.
• Established standardized practices for incident reporting, which have been adopted as a national model.
• Instituted continuous monitoring of the performance levels of all facilities and required the formation of action plans where necessary to correct deficiencies or improve performance.
• Implemented service lines to ensure the provision of comparable, high quality clinical care and support services throughout the Network.

We believe the establishment of the VISNs has clearly been beneficial to the assurance of quality care throughout the VA. The collaboration and cooperation inherent in the VISN organizational structure provide obvious channels for a broad-based approach to maintaining and enhancing quality across the system. These same benefits are also evident in the area of operations. The VISN concept fosters cooperation and can impose consistent standards of performance among all elements of the integrated system. The operational and strategic changes that have evolved with the implementation of the VISN reorganization have begun to break down some of the previous obstacles to effective cooperation among VA Medical Centers. Increased collaboration and interaction among all facilities are being encouraged and a new sense of belonging to a system of care is slowly emerging.

As you know, however, these operational and programmatic changes have been accompanied by a change in the way VHA allocates available resources. This has proven to be a complicating factor in VISN 1. In addition to the organizational restructuring and the shift to an integrated healthcare system we have also had to respond to the implementation of the Veterans Equitable Resource Allocation System (VERA). Under this allocation methodology, VISN 1 has experienced a reduction of $52 million dollars in our budget during the last eighteen months. Some individuals and groups have tried to tie the operational and programmatic changes described above to the reduction in the budget. While there can be no doubt that a decrease of $52 million dollars is significant, it did not drive the changes that have been made.

In FY 1996, each VISN produced its first Strategic Plan. This was prior to the development and implementation of VERA, which did not occur until mid-way through FY 1997. In VISN 1’s first Strategic Plan, we outlined several strategies for enhancing the quality and accessibility of care across the Network. We described several initiatives that were designed to facilitate the shift from inpatient to outpatient, from the "old VA" to the "new VA". These plans provided a blueprint for the VISN to prepare us to move into the next century as a viable, modern, state-of-the-art, integrated healthcare system. One of the main objectives was to construct an integrated healthcare delivery system that would use available resources in the most effective and cost efficient manner possible to enable us to provide the most care to the most veterans. Reducing inefficiencies, eliminating redundancies, and combining administrative functions have allowed us to redirect savings to patient care activities.

The strategies contained in this first plan positioned the VISN such that we were able to absorb the reductions associated with the VERA methodology without resorting to eliminating programs or services. We were already decreasing our operating costs through the initiatives outlined in the Strategic Plan. Programs were being streamlined and improved. There were shifts in focus from inpatient to outpatient programs based on clinical evaluations and the goal of enhancing quality and access for veterans. Administrative consolidations were developed and cooperation among facilities was encouraged. The second Strategic Plan provided an update to the initial plan and continued the basic strategies that were developed. There was not a cause and effect connection between VERA budget cuts and our operational or programmatic changes.

Any time an organization undergoes dramatic changes there are likely to be challenges and obstacles encountered along the road to the final objective that has been identified. Change does not come without some discomfort. The VA is no exception. While we have worked diligently to effect a smooth transition in VISN 1 there have been some rough spots along the way. We have taken substantial precautions to minimize any disruption to any patient’s care. Unfortunately, some veterans have attributed any problems they have experienced to the establishment of the VISN and/or to the implementation of VERA and the resultant decrease in available resources in VISN 1.

The shift from a hospital system to a healthcare system has changed how we deliver care to veterans. This includes shorter lengths of stay as an inpatient, fewer admissions to inpatient care, more ambulatory surgery, increased emphasis on wellness and preventive care, the establishment of primary care teams, and a managed care approach along the continuum of care. For many individuals these are new concepts that produce anxiety about the availability and quality of the care they feel they will receive. In spite of efforts to educate everyone about the need for change and the advantages of the proposed plans, some individuals remain skeptical and resistant. We have attempted to address the concerns expressed by such individuals as they have arisen but some of our efforts have not always been well received. There are still some veterans and even some employees who want to go back to the "old VA". This cannot, and should not happen. The shift to outpatient care and the implementation of a managed care, primary care model are significant improvements to the care delivery system for veterans. Those who have given this new approach a chance are generally pleased with these changes. We believe, in time, all veterans and employees will recognize and understand the benefits of the "new VA".

The organizational and cultural changes inherent in such a dramatic reorganization will require several years to achieve and will require significant adjustments on the part of employees and veterans. Our focus during this process, however, is on ensuring that quality of care is maintained throughout VISN 1. As Dr. Kizer said, "In the ‘new VA,’ patients will get the right care at the right time in the right place at the right cost." This is our goal in VISN 1.

Thank you for inviting me to speak before you today. I appreciate your support for our efforts to provide the best possible care to our nation’s veterans. I would be pleased to answer any questions you might have.