By Sandra Basu
WASHINGTON – As a general internist at the Boston VA, Ashish Jha, MD, MPH, believes that the voices of VA physicians are of critical importance in shaping veterans’ care in the future.
“Now that we are getting a much more public airing of both the strengths but also the challenges of the VA, I really hope that creates a context where more physicians feel comfortable about speaking up about what is important,” he told U.S. Medicine in a recent interview.
Jha, who also is a professor of Health Policy at the Harvard School of Public Health, and Kenneth Kizer, MD, who served as VA under secretary for health from 1994 to 1999, recently wrote a perspective article for the New England Journal of Medicine, asserting that “inadequate numbers of primary care providers, aged facilities, overly complicated scheduling processes, and other difficult challenges have thwarted the VA’s efforts to meet soaring demand for services.”
“For years, it has been no secret that the VA’s front lines of care delivery are understaffed for the needs. And though there can be no excuse for falsifying data, we believe that VA leadership created a toxic milieu when they imposed an unrealistic performance standard and placed high priority on meeting it in the face of these difficult challenges. They further compounded the situation by using a severely flawed wait-time–monitoring system and expressing a “no excuses” management attitude,” Kizer and Jha wrote.
They further argued that problems of “data manipulation and prolonged wait times” are symptoms of deeper pathology.
Lost Sight of Mission
“Quite simply, the VA has lost sight of its primary mission of providing timely access to consistently high-quality care. Although it has garnered less attention than the wait-time problems, a disturbing pattern of increasingly uneven quality of care also has evolved in recent years,” the two commentators emphasized.
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Jha told U.S. Medicine that the views shared in their perspective were not unique but widely held among clinicians and even some administrators.
“I’ve had a lot of VA physicians reach out to me. I think what we did is articulate a point of view that is widely felt by a lot of clinicians and even a lot of people in leadership,” he said.
The voices of VA physicians are important on a wide range of issues, including performance measurement, he noted. He and Kizer wrote in their perspective article that the “performance-measurement program — a management tool for improving quality and increasing accountability that was introduced in the reforms of the late 1990s — has become bloated and unfocused.”
“After ensuring that all veterans on wait lists are screened and triaged for care, the VA should refocus its performance-management system on fewer measures that directly address what is most important to veteran patients and clinicians — especially outcome measures,” according to that commentary.
They suggested in the article that the agency’s Strategic Analytics for Improvement and Learning (SAIL) dashboard, which focuses on 28 metrics “including access to care, mortality rates, infection rates, and patient satisfaction, is a good start that will improve with use and would help hold the VA accountable for results.”
“I want to see VA physicians engage on issues around performance measurement. If there are metrics being used that don’t make clinical sense, I think that it is important for physicians to speak up. I think, at times, we as physicians in the system have been too acquiescent to let people who don’t necessarily understand clinical medicine run the show,” Jha told U.S. Medicine.
Moreover, in their NEJM piece, he and Kizer called attention to the VHA’s central office burgeoning growth from about 800 employees in the late 1990s to nearly 11,000 in 2012. In recent years, they wrote, there has been “a shift to a more top-down style of management, whereby the central office has oversight of nearly every aspect of care delivery.”
With this reality, Jha acknowledged VA physician engagement is even more important.
“It’s part of our responsibility as physicians to advocate for our patients. And, as centralized as the VA has become, I do think it will be important for physicians to speak up,” he said.
At a crossroads
Jha explained in the interview that the overall point of the perspective article “is that there are real and important problems in both access and quality of care in the VA,” pointing out that the “problems in the VA are far bigger and more systemic than just difficulties in getting appointments.”
“And yet, I practice at the Boston VA. I know my colleagues. I know the nurses who work there. These are incredibly dedicated clinicians. They care deeply about veterans. They care deeply about the mission of the VA. … That is a pretty good place to start. If you are a healthcare system trying to reform itself, having dedicated staff who care deeply and are competent and effective is a great way to start,” he said.
“Ultimately, we practice in a larger system, and the point we wanted to make is that the leadership of the organization needs to do a lot more to support the clinicians,” he added.
Jha noted that the problems in the VA “are very fixable.” In addition to recommending that VA refocus its performance-management system on fewer measures, he and Kizer offered up other recommendations in their piece including that:
- “The agency should design a new access strategy that draws on modern information and advanced communications technologies to facilitate caregiver-patient connectivity and that uses personalized care plans to address patients’ individual access needs and preferences. Facility-by-facility assessments should determine whether VA facilities are using technology to leverage the best possible ‘care delivery return on investment’ and whether personnel are working at the top of their skills.”
- “The VA needs to engage more with private-sector health care organizations and the general public — participating fully in performance-reporting initiatives, expanding learning-and-improvement partnerships with outside entities (as it did in the late 1990s in spearheading national patient-safety improvement efforts), and making performance data broadly available.”