Posts Tagged process

VA appointment problems — same everywhere

vaphoenixAccording to “The Fix” blog by the Washington Post the VA has problems making timely appointments for patients to see a care provider.  The issue “hit the fan” when it was reported veterans died while waiting for appointments.   So, can an effort to provide quality care exist in an environment where funds are limited?

The first rule of quality management is  the outcome that a process or system delivers is exactly what it was designed to deliver (this is only obvious in retrospect).  The second rule is to change the process rather than blame the people involved if the outcome is not what is wanted.  The third rule is to change the process when needed.  The fourth rule is to be fair and allocate resources according to need.

The VA has a huge job.  But, it is often congratulated for delivering very good care at a price less than standard insurance based care for similar diseases.  Before firing the managers of the VA ask what the waiting time is for appointments at your local psychiatry office or local internist?  And, how many people die while waiting for those appointments  — lots.

Like it or not the VA is socialized medicine.  The congress sets the budget and sets the benefits veterans may receive.  The VA is not an open system, it has cost constraints.  For the US Congress to suggest otherwise is disingenuous (a lie).  The truth is Congress must manage the VA, must set the budget, must monitor cost, must decide what benefits to offer, must limit the medications to be used, must bargain for good medication prices and must provide access on a timely basis — to be fair.

Short waiting time for a needed appointment is a quality goal.  Monitoring the goal and correcting the process to meet the goal is essential.  The process needs tweaking frequently.  If the active military doctor says the discharged veteran needs to be seen within 2 weeks then make it so!  If other services with less impact on care need to be cut back then make it so!  Initial evaluation is very important because without evaluation the need for care can not be known and the fairness to deliver care to the ones most in need is lost.

Anticipating the need for care is also essential.  VA care is part of the cost of war.  300,000 soldiers suffered traumatic brain injury in the Afghanistan and Iraq wars.  It does not take a brain surgeon to realize the VA will need funds and staff to meet the care obligation.  If we need to train more doctors, nurses, PA’s and nurse practitioners then make it so!  Training takes many years which needs to be anticipated by Congress.  If the boat has a leak don’t wait until it is about to sink before doing something.

Back to the basics.  The very notion the VA problems should or could be fixed by firing someone is counterproductive and uninformed.  Should the process of evaluating recently discharged veterans be changed? — absolutely.   Throwing more money at a problem without changing the system is doomed to failure.  Punishing people is not the answer.  What the VA needs is quality management with guts!  The VA can and does deliver good care with appropriately limited resources.


Addendum (5/30/14)  General Shinseki tendered his resignation today and his second in command (on the job for 3 months) will take over.  One would hope the chaos that it causes will be temporary until a more experienced manager takes over (time will tell).  So what should be done?  The VA needs a manager familiar with quality care who also knows how to manage health care within a budget (that may require someone from outside the country!)  A few realistic things that could be done:

1.  Commission a lean engineering study to make binding recommendations for improved efficiency.

2.  Put the VA care statistics on-line.  Make the VA care  transparent.

3.  Get rid of financial incentives for people who have no control of the process that needs to be changed.

4.  Award innovation.  Awarding “employee of the month” to the person who just got to work on time is not innovation!


Another thought (6/11/14):  the VA should participate in Medicare Hospital Compare.  Obviously they do not require Medicare but they could submit the same data as other hospitals in the name of transparent care.  The current criticism centers on outpatient wait-times.  It might be interesting to know what wait times might be for other outpatient care clinics like Kaiser Permanente or other vertically integrated systems.





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Hospital Choice — quality now, cost later

Hospital and road

Denver Colorado is a metropolitan area with several hospitals so the city serves as good example of the dilemma people face to make a choice.

The Denver Metro area is lucky to have good hospitals.  But, the experience one might have as an inpatient depends on many factors including the individual doctors, the nurses and the strength of the quality improvement program at each hospital.  The Center for Medicare and Medicaid Services (CMS) sets quality targets for participating hospitals and measures how  those hospitals perform.  CMS publishes the data and several organizations extract the data and make them available online.  One such site is by the Commonwealth Fund.

Hospitals tend to emphasize heart care because it is profitable and it has a strong emotional appeal. However, the average consumer never really knows what will land them in the hospital.  CMS provides  many different hospital quality statistics but the “overall” statistic is actually  the most helpful to consumers.

Quality can be measured by an “outcome” such as mortality.  Or, quality can be measured by adherence to a “process” .  Process measures are popular because they don’t depend on patient factors such as age or poverty.

For example, leaving home in the morning should include the process of putting on shoes and closing the door.  Following that process does not guarantee a good outcome but lessens the possibility of humiliation at work or later finding a burglar in your home.  Hospital process measures reflect the quality of management and the ability of an organization to execute a plan with numerous players.

The following table is CMS data organized by  The “Overall” is a weighted average of all of the process-of-care, or “core” measures.

NAME — Selected Denver Hospitals


National Ranking

University Of Colorado Hospital Anschutz Inpatient (CO) 99.38% 162 of 1792
Swedish Medical Center (CO) 99.17% 265 of 1792
Presbyterian/st Luke’s Medical Center (CO) 98.76% 460 of 1792
Exempla Lutheran Medical Center (CO) 98.59% 551 of 1792
Exempla Saint Joseph Hospital (CO) 98.33% 698 of 1792
Denver Health Medical Center (CO) 97.56% 1093 of 1792
Centura Health-st Anthony Central Hospital (CO) 95.62% 1619 of 1792

Hospitals love the percentage statistic and hate the national ranking.  There are hospitals in other states that indeed do score 100%.  Just like climbing a Colorado mountain, the last mile is often the hardest.

99.38% or 95.62% means the hospital failed to follow a process 6 or 44 times out of 1000.  One time out of a million would be better.  Which hospital you choose may depend on where your doctor or insurance company sends you.  But, if you have a choice the information from CMS may be helpful.

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