Site Visit Report
NPR representatives – Amy Hertz, Curt Marshall, Betsy Currie
Veterans Health Administration
May 17, 1999
VHA representatives – Larry Papier, Anthony DiStasio, Odette Levesque
, Karen Greaney (Durham), Mary Ann King
VHA has 180,000 employees in the field and 500 in headquarters.
Establishing a Balanced Set of Measures
- Dr. Kizer established the Office of Performance Planning and Quality
- It was a definite top-down initiation – not grass roots. Dr. Kizer and Dr.
Nancy Wilson created performance measures initially with input from various
- A Performance Management Workgroup now serves as a clearinghouse for review
and adoption of performance measures. It is comprised of clinical mangers,
medical center directors, Office of Patient Care Services, chiefs of staff,
QMO, Office of Policy, Office of Quality and Performance, and Chief Network
- Initially there were too many performance measures. The field had difficulty
focusing on the key drivers. Program offices were developing measures independent
of the Network Directors’ contracts and were passing these to the program
staff in the field.
- The Work Group is streamlining the process –. In February, all the Special
Programs performance measures were reviewed and recommendations for refinement
- New potential measures may be monitored for one year - any hot issues may
get a "monitor" measure as part of those monitors tracked by the
- The Co-Chairs of the Work Group report to the Under Secretary of Health’s
Office . The Work Group developed a draft charter/directive for performance
measurement, to formalize the process.
- The Workgroup members are the process owners – they assess that the measures
have sound data that can support them. They try to avoid having to recall
weak measures from the field – this decreases their credibility.
- VHA’s 2000 APP has about 70 measures – 30 of which are process measures
or status reports. They are trying to eliminate these.
- There are 24 key measures for the Department’s APP that goes to the Hill
with the budget – 8 of these are from VHA
- The customer set of measures are well established.
- The VA Department has had one employee survey in recent years. This was
a one time only event.
- VHA mandates that each field-based employee have 30 hours of training/continuing
education per year.
- VA is developing a Learning University, which will help with employee training.
- There is likely some employee satisfaction activities occurring at the VISN
level. There are many local initiatives focused on performance management,
but they are not being monitored by Headquarters.
- Several VISNs and VAMCs have their own version of the balanced scorecard,
but there is not one for all of VHA. It would be too difficult to account
for regional differences in services and appropriately weight the measures.
The measures tracked within the Network Director’s Performance Agreement are
considered the balanced measures.
- There was a culture change within VHA. The Under Secretary for Health was
the major driver for this. One example is the change in the means with which
mistakes or errors are treated concerning patient safety. Instead of overly
punishing an employee who makes a mistake, they are encouraging people to
report mistakes/accidents so that others can learn from the accident and the
system can be improved. He strives to make an easy comparison between VHA
and any private sector provider. Dr. Kizer’s goal is for the VA to be the
benchmark for others to gauge against.
- There is exceptional stakeholder involvement.
- There are quarterly reviews with the Network Directors on performance data.
- The Under Secretary for Health has performance contracts with each of his
Network Directors and Chiefs within Headquarters.
- There is strong accountability. The Performance Plan drives the system.
- There is a document, The Journey of Change, which is the equivalent of an
annual business plan that supports the APP, the strategic plan, and the annual
Measuring Performance – Data Collection and Reporting
- The Strategic Planning Work Group is working to develop new strategic targets
for VHA for 2005. These new targets need to be reviewed by the Performance
Management Workgroup and approved by the Under Secretary for Health. Once
approved, the responsible program offices will develop new performance measures
for each of them. Not all of these performance measures will appear in the
APP or Strategic Plan. Some are for only one-year."
- The VISN Support Service Center developed a website to track the performance
- The Office of Quality and Performance develops quarterly reports which go
to the Under Secretary for Health and the Network Directors. The Chief Network
Officer has been instrumental in focusing the organization on performance
Analyzing and Reviewing Performance Data
- Each VISN has an Executive Leadership Council, in addition to a Quality
Manager, CIO, CFO, COO, and Clinical Manager.
Evaluating and Utilizing Performance Information and Reporting it to Customers
- There are extensive inpatient and outpatient Veteran surveys conducted during
the year. VISN and National Customer Service Reports are developed by the
National Performance Data Resource and Customer Feedback Centers.
Linkages Between the Strategic Plan and Resource Allocation
- Their APP is developed in the Policy and Planning Office and is attached
to the VHA Budget. The linkage between performance and resources is not there
yet. It will take a few years. The healthcare industry is changing quickly
and this has an effect on their ability to link performance with resources.
Benchmarking – Best Practices – Lessons Learned
- VHA believes their success with developing a more balanced set of performance
measures would have happened without GPRA. They attribute much of their progress
to their leadership (Dr. Kizer) and other external forces such as HEDIS.
- They benchmark as much as possible with private sector entities such as
HEDIS measures and JCAHO.