Site Visit Report
Veterans Health Administration
May 17, 1999

NPR representatives – Amy Hertz, Curt Marshall, Betsy Currie

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 sources.
  • 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 Office.
  • 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 made.
  • 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 CNO.
  • 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.

Establishing Accountability

  • 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 accountability report.

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 measures.
  • 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 measures.

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 & Stakeholders

  • 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.

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