and leadership structures (see Organizational Capabilities and Readiness), joint business offices and a joint strategic planning process, development of multidisciplinary teams and ongoing and continuous communication mechanisms, the combining of departments and services, the transferring of personnel, staff orientation, shared EHR system implementation, and many other such changes.

INTERMEDIATE OUTCOMES

Intermediate outcomes can be categorized in terms of cost and efficiency, clinical processes and outcomes, patient experience, and education and research. Cost and efficiency measures include various measures of productivity as well as cost per patient. Clinical process measures would include the Healthcare Effectiveness Data and Information Set, the DoD, and the Joint Commission benchmark measures. They might also include patient and staff satisfaction measures. Research and education measures could include the amount of research funding generated but also the number of articles published in peer-reviewed journals, particularly articles jointly authored by DoD and VA researchers.

Each potential collaboration should also be evaluated on intermediate outcomes based on its unique organizational mission, strategic goals, and objectives. Some examples at the Lovell FHCC included developing in-house surgical capacity, upgrading the emergency department, extending the range of specialty services provided onsite, increasing professional opportunities for staff, improving the operational readiness of the recruits and other active duty servicemembers, and increasing the clinical competence of Navy providers.

LONG-TERM IMPACT

While intermediate outcomes can usually be observed within a year or 2 of implementing an expanded collaboration, it is also important to examine the longer-term impact that emerges over a 3- to 5-year period. The impact can be measured by responses to key questions. For example, are the initial positive outcomes sustained over time (e.g., in the areas of health care value and efficiency, access, patient clinical outcomes, patient functional health status outcomes, patient experience measures, and related metrics)? Is there growth in the patient population served, admissions, and other indicators of service use? These data should be compared with comparable data available from private-sector institutions to better examine the overall nature of a DoD/VA health service impact in a given geographic area. Finally, it should be asked what additional innovations in



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