In general, health care in the United States is fragmented, costly, and with significant variation in quality of care. Systems are structured around the management of acute and urgent health problems with a focus on single episodes of treatment. Mental health care is typically separated both structurally and functionally from other components of the health care system. Coordination around the full range of patient health needs is often lacking, contributing to inefficiencies and higher costs. Such system deficiencies are among the barriers to care preventing Americans, particularly those with ongoing needs for care, from receiving appropriate health services (IOM, 2001). In Chapter 2, information about the non–Department of Veterans Affairs (VA) health care sector and about mental illness in the general population is presented for the purpose of general context. Building on that discussion, this chapter broadly describes health care quality in the United States and provides the conceptual foundation for the committee’s assessment of mental health care quality at the VA.
The chapter begins by defining health care quality and the attributes of integrated health care delivery systems, which is followed by a summary of the VA’s recent system reform initiative. The remainder of the chapter describes the organizational framework for Chapters 8 through 15 of the report, each corresponding to one of the eight dimensions of health care quality. Chapters 8 through 15 each address these quality dimensions by presenting findings from the research literature as well as details from the VA site visits that the committee conducted as part of this study.
In its landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), the Institute of Medicine (IOM) defines quality of care as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 21). Another common definition is
“doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results” from the federal Agency for Healthcare Research and Quality (AHRQ, 2016).
Health care quality is a multidimensional concept. Donabedian characterized three components of quality health care: technical quality (the provision of care produces achievable health gain), interpersonal quality (patient needs and preferences are addressed), and amenities (the attributes of the physical setting support care) (Donabedian, 1980). IOM’s Quality Chasm framework established six aims for high-quality health care that are relevant to mental health care as well as general medical care (IOM, 2001, 2006). All health care should be
- “Safe: avoiding injuries to patients from the care that is intended to help them.
- Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
- Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
- Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
- Efficient: avoiding waste, including waste of equipment, supplies, ideas, energy and human resources.
- Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.” (IOM, 2001, pp. 5–6)
Five years after Crossing the Quality Chasm (IOM, 2001), IOM released a subsequent report examining quality in the field of mental health and addictive disorders. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series (IOM, 2006) cited ample evidence of problems in the quality of care for mental and substance use problems and illnesses. In addition to the quality problems shared with health care generally, mental health care is distinctive in significant ways. Those distinctive features include the greater stigma attached to mental health diagnoses; more frequent coercion of patients into treatment, especially for substance use problems and conditions; a less developed infrastructure for measuring and improving the quality of care; the need for a greater number of linkages among the multiple clinicians, organizations, and systems providing care to patients with mental health conditions; less widespread use of information technology; and a more educationally diverse workforce (IOM, 2006).
Health care quality that reflects aspects of the IOM framework relies on monitoring how care is delivered. Chapter 15 provides more in-depth information about quality measurement in general and the VA’s quality measurement and improvement programs. Systematic quality measurement is necessary for quality improvement, accountability and transparency, and informed patient decision making.
The IOM’s Crossing the Quality Chasm (IOM, 2001) argued that integrated health care systems, such as the Veterans Health Administration (VHA) in the VA, are the best care delivery models for providing patients with access to effective, patient-centered, timely, efficient, equitable, and safe care. Integrated systems can improve care coordination and achieve continuous quality improvement and accountability. Optimal collaboration and coordination of patient care is essential for all patients, particularly when the diagnosis involves physical and mental health problems, a chronic condition, multiple conditions, or other complex health problems. Over half (51.7 percent) of all Americans have at least one chronic
health condition (Gerteis et al., 2014), and veterans are more likely than non-veterans to report having multiple chronic conditions (Kramarow and Pastor, 2012). (Chapter 4 provides more details about the high risk of mental health problems and comorbidities among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans.)
In a fully integrated delivery system, different levels of care from physicians, clinics, hospitals, academic medical centers, and long-term care facilities are under one management umbrella (Essential Hospitals Institute, 2013). As described in Chapter 2, the VHA is the largest fully integrated health care delivery system in the nation. Kaiser Permanente is the largest fully integrated system in the private sector. Accountable care organizations are rapidly emerging as another approach to integrated care. Common features of integrated systems include (1) communication and information sharing across the care continuum, and (2) the coordination of patient care to improve the patient experience and care quality (Hwang et al., 2013).
A growing body of empirical research shows that integrated delivery systems have a positive effect on the quality of care in such areas as clinical effectiveness, lengths of stay, medication errors, and the number of office visits (Enthoven and Tollen, 2005; Hwang et al., 2013). Favorable patient outcomes have been found in integrated systems using care planning, multidisciplinary teams, self-management, and ongoing assessment and follow-up (Collins et al., 2010; Wagner et al., 1996). Several studies have found better outcomes for patients treated in integrated delivery systems than in non-integrated delivery systems (Hwang et al., 2013).
Effective system synergies across the continuum of care are the cornerstone of integrated care and quality. Effective synergistic care delivery, or systemness, can be described as delivering patient-focused, seamless care across the many parts of the system in order to maximize value for customers and proactively address the health of populations (Zuckerman, 2014). With systemness, synergies are obtained when all the component parts come together as a system, and thus lead to predictably and consistently good outcomes (ECRI Institute, 2013).
The attributes of a “world-class medical facility” have implications for what a highly functioning integrated health system should like. As described by the Defense Health Board, an advisory body for the Department of Defense, the attributes of a world-class medical facility include “applying evidence-based healthcare principles and practices, along with the latest advances in the biomedical, informatics and engineering sciences; using the most appropriate state of-the-art technologies in an easily accessible and safe healing environment; providing services with adequate numbers of well trained, competent and compassionate caregivers who are attuned to the patient’s, and his or her family’s culture, life experience and needs; providing care in the most condition appropriate setting with the aim of restoring patients to optimal health and functionality; and being led by skilled and pragmatic visionaries” (Kizer, 2010).
Also a concept that is germane to highly functioning integrated health systems is a “culture of high reliability.” The attributes of high-reliability organizations include reciprocal accountability between management and clinical teams, strong and open communication among team members, leadership responsibility and dedication to safety and highly reliable organization performance, mutual respect among team members, and fair and just treatment for all team members (Wu and Kizer, 2016).
A recent independent assessment of VA’s health care delivery system and management processes concluded that VA should focus on interdependent systems components—governance, operations, data and tools, and leadership—if it is to successfully improve its complex health care system and achieve higher levels of “systemness” (MITRE Corporation, 2015). The assessment was authorized under Sec-
|Veteran Experience||Employee Experience|
SOURCE: VA, 2016.
tion 201 of the Veterans Access, Choice, and Accountability Act of 2014.1 In the report, the mechanisms for purchasing care, such as the Veterans Choice Program that allows eligible veterans to receive health care in their communities rather than waiting for a VA appointment or traveling to a VA facility, are offered as an example of an area that would benefit from a systems approach to overcome piecemeal tactics to reforming access problems as well as the lack of guiding strategy for VA’s purchased care enterprise as a whole (MITRE Corporation, 2015). More information about the Veterans Choice Program can be found in Chapter 9.
In 2014, following reports of persistent problems in access, quality, leadership accountability, and the associated downturn in public opinion, the VA launched a new system transformation, called MyVA, which is aimed at achieving customer service excellence and building a high-performing organization to serve the nation’s veterans (VA, 2015). Table 7-1 shows the 2016 priorities for MyVA, which include efforts to improve both the veteran experience and employee experience (VA, 2016).
MyVA’s goals include offering same-day access to mental health and primary care services when medically necessary (VA, 2016) and expanding mental health offerings, mainly through the Veterans Choice Program, which gives eligible veterans options for obtaining care from private-sector providers. MyVA’s other goals include creating mobile apps for mental health and improving the Veterans Crisis Line. The VA is tracking progress toward these goals (VA, 2013). For example, in 2017 the VA announced a policy to offer emergency mental health care to veterans with an other-than-honorable discharge status (VA, 2017) (see Chapter 6 for more details). The chapters that follow identify various other VA policies, initiatives, and programs for mental health service delivery and present the committee’s findings about VA mental health service delivery along the dimensions of quality discussed in this report.
The national health care context, quality frameworks, and the attributes of high-functioning health systems discussed above have informed the focus of the committee’s assessment of the VA’s mental health care services. Chapters 8 to 15 address five of the six IOM quality aims—effective, patient-centered, timely, efficient, and equitable care (patient safety issues are beyond the purview of this
1 Public Law 113-146.
study)—as well as the three structural areas of workforce and facilities, health technology, and quality improvement, which relate to the entire VA health care system and bear on all of the IOM quality aims.
With these eight aspects of quality in mind, the committee drafted examples of the types of questions that define each area operationally and that can help inform the public, health care administrators, policy makers, regulators, and others about the level of quality that a health system provides. Refer to Table 7-2.
Given the complex nature of health care systems and practice, assigning assessment questions to a particular quality aspect as shown in Table 7-2 is somewhat subjective and does not capture the overlap that exists across various aspects of quality. For instance, having processes in place to integrate and coordinate care makes care delivery more efficient, but it can also result in effective care. Access to care, which is central to the quality of a health care system, is an issue that must be addressed in a number ways, in addition to the timeliness of service delivery as expressed in the IOM quality framework. For
|Quality Aspect||Assessment Question|
|Workforce and facilities||
SOURCES: IOM, 2001; Ken Kizer for the Committee to Evaluate the Department of Veterans Affairs Mental Health Services.
example, to ensure that veterans can obtain needed care there must be sufficient staffing, facilities, and infrastructure in place to meet the demand for services. Services must be within reach for veterans who wish to obtain access to them, including by having the latest technology available to patients and providers—which is digitally accessible when appropriate—to maximize the reach and efficiency of services.
Taken together, the eight chapters that follow illustrate the complexity of assessing and improving health care quality, particularly in a large, multifaceted, and dynamic health system like the VHA. In the 1990s, the VHA’s reform efforts were focused on systematizing quality assessment and improvement in order to ensure that veterans received the highest-quality health care possible everywhere in the VA health care system. Those efforts were successful in many ways and had positioned the VA as a model for how to improve patient outcomes and achieve system-wide efficiencies (Kizer et al., 2000). Since then, the significant consequences of the long-standing military conflicts in Iraq and Afghanistan have challenged the VA to deliver consistently excellent quality of care and service to veterans. The information gathered and reviewed for this report demonstrates the VA’s attention on and progress toward quality care and service, but as summarized in Chapter 16, additional efforts are necessary for the VHA to become a high-reliability organization and reduce variation in care, address the unmet needs of individual patients, and improve the health of the veteran population.
AHRQ (Agency for Healthcare Research and Quality). 2016. Understanding health care quality. https://archive.ahrq.gov/consumer/guidetoq/guidetoq4.htm (accessed December 15, 2016).
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Hwang, W., J. Chang, M. Laclair, and H. Paz. 2013. Effects of integrated delivery system on cost and quality. American Journal of Managed Care 19(5):e175–e184.
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IOM. 2006. Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington, DC: The National Academies Press.
Kizer, K. W. 2010. What is a world-class medical facility? American Journal of Medical Quality 25(2):154–156.
Kizer, K. W., J. G. Demakis, and J. R. Feussner. 2000. Reinventing VA health care: Systematizing quality improvement and quality innovation. Medical Care 38(6 Suppl 1):I7–I16.
Kramarow, E. A., and P. N. Pastor. 2012. The health of male veterans and nonveterans aged 25–64: United States, 2007–2010. Hyattsville, MD: U.S. Department of Health and Human Services.
MITRE Corporation. 2015. Independent assessment of the health care delivery systems and management processes of the Department of Veterans Affairs volume i: Integrated report.
VA (Department of Veterans Affairs). 2013. VHA Strategic Plan: FY 2013–2018. Washington, DC: Department of Veterans Affairs.
VA. 2015. MyVA integrated plan overview. Washington, DC: Department of Veterans Affairs.
VA. 2016. MyVA transformation update. Washington, DC: Department of Veterans Affairs.
VA. 2017. VA secretary announces intention to expand mental health care to former service members with other-than-honorable discharges and in crisis. Washington, DC: Department of Veterans Affairs.
Wagner, E. H., B. T. Austin, and M. Von Korff. 1996. Organizing care for patients with chronic illness. Milbank Quarterly 74(4):511–544.
Wu, H. W., and K. W. Kizer. 2016. Surgical adverse events in California: Trends in reporting and recommendations for prevention and management of reported events. Sacramento, CA: Institute for Population Health Improvement, University of California, Davis.
Zuckerman, A. M. 2014. Systemness: The next frontier for integrated health delivery. Chicago, IL: Becker’s Hospital Review.
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