Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans (2019) / Chapter Skim
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4 Characteristics of a High-Quality Process for Determining Disability Resulting from Traumatic Brain Injury
4 Characteristics of a High-Quality Process for Determining Disability Resulting from Traumatic Brain Injury
Pages 83-96
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From page 83... ...
Building on the descriptions in Chapter 3 of VBA's current adjudication process for residuals of TBI and the quality indicators that VBA currently measures, this chapter evaluates those and provides considerations for additional indicators that could be used to assess and improve the disability rating process. The committee has included this chapter in its report because in discussions with VBA officials, there was great emphasis on the consistency of the rating process itself (as noted in Chapter 3)
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From page 84... ...
quality assurance measures found that the VA's quality measures focus on consistency within the disability rating step of the process (see Chapter 3)
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From page 85... ...
A determination process cannot be valid without also being reliable. A valid disability evaluation process is one that would yield the "right answer," i.e., accurately identify and quantify the service-connected TBI-related disability for each veteran evaluated over a wide range of injury severity, veteran characteristics, and geographic locations.
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From page 86... ...
Another example of poor construct validity would be if the rating process assumed that all sequelae of TBI were immediately apparent, when current knowledge of TBI indicates that manifestations are often delayed. Finally, criterion validity, a subset of construct validity, is the degree with which the results of the disability determination process match a criterion or "gold standard" that is assumed to define the degree of disability incurred by the veteran (Price, 2016)
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From page 87... ...
Process quality includes the domains of burden, transparency, and credibility, whereas outcome quality includes reliability and validity in its various forms. The variables or metrics that are used to measure quality in each of those domains are called indicators or quality indicators.
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From page 88... ...
For the rating process, indicators could include time to initial disability determination, the accuracy of the rating as determined by higher-level review, the credibility and transparency of the rating system, and the timeliness of the appeals process. Ideally, process quality indicators should represent characteristics inherently valuable to veterans and to the process owner (the Department of Veterans Affairs)
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From page 89... ...
. Transparency from a system-wide point of view would include easy access to and widespread distribution of data on the system performance, including performance with respect to both process quality measures (e.g., timeliness of and access to VHA examinations, percent of examinations conducted by contracted examiners)
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From page 90... ...
The biggest challenge is determining what "accuracy" means within this context and providing a practical and widely accepted criterion standard assessment against which the disability rating system can be judged.
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From page 91... ...
The committee recommends that the Department of Veterans Affairs institute processes and programs to measure the reliability and validity of the adjudication process, identify opportunities for improvement in the quality of outcomes, and implement modifications of the adjudication process as needed to optimize the quality of both the adjudication process and the reliability and validity of the outcomes. The committee further recommends that the VA take the following initial, specific actions to evaluate the reliability and validity of disability determinations: 1.
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From page 92... ...
Standard patient examinations may be used to identify random variability or systematic errors associated with individual examiners or offices, to measure the overall quality of the system, and to determine the settings in which the rating system is most likely to yield invalid disability ratings (Beullens et al., 1997)
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From page 93... ...
To ensure and maintain high quality, systems need to measure both process and outcome quality, incorporate feedback, correct themselves, and measure outcomes after such a correction. The committee's review of the VA's quality assurance measures found that the VA's quality measures focus on consistency in the disability rating step of the process.
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From page 94... ...
. Transparency from a system-wide point of view would include easy access to and widespread distribution of data on the system performance, including both performance with respect to process quality measures (e.g., timeliness of and access to VHA examinations, the percent of examinations conducted by contracted examiners)
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From page 95... ...
Furthermore, by adopting an explicit learning structure in which the reliability and validity of disability determinations are directly assessed, the VA will be able to devote its resources to the modifications and enhancements of the disability evaluation system that will have the greatest impact in improving the service provided to injured veterans. REFERENCES Beullens, J., J
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From page 96... ...
96 TRAUMATIC BRAIN INJURY IN VETERANS Wilbur, K., A Elmubark, and S
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