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QUALITY MANAGEMENT AT THE VETERANS HEALTH ADMINISTRATION

THURSDAY, MARCH 19, 1998
House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
    The subcommittee met, pursuant to notice at 9:45 a.m., in room 334 Cannon House Office Building, Hon. Cliff Stearns (chairman of the subcommittee) presiding.
    Present: Representatives Stearns, Bilirakis, Cooksey, Gutierrez, and Peterson.
    Also present: Representative Evans.
OPENING STATEMENT OF CHAIRMAN STEARNS

    Mr. STEARNS (presiding). Good morning. Last October, this subcommittee held a hearing on patient safety and mechanisms to reduce risk in VA patient care. Two weeks before that hearing, VA significantly revised its 3 month old policy on improving patient safety. It was too early to tell what effects these new VA policies would have on medical practices. It was also not clear as of last October whether the VA headquarters was getting reliable information on the numbers and kinds of incidences occurring across the system. VA officials could not tell us whether patient safety incidents were declining, or whether they were simply being underreported at a higher rate.
    Today's hearing provides an opportunity both to learn what has been done on patient safety issues since our October hearing, and to take a broader look at VA efforts to manage quality. It is obvious that quality management has been an important headquarters' concern. We're aware that Dr. Kizer has initiated many new programs, developed new measurement tools, established advisory bodies, increased staffing, and made organizational changes, all focused on quality of care.
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    The Veterans' Affairs Committee supports the commitment to improve quality. Just yesterday, we adopted budget views and estimates which in addition to recommending a substantial increase in medical care funding, call for increased central office staffing for quality management, and oversight. But while we are a supporter, we are also concerned about inconsistencies in implementation of quality management policies. It is obviously not enough to develop good policies. It is critical that those policies take hold and become translated into practice in our medical facilities across this country.
    This morning we will continue our inquiry into these important questions, and we'll hear from experts on the state-of-the-art of quality management, and the state of quality management policy and practice in the VA.
    Before calling our first panel of witnesses, I'd like to invite the ranking member, Mr. Gutierrez, to offer any opening remarks he may have.
OPENING STATEMENT OF HON. LUIS V. GUTIERREZ

    Mr. GUTIERREZ. Thank you, thank you, Chairman Stearns. I strongly believe there's no more important subject for the subcommittee to address than the quality of health care our Nation's veterans receive, and I'm encouraged that we're beginning the year by opening this hearing.
    Throughout my 5 years on the Veterans' Affairs Committee, I've closely followed the progress of the VA in improving health care services it provides to veterans, and it is certainly becoming a more complex job.
    The VA is undergoing a historic transformation from centralized hospital base system to a more flexible, adapted one. Outpatient services are emphasized and direct control and responsibility is held in the 22 service networks, and not at the Vermont Avenue headquarters.
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    As we are all aware, ensuring quality management in this new environment is not an easy task. Nevertheless, despite these challenges quality care must remain the paramount goal of the VA. I do believe that the VA is expending significant efforts and resources to improve. They're developing techniques from the private sector and other quality management.
    I do believe, however, that a word of caution is warranted. All too often I hear from veterans, VA employees at various levels and in a variety of roles, and independent health care experts, that the financial bottom line dictates VA policy to the detriment of quality of care veterans receive. Too often, vital positions at VA medical centers go unfilled because of accountant driven policy making. Specialized services are impaired. Employee morale declines and veterans suffer.
    Now, I acknowledge the budget constraints that VA currently confronts. I do not believe that Congress and the Administration have provided adequate resources for VA medical care. I do, however, feel that it is absolutely necessary, regardless of revenue projections, to determine health care policy in the interests of our veterans, and not in the interests of accountants.
    The long-term costs of allowing the bottom line to write VA health care policy are too great for our veterans to bear.
    Mr. Chairman, I thank you once again for calling this hearing, and I look forward to present my questions to the witnesses later this morning.
    Mr. STEARNS. I thank the ranking member. Any other members, Mr. Evans?
    Mr. EVANS. Mr. Chairman?
    Mr. STEARNS. Yes, I recognize you for 5 minutes.
OPENING STATEMENT OF HON. LANE EVANS, RANKING DEMOCRATIC MEMBER, FULL COMMITTEE ON VETERANS' AFFARIS
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    Mr. EVANS. Thank you, Mr. Chairman. I'm pleased to be here today to revisit the issue of quality management in the Veterans Health Administration. I really think this shows your commitment to the issue, Mr. Chairman, and our ranking member's interest.
    I know there's been a great deal of activity since this subcommittee met last October to discuss VHA's risk management initiatives. I believe it is to VHA's credit that they're looking at new and innovative ways of defining and ensuring quality. But I am somewhat concerned that VHA headquarters has given the field too much control over developing their own systems for assuring quality. I have no doubt that headquarter's commitment to quality assurance is sincere. It is this Congress' job, however, to be responsive to the criticisms we hear from both internal and external sources.
    When we hear that VA's Medical Inspector found that 20 percent of the care delivered at Castle Point and Montrose VA Medical Centers was, at best, marginal, we need to be concerned and to find out what went wrong, and how best to prevent it from happening again. What we hear seems to indicate that the headquarters must do more to support traditional quality management activities, and to ensure consistent application of practice standards throughout the system.
    When the House Committee on Veterans' Affairs first heard VHA's vision to decentralize management, it described headquarter's role as one to steer, but not to row, by providing policy guidance from the highest level, and providing its field with the tools that it needed to do the job. While headquarters seems to be identifying the broad goals for its field managers, often it appears that the field is not following the intent of the guidance that it has been called on, and no one is questioning them on it.
    I'm not convinced that there is enough steering going on. This committee seems to agree that headquarters needs more resources to ensure that it can develop effective policy, and monitor its interpretation in the field.
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    Mr. Chairman, I have the rest of a lengthy statement that I'd ask to put in the record.
    Mr. STEARNS. Without objection, so ordered.
    [The prepared statement of Congressman Evans appears on p. 29.]

    Mr. STEARNS. And I thank the ranking member of the full committee. Mr. Bilirakis.
OPENING STATEMENT OF HON. MICHAEL BILIRAKIS

    Mr. BILIRAKIS. Mr. Chairman, just very quickly, I appreciate the opportunity. I endorse the remarks of my predecessors, and certainly thank you for holding this hearing. Mr. Chairman, over the years, most of the complaints that I've heard from our fellow veterans, has been an attitude kind of a thing, about the people at the reception level or, the people may be above them. Veterans complain that they're being treated like they're on welfare, things of that nature. It goes back again to the things we talked about when we talked about sexual harassment, or what not, a mind set type of a thing. I think that maybe we all hear that. There's no way you can legislate something like this, but certainly we've got to be able to try to concentrate on clearing the minds of people, the employees and what not, in the VA system so that they realize that their job should be one of pride and privilege. And I thank you, and again I apologize for not being able to stay.
    Mr. STEARNS. Well, I thank the distinguished member from Florida. I appreciate his comments.
    [The prepared statement of Congresswoman Chenoweth appears on p. 30.]

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    Mr. STEARNS. Without further objection, we'll hear from our first witness, Molla Donaldson, Project Director, National Roundtable on Health Care Quality, Institute of Medicine. Good morning, and welcome.
STATEMENT OF MOLLA DONALDSON, M.S., PROJECT DIRECTOR, NATIONAL ROUNDTABLE ON HEALTH CARE QUALITY, INSTITUTE OF MEDICINE

    Ms. DONALDSON. Good morning, Mr. Chairman, and members of the subcommittee. My name is Molla Donaldson. I am the project director for the National Roundtable on Health Care Quality of the Institute of Medicine. I appreciate the opportunity to address you today on quality management. Managing quality requires being able to define it, to measure it accurately, and most important, to improve the care that is provided. My comments will address all these three issues.
    In 1994, the Institute of Medicine of the National Academy of Sciences formed the National Roundtable on Health Care Quality, a diverse group of individuals from the public and from the private sector, to focus attention on measuring and improving the quality of health care in the United States. The Roundtable will soon release a statement on the quality of care in this country. In the meantime, I will summarize some of its conclusions.
    Regarding the definition of ''quality,'' many people believe that quality cannot be defined, and cannot be measured. This is simply not true. In 1990, the Institute of Medicine developed a useful definition that has proved robust, and widely adopted, defines quality 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.'' Using the IOM definition, the quality of care can be measured with scientific accuracy comparable to that of most measures in clinical medicine.
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    Studies have addressed three kinds of problems: overuse, underuse and misuse. Overuse occurs when the risk of a health service is likely to be greater than its benefit. Underuse is the failure to provide a health service that would be expected to have produced benefit. Misuse occurs when a needed service is provided poorly, and a patient experiences a preventable complication.
    The message from these studies is clear. A growing body of rigorous research has documented serious and widespread quality problems in American medicine in all three of these areas. When a news story is published about a mishap in one setting, or financing system, such as fee-for-service or managed care, or in the private sector or public sector system, such as the VA, people sometimes conclude that all the care in that setting is bad. Our experience has shown, however, that the quality of care in all settings varies across the spectrum.
    There is also ample room for improvement in all settings and financing systems. Very large numbers of Americans, perhaps millions, are harmed by overuse. Large numbers of Americans fail to receive health services that save lives, and prevent disability. More are injured when avoidable complications are not prevented. These problems occur in all parts of the country in small and large communities.
    Recognizing the seriousness of our quality problems in health care, should not trigger a search for individuals to blame. The answers are not that simple, and often involve shortcomings in the complex systems in which health care is delivered. In part, these problems are the result of the remarkable new knowledge about the effectiveness of health services. As knowledge accumulates, ways to supply practitioners with the information they need have not kept pace. And we have not yet found ways to anticipate human error, and reduce the likelihood of harm.
    Today, no health care practitioner can deliver high quality alone. More and more, they practice within groups and systems of care, including the VA. The functioning of these systems in coordinating care, and ensuring that accurate health information is available when needed, is critical.
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    To learn more about how to improve quality of care, the IOM held a conference on current approaches to protect citizens, and to improve quality of care across the entire system. Invited papers addressed four major quality improvement strategies. They were: continuous quality improvement, or internal methods of improving quality, regulation, competition and financial incentives.
    An extraordinarily diverse group of 60 people debated the evidence that each of these strategies has actually improved care, and how they might fit together in an integrated approach. Each of the four strategies has important strengths and important weaknesses. By the end of the conference a remarkable consensus had emerged among the participants.
    First, health care quality problems or opportunities to improve are of major significance. Variations in quality are unacceptably large. Second, taken individually our current approaches to quality improvement are unlikely to produce rapid progress. A small number of hospitals, health plans, and integrated delivery systems, have made notable efforts to improve, and some successes have been documented, but we do not yet have role models that provide care that is consistently and uniformly free of quality problems. Improvement efforts usually occur in large institutions, most often in hospitals. Long-term, multi-institutional or regional efforts to improve are rare. Realizing the most value in improved health from our investment in health care requires re-engineering of how we deliver health services and try to improve quality.
    Finally, let me say that health care in the United States is often superb. Unfortunately, it is often not at its best. Americans bear a great burden of harm because of these failures, a burden that is measured in lives lost, in reduced functioning, and wasted resources. The Roundtable believes that addressing these issues vigorously should be among the highest priorities in health care. Thank you.
    [The prepared statement of Ms. Donaldson appears on p. 31.]

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    Mr. STEARNS. Ms. Donaldson, you described the results of a National Roundtable on Health Care Quality report, as concluding that we need ''a major overall of how we deliver health services, educate and train clinicians, and assess and improve quality.'' What do you see as a most critical element of that recommendation, and what does that finding mean for the VA?
    Ms. DONALDSON. There are several things. One is that we, the people at the conference, felt that if you want to make sure that we have a safe and reliable system for patients to enter and to receive high-quality care, we have not yet designed delivery systems that can safely and reliably do that, and that we really need to re-think how those delivery systems operate. A 2-year study that is about to begin at the IOM. It's going to be looking at exactly how that can be done, so I would say that I don't have the answer to how it should be done in the VA. I think the VA has begun, and the interesting thing about the Veterans Affairs is that it has a consistent set of incentives, and a consistent set of delivery arrangements, which make it a wonderful opportunity to learn about how to improve quality.
    Mr. STEARNS. How familiar are you with the VA health care system and can you comment on the steps that have been taken in the area of quality management?
    Ms. DONALDSON. The area of quality management in the VA has not been discussed by the Roundtable members, so I will have to give you my own opinion. I have seen preliminary data on work to improve screening and of follow-up in the VA. The preliminary data that I saw showed remarkable improvement in the short term, and I thought, even more surprisingly, across a range of measures. It will be very interesting to me to see if these improvements are maintained over a period of time. Again, that is my own opinion.
    It is very difficult to bring about even small improvements in care, let alone across a range of clinical practices. We have heard from many experts in quality of care measurement and quality of care improvement, a number of very dedicated and knowledgeable individuals who have been working in this field in the private sector for a long time. Although we can point to isolated instances of very successful improved quality, these individuals would be the first to say that they have not been able to deploy this across the institution, or across institutions. This is a very difficult task to do.
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    Mr. STEARNS. Ms. Donaldson, you discuss the role of payment mechanism in shaping behavior of health care providers. Is there, even in theory, a funding model that strikes the right balance and rewards excellence?
    Ms. DONALDSON. We don't know of any is the short answer to that. We know that a fee-for-service systems encourages overuse. We know that capitation systems can encourage underuse of service, but we don't know of any financial system that has been harnessed to other strategies, or, in and of itself, recognizes and rewards high-quality.
    Mr. STEARNS. You note that industrial quality management methods often offer important tools for improving quality, but you say they tend to be used narrowly on administrative aspects of care, rather than clinical ones. Would you please amplify on that point, and offer us some examples?
    Ms. DONALDSON. Certainly. Many of the examples that we know of continuous improvement have looked at improving efficiencies of administrative processes, or looking at improving what we called misuse, the technical issues in quality care. Virtually none of these looks at overuse issues, which are major, and underuse issues.
    Mr. STEARNS. Those are the questions I have, thank you. The ranking member, Mr. Gutierrez?
    Mr. GUTIERREZ. Thank you. You mentioned that preventive techniques are often not employed by health care providers, can you comment on the VA's efforts to improve preventive care services?
    Ms. DONALDSON. Well, again, I have to respond with my opinion, rather than the Roundtable, but to say that I've looked at those preliminary data. They have looked at a number of preventive services, and follow up of services, and have shown not only improvement, but remarkable improvement, and across the board in all of the services that they have looked at. And I think that they have tried, as I understand it, to combine both financial incentives and other kinds of internal incentives, to bring that about.
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    Mr. GUTIERREZ. In large medical systems, such as the VA, what are the major quality management problems, in your belief?
    Ms. DONALDSON. I'm sorry in major?
    Mr. GUTIERREZ. In major in—I'm sorry—in large medical care systems, such as the VA, what are the major quality management problems that you see in your belief? And are they different than those confronted at the private sector?
    Ms. DONALDSON. I hesitate to speak for the VA because I don't have personal knowledge of that, but I would say that what we've seen in every other system is that most of the quality problems are what we call ''systems problems.'' They're not problems of the lack of good training, or intention on the part of the health care providers. They are problems in coordinating care and making sure that information gets to people when they need it, of making sure that referrals, lab results, all kinds of things are done, and they're also problems in terms of not having systems to catch errors and prevent them from doing harm.
    Mr. GUTIERREZ. Is that, if there was one suggestion, is that where you think we really need to focus on these systems?
    Ms. DONALDSON. I believe so, yes.
    Mr. GUTIERREZ. Thank you very much.
    Mr. STEARNS. We thank you this morning for coming here, Ms. Donaldson. And we'll take the next panelists, Dr. Thomas Garthwaite, M.D., Deputy Under Secretary for Health, Department of Veterans Affairs, together with John Mather, M.D., Assistant Inspector General for Health Care Inspections, Department of VA; Maura Farrell Miller, Ph.D., President, Nurses Organization of Veterans Affairs. And we also have Nancy Wilson, Dr. Wilson, Director, Office of Performance and Quality, Department of Veterans Affairs.     Good morning, I want to welcome all of you, and thank you for your time. And Dr. Garthwaite, we'll let you start, go ahead.
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STATEMENT OF THOMAS GARTHWAITE, M.D., DEPUTY UNDER SECRETARY OF HEALTH, DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY NANCY WILSON, M.D., DIRECTOR, OFFICE OF PERFORMANCE AND QUALITY, DEPARTMENT OF VETERANS AFFAIRS; JAMES MCMANUS, M.D., MEDICAL INSPECTOR, DEPARTMENT OF VETERANS AFFAIRS; AND JOHN MATHER, M.D., ASSISTANT INSPECTOR GENERAL FOR HEALTH CARE INSPECTIONS, DEPARTMENT OF VETERANS AFFAIRS; AND MAURA FARRELL MILLER, PH.D., ARNP, CS, PRESIDENT, NURSES ORGANIZATION OF VETERANS AFFAIRS

STATEMENT OF THOMAS GARTHWAITE, M.D.

    Dr. GARTHWAITE. Good morning, thank you Mr. Chairman, and thank you for your articulated support for enhancing our quality management endeavors in VA headquarters, and throughout the system.
    I am pleased to be here to discuss the effectiveness of quality management in the Veterans Health Administration. First let me state that improving the consistency and predictability of high quality care in the VHA has been a central tenet of our re-engineering efforts. This was stated in our ''Vision for Change,'' and ''Prescription for Change,'' and multiple other documents.
    Secondly, I think it is important, as stated by the previous witness, to recognize that no one has yet established a definitive approach to quality management in health care, or the best method of deploying quality management throughout large health care systems. There are significant knowledge gaps, as well as variance in opinion about preferred strategies, and we're committed to leading the way to a much better health care system for all Americans.
    I'll briefly describe a few of the changes that we have made since the previous hearing, and then we welcome your questions. First, improved patient outcomes are health care quality's bottom line. Our data demonstrate unprecedented improvement in the quality of VA health care outcomes, including increased longevity rates for persons having serious medical conditions, lowered rates of surgical morbidity and mortality, improvements in the quality of care indicators tracked by our chronic disease, prevention, and palliative care indices, as well as improved patient reported outcomes.
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    Our prevention index consists of nine quality outcome indicators that measure how well VA follows national primary prevention and early detection recommendations toward diseases having major consequences, such as cancer, smoking, and alcohol abuse. VA outperforms the private sector on all indicators where comparable data exists, ranging from 5 to 69 percent better on individual quality indicators. In addition, VA has already surpassed United States Public Health Service, ''Healthy People 2000 Goals'' in five of the indicators. Examples include: immunizations for pneumonia, 61 percent better; influenza, 61 percent better—influenza immunization; and the percentage of women receiving cervical cancer screening, 90 percent.
    The Chronic Disease Care Index consists of 14 quality outcome indicators for high volume diagnoses such as ischemic heart disease and diabetes. The percentages reflect the number of patients who actually receive required medical intervention. The Chronic Disease Care Index in the aggregate rose 73 percent in fiscal year 1997 after we put the light on this and began to measure.
    Again, where comparable data exists, VA consistently outperforms the private sector ranging from 21 to 124 percent on individual quality indicators. Such examples include the rate of aspirin therapy for patients after a heart attack and the percentage of diabetics whose blood sugar controls are monitored annually by blood tests. We achieved 85 percent monitoring versus 38 percent that has been reported in other systems.
    It's important to note, that these instruments, which did not exist 3 years ago, were specifically designed to allow us to accurately compare VA health care with the private sector. Further, the VA data, upon which these comparisons are based, comes from external reviewers that we hired to go into our medical centers so as to eliminate bias and to ensure impartiality.
    As part of our re-engineering effort, we have also been tracking the one year survival rates for nine high volume conditions. Some of these are our most vulnerable patients, and include patients with heart failure, chronic obstructive pulmonary disease, and pneumonia, among others. Survival rates for several of these important conditions have improved while rates for other conditions have remained stable.
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    In surgery, since we implemented our VA national surgical quality improvement program, morbidity and mortality rates have improved by 10 percent for morbidity, and 28 percent for mortality. The Chairman of Surgery at Duke University, in a recent editorial, endorsed VA's approach as one that will improve the quality of surgical care throughout the Nation.
    We've also spent considerable effort looking not just at outcomes, but at the processes by which we deliver care, and have put together the individual components of our efforts in quality management into a strategic framework of quality management.
    As presented in previous testimony, we delineated a comprehensive strategy for quality management that recognizes quality improvement as an overarching goal of transforming our organization. The framework takes a broad view of quality management, addressing traditional and new quality assurance mechanisms, management decisionmaking, and various support functions. The current iteration of the framework arrays improvement initiatives, with specific strategic goals.
    However, integration of these initiatives requires more than just a framework. It requires, as I think was just mentioned, teamwork. Our new Quality Management Integration Council, chaired by the Under Secretary for Health, and composed of VHA executives from all levels of the organization, as well as our union partners, provides the venue for monitoring, evaluating, and overseeing the coordination and coherence of VHA's quality improvement activities. As one of its first initiatives, which I think is responsive to points raised during the initial introductions, the Council has begun to address how we disseminate quality enhancement initiatives to front-line employees, and how we assure their implementation.
    To further promote the integration of quality activities, the Office of Performance and Quality now reports directly to the Under Secretary for Health, and each network has designated a quality management officer. To provide input from quality management authorities outside the VA, we've established a Quality Management Advisory Panel. This Panel will evaluate the clarity, coherence, and comprehensiveness of VHA's strategic framework for quality, and advise the Veterans Health Administration about specific quality initiatives. We've been fortunate to recruit nationally renowned quality management experts from very prestigious organizations to help us in this regard.
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    Other initiatives to improve the focus on quality include: the creation of the VHA Patient Safety Improvement Awards Program for individuals in the front-line who identify and implement successful system redesigns; the Veterans Health Administration $1 million Quality Achievement Recognition Grant for networks that demonstrate exceptional outcomes in quality; and the recent announcement of a unique fellowship in quality management for clinicians interested in leading health care quality improvement efforts into the future. We've committed to fund as many as 12 of these fellowships in the academic year 1998 and 1999.
    And finally, to further ensure a broad range of input into our quality management programs, we have asked the consultants that reviewed the function and size of the Office of Medical Inspector, to expand their project and to look at our entire approach to quality management, comparing it with other health care and non-health care bench marking organizations.
    Let me speak a minute about patient safety. Since patient safety is such a crucial part of the framework for improving quality, I'd like to update you on our activities since the last committee meeting. As you recall, VHA published a new policy on risk management in June of 1997 that emphasized the need to examine all adverse events for potential national process improvements. The policy also formalized responsibilities at facilities, networks, and headquarters for reporting and analyzing adverse events, and taking corrective action. Since underreporting of adverse events is a significant obstacle to improving patient safety in all health care systems, one of the primary goals of our policy is to increase reporting. And, in fact, since the policy was implemented, reporting of adverse events has substantially increased in every network.
    Although we are pleased with our progress to date in implementing the new risk management policy, we believe we have more to learn, especially from high risk industries, such as aviation, who have expertise and experience in designing and maintaining incident reporting systems that would foster safety. To this end, we recently convened an expert advisory panel on patient safety system design that included the creator and current director of the Aviation Safety Reporting System.
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    And finally, with regard to the role of the Medical Inspector, on January 9, based on recommendations of review performed by outside consultants, the Under Secretary for Health authorized the Medical Inspector to increase his staff and expand the role of his office. This would include, among other activities, a review of the analysis of sentinel events, boards of investigation, and focused reviews conducted at VA facilities. The Medical Inspector began an active recruiting process, and has thus far signed up two new nurses and one physician. Recruitment of additional staff is in progress.
    Within the context of patient safety improvement, the Medical Inspector will play an active role. The Medical Inspector is a member of both the Quality Management Improvement Council and the Patient Safety Improvement Oversight Committee. The latter committee meets every 2 weeks, and reviews significant adverse events to determine the quality of the review conducted by the facility, and to help facilities identify system-wide lessons learned, and to detect any patterns and trends in the kinds of events that are reported.
    I am pleased to report to you, in conclusion, that the VA health care system has accomplished significant improvements in the quality of care during a period of unprecedented change in the system. This is a tribute to the efforts of tens of thousands of dedicated VA employees who are first and foremost concerned with the welfare of their patients. As discussed last October and today, we are continuing to seek ways to further improve the predictability and consistency of high quality health care.
    I think we believe, as the previous witness pointed out, that all of health care needs to move forward to improve health care quality and safety, and what we're committing to you is that we plan to lead the pack.
    I thank you for your interest. This concludes my statement, and we welcome your questions.
    [The prepared statement of Dr. Garthwaite appears on p. 41.]
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    Mr. STEARNS. Thank you, Dr. Garthwaite. Dr. Mather, your opening statement?
STATEMENT OF DR. JOHN MATHER

    Dr. MATHER. Mr. Chairman and members of the subcommittee, I appreciate this opportunity to appear today, and to discuss the effectiveness of quality management in the Veterans Health Administration. In these remarks, I will emphasize a report recently released by my office on this topic. With your permission, Mr. Chairman, I request that my written prepared statement be entered into the record, and I really use these remarks, and this opportunity to summarize the key issues.
    Veterans receiving their medical care through the VA can expect the health care professionals who treat them to do it well. They can also expect the health care system to consistently deliver first-rate medical care. In order for veterans to be assured that they are receiving such medical care, the VA must have effective policies and programs to ensure the consistent delivery of high quality medical care.
    The report we issued last month evaluated the effectiveness of VA's programs for monitoring the quality of medical care to the veterans it serves. This comprehensive review assessed the current quality management programs throughout the whole system, including central office, the networks, and local VA medical facilities. We specifically reviewed guidance on quality management, comparing the programs before and after Dr. Kizer became the Under Secretary for Health. Also, we completed a preliminary review of the assigned personnel responsible for quality management and the resources they have at all three levels of the operation.
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    The Veterans Health Administration, that is the VHA, is challenged to operate an effective quality management program in what is one of the largest and most complex health care systems in existence today. As VHA moves toward ambulatory care and increased performance accountability in its health care system, quality management processes also must adapt. VHA has accordingly initiated many changes. VHA is developing more medical and quality related information systems which have a great potential for improving the effectiveness of medical care. These data sources enable managers to continuously monitor and improve the quality of medical care, including the prevention and reduction of the adverse consequences of poor medical care.
    In completing this overview of VHA's quality management program, we gave careful consideration to a number of factors. Of primary concern was the conduct of a careful and robust oversight review while simultaneously remaining alert to the continuing changes in the VA's health care system. This review sought to acknowledge the most effective VHA changes in structure, process and outcomes, and not substitute another approach. If anything, our recommendations give an added impetus to Dr. Kizer to make the delivery of optimal quality of medical care to veterans the first priority in VHA.
    We concluded that the VHA has many reasonable quality management policies that are designed to ensure good quality care. These policies ensure effective high-quality care at minimal risks, only if the clinicians consistently implement them. However, consistent implementation of policies in VHA has always been, and continues to be, a problem. Inconsistent and ineffective policy adherence, plus any failure to use the latest available information to improve systems, render policies ineffective, and create the impression that quality management efforts are wasted. VHA managers need to actively and seriously address this issue. It is necessary that VHA managers who are directly and indirectly responsible for delivering health care services ensure that the clinical and quality data are accurate, timely, complete and useful.
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    VHA is currently working hard to provide health care providers and managers with more immediate access to on-line information, rather than relying on retrospective data stored in VHA electronic archives or files. Data analyses that are based on current and valid data could potentially improve many of the present review mechanisms. Data validation has been a longstanding problem in VHA, and continues to require significant management attention before it is resolved.
    Additionally, VHA's continued movement towards a more decentralized management structure can lead to fragmentation of knowledge. This potentially compromises the senior field manager's ability to rapidly apply lessons learned from best practices. If a VA medical center or network actually identifies and corrects a system weakness, it is not clear how other VA medical centers or network managers would immediately learn about such improvements. We did not identify any single entity in VHA that had the capability of disseminating on a timely and system-wide basis all quality assurance information, and thus potentially avoid the repetition of problems elsewhere.
    We found that Dr. Kizer, over the past several months, has been very active in issuing directives which will improve the ability of VHA to monitor the delivery of first-rate medical care. He has issued a statement of core values, clarified the role and responsibilities of the Office of the Medical Inspector, re-issued the risk management directive, has a directive on patient safety improvement, and established two oversight and advisory groups. In particular, he has established an overall framework for quality called ''The Twelve Dimensions for VHA's Health care Quality.''
    In our report, we make nine recommendations, and concluded that this twelve dimensions quality framework would be more evidently and effectively supported and implemented by elevating the current Office of Performance and Quality to report directly to Dr. Kizer. This office would incorporate all key programmatic and structural components under administrative direction such as credentialing, privileging, the patient safety improvement initiative, and the lessons learned activity. This office would also have responsibility and in-line authority for education and training, and for the lead in developing a research agenda in quality assurance.
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    We believe this is consistent with the declared intent of Dr. Kizer to give significantly greater prominence to issues assuring optimal quality medical services in VHA. In addition, we concluded that he needed to strengthen the role and resources of the Office of Medical Inspector, and for it to work collaboratively with the Office of Performance and Quality. Dr. Kizer completely agreed.
    We found that VHA's discontinued annual report on quality assurance, and other similar reports, should be re-instituted. Additional publications and guidance that would strengthen the quality management program would include trending and reporting a compilation of all external review findings for facility level managers, a quality management reference guide to standardize processes in the field, and guidance for required reporting to external agencies. Dr. Kizer agreed with these, at least in principle, and several other important recommendations.
    Extensive management follow-up will be required by VHA to ensure that the recommendations on quality management are effectively implemented. Moreover, we believe that Dr. Kizer needs to ensure that senior managers are explicitly held accountable for the effective implementation of all the report's recommendations in a timely manner.
    One final set of observations concern the quality management staffing levels and resources in the networks and in the VA medical centers. Our survey found great variations in the staffing. The wide ranges in reported staffing levels need to be analyzed in more depth to understand the appropriateness of these staffing variations. Dr. Kizer established network statistical consultants when issuing the now-named Patient Safety Improvement Policy nearly 6 months ago. The requirement for statistical consultants was a positive step. However, the system-wide responsibilities and procedures still need to be developed. The actual working relationships for the newly established network quality management offices has yet to be defined in any detail.
    We are developing two follow-up quality management evaluations which will complement our findings so far. One evaluation of quality management will more definitively clarify VHA's staffing patterns, assess the resources available to staff, and determine employer authority to make necessary changes. We'll assess more precisely the roles that staff fulfill, and particularly evaluate at the network level the roles and cooperation between the quality management officer and the statistical consultant.
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    The other program evaluation will assess the effectiveness and utility of external accreditation bodies' efforts in improving and maintaining the quality of patient care.
    In summary, VHA has created a quality management program structure with many policies and processes which, if applied consistently and effectively, would adequately monitor the quality of care, identify problems in a timely manner, and assure that corrective action is taken, thus ensuring patients receive good quality care. However, we found several areas in VHA's quality management program and its components which require continuing and conscientious management attention. Our overall impression, nonetheless, is that Dr. Kizer has now placed the issues concerning the assurance of first rate quality of care to veterans very close to the highest, if not the highest, priority within VHA.
    This completes my oral testimony, Mr. Chairman, and I thank you for your kind attention, and I shall be pleased to answer any questions here or in writing.
    [The prepared statement of Dr. Mather appears on p. 73.]

    Mr. STEARNS. Thank you, Dr. Mather. Dr. Miller, would you like to give your opening statement?
STATEMENT OF MS. MILLER

    Ms. MILLER. Yes, thank you. Mr. Chairman and members of the subcommittee, I appreciate the opportunity to appear today to discuss the effectiveness of quality management in VHA, focusing in particular on the views of registered professional nurses from the field.
    For the past 18 years, NOVA's legislative priorities have focused on ensuring quality of care in VHA. NOVA applauds Under Secretary for Health, Dr. Kenneth Kizer, for his visionary initiatives to improve care. VA registered nurses believe that they give excellent patient care, but also believe there's always room for improvement.
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    I'd like to focus my time this morning, on my 10 recommendations that have been included in my written testimony, and then be open to dialogue with this group and the subcommittee.
    NOVA has the following recommendations to improve the quality of veteran health care: One, remove barriers, restrictions to practice based solely on cost of care. Two, develop continuum of care benchmarks to determine safe patient provider mix. Three, reward quality improvement behaviors at all levels of the VHA organizational hierarchy. Four, shift priorities from restructuring to focus more on process and outcomes measurements as the VA experiences a flattening out of the organization, shift to product lines, and integration of services. Five, develop some constancy in organizational structure across the 22 VISNs. Six, increase the interdisciplinary of VHA leadership by removing barriers and restrictions that exist which limit nursing executives, and others from leadership positions at the highest levels in VHA management. Seven, increase the number of staff devoted to education and research efforts so that the VA will truly be an employer of choice. Eight, adjust managed care ''philosophy'' to care for frail elderly and other complex costly populations. Nine, increase nursing executive leadership at all levels of the organization. And lastly, ten, develop initiatives to retain and potentially recruit appropriate qualified professional nursing staff to meet the present and future needs of veteran health care.
    I'll now be welcoming your questions.
    [The prepared statement of Ms. Miller appears on p. 84.]

    Mr. STEARNS. Thank you, Dr. Miller.
    Ms. MILLER. Thank you.
    Mr. STEARNS. When I was thinking about this hearing, I think I coined the term, ''Where is the beef?'' Last year when we had a series of hearings and we started talking about these issues with Dr. Kizer, he agreed in fact we need to change the culture in VA hospitals. And so today we're here to hear about these changes and to determine whether some of the things you suggested, or Dr. Kizer has suggested, have been implemented. And, as you know, a lot of us are concerned about the VA quality of health care. I don't know, Dr. Mather, whether you would grade the process ''A'' through ''F.'' Would you give it a ''C'' or ''C+?'' Do you want to venture here something to keep this lively?
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    Dr. MATHER. Mr. Chairman, I feel provoked. [Laughter.] I think the VA health care system has the clear potential for providing the highest quality of care to all veterans, and I don't think Dr. Kizer, or even Dr. Garthwaite, would claim here that, across the board, this is indeed completely evident.
    Mr. STEARNS. Okay, so they don't have an ''A?''
    Dr. MATHER. No, and they certainly don't have an ''F.''
    Mr. STEARNS. Okay. Okay, so it's our job, myself and this great ranking member, to try and push forward here to try and increase, in Dr. Kizer's words, ''to improve the culture of the VA hospitals,'' and to get through all the muckety-muck here and all the ''bureaucrat-ize,'' and to come down to what is actually being done, and see if we can take the best of what we have here to see that we're moving forward.
    Dr. Garthwaite, the first question I have to you is about some of these steps. I'm concerned that some of the steps that we've talked about don't seem to be carefully thought out. What they're doing is just presenting these ideas and saying, ''This sounds great,'' and is there any follow through? I'm going to give you four examples, and I'd like your response on each of these. What is the status of the Lessons Learned database that was described in last October's hearing? I mean, what has actually occurred on this? Two, what specifically has the Risk Management Oversight Committee accomplished since its establishment last year? Three, why are you both spending several hundred of thousands of dollars for a consultant study on VA quality management, and also establishing a blue-ribbon quality management advisory panel? Up here in Congress, whenever we have some controversy, we establish what's called a ''blue-ribbon advisory panel'' or some caucus or something and that pushes it off the headlines, and then nothing ever happens. And I guess, four, exactly what will the Quality Management Integration Council do, and what has it done so far?
    Now I think what we can do is we've got about 10 minutes, now we can either take a break and let you think about those, and we'd come back, or would you want to answer them in the next 4 or 5 minutes?
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    Dr. GARTHWAITE. I'd be happy to take a crack at it, and——

    Mr. STEARNS. Okay.
    Dr. GARTHWAITE (continuing). See what we can talk about in that amount of time. The Lessons Learned database exists in a couple of different ways. First, it exists in the database about risk management in which we attempt to find out about errors and learn by reviewing our mistakes. In addition, we would like to learn lessons that are near misses, or learn about patient safety margins that we can enhance, or just find better ways of thinking about doing things. We continue to collect those lessons learned and disseminate them to the field. We've done eight national calls, in which we've disseminated lessons to the field. We have an intranet database that is available to all VA employees who can sign on to the intranet. But, we're about to promote it as soon as we're sure the software is stable. I think it opens communications so that any nurse, any place in the field who wants to share with any other nurse, or put an idea forward, has essentially no barriers. There are no management layers. I look at the database on a regular basis.
    Secondly, if you ask specifically what kind of things that we found out by approaching and looking at quality, and what sort of actions have we taken, I think there are many and they continue to occur. We learned that when we'd hire a contractor to change oxygen, we can't rely totally on them to use a clean hose, and so we've changed how we hire contractors, and the specificity in which we write the contracts. We've learned that if we put concentrated potassium chloride on the wards, occasionally people mistake that vial, because health care is not designed for safety, for other medications. So we've taken all concentrated potassium chloride out of the wards across the United States. In fact, the Joint Commission just warned private hospitals to do that. We had done that several months prior to their warning.
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    We have implemented needle stick prevention programs across the United States because of the frequency of needle sticks for our employees. We have noticed that as we've looked at sentinel events that suicide is not an uncommon occurrence in our medical centers. It's not an uncommon occurrence in any facilities that deal with a lot of psychiatrically ill patients. However, struck by the number of suicides, we've convened a summit on suicide to bring the best minds together later this year.
    But the goal is to look afresh at other things that we could re-think that would improve quality. We've changed patient identification procedures based on, what I would consider, a near miss episode. Veterans are older, they're hard of hearing, they don't read as well, and they might even be a bit confused at times, and we need to intensify our efforts to make sure that our patient identification is correct.
    We found out that when you drop Zippo lighters, they are popular because they don't go out in the wind, well, they don't go out on your lap either. One patient burned himself when he was smoking because he dropped his Zippo lighter and it did not go out. And we've taken Zippo lighters away from patients to the extent that it is humanly possible, and made sure they're not sold in our medical centers.
    We've found that its possible to confuse units of blood, and in the next couple of months we will use bar-coding on all the units of blood that are transfused in VA hospitals. And we're in the assessment phase of understanding what bar-coding can do for us in reducing medication errors.
    The third thing you asked is why do we ask consultants. We ask consultants for the reason you didn't ask me whether we got an ''A'' through an ''F'' on our health care delivery. You ask somebody who is considered to be less biased. Also, I believe, that we can learn from people who do system quality for a living, and we've tried to find people who do it well. The only reason we asked the consultants from Abt Associates to continue is because we thought we got good advice from them in their Office of Medical Inspector report. It made sense. They seemed to be bringing something new to the table. Otherwise, I think we wouldn't have asked for more of their advice. In the case of the outside experts that we've asked to be on the Advisory Panel, they're the best in the country. And I think you can always learn something from the best in the country.
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    With regards to the Quality Management Improvement Council, I'll say we've only really had one meeting. There's an agenda for the next meeting, and we'll be glad to come back and explain what we're able to accomplish with that committee as we get into it.
    Mr. STEARNS. I'm going to recess the committee momentarily. We've got two votes and I'll be right back, and I want to also allow all members and staff to submit questions for the record. So ordered, and with that we'll adjourn.
    [Recess.]
    The House subcommittee will reconvene. And I think you had finished, Dr. Garthwaite.
    Dr. GARTHWAITE. Just barely under the wire.
    Mr. STEARNS. Okay, let me ask you a couple of questions and just see if you can give me an answer, yes or no. I know this is a little difficult. Am I correct in understanding that the VHA has spent, or will ultimately spend about $200 million to acquire software to implement an automatic decision support system? It's a big computer system, the TSI.
    Dr. GARTHWAITE. The decision support system?
    Mr. STEARNS. Yes. Is that true that you——

    Dr. GARTHWAITE. I can get you the exact dollars. It's a large amount of money.
    Mr. STEARNS. So it might be, okay. And VA had substantially implemented and trained site teams in using this new system at 80 VA medical centers? I'm trying to help you here, I mean.
    Dr. GARTHWAITE. It sounds like a reasonable number——

    Mr. STEARNS. If you don't know about it, you better——
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    [Laughter.]
    Dr. GARTHWAITE (continuing). So the answer is——

    Mr. STEARNS (continuing). Check into it because this is supposed to be part of your quality assurance program.
    Dr. GARTHWAITE. Okay, yes, right, yes, yes.
    Mr. STEARNS. I'm told that institutions like the Mayo Clinic and the Cleveland Clinic use the same application which came with the system.
    Dr. GARTHWAITE. Yes, a lot of large health care systems use TSI's product.
    Mr. STEARNS. Then I guess our question is, you know, why haven't we implemented a system like that as a quality management tool just in general?
    Dr. GARTHWAITE. My understanding, sir, is that what we're implementing is really about costing and it will give some information that could help in understanding some quality issues. They have other modules which they're interested in selling us that could address quality, and we're in the process of looking at the next phase of evolution of our computerized patient records. And we have a memorandum of understanding with the Department of Defense and Louisiana State University Health Service to develop a government computerized record that allows sort of seamless transition. We also believe that we will not develop that in-house since we're really not a software firm. And so our goal is to look at the best solution for the long-term computerized record for patients.
    Mr. STEARNS. Dr. Miller, you heard my opening comments about ''Where's the beef?'' and you know what's happening here to change the culture. I wanted you also to maybe respond to the four questions that I had asked previously. Just get maybe your perspective on Lessons Learned database, the Risk Management Oversight Committee, what's its accomplishments, maybe your idea about the consultants, if you think they're worthwhile, and, you know, exactly what the Quality Management Integration Council has, you know, the nurses organizations of the Veterans Affairs, you know, how are they interfacing?
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    Ms. MILLER. The Lessons Learned database, I think that would be very helpful. I know that Dr. Garthwaite and Dr. Kizer have written, published some of those in various journals, and I think that that kind of data is very helpful for those of us in the field who learn from error. We all learn from making mistakes, and growing from that, and sharing it with others, so that we don't have to repeat the same error across the system. I think that having that on our computer database, having access to that, access to Dr. Garthwaite, and the risk management professionals in VHA would be probably a good thing so that if I have an identified deficit or problem, I can work that up at my—at the team level, and up the organizational hierarchy, and aggregate data, looking at similar problems can be looked at across the system. And right now our computerized database is a very wonderful asset to the VA health care system, and that the data is there, it just has to be applied and utilized properly.
    And I think that's where the—your last question comes in, what is the utilizing the experts. Certainly, as a professional nurse, I'm not an expert in quality management, although I have participated in quality management in my complete VA career. However, having the expertise of someone that does know what is a good application, for example, what are other hospitals doing, what kind of problems are commonly generated in similar hospitals, and utilizing that aggregate data to look at ways to improve VHA. That's really what we need.
    My knowledge of the Quality Management Council, I know, Dr. Kizer is head of it. That's about all I know. I think that's a relatively new development this year. Prior to that I really can't speak to that.
    Having a risk management oversight group at any facility, or any level of the organization is very important, but the front-line providers to have access to the process of reporting and seeing follow-through, I think that's the most important issue, that if I'm a registered nurse on a patient care unit, and I identify a problem, I think the deficit now is that, sometimes that nurse or that person is not being heard, and they don't see an outcome resolution of that problem, and that problem, whatever the problem is, probably is happening in other VA hospitals across the system. And that's the kind of aggregate data that we need to look at as a system. Maybe, you know, maybe this is happening in 50 percent of our facilities, and we could easily look at that, track it, improve it, and make the VA a leader in health care.
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    Mr. STEARNS. After a highly publicized detailed investigation of quality care at the Castle Point and Montrose VA medical centers, the Medical Inspector made 158 recommendations, and identified 13 lessons learned. What lessons have other VA medical centers and networks learned from their investigation, and, how has this actually affected and changed the system? Have you seen all those 158 recommendations?
    Dr. GARTHWAITE. Sure.
    Mr. STEARNS. And you could detail for me the 13 lessons learned this morning?
    Dr. GARTHWAITE. With some prompting we could work through it. Dr. McManus, who is the Medical Inspector, is with us today. If you'd like, I'd let him comment. I'd be happy to comment, some of these are specific to the local area, and some of them are generalizable to the system.
    Mr. STEARNS. Well, it's so easy to make recommendations.
    Dr. GARTHWAITE. Right.
    Mr. STEARNS. You know, have these recommendations been implemented? Have we learned from these lessons? And have they been distributed among all the VA centers? And this is a critical aspect about what we're talking about this morning. Maybe Dr.—you or Dr. McManus could comment on that.
    Dr. GARTHWAITE. Let me just say before he comments. We have a long history, I've been in the VA 24 years, and we have a long history of taking many events, and making a policy or directive and sending that out. And then as you suggest, maybe it doesn't really get incorporated in every day practice. So if we do this for every lesson that's possible to learn, the VA manuals which already take up a full bookshelf, would take up several bookshelves.
    The key is, we believe, in addition to appropriate education of individuals, that we must design systems that don't require training of every new employee on a 1,000 different new procedures, and a 1,000 different possibilities of things to go wrong. Ultimately, human beings will be fallible. They will not be perfectly educated. And it's true in any industry you want to look at. What is lacking in health care because it used to be a patient and a doctor, or a patient and another professional, sitting down in a room together—is the system aspect of it. And the systems have to be built smarter. There have to be consistently colored stoppers on medications that must be diluted. There have to be pills that don't look like each other, or if they're dangerous, they have a specific appearance. That whole engineering into health care needs to happen. And we're very encouraged by our Patient Safety Committee from the American Health Association and others.
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    Mr. STEARNS. Let me just interrupt you for a second. Let me just get down to the brass tacks that we got involved with, the underreporting of adverse incidents. Dr. Kizer acknowledged last October that VA medical centers substantially underreport adverse incidents. And we brought this up. He believes that, you know, we're going to change the culture. Have you audited or otherwise validated the data that show huge jumps in certain performance measures over just one year, and how do you ensure that your managers aren't, you know, changing, massaging this data to ensure good results? Because that's what we're concerned about. I mean, this is very crucial, Dr. Wilson.
    Dr. GARTHWAITE. Dr. Wilson.
    Dr. WILSON. We have done some auditing of the performance measures. However, due to our own internal lack of resources, we have not been able to go out to the field and do as extensive audits as we would like. Where audits have occurred, the data do seem to be valid. There are a number of innovative systems, that have been put in place. For example, one of our performance——

    Mr. STEARNS. Go ahead, well, I mean, he could be up here in Washington and get all this unaudited information that shows that they are doing great, and he could come up here and tell me all these wonderful things, but the point of the question is, there has been underreporting. There appears to be some question of these performance measures being accurate, and yet you're saying that you haven't been able to corroborate that the information you're getting today is substantially correct?
    Dr. WILSON. The performance measures that are collected by external chart review such as the Chronic Disease Care Index and the Prevention Index, undergo audit by our contractor. They go back out and validate the collection of the information, and do studies on the reliability of the hospital abstractors who are collecting that information. The underreporting of adverse events is something that we have not looked at. We recognize that adverse events are underreported. We are pleased that in reviewing the results from every network, that networks are calling in more adverse events than they did historically. I am sure that there is still more to learn. The recent committee on system redesign met, and Dr. Billings, who created the Aviation Safety Reporting System, showed us information that, when they first implemented their reporting system, they got 5,000 reports, and now 20 years later they're getting 33,000 reports per year. So I'm assuming we have a ways to go in terms of our underreporting, but we in 6 months are at least gratified that we are taking small steps forward.
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    Dr. GARTHWAITE. I would also say that we have had conversations with Dr. Mather's bosses in the Inspector General's Office. We believe we are driving this system on performance data, which includes quality performance data, and that, we believe, if we're going to make good decisions then we must be able to rely totally on those results. We have asked them to help us verify and validate data as well.
    Mr. STEARNS. Dr. McManus, is there anything you would wish to add to this?
    Dr. MCMANUS. Yes, Mr. Chairman, thank you. As Dr. Garthwaite pointed out, I'm a member of the Patient Safety Improvement Oversight Committee, and when these adverse events are reported to this committee, we are part of the reviewing team that looks at how well the facilities reviewed the adverse event and what they intend to do to prevent it from happening in the future. You're right, there is a weak link here which has to be addressed either by some outside (external) visitor, or by another mechanism to determine whether facilities actually have implemented the lessons learned, or not.
    As Dr. Garthwaite pointed out, the process is evolving. In the past, many of the policies and procedures that are applicable to patient care, have grown out of an adverse event. For example, how to prevent patients from getting the wrong medication, how to prevent patients from falling, even how to prevent patients from taking their own life. There are already policies and procedures in place, but as Dr. Leape has pointed out,* somewhere between 6 percent and 15 percent of patients have an adverse event while they are in the hospital. This is something that we have to carefully look at.

    *Lucian Leape, M.D.Leape, LL. Error in Medicine JAMA 272:1851–1857, 1994

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    Mr. STEARNS. Dr. Wilson, you're saying you don't have the funds to get out and corroborate or inspect to make sure that these reports are accurate, is that what I heard you say?
    Dr. WILSON. We do not have the resources to go out and do site visit random audits as extensively as I would like. I had my staff go out and do site visits to audit all self-reported data that had been reported in fiscal year 1997. In fiscal year 1998, we have not yet had staff go out and do another level of independent auditing of all performance measures. I would add that there is ongoing data validation, however, of the input at the field level for all of the information that we use to monitor health care that goes into our electronic database.
    Mr. STEARNS. By whom? Who does that at the site?
    Dr. WILSON. At the site, the people, the front-line workers who are actually entering the information.
    Mr. STEARNS. But don't they report to the administrator of the hospital? I mean, you don't have anybody on site to validate?
    Dr. WILSON. No, I do not.
    Mr. STEARNS. Well, in any corporation, if they have subsidiaries, they send an audit team out to look at them. And you cannot take everything that comes from a corporation subsidiary without some kind of corroboration. So you need that in place. So I urge you to do that, and I don't know what we as a committee could do except make it a higher priority here to get you the funding?
    Dr. WILSON. Yes, sir.
    Dr. GARTHWAITE. Mr. Chairman, there are several auditors that go out to our facilities: the General Accounting Office will go out, the Inspector General will go out and look. There is a line drawn between funding for MAMOE, or headquarters funding, and field funding so that if you want someone within the Veterans Health Administration to do a centralized review and audit function, we're limited by law in that. While we can move more money into the Office of the Medical Inspector, and are actually attempting to do that, our overall MAMOE staffing has gone from 800 3 years ago, to about 530. As we've gone through that painful downsizing process, it's not been simple to free up additional slots for the MI and quality management as quickly as we would like to do.
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    Mr. STEARNS. Let me just switch gears here and talk a little bit about the Gulf War illness. Is there a person dealing with quality management for the Gulf War illness? You know, specifically looking at that within this program?
    Dr. GARTHWAITE. Well, I think Dr. Murphy and Dr. [Susan] Mather see it as their prime responsibility to improve quality for Gulf War veterans. We've had several meetings with Dr. Wilson looking at her data sets to specifically pull out Gulf War veterans in terms of their symptoms or functional status, and their satisfaction with care. Our first Lessons Learned national teleconference was on improving the care and satisfaction of care of Gulf War veterans. In fact, the lesson we learned was that one of our medical centers trained and assigned specific primary care physicians to patients with Gulf War illnesses and it resulted in much higher patient satisfaction. We've replicated that in a variety of other medical centers with some improvement. It's hard to tease out into one individual's responsibility, but I think my answer to your question is that it is a continuing concern, and everyone is involved, and we've targeted that group for specific scrutiny.
    Mr. STEARNS. So, Dr. Wilson, if I checked into a hospital in the VA in Gainesville, and I had complaints about Gulf War illness, would you have in place a way to track that dealing at that hospital, and then make suggestions for improvement in sharing what happened to me at that hospital with all the hospitals, 172 hospitals in the Nation, do you have that in place?
    Dr. WILSON. Yes, as a component of our patient advocacy program, we have a complaint and compliment tracking system. One of the enhancements that we made to that complaint tracking system was our ability to not simply flag the patient as a Gulf War veteran, but to differentiate concerns of deployed Gulf War veterans, from non-deployed Gulf War veterans. That information is reviewed by the service evaluation and action team at the network level, and then submitted centrally to Dr. Murphy. She's shared those reports with me as well on a quarterly basis.
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    Mr. STEARNS. We had a hearing here in which we had the administrator of the Miami Hospital, and he said he hired a doctor who had failed the Florida medical exam, four, five, eight, I don't know how many times it was. It was just unbelievable. So the question came back to him, ''Well, why did you hire him?'' He said well I had to hire him because I feared that we would be sued because he would claim that he failed because of anxiety. And with that in mind, in his investigation in New York last year, the MI concluded, among other things, that the medical staff failed to carry out a suitable credentialing privilege function. The Inspector General cites non-compliance in this area as a system-wide problem requiring attention. And so my question is, you know, what's going to change here?
    Dr. GARTHWAITE. I think several things are in the works, and have been in the works. My suspicion is that it's less a system-wide problem, perhaps, than in those medical centers pointed out by the MI based on my own personal experience in one major VA medical center, being president of the VA chiefs of staff, and knowing the effort that was put into improving credentialing.
    Mr. STEARNS. So, excuse me, then you disagree with the——

    Dr. GARTHWAITE. I'm just saying that I, I think to say that it's a system-wide problem in every medical center, is probably inaccurate, but let me tell you what we're doing in a positive way to address it, because I do think that credentialing of practitioners nationally could be done better, and it's enormously inefficient today. About 8 to 10 months ago, we detailed a VA employee to the Department of Health and Human Services to develop a centralized physician or provider credentialing database at the national practitioner database. The national practitioner database files includes every practitioner in the United States. Over the next few months, and the contractors are fairly far along in writing the code to allow this to happen, we anticipate that we will have a centralized primary source of verified information on every practitioner in the VA system. It will take us a while to feed the data in. That's the first phase. I call it ''the silver standard.'' If you move to the gold standard, every piece of information in that database is fed in by the primary authority, the state licensing board, the credentialing authority, the medical school, or wherever it was that the individual acquired a credential. I call it ''the gold standard,'' because there's no chance for compromised data because the data is fed directly. They can do it once. They can do it well. It can be done, I believe, electronically.
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    The final piece that needs to be nailed down, that we also have included in our statement of work, is that identification of the individual needs to happen. We don't know whether the best method is a thumbprint, retinal scan, a fingerprint, or something else. But we believe that in the beginning, probably part one of your national boards, you present evidence of who you are including an identification component. Once all things are tied together it becomes a fail safe system. The system doesn't have that many failures, but it should not have any failures. And we believe we're going to invent a system that has no failures.
    The final piece is that we have agreed with the national practitioner data bank that the software we develop, which will allow us to do a better job, will also allow the Department of Defense, and other Federal providers to do a better job and it is entirely generalizable to the population at large. So that instead of being credentialed inefficiently and incompletely 16 times, as most providers in the United States are as they join different health plans, it could be done once right, and we could put our efforts into a more constructive evaluation of care.
    Mr. STEARNS. I think that's a key task for you. I'm surprised it hasn't been done a long time ago, aren't you?
    Dr. GARTHWAITE. Well, when I was in Milwaukee, we did it for the entire city.
    Mr. STEARNS. That's right.
    Dr. GARTHWAITE. But now I'm at a national level, we're trying to do it for the entire VA system. We'll see what we can do.
    Mr. STEARNS. What about the privileging issue, that's that the doctor is able to do the kind of practice he's assigned?
    Dr. GARTHWAITE. Well, I think the first step is to match your qualifications, what you have been trained and certified to do, with what you're actually doing in a hospital. For the most part, I think that gets done reasonably well. The nurse checks the assigned privileges versus the surgery being done that day, it's a human process. So although we have processes to try to make sure that happens, that's subject to training everyone and getting them to do that on a regular routine basis.
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    The hard part, which I don't think any health care organization has solved totally, is how do you demonstrate current clinical competence in a given area. Part of VA's problem is that we have part-time physicians, so a part of the practice is at the VA, but most of their practice is across the street at the university. Private sector hospitals have been reluctant to share quality assurance data especially negative outcomes, with us. So that we would have to then accumulate enough experience based on their VA work with a given practitioner to really understand whether they are currently clinically competent. So there's still some very significant challenges in that privileging aspect.
    Mr. STEARNS. Dr. Mather, is there anything you'd like to contribute before we complete?
    Dr. MATHER. Just a couple of thoughts. I think the issue that you and Dr. Garthwaite's raised, about cultural change is a very important issue to keep before us all. The issue of underreporting of adverse events that you alluded to is not a simple matter of saying, ''Now, do it.'' It is a matter also of individuals in the health care system feeling that there's a certain amount of confidence that those events reported will be followed through on. There's a sense that they should have, I think, a level of confidentiality with a less punitive attitude to actually reporting such events. This I think is a very difficult conundrum for the Veterans Health Administration to deal with. On the one hand, there are individuals VHA would want to come forth and report quite voluntarily and freely that something adverse has happened. But traditionally there's been a sense that that's alright but individual culpability seems to presently override any systems that VHA might want to change. I think this is a cultural thing that has to be overcome. I think we could be back here in 6 months, sir, and you could be asking the same question. ''How do we know all the errors have been reported?'', and potentially the answer could still be, ''Well, we still don't know if all the errors are being reported.''
    Some way has to be devised so that individuals not only come forth with those errors, but they have to have some assurance that, as they report on the full magnitude of them, and the seriousness of others, that, unless there's the potential in certain situations for criminal negligence then there should be a way in which they can feel assured that in coming forth with information that is worthwhile, it is going to improve the whole system.
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    If there's any criticism of VHA we had in our report, it was that there's a lot to be learned, and that this information needs to be disseminated across the whole system as quickly as possible. Then, the same error may not be repeated in the next facility, tomorrow. There needs to be a mechanism of showing that information gets back, it's rolled up, it's trended, it goes back in the system and there truly are lessons learned that result in changes of behaviors, and that people are alert to what might be problems.
    Mr. STEARNS. Okay, anyone else that would like to—yes sir.
    Dr. MCMANUS. I might add that the Director of VISN 3 was asked by Dr. Kizer to present lessons learned from the Castle Point/Montrose situation at the Board of VISN Directors' meeting last month, and there were numerous questions about that. The Medical Inspector also recommended that the VISN 3 Director share with the other medical facilities those recommendations which he felt were generic, and not specific to Castle Point and Montrose.
    I might also say that at the end of February, the Medical Inspector's Office received an action plan from Castle Point and Montrose that addressed each one of the 158 recommendations. This office is now in the process of evaluating those actions. Some of them won't be fulfilled for 6 to 12 months, but we intend to follow these.
    Mr. STEARNS. Let me throw Dr. Mather just a curve here. [Laughter.] You know, in private practice when they have incompetence, or they have people that appear to have made some serious errors that they take steps—does the VA hospital suffer from a culture that people say, ''Well, I can't be fired, I can't be let go''? Is there a mechanism within the VA for remedial corrective measure here so that once we find the problem, we can actually make some steps and correct the steps? I'd like your honest opinion on that because if everybody's reporting and everything's doing good and you find somebody that's incompetent that's doing something bad, you've got to be able to do something—and in the private sector—can you do this in these VA hospitals with a certain confidence level?
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    Dr. MATHER. Mr. Chairman, I think the simple answer to that question is yes. There are some very clear prescriptive administrative mechanisms for those situations. There are also requirements for reporting to appropriate professional boards that level of incompetence, so we don't have the same thing translated elsewhere to the private sector or other government systems.
    I think it's very clear now that, in certain circumstances, and indeed the patient safety improvement directive lays it out. If you have suspicions of potential criminal activity, these are what you need to do, and so I think at this point in time. It's the old story, there are good policies, we need to ensure that they are complied with and followed. And I think the VISN network directors have a clear responsibility in this regard in this decentralized system to ensure that these things are being done.
    Mr. STEARNS. And you think within this system, the VA system, there is a procedure and mechanism to isolate, correct, and, if necessary, to take major steps to change it?
    Dr. MATHER. Again, I think the simple answer is yes. I think we could discuss a number of examples, and we could dwell on some fairly egregious examples. Where there has been an attempt to cover up a very serious situation, when that has been revealed the agency and VHA in particular, has been able to take definitive action because it had the force of the regulations, or other authorities backing them to take action. Sometimes it's a matter of the will to do it, and to have a sense that when I have the will to do it, I'm going to be backed up all the way along the line. And I hear, at this point in time, at least in the brief discussions I've had with Dr. Kizer, there is a will to make sure that these kinds of things are done. If there are found to be adverse events, we need to look at two things: One, the individual, and two what it is that led to the circumstances of this adverse event. If it was less than inadvertent and it was egregious, something needs to be done, and are there administrative mechanisms to approach the individual issue. Again, it gets to the previous issue, you can have good policy, but you have to apply the policy systematically, conscientiously and appropriately.
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    Mr. STEARNS. I don't have the figures at the tip of my finger about instances in which the VA has been sued, has to pay out millions of dollars in court fees because of malpractice, and obviously it's true in the private sector too. We've had testimony from an individual who said—comparing the VA and the commercial, but in the commercial side, or shall we say, the private sector hospital, the culture is obviously, I think a little different than in the VA which is a government-run institution, so I just want to make sure that we have, when it's so crucial to our veterans to protect them, that we have a mechanism that if we find egregious or criminal behavior, that there are steps allowed to change that.
    Dr. MATHER. Mr. Chairman, I can add to that. I think there's an adage that ''An ounce of prevention is worth a pound of cure.'' I do believe that the VHA systems that are being put in place have an emphasis on prevention, and while we will never I think in any health care system be able to eliminate the obvious egregious errors, one would hope that the systems first of all, do all they can to prevent them, and secondly, when they do, there's an immediate action taken to rectify, if possible, the situation.
    Mr. STEARNS. Okay, anything you might want to add, or anything you think this committee should be concerned in that area to help you?
    Dr. GARTHWAITE. Sure. I get to sign off on the final disciplinary appeals boards, so I know on a regular basis that we are taking actions against practitioners in the VA health care system because often they disagree with our action, and request a disciplinary appeals board hearing. And so that's my job, along with some other professionals to assure that the proper procedures and data were followed. So I know that does occur. I see at least two a month of those kind of cases. In fact, it's enough concern to me that on Tuesday this week, I went out of my way to fly down to a meeting of new Disciplinary Appeals Board examiners to give them our perspective on how important I thought their task was.
    A second piece that I think is important, because it has been raised in the public forum previously, is the question about how often we report to the National Practitioner databank when we have a pay-out. When you sue someone in the private sector, you sue someone. When you are someone in the VA, you sue the government. And so we have to have a procedure in which we make that determination. A couple of years ago, we were asked whether or not our procedure was effective and fair. And as we heard the concerns the GAO at the time had, it was immediately obvious to me that it was impossible to ask VA physicians to rule on their friends and their colleagues.
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    And so about a year and a half ago, we began using outside clinicians to do a peer review on the cases that we settle. We've had nine outside panels, 108 cases. We reported 36, or one-third of individuals were felt under peer review to be reportable. They also found that a few of the cases they think may have been winnable. We're working with our general counsel to get a better clinical input into some of the cases. But I think the bottom line is we've improved significantly from about 5 percent to 33 percent. Not that our goal is to report our clinicians, our goal is to appropriately protect the public, and appropriately provide health practitioners with their due process as well. And I think we've instituted a process that seems quite reasonable in that regard.
    Mr. STEARNS. Well, I thank you very much for your participation this morning. I think it's helpful. And let me encourage all of you. We have confidence in you. We look to you for solving these problems, because we're sort of an oversight trying to get a feel and, you know, obviously we have a lot on our plate from day to day. But, your experience in Milwaukee, and you've got great reputations, so now when you go back to your office and you sit down, I mean the name of the game is to improve it. And your coming up here to be forthright and tell us and let us know what we can do in a bipartisan fashion. So thanks very much.
    Dr. GARTHWAITE. Thank you.
    Mr. STEARNS. And of course the Minority will be asking questions that they'll submit that we hope you'll take the time to answer quickly.
    Dr. GARTHWAITE. Pleased to.
    Mr. STEARNS. With that, the subcommittee is adjourned.
    [Whereupon, at 11:55 a.m., the subcommittee adjourned subject to the call of the chair.]