Military Might
Today's VA hospitals are models of top-notch care
Such prompting is largely why the VA vaccinates 92 percent of patients ages 65 and older against pneumonia versus 29 percent 10 years ago, says Jonathan Perlin, the top doctor in the Department of Veterans Affairs. Outside the VA, he says, the rate averages below 55 percent. "The increase not only has saved the lives of 6,000 patients with emphysema," says Perlin; "we've halved hospitalizations for [patients with] community-acquired pneumonia."
And the computerized system reduces medication errors, blamed for thousands of deaths in hospitalized patients, by flagging an order if there's a possible drug interaction, if the dosage doesn't match a doctor's order, or if there is a potential allergic reaction. Retired Army Sgt. Maj. Lance Sweigart of Laurel, Md., takes six medications for arthritis, high cholesterol, and depression. The 61-year-old Sweigart says he has "never gotten the wrong medication" at VA facilities in Baltimore.
All drugs carry bar codes, as do patients' ID bracelets. Both are scanned before a medication is administered to make sure the drug and patient match and last-minute order changes are caught. It's not yet sophisticated enough to offer the appropriate dosage, but Isabel Sotomayor, a nurse at the VA Medical Center in Washington, D.C., says the system snags one or two potential errors every day during her medication rounds.
The impact of such changes is real, says Harvard School of Public Health professor and renowned patient-safety advocate Lucian Leape. "Recent evidence shows [that care at the VA system] is at least as good as, if not better," he says, than care delivered elsewhere. In the 1990s, for example, the VA began using a new way--since adopted by the American College of Surgeons--to evaluate surgical quality. It enabled VA surgeons to reduce postoperative deaths by 27 percent and post-surgical complications by 45 percent. Recently published studies have found that the VA rates much better than Medicare fee-for-service providers in 11 basic measures of quality, such as regular mammograms and counseling for smokers. Late last year, the Annals of Internal Medicine published a study showing that the VA had "substantially better quality of care" than other providers in many of nearly 350 indicators of quality, such as screening and treating depression, diabetes, and hypertension.
Overhauling a system of 157 hospitals, 134 nursing homes, and 887 clinics is never finished. Recent reports by the inspector general of the Department of Veterans Affairs have highlighted such problems as cancellation of surgeries, unexpected deaths, and radiology backups at VA facilities in Florida. Surgeries have had to be canceled at some facilities because surgical supplies were unavailable or improperly sterilized. But John Daigh, who as assistant inspector general for healthcare inspections is responsible for exposing such flaws, says that VA top brass haven't retreated into denial. They "have stepped up to the plate and fixed the problems" that his investigators uncover.
That, too, is evidence of a seismic shift, brought about not by high-tech breakthroughs but by a fundamental change in VA culture. A new emphasis, on patient safety and on a work ethic that stresses constant examination of the processes and procedures that go into caregiving, arrived in 1994 when Kenneth Kizer, former director of California's Department of Health Services, was tapped to run the VA health empire. His mission, as he saw it, was to remake the unwieldy system into one of the world's safest and finest. Kizer started holding doctors, administrators, and managers directly accountable for the quality of their patient care, linking, for example, how many heart-attack patients received recommended beta blockers and aspirin to job reviews. And the performance for each facility was made public, which turned out to be a major motivator. "People competed like hell," says Kizer, now president of the nonprofit National Quality Forum, which develops national standards for assessing the quality of healthcare.
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