VA Health Care Quality: VA Should Improve the Information It Publicly Reports on the Quality of Care at Its Medical Facilities

GAO-17-741 Published: Sep 29, 2017. Publicly Released: Sep 29, 2017.
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Fast Facts

Health care quality measures provide standard data that help inform consumers about which providers are most likely to deliver high quality care. They also help providers improve the care they give patients.

To help veterans make informed choices, Veterans Affairs reports on 110 of these measures for VA medical centers on its website (as of June 2017). We found that information on these measures is in two separate parts of the site. The easily-accessible page contains 15 of the 110 measures. The other, older page contains 100 measures, but is hard to find and to understand.

We recommended two actions to improve reporting.

Access and Quality Webpage on the Department of Veterans Affairs Website as of June 2017

Webpage screenshot from the Veterans Affairs website

Webpage screenshot from the Veterans Affairs website

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Highlights

What GAO Found

As of June 2017, the Department of Veterans Affairs (VA) publicly reported 35 health care quality measures on the Hospital Compare website, which is maintained by the Department of Health and Human Services. Veterans can use information on this website to compare the performance of VA medical centers (VAMC) and non-VA hospitals on a common set of quality measures. Those measures include patient reports of their experience of care, such as how well doctors and nurses communicated with them, and actual outcomes of care, such as readmissions to the hospital. On its own website, VA reported 110 quality measures, including some of the same measures reported on Hospital Compare . VA also reports quality measures not found on Hospital Compare , such as measures of how long veterans must wait to access care at VAMCs.

VA reports health care quality measures on two separate webpages of its website. VA launched the Access and Quality webpage in April 2017, which according to VA officials is the primary source of information for veterans on the quality of care at VAMCs. GAO found that this information is generally presented in a way that is accessible and easy to understand. However, GAO also found that the primary webpage provides information from a small subset—15—of the 110 measures VA reports on its website as of June 2017. Most of the other measures are available on a second, older webpage that resides elsewhere on VA's website and is generally not easily accessible and understandable. Until VA can provide information on a broader range of health care measures and services and present this information in a way that is easily accessible and understandable, VA cannot ensure that its website is functioning as intended in helping veterans make informed choices about their care.

Within VA, VA Central Office is responsible for calculating the health care quality measures that VA publicly reports for each of its VAMCs and ensuring that these measures provide accurate information on the VAMCs' quality of care. However, GAO found that VA Central Office has not systematically assessed the completeness and accuracy of the underlying clinical information that is used to calculate these measures. This clinical information is recorded in veterans' medical records and includes diagnoses given and treatments provided. Several studies have found potential problems with the accuracy and completeness of this clinical information at some VAMCs. For example, a 2015 independent assessment conducted by McKinsey & Company found that VA's clinical documentation procedures are below industry standards and that many VAMCs do not have programs in place to improve clinical documentation practices. VA Central Office officials told GAO that they have not systematically assessed the completeness and accuracy of the clinical information across VAMCs and the extent to which this affects the accuracy of its quality measures because they have focused on other priorities. However, the lack of such an assessment is inconsistent with federal standards for internal controls related to information and monitoring. As a result, VA does not have assurance that the quality measures it publicly reports on Hospital Compare and its own website accurately reflect the performance of its VAMCs and provide veterans with the information they need to make informed choices about their care.

Why GAO Did This Study

To help veterans make informed choices about their care, the Veterans Access, Choice, and Accountability Act of 2014 (Choice Act) directs VA to publicly report applicable health care quality measures for its medical facilities on HHS's Hospital Compare website and on VA's own website.

The Choice Act also contains provisions for GAO to review the health care quality measures VA publicly reports. In this report, GAO 1) describes the quality measures VA reports on Hospital Compare and its own website; 2) evaluates VA's reporting of quality measures on its website; and 3) examines the extent to which VA has assessed the accuracy of the quality measures it publicly reports. GAO reviewed the quality measures VA publicly reports, reviewed studies and interviewed VA officials about the accuracy and completeness of the clinical information used to calculate the measures, and assessed the presentation and relevance of VA's information on quality of care using criteria identified in previous GAO work to evaluate health care websites.

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Recommendations

GAO recommends that VA 1) report a broader range of health care quality measures in an accessible and understandable way on its website and 2) conduct a systematic assessment of the patient clinical information across VAMCs to ensure its accuracy and completeness. VA concurred with GAO's first recommendation and concurred in principle with the second recommendation, and described steps to implement the recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs The Undersecretary for Health should take additional steps to ensure that VA's website reports health care quality measures that cover a broad range of health care services, highlights key differences in the clinical quality of care, and presents this information in an easily accessible and understandable way (Recommendation 1).
Open
As of January 2020, VA provided information that they had updated information on its website to include more quality measures, particularly as they relate to outpatient care. While VA has made progress in reporting on additional measures, we reviewed VA's website-specifically, their Access and Quality webpage which is the primary webpage for veterans to access information on quality-as of February 2020 and found that VA has still yet to report on a broad range of quality measures that would assist veterans in making health care decisions for inpatient care. For example, VA does not report any quality measures related to readmissions and mortality; length-of-stay; or efficiency. VA also continues to report only one timely and effective care measure for inpatient care. With regards to presentation of its quality measures, VA no longer links its Access and Quality webpage to the homepage of VA's website, making it more difficult to find. Additionally, for the new outpatient measures that VA has added to its website, VA has not presented these measures in an easily understandable way as there is little explanation of what they are measuring and how veterans can use these measures to make healthcare decisions. We will keep this recommendation open until VA has made further updates to its website.
Department of Veterans Affairs The Undersecretary for Health should direct VA Central Office to conduct a systematic assessment of the completeness and accuracy of patient clinical information across VAMCs that is used to calculate the health care quality measures VA reports and address any deficiencies that affect the accuracy of these measures (Recommendation 2).
Open
As of January 2020, VA has said they have focused on three main efforts as it relates to documenting information on VA quality of care, including: timeliness of access information (e.g., wait times) to health care within VA facilities; timeliness and accuracy of payments to community care providers; and accuracy of coding and documentation within VA and from community providers. In particular, VA has conducted several efforts to improve education and training on clinical documentation and coding, particularly for providers. VA has also said it has made efforts in requiring programs across regional networks aimed at improving clinical documentation and coding. While these efforts can help with improving documentation of care to veterans, it is unclear how VA Central Office has assessed whether these efforts have actually achieved its goals and improved the accuracy of its quality measures. As we stated in our report, VA Central Office has not conducted a systematic assessment of the completeness and accuracy of the clinical data recorded in VA patient medical records across all VAMCs. The results of such a systematic analysis could help identify the deficiencies, if any, in the recording of patient clinical information and what steps, if any, VA Central Office may need to take to address them. We will keep this recommendation open until VA provides information on a systematic assessment of clinical documentation.

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