This special issue of the Journal of Health Care Quality (JHQ) solicited manuscripts on quality healthcare initiatives for Veterans. The response to this call brought more than two dozen manuscripts, more than have ever been submitted for a single issue of JHQ. The submitted manuscripts ranged from improvement efforts focused within clinics or service lines to innovative dissemination and implementation programs led by the Department of Veterans Health Affairs.
Of the manuscripts accepted, the focus centered on several timely central themes related to quality and safety initiatives; these included population health and care transitions, interprofessional quality performance and process improvement, health data analytics, and quality review and accountability. The dissemination and implementation quality topics in these papers range across hospitalized and community-based Veteran populations who are elderly, needing surgical, perioperative, mental health and primary care to process mapping and screening for colorectal cancer, inpatient suicide, provider adherence to prescribing guidelines, and a model for a graduate nurse practitioner residency. Specific overview of the papers selected for this special issue follows.
Timely access to services is a challenge for any large healthcare system. Munir et al describe an improvement project to reduce preventable causes of ophthalmology surgical case cancellations. Process improvements significantly reduced cancellations and increased operating room utilization. Preventive services are critical to improving health, quality care, and decreasing costs. Cheng et al describe an improvement project to decrease the rate of rejected fecal immunochemical tests for colorectal cancer screening. In this paper, an interprofessional team tested several process changes to significantly reduce rejection rates.
Transitions from one level of care to another can result in a lack of coordinated care, problems with follow-up, and medication reconciliation. Most Veterans do not get all their healthcare needs from the VA system. The paper by Libbon et al describes a project to improve care transition from a non-VA hospital back to VA primary care services. Dworksy's team describes a prehabilitation program to proactively reduce perioperative risks for frail, older Veterans before surgery.
These papers are examples of the improvement activities that interprofessional teams across the VA engage in to improve quality and safety at the point of care. But VA employees are also actively examining quality at the system level. Cordasco et al examined guideline adherence for systemic hormone therapy across four Veteran health facilities using the VA Corporate Data Warehouse. Hormone therapy guideline adherence was similar to other reports of guideline adherence, and the authors suggest the use of clinical decision support tools and/or panel management to increase hormone therapy safety.
The VA plays an important role in healthcare professional education in the United States beyond medical training. McGuiness et al describe how mental healthcare by nurse practitioner residents using measurement-based care reduced variability of assessment, improved continuity of care, and decreased psychiatric symptoms among Veterans. Likewise, the VA Quality Scholars program is an interprofessional postdoctoral training program that develops healthcare improvement leaders and scholars for the VA and beyond. Godwin et al. describe an innovative activity of process mapping current suicide prevention practices across eight VA medical centers across the United States. The findings suggest progressive improvement and increase in supportive resources across the sites and identify opportunities for improvement around risk detection, refinement of protocols, and engaging patients and their family.
Few healthcare systems have the resources to do the important work to systematically develop innovative models of care and to measure and improve quality and safety. As the nation's largest integrated healthcare system, the VHA frequently leads innovative models of care delivery and academic affiliations. Significantly, innovative and interprofessional approaches to improving quality healthcare for Veterans in these manuscripts substantiate the heterogeneous efforts manifested throughout the healthcare system serving our nation's Veterans.