摘要：Objectives. Suffering from waning demand, poor quality, and reform efforts enabling veterans to “vote with their feet” and leave, the Veterans Health Administration (VA) health care system transformed itself through a series of substantive changes. We examined the evolution of primary care changes underlying VA’s transformation. Methods. We used 3 national organizational surveys from 1993, 1996, and 1999 that measured primary care organization, staffing, management, and resource sufficiency to evaluate changes in VA primary care delivery. Results. Only rudimentary primary care was in place in 1993. Primary care enrollment grew from 38% in 1993 to 45% in 1996, and to 95% in 1999 as VA adopted team structures and increased the assignment of patients to individual providers. Specialists initially staffed primary care until generalist physicians and nonphysican providers increased. Primary care-based quality improvement and authority expanded, and resource sufficiency (e.g., computers, space) grew. Provider notification of admissions and emergency department, urgent-care visit, and sub-specialty-consult results increased nearly 5 times. Conclusions. Although VA’s quality transformation had many underlying causes, investment in primary care development may have served as an essential substrate for many VA quality gains. At the heart of the Institute of Medicine’s report Crossing the Quality Chasm was the need to address the improvement of quality of care through major changes in how health care is organized. 1 The Institute of Medicine’s central tenet was that only through significant, sustained, and innovative efforts to reorganize the health care system were substantive gains in quality of care and health outcomes possible. Launched in the mid-1990s, the Veterans Health Administration’s (VA’s) reorganization of care presaged the Institute of Medicine report by having already initiated significant internal restructuring of the care delivery system, including changes in delivery models (e.g., integrated networks, primary care teams), adoption of new technologies (e.g., electronic medical records), and implementation of new management strategies (e.g., reminders, guideline implementation, performance audit and feedback). 2 – 8 In the aggregate, these organizational changes have been associated with significant gains in VA quality over time and in comparison to Medicare 9 and have resulted in substantial media attention surrounding the VA’s potential to serve as a model health care system for the United States. 10 – 13 Despite this organizational transformation, remarkably little is known about the discrete organizational characteristics in VA facilities that specifically contributed to these performance changes; that is, we are yet to empirically open the “black box.” Prior to the reorganization, the VA health care system had been suffering from waning demand, perceptions of poor quality and customer service, and a threat from health care reform efforts as market research suggested that 3 out of 4 veterans would “vote with their feet” and leave if given a national health care card. 14 – 16 This survival threat was a call to action. One of VA’s first actions was to commission an assessment of its staffing, management, and resources to determine how ready the VA health care system was for transformative change, which led to the establishment of an evidence-based policy to nationally adopt primary care as its foundation. 17 VA’s subsequent policy changes and strategic plans comprised substantive changes in network restructuring, electronic charting, health care financing, and performance measurement, as well as augmentations to primary care delivery (e.g., increased access to nonphysician providers). 3 , 4 , 18 These policy changes and the strategic plan provided added fuel and a roadmap. Although VA’s quality transformation has many underlying causes and outcomes, many of the gains may have had their early roots in VA’s investment in primary care development, a necessary substrate for organizational change. The notion that the VA’s transformation had its roots in primary care development is consistent with recommendations for improving quality through greater attention to internal structural changes in how primary care practice is organized and delivered. 19 We report on the results of a series of highly unique data sources that span VA’s reorganization, which was launched in 1996 with Kizer’s Vision for Change and Journey for Change policy directive and implementation plan. 20 – 22 We analyzed surveys from a predirective year (1993), through early reorganization (1996), and later reorganization (1999–2000), during which most of the early performance gains had been achieved. 9 To date, these surveys have been used individually in cross-sectional snapshots to good effect; they have substantively informed our understanding of the environmental, organizational, and primary care practice structural features associated with quality of care in general. 23 – 27 However, they have never been combined and examined crosssectionally over time to tell the story of VA as a public sector turnaround. Capitalizing on these national organizational surveys conducted over the course of VA’s natural experiment, we provide the first quantitative evaluation of the detailed primary care organizational changes underlying VA’s quality transformation. Our overarching goal is to provide an empirical base for informing evidence-based management, practice, and policy, and to provide practical knowledge for use by other health care systems, organizations, and health plans. 28
