Poor Checkup for Veterans Hospitals : Health care: Typical facility is at least 20% more likely than non-VA hospitals to fail quality standards, according to a study. System is burdened with aging facilities and in need of restructuring.
The typical veterans hospital is considerably more likely than other hospitals to fail quality standards in key areas such as surgery, emergency care and intensive care, according to a major study by the commission that accredits most of the nation’s health care facilities.
The study of 116 veterans’ hospitals, obtained by The Times from the Department of Veterans Affairs last week, is likely to trigger renewed debate over the adequacy of government medical care for the nation’s 27 million veterans. About 3.5 million veterans use the 172 medical centers administered by the VA each year.
The Joint Commission on the Accreditation of Healthcare Organizations in Oakbrook Terrace, Ill., found that VA medical centers are at least 20% more likely than non-VA hospitals to fail quality standards in six important areas: emergency services, special care services, surgery and anesthesia services, surgical case review, alcohol and drug treatment planning, and fire safety. The study compiled overall statistics and did not name facilities.
Dr. Arthur J. Lewis, the VA’s acting chief medical director, said he “was concerned by the wide disparities” and that medical centers would be expected to “attend promptly to those areas where remedies can be achieved quickly.”
Lewis maintained that many of the areas of non-compliance represented inadequate “documentation” and “did not necessarily equate to poor care” or to “loss of accreditation.”
Despite expenditures of $11.6 billion a year, the VA medical care system is burdened with aging facilities. It is often characterized as being understaffed, under-funded, inefficient, and in need of fundamental restructuring. Last year, a VA study found higher than predicted death rates among patients at about one-fourth of the medical centers, including 22 that were judged to have “likely quality of care problems.”
“I have worked with the VA for a number of years and they have had an increasing number of problems,” said Don Avant, a special assistant to the president of the commission. “It is a big, cumbersome, bureaucratic system. They have a lot of very good people, but they may be trying to keep too many hospitals afloat.”
Dr. William Jessee, the commission’s vice president for accreditation surveys, said the VA had “a seriously aging infrastructure in its health care facilities” and had not been “adequately funded to bring these physical plants up to current life-safety standards.”
VA officials and the commission staff will meet in early June to “try to make sense out of (the data),” Lewis said. The VA also plans a variety of programs, including a satellite video teleconference in September, to help hospitals address high priority issues.
The VA asked the commission to compile the statistics in response to a request in January from Sen. Alan Cranston (D-Calif.), chairman of the Senate Committee on Veterans Affairs.
“I am quite concerned about the differences,” Cranston said in a statement Friday. “The VA must do a better job and it will.”
A spokesperson said the senator had asked the General Accounting Office to “investigate on an expedited basis the significance of the data.”
The study, sent to the VA in April, compared 116 VA medical centers to the 5,182 other hospitals that the commission surveyed between 1987 and 1989. Hospitals are surveyed an average of once every three years.
On the commission’s complicated 100-point rating system, the typical VA hospital scored 69.8, compared to a score of 77 for the typical non-VA hospital.
Only 6% of VA medical centers received 87.5 points or more--a very high score--compared to nearly a quarter of the other hospitals. At the low end of the scale, 16% of VA medical centers scored 57.5 points or less, compared to 4% of other hospitals.
Hospitals with inspection scores of 50 or below are placed on probationary status, as are some facilities with higher scores but serious problems in key areas. These hospitals risk losing their accreditation if the deficiencies are not quickly corrected. The names of probationary hospitals and non-accredited facilities are made public, but the inspection reports are confidential.
According to the VA, six medical centers are on “conditional accreditation” status. These include three in California--Long Beach, Sepulveda and Palo Alto--two in Oregon and one in Washington. None of the nation’s VA hospitals are non-accredited.
The commission’s quality standards scrutinize the systems that protect patients and improve their care, according to the commission’s Jessee. They do not measure the care received by patients.
“The greater the number of contingencies (areas of non-compliance), the greater the likelihood that there might be an adverse event in patient care that could have been prevented,” Jessee said.
A key limitation of the study is that it compared VA hospitals to all non-VA hospitals, not to a matched random sample of hospitals of similar size, type and scope of services. In addition, the three deficiency rankings for the quality standards--partial compliance, minimal compliance and non-compliance--were all given equal weight in the analysis.
Jessee said the VA would have to consider the “political risk” of asking the commission to perform more sophisticated analyses. “It could cut both ways,” he said. “It might help them improve the care in their system . . . (but) it could make them look better or look worse.”
Conditionally accredited hospitals must submit plans of corrections. If the plan is accepted, the hospital is reinspected six months later. Fully accredited hospitals must either submit written progress reports or undergo focused surveys that target the specific problem areas.
The commission considers its standards to represent optimal performance. As a result, nearly all hospitals are found to be deficient in at least one of about 20 core areas. These areas include quality assurance, medical staff monitoring and nursing staffing and procedures. Many hospitals have deficiencies in four or five areas.
But the typical VA facility racks up far more deficiencies, or “contingencies,” on key quality standards than the typical non-VA hospital, according to the study.
As a group, VA hospitals were found deficient in six of the core areas on more than 60% of the inspections. A total of 69.8% of VA hospitals were found deficient in medical staff quality monitoring; 71.7% in surgical case review; 74.6% in special care services such as intensive or coronary care; 62.7% in surgery and anesthesia services; 66.2% in the alcohol and drug treatment planning process; and 82.4% in hospital life-safety. For emergency services, VA hospitals had a 50.9% deficiency rate.
By comparison, as a group, non-VA hospitals had much lower levels of non-compliance--typically between 30% and 50%--in these areas.
“There are always going to be unfortunate adverse events,” Jessee said. “But if (hospitals) are in substantial compliance with these standards, you are less likely to see the same adverse event happen more than once.”