2019-21538. VA Standards for Quality

AGENCY:

Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

The Secretary of the Department of Veterans Affairs (VA) establishes these standards for quality to satisfy the requirements in section 1703C of title 38, United States Code (U.S.C.), as added by section 104 of the VA MISSION Act of 2018.

FOR FURTHER INFORMATION CONTACT:

Joseph Francis, Office of Reporting, Analytics, Performance, Improvement, and Deployment (RAPID), 10A8, Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, [phone]. This is not a toll-free number.

SUPPLEMENTARY INFORMATION:

Section 1703C of 38 U.S.C., as added by section 104 of the VA MISSION Act of 2018 requires VA to establish standards for quality regarding hospital care, medical services, and extended care services furnished by the Department, including through non-Department health care providers pursuant to section 1703 of this title. Starting in August 2018, VA began consulting with various stakeholders and experts including the Department of Defense (DoD) Defense Health Agency, the Centers for Medicare & Medicaid Services, the Department of Health and Human Services (HHS), Veterans Insight Panel focus groups selected from a standing veteran consumer panel (maintained by a neutral third-party) that is demographically representative of veterans served by VA, regulatory and accreditation groups, Veterans Service Organizations, Federal employee representatives, and health care specialty associations and organizations. VA also solicited comments from the public through a Notice in the Federal Register on August 24, 2018, (83 FR 42983), and held a public meeting on September 24, 2018, inviting the public to discuss and provide input regarding what VA should consider when developing the standards for quality. VA submitted a report to Congress on the proposed VA standards for quality on March 13, 2019. This Notice formally establishes VA's standards for quality.

In defining VA's standards for quality established by the Secretary, VA incorporated findings from a review of existing standards, stakeholder feedback, and the framework for quality put forth by the National Academy of Medicine in its report, “Crossing the Quality Chasm”. The standards for quality consist of Quality Domains and Quality Measures.

• Quality Domains—broad categories of quality used to describe the desired characteristics of care received by veterans, whether furnished by VA or community-based providers.
• Quality Measures—an evolving series of numeric indicators that evaluate clinical performance within each of the quality domains.

These standards for quality are:

• Timely Care—provided without inappropriate or harmful delays.
• Effective Care—based on scientific knowledge of what is likely to provide benefits to veterans.
• Safe Care—avoids harm from care that is intended to help veterans.
• Veteran-Centered Care—anticipates and responds to veterans' and their caregivers' preferences and needs and ensures that veterans have input into clinical decisions.

The initial quality measures for each standard for quality are:

• Timely Care

○ Patient-reported measures on getting timely appointments, care, and information

○ Wait times for outpatient care

• Effective Care

○ Risk adjusted mortality rate for heart attack

○ Risk adjusted mortality rate for pneumonia

○ Risk adjusted mortality rate for heart failure

○ Risk adjusted mortality rate for chronic obstructive pulmonary disease

○ Smoking and tobacco use cessation—advising smokers to quit

○ Immunization for influenza

○ Controlling high blood pressure

○ Beta-blocker treatment after a heart attack

○ Comprehensive diabetes care—blood pressure control

○ Comprehensive diabetes care—Hemoglobin A1c poor control

○ Breast cancer screening

○ Cervical cancer screening

○ Improvement in function (short-stay skilled nursing facility patients)

○ Newly received antipsychotic medications (short-stay skilled nursing facility patients)

• Safe Care

○ Catheter associated urinary tract infection rate

○ Central line associated bloodstream infection rate

○ Clostridioides difficile infection rate

○ Death rate among surgical patients with serious treatable complications

○ New or worse pressure ulcer (short-stay skilled nursing facility patients)

○ Falls with major injury (long-stay skilled nursing facility patients)

○ Physical restraints (long-stay skilled nursing facility patients)

• Veteran-Centered Care

○ Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) overall summary star rating

○ HCAHPS Care Transition summary star rating

○ Patient's overall rating of the provider on the Consumer Assessment of Health Providers and Systems (CAHPS) survey

○ Patient's rating of coordination of care on the CAHPS survey

These standards for quality were selected based on availability of comparative data for community providers and importance to veterans, as determined through an extensive review of existing health care standards for quality and consultation with Federal, regulatory, and public stakeholders through focus groups, meetings, and requests for information. The standards for quality established through this Notice and presented above will be posted on VA's Access to Care website, https://www.accesstocare.va.gov/​. Further changes to the standards will be made on that website, and the public can review those changes at any time.

VA will use these standards as a framework to guide internal improvement efforts, provide a basis for determining eligibility for the Veterans Community Care Program under 38 Code of Federal Regulations 17.4010(a)(6) and 17.4015, and inform decisions on where to furnish care from community providers, when that information is available. To facilitate the most effective partnership with community providers caring for veterans, VA will take an iterative approach, collaborating with our Federal partners at DoD and HHS, as well as community partners in the private sector, to remain in lockstep with the evolution of standards for quality as the industry advances.

Signing Authority

The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. Pamela Powers, Chief of Staff, Department of Veterans Affairs, approved this document on September 27, 2019, for publication.

Dated: September 30, 2019.

Luvenia Potts,

Regulation Development Coordinator, Office of Regulation Policy & Management, Office of the Secretary, Department of Veterans Affairs.