2021-24042. VA Standards for Quality

AGENCY:

Department of Veterans Affairs.

ACTION:

Solicitation of public comment.

SUMMARY:

The Secretary of the Department of Veterans Affairs (VA) is soliciting public comment on VA's current standards for quality to ensure that they include the most up to date and applicable measures for veterans.

DATES:

Comments must be received on or before December 6, 2021.

ADDRESSES:

Comments may be submitted through www.regulations.gov. Comments should indicate that they are submitted in response to “VA Standards for Quality.” Comments received will be available at www.regulations.gov for public viewing, inspection or copies.

FOR FURTHER INFORMATION CONTACT:

Joseph Francis, VHA Office of Analytics and Performance Integration (API), 17 API, Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Room 668, Washington, DC 20420, [phone]. This is not a toll-free number.

SUPPLEMENTARY INFORMATION:

In accordance with section 1703C of 38 U.S.C., as added by section 104 of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 or the VA MISSION Act of 2018, VA formally established standards for quality regarding hospital care, medical services, and extended care services furnished by the Department in October 2019 (84 FR 52932). VA's quality standards were chosen based on a comprehensive assessment of health care industry standards for quality, their relevance to veterans, and the availability of comparative data for community providers. Wide ranging expert guidance and stakeholder input was also sought from veterans, Veteran Service Organizations, federal partners, health care specialty associations and organizations, and the public through focus groups, meetings, and requests for information. The current VA standards for quality and associated measures are publicly available on VA's Access to Care website ( https://www.accesstocare.va.gov ).

After internal review of VA's standards for quality in 2021, significant changes were not made to the initial standards established in 2019. The current quality standards address important dimensions of care for veterans and are aligned with industry standards. The addition of new metrics is limited in many cases by the lack of appropriate community comparison data; and this has been compounded in CY 2020 and 2021 by the impact of the COVID-19 pandemic. Notably, the pandemic resulted in gaps in the available healthcare data and temporary suspension of some measures ( e.g., COVID-19 Quality Reporting Programs Guidance Memo—Centers for Medicare and Medicaid Services (CMS) (March 27, 2020); https://www.cms.gov/​files/​document/​guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf ). This has created a problematic situation where, in some cases, VA's current quality data results are being compared to pre-COVID periods of community data. VA has an ongoing commitment to evolving the quality standards in accordance with veteran needs and industry advancements. The quality standards will be reviewed internally again in FY 2022 to ensure they are up- to-date and addressing veteran priorities. As required by 38 U.S.C. 1703C(b)(2), this notice is to solicit and consider public comment on potential changes to VA's current quality standards to ensure that they include the most up-to-date and applicable measures for veterans. VA will use the comments it receives to help update the quality standards. Changes to the standards can be accessed by veterans and the public on VA's Access to Care website ( https://www.accesstocare.va.gov ).

VA's current 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.

The standards for quality and included domains 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 current quality measures for the quality domains are detailed below along with relevant annotations regarding changes since October 2019:

• 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 (Note: VA does not currently have patient level comparison data for this measure. VA is undertaking improvements to strengthen the reporting approach going forward as data availability changes.)

○ Death rate among surgical patients with serious treatable complications (Note: Availability of accurate community comparison data has improved since initial publication of this measure in 2019 and related updates will be made to VA's external reporting of this measure.)

○ New or worsened pressure ulcers/pressure injuries (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 (Note: VA now utilizes the measure or composite for these key indicators of patient experience, rather than the star rating, because this allows more precision in comparisons and can better track improvement over time.)

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

○ HCAHPS care transition composite

○ 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

Signing Authority

Denis McDonough, Secretary of Veterans Affairs, approved this document on October 28, 2021, 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.

Michael P. Shores,

Director, Office of Regulation Policy & Management, Office of General Counsel, Department of Veterans Affairs.