Quality and Safety Initiatives at the Veterans Health Administration

The delivery of high-quality and cost-effective chronic hemodialysis care is a daunting challenge as evidenced by ongoing poor health outcomes and high costs across the United States. The prevalence of end stage renal disease (ESRD) among veterans is quite high, approximately double that of nonveterans, owing in part to high rates of predisposing comorbid illnesses (e.g., diabetes or hypertension) and other sociodemographic risk factors. Similar to their non-VA counterparts, veterans receiving chronic hemodialysis experience an annual mortality rate in excess of 15 percent and more than 30 days hospitalization annually. Such poor outcomes highlight the critical need to improve quality of dialysis care.

A variety of recent steps have been taken within the VA to improve quality of dialysis care nationally for our veterans: 1) determination of clinical performance measures that assess quality of dialysis care; 2) establishment of data collection procedures needed to assess clinical performance measures; and 3) analysis and reporting of clinical performance measures for the facilities at the local, regional, and national level.

Clinical performance measures for quality of hemodialysis care

Beginning in July 2012 and concluding in February 2013, a transparent, stakeholder-driven process was launched to identify clinical performance measures for chronic hemodialysis in the VA. Clinical performance measures are defined as tools to assess compliance with standards for clinical care, and their purpose is to measure, report, and compare quality of care, and to improve clinical performance. At the direction of Susan Crowley, MD, FASN, Veterans Health Administration National Program Director for Kidney Disease and Dialysis, a VA committee with representation from diverse domains of leadership, operations, clinical services, and research within VA was created to review, discuss, and select clinical performance measures for this evaluation. The sources for our measures included several organizations that develop, implement, review, endorse, and adopt measures, such as the Centers for Medicare & Medicaid Services and the National Quality Forum.

The committee agreed upon several key criteria that would be important requirements for measures to be adopted by the VA, including that they must be mature vetted measures, designed as facility-level measures, and that they address distinct aspects of ESRD care. Other criteria included that they have a solid evidence base and be timely, clinically relevant, feasible and usable to improve quality. In addition to an in-person meeting, a series of conference calls and interval web-based SharePoint commenting and voting procedures were utilized by the committee to review and adopt clinical performance measures. Out of a total of 78 measures reviewed and discussed, 11 measures were adopted. The performance measures encompass dialysis adequacy, vascular access, anemia, bone and mineral metabolism, infection, and immunization.

Establishment of data collection procedures

A particular strength of VA is its fully integrated national electronic medical record (EMR), which includes all VA dialysis units across the United States. Data colllected to calculate the chosen hemodialysis quality measures are predominantly extracted from laboratory and medication data available via the corporate data warehouse. These data elements are extracted and synchronized nightly from the EMR. Some data elements that cannot be obtained from the EMR are self-reported data by personnel at the hemodialysis facilities. An interdisciplinary collaboration between the working group, VHA Support Service Center (VSSC), and VA Inpatient Evaluation Center led to the development and design of a new web-based electronic interface available to facilitate reporting. When this process is complete, we will be able to capture and report data on a monthly basis and examine trends over time.

Analysis and reporting of hemodialysis clinical performance measures

The chief goal of analyzing and reporting hemodialysis performance measures is to have a “real-time” method of monitoring and improving quality of care to veterans. None of the measures has absolutely identified performance targets (i.e., prespecified goal targets). Rather, measure scores or percentages will be evaluated on a numerical score from 0 to 100. For some measures, a higher or increasing value (percentage) is desirable, whereas for others a lower value/percentage is desirable. Measures will be reported via a new national VA hemodialysis quality measure dashboard, which was constructed in collaboration with VSSC. This dashboard can be viewed by VA operations and clinical dialysis staff, and thereby furthers quality assurance and improvement at the facility level. The dashboard enables dialysis providers to navigate to patient-level details and generate a list of patients not meeting the desired target for given measures at their facility. For example, one of the measures collects and reports information on bloodstream infections in hemodialysis patients at each facility. If there was a noticeable increase in infections at any given facility, this would trigger further examination at the patient, facility, and national level.

Future directions

Improving quality of care for veterans receiving chronic hemodialysis is a top priority in VA. Establishing and reporting quality measures is one of many recent initiatives in VA that aims to further this goal. Recognizing the constant evolution in the dialysis evidence base, the VA working group continues to meet regularly to review and discuss revisions and additions to the current quality measures. An additional future direction of this working group that has recently begun is to internally pilot less mature, yet innovative and novel, hemodialysis quality measures to further improve quality of care.


[1] Michael J. Fischer, MD, MSPH, is affiliated with the Center for Innovation of Complex Chronic Healthcare, the Jesse Brown VA Medical Center and Hines VA Hospital, and the University of Illinois Hospital and Health Sciences System in Chicago, IL. Karen B. Sovern, MSN, RN, is affiliated with the Cincinnati VA Medical Center in Cincinnati, OH. Wissam M. Kourany, MD, is affiliated with the Durham VA Medical Center, and the Duke University Medical Center, in Durham, NC.

February 2014 (Vol. 6, Number 2)