Patient Safety Indicators at an Academic Veterans Affairs Hospital: Addressing Dual Goals of Clinical Care and Validity.

Background: Hospital-acquired complications add to patient morbidity and mortality, costs, length of stay, and negative patient experience. Patient Safety Indicators (PSIs) are a validated and widely used metric to evaluate hospital administrative data on preventing these events. Although many studies have addressed PSI validity, few have aimed to reduce PSI through clinical care.

Why Veterans Choose VA Versus non-VA Emergency Care: A Qualitative Study.

Introduction: In ensuring the timely delivery of emergency care to Veterans, Veterans Affairs (VA) offers both emergency care services in its own facilities and, increasingly, purchases care for Veterans in non-VA (community) emergency department (ED) settings. Although in recent years emergency care coverage has become the single largest contributor to VA community care spending, no study to date has examined Veteran decision-making as it relates to ED setting choice. The purpose of this study is to identify and describe reasons why Veterans choose VA versus non-VA emergency care settings.

Emergency Department Use Among Combat and Non-Combat Post-9/11 Military Veterans.

Introduction: Most post-9/11 Veterans have completed at least 1 combat deployment-a known factor associated with adverse health outcomes. Such Veterans are known to have unmet health care needs, and the emergency department (ED) may serve as a safety net, yet little is known about whether combat status is associated with more frequent ED use. We sought to evaluate the relationship between combat status and frequency of ED use among post-9/11 Veterans and assess the most common reasons for ED visits.

Community Emergency Care Use by Veterans in an Era of Expanding Choice.

Importance: Recently passed legislation aimed at improving access to care has considerably expanded options for veterans to receive emergency care in community, or non-Veterans Affairs (VA) settings. However, national trends in community emergency department (ED) use by veterans are unknown.

Objective: To examine national, temporal trends in the frequencies and types of ED visits provided in community settings and explore the association between facilities' purchase of community care with facility and regional characteristics.

Research and policy recommendations from the SOTA XVI: State of the Art Conference on VA Emergency Medicine.

To better understand and prioritize research on emergency care for Veterans, the Department of Veteran Affairs (VA) Health Services Research and Development convened the 16th State of the Art Conference on VA Emergency Medicine (SAVE) in Winter 2022 with emergency clinicians, researchers, operational leaders, and additional stakeholders in attendance. Three specific areas of focus were identified including older Veterans, Veterans with mental health needs, and emergency care in the community (non-VA) settings. Among older Veterans, identified priorities included examination of variation in care and its impact on patient outcomes, utilization, and costs; quality of emergency department (ED) care transitions and strategies to improve them; impact of geriatric ED care improvement initiatives; and use of geriatric assessment tools in the ED.

Hospital-level variation in risk-standardized admission rates for emergency care-sensitive conditions among older and younger Veterans.

Objectives: Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility-level variation in risk-standardized admission rates (RSARs) for emergency care-sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs.

Methods: Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established.

Emergency department utilization and presenting chief complaints by Veterans living with dementia.

Objectives: Veteran persons living with dementia (PLWDs) have high acute care utilization. We aim to understand why PLWDs seek care in the emergency department (ED) and how their utilization differs from older Veterans with no dementia diagnosis. We demonstrate the use of a novel national chief complaint data set in the Veteran Affairs Health Care System.

Achieving transformation to lean management systems in health care.

Objective: To understand what factors and organizational dynamics enable Lean transformation of health care organizations.

Data Sources: Primary data were collected through two waves of interviews in 2016-2017 with leaders and staff at seven veterans affairs medical centers participating in Lean enterprise transformation.

Study Design: Using an observational study design, for each site we coded and rated seven potential enablers of transformation.

Veterans' Use of Telehealth for Veterans Health Administration Community Care Urgent Care During the Early COVID-19 Pandemic.

Background: Since the onset of the COVID-19 pandemic, telehealth has been an option for Veterans receiving urgent care through Veterans Health Administration Community Care (CC).

Objective: We assessed use, arrangements, Veteran decision-making, and experiences with CC urgent care delivered via telehealth.

Design: Convergent parallel mixed methods, combining multivariable regression analyses of claims data with semistructured Veteran interviews.

Engaging Patients in the Veterans Health Administration's Lean Enterprise Transformation: A Qualitative Study.

Background And Objectives: Lean management is a strategy for improving health care experiences of patients. While best practices for engaging patients in quality improvement have solidified in recent years, few reports specifically address patient engagement in Lean activities. This study examines the benefits and challenges of incorporating patient engagement strategies into the Veterans Health Administration's (VA) Lean transformation.

The Veterans Health Administration (VHA) Innovators Network: Evaluation design, methods and lessons learned through an embedded research approach.

Background: Collaboration between researchers, implementers and policymakers improves uptake of health systems research. In 2018, researchers and VHA Innovators Network (iNET) leadership used an embedded research model to conduct an evaluation of iNET. We describe our evaluation design, early results, and lessons learned.

Veterans' Experiences With Accessing Community Emergency Care.

Introduction: Under current regulations, there are three separate authorities for which the Veterans Health Administration (VHA) can pay for emergency medical care received by Veterans in the community. The three VHA authorities have overlapping criteria and eligibility requirements that contribute to a complex and confusing landscape for Veterans when they obtain emergency care in the community. Given the intricacies in how VHA provides coverage for community emergency care and the desire to provide seamless Veteran-centric care, it is imperative to understand Veterans' experiences with navigating coverage for community emergency care.

Community Urgent Care Use Following Implementation of the Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.

Background: Effective June 6, 2019, Veterans Affairs (VA) began offering a new urgent care (UC) benefit that provides eligible Veterans with greater choice and access to care for the treatment of minor injuries and illnesses in their local communities.

Objectives: The aim was to describe trends in UC use, identify predictors of UC benefit use, and understand the factors associated with community UC use versus VA emergency department (ED) or urgent care center (UCC) use.

Study Design: Using VA administrative data, this was a retrospective cross-sectional study of Veterans that were enrolled in VA in FY19.

Short-term Effects of Canceled Elective Procedures Due to COVID-19: Evidence From the Veterans Affairs Healthcare System.

Objective: To determine whether delayed or canceled elective procedures due to COVID-19 resulted in higher rates of ED utilization and/or increased mortality.

Summary Of Background Data: On March 15, 2020, the VA issued a nationwide order to temporarily pause elective cases due to COVID-19. The effects of this disruption on patient outcomes are not yet known.

To Admit or Not to Admit: Emergency Department Discharges After Request for Medicine Admission.

Background: The decision to discharge versus admit a patient from the emergency department (ED) carries significant consequences to the patient and healthcare system.

Methods: We evaluated all ED visits at a single facility from January 1-December 31, 2015, where the ED provider initially requested admission to medicine; however, following medicine evaluation, the patient was discharged from the ED.

Results: 8.

Facilitators and barriers to the Lean Enterprise Transformation program at the Veterans Health Administration.

Background: The Veterans Health Administration piloted a nationwide Lean Enterprise Transformation program to optimize delivery of services to patients for high value care.

Purpose: Barriers and facilitators to Lean implementation were evaluated.

Methods: Guided by the Lean Enterprise Transformation evaluation model, 268 interviews were conducted, with stakeholders across 10 Veterans Health Administration medical centers.

Identification of Emergency Care-Sensitive Conditions and Characteristics of Emergency Department Utilization.

Importance: Monitoring emergency care quality requires understanding which conditions benefit most from timely, quality emergency care.

Objectives: To identify a set of emergency care-sensitive conditions (ECSCs) that are treated in most emergency departments (EDs), are associated with a spectrum of adult age groups, and represent common reasons for seeking emergency care and to provide benchmark national estimates of ECSC acute care utilization.

Design, Setting, And Participants: A modified Delphi method was used to identify ECSCs.

Lean Enterprise Transformation in VA: a national evaluation framework and study protocol.

Background: The goal of Lean Enterprise Transformation (LET) is to go beyond simply using Lean tools and instead embed Lean principles and practices in the system so that it becomes a fundamental, collective mindset of the entire enterprise. The Veterans Engineering Resource Center (VERC) launched the Veterans Affairs (VA) LET pilot program to improve quality, safety, and the Veteran's experience. A national evaluation will examine the pilot program sites' implementation processes, outcomes and impacts, and abilities to improve LET adoption and sustainment.

Reducing Frequent Utilization of Psychiatric Emergency Services Among Veterans While Maintaining Quality of Care.

Objective: Use of psychiatric emergency services in emergency departments (EDs) and inpatient psychiatry units contributes substantially to the cost of mental health care. Among patients who utilize psychiatric emergency services, a small percentage ("high utilizers") contributes a disproportionate share of the total cost, yet little is known about the context of care for these patients. This study employed qualitative methods to identify barriers to and facilitators of reducing use of psychiatric emergency services among high utilizers.

Observation encounters and subsequent nursing facility stays.

Background: Medicare coverage of skilled nursing facility (SNF) care requires that beneficiaries have a 3-night inpatient stay in the prior 30 days to be eligible. Time spent by beneficiaries receiving hospital-based observation services does not count toward this requirement.

Objectives: To examine the frequency of Medicare beneficiary discharge from hospital-based observation services to SNFs and its impact on Medicare coverage.

A variation in the value of colectomy for cancer across hospitals: mortality, readmissions, and costs.

Introduction: Although hospital variation in costs and outcomes has been described for patients undergoing operation, the relationship between them is unknown. The purpose of this study was to evaluate this relationship among patients undergoing colon resection for cancer and identify characteristics of "high-quality, low-cost" hospitals.

Methods: We identified adult patients who underwent colon resection for cancer in California, Florida, and New York from 2009 to 2010.

"Rewarding and challenging at the same time": emergency medicine residents' experiences caring for patients who are homeless.

Objectives: The objectives were to examine how emergency medicine (EM) residents learn to care for patients in the emergency department (ED) who are homeless and how providing care for patients who are homeless influences residents' education and professional development as emergency physicians.

Methods: We conducted in-depth, one-on-one interviews with EM residents from two programs. A random sample of residents stratified by training year was selected from each site.