Background: Since initiation of the National Surgical Quality Improvement Program nearly 30 years ago, VA has been at the forefront of surgical quality measurement and improvement. Much of this work has been focused on assessing risk-adjusted postoperative complications, with less attention paid to important care processes, and even less attention to evaluating and improving quality across the full continuum of surgical care, including the presurgical period. The importance of adapting current and new measures to reliably and accurately assess the full continuum of surgical care will increase as greater numbers of Veterans use VA- purchased Community Care (CC). While one out of three VA patients receive CC, quality assessment is far less developed for CC than for those receiving care within the VA. Significance: With the focus of quality assessment being on postoperative outcomes and complications, quality of care across the entire surgical continuum is largely ignored, especially issues of timeliness, overuse, and underuse in the presurgical period. Defined episodes of care, which constitute a set of services provided to treat a clinical condition, have been promoted to assess quality, coordination, and cost among providers involved in a patient’s care. Although episode models have not been used by VA to monitor quality, VA has the opportunity to use a surgical episode framework to measure surgical quality more broadly, understand the value of this approach, and inform future quality reporting needs for VA-delivered and VA-purchased CC. The importance of examining surgical episode quality is even more salient given the rapid increase in VA- purchased CC, with an inevitable need to ensure that quality is maintained across all settings. Innovation and Impact: The goal of this proposal is to develop an innovative model to measure condition- specific surgical episode quality, including pre-, peri-, and postoperative care phases, for 3 common procedures of varying complexity. This work will advance the science of quality measurement through assessment across the entire surgical continuum. In applying this model to existing VA and CC data, we will identify new opportunities for surgical quality improvement in VA medical centers and will facilitate a condition- specific comparison of episode quality differences between VA and CC settings. We will also identify limitations in episode quality assessment for CC relative to VA using existing CC data sources. Specific Aims: Aim 1: Define condition-specific quality measures for surgical episode quality evaluation. Aim 2: Measure the performance gap and reliability of episode-based quality measures across VA medical centers. Aim 3: Assess the feasibility of applying episode-based quality measurement in the CC setting. Methodology: Aim 1: We will identify new quality measures in response to identified episode measurement gaps. A Delphi panel will rate the newly proposed quality measures for face validity, importance, and feasibility for inclusion in the surgical episode quality measurement model. Aim 2: We will apply the episode quality measurement model (defined in Aim 1) to VA national data to assess facility-level variation in episode quality and measure the reliability of the model to profile VA facility performance. Aim 3: Using quality measures applicable to both VA and CC administrative data sources, we will compare episode quality in VA and CC settings within similar healthcare markets, identifying limitations in applying the episode quality measurement model to existing CC data for meaningful VA and CC quality comparisons. Next Steps/Implementation: We will use the findings of this research to work with partners to refine and expand the measurement model to other surgical conditions to improve care quality for Veterans more broadly, identify targets for cooperative quality improvement within VA and CC settings, and provide recommendations for improvement of episode quality measurement for CC. This work can also be used by partners to inform Veteran choices and will assist VA leaders to inform “make versus buy” policy decisions.

For the past 30 years, the VA has been a leader in measuring the quality of surgical care. However, most of the VA’s work has focused on quality outcomes that happen after surgery. There is a need to develop new reliable and more accurate measures of quality of care for the Veteran’s entire health care journey, both before and after surgery. The goals of the current study are to develop an approach for measuring the quality of Veterans’ full surgical experience (the “surgical episode”) for three common surgical procedures and to apply this approach to VA and Community Care settings in which Veterans receive care. This work will advance the science of quality measurement to more thoroughly assess quality before, during, and after surgery in order to identify opportunities for quality improvement. The proposed study will also compare VA and Community Care quality, providing recommendations to improve quality measurement for Community Care, and helping to inform Veterans about their choices for surgical care in VA and Community Care settings.