Improvement Insights

By Justin M. List, MD, MAR, MSc, FACP; Lauren E. Russell, MPH, MPP; and Ernest Moy, MD, MPH

At the Veterans Health Administration (VHA), health care equity has long been a concern, and we embraced The Joint Commission’s National Patient Safety Goal (NPSG) that launched on July 1, 2023. The NPSG, which addresses health care disparities as a quality and safety priority, has helped health care equity become deeply embedded into the quality and patient safety framework.¹

Addressing health care equity across the U.S. health care landscape has often been fragmented, inadequately funded, and reliant on champions at the health care system and institutional levels. Our article, published in the January 2024 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS), discusses how the NPSG provided VHA with an accelerant for more closely aligning and bundling existing efforts to identify and address social needs and improve health care disparities.

VHA Equity Improvement Opportunities

We recognize VHA is different than many other health care systems, largely due to its unique population, financing mechanism, early adoption of an electronic medical record, and generally lower churn than in the private sector – the latter of which allows for robust longitudinal population health data available for stratification. This is a key requirement for understanding and addressing health care disparities. Additionally, VHA has a greater capacity than many other health care systems to address patient-identified unmet social needs internally, as opposed to through external referrals.

These factors put VHA in a position to be at the forefront in addressing social needs and driving forward equity-guided quality improvement. Using a combination of existing initiatives, we identified quality improvement opportunities to further integrate and expand how VHA addresses health care disparities and health-related social needs (HRSNs):

• Data tools (i.e., Primary Care Equity Dashboard [PCED]², a multi-faceted tool that integrates equity into quality improvement activities within primary care settings)
• Resource tools (i.e., Assessing Circumstances and Offering Resources for Needs [ACORN]³, a tool to systematically screen veterans for social needs in nine social risk domains)
• Care delivery approach (i.e., Whole Health, an approach to care that supports health and well-being through a personalized health plan)

Through these efforts, we identified several lessons learned to optimize organizational implementation and utilization of these tools, including:

• Awareness: The adage “If you build it, they will come” is an insufficient approach. Both the existence of our initiatives and tools, plus growing awareness of new regulatory standards, did not translate into quick and universal adoption of them. We learned instead, “After you build it, take it to them.” Building awareness takes a high level of coordinated communication efforts in collaboration with internal stakeholders.
• Communication: Culture change requires “last mile” engagement strategies: reaching the end user, including facilities and frontline staff. Our experience suggests organizations invest time in multiple communication methods and repetition to raise awareness and adoption of initiatives and tools. We continually seek out opportunities to routinely present our efforts across a wide array of administrative and clinical audiences at all levels of VHA, making the case for how these initiatives and tools help facilities and teams care for their patients and how we can support them in incorporating these resources into clinical practice.
• Support: We have created an ecosystem of active and passive supports and bidirectional feedback for facilities interested in or already using these tools and initiatives. These include technical assistance, low barrier ways to express interest in implementation, and online educational tools, dashboards and workgroups. We also promote a “lead by example” approach, where examples of how disparities or social needs have been addressed at the medical facility level can be shared widely across the entire VHA system.

No matter the level of resources a health care system has, we believe these three lessons learned, while commonsense in principle, take time and effort to execute well and sustain. The larger the organization, the more important generating awareness, communicating effectively, and supporting and encouraging staff become given inherent dynamics in complex, large organizations.

VHA looks forward to continuing to expand its use and number of health care equity-related initiatives, tools and learning internally and externally to reduce health care disparities and better address health-related social needs.

¹The Joint Commission. R3 Report. National Patient Safety Goal to Improve Health Care Equity. Issue 38. The Joint Commission. December 20, 2022. Available from: https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_npsg-16.pdf [Last accessed: January 18, 2024].
²Hausmann LRM, Cashy JP, Ernest Moy. Leveraging VA Data and Partnerships to Advance Equity-Guided Improvement: Introducing the Primary Care Equity Dashboard. VA Health Services Research & Development Cyber Seminars: Using Data and Information Systems in Partnered Research. February 16, 2021. Available from: https://youtu.be/izVzuJ1EQgg [Last accessed: January 18, 2024].
³Russell LE*, Cohen AJ* (*co-first authors), Chrzas S, et al. Implementing a Social Needs Screening and Referral Program Among Veterans: Assessing Circumstances & Offering Resources for Needs (ACORN). J Gen Intern Med. 2023;38(13):2906-2913. doi:10.1007/s11606-023-08181-9. [PCED]

Editor’s note: The article, “Addressing Veteran Health-Related Social Needs: How Joint Commission Standards Accelerated Integration and Expansion of Tools and Services in the Veterans Health Administration,” in the January 2024 issue of The Joint Commission Journal on Quality and Patient Safety, is available for free on the JQPS website.

Disclaimer: The contents do not represent the views of the U.S. Department of Veterans Affairs, the U.S. government or any other organizations.

Justin M. List, MD, MAR, MSc, FACP, is Director, Health Care Outcomes, Office of Health Equity, U.S. Department of Veterans Affairs (VA), Washington, D.C. Lauren E. Russell, MPH, MPP, is Health System Specialist and ACORN Co-Lead, Office of Health Equity, VA. Ernest Moy, MD, MPH, is Executive Director, Office of Health Equity, VA.