Creating a Culture of Quality: The Remarkable Transformation of the Department of Veterans Affairs Health Care System

For decades, fairly or unfairly, the Department of Veterans Affairs (VA) health care system had a suboptimal image in the quality of care it provided and in the evaluation of that care. About 10 years ago, the VA leadership began a major national reorganization that has transformed the VA health care system. What was largely an inpatient, subspecialty-based system became a “full-service,” integrated delivery system committed to a new model of health promotion, disease prevention, and coordination of care. The VA's transformation was 2-part. First, it implemented a sweeping overhaul of service delivery. Second, it created a “culture of quality,” committed to the systematic, rigorous evaluation of care. Others have documented the first part of the transformation (1, 2). We focus on whether these efforts actually improved care, as carefully studied by Kerr and colleagues in this issue (3), and whether the lessons learned from the VA may apply to care provided to the general U.S. health care population.

The “culture of quality” depended on the successful implementation of several innovations: a uniform data collection system facilitated by nationwide implementation of an electronic medical record system, systematic application of quality standards, and externally monitored local area networks to monitor quality. The VA also committed resources to advancing the science of quality-of-care evaluation. The quality of care at the VA improved (as documented by Kerr and colleagues). The caliber of VA research on quality of care has also improved. Both can be linked to the development of specific programs: the VA Health Services Research and Development (VA HSR&D) program; the VA Quality Enhancement Research Initiative (QUERI); the HSR&D Centers of Excellence, Resource Centers, Research Enhancement Award Program, and Targeted Research Enhancement Program; and the Translating Research …