Baldrige Framework

At the Veteran’s Administration Medical Center we use the Baldrige framework of excellence and a lean sigma method of performance improvement to make data driven decisions regarding the five areas of organizational excellence. The five areas of excellence include population health, patient experience, workforce excellence, financial stewardship, and service to the community. The VA has an unparalleled array of programs (dashboards) where data is gathered, critically analyzed and compared with established goals or targets. The programs report on all aspects of quality and safety, both in an inpatient and outpatient setting with implementing and evaluating actions put into place. There are four inpatient core measurement sets evaluated for quality at the VAMC and they are Acute

In the outpatient setting, the Healthcare Effectiveness Data and Information Set (HEDIS), is used as the tool to measure performance on important evidenced-based dimensions of care and service. These dimensions of care include diabetes, prevention and screening for cancer, cardiovascular care, immunizations and smoking cessation. The rates of health care associated occurrences for Ventilator Associated Pneumonia; Central Line Associated Bacteremia and Methicillin-resistant Staphylococcus aureus are also tracked and reported with improvements made. In the area of patient safety measures ICU risk adjusted length of stay, Insulin Induced Hypoglycemia and Health Acquired Pressure Ulcers are measured. The VHA also monitors rates of hospitalization for Ambulatory Care Sensitive Conditions (ACSCs), such as pneumonia and heart failure in order to track the effectiveness of primary care. There are a plethora of quality measures in the VA and this just touches upon some of the key measures (U.S. Department of Veteran Affairs,