Hospital Medicine

Electronic health records (EHRs) are an integral part of modern health care. The 2009, Health Information Technology for Economic and Clinical Health Act established financial incentives for US hospitals to adopt EHRs. In 2009 only 12% of nonfederal acute care hospitals had adopted a certified EHR system, which increased to 96% by 2021.¹

EHRs have transformed the way patient data are stored and accessed, streamlining the process of providing quality patient care with improvements in efficiency, effectiveness, patient satisfaction, and safety.² Despite their widespread adoption and benefits, EHRs have generally been met with mixed physician satisfaction.³ Interactions with EHRs are linked to disproportionate time at the computer and physician burnout.^4-6

The US Department of Veterans Affairs (VA) was at the forefront of EHR development, establishing the Veterans Health Information Systems and Technology Architecture (VistA) in the 1970s. The VA released the Computerized Patient Record System (CPRS) in 1997, the first clinical user interface for VistA. In May 2018, the VA signed a $10 billion contract with Cerner (now Oracle Health) to modernize its EHR.⁷ This was later revised to $16.1 billion, and the Institute for Defense Analyses estimates it will cost $49.8 billion.⁸ The transition to Oracle Health has been faced with significant challenges, including patient safety risks and workflow inefficiencies, leading to a pause in rollout.⁹

Due to the known challenges with EHRs and the aging CPRS system (without a scheduled replacement date), innovations that facilitate the synthesis and display of clinical information are needed. To address this gap, the VA Ann Arbor Healthcare System (VAAAHS) developed the Inpatient Dashboard, an online EHR companion tool. The Inpatient Dashboard was designed to draw data from VistA to reduce time spent at the computer by streamlining clinical information presentation, standardizing inpatient notes, improving safety measures, and enhancing overall clinician satisfaction. This study evaluated the adoption and user experience with the Inpatient Dashboard.

INPATIENT DASHBOARD

The Inpatient Dashboard consists of several modules created by a contractor for the VAAAHS that is housed on VA servers with access restricted to individuals with patient health data privileges. As the Inpatient Dashboard draws data from VistA, it can display laboratory information, studies, and notes from all VA sites.

The main dashboard is a snapshot summary of patient information, including patient location, code status, last vital sign readings, vital sign ranges over the previous 24 hours, intake/output, deep vein thrombosis (DVT) prophylaxis, the presence of telemetry orders, or use of Foley or central catheters (Figure). It also includes a customizable to-do list and contact information for the patient’s clinician and nurse. Significant events, such as abnormal vital signs or speciation/sensitivities for blood cultures, are automatically populated on the to-do list. From this main dashboard overview, clinicians can customize which patients are displayed, create and print a rounding list, print a sign-out sheet, or select individual patients to open a progress note module.

Notes can be written in the patient history and physical module, progress note module, and discharge summary module. The patient history and physical module has text blocks allocated to the traditional components of a history and physical note (ie, chief complaint, history of present illness, review of systems, past medical history, family history, social history, allergies, medications, physical examination, assessment, and plan) (eAppendix 1). Some elements, such as past medical history, family history, and social history are prepopulated if the patient was previously admitted. Vital signs, laboratory results, studies, microbiology/ pathology reports, and other CPRS notes are displayed in this module.

The progress note module contains text blocks allocated to the traditional components of a progress note, such as subjective/interval events, physical examination, assessment, and plan (eAppendix 2). Vital signs, laboratory results, studies, microbiology/ pathology reports, other CPRS notes, and the patient’s medication administration record are also displayed in this module. Lastly, the discharge summary module includes patient follow-up, patient instructions, hospitalization summary, medication reconciliation, laboratory results, and studies/procedures, ensuring a comprehensive discharge summary for patients and clinicians (eAppendix 3).

A medication reconciliation tool was embedded within the history and physical and discharge summary modules. This tool has been shown to reduce medication errors in patients admitted from the emergency department to the hospital (eAppendix 4).¹⁰ The handoff/sign-out tool (eAppendix 5) accessible through the main dashboard page is modeled on the I-PASS handoff framework.^11,12 This includes the patient identifier, interval events, inpatient medications, specific sign-out guidance, sign-out tasks/to-dos, and any other pertinent information.

The Inpatient Dashboard is a team-based construct shared by the attending physicians, residents, and medical students. Each team (eg, general medicine, general surgery) is its own entity; only team members can change the content or add to the documentation. Each facility can have multiple teams caring for the same patient (eg, primary and consulting teams). Additional care members can also be incorporated (eg, pharmacists assist with medication reconciliation for admission and discharge at VAAAHS). The Inpatient Dashboard can export information directly to CPRS for clinicians to review and sign. It can also generate a note that can be pasted into CPRS.

Clinician Feedback and Satisfaction

A survey was developed to evaluate clinician experiences with using the Inpatient Dashboard as an adjunct to the CPRS. The Inpatient Dashboard was made available to general medicine teams in November 2018. The survey was conducted from December 2018 to September 2019. The study was conducted at the VAAAHS and included 4 general medicine teams. Each team included an attending physician, a senior resident, 2 to 3 interns, and 3 to 4 medical students. Eligibility was extended to any team member who used both the CPRS and Inpatient Dashboard. Participation in the survey was voluntary. All respondents were informed of the study’s purpose and encouraged to provide candid feedback to ensure the reliability and validity of the findings.

Data were collected through a semistructured survey administered via the Qualtrics platform. The questionnaire was designed to capture multidimensional insights into clinician experience, with particular focus on satisfaction, efficiency, and perceived safety when using the tool as an adjunct to CPRS compared to using CPRS alone. The questionnaire primarily used a Likert scale for responses. Surveys were emailed at the completion of a team’s 1-month inpatient block. An answer was not required for every question, resulting in slightly different response numbers for some questions.

A question regarding the tool’s impact on workload stress was added halfway through the study period, which resulted in fewer responses. Adoption was assessed by counting the Inpatient Dashboard unique users. Descriptive statistics were used within individual survey responses to report the distribution of responses. Differences in response between levels of training were assessed using a X² test of independence.

Survey Results

From September 2023 through November 2023, there were 1549 rounding printouts across 144 unique users (5 nurses, 40 medical students, 87 residents, and 12 attending physicians) and 1468 handoff printouts across 148 unique users (5 nurses, 10 medical students, 111 residents, and 22 attending physicians). The clinician survey received 68 responses from users at various levels of medical training: 23 medical students, 31 interns, 12 senior residents, and 2 attending physicians. All 68 participants confirmed they had used the Inpatient Dashboard.

User satisfaction and preference for the Inpatient Dashboard vs CPRS were assessed. Sixty-one respondents (90%) expressed overall satisfaction with the Inpatient Dashboard; 22 (32%) were extremely satisfied, and 39 (57%) were somewhat satisfied (Table 1). Three respondents (4%) were neutral, 2 (3%) were somewhat dissatisfied, and 2 (3%) were extremely dissatisfied with the Inpatient Dashboard. Responses differed by level of training (P = .03), with medical students trending towards higher satisfaction.

Respondents preferred the Inpatient Dashboard over CPRS for gathering information and writing progress notes; 42 (64%) respondents mostly favored the Inpatient Dashboard, 15 (23%) slightly favored the Inpatient Dashboard over CPRS, and 8 (12%) were neutral. One respondent (2%) slightly favored CPRS to the Inpatient Dashboard (Table 2).

Sixty-five respondents (100%) found the Inpatient Dashboard’s ability to summarize patient information in a central place helpful (Table 3). Among them, 53 (82%) respondents reported it was very or extremely helpful, 10 (15%) respondents reported it was moderately helpful, and 2 (3%) respondents reported it was slightly helpful. This feature positively impacted users’ awareness of patients with DVT prophylaxis or a Foley catheter. Ten (15%) respondents reported being much more aware, and 29 (45%) respondents reporting they were slightly more aware. The remaining 26 (40%) respondents reported no change in awareness.

The Inpatient Dashboard was reported to save time preparing for physician rounds by 52 (80%) respondents, contributing to much greater efficiency for 29 (45%) respondents and slightly more efficiency for 23 (35%) respondents. However, 10 (15%) respondents reported no change in efficiency, and 3 (5%) respondents reduced efficiency, with 1 (2%) respondent reporting it slightly less efficient and 2 (3%) respondents reporting it much less efficient. Responses differed by level of training (P = .01), with medical students trending towards higher efficiency. Of the 23 respondents who reported on the Inpatient Dashboard’s impact on daily workload stress level, 22 (96%) indicated the tool had a stress-reducing effect, with 9 (39%) experiencing a major reduction in stress level, and 13 (57%) experiencing somewhat reduced stress level. Only 1 participant (4%) reported no change in stress. No participants reported an increase in stress.

DISCUSSION

The adoption of EHRs has transformed operational modalities in contemporary health care systems, heralding advancements in patient satisfaction, safety, and overall quality and efficiency of care.^1,2 However, EHRs still present challenges, predominantly around clinician satisfaction, marked by instances of burnout and increased time spent on computers.^2-6 In this context, the Inpatient Dashboard, an online companion to the CPRS, exemplifies how user-centered innovations in EHRs can address and mitigate associated challenges.

The Inpatient Dashboard has been well received with most respondents of the survey conducted in this study indicating they were both satisfied with the instrument and preferring it to CPRS. This high approval aligns with existing literature on the potential advantages of user-centered design in health care technology.¹³ The tool has gained widespread acceptance at the VAAAHS even in the absence of obligatory usage or institutional incentives. The appeal of the Inpatient Dashboard may stem from its increased efficiency, with most users affirming its timesaving nature. While CPRS can only display local notes, laboratory results, and studies, the Inpatient Dashboard can display data from across all VA sites. The VA Joint Longitudinal Viewer can similarly display data from across all sites, but the display is not streamlined as it is in the Inpatient Dashboard. The Inpatient Dashboard incorporates this clinical information into a single page to facilitate day-to-day workflow and dynamic documentation (ie, reviewing laboratory results, medications, writing notes, and signing out patients). This increased efficiency allows clinicians to counter 2 common barriers to EHR implementation: productivity loss and insufficient time.¹⁴

The association between EHRs and improved quality and safety in health care is well-documented.³ The Inpatient Dashboard fortifies this association by enhancing awareness around patient status, evidenced by a majority of respondents, and by integrating a medication reconciliation tool to decrease medication errors on transition from the emergency department to inpatient hospitalization.¹⁰

The Inpatient Dashboard’s impact on alleviating daily workload stress is noteworthy, with almost all respondents experiencing reduced stress levels and physician burnout, which has been linked to deteriorating well-being, compromised patient safety, and escalated health care costs.^15,16 The heightened susceptibility of physicians to burnout compared to other professionals underscores the imperative for incorporating stress-mitigating interventions in the EHR.^17,18

While responses to most questions did not significantly differ by training levels, overall satisfaction with the Inpatient Dashboard and its ability to save time preparing for rounds were rated higher by medical students. This may be attributable to a greater derived benefit from collating and presenting data to learners with less familiarity with the native EHR. It is also notable that the Inpatient Dashboard allows medical students to directly contribute to a patient’s note, which could be another driver in satisfaction. While most interns still felt the Inpatient Dashboard enabled them to save time preparing for rounds, there were a considerable number of ‘no change’ responses, which suggests some interns may not have modified their existing prerounding strategies. These associations are limited by the relatively small number of respondents by learner category, with senior medical residents and attending physicians being underrepresented.

While there are a multitude of dashboards available at the VA, most are made to track certain quality metrics and are used more by administrative and leadership staff. The Inpatient Dashboard was created specifically for frontline clinicians to facilitate their day-to-day workflow and dynamic documentation. This tool can additionally help with quality metrics, though its main purpose was and is to make clinician workflow easier and more efficient.

These results are especially timely because the VA is modernizing its EHR by transitioning to Oracle Health.⁷ Due to the numerous reports both from veterans and VA clinicians that the Oracle Health EHR is not meeting expectations, deployment at further sites has been halted while improving the experience of the 5 institutions using Oracle Health is prioritized.⁹ The Inpatient Dashboard, instead of being merely an enhancement to CPRS, could emerge as a potential bridge to Oracle Health if adapted to display data from Oracle Health as it does VistA. This would facilitate a smoother, more integrated transition for those health care institutions employing the Inpatient Dashboard.

Limitations

The reliance on self-reported data inherently carries the risk of bias, and the absence of objective measures, like time-tracking studies, limits the quantifiable assessment of the Inpatient Dashboard efficacy. The single-center nature of the study also may restrict the generalizability of the results.

CONCLUSIONS

Optimal integration of EHRs into health care delivery is critical to high-quality patient care and operational efficiency. The Inpatient Dashboard is an example of an innovative, user-centric solution that integrated and presented clinical information in a way that produced high satisfaction and adoption by users at a VA hospital.

Electronic health records (EHRs) are an integral part of modern health care. The 2009, Health Information Technology for Economic and Clinical Health Act established financial incentives for US hospitals to adopt EHRs. In 2009 only 12% of nonfederal acute care hospitals had adopted a certified EHR system, which increased to 96% by 2021.¹

EHRs have transformed the way patient data are stored and accessed, streamlining the process of providing quality patient care with improvements in efficiency, effectiveness, patient satisfaction, and safety.² Despite their widespread adoption and benefits, EHRs have generally been met with mixed physician satisfaction.³ Interactions with EHRs are linked to disproportionate time at the computer and physician burnout.^4-6

The US Department of Veterans Affairs (VA) was at the forefront of EHR development, establishing the Veterans Health Information Systems and Technology Architecture (VistA) in the 1970s. The VA released the Computerized Patient Record System (CPRS) in 1997, the first clinical user interface for VistA. In May 2018, the VA signed a $10 billion contract with Cerner (now Oracle Health) to modernize its EHR.⁷ This was later revised to $16.1 billion, and the Institute for Defense Analyses estimates it will cost $49.8 billion.⁸ The transition to Oracle Health has been faced with significant challenges, including patient safety risks and workflow inefficiencies, leading to a pause in rollout.⁹

Due to the known challenges with EHRs and the aging CPRS system (without a scheduled replacement date), innovations that facilitate the synthesis and display of clinical information are needed. To address this gap, the VA Ann Arbor Healthcare System (VAAAHS) developed the Inpatient Dashboard, an online EHR companion tool. The Inpatient Dashboard was designed to draw data from VistA to reduce time spent at the computer by streamlining clinical information presentation, standardizing inpatient notes, improving safety measures, and enhancing overall clinician satisfaction. This study evaluated the adoption and user experience with the Inpatient Dashboard.

INPATIENT DASHBOARD

The Inpatient Dashboard consists of several modules created by a contractor for the VAAAHS that is housed on VA servers with access restricted to individuals with patient health data privileges. As the Inpatient Dashboard draws data from VistA, it can display laboratory information, studies, and notes from all VA sites.

The main dashboard is a snapshot summary of patient information, including patient location, code status, last vital sign readings, vital sign ranges over the previous 24 hours, intake/output, deep vein thrombosis (DVT) prophylaxis, the presence of telemetry orders, or use of Foley or central catheters (Figure). It also includes a customizable to-do list and contact information for the patient’s clinician and nurse. Significant events, such as abnormal vital signs or speciation/sensitivities for blood cultures, are automatically populated on the to-do list. From this main dashboard overview, clinicians can customize which patients are displayed, create and print a rounding list, print a sign-out sheet, or select individual patients to open a progress note module.

Notes can be written in the patient history and physical module, progress note module, and discharge summary module. The patient history and physical module has text blocks allocated to the traditional components of a history and physical note (ie, chief complaint, history of present illness, review of systems, past medical history, family history, social history, allergies, medications, physical examination, assessment, and plan) (eAppendix 1). Some elements, such as past medical history, family history, and social history are prepopulated if the patient was previously admitted. Vital signs, laboratory results, studies, microbiology/ pathology reports, and other CPRS notes are displayed in this module.

The progress note module contains text blocks allocated to the traditional components of a progress note, such as subjective/interval events, physical examination, assessment, and plan (eAppendix 2). Vital signs, laboratory results, studies, microbiology/ pathology reports, other CPRS notes, and the patient’s medication administration record are also displayed in this module. Lastly, the discharge summary module includes patient follow-up, patient instructions, hospitalization summary, medication reconciliation, laboratory results, and studies/procedures, ensuring a comprehensive discharge summary for patients and clinicians (eAppendix 3).

A medication reconciliation tool was embedded within the history and physical and discharge summary modules. This tool has been shown to reduce medication errors in patients admitted from the emergency department to the hospital (eAppendix 4).¹⁰ The handoff/sign-out tool (eAppendix 5) accessible through the main dashboard page is modeled on the I-PASS handoff framework.^11,12 This includes the patient identifier, interval events, inpatient medications, specific sign-out guidance, sign-out tasks/to-dos, and any other pertinent information.

The Inpatient Dashboard is a team-based construct shared by the attending physicians, residents, and medical students. Each team (eg, general medicine, general surgery) is its own entity; only team members can change the content or add to the documentation. Each facility can have multiple teams caring for the same patient (eg, primary and consulting teams). Additional care members can also be incorporated (eg, pharmacists assist with medication reconciliation for admission and discharge at VAAAHS). The Inpatient Dashboard can export information directly to CPRS for clinicians to review and sign. It can also generate a note that can be pasted into CPRS.

Clinician Feedback and Satisfaction

A survey was developed to evaluate clinician experiences with using the Inpatient Dashboard as an adjunct to the CPRS. The Inpatient Dashboard was made available to general medicine teams in November 2018. The survey was conducted from December 2018 to September 2019. The study was conducted at the VAAAHS and included 4 general medicine teams. Each team included an attending physician, a senior resident, 2 to 3 interns, and 3 to 4 medical students. Eligibility was extended to any team member who used both the CPRS and Inpatient Dashboard. Participation in the survey was voluntary. All respondents were informed of the study’s purpose and encouraged to provide candid feedback to ensure the reliability and validity of the findings.

Data were collected through a semistructured survey administered via the Qualtrics platform. The questionnaire was designed to capture multidimensional insights into clinician experience, with particular focus on satisfaction, efficiency, and perceived safety when using the tool as an adjunct to CPRS compared to using CPRS alone. The questionnaire primarily used a Likert scale for responses. Surveys were emailed at the completion of a team’s 1-month inpatient block. An answer was not required for every question, resulting in slightly different response numbers for some questions.

A question regarding the tool’s impact on workload stress was added halfway through the study period, which resulted in fewer responses. Adoption was assessed by counting the Inpatient Dashboard unique users. Descriptive statistics were used within individual survey responses to report the distribution of responses. Differences in response between levels of training were assessed using a X² test of independence.

Survey Results

From September 2023 through November 2023, there were 1549 rounding printouts across 144 unique users (5 nurses, 40 medical students, 87 residents, and 12 attending physicians) and 1468 handoff printouts across 148 unique users (5 nurses, 10 medical students, 111 residents, and 22 attending physicians). The clinician survey received 68 responses from users at various levels of medical training: 23 medical students, 31 interns, 12 senior residents, and 2 attending physicians. All 68 participants confirmed they had used the Inpatient Dashboard.

User satisfaction and preference for the Inpatient Dashboard vs CPRS were assessed. Sixty-one respondents (90%) expressed overall satisfaction with the Inpatient Dashboard; 22 (32%) were extremely satisfied, and 39 (57%) were somewhat satisfied (Table 1). Three respondents (4%) were neutral, 2 (3%) were somewhat dissatisfied, and 2 (3%) were extremely dissatisfied with the Inpatient Dashboard. Responses differed by level of training (P = .03), with medical students trending towards higher satisfaction.

Respondents preferred the Inpatient Dashboard over CPRS for gathering information and writing progress notes; 42 (64%) respondents mostly favored the Inpatient Dashboard, 15 (23%) slightly favored the Inpatient Dashboard over CPRS, and 8 (12%) were neutral. One respondent (2%) slightly favored CPRS to the Inpatient Dashboard (Table 2).

Sixty-five respondents (100%) found the Inpatient Dashboard’s ability to summarize patient information in a central place helpful (Table 3). Among them, 53 (82%) respondents reported it was very or extremely helpful, 10 (15%) respondents reported it was moderately helpful, and 2 (3%) respondents reported it was slightly helpful. This feature positively impacted users’ awareness of patients with DVT prophylaxis or a Foley catheter. Ten (15%) respondents reported being much more aware, and 29 (45%) respondents reporting they were slightly more aware. The remaining 26 (40%) respondents reported no change in awareness.

The Inpatient Dashboard was reported to save time preparing for physician rounds by 52 (80%) respondents, contributing to much greater efficiency for 29 (45%) respondents and slightly more efficiency for 23 (35%) respondents. However, 10 (15%) respondents reported no change in efficiency, and 3 (5%) respondents reduced efficiency, with 1 (2%) respondent reporting it slightly less efficient and 2 (3%) respondents reporting it much less efficient. Responses differed by level of training (P = .01), with medical students trending towards higher efficiency. Of the 23 respondents who reported on the Inpatient Dashboard’s impact on daily workload stress level, 22 (96%) indicated the tool had a stress-reducing effect, with 9 (39%) experiencing a major reduction in stress level, and 13 (57%) experiencing somewhat reduced stress level. Only 1 participant (4%) reported no change in stress. No participants reported an increase in stress.

DISCUSSION

The adoption of EHRs has transformed operational modalities in contemporary health care systems, heralding advancements in patient satisfaction, safety, and overall quality and efficiency of care.^1,2 However, EHRs still present challenges, predominantly around clinician satisfaction, marked by instances of burnout and increased time spent on computers.^2-6 In this context, the Inpatient Dashboard, an online companion to the CPRS, exemplifies how user-centered innovations in EHRs can address and mitigate associated challenges.

The Inpatient Dashboard has been well received with most respondents of the survey conducted in this study indicating they were both satisfied with the instrument and preferring it to CPRS. This high approval aligns with existing literature on the potential advantages of user-centered design in health care technology.¹³ The tool has gained widespread acceptance at the VAAAHS even in the absence of obligatory usage or institutional incentives. The appeal of the Inpatient Dashboard may stem from its increased efficiency, with most users affirming its timesaving nature. While CPRS can only display local notes, laboratory results, and studies, the Inpatient Dashboard can display data from across all VA sites. The VA Joint Longitudinal Viewer can similarly display data from across all sites, but the display is not streamlined as it is in the Inpatient Dashboard. The Inpatient Dashboard incorporates this clinical information into a single page to facilitate day-to-day workflow and dynamic documentation (ie, reviewing laboratory results, medications, writing notes, and signing out patients). This increased efficiency allows clinicians to counter 2 common barriers to EHR implementation: productivity loss and insufficient time.¹⁴

The association between EHRs and improved quality and safety in health care is well-documented.³ The Inpatient Dashboard fortifies this association by enhancing awareness around patient status, evidenced by a majority of respondents, and by integrating a medication reconciliation tool to decrease medication errors on transition from the emergency department to inpatient hospitalization.¹⁰

The Inpatient Dashboard’s impact on alleviating daily workload stress is noteworthy, with almost all respondents experiencing reduced stress levels and physician burnout, which has been linked to deteriorating well-being, compromised patient safety, and escalated health care costs.^15,16 The heightened susceptibility of physicians to burnout compared to other professionals underscores the imperative for incorporating stress-mitigating interventions in the EHR.^17,18

While responses to most questions did not significantly differ by training levels, overall satisfaction with the Inpatient Dashboard and its ability to save time preparing for rounds were rated higher by medical students. This may be attributable to a greater derived benefit from collating and presenting data to learners with less familiarity with the native EHR. It is also notable that the Inpatient Dashboard allows medical students to directly contribute to a patient’s note, which could be another driver in satisfaction. While most interns still felt the Inpatient Dashboard enabled them to save time preparing for rounds, there were a considerable number of ‘no change’ responses, which suggests some interns may not have modified their existing prerounding strategies. These associations are limited by the relatively small number of respondents by learner category, with senior medical residents and attending physicians being underrepresented.

While there are a multitude of dashboards available at the VA, most are made to track certain quality metrics and are used more by administrative and leadership staff. The Inpatient Dashboard was created specifically for frontline clinicians to facilitate their day-to-day workflow and dynamic documentation. This tool can additionally help with quality metrics, though its main purpose was and is to make clinician workflow easier and more efficient.

These results are especially timely because the VA is modernizing its EHR by transitioning to Oracle Health.⁷ Due to the numerous reports both from veterans and VA clinicians that the Oracle Health EHR is not meeting expectations, deployment at further sites has been halted while improving the experience of the 5 institutions using Oracle Health is prioritized.⁹ The Inpatient Dashboard, instead of being merely an enhancement to CPRS, could emerge as a potential bridge to Oracle Health if adapted to display data from Oracle Health as it does VistA. This would facilitate a smoother, more integrated transition for those health care institutions employing the Inpatient Dashboard.

Limitations

The reliance on self-reported data inherently carries the risk of bias, and the absence of objective measures, like time-tracking studies, limits the quantifiable assessment of the Inpatient Dashboard efficacy. The single-center nature of the study also may restrict the generalizability of the results.

CONCLUSIONS

Optimal integration of EHRs into health care delivery is critical to high-quality patient care and operational efficiency. The Inpatient Dashboard is an example of an innovative, user-centric solution that integrated and presented clinical information in a way that produced high satisfaction and adoption by users at a VA hospital.

Electronic health records (EHRs) are an integral part of modern health care. The 2009, Health Information Technology for Economic and Clinical Health Act established financial incentives for US hospitals to adopt EHRs. In 2009 only 12% of nonfederal acute care hospitals had adopted a certified EHR system, which increased to 96% by 2021.¹

EHRs have transformed the way patient data are stored and accessed, streamlining the process of providing quality patient care with improvements in efficiency, effectiveness, patient satisfaction, and safety.² Despite their widespread adoption and benefits, EHRs have generally been met with mixed physician satisfaction.³ Interactions with EHRs are linked to disproportionate time at the computer and physician burnout.^4-6

The US Department of Veterans Affairs (VA) was at the forefront of EHR development, establishing the Veterans Health Information Systems and Technology Architecture (VistA) in the 1970s. The VA released the Computerized Patient Record System (CPRS) in 1997, the first clinical user interface for VistA. In May 2018, the VA signed a $10 billion contract with Cerner (now Oracle Health) to modernize its EHR.⁷ This was later revised to $16.1 billion, and the Institute for Defense Analyses estimates it will cost $49.8 billion.⁸ The transition to Oracle Health has been faced with significant challenges, including patient safety risks and workflow inefficiencies, leading to a pause in rollout.⁹

Due to the known challenges with EHRs and the aging CPRS system (without a scheduled replacement date), innovations that facilitate the synthesis and display of clinical information are needed. To address this gap, the VA Ann Arbor Healthcare System (VAAAHS) developed the Inpatient Dashboard, an online EHR companion tool. The Inpatient Dashboard was designed to draw data from VistA to reduce time spent at the computer by streamlining clinical information presentation, standardizing inpatient notes, improving safety measures, and enhancing overall clinician satisfaction. This study evaluated the adoption and user experience with the Inpatient Dashboard.

INPATIENT DASHBOARD

The Inpatient Dashboard consists of several modules created by a contractor for the VAAAHS that is housed on VA servers with access restricted to individuals with patient health data privileges. As the Inpatient Dashboard draws data from VistA, it can display laboratory information, studies, and notes from all VA sites.

The main dashboard is a snapshot summary of patient information, including patient location, code status, last vital sign readings, vital sign ranges over the previous 24 hours, intake/output, deep vein thrombosis (DVT) prophylaxis, the presence of telemetry orders, or use of Foley or central catheters (Figure). It also includes a customizable to-do list and contact information for the patient’s clinician and nurse. Significant events, such as abnormal vital signs or speciation/sensitivities for blood cultures, are automatically populated on the to-do list. From this main dashboard overview, clinicians can customize which patients are displayed, create and print a rounding list, print a sign-out sheet, or select individual patients to open a progress note module.

Notes can be written in the patient history and physical module, progress note module, and discharge summary module. The patient history and physical module has text blocks allocated to the traditional components of a history and physical note (ie, chief complaint, history of present illness, review of systems, past medical history, family history, social history, allergies, medications, physical examination, assessment, and plan) (eAppendix 1). Some elements, such as past medical history, family history, and social history are prepopulated if the patient was previously admitted. Vital signs, laboratory results, studies, microbiology/ pathology reports, and other CPRS notes are displayed in this module.

The progress note module contains text blocks allocated to the traditional components of a progress note, such as subjective/interval events, physical examination, assessment, and plan (eAppendix 2). Vital signs, laboratory results, studies, microbiology/ pathology reports, other CPRS notes, and the patient’s medication administration record are also displayed in this module. Lastly, the discharge summary module includes patient follow-up, patient instructions, hospitalization summary, medication reconciliation, laboratory results, and studies/procedures, ensuring a comprehensive discharge summary for patients and clinicians (eAppendix 3).

A medication reconciliation tool was embedded within the history and physical and discharge summary modules. This tool has been shown to reduce medication errors in patients admitted from the emergency department to the hospital (eAppendix 4).¹⁰ The handoff/sign-out tool (eAppendix 5) accessible through the main dashboard page is modeled on the I-PASS handoff framework.^11,12 This includes the patient identifier, interval events, inpatient medications, specific sign-out guidance, sign-out tasks/to-dos, and any other pertinent information.

The Inpatient Dashboard is a team-based construct shared by the attending physicians, residents, and medical students. Each team (eg, general medicine, general surgery) is its own entity; only team members can change the content or add to the documentation. Each facility can have multiple teams caring for the same patient (eg, primary and consulting teams). Additional care members can also be incorporated (eg, pharmacists assist with medication reconciliation for admission and discharge at VAAAHS). The Inpatient Dashboard can export information directly to CPRS for clinicians to review and sign. It can also generate a note that can be pasted into CPRS.

Clinician Feedback and Satisfaction

A survey was developed to evaluate clinician experiences with using the Inpatient Dashboard as an adjunct to the CPRS. The Inpatient Dashboard was made available to general medicine teams in November 2018. The survey was conducted from December 2018 to September 2019. The study was conducted at the VAAAHS and included 4 general medicine teams. Each team included an attending physician, a senior resident, 2 to 3 interns, and 3 to 4 medical students. Eligibility was extended to any team member who used both the CPRS and Inpatient Dashboard. Participation in the survey was voluntary. All respondents were informed of the study’s purpose and encouraged to provide candid feedback to ensure the reliability and validity of the findings.

Data were collected through a semistructured survey administered via the Qualtrics platform. The questionnaire was designed to capture multidimensional insights into clinician experience, with particular focus on satisfaction, efficiency, and perceived safety when using the tool as an adjunct to CPRS compared to using CPRS alone. The questionnaire primarily used a Likert scale for responses. Surveys were emailed at the completion of a team’s 1-month inpatient block. An answer was not required for every question, resulting in slightly different response numbers for some questions.

A question regarding the tool’s impact on workload stress was added halfway through the study period, which resulted in fewer responses. Adoption was assessed by counting the Inpatient Dashboard unique users. Descriptive statistics were used within individual survey responses to report the distribution of responses. Differences in response between levels of training were assessed using a X² test of independence.

Survey Results

From September 2023 through November 2023, there were 1549 rounding printouts across 144 unique users (5 nurses, 40 medical students, 87 residents, and 12 attending physicians) and 1468 handoff printouts across 148 unique users (5 nurses, 10 medical students, 111 residents, and 22 attending physicians). The clinician survey received 68 responses from users at various levels of medical training: 23 medical students, 31 interns, 12 senior residents, and 2 attending physicians. All 68 participants confirmed they had used the Inpatient Dashboard.

User satisfaction and preference for the Inpatient Dashboard vs CPRS were assessed. Sixty-one respondents (90%) expressed overall satisfaction with the Inpatient Dashboard; 22 (32%) were extremely satisfied, and 39 (57%) were somewhat satisfied (Table 1). Three respondents (4%) were neutral, 2 (3%) were somewhat dissatisfied, and 2 (3%) were extremely dissatisfied with the Inpatient Dashboard. Responses differed by level of training (P = .03), with medical students trending towards higher satisfaction.

Respondents preferred the Inpatient Dashboard over CPRS for gathering information and writing progress notes; 42 (64%) respondents mostly favored the Inpatient Dashboard, 15 (23%) slightly favored the Inpatient Dashboard over CPRS, and 8 (12%) were neutral. One respondent (2%) slightly favored CPRS to the Inpatient Dashboard (Table 2).

Sixty-five respondents (100%) found the Inpatient Dashboard’s ability to summarize patient information in a central place helpful (Table 3). Among them, 53 (82%) respondents reported it was very or extremely helpful, 10 (15%) respondents reported it was moderately helpful, and 2 (3%) respondents reported it was slightly helpful. This feature positively impacted users’ awareness of patients with DVT prophylaxis or a Foley catheter. Ten (15%) respondents reported being much more aware, and 29 (45%) respondents reporting they were slightly more aware. The remaining 26 (40%) respondents reported no change in awareness.

The Inpatient Dashboard was reported to save time preparing for physician rounds by 52 (80%) respondents, contributing to much greater efficiency for 29 (45%) respondents and slightly more efficiency for 23 (35%) respondents. However, 10 (15%) respondents reported no change in efficiency, and 3 (5%) respondents reduced efficiency, with 1 (2%) respondent reporting it slightly less efficient and 2 (3%) respondents reporting it much less efficient. Responses differed by level of training (P = .01), with medical students trending towards higher efficiency. Of the 23 respondents who reported on the Inpatient Dashboard’s impact on daily workload stress level, 22 (96%) indicated the tool had a stress-reducing effect, with 9 (39%) experiencing a major reduction in stress level, and 13 (57%) experiencing somewhat reduced stress level. Only 1 participant (4%) reported no change in stress. No participants reported an increase in stress.

DISCUSSION

The adoption of EHRs has transformed operational modalities in contemporary health care systems, heralding advancements in patient satisfaction, safety, and overall quality and efficiency of care.^1,2 However, EHRs still present challenges, predominantly around clinician satisfaction, marked by instances of burnout and increased time spent on computers.^2-6 In this context, the Inpatient Dashboard, an online companion to the CPRS, exemplifies how user-centered innovations in EHRs can address and mitigate associated challenges.

The Inpatient Dashboard has been well received with most respondents of the survey conducted in this study indicating they were both satisfied with the instrument and preferring it to CPRS. This high approval aligns with existing literature on the potential advantages of user-centered design in health care technology.¹³ The tool has gained widespread acceptance at the VAAAHS even in the absence of obligatory usage or institutional incentives. The appeal of the Inpatient Dashboard may stem from its increased efficiency, with most users affirming its timesaving nature. While CPRS can only display local notes, laboratory results, and studies, the Inpatient Dashboard can display data from across all VA sites. The VA Joint Longitudinal Viewer can similarly display data from across all sites, but the display is not streamlined as it is in the Inpatient Dashboard. The Inpatient Dashboard incorporates this clinical information into a single page to facilitate day-to-day workflow and dynamic documentation (ie, reviewing laboratory results, medications, writing notes, and signing out patients). This increased efficiency allows clinicians to counter 2 common barriers to EHR implementation: productivity loss and insufficient time.¹⁴

The association between EHRs and improved quality and safety in health care is well-documented.³ The Inpatient Dashboard fortifies this association by enhancing awareness around patient status, evidenced by a majority of respondents, and by integrating a medication reconciliation tool to decrease medication errors on transition from the emergency department to inpatient hospitalization.¹⁰

The Inpatient Dashboard’s impact on alleviating daily workload stress is noteworthy, with almost all respondents experiencing reduced stress levels and physician burnout, which has been linked to deteriorating well-being, compromised patient safety, and escalated health care costs.^15,16 The heightened susceptibility of physicians to burnout compared to other professionals underscores the imperative for incorporating stress-mitigating interventions in the EHR.^17,18

While responses to most questions did not significantly differ by training levels, overall satisfaction with the Inpatient Dashboard and its ability to save time preparing for rounds were rated higher by medical students. This may be attributable to a greater derived benefit from collating and presenting data to learners with less familiarity with the native EHR. It is also notable that the Inpatient Dashboard allows medical students to directly contribute to a patient’s note, which could be another driver in satisfaction. While most interns still felt the Inpatient Dashboard enabled them to save time preparing for rounds, there were a considerable number of ‘no change’ responses, which suggests some interns may not have modified their existing prerounding strategies. These associations are limited by the relatively small number of respondents by learner category, with senior medical residents and attending physicians being underrepresented.

While there are a multitude of dashboards available at the VA, most are made to track certain quality metrics and are used more by administrative and leadership staff. The Inpatient Dashboard was created specifically for frontline clinicians to facilitate their day-to-day workflow and dynamic documentation. This tool can additionally help with quality metrics, though its main purpose was and is to make clinician workflow easier and more efficient.

These results are especially timely because the VA is modernizing its EHR by transitioning to Oracle Health.⁷ Due to the numerous reports both from veterans and VA clinicians that the Oracle Health EHR is not meeting expectations, deployment at further sites has been halted while improving the experience of the 5 institutions using Oracle Health is prioritized.⁹ The Inpatient Dashboard, instead of being merely an enhancement to CPRS, could emerge as a potential bridge to Oracle Health if adapted to display data from Oracle Health as it does VistA. This would facilitate a smoother, more integrated transition for those health care institutions employing the Inpatient Dashboard.

Limitations

The reliance on self-reported data inherently carries the risk of bias, and the absence of objective measures, like time-tracking studies, limits the quantifiable assessment of the Inpatient Dashboard efficacy. The single-center nature of the study also may restrict the generalizability of the results.

CONCLUSIONS

Optimal integration of EHRs into health care delivery is critical to high-quality patient care and operational efficiency. The Inpatient Dashboard is an example of an innovative, user-centric solution that integrated and presented clinical information in a way that produced high satisfaction and adoption by users at a VA hospital.

A burst sprinkler pipe and broken steam system caused significant infrastructure failures and wreaked havoc on patient care at Walter Reed National Military Medical Center in January. 

An email sent to Walter Reed staff from the medical center’s director, Navy Capt. Melissa C. Austin, said 60,000 gallons of water, or enough “to fill a 25x50 foot swimming pool” flooded throughout the facility on Jan. 20 before it was contained, damaging 50 rooms and 6 elevators. 

Frozen pipes burst due to extreme cold, and the issues were exacerbated by aging infrastructure and “deferred maintenance due to underfunding,” the Defense Health Agency (DHA), which oversees Walter Reed, said in a public statement. 

The damage was severe enough to impact patient care. The facility had to evacuate the neonatal intensive care unit as well as several clinics. The steam system outages also meant operating rooms had fewer clean surgical tools available and had to send them to regional hospitals for sterilization, staffers told The Washington Post. Health care workers could not “flash sterilize” equipment in emergencies, further risking patient safety.

Rick McNamara, a spokesperson for the Defense Health Network National Capital Region, confirmed other hospitals are “sharing the burden” to sterilize equipment. McNamara said it could take 6 weeks to complete the immediate repairs, which will cost between $1 million and $2 million.

Patient appointments were delayed, and nonemergency procedures were canceled or delayed. Overall, 212 patients were “deferred or rescheduled,” and 56 other patients were sent to other hospitals to receive care.

Defense Secretary Pete Hegseth said on Jan. 31 the problem was “real and unacceptable” in response to a video circulating on social media that showed flooding.

Acknowledging that the water damage “temporarily impacted health care operations,” the Defense Department says DHA and Walter Reed staff were “working diligently around the clock” to find and implement solutions while minimizing disruptions to patient care: “High waters and loss of steam pressure impacted the capacity of services delivered, but the ability to deliver the hospital’s core capabilities of safe, quality care was never compromised,” the agency said.

In response to the flooding, the hospital moved quickly to provide the required urgent care: “We are utilizing all the hospitals and clinics in the National Capital Region Network from Malcom Grow at Joint Base Andrews to Kimbrough Ambulatory Care Center at Fort Meade to the Alexander T. Augusta Military Medical Center at Fort Belvoir,” Capt. Austin said. 

DHA is also funding emergency work orders and contract modifications required to return Walter Reed to full operational capability. It is prioritizing resources for repairs and is collaborating with the Naval Installations Command and Naval Support Activity Bethesda to implement necessary repairs.

“This acute issue is being managed aggressively to ensure patient care continues to be delivered safely,” DHA said

A burst sprinkler pipe and broken steam system caused significant infrastructure failures and wreaked havoc on patient care at Walter Reed National Military Medical Center in January. 

An email sent to Walter Reed staff from the medical center’s director, Navy Capt. Melissa C. Austin, said 60,000 gallons of water, or enough “to fill a 25x50 foot swimming pool” flooded throughout the facility on Jan. 20 before it was contained, damaging 50 rooms and 6 elevators. 

Frozen pipes burst due to extreme cold, and the issues were exacerbated by aging infrastructure and “deferred maintenance due to underfunding,” the Defense Health Agency (DHA), which oversees Walter Reed, said in a public statement. 

The damage was severe enough to impact patient care. The facility had to evacuate the neonatal intensive care unit as well as several clinics. The steam system outages also meant operating rooms had fewer clean surgical tools available and had to send them to regional hospitals for sterilization, staffers told The Washington Post. Health care workers could not “flash sterilize” equipment in emergencies, further risking patient safety.

Rick McNamara, a spokesperson for the Defense Health Network National Capital Region, confirmed other hospitals are “sharing the burden” to sterilize equipment. McNamara said it could take 6 weeks to complete the immediate repairs, which will cost between $1 million and $2 million.

Patient appointments were delayed, and nonemergency procedures were canceled or delayed. Overall, 212 patients were “deferred or rescheduled,” and 56 other patients were sent to other hospitals to receive care.

Defense Secretary Pete Hegseth said on Jan. 31 the problem was “real and unacceptable” in response to a video circulating on social media that showed flooding.

Acknowledging that the water damage “temporarily impacted health care operations,” the Defense Department says DHA and Walter Reed staff were “working diligently around the clock” to find and implement solutions while minimizing disruptions to patient care: “High waters and loss of steam pressure impacted the capacity of services delivered, but the ability to deliver the hospital’s core capabilities of safe, quality care was never compromised,” the agency said.

In response to the flooding, the hospital moved quickly to provide the required urgent care: “We are utilizing all the hospitals and clinics in the National Capital Region Network from Malcom Grow at Joint Base Andrews to Kimbrough Ambulatory Care Center at Fort Meade to the Alexander T. Augusta Military Medical Center at Fort Belvoir,” Capt. Austin said. 

DHA is also funding emergency work orders and contract modifications required to return Walter Reed to full operational capability. It is prioritizing resources for repairs and is collaborating with the Naval Installations Command and Naval Support Activity Bethesda to implement necessary repairs.

“This acute issue is being managed aggressively to ensure patient care continues to be delivered safely,” DHA said

A burst sprinkler pipe and broken steam system caused significant infrastructure failures and wreaked havoc on patient care at Walter Reed National Military Medical Center in January. 

An email sent to Walter Reed staff from the medical center’s director, Navy Capt. Melissa C. Austin, said 60,000 gallons of water, or enough “to fill a 25x50 foot swimming pool” flooded throughout the facility on Jan. 20 before it was contained, damaging 50 rooms and 6 elevators. 

Frozen pipes burst due to extreme cold, and the issues were exacerbated by aging infrastructure and “deferred maintenance due to underfunding,” the Defense Health Agency (DHA), which oversees Walter Reed, said in a public statement. 

The damage was severe enough to impact patient care. The facility had to evacuate the neonatal intensive care unit as well as several clinics. The steam system outages also meant operating rooms had fewer clean surgical tools available and had to send them to regional hospitals for sterilization, staffers told The Washington Post. Health care workers could not “flash sterilize” equipment in emergencies, further risking patient safety.

Rick McNamara, a spokesperson for the Defense Health Network National Capital Region, confirmed other hospitals are “sharing the burden” to sterilize equipment. McNamara said it could take 6 weeks to complete the immediate repairs, which will cost between $1 million and $2 million.

Patient appointments were delayed, and nonemergency procedures were canceled or delayed. Overall, 212 patients were “deferred or rescheduled,” and 56 other patients were sent to other hospitals to receive care.

Defense Secretary Pete Hegseth said on Jan. 31 the problem was “real and unacceptable” in response to a video circulating on social media that showed flooding.

Acknowledging that the water damage “temporarily impacted health care operations,” the Defense Department says DHA and Walter Reed staff were “working diligently around the clock” to find and implement solutions while minimizing disruptions to patient care: “High waters and loss of steam pressure impacted the capacity of services delivered, but the ability to deliver the hospital’s core capabilities of safe, quality care was never compromised,” the agency said.

In response to the flooding, the hospital moved quickly to provide the required urgent care: “We are utilizing all the hospitals and clinics in the National Capital Region Network from Malcom Grow at Joint Base Andrews to Kimbrough Ambulatory Care Center at Fort Meade to the Alexander T. Augusta Military Medical Center at Fort Belvoir,” Capt. Austin said. 

DHA is also funding emergency work orders and contract modifications required to return Walter Reed to full operational capability. It is prioritizing resources for repairs and is collaborating with the Naval Installations Command and Naval Support Activity Bethesda to implement necessary repairs.

“This acute issue is being managed aggressively to ensure patient care continues to be delivered safely,” DHA said

Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.¹ There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.² Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.³

The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.^4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.^6,7

Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.^1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.¹ Frequently, a VMB is incorporated into the structure and flow of the huddle.

In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.¹ VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.¹ In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.^6,8-12

This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.

Implementation

The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.

The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.

Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.

The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.¹³

Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.¹⁴ Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.¹⁴ Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.

After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.

Program Impact

A total of 55 improvement opportunity tickets were submitted by staff members during the initial 23 months after the implementation of the outpatient cardiology clinic VMB. Most were submitted by nurse practitioners, although there were contributions from all faculty and staff. The high percentage of ticket submissions by nurse practitioners may be related to their full-time daily presence in the clinic, whereas some other staff members are part-time (most physicians are present 1 day each week). Improvement opportunities were noted within a variety of areas, including clinic facilities (eg, clinic equipment), communication between the clinic and patients (eg, telephone calls from patients or appointment letters), and patient care (eg, medication reconciliation and laboratory requisition).

In an improvement opportunity ticket, a staff member identified that the low seating in the patient waiting area was a fall risk and not diversified for varying body types. They posted a ticket, and the issue was discussed as a group. This staff member assumed ownership of the problem and placed an interior design request for taller chairs and bariatric options. The ticket was resolved when the waiting area was upgraded to include safer and more inclusive seating options for patients. Of 55 tickets submitted by staff as of June 2024, 45 have identified solutions, 4 are in process, and 6 have been placed in the parking lot. On average, the morning huddle spends about 5 to 10 minutes addressing tickets, but on occasion, more complex topics require additional time. The kudos board receives feedback from patients who express their gratitude, and serves as a space to celebrate awards received by staff members.

Implementing a VMB into daily huddles within the cardiology clinic led to increased staff engagement and ownership of challenges, as well as improved communication between frontline workers and leadership. VMBs have proven to be useful for annual staff performance evaluations because staff members who engaged in the board and volunteered to take accountability for ticket resolution could use those accomplishments in their assessments. Finally, VMBs made quality improvement and safety work accessible by normalizing frequent conversations. This empowered staff to engage in improvement projects and even led some members to enroll in formal Lean training.

The outpatient cardiology clinic VMB at the VAAAHS was identified as a best practice during a site visit by the Promising Practice Team in the Veterans Health Administration Office of Integrated Veteran Care. The outpatient cardiology clinic leadership team, including the authors of this article, was invited to present our visual management work as a main topic at the January 2024 Office of Integrated Veteran Care collaborative meeting.

Further Implementation

The SR program has collaborated with additional VAAAHS teams to implement VMBs. Forty-four physical VMBs and 20 virtual VMBs are currently in use throughout the VAAAHS. Virtual VMB content is similar to a physical board and can be modified by each team to meet its particular needs. Several virtual VMBs have been implemented at the VAAAHS and can achieve the same goals of staff teamwork, empowerment, and engagement. Each team can choose the format of the VMB that best fits their needs, which may be partially influenced by the team’s overall interaction style (on-site teams may function better with a physical VMB, and off-site teams may find a virtual VMB works best). VMBs have been implemented in various work areas, including laboratories, inpatient wards, subspecialty outpatient clinics, procedural areas, and the engineering department. In fiscal year 2024, 180 tickets were electronically submitted by teams across the VAAAHS, of which 170 identified solutions and were marked completed. Ticket counts may be underestimated since not all physical board tickets are reported in the electronic system. The SR program periodically attends morning huddles of various teams and obtains feedback on their VMBs, a practice that highlights its contribution to staff engagement, transparency, teamwork, and continuous improvement (Table). A goal of the SR program is to identify areas of the VAAAHS in which VMBs would add value to the team and implement them as necessary.

Discussion

VMBs are common in health care and are implemented to promote the core principlesof Lean thinking and HROs, including visual management and daily accountability. The goals of a visual management tool are to make problems visible and document their management. A VMB can serve as a focal point for team discussion and a physical space to track each problem through its initial identification, understanding of root causes, consideration of potential solutions, and recording of intervention results.

A VMB can foster a culture of safety, leadership commitment, and continuous process improvement when designed and implemented to reflect team needs. VMBs can empower staff members to share work concerns and openly promote engagement. As a central place for discussion between staff and leaders, VMBs can also foster teamwork and communication. The daily huddle provides a safe, productive working environment by ensuring that lines of communication are open among all team members, regardless of role or leadership designation.

Limitations

This article focused on the implementation of 1 type of visual management tool. It provides an in-depth discussion of the development, implementation, and experience with a VMB at multiple clinics of a single section in 1 health care system. These reported experiences may not represent other VA facilities. Perceptions of the impact and usefulness of the VMB were mostly anecdotal. Further evaluation of the VMB implementation experience and utility at other VA health care systems would provide additional insight into the optimal implementation of VMBs.

Conclusions

Through increased transparency, empowerment, and communication, VMBs are an important tool in the visual management tool belt for organizations committed to HROs and Lean management. Given the successful institution of VMBs at the VAAAHS, the description of our experience may aid other VA systems for the incorporation of visual management into the daily culture of their respective health care teams.

Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.¹ There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.² Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.³

The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.^4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.^6,7

Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.^1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.¹ Frequently, a VMB is incorporated into the structure and flow of the huddle.

In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.¹ VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.¹ In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.^6,8-12

This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.

Implementation

The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.

The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.

Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.

The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.¹³

Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.¹⁴ Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.¹⁴ Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.

After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.

Program Impact

A total of 55 improvement opportunity tickets were submitted by staff members during the initial 23 months after the implementation of the outpatient cardiology clinic VMB. Most were submitted by nurse practitioners, although there were contributions from all faculty and staff. The high percentage of ticket submissions by nurse practitioners may be related to their full-time daily presence in the clinic, whereas some other staff members are part-time (most physicians are present 1 day each week). Improvement opportunities were noted within a variety of areas, including clinic facilities (eg, clinic equipment), communication between the clinic and patients (eg, telephone calls from patients or appointment letters), and patient care (eg, medication reconciliation and laboratory requisition).

In an improvement opportunity ticket, a staff member identified that the low seating in the patient waiting area was a fall risk and not diversified for varying body types. They posted a ticket, and the issue was discussed as a group. This staff member assumed ownership of the problem and placed an interior design request for taller chairs and bariatric options. The ticket was resolved when the waiting area was upgraded to include safer and more inclusive seating options for patients. Of 55 tickets submitted by staff as of June 2024, 45 have identified solutions, 4 are in process, and 6 have been placed in the parking lot. On average, the morning huddle spends about 5 to 10 minutes addressing tickets, but on occasion, more complex topics require additional time. The kudos board receives feedback from patients who express their gratitude, and serves as a space to celebrate awards received by staff members.

Implementing a VMB into daily huddles within the cardiology clinic led to increased staff engagement and ownership of challenges, as well as improved communication between frontline workers and leadership. VMBs have proven to be useful for annual staff performance evaluations because staff members who engaged in the board and volunteered to take accountability for ticket resolution could use those accomplishments in their assessments. Finally, VMBs made quality improvement and safety work accessible by normalizing frequent conversations. This empowered staff to engage in improvement projects and even led some members to enroll in formal Lean training.

The outpatient cardiology clinic VMB at the VAAAHS was identified as a best practice during a site visit by the Promising Practice Team in the Veterans Health Administration Office of Integrated Veteran Care. The outpatient cardiology clinic leadership team, including the authors of this article, was invited to present our visual management work as a main topic at the January 2024 Office of Integrated Veteran Care collaborative meeting.

Further Implementation

The SR program has collaborated with additional VAAAHS teams to implement VMBs. Forty-four physical VMBs and 20 virtual VMBs are currently in use throughout the VAAAHS. Virtual VMB content is similar to a physical board and can be modified by each team to meet its particular needs. Several virtual VMBs have been implemented at the VAAAHS and can achieve the same goals of staff teamwork, empowerment, and engagement. Each team can choose the format of the VMB that best fits their needs, which may be partially influenced by the team’s overall interaction style (on-site teams may function better with a physical VMB, and off-site teams may find a virtual VMB works best). VMBs have been implemented in various work areas, including laboratories, inpatient wards, subspecialty outpatient clinics, procedural areas, and the engineering department. In fiscal year 2024, 180 tickets were electronically submitted by teams across the VAAAHS, of which 170 identified solutions and were marked completed. Ticket counts may be underestimated since not all physical board tickets are reported in the electronic system. The SR program periodically attends morning huddles of various teams and obtains feedback on their VMBs, a practice that highlights its contribution to staff engagement, transparency, teamwork, and continuous improvement (Table). A goal of the SR program is to identify areas of the VAAAHS in which VMBs would add value to the team and implement them as necessary.

Discussion

VMBs are common in health care and are implemented to promote the core principlesof Lean thinking and HROs, including visual management and daily accountability. The goals of a visual management tool are to make problems visible and document their management. A VMB can serve as a focal point for team discussion and a physical space to track each problem through its initial identification, understanding of root causes, consideration of potential solutions, and recording of intervention results.

A VMB can foster a culture of safety, leadership commitment, and continuous process improvement when designed and implemented to reflect team needs. VMBs can empower staff members to share work concerns and openly promote engagement. As a central place for discussion between staff and leaders, VMBs can also foster teamwork and communication. The daily huddle provides a safe, productive working environment by ensuring that lines of communication are open among all team members, regardless of role or leadership designation.

Limitations

This article focused on the implementation of 1 type of visual management tool. It provides an in-depth discussion of the development, implementation, and experience with a VMB at multiple clinics of a single section in 1 health care system. These reported experiences may not represent other VA facilities. Perceptions of the impact and usefulness of the VMB were mostly anecdotal. Further evaluation of the VMB implementation experience and utility at other VA health care systems would provide additional insight into the optimal implementation of VMBs.

Conclusions

Through increased transparency, empowerment, and communication, VMBs are an important tool in the visual management tool belt for organizations committed to HROs and Lean management. Given the successful institution of VMBs at the VAAAHS, the description of our experience may aid other VA systems for the incorporation of visual management into the daily culture of their respective health care teams.

Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.¹ There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.² Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.³

The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.^4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.^6,7

Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.^1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.¹ Frequently, a VMB is incorporated into the structure and flow of the huddle.

In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.¹ VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.¹ In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.^6,8-12

This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.

Implementation

The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.

The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.

Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.

The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.¹³

Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.¹⁴ Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.¹⁴ Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.

After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.

Program Impact

A total of 55 improvement opportunity tickets were submitted by staff members during the initial 23 months after the implementation of the outpatient cardiology clinic VMB. Most were submitted by nurse practitioners, although there were contributions from all faculty and staff. The high percentage of ticket submissions by nurse practitioners may be related to their full-time daily presence in the clinic, whereas some other staff members are part-time (most physicians are present 1 day each week). Improvement opportunities were noted within a variety of areas, including clinic facilities (eg, clinic equipment), communication between the clinic and patients (eg, telephone calls from patients or appointment letters), and patient care (eg, medication reconciliation and laboratory requisition).

In an improvement opportunity ticket, a staff member identified that the low seating in the patient waiting area was a fall risk and not diversified for varying body types. They posted a ticket, and the issue was discussed as a group. This staff member assumed ownership of the problem and placed an interior design request for taller chairs and bariatric options. The ticket was resolved when the waiting area was upgraded to include safer and more inclusive seating options for patients. Of 55 tickets submitted by staff as of June 2024, 45 have identified solutions, 4 are in process, and 6 have been placed in the parking lot. On average, the morning huddle spends about 5 to 10 minutes addressing tickets, but on occasion, more complex topics require additional time. The kudos board receives feedback from patients who express their gratitude, and serves as a space to celebrate awards received by staff members.

Implementing a VMB into daily huddles within the cardiology clinic led to increased staff engagement and ownership of challenges, as well as improved communication between frontline workers and leadership. VMBs have proven to be useful for annual staff performance evaluations because staff members who engaged in the board and volunteered to take accountability for ticket resolution could use those accomplishments in their assessments. Finally, VMBs made quality improvement and safety work accessible by normalizing frequent conversations. This empowered staff to engage in improvement projects and even led some members to enroll in formal Lean training.

The outpatient cardiology clinic VMB at the VAAAHS was identified as a best practice during a site visit by the Promising Practice Team in the Veterans Health Administration Office of Integrated Veteran Care. The outpatient cardiology clinic leadership team, including the authors of this article, was invited to present our visual management work as a main topic at the January 2024 Office of Integrated Veteran Care collaborative meeting.

Further Implementation

The SR program has collaborated with additional VAAAHS teams to implement VMBs. Forty-four physical VMBs and 20 virtual VMBs are currently in use throughout the VAAAHS. Virtual VMB content is similar to a physical board and can be modified by each team to meet its particular needs. Several virtual VMBs have been implemented at the VAAAHS and can achieve the same goals of staff teamwork, empowerment, and engagement. Each team can choose the format of the VMB that best fits their needs, which may be partially influenced by the team’s overall interaction style (on-site teams may function better with a physical VMB, and off-site teams may find a virtual VMB works best). VMBs have been implemented in various work areas, including laboratories, inpatient wards, subspecialty outpatient clinics, procedural areas, and the engineering department. In fiscal year 2024, 180 tickets were electronically submitted by teams across the VAAAHS, of which 170 identified solutions and were marked completed. Ticket counts may be underestimated since not all physical board tickets are reported in the electronic system. The SR program periodically attends morning huddles of various teams and obtains feedback on their VMBs, a practice that highlights its contribution to staff engagement, transparency, teamwork, and continuous improvement (Table). A goal of the SR program is to identify areas of the VAAAHS in which VMBs would add value to the team and implement them as necessary.

Discussion

VMBs are common in health care and are implemented to promote the core principlesof Lean thinking and HROs, including visual management and daily accountability. The goals of a visual management tool are to make problems visible and document their management. A VMB can serve as a focal point for team discussion and a physical space to track each problem through its initial identification, understanding of root causes, consideration of potential solutions, and recording of intervention results.

A VMB can foster a culture of safety, leadership commitment, and continuous process improvement when designed and implemented to reflect team needs. VMBs can empower staff members to share work concerns and openly promote engagement. As a central place for discussion between staff and leaders, VMBs can also foster teamwork and communication. The daily huddle provides a safe, productive working environment by ensuring that lines of communication are open among all team members, regardless of role or leadership designation.

Limitations

This article focused on the implementation of 1 type of visual management tool. It provides an in-depth discussion of the development, implementation, and experience with a VMB at multiple clinics of a single section in 1 health care system. These reported experiences may not represent other VA facilities. Perceptions of the impact and usefulness of the VMB were mostly anecdotal. Further evaluation of the VMB implementation experience and utility at other VA health care systems would provide additional insight into the optimal implementation of VMBs.

Conclusions

Through increased transparency, empowerment, and communication, VMBs are an important tool in the visual management tool belt for organizations committed to HROs and Lean management. Given the successful institution of VMBs at the VAAAHS, the description of our experience may aid other VA systems for the incorporation of visual management into the daily culture of their respective health care teams.

It is common practice to routinely measure postoperative hematocrit levels at US Department of Veterans Affairs (VA) hospitals for a wide range of elective general surgeries. While hematocrit measurement is a low-cost test, the high frequency with which these tests are performed may drastically increase overall costs.

Numerous studies have suggested that physicians overuse laboratory testing.^1-10 Kohli and colleagues recommended that the routine practice of obtaining postoperative hematocrit tests following elective gynecologic surgery be abandoned.¹ A similar recommendation was made by Olus and colleagues after studying uneventful, unplanned cesarean sections and by Wu and colleagues after investigating routine laboratory tests post total hip arthroplasty.^2,3

To our knowledge, a study assessing routine postoperative hematocrit testing in elective general surgery has not yet been conducted. Many laboratory tests ordered in the perioperative period are not indicated, including complete blood count (CBC), electrolytes, and coagulation studies.⁴ Based on the results of these studies, we expected that the routine measurement of postoperative hematocrit levels after elective general surgeries at VA medical centers would not be cost effective. A PubMed search for articles published from 1990 to 2023 using the search terms “hematocrit,” “hemoglobin,” “general,” “surgery,” “routine,” and “cost” or “cost-effectiveness,” suggests that the clinical usefulness of postoperative hematocrit testing has not been well studied in the general surgery setting. The purpose of this study was to determine the clinical utility and associated cost of measuring routine postoperative hematocrit levels in order to generate a guide as to when the practice is warranted following common elective general surgery.

Although gynecologic textbooks may describe recommendations of routine hematocrit checking after elective gynecologic operations, one has difficulty finding the same recommendations in general surgery textbooks.¹ However, it is common practice for surgical residents and attending surgeons to routinely order hematocrit on postoperative day-1 to ensure that the operation did not result in unsuspected anemia that then would need treatment (either with fluids or a blood transfusion). Many other surgeons rely on clinical factors such as tachycardia, oliguria, or hypotension to trigger a hematocrit (and other laboratory) tests. Our hypothesis is that the latter group has chosen the most cost-effective and prudent practice. One problem with checking the hematocrit routinely, as with any other screening test, is what to do with an abnormal result, assuming an asymptomatic patient? If the postoperative hematocrit is lower than expected given the estimated blood loss (EBL), what is one to do?

Methods

This retrospective case-control study conducted at the New Mexico VA Health Care System (NMVAHCS) in Albuquerque compared data for patients who received transfusion within 72 hours of elective surgeries vs patients who did not. Patients who underwent elective general surgery from January 2011 through December 2014 were included. An elective general surgery was defined as surgery performed following an outpatient preoperative anesthesia evaluation ≥ 30 days prior to operation. Patients who underwent emergency operations, and those with baseline anemia (preoperative hematocrit < 30%), and those transfused > 72 hours after their operation were excluded. The NMVAHCSInstitutional Review Board approved this study (No. 15-H184).

A detailed record review was conducted to collect data on demographics and other preoperative risk factors, including age, sex, body mass index (BMI), race and ethnicity, cardiac and pulmonary comorbidities, tobacco use, alcohol intake, diabetes, American Society of Anesthesiologists Physical Status Classification, metabolic equivalent of task, hematologic conditions, and renal disease.

For each procedure, we recorded the type of elective general surgery performed, the diagnosis/indication, pre- and postoperative hemoglobin/hematocrit, intraoperative EBL, length of operation, surgical wound class, length of hospital stay (LOS), intensive care unit (ICU) status, number of hematocrit tests, cardiovascular risk of operation (defined by anesthesia assessment), presence or absence of malignancy, preoperative platelet count, albumin level, preoperative prothrombin time/activated partial thromboplastin time (aPTT), international normalized ratio (INR), hemoglobin A_1c, and incidence of transfusion. Signs and symptoms of anemia were recorded as present if the postoperative vital signs suggested low intravascular volume (pulse > 120 beats/minute, systolic blood pressure < 90 mm Hg, or vasoactive medication requirement [per anesthesia postoperative note]) or if the patient reported or exhibited symptoms of dizziness or fatigue or evidence of clinically apparent bleeding (ie, hematoma formation). Laboratory charges for hematocrit tests and CBC at the NMAVAHCS were used to assess cost.¹¹

To stratify the transfusion risk, patients were distributed among 3 groups based on the following criteria: discharged home the same day as surgery; admitted but did not have postoperative hematocrit testing; and admitted and had postoperative hematocrit testing. We also stratified operations into low or high risk based on the risk for postoperative transfusion (Figure). Recognizing that the American College of Chest Physicians guidelines for perioperative management of antithrombotic therapy places bowel resection in a high-risk category, we designated a surgery as high risk when ≥ 2 patients in the transfusion group had that type of surgery over the 4 years of the study.¹² Otherwise, the operations were deemed low risk.

Statistical Analysis

Numeric analysis used t tests and Binary and categorical variables used Fisher exact tests. P value ≤ .05 was considered statistically significant. SAS software was used for all statistical analyses.

From 2011 through 2014, 1531 patients had elective general surgery at NMVAHCS. Twenty-two patients with preoperative anemia (hematocrit < 30%) and 1 patient who received a transfusion > 72 hours after the operation were excluded. Most elective operations (70%, n = 1075) were performed on an outpatient basis; none involved transfusion. Inguinal hernia repair was most common with 479 operations; 17 patients were treated inpatient of which 2 patients had routine postoperative hematocrit checks; (neither received transfusion). One patient with inguinal hernia surgery received transfusion without routine postoperative hematocrit monitoring.

Of 112 partial colon resections, 1 patient had a postoperative transfusion; and all but 3 received postoperative hematocrit monitoring. Nineteen patients undergoing partial colon resection had a clinical indication for postoperative hematocrit monitoring. None of the 5 patients with partial gastrectomy received a postoperative transfusion. Of 121 elective cholecystectomies, no patients had postoperative transfusion, whereas 34 had postoperative hematocrit monitoring; only 2 patients had a clinical reason for the hematocrit monitoring.

Of 430 elective inpatient operations, 12 received transfusions and 288 patients had ≥ 1 postoperative hematocrit test (67%). All hematocrit tests were requested by the attending surgeon, resident surgeon, or the surgical ICU team. Of the group that had postoperative hematocrit monitoring, there was an average of 4.4 postoperative hematocrit tests per patient (range, 1-44).

There were 12 transfusions for inpatients (2.8%), which is similar to the findings of a recent study of VA general surgery (2.3%).¹³ Five of the 12 patients received intraoperative transfusions while 7 were transfused within 72 hours postoperation. All but 1 patient receiving transfusion had EBL > 199 mL (range, 5-3000; mean, 950 mL; median, 500 mL) and/or signs or symptoms of anemia or other indications for measurement of the postoperative hematocrit. There were no statistically significant differences in patients’ age, sex, BMI, or race and ethnicity between groups receiving and not receiving transfusion (Table 1).

When comparing the transfusion vs the nontransfusion groups (after excluding those with clinical preoperative anemia) the risk factors for transfusion included: relatively low mean preoperative hematocrit (mean, 36.9% vs 42.7%, respectively; P = .003), low postoperative hematocrit (mean, 30.2% vs 37.1%, respectively; P < .001), high EBL (mean, 844 mL vs 109 mL, respectively; P = .005), large infusion of intraoperative fluids (mean, 4625 mL vs 2505 mL, respectively; P = .005), longer duration of operation (mean, 397 min vs 183 min, respectively; P < .001), and longer LOS (mean, 14.5 d vs 4.9 d, respectively; P < .001) (Table 2). Similarly, we found an increased risk for transfusion with high/intermediate cardiovascular risk (vs low), any wound not classified as clean, ICU stay, and postoperative symptoms of anemia.

We found no increased risk for transfusion with ethanol, tobacco, warfarin, or clopidogrel use; polycythemia; thrombocytopenia; preoperative INR; preoperative aPTT; preoperative albumin; Hemoglobin A_1c; or diabetes mellitus; or for operations performed for malignancy. Ten patients in the ICU received transfusion (5.8%) compared with 2 patients (0.8%) not admitted to the ICU.

Operations were deemed high risk when ≥ 2 of patients having that operation received transfusions within 72 hours of their operation. There were 15 abdominoperineal resections; 3 of these received transfusions (20%). There were 7 total abdominal colectomies; 3 of these received transfusions (43%). We therefore had 22 high-risk operations, 6 of which were transfused (27%).

Routine measurement of postoperative hematocrit levels after elective general surgery at NMVAHCS was not necessary. There were 12 transfusions for inpatients (2.8%), which is similar to the findings of a recent study of VA general surgery (2.3%).¹³ We found that routine postoperative hematocrit measurements to assess anemia had little or no effect on clinical decision-making or clinical outcomes.

According to our results, 88% of initial hematocrit tests after elective partial colectomies could have been eliminated; only 32 of 146 patients demonstrated a clinical reason for postoperative hematocrit testing. Similarly, 36 of 40 postcholecystectomy hematocrit tests (90%) could have been eliminated had the surgeons relied on clinical signs indicating possible postoperative anemia (none were transfused). Excluding patients with major intraoperative blood loss (> 300 mL), only 29 of 288 (10%) patients who had postoperative hematocrit tests had a clinical indication for a postoperative hematocrit test (ie, symptoms of anemia and/or active bleeding). One patient with inguinal hernia surgery who received transfusion was taking an anticoagulant and had a clinically indicated hematocrit test for a large hematoma that eventually required reoperation.

Our study found that routine hematocrit checks may actually increase the risk that a patient would receive an unnecessary transfusion. For instance, one elderly patient, after a right colectomy, had 6 hematocrit levels while on a heparin drip and received transfusion despite being asymptomatic. His lowest hematocrit level prior to transfusion was 23.7%. This patient had a total of 18 hematocrit tests. His EBL was 350 mL and his first postoperative HCT level was 33.1%. In another instance, a patient undergoing abdominoperineal resection had a transfusion on postoperative day 1, despite being hypertensive, with a hematocrit that ranged from 26% before transfusion to 31% after the transfusion. These 2 cases illustrate what has been shown in a recent study: A substantial number of patients with colorectal cancer receive unnecessary transfusions.¹⁴ On the other hand, one ileostomy closure patient had 33 hematocrit tests, yet his initial postoperative hematocrit was 37%, and he never received a transfusion. With low-risk surgeries, clinical judgment should dictate when a postoperative hematocrit level is needed. This strategy would have eliminated 206 unnecessary initial postoperative hematocrit tests (72%), could have decreased the number of unnecessary transfusions, and would have saved NMVAHCS about $1600 annually.

Abdominoperineal resections and total abdominal colectomies accounted for a high proportion of transfusions in our study. Inpatient elective operations can be risk stratified and have routine hematocrit tests ordered for patients at high risk. The probability of transfusion was greater in high-risk vs low-risk surgeries; 27% (6 of 22 patients) vs 2% (6 of 408 patients), respectively (P < .001). Since 14 of the 22 patients undergoing high-risk operation already had clinical reasons for a postoperative hematocrit test, we only need to add the remaining 8 patients with high-risk operations to the 74 who had a clinical reason for a hematocrit test and conclude that 82 of 430 patients (19%) had a clinical reason for a hematocrit test, either from signs or symptoms of blood loss or because they were in a high-risk group.

While our elective general surgery cases may not represent many general surgery programs in the US and VA health care systems, we can extrapolate cost savings using the same cost analyses outlined by Kohli and colleagues.¹ Assuming 1.9 million elective inpatient general surgeries per year in the United States with an average cost of $21 per CBC, the annual cost of universal postoperative hematocrit testing would be $40 million.^11,15 If postoperative hematocrit testing were 70% consistent with our findings, the annual cost for hematocrit tests on 51% of the inpatient general surgeries would be approximately $20.4 million. A reduction in routine hematocrit testing to 25% of all inpatient general surgeries (vs our finding that 19% were deemed necessary) results in an annual savings of $30 million. This conservative estimate could be even higher since there were 4.4 hematocrit tests per patient; therefore, we have about $132 million in savings.

Assuming 181,384 elective VA inpatient general surgeries each year, costing $7.14 per CBC (the NMVAHCS cost), the VA could save $1.3 million annually. If postoperative HCT testing were 70% consistent with our findings, the annual cost for hematocrit tests on 50.4% of inpatient general surgery operations would be about $653,000. A reduction in routine hematocrit testing to 25% of all inpatient general surgeries (vs our 19%) results in annual VA savings of $330,000. This conservative estimate could be even higher since there were on average 4.4 hematocrit levels per patient; therefore, we estimate that annual savings for the VA of about $1.45 million.

Limitations

The retrospective chart review nature of this study may have led to selection bias. Only a small number of patients received a transfusion, which may have skewed the data. This study population comes from a single VA medical center; this patient population may not be reflective of other VA medical centers or the US population as a whole. Given that NMVAHCS does not perform hepatic, esophageal, pancreas, or transplant operations, the potential savings to both the US and the VA may be overestimated, but this could be studied in the future by VA medical centers that perform more complex operations.

Conclusions

This study found that over a 4-year period routine postoperative hematocrit tests for patients undergoing elective general surgery at a VA medical center were not necessary. General surgeons routinely order various pre- and postoperative laboratory tests despite their limited utility. Reduction in unneeded routine tests could result in notable savings to the VA without compromising quality of care.

Only general surgery patients undergoing operations that carry a high risk for needing a blood transfusion should have a routine postoperative hematocrit testing. In our study population, the chance of an elective colectomy, cholecystectomy, or hernia patient needing a transfusion was rare. This strategy could eliminate a considerable number of unnecessary blood tests and would potentially yield significant savings.

It is common practice to routinely measure postoperative hematocrit levels at US Department of Veterans Affairs (VA) hospitals for a wide range of elective general surgeries. While hematocrit measurement is a low-cost test, the high frequency with which these tests are performed may drastically increase overall costs.

Numerous studies have suggested that physicians overuse laboratory testing.^1-10 Kohli and colleagues recommended that the routine practice of obtaining postoperative hematocrit tests following elective gynecologic surgery be abandoned.¹ A similar recommendation was made by Olus and colleagues after studying uneventful, unplanned cesarean sections and by Wu and colleagues after investigating routine laboratory tests post total hip arthroplasty.^2,3

To our knowledge, a study assessing routine postoperative hematocrit testing in elective general surgery has not yet been conducted. Many laboratory tests ordered in the perioperative period are not indicated, including complete blood count (CBC), electrolytes, and coagulation studies.⁴ Based on the results of these studies, we expected that the routine measurement of postoperative hematocrit levels after elective general surgeries at VA medical centers would not be cost effective. A PubMed search for articles published from 1990 to 2023 using the search terms “hematocrit,” “hemoglobin,” “general,” “surgery,” “routine,” and “cost” or “cost-effectiveness,” suggests that the clinical usefulness of postoperative hematocrit testing has not been well studied in the general surgery setting. The purpose of this study was to determine the clinical utility and associated cost of measuring routine postoperative hematocrit levels in order to generate a guide as to when the practice is warranted following common elective general surgery.

Although gynecologic textbooks may describe recommendations of routine hematocrit checking after elective gynecologic operations, one has difficulty finding the same recommendations in general surgery textbooks.¹ However, it is common practice for surgical residents and attending surgeons to routinely order hematocrit on postoperative day-1 to ensure that the operation did not result in unsuspected anemia that then would need treatment (either with fluids or a blood transfusion). Many other surgeons rely on clinical factors such as tachycardia, oliguria, or hypotension to trigger a hematocrit (and other laboratory) tests. Our hypothesis is that the latter group has chosen the most cost-effective and prudent practice. One problem with checking the hematocrit routinely, as with any other screening test, is what to do with an abnormal result, assuming an asymptomatic patient? If the postoperative hematocrit is lower than expected given the estimated blood loss (EBL), what is one to do?

Methods

This retrospective case-control study conducted at the New Mexico VA Health Care System (NMVAHCS) in Albuquerque compared data for patients who received transfusion within 72 hours of elective surgeries vs patients who did not. Patients who underwent elective general surgery from January 2011 through December 2014 were included. An elective general surgery was defined as surgery performed following an outpatient preoperative anesthesia evaluation ≥ 30 days prior to operation. Patients who underwent emergency operations, and those with baseline anemia (preoperative hematocrit < 30%), and those transfused > 72 hours after their operation were excluded. The NMVAHCSInstitutional Review Board approved this study (No. 15-H184).

A detailed record review was conducted to collect data on demographics and other preoperative risk factors, including age, sex, body mass index (BMI), race and ethnicity, cardiac and pulmonary comorbidities, tobacco use, alcohol intake, diabetes, American Society of Anesthesiologists Physical Status Classification, metabolic equivalent of task, hematologic conditions, and renal disease.

For each procedure, we recorded the type of elective general surgery performed, the diagnosis/indication, pre- and postoperative hemoglobin/hematocrit, intraoperative EBL, length of operation, surgical wound class, length of hospital stay (LOS), intensive care unit (ICU) status, number of hematocrit tests, cardiovascular risk of operation (defined by anesthesia assessment), presence or absence of malignancy, preoperative platelet count, albumin level, preoperative prothrombin time/activated partial thromboplastin time (aPTT), international normalized ratio (INR), hemoglobin A_1c, and incidence of transfusion. Signs and symptoms of anemia were recorded as present if the postoperative vital signs suggested low intravascular volume (pulse > 120 beats/minute, systolic blood pressure < 90 mm Hg, or vasoactive medication requirement [per anesthesia postoperative note]) or if the patient reported or exhibited symptoms of dizziness or fatigue or evidence of clinically apparent bleeding (ie, hematoma formation). Laboratory charges for hematocrit tests and CBC at the NMAVAHCS were used to assess cost.¹¹

To stratify the transfusion risk, patients were distributed among 3 groups based on the following criteria: discharged home the same day as surgery; admitted but did not have postoperative hematocrit testing; and admitted and had postoperative hematocrit testing. We also stratified operations into low or high risk based on the risk for postoperative transfusion (Figure). Recognizing that the American College of Chest Physicians guidelines for perioperative management of antithrombotic therapy places bowel resection in a high-risk category, we designated a surgery as high risk when ≥ 2 patients in the transfusion group had that type of surgery over the 4 years of the study.¹² Otherwise, the operations were deemed low risk.

Statistical Analysis

Numeric analysis used t tests and Binary and categorical variables used Fisher exact tests. P value ≤ .05 was considered statistically significant. SAS software was used for all statistical analyses.

From 2011 through 2014, 1531 patients had elective general surgery at NMVAHCS. Twenty-two patients with preoperative anemia (hematocrit < 30%) and 1 patient who received a transfusion > 72 hours after the operation were excluded. Most elective operations (70%, n = 1075) were performed on an outpatient basis; none involved transfusion. Inguinal hernia repair was most common with 479 operations; 17 patients were treated inpatient of which 2 patients had routine postoperative hematocrit checks; (neither received transfusion). One patient with inguinal hernia surgery received transfusion without routine postoperative hematocrit monitoring.

Of 112 partial colon resections, 1 patient had a postoperative transfusion; and all but 3 received postoperative hematocrit monitoring. Nineteen patients undergoing partial colon resection had a clinical indication for postoperative hematocrit monitoring. None of the 5 patients with partial gastrectomy received a postoperative transfusion. Of 121 elective cholecystectomies, no patients had postoperative transfusion, whereas 34 had postoperative hematocrit monitoring; only 2 patients had a clinical reason for the hematocrit monitoring.

Of 430 elective inpatient operations, 12 received transfusions and 288 patients had ≥ 1 postoperative hematocrit test (67%). All hematocrit tests were requested by the attending surgeon, resident surgeon, or the surgical ICU team. Of the group that had postoperative hematocrit monitoring, there was an average of 4.4 postoperative hematocrit tests per patient (range, 1-44).

There were 12 transfusions for inpatients (2.8%), which is similar to the findings of a recent study of VA general surgery (2.3%).¹³ Five of the 12 patients received intraoperative transfusions while 7 were transfused within 72 hours postoperation. All but 1 patient receiving transfusion had EBL > 199 mL (range, 5-3000; mean, 950 mL; median, 500 mL) and/or signs or symptoms of anemia or other indications for measurement of the postoperative hematocrit. There were no statistically significant differences in patients’ age, sex, BMI, or race and ethnicity between groups receiving and not receiving transfusion (Table 1).

When comparing the transfusion vs the nontransfusion groups (after excluding those with clinical preoperative anemia) the risk factors for transfusion included: relatively low mean preoperative hematocrit (mean, 36.9% vs 42.7%, respectively; P = .003), low postoperative hematocrit (mean, 30.2% vs 37.1%, respectively; P < .001), high EBL (mean, 844 mL vs 109 mL, respectively; P = .005), large infusion of intraoperative fluids (mean, 4625 mL vs 2505 mL, respectively; P = .005), longer duration of operation (mean, 397 min vs 183 min, respectively; P < .001), and longer LOS (mean, 14.5 d vs 4.9 d, respectively; P < .001) (Table 2). Similarly, we found an increased risk for transfusion with high/intermediate cardiovascular risk (vs low), any wound not classified as clean, ICU stay, and postoperative symptoms of anemia.

We found no increased risk for transfusion with ethanol, tobacco, warfarin, or clopidogrel use; polycythemia; thrombocytopenia; preoperative INR; preoperative aPTT; preoperative albumin; Hemoglobin A_1c; or diabetes mellitus; or for operations performed for malignancy. Ten patients in the ICU received transfusion (5.8%) compared with 2 patients (0.8%) not admitted to the ICU.

Operations were deemed high risk when ≥ 2 of patients having that operation received transfusions within 72 hours of their operation. There were 15 abdominoperineal resections; 3 of these received transfusions (20%). There were 7 total abdominal colectomies; 3 of these received transfusions (43%). We therefore had 22 high-risk operations, 6 of which were transfused (27%).

Routine measurement of postoperative hematocrit levels after elective general surgery at NMVAHCS was not necessary. There were 12 transfusions for inpatients (2.8%), which is similar to the findings of a recent study of VA general surgery (2.3%).¹³ We found that routine postoperative hematocrit measurements to assess anemia had little or no effect on clinical decision-making or clinical outcomes.

According to our results, 88% of initial hematocrit tests after elective partial colectomies could have been eliminated; only 32 of 146 patients demonstrated a clinical reason for postoperative hematocrit testing. Similarly, 36 of 40 postcholecystectomy hematocrit tests (90%) could have been eliminated had the surgeons relied on clinical signs indicating possible postoperative anemia (none were transfused). Excluding patients with major intraoperative blood loss (> 300 mL), only 29 of 288 (10%) patients who had postoperative hematocrit tests had a clinical indication for a postoperative hematocrit test (ie, symptoms of anemia and/or active bleeding). One patient with inguinal hernia surgery who received transfusion was taking an anticoagulant and had a clinically indicated hematocrit test for a large hematoma that eventually required reoperation.

Our study found that routine hematocrit checks may actually increase the risk that a patient would receive an unnecessary transfusion. For instance, one elderly patient, after a right colectomy, had 6 hematocrit levels while on a heparin drip and received transfusion despite being asymptomatic. His lowest hematocrit level prior to transfusion was 23.7%. This patient had a total of 18 hematocrit tests. His EBL was 350 mL and his first postoperative HCT level was 33.1%. In another instance, a patient undergoing abdominoperineal resection had a transfusion on postoperative day 1, despite being hypertensive, with a hematocrit that ranged from 26% before transfusion to 31% after the transfusion. These 2 cases illustrate what has been shown in a recent study: A substantial number of patients with colorectal cancer receive unnecessary transfusions.¹⁴ On the other hand, one ileostomy closure patient had 33 hematocrit tests, yet his initial postoperative hematocrit was 37%, and he never received a transfusion. With low-risk surgeries, clinical judgment should dictate when a postoperative hematocrit level is needed. This strategy would have eliminated 206 unnecessary initial postoperative hematocrit tests (72%), could have decreased the number of unnecessary transfusions, and would have saved NMVAHCS about $1600 annually.

Abdominoperineal resections and total abdominal colectomies accounted for a high proportion of transfusions in our study. Inpatient elective operations can be risk stratified and have routine hematocrit tests ordered for patients at high risk. The probability of transfusion was greater in high-risk vs low-risk surgeries; 27% (6 of 22 patients) vs 2% (6 of 408 patients), respectively (P < .001). Since 14 of the 22 patients undergoing high-risk operation already had clinical reasons for a postoperative hematocrit test, we only need to add the remaining 8 patients with high-risk operations to the 74 who had a clinical reason for a hematocrit test and conclude that 82 of 430 patients (19%) had a clinical reason for a hematocrit test, either from signs or symptoms of blood loss or because they were in a high-risk group.

While our elective general surgery cases may not represent many general surgery programs in the US and VA health care systems, we can extrapolate cost savings using the same cost analyses outlined by Kohli and colleagues.¹ Assuming 1.9 million elective inpatient general surgeries per year in the United States with an average cost of $21 per CBC, the annual cost of universal postoperative hematocrit testing would be $40 million.^11,15 If postoperative hematocrit testing were 70% consistent with our findings, the annual cost for hematocrit tests on 51% of the inpatient general surgeries would be approximately $20.4 million. A reduction in routine hematocrit testing to 25% of all inpatient general surgeries (vs our finding that 19% were deemed necessary) results in an annual savings of $30 million. This conservative estimate could be even higher since there were 4.4 hematocrit tests per patient; therefore, we have about $132 million in savings.

Assuming 181,384 elective VA inpatient general surgeries each year, costing $7.14 per CBC (the NMVAHCS cost), the VA could save $1.3 million annually. If postoperative HCT testing were 70% consistent with our findings, the annual cost for hematocrit tests on 50.4% of inpatient general surgery operations would be about $653,000. A reduction in routine hematocrit testing to 25% of all inpatient general surgeries (vs our 19%) results in annual VA savings of $330,000. This conservative estimate could be even higher since there were on average 4.4 hematocrit levels per patient; therefore, we estimate that annual savings for the VA of about $1.45 million.

Limitations

The retrospective chart review nature of this study may have led to selection bias. Only a small number of patients received a transfusion, which may have skewed the data. This study population comes from a single VA medical center; this patient population may not be reflective of other VA medical centers or the US population as a whole. Given that NMVAHCS does not perform hepatic, esophageal, pancreas, or transplant operations, the potential savings to both the US and the VA may be overestimated, but this could be studied in the future by VA medical centers that perform more complex operations.

Conclusions

This study found that over a 4-year period routine postoperative hematocrit tests for patients undergoing elective general surgery at a VA medical center were not necessary. General surgeons routinely order various pre- and postoperative laboratory tests despite their limited utility. Reduction in unneeded routine tests could result in notable savings to the VA without compromising quality of care.

Only general surgery patients undergoing operations that carry a high risk for needing a blood transfusion should have a routine postoperative hematocrit testing. In our study population, the chance of an elective colectomy, cholecystectomy, or hernia patient needing a transfusion was rare. This strategy could eliminate a considerable number of unnecessary blood tests and would potentially yield significant savings.

It is common practice to routinely measure postoperative hematocrit levels at US Department of Veterans Affairs (VA) hospitals for a wide range of elective general surgeries. While hematocrit measurement is a low-cost test, the high frequency with which these tests are performed may drastically increase overall costs.

Numerous studies have suggested that physicians overuse laboratory testing.^1-10 Kohli and colleagues recommended that the routine practice of obtaining postoperative hematocrit tests following elective gynecologic surgery be abandoned.¹ A similar recommendation was made by Olus and colleagues after studying uneventful, unplanned cesarean sections and by Wu and colleagues after investigating routine laboratory tests post total hip arthroplasty.^2,3

To our knowledge, a study assessing routine postoperative hematocrit testing in elective general surgery has not yet been conducted. Many laboratory tests ordered in the perioperative period are not indicated, including complete blood count (CBC), electrolytes, and coagulation studies.⁴ Based on the results of these studies, we expected that the routine measurement of postoperative hematocrit levels after elective general surgeries at VA medical centers would not be cost effective. A PubMed search for articles published from 1990 to 2023 using the search terms “hematocrit,” “hemoglobin,” “general,” “surgery,” “routine,” and “cost” or “cost-effectiveness,” suggests that the clinical usefulness of postoperative hematocrit testing has not been well studied in the general surgery setting. The purpose of this study was to determine the clinical utility and associated cost of measuring routine postoperative hematocrit levels in order to generate a guide as to when the practice is warranted following common elective general surgery.

Although gynecologic textbooks may describe recommendations of routine hematocrit checking after elective gynecologic operations, one has difficulty finding the same recommendations in general surgery textbooks.¹ However, it is common practice for surgical residents and attending surgeons to routinely order hematocrit on postoperative day-1 to ensure that the operation did not result in unsuspected anemia that then would need treatment (either with fluids or a blood transfusion). Many other surgeons rely on clinical factors such as tachycardia, oliguria, or hypotension to trigger a hematocrit (and other laboratory) tests. Our hypothesis is that the latter group has chosen the most cost-effective and prudent practice. One problem with checking the hematocrit routinely, as with any other screening test, is what to do with an abnormal result, assuming an asymptomatic patient? If the postoperative hematocrit is lower than expected given the estimated blood loss (EBL), what is one to do?

Methods

This retrospective case-control study conducted at the New Mexico VA Health Care System (NMVAHCS) in Albuquerque compared data for patients who received transfusion within 72 hours of elective surgeries vs patients who did not. Patients who underwent elective general surgery from January 2011 through December 2014 were included. An elective general surgery was defined as surgery performed following an outpatient preoperative anesthesia evaluation ≥ 30 days prior to operation. Patients who underwent emergency operations, and those with baseline anemia (preoperative hematocrit < 30%), and those transfused > 72 hours after their operation were excluded. The NMVAHCSInstitutional Review Board approved this study (No. 15-H184).

A detailed record review was conducted to collect data on demographics and other preoperative risk factors, including age, sex, body mass index (BMI), race and ethnicity, cardiac and pulmonary comorbidities, tobacco use, alcohol intake, diabetes, American Society of Anesthesiologists Physical Status Classification, metabolic equivalent of task, hematologic conditions, and renal disease.

For each procedure, we recorded the type of elective general surgery performed, the diagnosis/indication, pre- and postoperative hemoglobin/hematocrit, intraoperative EBL, length of operation, surgical wound class, length of hospital stay (LOS), intensive care unit (ICU) status, number of hematocrit tests, cardiovascular risk of operation (defined by anesthesia assessment), presence or absence of malignancy, preoperative platelet count, albumin level, preoperative prothrombin time/activated partial thromboplastin time (aPTT), international normalized ratio (INR), hemoglobin A_1c, and incidence of transfusion. Signs and symptoms of anemia were recorded as present if the postoperative vital signs suggested low intravascular volume (pulse > 120 beats/minute, systolic blood pressure < 90 mm Hg, or vasoactive medication requirement [per anesthesia postoperative note]) or if the patient reported or exhibited symptoms of dizziness or fatigue or evidence of clinically apparent bleeding (ie, hematoma formation). Laboratory charges for hematocrit tests and CBC at the NMAVAHCS were used to assess cost.¹¹

To stratify the transfusion risk, patients were distributed among 3 groups based on the following criteria: discharged home the same day as surgery; admitted but did not have postoperative hematocrit testing; and admitted and had postoperative hematocrit testing. We also stratified operations into low or high risk based on the risk for postoperative transfusion (Figure). Recognizing that the American College of Chest Physicians guidelines for perioperative management of antithrombotic therapy places bowel resection in a high-risk category, we designated a surgery as high risk when ≥ 2 patients in the transfusion group had that type of surgery over the 4 years of the study.¹² Otherwise, the operations were deemed low risk.

Statistical Analysis

Numeric analysis used t tests and Binary and categorical variables used Fisher exact tests. P value ≤ .05 was considered statistically significant. SAS software was used for all statistical analyses.

From 2011 through 2014, 1531 patients had elective general surgery at NMVAHCS. Twenty-two patients with preoperative anemia (hematocrit < 30%) and 1 patient who received a transfusion > 72 hours after the operation were excluded. Most elective operations (70%, n = 1075) were performed on an outpatient basis; none involved transfusion. Inguinal hernia repair was most common with 479 operations; 17 patients were treated inpatient of which 2 patients had routine postoperative hematocrit checks; (neither received transfusion). One patient with inguinal hernia surgery received transfusion without routine postoperative hematocrit monitoring.

Of 112 partial colon resections, 1 patient had a postoperative transfusion; and all but 3 received postoperative hematocrit monitoring. Nineteen patients undergoing partial colon resection had a clinical indication for postoperative hematocrit monitoring. None of the 5 patients with partial gastrectomy received a postoperative transfusion. Of 121 elective cholecystectomies, no patients had postoperative transfusion, whereas 34 had postoperative hematocrit monitoring; only 2 patients had a clinical reason for the hematocrit monitoring.

Of 430 elective inpatient operations, 12 received transfusions and 288 patients had ≥ 1 postoperative hematocrit test (67%). All hematocrit tests were requested by the attending surgeon, resident surgeon, or the surgical ICU team. Of the group that had postoperative hematocrit monitoring, there was an average of 4.4 postoperative hematocrit tests per patient (range, 1-44).

There were 12 transfusions for inpatients (2.8%), which is similar to the findings of a recent study of VA general surgery (2.3%).¹³ Five of the 12 patients received intraoperative transfusions while 7 were transfused within 72 hours postoperation. All but 1 patient receiving transfusion had EBL > 199 mL (range, 5-3000; mean, 950 mL; median, 500 mL) and/or signs or symptoms of anemia or other indications for measurement of the postoperative hematocrit. There were no statistically significant differences in patients’ age, sex, BMI, or race and ethnicity between groups receiving and not receiving transfusion (Table 1).

When comparing the transfusion vs the nontransfusion groups (after excluding those with clinical preoperative anemia) the risk factors for transfusion included: relatively low mean preoperative hematocrit (mean, 36.9% vs 42.7%, respectively; P = .003), low postoperative hematocrit (mean, 30.2% vs 37.1%, respectively; P < .001), high EBL (mean, 844 mL vs 109 mL, respectively; P = .005), large infusion of intraoperative fluids (mean, 4625 mL vs 2505 mL, respectively; P = .005), longer duration of operation (mean, 397 min vs 183 min, respectively; P < .001), and longer LOS (mean, 14.5 d vs 4.9 d, respectively; P < .001) (Table 2). Similarly, we found an increased risk for transfusion with high/intermediate cardiovascular risk (vs low), any wound not classified as clean, ICU stay, and postoperative symptoms of anemia.

We found no increased risk for transfusion with ethanol, tobacco, warfarin, or clopidogrel use; polycythemia; thrombocytopenia; preoperative INR; preoperative aPTT; preoperative albumin; Hemoglobin A_1c; or diabetes mellitus; or for operations performed for malignancy. Ten patients in the ICU received transfusion (5.8%) compared with 2 patients (0.8%) not admitted to the ICU.

Operations were deemed high risk when ≥ 2 of patients having that operation received transfusions within 72 hours of their operation. There were 15 abdominoperineal resections; 3 of these received transfusions (20%). There were 7 total abdominal colectomies; 3 of these received transfusions (43%). We therefore had 22 high-risk operations, 6 of which were transfused (27%).

Routine measurement of postoperative hematocrit levels after elective general surgery at NMVAHCS was not necessary. There were 12 transfusions for inpatients (2.8%), which is similar to the findings of a recent study of VA general surgery (2.3%).¹³ We found that routine postoperative hematocrit measurements to assess anemia had little or no effect on clinical decision-making or clinical outcomes.

According to our results, 88% of initial hematocrit tests after elective partial colectomies could have been eliminated; only 32 of 146 patients demonstrated a clinical reason for postoperative hematocrit testing. Similarly, 36 of 40 postcholecystectomy hematocrit tests (90%) could have been eliminated had the surgeons relied on clinical signs indicating possible postoperative anemia (none were transfused). Excluding patients with major intraoperative blood loss (> 300 mL), only 29 of 288 (10%) patients who had postoperative hematocrit tests had a clinical indication for a postoperative hematocrit test (ie, symptoms of anemia and/or active bleeding). One patient with inguinal hernia surgery who received transfusion was taking an anticoagulant and had a clinically indicated hematocrit test for a large hematoma that eventually required reoperation.

Our study found that routine hematocrit checks may actually increase the risk that a patient would receive an unnecessary transfusion. For instance, one elderly patient, after a right colectomy, had 6 hematocrit levels while on a heparin drip and received transfusion despite being asymptomatic. His lowest hematocrit level prior to transfusion was 23.7%. This patient had a total of 18 hematocrit tests. His EBL was 350 mL and his first postoperative HCT level was 33.1%. In another instance, a patient undergoing abdominoperineal resection had a transfusion on postoperative day 1, despite being hypertensive, with a hematocrit that ranged from 26% before transfusion to 31% after the transfusion. These 2 cases illustrate what has been shown in a recent study: A substantial number of patients with colorectal cancer receive unnecessary transfusions.¹⁴ On the other hand, one ileostomy closure patient had 33 hematocrit tests, yet his initial postoperative hematocrit was 37%, and he never received a transfusion. With low-risk surgeries, clinical judgment should dictate when a postoperative hematocrit level is needed. This strategy would have eliminated 206 unnecessary initial postoperative hematocrit tests (72%), could have decreased the number of unnecessary transfusions, and would have saved NMVAHCS about $1600 annually.

Abdominoperineal resections and total abdominal colectomies accounted for a high proportion of transfusions in our study. Inpatient elective operations can be risk stratified and have routine hematocrit tests ordered for patients at high risk. The probability of transfusion was greater in high-risk vs low-risk surgeries; 27% (6 of 22 patients) vs 2% (6 of 408 patients), respectively (P < .001). Since 14 of the 22 patients undergoing high-risk operation already had clinical reasons for a postoperative hematocrit test, we only need to add the remaining 8 patients with high-risk operations to the 74 who had a clinical reason for a hematocrit test and conclude that 82 of 430 patients (19%) had a clinical reason for a hematocrit test, either from signs or symptoms of blood loss or because they were in a high-risk group.

While our elective general surgery cases may not represent many general surgery programs in the US and VA health care systems, we can extrapolate cost savings using the same cost analyses outlined by Kohli and colleagues.¹ Assuming 1.9 million elective inpatient general surgeries per year in the United States with an average cost of $21 per CBC, the annual cost of universal postoperative hematocrit testing would be $40 million.^11,15 If postoperative hematocrit testing were 70% consistent with our findings, the annual cost for hematocrit tests on 51% of the inpatient general surgeries would be approximately $20.4 million. A reduction in routine hematocrit testing to 25% of all inpatient general surgeries (vs our finding that 19% were deemed necessary) results in an annual savings of $30 million. This conservative estimate could be even higher since there were 4.4 hematocrit tests per patient; therefore, we have about $132 million in savings.

Assuming 181,384 elective VA inpatient general surgeries each year, costing $7.14 per CBC (the NMVAHCS cost), the VA could save $1.3 million annually. If postoperative HCT testing were 70% consistent with our findings, the annual cost for hematocrit tests on 50.4% of inpatient general surgery operations would be about $653,000. A reduction in routine hematocrit testing to 25% of all inpatient general surgeries (vs our 19%) results in annual VA savings of $330,000. This conservative estimate could be even higher since there were on average 4.4 hematocrit levels per patient; therefore, we estimate that annual savings for the VA of about $1.45 million.

Limitations

The retrospective chart review nature of this study may have led to selection bias. Only a small number of patients received a transfusion, which may have skewed the data. This study population comes from a single VA medical center; this patient population may not be reflective of other VA medical centers or the US population as a whole. Given that NMVAHCS does not perform hepatic, esophageal, pancreas, or transplant operations, the potential savings to both the US and the VA may be overestimated, but this could be studied in the future by VA medical centers that perform more complex operations.

Conclusions

This study found that over a 4-year period routine postoperative hematocrit tests for patients undergoing elective general surgery at a VA medical center were not necessary. General surgeons routinely order various pre- and postoperative laboratory tests despite their limited utility. Reduction in unneeded routine tests could result in notable savings to the VA without compromising quality of care.

Only general surgery patients undergoing operations that carry a high risk for needing a blood transfusion should have a routine postoperative hematocrit testing. In our study population, the chance of an elective colectomy, cholecystectomy, or hernia patient needing a transfusion was rare. This strategy could eliminate a considerable number of unnecessary blood tests and would potentially yield significant savings.

The US Department of Veterans Affairs (VA) has partnered with academic medical centers and programs since 1946 to provide clinical training for physician residents. Ranking second in federal graduate medical education (GME) funding to the Centers for Medicare and Medicaid Services (CMS), the $850 million VA GME budget annually reimburses > 250 GME-sponsoring institutions (affiliates) of 8000 GME programs for the clinical training of 49,000 individual residents rotating through > 11,000 full-time equivalent (FTE) positions.¹ The VA also distributes $1.6 billion to VA facilities to offset the costs of conducting health professions education (HPE) (eg, facility infrastructure, salary support for VA instructors and preceptors, education office administration, and instructional equipment).² The VA financial and educational contributions account for payment of 11% of resident positions nationally and allow academic medical centers to be less reliant on CMS GME funding.^3,4 The VA contributions also provide opportunities for GME expansion,^1,5,6 educational innovations,^5,7 interprofessional and team-based care,^8,9 and quality and safety training.^10,11 The Table provides a comparison of CMS and VA GME reimbursability based on activity.

GME financing is complex, particularly the formulaic approach used by CMS, the details of which are often obscured in federal regulations. Due to this complexity and the $16 billion CMS GME budget, academic publications have focused on CMS GME financing while not fully explaining the VA GME policies and processes.^4,12-14 By comparison, the VA GME financing model is relatively straightforward and governed by different statues and VA regulations, yet sharing some of the same principles as CMS regulations. Given the challenges in CMS reimbursement to fully support the cost of resident education, as well as the educational opportunities at the VA, the VA designs its reimbursement model to assure that affiliates receive appropriate payments.^4,12,15 To ensure the continued success of VA GME partnerships, knowledge of VA GME financing has become increasingly important for designated institutional officers (DIOs) and residency program directors, particularly in light of recent investigations into oversight of the VA’s reimbursement to academic affiliates.^16-18 This report describes VA GME reimbursement and, where applicable, VA and CMS reimbursement policies are compared to highlight similarities, differences, and common principles.

VA AUTHORITY

While the VA’s primary mission is “to provide a complete hospital medical service for the medical care and treatment of veterans,”early VA leaders recognized the importance of affiliating with the nation’s academic institutions.¹⁹ In 1946, the VA Policy Memorandum Number 2 established a partnership between the VA and the academic medical community.²⁰ Additional legislation authorized specific agreements with academic affiliates for the central administration of salary and benefits for residents rotating at VA facilities. This process, known as disbursement, is an alternative payroll mechanism whereby the VA reimburses the academic affiliate for resident salary and benefits and the affiliate acts as the disbursing agent, issuing paychecks to residents.^21,22

Resident FUNDING

By policy, with rare exceptions, the VA does not sponsor residency programs due to the challenges of providing an appropriate patient mix of age, sex, and medical conditions to meet accreditation standards.⁴ Nearly all VA reimbursements are for residents in affiliate-sponsored programs, while just 1% pays for residents in legacy, VA-sponsored residency programs at 2 VA facilities. The VA budget for resident (including fellows) salary and benefits is managed by the VA Office of Academic Affiliations (OAA), the national VA office responsible for oversight, policy, and funding of VA HPE programs.

Resident Salaries and Benefits

VA funding of resident salary and benefits are analogous with CMS direct GME (DGME), which is designed to cover resident salary and benefits costs.^4,14,23 CMS DGME payments depend on a hospital’s volume of CMS inpatients and are based on a statutory formula, which uses the hospital’s resident FTE positions, the per-resident amount, and Medicare’s share of inpatient beds (Medicare patient load) to determine payments.¹² The per-resident amount is set by statute, varies geographically, and is calculated by dividing the hospital’s allowable costs of GME (percentage of CMS inpatient days) divided by the number of residents.^12,24

By comparison, the VA GME payment reimburses for each FTE based on the salary and benefits rate set by the academic affiliate. Reimbursement is calculated based on resident time spent at the VA multiplied by a daily salary rate. The daily salary rate is determined by dividing the resident’s total compensation (salary and benefits) by the number of calendar days in an academic year. Resident time spent at the VA facility is determined by obtaining rotation schedules provided by the academic affiliate and verifying resident clinical and educational activity during scheduled rotations.

Indirect Medical Education Funding

In addition to resident salary and benefits, funds to offset the cost of conducting HPE are provided to VA facilities. These funds are intended to improve and maintain necessary infrastructure for all HPE programs not just GME, including education office administration needs, teaching costs (ie, a portion of VA preceptors salary), and instructional equipment.

The Veterans Equitable Resource Allocation (VERA) is a national budgeting process for VA medical facilities that funds facility operational needs such as staff salary and benefits, infrastructure, and equipment.² The education portion of the VERA, the VERA Education Support Component (VESC), is not managed by the OAA, but rather is distributed through the VERA model to the general budget of VA facilities hosting HPE (Figure). VESC funding in the VA budget is based on labor mapping of physician time spent in education; other labor mapping categories include clinical care, research, and administration. VA facility VESC funding is calculated based on the number of paid health profession trainees (HPTs) from all professions, apportioned according to the number of FTEs for physician residents and VA-paid HPTs in other disciplines. In fiscal year 2024, VA facilities received $115,812 for each physician resident FTE position and $84,906 for each VA-paid, non-GME FTE position.

The VESC is like CMS's indirect GME funding, termed Indirect Medical Education (IME), an additional payment for each Medicare patient discharged reflecting teaching hospitals’ higher patient care costs relative to nonteaching hospitals. Described elsewhere, IME is calculated using a resident-to-bed ratio and a multiplier, which is set by statute.^4,25 While IME can be used for reimbursement for some resident clinical and educational activities(eg, research), VA VESC funds cannot be used for such activities and are part of the general facility budget and appropriated per the discretion of the medical facility director.

ESTABLISHING GME PARTNERSHIPS

An affiliation agreement establishes the administrative and legal requirements for educational relationships with academic affiliates and includes standards for conducting HPE, responsibilities for accreditation standards, program leadership, faculty, resources, supervision, academic policies, and procedures. The VA uses standardized affiliation agreement templates that have been vetted with accrediting bodies and the VA Office of General Counsel.

A disbursement agreement authorizes the VA to reimburse affiliates for resident salary and benefits for VA clinical and educational activities. The disbursement agreement details the fiscal arrangements (eg, payment in advance vs arrears, salary, and benefit rates, leave) for the reimbursement payments. Veterans Health Administration (VHA) Directive 1400.05 provides the policy and procedures for calculating reimbursement for HPT educational activities.²⁶

The VA facility designated education officer (DEO) oversees all HPE programs and coordinates the affiliation and disbursement agreement processes.²⁷ The DEO, affiliate DIO, residency program director, and VA residency site director determine the physician resident FTE positions assigned to a VA facility based on educational objectives and availability of educational resources at the VA facility, such as patient care opportunities, faculty supervisors, space, and equipment. The VA facility requests for resident FTE positions are submitted to the OAA by the facility DEO.

Once GME FTE positions are approved by the OAA, VA facilities work with their academic affiliate to submit the physician resident salary and benefit rate. Affiliate DIOs attest to the accuracy of the salary rate schedule and the local DEO submits the budget request to the OAA. Upon approval, the funds are transferred to the VA facility each fiscal year, which begins October 1. DEOs report quarterly to the OAA both budget needs and excesses based on variations in the approved FTEs due to additional VA rotations, physician resident attrition, or reassignment.

Resident Position Allocation

VA GME financing provides flexibility through periodic needs assessments and expansion initiatives. In August and December, DEOs collaborate with an academic affiliate to submit reports to the OAA confirming their projected GME needs for the next academic year. Additional positions requests are reviewed by the OAA; funding depends on budget and the educational justification. The OAA periodically issues GME expansion requests for proposal, which typically arise from legislation to address specific VA workforce needs. The VA facility DEO and affiliate GME leaders collaborate to apply for additional positions. For example, a VA GME expansion under the Veterans Access, Choice, and Accountability Act of 2014 added 1500 GME positions in 8 years for critically needed specialties and in rural and underserved areas.⁵ The Maintaining Internal Systems and Strengthening Outside Networks (MISSION) Act of 2018 authorized a pilot program for VA to fund residents at non-VA facilities with priority for Indian Health Services, Tribes and Tribal Organizations, Federally Qualified Health Centers, and US Department of Defense facilities to provide access to veterans in underserved areas.⁶

The VA GME financing system has flexibility to meet local needs for additional resident positions and to address broader VA workforce gaps through targeted expansion. Generally, CMS does not fund positions to address workforce needs, place residents in specific geographic areas, or require the training of certain types of residents.⁴ However, the Consolidated Appropriations Act of 2021 has provided the opportunity to address rural workforce needs.²⁸

Reimbursement

The VA provides reimbursement for clinical and educational activities performed in VA facilities for the benefit of veterans as well as research, didactics, meetings and conferences, annual and sick leave, and orientation. The VA also may provide reimbursement for educational activities that occur off VA grounds (eg, the VA proportional share of a residency program’s didactic sessions). The VA does not reimburse for affiliate clinical duties or administrative costs, although a national policy allows VA facilities to reimburse affiliates for some GME overhead costs.²⁹

CMS similarly reimburses for residency training time spent in patient care activities as well as orientation activities, didactics, leave, and, in some cases, research.^4,30,31 CMS makes payments to hospitals, which may include sponsoring institutions and Medicare-eligible participating training sites.^4,30,31 For both the VA and CMS, residents may not be counted twice for reimbursement by 2 federal agencies; in other words, a resident may not count for > 1 FTE.^4,30-32

GME Oversight

VA GME funding came under significant scrutiny. At a 2016 House Veterans Affairs Committee hearing, Representative Phil Roe, MD (R-Tennessee), noted that no process existed at many VA facilities for “determining trainee presence” and that many VA medical centers had “difficulty tracking resident rotations”¹⁶ A VA Office of the Inspector General investigation recommended that the VA implement policies and procedures to improve oversight to “ensure residents are fully participating in educational activities” and that the VA is “paying the correct amount” to the affiliate.¹⁷ A 2020 General Accountability Office report outlined unclear policy guidance, incomplete tracking of resident activities, and improper fiscal processes for reimbursement and reconciliation of affiliate invoices.¹⁸

In response, the OAA created an oversight and compliance unit, revised VHA Directive 1400.05 (the policy for disbursement), and improved resident tracking procedures.²⁶ The standard operating procedure that accompanied VHA Directive 1400.05 provides detailed information for the DEO and VA facility staff for tracking resident clinical and educational activities. FTE counts are essential to both VA and CMS for accurate reimbursement. The eAppendix and the Table provide a guide to reimbursable activities in the VA for the calculation of reimbursement, with a comparison to CMS.^33,34 The OAA in cooperation with other VA staff and officers periodically conducts audits to assess compliance with disbursement policy and affiliate reimbursement accuracy.

In the VA, resident activities are captured on the VA Educational Activity Record, a standardized spreadsheet to track activities and calculate reimbursement. Each VA facility hosting resident physicians manually records resident activity by the half-day. This process is labor intensive, involving both VA and affiliate staff to accurately reconcile payments. To address the workload demands, the OAA is developing an online tool that will automate aspects of the tracking process. Also, to ensure adequate staffing, the OAA is in the process of implementing an office optimization project, providing standardized position descriptions, an organizational chart, and staffing levels for DEO offices in VA facilities.

This report describes the key policies and principles of VA GME financing, highlighting the essential similarities and differences between VA and CMS. Neither the VA nor CMS regulations allow for reimbursement for > 1 FTE position per resident, a principle that underpins the assignment of resident rotations and federal funding for GME and are similar with respect to reimbursement for patient care activities, didactics, research, orientation, and scholarly activity. While reimbursable activities in the VA require physical presence and care of veteran patients, CMS also limits reimbursement to resident activities in the hospital and approved other settings if the hospital is paying for resident salary and benefits in these settings. The VA provides some flexibility for offsite activities including didactics and, in specific circumstances, remote care of veteran patients (eg, teleradiology).

The VA and CMS use different GME financing models. For example, the CMS calculations for resident FTEs are complex, whereas VA calculations reimburse the salary and benefits as set by the academic affiliate. The VA process accounts for local variation in salary rates, whereas the per-resident amount set by CMS varies regionally and does not fully account for differences in the cost of living.²⁴ Because all patients in VA facilities are veterans, VA calculations for reimbursement do not involve ratios of beds like the CMS calculations to determine a proportional share of reimbursement. The VA GME expansion tends to be more directed to VA health workforce needs than CMS, specifying the types of programs and geographic locations to address these needs.

The VA regularly reevaluates how affiliates are reimbursed for VA resident activity, balancing compliance with VA policies and the workload for VA and its affiliates. The VA obtains input from key stakeholders including DEOs, DIOs, and professional organizations such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education.^35,36

Looking ahead, the VA is developing an online tool to improve the accuracy of affiliate reimbursement. The VA will also implement a standardized staffing model, organizational structure, and position descriptions for DEO offices. These initiatives will help reduce the burden of tracking and verifying resident activity and continue to support the 77-year partnership between VA and its affiliated institutions.

The US Department of Veterans Affairs (VA) has partnered with academic medical centers and programs since 1946 to provide clinical training for physician residents. Ranking second in federal graduate medical education (GME) funding to the Centers for Medicare and Medicaid Services (CMS), the $850 million VA GME budget annually reimburses > 250 GME-sponsoring institutions (affiliates) of 8000 GME programs for the clinical training of 49,000 individual residents rotating through > 11,000 full-time equivalent (FTE) positions.¹ The VA also distributes $1.6 billion to VA facilities to offset the costs of conducting health professions education (HPE) (eg, facility infrastructure, salary support for VA instructors and preceptors, education office administration, and instructional equipment).² The VA financial and educational contributions account for payment of 11% of resident positions nationally and allow academic medical centers to be less reliant on CMS GME funding.^3,4 The VA contributions also provide opportunities for GME expansion,^1,5,6 educational innovations,^5,7 interprofessional and team-based care,^8,9 and quality and safety training.^10,11 The Table provides a comparison of CMS and VA GME reimbursability based on activity.

GME financing is complex, particularly the formulaic approach used by CMS, the details of which are often obscured in federal regulations. Due to this complexity and the $16 billion CMS GME budget, academic publications have focused on CMS GME financing while not fully explaining the VA GME policies and processes.^4,12-14 By comparison, the VA GME financing model is relatively straightforward and governed by different statues and VA regulations, yet sharing some of the same principles as CMS regulations. Given the challenges in CMS reimbursement to fully support the cost of resident education, as well as the educational opportunities at the VA, the VA designs its reimbursement model to assure that affiliates receive appropriate payments.^4,12,15 To ensure the continued success of VA GME partnerships, knowledge of VA GME financing has become increasingly important for designated institutional officers (DIOs) and residency program directors, particularly in light of recent investigations into oversight of the VA’s reimbursement to academic affiliates.^16-18 This report describes VA GME reimbursement and, where applicable, VA and CMS reimbursement policies are compared to highlight similarities, differences, and common principles.

VA AUTHORITY

While the VA’s primary mission is “to provide a complete hospital medical service for the medical care and treatment of veterans,”early VA leaders recognized the importance of affiliating with the nation’s academic institutions.¹⁹ In 1946, the VA Policy Memorandum Number 2 established a partnership between the VA and the academic medical community.²⁰ Additional legislation authorized specific agreements with academic affiliates for the central administration of salary and benefits for residents rotating at VA facilities. This process, known as disbursement, is an alternative payroll mechanism whereby the VA reimburses the academic affiliate for resident salary and benefits and the affiliate acts as the disbursing agent, issuing paychecks to residents.^21,22

Resident FUNDING

By policy, with rare exceptions, the VA does not sponsor residency programs due to the challenges of providing an appropriate patient mix of age, sex, and medical conditions to meet accreditation standards.⁴ Nearly all VA reimbursements are for residents in affiliate-sponsored programs, while just 1% pays for residents in legacy, VA-sponsored residency programs at 2 VA facilities. The VA budget for resident (including fellows) salary and benefits is managed by the VA Office of Academic Affiliations (OAA), the national VA office responsible for oversight, policy, and funding of VA HPE programs.

Resident Salaries and Benefits

VA funding of resident salary and benefits are analogous with CMS direct GME (DGME), which is designed to cover resident salary and benefits costs.^4,14,23 CMS DGME payments depend on a hospital’s volume of CMS inpatients and are based on a statutory formula, which uses the hospital’s resident FTE positions, the per-resident amount, and Medicare’s share of inpatient beds (Medicare patient load) to determine payments.¹² The per-resident amount is set by statute, varies geographically, and is calculated by dividing the hospital’s allowable costs of GME (percentage of CMS inpatient days) divided by the number of residents.^12,24

By comparison, the VA GME payment reimburses for each FTE based on the salary and benefits rate set by the academic affiliate. Reimbursement is calculated based on resident time spent at the VA multiplied by a daily salary rate. The daily salary rate is determined by dividing the resident’s total compensation (salary and benefits) by the number of calendar days in an academic year. Resident time spent at the VA facility is determined by obtaining rotation schedules provided by the academic affiliate and verifying resident clinical and educational activity during scheduled rotations.

Indirect Medical Education Funding

In addition to resident salary and benefits, funds to offset the cost of conducting HPE are provided to VA facilities. These funds are intended to improve and maintain necessary infrastructure for all HPE programs not just GME, including education office administration needs, teaching costs (ie, a portion of VA preceptors salary), and instructional equipment.

The Veterans Equitable Resource Allocation (VERA) is a national budgeting process for VA medical facilities that funds facility operational needs such as staff salary and benefits, infrastructure, and equipment.² The education portion of the VERA, the VERA Education Support Component (VESC), is not managed by the OAA, but rather is distributed through the VERA model to the general budget of VA facilities hosting HPE (Figure). VESC funding in the VA budget is based on labor mapping of physician time spent in education; other labor mapping categories include clinical care, research, and administration. VA facility VESC funding is calculated based on the number of paid health profession trainees (HPTs) from all professions, apportioned according to the number of FTEs for physician residents and VA-paid HPTs in other disciplines. In fiscal year 2024, VA facilities received $115,812 for each physician resident FTE position and $84,906 for each VA-paid, non-GME FTE position.

The VESC is like CMS's indirect GME funding, termed Indirect Medical Education (IME), an additional payment for each Medicare patient discharged reflecting teaching hospitals’ higher patient care costs relative to nonteaching hospitals. Described elsewhere, IME is calculated using a resident-to-bed ratio and a multiplier, which is set by statute.^4,25 While IME can be used for reimbursement for some resident clinical and educational activities(eg, research), VA VESC funds cannot be used for such activities and are part of the general facility budget and appropriated per the discretion of the medical facility director.

ESTABLISHING GME PARTNERSHIPS

An affiliation agreement establishes the administrative and legal requirements for educational relationships with academic affiliates and includes standards for conducting HPE, responsibilities for accreditation standards, program leadership, faculty, resources, supervision, academic policies, and procedures. The VA uses standardized affiliation agreement templates that have been vetted with accrediting bodies and the VA Office of General Counsel.

A disbursement agreement authorizes the VA to reimburse affiliates for resident salary and benefits for VA clinical and educational activities. The disbursement agreement details the fiscal arrangements (eg, payment in advance vs arrears, salary, and benefit rates, leave) for the reimbursement payments. Veterans Health Administration (VHA) Directive 1400.05 provides the policy and procedures for calculating reimbursement for HPT educational activities.²⁶

The VA facility designated education officer (DEO) oversees all HPE programs and coordinates the affiliation and disbursement agreement processes.²⁷ The DEO, affiliate DIO, residency program director, and VA residency site director determine the physician resident FTE positions assigned to a VA facility based on educational objectives and availability of educational resources at the VA facility, such as patient care opportunities, faculty supervisors, space, and equipment. The VA facility requests for resident FTE positions are submitted to the OAA by the facility DEO.

Once GME FTE positions are approved by the OAA, VA facilities work with their academic affiliate to submit the physician resident salary and benefit rate. Affiliate DIOs attest to the accuracy of the salary rate schedule and the local DEO submits the budget request to the OAA. Upon approval, the funds are transferred to the VA facility each fiscal year, which begins October 1. DEOs report quarterly to the OAA both budget needs and excesses based on variations in the approved FTEs due to additional VA rotations, physician resident attrition, or reassignment.

Resident Position Allocation

VA GME financing provides flexibility through periodic needs assessments and expansion initiatives. In August and December, DEOs collaborate with an academic affiliate to submit reports to the OAA confirming their projected GME needs for the next academic year. Additional positions requests are reviewed by the OAA; funding depends on budget and the educational justification. The OAA periodically issues GME expansion requests for proposal, which typically arise from legislation to address specific VA workforce needs. The VA facility DEO and affiliate GME leaders collaborate to apply for additional positions. For example, a VA GME expansion under the Veterans Access, Choice, and Accountability Act of 2014 added 1500 GME positions in 8 years for critically needed specialties and in rural and underserved areas.⁵ The Maintaining Internal Systems and Strengthening Outside Networks (MISSION) Act of 2018 authorized a pilot program for VA to fund residents at non-VA facilities with priority for Indian Health Services, Tribes and Tribal Organizations, Federally Qualified Health Centers, and US Department of Defense facilities to provide access to veterans in underserved areas.⁶

The VA GME financing system has flexibility to meet local needs for additional resident positions and to address broader VA workforce gaps through targeted expansion. Generally, CMS does not fund positions to address workforce needs, place residents in specific geographic areas, or require the training of certain types of residents.⁴ However, the Consolidated Appropriations Act of 2021 has provided the opportunity to address rural workforce needs.²⁸

Reimbursement

The VA provides reimbursement for clinical and educational activities performed in VA facilities for the benefit of veterans as well as research, didactics, meetings and conferences, annual and sick leave, and orientation. The VA also may provide reimbursement for educational activities that occur off VA grounds (eg, the VA proportional share of a residency program’s didactic sessions). The VA does not reimburse for affiliate clinical duties or administrative costs, although a national policy allows VA facilities to reimburse affiliates for some GME overhead costs.²⁹

CMS similarly reimburses for residency training time spent in patient care activities as well as orientation activities, didactics, leave, and, in some cases, research.^4,30,31 CMS makes payments to hospitals, which may include sponsoring institutions and Medicare-eligible participating training sites.^4,30,31 For both the VA and CMS, residents may not be counted twice for reimbursement by 2 federal agencies; in other words, a resident may not count for > 1 FTE.^4,30-32

GME Oversight

VA GME funding came under significant scrutiny. At a 2016 House Veterans Affairs Committee hearing, Representative Phil Roe, MD (R-Tennessee), noted that no process existed at many VA facilities for “determining trainee presence” and that many VA medical centers had “difficulty tracking resident rotations”¹⁶ A VA Office of the Inspector General investigation recommended that the VA implement policies and procedures to improve oversight to “ensure residents are fully participating in educational activities” and that the VA is “paying the correct amount” to the affiliate.¹⁷ A 2020 General Accountability Office report outlined unclear policy guidance, incomplete tracking of resident activities, and improper fiscal processes for reimbursement and reconciliation of affiliate invoices.¹⁸

In response, the OAA created an oversight and compliance unit, revised VHA Directive 1400.05 (the policy for disbursement), and improved resident tracking procedures.²⁶ The standard operating procedure that accompanied VHA Directive 1400.05 provides detailed information for the DEO and VA facility staff for tracking resident clinical and educational activities. FTE counts are essential to both VA and CMS for accurate reimbursement. The eAppendix and the Table provide a guide to reimbursable activities in the VA for the calculation of reimbursement, with a comparison to CMS.^33,34 The OAA in cooperation with other VA staff and officers periodically conducts audits to assess compliance with disbursement policy and affiliate reimbursement accuracy.

In the VA, resident activities are captured on the VA Educational Activity Record, a standardized spreadsheet to track activities and calculate reimbursement. Each VA facility hosting resident physicians manually records resident activity by the half-day. This process is labor intensive, involving both VA and affiliate staff to accurately reconcile payments. To address the workload demands, the OAA is developing an online tool that will automate aspects of the tracking process. Also, to ensure adequate staffing, the OAA is in the process of implementing an office optimization project, providing standardized position descriptions, an organizational chart, and staffing levels for DEO offices in VA facilities.

This report describes the key policies and principles of VA GME financing, highlighting the essential similarities and differences between VA and CMS. Neither the VA nor CMS regulations allow for reimbursement for > 1 FTE position per resident, a principle that underpins the assignment of resident rotations and federal funding for GME and are similar with respect to reimbursement for patient care activities, didactics, research, orientation, and scholarly activity. While reimbursable activities in the VA require physical presence and care of veteran patients, CMS also limits reimbursement to resident activities in the hospital and approved other settings if the hospital is paying for resident salary and benefits in these settings. The VA provides some flexibility for offsite activities including didactics and, in specific circumstances, remote care of veteran patients (eg, teleradiology).

The VA and CMS use different GME financing models. For example, the CMS calculations for resident FTEs are complex, whereas VA calculations reimburse the salary and benefits as set by the academic affiliate. The VA process accounts for local variation in salary rates, whereas the per-resident amount set by CMS varies regionally and does not fully account for differences in the cost of living.²⁴ Because all patients in VA facilities are veterans, VA calculations for reimbursement do not involve ratios of beds like the CMS calculations to determine a proportional share of reimbursement. The VA GME expansion tends to be more directed to VA health workforce needs than CMS, specifying the types of programs and geographic locations to address these needs.

The VA regularly reevaluates how affiliates are reimbursed for VA resident activity, balancing compliance with VA policies and the workload for VA and its affiliates. The VA obtains input from key stakeholders including DEOs, DIOs, and professional organizations such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education.^35,36

Looking ahead, the VA is developing an online tool to improve the accuracy of affiliate reimbursement. The VA will also implement a standardized staffing model, organizational structure, and position descriptions for DEO offices. These initiatives will help reduce the burden of tracking and verifying resident activity and continue to support the 77-year partnership between VA and its affiliated institutions.

The US Department of Veterans Affairs (VA) has partnered with academic medical centers and programs since 1946 to provide clinical training for physician residents. Ranking second in federal graduate medical education (GME) funding to the Centers for Medicare and Medicaid Services (CMS), the $850 million VA GME budget annually reimburses > 250 GME-sponsoring institutions (affiliates) of 8000 GME programs for the clinical training of 49,000 individual residents rotating through > 11,000 full-time equivalent (FTE) positions.¹ The VA also distributes $1.6 billion to VA facilities to offset the costs of conducting health professions education (HPE) (eg, facility infrastructure, salary support for VA instructors and preceptors, education office administration, and instructional equipment).² The VA financial and educational contributions account for payment of 11% of resident positions nationally and allow academic medical centers to be less reliant on CMS GME funding.^3,4 The VA contributions also provide opportunities for GME expansion,^1,5,6 educational innovations,^5,7 interprofessional and team-based care,^8,9 and quality and safety training.^10,11 The Table provides a comparison of CMS and VA GME reimbursability based on activity.

GME financing is complex, particularly the formulaic approach used by CMS, the details of which are often obscured in federal regulations. Due to this complexity and the $16 billion CMS GME budget, academic publications have focused on CMS GME financing while not fully explaining the VA GME policies and processes.^4,12-14 By comparison, the VA GME financing model is relatively straightforward and governed by different statues and VA regulations, yet sharing some of the same principles as CMS regulations. Given the challenges in CMS reimbursement to fully support the cost of resident education, as well as the educational opportunities at the VA, the VA designs its reimbursement model to assure that affiliates receive appropriate payments.^4,12,15 To ensure the continued success of VA GME partnerships, knowledge of VA GME financing has become increasingly important for designated institutional officers (DIOs) and residency program directors, particularly in light of recent investigations into oversight of the VA’s reimbursement to academic affiliates.^16-18 This report describes VA GME reimbursement and, where applicable, VA and CMS reimbursement policies are compared to highlight similarities, differences, and common principles.

VA AUTHORITY

While the VA’s primary mission is “to provide a complete hospital medical service for the medical care and treatment of veterans,”early VA leaders recognized the importance of affiliating with the nation’s academic institutions.¹⁹ In 1946, the VA Policy Memorandum Number 2 established a partnership between the VA and the academic medical community.²⁰ Additional legislation authorized specific agreements with academic affiliates for the central administration of salary and benefits for residents rotating at VA facilities. This process, known as disbursement, is an alternative payroll mechanism whereby the VA reimburses the academic affiliate for resident salary and benefits and the affiliate acts as the disbursing agent, issuing paychecks to residents.^21,22

Resident FUNDING

By policy, with rare exceptions, the VA does not sponsor residency programs due to the challenges of providing an appropriate patient mix of age, sex, and medical conditions to meet accreditation standards.⁴ Nearly all VA reimbursements are for residents in affiliate-sponsored programs, while just 1% pays for residents in legacy, VA-sponsored residency programs at 2 VA facilities. The VA budget for resident (including fellows) salary and benefits is managed by the VA Office of Academic Affiliations (OAA), the national VA office responsible for oversight, policy, and funding of VA HPE programs.

Resident Salaries and Benefits

VA funding of resident salary and benefits are analogous with CMS direct GME (DGME), which is designed to cover resident salary and benefits costs.^4,14,23 CMS DGME payments depend on a hospital’s volume of CMS inpatients and are based on a statutory formula, which uses the hospital’s resident FTE positions, the per-resident amount, and Medicare’s share of inpatient beds (Medicare patient load) to determine payments.¹² The per-resident amount is set by statute, varies geographically, and is calculated by dividing the hospital’s allowable costs of GME (percentage of CMS inpatient days) divided by the number of residents.^12,24

By comparison, the VA GME payment reimburses for each FTE based on the salary and benefits rate set by the academic affiliate. Reimbursement is calculated based on resident time spent at the VA multiplied by a daily salary rate. The daily salary rate is determined by dividing the resident’s total compensation (salary and benefits) by the number of calendar days in an academic year. Resident time spent at the VA facility is determined by obtaining rotation schedules provided by the academic affiliate and verifying resident clinical and educational activity during scheduled rotations.

Indirect Medical Education Funding

In addition to resident salary and benefits, funds to offset the cost of conducting HPE are provided to VA facilities. These funds are intended to improve and maintain necessary infrastructure for all HPE programs not just GME, including education office administration needs, teaching costs (ie, a portion of VA preceptors salary), and instructional equipment.

The Veterans Equitable Resource Allocation (VERA) is a national budgeting process for VA medical facilities that funds facility operational needs such as staff salary and benefits, infrastructure, and equipment.² The education portion of the VERA, the VERA Education Support Component (VESC), is not managed by the OAA, but rather is distributed through the VERA model to the general budget of VA facilities hosting HPE (Figure). VESC funding in the VA budget is based on labor mapping of physician time spent in education; other labor mapping categories include clinical care, research, and administration. VA facility VESC funding is calculated based on the number of paid health profession trainees (HPTs) from all professions, apportioned according to the number of FTEs for physician residents and VA-paid HPTs in other disciplines. In fiscal year 2024, VA facilities received $115,812 for each physician resident FTE position and $84,906 for each VA-paid, non-GME FTE position.

The VESC is like CMS's indirect GME funding, termed Indirect Medical Education (IME), an additional payment for each Medicare patient discharged reflecting teaching hospitals’ higher patient care costs relative to nonteaching hospitals. Described elsewhere, IME is calculated using a resident-to-bed ratio and a multiplier, which is set by statute.^4,25 While IME can be used for reimbursement for some resident clinical and educational activities(eg, research), VA VESC funds cannot be used for such activities and are part of the general facility budget and appropriated per the discretion of the medical facility director.

ESTABLISHING GME PARTNERSHIPS

An affiliation agreement establishes the administrative and legal requirements for educational relationships with academic affiliates and includes standards for conducting HPE, responsibilities for accreditation standards, program leadership, faculty, resources, supervision, academic policies, and procedures. The VA uses standardized affiliation agreement templates that have been vetted with accrediting bodies and the VA Office of General Counsel.

A disbursement agreement authorizes the VA to reimburse affiliates for resident salary and benefits for VA clinical and educational activities. The disbursement agreement details the fiscal arrangements (eg, payment in advance vs arrears, salary, and benefit rates, leave) for the reimbursement payments. Veterans Health Administration (VHA) Directive 1400.05 provides the policy and procedures for calculating reimbursement for HPT educational activities.²⁶

The VA facility designated education officer (DEO) oversees all HPE programs and coordinates the affiliation and disbursement agreement processes.²⁷ The DEO, affiliate DIO, residency program director, and VA residency site director determine the physician resident FTE positions assigned to a VA facility based on educational objectives and availability of educational resources at the VA facility, such as patient care opportunities, faculty supervisors, space, and equipment. The VA facility requests for resident FTE positions are submitted to the OAA by the facility DEO.

Once GME FTE positions are approved by the OAA, VA facilities work with their academic affiliate to submit the physician resident salary and benefit rate. Affiliate DIOs attest to the accuracy of the salary rate schedule and the local DEO submits the budget request to the OAA. Upon approval, the funds are transferred to the VA facility each fiscal year, which begins October 1. DEOs report quarterly to the OAA both budget needs and excesses based on variations in the approved FTEs due to additional VA rotations, physician resident attrition, or reassignment.

Resident Position Allocation

VA GME financing provides flexibility through periodic needs assessments and expansion initiatives. In August and December, DEOs collaborate with an academic affiliate to submit reports to the OAA confirming their projected GME needs for the next academic year. Additional positions requests are reviewed by the OAA; funding depends on budget and the educational justification. The OAA periodically issues GME expansion requests for proposal, which typically arise from legislation to address specific VA workforce needs. The VA facility DEO and affiliate GME leaders collaborate to apply for additional positions. For example, a VA GME expansion under the Veterans Access, Choice, and Accountability Act of 2014 added 1500 GME positions in 8 years for critically needed specialties and in rural and underserved areas.⁵ The Maintaining Internal Systems and Strengthening Outside Networks (MISSION) Act of 2018 authorized a pilot program for VA to fund residents at non-VA facilities with priority for Indian Health Services, Tribes and Tribal Organizations, Federally Qualified Health Centers, and US Department of Defense facilities to provide access to veterans in underserved areas.⁶

The VA GME financing system has flexibility to meet local needs for additional resident positions and to address broader VA workforce gaps through targeted expansion. Generally, CMS does not fund positions to address workforce needs, place residents in specific geographic areas, or require the training of certain types of residents.⁴ However, the Consolidated Appropriations Act of 2021 has provided the opportunity to address rural workforce needs.²⁸

Reimbursement

The VA provides reimbursement for clinical and educational activities performed in VA facilities for the benefit of veterans as well as research, didactics, meetings and conferences, annual and sick leave, and orientation. The VA also may provide reimbursement for educational activities that occur off VA grounds (eg, the VA proportional share of a residency program’s didactic sessions). The VA does not reimburse for affiliate clinical duties or administrative costs, although a national policy allows VA facilities to reimburse affiliates for some GME overhead costs.²⁹

CMS similarly reimburses for residency training time spent in patient care activities as well as orientation activities, didactics, leave, and, in some cases, research.^4,30,31 CMS makes payments to hospitals, which may include sponsoring institutions and Medicare-eligible participating training sites.^4,30,31 For both the VA and CMS, residents may not be counted twice for reimbursement by 2 federal agencies; in other words, a resident may not count for > 1 FTE.^4,30-32

GME Oversight

VA GME funding came under significant scrutiny. At a 2016 House Veterans Affairs Committee hearing, Representative Phil Roe, MD (R-Tennessee), noted that no process existed at many VA facilities for “determining trainee presence” and that many VA medical centers had “difficulty tracking resident rotations”¹⁶ A VA Office of the Inspector General investigation recommended that the VA implement policies and procedures to improve oversight to “ensure residents are fully participating in educational activities” and that the VA is “paying the correct amount” to the affiliate.¹⁷ A 2020 General Accountability Office report outlined unclear policy guidance, incomplete tracking of resident activities, and improper fiscal processes for reimbursement and reconciliation of affiliate invoices.¹⁸

In response, the OAA created an oversight and compliance unit, revised VHA Directive 1400.05 (the policy for disbursement), and improved resident tracking procedures.²⁶ The standard operating procedure that accompanied VHA Directive 1400.05 provides detailed information for the DEO and VA facility staff for tracking resident clinical and educational activities. FTE counts are essential to both VA and CMS for accurate reimbursement. The eAppendix and the Table provide a guide to reimbursable activities in the VA for the calculation of reimbursement, with a comparison to CMS.^33,34 The OAA in cooperation with other VA staff and officers periodically conducts audits to assess compliance with disbursement policy and affiliate reimbursement accuracy.

In the VA, resident activities are captured on the VA Educational Activity Record, a standardized spreadsheet to track activities and calculate reimbursement. Each VA facility hosting resident physicians manually records resident activity by the half-day. This process is labor intensive, involving both VA and affiliate staff to accurately reconcile payments. To address the workload demands, the OAA is developing an online tool that will automate aspects of the tracking process. Also, to ensure adequate staffing, the OAA is in the process of implementing an office optimization project, providing standardized position descriptions, an organizational chart, and staffing levels for DEO offices in VA facilities.

This report describes the key policies and principles of VA GME financing, highlighting the essential similarities and differences between VA and CMS. Neither the VA nor CMS regulations allow for reimbursement for > 1 FTE position per resident, a principle that underpins the assignment of resident rotations and federal funding for GME and are similar with respect to reimbursement for patient care activities, didactics, research, orientation, and scholarly activity. While reimbursable activities in the VA require physical presence and care of veteran patients, CMS also limits reimbursement to resident activities in the hospital and approved other settings if the hospital is paying for resident salary and benefits in these settings. The VA provides some flexibility for offsite activities including didactics and, in specific circumstances, remote care of veteran patients (eg, teleradiology).

The VA and CMS use different GME financing models. For example, the CMS calculations for resident FTEs are complex, whereas VA calculations reimburse the salary and benefits as set by the academic affiliate. The VA process accounts for local variation in salary rates, whereas the per-resident amount set by CMS varies regionally and does not fully account for differences in the cost of living.²⁴ Because all patients in VA facilities are veterans, VA calculations for reimbursement do not involve ratios of beds like the CMS calculations to determine a proportional share of reimbursement. The VA GME expansion tends to be more directed to VA health workforce needs than CMS, specifying the types of programs and geographic locations to address these needs.

The VA regularly reevaluates how affiliates are reimbursed for VA resident activity, balancing compliance with VA policies and the workload for VA and its affiliates. The VA obtains input from key stakeholders including DEOs, DIOs, and professional organizations such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education.^35,36

Looking ahead, the VA is developing an online tool to improve the accuracy of affiliate reimbursement. The VA will also implement a standardized staffing model, organizational structure, and position descriptions for DEO offices. These initiatives will help reduce the burden of tracking and verifying resident activity and continue to support the 77-year partnership between VA and its affiliated institutions.