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The Department of Veterans Affairs (VA) both delivers health care in its own facilities and, increasingly, purchases care for veterans in the community. Policy makers, administrators, health care providers, and veterans frequently face decisions about which services should be delivered versus purchased by the VA. Comparisons of quality across settings are essential if veterans are to receive care that is consistently accessible, patient centered, effective, and safe. We compared risk-adjusted major postoperative complication rates for total knee arthroplasties that were delivered in VA facilities versus purchased from community providers. Overall, adjusted complication rates were significantly lower for arthroplasties delivered by the VA compared with those that were purchased. However, hospital-level comparisons revealed five locations where VA-purchased care outperformed VA-delivered care. As the amount of VA-purchased care continues to increase under the Veterans Access, Choice, and Accountability Act of 2014 and the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, these results support VA monitoring of overall and local comparative hospital performance to improve the quality of the care that the VA delivers while ensuring optimal outcomes in VA-purchased care.

Background: Hospitals face ongoing pressure to reduce patient safety events. However, given resource constraints, hospitals must prioritize their safety improvements. There is limited literature on how hospitals select their safety priorities., Purpose: The aim of this research was to describe and compare the approaches used by Veterans Health Administration (VA) hospitals to select their safety priorities., Methodology: Semistructured telephone interviews with key informants (n = 16) were used to collect data on safety priorities in four VA hospitals from May to December 2016. We conducted a directed content analysis of the interview notes using an organizational learning perspective. We coded for descriptive data on the approaches (e.g., set of cues, circumstances, and activities) used to select safety priorities, a priori organizational learning capabilities (learning processes, learning environment, and learning-oriented leadership), and emergent domains. For cross-site comparisons, we examined the coded data for patterns., Results: All hospitals used multiple approaches to select their safety priorities; these approaches used varied across hospitals. Although no single approach was reported as particularly influential, all hospitals used approaches that addressed system level or national requirements (i.e., externally required activities). Additional approaches used by hospitals (e.g., responding to staff concerns of patient safety issues, conducting a multidisciplinary team investigation) were less connected to externally required activities and demonstrated organizational learning capabilities in learning processes (e.g., performance monitoring), learning environment (e.g., staff's psychological safety), and learning-oriented leadership (e.g., establishing a nonpunitive culture)., Practice Implications: Leaders should examine the approaches used to select safety priorities and the role of organizational learning in these selection approaches. Exclusively relying on approaches focused on externally required activities may fail to identify safety priorities that are locally relevant but not established as significant at the system or national levels. Organizational learning may promote hospitals' use of varied approaches to guide their selection of safety priorities and thereby benefit hospital safety improvement efforts.

Timely access to outpatient care was a primary driver behind the Department of Veterans Affairs' (VA's) increased purchase of community-based care under the Veterans Access, Choice, and Accountability Act of 2014, known as the Choice Act. To compare veterans' experiences in VA-delivered and community-based outpatient care after implementation of the act, we assessed veterans' scores on four dimensions of experience-access, communication, coordination, and provider rating-for outpatient specialty, primary, and mental health care received during 2016-17. Patient experiences were better for VA than for community care in all respects except access. For specialty care, access scores were better in the community; for primary and mental health care, access scores were similar in the two settings. Although all specialty care scores and the primary care coordination score improved over time, the gaps between settings did not shrink. As purchased care further expands under the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, which replaced the Choice Act in 2019, monitoring of meaningful differences between settings should continue, with the results used to inform both VA purchasing decisions and patients' care choices.