Documents reveal secret star ratings on VA quality
Lowest-scoring centers concentrated in Texas, Tenn.; highest are in Northeast, Midwest
The poorest-performing VA medical centers are clustered in Texas and Tennessee while some of the best are in Massachusetts and New York, according to internal VA ratings obtained by USA TODAY.
The Department of Veterans Affairs has for years assigned star ratings for each of its medical centers based on the quality of care and service they provide, but the agency has repeatedly refused to make them public, saying they are meant for internal use only.
The ratings show VA hospitals in Dallas, El Paso, Nashville, Memphis and Murfreesboro all received one star out of five for performance as of June 30, the most recent period available.
Many of the highest-rated facilities are in the Northeast and the upper Midwest, including in South Dakota and Minnesota. Those medical centers scored five out of five stars.
The VA determines the ratings for 146 of its medical centers each quarter and bases them on dozens of factors, including death and infection rates, instances of avoidable complications and wait times.
USA TODAY Network is publishing the ratings in full for the first time, so members of the public — including patients and their families — can see how their VA medical centers stack up against others across the country.
Some lower-ranking medical centers have remained poor performers despite high-profile crises and years of attention and resources from Washington.
The Phoenix VA was a onestar medical center in 2014 when news broke that veterans died awaiting care while schedulers kept secret wait lists masking how long veterans waited for
appointments. The revelations triggered a national scandal, hearings on Capitol Hill and the replacement of the VA secretary.
Phoenix remained a one-star facility in the most recent ratings.
VA Undersecretary for Health David Shulkin cautioned against using the ratings as a “ranking tool” and said they are considered an “internal improvement tool.”
“It is essentially a system within VA to see who’s improving, who’s getting worse, so we can identify both,” he said.
The documents obtained by USA TODAY list star ratings for every facility for the fourth quarter of 2015. The VA subsequently agreed to provide a list of oneand five-star facilities for the quarter that ended June 30, the most recent ratings available, but declined to identify those with two to four stars.
Shulkin said he was apprehensive about any ratings becoming public. “My concern is that veterans are going to see that their hospital is a ‘one’ in our star system, assume that’s bad quality and veterans that need care are not going to get care,” he said. “And they’re going to stay away from hospitals, and that’s going to hurt people.”
Without the star ratings, the public — including patients, members of Congress and others outside the agency who could hold it accountable — has no way of knowing whether VA medical centers are improving or declining, except to plow through a dizzying array of hundreds of spreadsheets on the agency’s website. “The data’s there, but you’d have to be an expert to get through it,” Shulkin conceded.
He said 120 of the 146 medical centers that the VA rates on the star scale have shown improvement since he began overseeing the Veterans Health Administration in July 2015.
He said all of the one-star facilities have shown improvement except for the VA medical center in Detroit, which has declined.
Pamela Reeves, director of the Dingell VA Center in Detroit, said officials are “working closely with our performance improvement teams in the development and oversight of action plans to address the opportunities identified by the … data.” In Phoenix, VA officials appointed a new director in October and are pumping millions into the effort to improve the medical center.
Shulkin said that nationwide, medical centers where performance declined get extra scrutiny and help from national VA officials. If they don’t show sufficient progress, hospital management could be replaced.
That happened in Wilmington, Del., where the VA ousted the medical center’s director in October after months of deteriorating quality. Wilmington was among several hospitals placed on a “high-risk” watch list this year because of declining performance, according to the internal VA documents. Also on the list were hospitals in Tomah, Wis., and Oklahoma City.
The Tomah VA Medical Center made national headlines nearly two years ago after a veteran died when he was prescribed a fatal cocktail of narcotics. A USA TODAY investigation published last December revealed gaping lapses in care at the Oklahoma City VA.
Rep. Jeff Miller, R-Fla., chairman of the House Veterans Af- fairs Committee, said the VA should immediately release all the ratings and quality data and do so on a continuing basis. He said the status quo — “in which VA officials often attempt to downplay and sometimes mislead the public about serious problems until it’s too late” — is unacceptable.
“The secrecy with which VA treats these quality ratings is alarming,” Miller told USA TODAY. “Veterans seeking care at VA hospitals deserve to know exactly what they are walking into. Additionally, Congress, taxpayers and other stakeholders need to have a quick and efficient means of comparing the performance of various VA medical centers in order to identify facilities in need of improvement.”
Alex Howard, senior analyst at the Sunlight Foundation, a nonpartisan transparency advocate in Washington, said there’s “no rationale that I see for withholding that from veterans, much less the general public.”
“I would think the only entity that wouldn’t want that data pub- lic would be the facilities themselves, which is not sufficient cause,” he said.
The VA rarely releases nationwide averages showing overall improvements or declines in agency performance measures, so it can be hard to determine exactly what’s changed since the scandal in 2014, when President Obama tapped Bob McDonald, a former Procter & Gamble CEO, to take over as secretary and overhaul the agency.
The documents obtained by USA TODAY detail those averages, and when asked about them, VA officials agreed to provide updated statistics. Overall, the data show improvements in some areas and declines in others.
On average, veterans die at lower rates and contract fewer staph and urinary tract infections from catheters in VA medical centers since 2014. Veterans don’t stay as long in VA hospitals and they are readmitted within 30 days at lower rates.
At the same time, veterans experience higher rates of preventable complications during hospital stays, on average, than they did in 2014. Those on ventilators suffered more problems, such as catching pneumonia, and the rate of turnover for nurses increased.
The VA has seen increases in the percentage of veterans who have to wait longer than 30 days for appointments when they are new patients. Overall, more than 500,000 veterans waited longer than 30 days to be seen as of Nov. 15. More than 125,000 of them waited longer than two months, and 46,000 waited more than six months.
Shulkin said half of the 500,000 appointments are for more minor needs such as dental, hearing, vision and diet consultations. “I can sleep at night,” he said. “The ones I worry about are the ones who can’t wait or shouldn’t be waiting, so that’s where our entire focus of our system is right now. I don’t care about you waiting for eyeglasses. I mean that’s poor customer service, I understand, but I do care if you have a lung nodule. I mean, that matters.”
Shulkin said the number of veterans waiting longer than a month for urgent care has decreased from 57,000 to 600 since he took over last year.
He said he works to ensure that veterans get same-day care — if they have urgent needs — at VA medical facilities across the country by the end of the year.
“If you have an urgent care problem, your wait should be zero,” he said.