title: The evolution of changes in primary care delivery underlying the Veterans Health Administration's quality transformation.
abstract: OBJECTIVE
  Suffering from waning demand, poor quality, and reform efforts enabling veterans to "vote with their feet" and leave, the Veterans Health Administration (VA) health care system transformed itself through a series of substantive changes. We examined the evolution of primary care changes underlying VA's transformation.
  
  
  METHODS
  We used 3 national organizational surveys from 1993, 1996, and 1999 that measured primary care organization, staffing, management, and resource sufficiency to evaluate changes in VA primary care delivery.
  
  
  RESULTS
  Only rudimentary primary care was in place in 1993. Primary care enrollment grew from 38% in 1993 to 45% in 1996, and to 95% in 1999 as VA adopted team structures and increased the assignment of patients to individual providers. Specialists initially staffed primary care until generalist physicians and nonphysican providers increased. Primary care-based quality improvement and authority expanded, and resource sufficiency (e.g., computers, space) grew. Provider notification of admissions and emergency department, urgent-care visit, and sub-specialty-consult results increased nearly 5 times.
  
  
  CONCLUSIONS
  Although VA's quality transformation had many underlying causes, investment in primary care development may have served as an essential substrate for many VA quality gains.
authors.affiliation: Veterans Health Administration Greater Los Angeles Health Services Research and Development (HSR&D) Center of Excellence, Los Angeles, Calif 91343, USA. elizabeth.yano@va.gov
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Yano
authors.forename: Barbara F
authors.initials: BF
authors.lastname: Simon
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Lanto
authors.forename: Lisa V
authors.initials: LV
authors.lastname: Rubenstein
mesh_terms: D018166:Health Care Reform; D019538:Health Care Surveys; D006801:Humans; D017146:Models, Organizational; D009936:Organizational Innovation; D010561:Personnel Staffing and Scheduling / Q000639:trends; D011216:Practice Management, Medical / Q000639:trends; D011320:Primary Health Care / Q000458:organization & administration / Q000639:trends*; D016730:Program Development; D011787:Quality of Health Care / Q000458:organization & administration / Q000639:trends*; D014481:United States; D014493:United States Department of Veterans Affairs