Denver VA surgeries cancelled due to anesthesiologist shortage

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When I rotated through the VA as a resident, they had a policy that no elective cases could start after 3pm. That probably contributes to the delays and backlogs.

They have 16 anesthesia providers to do 380 cases/mo??? That's 23cases per person per month. I don't consider that an anesthesia shortage. We could easily do that with 6+1 on vacation. And that would still literally be a part time job.

Our federal government at work. What a waste.
 
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nimbus said:
When I rotated through the VA as a resident, they had a policy that no elective cases could start after 3pm. That probably contributes to the delays and backlogs.

They have 16 anesthesia providers to do 380 cases/mo??? That's 23cases per person per month. I don't consider that an anesthesia shortage. We could easily do that with 6+1 on vacation. And that would literally be a part time job.

Our federal government at work. What a waste.
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My guess is that we see market forces at work. If it were that easy and cushy, there would be people lining up for the jobs, not leaving.

You don't realize how slow some VA surgeons are (when compared to PP), plus this is a teaching hospital. Plus a lot of veterans are as sick as the top 20th percentile in PP. Plus you have on call and post-call people, and people on vacation etc. Plus some of those anesthesiologists could be part-time pain or critical care. Plus "provider" can also mean CRNA, who cannot work independently. So I doubt it's that simple.

While the VA advertises salaries up to 400K, that's what one can get after like 20-30 years at the VA. The starting salaries are under 300K usually. So, if you make it feel like PP, while PP pays 50% more, guess what happens?
 
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FFP said:
My guess is that we see market forces at work. If it were that easy and cushy, there would be people lining up for the jobs, not leaving.

You don't realize how slow some VA surgeons are (when compared to PP), plus this is a teaching hospital. Plus a lot of veterans are as sick as the top 20th percentile in PP. Plus you have on call and post-call people, and people on vacation etc. Plus some of those anesthesiologists could be part-time pain or critical care. Plus "provider" can also mean CRNA, who cannot work independently. So I doubt it's that simple.

While the VA advertises salaries up to 400K, that's what one can get after like 20-30 years at the VA. The starting salaries are under 300K usually. So, if you make it feel like PP, while PP pays 50% more, guess what happens?
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Depending on the month and case mix, I personally do 60-100cases/month. That VA has 8 doctors on staff to do 380 cases/month. That's 47cases/month/doctor. And they have 8 CRNAs. I think they are all riding the federal government gravy train.
 
nimbus said:
Depending on the month and case mix, I personally do 60-100cases/month. That VA has 8 doctors on staff to do 380 cases/month. That's 47cases/month/doctor. And they have 8 CRNAs. I think they are riding the federal government gravy train.
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That's possible. On the other hand, we have no idea what cases they do. There may be a ton of cardiac, vascular and thoracic. That's a big VA, as far as I remember.

I, like Charlie Munger, am a big believer in the power of incentives. So, just by looking at the fact that people are leaving in droves, I think you are misjudging the situation.

From what I understand, there is a deficit of providers in other specialties (e.g. primary care), too, not just anesthesiology. Market forces at work.
 
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My VA experience was the same, massively inefficient and no elective cases starting late. But, they never paid enough for anyone to try harder so why would they? Nobody is going to get fired, and there’s no incentive to be more efficient. That goes all the way from the surgeons on down to the nurses.
My guess is they’re also not paying enough(even at 400k) which normally happens in desirable places such as Denver, but for some reason it’s not working out there.
 
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There's definitely something strange going on here. It's a VA...in Denver (desirable)...in anesthesia. There must be an imbalance of pay vs workload because as FFP said there should be a line out the door.
 
Twiggidy said:
There's definitely something strange going on here. It's a VA...in Denver (desirable)...in anesthesia. There must be an imbalance of pay vs workload because as FFP said there should be a line out the door.
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Yeah, agree. People I know are tripping over themselves to get to Colorado (is it some promised land I’m not aware of), and military folks flock to the VA for the benefits. I know several personal friends who would jump at the opportunity if there was an opening. Sounds almost like a joke article - when in doubt, blame anesthesia!

No chance a new hire is being offered $400K at the VA. There is absolutely more to this story
 
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Spin to justify revisiting the removal of CRNA supervision requirements at VA Hospitals?
 
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IlDestriero said:
Are they hiring?
PS the university folks aren't making $400, I don't think the VA is paying close to that. I don't think they even make that much in Palo Alto.


--
Il Destriero
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Yes they are hiring.
The program director is out.
Many others are leaving.
This has been on the horizon for some time now and nobody did anything to avoid it.
Locums are being sought as we post.
 
Not really surprised, from my experience when i rotated there, it's slow, but more because the surgeons are slow. A hemicolectomy took like half a day.. In terms of turn over time it was comparable to the academic center i train at. The salaries were <300k .. and over half of them left when the surgeons wanted to start doing transplant surgery. (would mean a lot worse calls for anesthesiologists since they are all emergent). All those left got replaced by new graduates who were willing to work for the low salary.

And honestly id also rather not start a big case after 3pm in the VA..
 
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Noyac said:
Yes they are hiring.
The program director is out.
Many others are leaving.
This has been on the horizon for some time now and nobody did anything to avoid it.
Locums are being sought as we post.
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Interesting opportunity, any state license probably accepted, ski on weekends.
 
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anbuitachi said:
Not really surprised, from my experience when i rotated there, it's slow, but more because the surgeons are slow. A hemicolectomy took like half a day.. In terms of turn over time it was comparable to the academic center i train at. The salaries were <300k .. and over half of them left when the surgeons wanted to start doing transplant surgery. (would mean a lot worse calls for anesthesiologists since they are all emergent). All those left got replaced by new graduates who were willing to work for the low salary.

And honestly id also rather not start a big case after 3pm in the VA..
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The thing that bugged me about no late starts is that patients' surgery would get postponed because the previous cases ran long and they had slow turnovers. If the 2nd case of the day finished at 2:15 pm, zero effort would be made to get the 3rd patient in the room by 3pm. The patients would be very disappointed after waiting all day for their surgery. It was definitely a staff centered and not patient centered enterprise. You would never see that where I work now. It just struck me as lazy and mediocre. I'm not surprised at all that they have backlogs. Maybe they need some incentives to be more productive and efficient.
 
i mean, it is gov't work. there is probably zero incentive to do more than what is required, especially if the cases aren't emergencies. i'm not implying that's a good or bad thing, I'm just saying that's my impression of how gov't facilities work and it's been my experience at every VA i've rotated through. VA was always known as the "cush" rotation.

as far as pay, i would argue you don't go to work for a VA to make alot of money. you go there because it's probably it's more of a lifestyle job (ie no elective cases after 3pm) and you take the 6 figures they give you and go on with your life. it's not the place to get rich
 
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Twiggidy said:
i mean, it is gov't work. there is probably zero incentive to do more than what is required, especially if the cases aren't emergencies. i'm not implying that's a good or bad thing, I'm just saying that's my impression of how gov't facilities work and it's been my experience at every VA i've rotated through. VA was always known as the "cush" rotation.

as far as pay, i would argue you don't go to work for a VA to make alot of money. you go there because it's probably it's more of a lifestyle job (ie no elective cases after 3pm) and you take the 6 figures they give you and go on with your life. it's not the place to get rich
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Yes the postal workers of medicine. I've never seen one move fast regardless of how long the line is.
 
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Twiggidy said:
i mean, it is gov't work. there is probably zero incentive to do more than what is required, especially if the cases aren't emergencies. i'm not implying that's a good or bad thing, I'm just saying that's my impression of how gov't facilities work and it's been my experience at every VA i've rotated through. VA was always known as the "cush" rotation.

as far as pay, i would argue you don't go to work for a VA to make alot of money. you go there because it's probably it's more of a lifestyle job (ie no elective cases after 3pm) and you take the 6 figures they give you and go on with your life. it's not the place to get rich
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Yea I can totally see this happening. This didn't happen at the VA I was at but once the schedule was made pretty much no elective add ons past 3. But if it was already on schedule they still did it even if it got delayed by previous case
 
I can only speak for my shop (SF), but we definitely do elective cases after 3! Due to nursing shortages, we have a hard time keeping more than 2-3 rooms open after 5, but we typically have cases going until 7-10. I'd like to see for myself the shops that you all are referencing that shut down at 3; that would be sweet indeed.

Having seen the inner workings, I can say that we are slow. Nurses take extra time, in part, due to additional "safety" measures that get instituted. Lots of huddles, lots of cross-check, etc. Surgeons take extra time because they are teaching, but also because, at least what I see, is a lack of accountability in some cases. I've heard surgeons say things like, "It's my block and I use it how I want; if I want to take time between cases for other things and the room runs all the way until 5, so be it." Honestly, my longest delays are waiting for surgical attendings to show up and help the resident position the patient. Anesthesia can be slow at times too. Some times it's blocks, sometimes we don't always get the A+ hires and people are just less skilled, and sometimes it's probably a subtle impact of not being incentivized. One thing that stands out to me is that it often seems simultaneously that everyone is in charge and no one is in charge. If the scrub machine is empty and no one can get dressed (thereby delaying cases), the scrub guy can just tell you to shove it, or maybe the scrub truck didn't come; there's never anyone that can make that guy do his job better; no one's really in charge.

Anyway, re: Denver, I spoke with a colleague who's there and, no, they're not offering anywhere close to 400K. They run 10 locations/day with the staffing levels reported in the paper. Doesn't leave much time for academic productivity, to say the least. It is a matter of money and time. Even if the VA came up with a competitive salary, at least in our shop, we lose candidates because the hiring process is so slow and opaque. No decent candidate wants to pass up other jobs waiting for use to re- re- re-do the paperwork because it keeps getting lost in HR. It can be maddening.
 
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cchoukal said:
I can only speak for my shop (SF), but we definitely do elective cases after 3! Due to nursing shortages, we have a hard time keeping more than 2-3 rooms open after 5, but we typically have cases going until 7-10. I'd like to see for myself the shops that you all are referencing that shut down at 3; that would be sweet indeed.

Having seen the inner workings, I can say that we are slow. Nurses take extra time, in part, due to additional "safety" measures that get instituted. Lots of huddles, lots of cross-check, etc. Surgeons take extra time because they are teaching, but also because, at least what I see, is a lack of accountability in some cases. I've heard surgeons say things like, "It's my block and I use it how I want; if I want to take time between cases for other things and the room runs all the way until 5, so be it." Honestly, my longest delays are waiting for surgical attendings to show up and help the resident position the patient. Anesthesia can be slow at times too. Some times it's blocks, sometimes we don't always get the A+ hires and people are just less skilled, and sometimes it's probably a subtle impact of not being incentivized. One thing that stands out to me is that it often seems simultaneously that everyone is in charge and no one is in charge. If the scrub machine is empty and no one can get dressed (thereby delaying cases), the scrub guy can just tell you to shove it, or maybe the scrub truck didn't come; there's never anyone that can make that guy do his job better; no one's really in charge.

Anyway, re: Denver, I spoke with a colleague who's there and, no, they're not offering anywhere close to 400K. They run 10 locations/day with the staffing levels reported in the paper. Doesn't leave much time for academic productivity, to say the least. It is a matter of money and time. Even if the VA came up with a competitive salary, at least in our shop, we lose candidates because the hiring process is so slow and opaque. No decent candidate wants to pass up other jobs waiting for use to re- re- re-do the paperwork because it keeps getting lost in HR. It can be maddening.
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I was a resident at a VA in the early 1990s so maybe things have changed. Back then the medical records department would close at 3. Sometimes you'd get there at 3:10 to retrieve a record for a case the next day. There might be someone still there but there reply would always be "sorry we're closed". And any way you count it, 16 warm bodies is a LOT of manpower to get through 380 cases/month. I think we are seeing the future if we get single payer government run healthcare. Guess it's not all bad depending on your perspective. One just needs to adopt a civil servant mindset.
 
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I also think the emphasis on case numbers is a bit misguided. The attending has to be there to staff the location regardless of how many cases get done in a given location each day. My friend says they staff 10 locations per day. With only 6 attending, that’s pretty tight. At our shop, we have to do in house call on saturdays to supervise the resident on call for airways. We don’t do a lot of cases on saturdays, so it looks like I’m not doing anything. A Saturday in house is a weekday I’m not in the or. You just need a Lot of people to get all that covered, especially at VA prices.
 
I hardly know where to start on the VA. As noted above there is a serious problem with no accountability. Nobody can be fired and the motivation is to do less. The thing about dragging feet so that the room can't be ready is a classic. I totally reminds me of the Army where there would be 5 housekeepers each working in a different room and taking forever to turn it over and consequently none of those five rooms was ready to go in time to do a case. Around 1300 they would start telling the surgeons, "Sorry you can't start your case because it won't be done by 1500 and we go down rooms then. The VA hiring thing is also maddening. I applied several years ago and despite the fact that I was former active duty and at the time working as a contractor at a military hospital I had to fax like 40 different pieces of paper and even then it took them 6 months to tell me they hired somebody else. In contrast my civilian gig took a CV and the phone numbers of 2 references. Got hired in a week. The VA is almost certainly the best argument ever against single payer.
 
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Why not how many nurses or surgical techs or even surgeons? How are they sure it's an anesthesiology issue anyway?
 
Crabbygas said:
I hardly know where to start on the VA. As noted above there is a serious problem with no accountability. Nobody can be fired and the motivation is to do less. The thing about dragging feet so that the room can't be ready is a classic. I totally reminds me of the Army where there would be 5 housekeepers each working in a different room and taking forever to turn it over and consequently none of those five rooms was ready to go in time to do a case. Around 1300 they would start telling the surgeons, "Sorry you can't start your case because it won't be done by 1500 and we go down rooms then. The VA hiring thing is also maddening. I applied several years ago and despite the fact that I was former active duty and at the time working as a contractor at a military hospital I had to fax like 40 different pieces of paper and even then it took them 6 months to tell me they hired somebody else. In contrast my civilian gig took a CV and the phone numbers of 2 references. Got hired in a week. The VA is almost certainly the best argument ever against single payer.
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Technically it’s an argument against a complete government healthcare takeover since with “single payer” there still would be private doctors and hospitals doing the work and billing the “payer,” the federal government. Theoretically they would still have profit motive. But either system would probably be a $hit sandwich for Anesthesia.
 
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A few good VA tales from residency:

Most of the OR crew was pretty decent at our VA - by VA standards of course. We did have one particularly obstinate circulator though. One day during turn over, after what I felt was an appropriate amount of VA turnover time, I poked my head in the room and politely asked her "Hey, let me know how much time you need before I can head back with the patient." She responded "HOLD ON!!!!!!!!" in the most bite your head off tone possible. I calmly left the room, came back about 5 mins later and said "Hey, let me know how much time you need before I can ask when I can come back with the patient."

One weekend call day at the VA 2 junior ortho residents were really trying to crack at the whip and get their cases started ASAP. Not having much success as the OR crew produced one excuse after the other. My attending happened to be one of our most beloved staff members. Taiwanese with a very thick accent - very sweet, very wise guy, and also clinically very good. He walks up to them and says "VA is rike a revolving door - harder you push - more resistance."
 
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Isn't VA the one that gave independence/power to CRNAs relative to Anesthesiologists? If that is the case, I have no sympathy for what is going on. They can use their CRNAs all they want.
 
HueySmith said:
Isn't VA the one that gave independence/power to CRNAs relative to Anesthesiologists? If that is the case, I have no sympathy for what is going on. They can use their CRNAs all they want.
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No, that got defeated and rightfully so. These veterans are better off waiting for their elective surgery than getting it quicker and having a solo CRNA. It sounds like emergent/urgent surgeries aren’t being delayed. I’m thinking back to the VA patients and very few were straight forward, not appropriate for substandard care.
This is a simple solution- let them seek care elsewhere.
 
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close all vamc, fire all admin.

give 100% medicare coverage to our vets. they earned it. let them go where they want. they deserve better.

oops, just improved care and saved usa a trillion.
 
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The thing that pisses me off the most is when surgeons take 5 hours to do a 1-2 hour case and get pissy about what they think are anesthesia delays both before and after the surgical portion. Bonus points if it was a crappy resident that took forever.
 
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^^^ Give them all medicare and let the VA compete without any additional subsidy. That would be worth watching. And it might even work. Love the way the CRNA lobby makes this all about them, because, you know being independent really is the most important thing. Way more important than any other issues for the vets. BTW last time I looked there were no ads for docs at the Denver VA either on USA jobs or gaswork. If they really are short then the head of the Denver VA needs to get his ass handed to him for not even trying to fix the problem. His boss needs the same.
 
I'm not a Vet so I can't speak for them, but I I wonder would veterans would rather have Medicare vs VA coverage because I've heard VA "coverage" is very good, even if the system is bad. Again, I have no idea, only what I've heard.
 
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Twiggidy said:
I'm not a Vet so I can't speak for them, but I I wonder would veterans would rather have Medicare vs VA coverage because I've VA "coverage" is very good, even if the system is bad. Again, I have no idea, only what I've heard.
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? What?
 
Psai said:
The thing that pisses me off the most is when surgeons take 5 hours to do a 1-2 hour case and get pissy about what they think are anesthesia delays both before and after the surgical portion. Bonus points if it was a crappy resident that took forever.
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Not really specific to va. Anesthesia gets blamed for everything
 
Crabbygas said:
^^^ Give them all medicare and let the VA compete without any additional subsidy. That would be worth watching. And it might even work.
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The thing about the various schemes towards privitization is complicated.

First, the VA does a lot of things other than healthcare; it's other disability and housing benefits are integrated with healthcare and are difficult to untangle.

Second, the VA is really good at things that are hard to make money on in the private sector: mental health, really integrated/coordinated primary care, and housing (many cities are now at net-zero homeless veterans). Yes, you hear stories all the time about individual failings, but you must recognize that the VA is in the national spotlight in a way that other care systems are not. Many of the VA's "failings" around wait times and other things are only known because the VA actually collects and reports data on these things; most systems do not.

Third, as Veterans' Choice has expanded, I'm seeing more and more that veterans are getting some care outside the VA. While this sounds good, we can almost never access records of such care, so we're left not knowing what happened and why. Everything that happens within the VA is right at our fingertips, and this is an enormous benefit. Of course, reasonable people can argue about whether community care is as good as University/academic care, in terms of the latest/greatest or whatever, but I've seen a handful of times already when the outside cardiologist does something that doesn't make a whole lot of sense to the University guys that staff the VA.

Fourth, and perhaps most importantly, notwithstanding a few vocal opponents, veterans don't tend to want care outside the VA. Anecdotally, I find this to be nearly universally true, and a number of veterans advocacy groups (including the VFW) have advocated against spending more on Veterans' Choice, and instead spending that money to improve VA care.
 
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cchoukal said:
Fourth, and perhaps most importantly, notwithstanding a few vocal opponents, veterans don't tend to want care outside the VA. Anecdotally, I find this to be nearly universally true, and a number of veterans advocacy groups (including the VFW) have advocated against spending more on Veterans' Choice, and instead spending that money to improve VA care.
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Your universal truth is probably due to sampling bias because you work at a VA. I have the opposite experience and take care of many veterans who choose to come to our private hospital. I also work with a lot of VA eligible ex military doctors, nurses, and techs who don’t use the VA.
 
nimbus said:
Your universal truth is probably due to sampling bias because you work at a VA. I have the opposite experience and take care of many veterans who choose to come to our private hospital. I also work with a lot of VA eligible ex military doctors, nurses, and techs who don’t use the VA.
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Plenty of us who have worked in both VA and private. My experience has been similar to cchoukal. Also, I come from a military family and they all prefer their care through the VA. My problem with the VA, and why I left, wasn't on the patient care side, it was that I can get a much higher salary, with similar benefits, and less unnecessary mid management oversight in other settings. As far as care, my VA patients received better clinical care than my non-VA patients in the non-VA hospitals I've worked/work at.
 
lobelsteve said:
close all vamc, fire all admin.

give 100% medicare coverage to our vets. they earned it. let them go where they want. they deserve better.

oops, just improved care and saved usa a trillion.
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Im going to save you a trillion more. Close all military hospitals and facilities and provide the same care congress gets . Increase the reserve component place all military providers in civilian hospitals. Make sure all people involved in patient care have licenses and board certification. Increase the medical service corps to function as liasons between the physicans and military.
 
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WisNeuro said:
Plenty of us who have worked in both VA and private. My experience has been similar to cchoukal. Also, I come from a military family and they all prefer their care through the VA. My problem with the VA, and why I left, wasn't on the patient care side, it was that I can get a much higher salary, with similar benefits, and less unnecessary mid management oversight in other settings. As far as care, my VA patients received better clinical care than my non-VA patients in the non-VA hospitals I've worked/work at.
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Maybe in psych care. I don’t presume to know.

I live and work in a military town. 20-30 percent of our medical staff is ex-military and probably 50% of our OR staff (scrub techs and nurses) are as well. They are not going to the local VA when they need surgery.

When I was a resident, the surgeons at the VA were definitely not cream of the crop. The cardiac surgeon in particular was notoriously bad. We are talking 3-4hr pump runs for a cabg. He eventually ended up returning to his home country.
 
nimbus said:
Maybe in psych care. I don’t presume to know.

I live and work in a military town. 20-30 percent of our medical staff is ex-military and probably 50% of our OR staff (scrub techs and nurses) are as well. They are not going to the local VA when they need surgery.
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Not just psych care, outcomes studies and polls about preference would support vets preferring VA care. I imagine just like any private system, there are definitely bad hospitals in the bunch when you look at hundreds of hospitals, but, on average, the VA does pretty well. I don't have any dog in this fight any more, I put my time in, and I'm ok with going for more money and more autonomy, but I still think the attitudes of the VA are more driven by politics than actual data when compared vs private sector.
 
WisNeuro said:
Not just psych care, outcomes studies and polls about preference would support vets preferring VA care. I imagine just like any private system, there are definitely bad hospitals in the bunch when you look at hundreds of hospitals, but, on average, the VA does pretty well. I don't have any dog in this fight any more, I put my time in, and I'm ok with going for more money and more autonomy, but I still think the attitudes of the VA are more driven by politics than actual data when compared vs private sector.
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I’m sure the VA does well in terms of quality measures because they are fanatical about checking all the boxes. But they don’t measure the countless 3-4hr total hips with 800ml blood loss that would get flagged at any other hospital but was routine at the VA.
 
nimbus said:
I’m sure the VA does well in terms of quality measures because they are fanatical about checking all the boxes. But they don’t measure the countless 3-4hr total hips with 800ml blood loss that would get flagged at any other hospital but was routine at the VA.
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Mayhaps, but they still outperform on many long-term outcome measures. Not really much of a concern of mine any more, but I think disregarding the VA as a whole with no real justification is not good clinical science. There are things that it does that the private sector would do well to adopt. The same goes vice-versa, but far too many people want to use the VA as a political football absent any meaningful quantitative reason to do so.
 
WisNeuro said:
Mayhaps, but they still outperform on many long-term outcome measures. Not really much of a concern of mine any more, but I think disregarding the VA as a whole with no real justification is not good clinical science. There are things that it does that the private sector would do well to adopt. The same goes vice-versa, but far too many people want to use the VA as a political football absent any meaningful quantitative reason to do so.
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Outperform who? And what long term outcome measures? I’m skeptical.
 
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WisNeuro said:
Mayhaps, but they still outperform on many long-term outcome measures. Not really much of a concern of mine any more, but I think disregarding the VA as a whole with no real justification is not good clinical science. There are things that it does that the private sector would do well to adopt. The same goes vice-versa, but far too many people want to use the VA as a political football absent any meaningful quantitative reason to do so.
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An incentive based system will ALWAYS outperform a salary based system. As an active duty physician the military creates metrics that are not applicable to the civillian standard. As someone who has seen both systems their is an apathy in military medicine as it pertains to pace and patient care. People stop working hard when they know they cannot be fired. In any civilian OR people can be fired in the military its more complicated. I imagine the VA to similar to military medicine.
 
nimbus said:
Your universal truth is probably due to sampling bias because you work at a VA. I have the opposite experience and take care of many veterans who choose to come to our private hospital. I also work with a lot of VA eligible ex military doctors, nurses, and techs who don’t use the VA.
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That's fair; I'm sure I'm biased. I do generally find that we treat mostly vets who don't have other options (e.g., we don't get a lot of former officers; those people got jobs with insurance after they served), which probably impacts perceptions in both directions. The exception is for surgeries, actually; we get a good number of people who have insurance and get the bulk of their care on the outside, but come to the VA for their cataracts, knees, backs, and other things.

And my situation is a little different in that I'm at a large, urban, academic VA; all the physicians, residents, and fellows are from UCSF, which probably drives the standard up compared to a small, rural VA. Our surgeons are often slow (not always; our orthopods do/teach TKAs, THAs in about 90-120 min, which isn't crazy), but mostly very engaged and highly competent. I can't remember a primary hip with anywhere near 800 mL EBL.

In terms of outcomes, most of what I've seen has been related to mental health engagement and primary care outcomes (think Hba1c reductions, whether patients were prescribed the right meds to comply with best practices for HTN, CAD, etc.). The VA has had large databases and dashboards a lot longer than anyone else, which they've been able to leverage to identify and correct when patients within a large cohort aren't "between the lines," so to speak, on adherence to clinical guidelines.
 
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