Performance standards: Piece of cake or pie in the sky?

Background. Centrally mandated levels of performance are now common in the Veterans Health Administration. Performance standards for ambulatory procedures were developed based on HCFA data. The 11 procedures to be measured were arthroscopy, breast biopsy, eyelid procedures, lens/cataracts, bronchoscopy, endoscopy, colonoscopy, hernia repair, cystoscopy, laparoscopy, and cardiac catheterization. Were the performance standards for ambulatory procedures reasonable and achievable in a tertiary care VA? Methods. Ambulatory procedure performance standards for the 11 selected procedures were evaluated for Fiscal Year 1998 at one tertiary care VA and at each of the 22 Veteran's Integrated Service Networks (VISNs). Further review was undertaken for those procedures in which performance was below the fully successful level. This included chart reviews at the tertiary care VA and analysis of caseloads by VISN. Descriptive statistics were used as well as Student's t test to analyze the difference in means. Results. The tertiary care VA performed at the fully successful level for 6 procedures and at the exceptional level for 3 procedures. Performance levels for bronchoscopy and laparoscopy were below the preset goals. At the VISN level, 8 VISNs performed at the fully successful/exceptional level for all 11 procedures. The remaining 14 were deficient in 1 to 4 procedures. Eight of the VISNs were deficient in 2 or 3 procedures. Six VISNs were deficient in laparoscopy. Conclusions. The majority of centrally mandated performance standards appear to be reasonable and achievable. One notable exception is laparoscopy. Surgeons should understand how performance standards are calculated at their institution and review the data carefully for any systematic errors. Underperformance can be used as an opportunity to improve both data collection and outcomes.