VA Leaders Support New Primary Care Efficiency Measure

Primary care leaders and clinicians within the Veterans Affairs (VA) system generally perceive a novel productivity and efficiency measure called the Interprofessional Technical Efficiency Measure (ITEM) as valid and potentially useful for improving practice efficiency. This qualitative study, published in the Journal of General Internal Medicine, assessed user perspectives on ITEM’s validity and potential usefulness through feedback from VA primary care directors, data experts, and frontline clinical team leaders. The research aimed to determine whether the measure, which integrates quality and quantity of care goals, is acceptable to the interprofessional teams responsible for initiating local efficiency improvements.

Existing primary care productivity and efficiency measures, such as relative value units (RVUs) and patient panel sizes, have inherent limitations. RVUs measure limited aspects of individual clinician work and do not account for the work of interprofessional teams or the achievement of multiple non-procedure-based outcomes. Patient panel sizes indicate little about the quality or quantity of care received. To address these gaps, the research team developed ITEM, a measure that juxtaposes the quantity of clinical time a practice invests as inputs against simultaneously observed outputs that signify care quality and quantity.

ITEM uses data envelopment analysis to measure primary care practices’ relative technical efficiency. It assesses the extent to which inputs, such as staff time invested, can be minimized while desired products, or outputs, are maximized. The measure accounts for patient population complexity and was preliminarily tested across 703 VA community-based primary care practices nationally. The intended use case for ITEM is to provide audit and feedback measurement as a stimulus and guide for primary care practice efficiency improvement efforts directed at simultaneous achievement of multiple potentially competing patient care goals.

The study employed a rapid qualitative analysis approach, collecting data from semi-structured interviews and focus groups. A convenience sample of 34 interprofessional primary care leaders, managers, and frontline clinical team members from nine geographically dispersed VA medical centers and affiliated community-based outpatient clinics participated. Twenty individuals participated in 12 interviews, while 14 individuals participated in four focus groups. Participants spanned most major regions of the United States and included physicians, nurses, administrators, and data experts, although participating primary care directors were nearly all physicians.

Participants reviewed graphic data visualizations comparing their practice scores to national VA averages. The visualizations used color-coded boxes to show what quartile a practice fell into based on its scores in comparison to all VA community-based outpatient clinics nationally. Interviewees were shown identifiable ITEM displays for their linked clinics, while focus group participants viewed de-identified displays from real but diverse locations. The qualitative thematic analysis focused on face, construct, and content validity, as well as the measure’s usefulness for primary care efficiency improvement.

Overall, participants perceived the ITEM measure as having face, construct, and content validity. They viewed ITEM and its data visualization approach as potentially useful for primary care practice efficiency improvement. Interviewees generally found the overall ITEM score to be accurate, noting that it aligned with their perceptions of practice performance, including staffing sufficiency and patient panel sizes. However, some inconsistencies were noted, particularly when staffing changes were recent, patient population characteristics were unusual, or clinic structures were evolving.

Feedback on the accuracy of specific input and output scores revealed mixed results. For outputs, interviewees gave positive accuracy comments for 73% of practices regarding patient experience, 64% for total patients served, 62% for access, and 58% for clinical quality of care. For inputs, positive accuracy comments were given for 65% of practices for pharmacists and registered nurses, and 62% for administrative staff, clinical associates, and providers. Negative comments frequently centered on the validity of specific data for particular clinics, such as staffing full-time equivalent inputs that did not reflect recent turnover or new hires.

Participants identified both strengths and gaps in the ITEM output, input, and context measures. They appreciated that component measures aligned with primary care priorities such as patient experience, quality, and access. However, concerns were raised about the use of patient-reported data to measure access and patient experience, citing small sample sizes and high subjectivity. Some participants suggested using administrative data, such as objective appointment wait times, as a measure of access. Internal patient transfer requests were also proposed as a potential objective indicator for patient experience.

A recurring theme in the feedback was the omission of provider satisfaction as an output. Participants noted that failure to account for provider burnout might skew measure results and mask lower-performing clinics. One primary care director explained that a clinic with high efficiency scores could still have a poor work environment if staff turnover was high and documentation was inadequate. The study team concluded that mediating variables such as burnout are neither staff time inputs nor patient-generated outputs and should not be integrated into the economics-based ITEM calculation, but should be considered in improvement efforts.

Feedback on input measures centered on the challenge of accurately capturing teamwork using available metrics. Participants clarified that ITEM measures the work of the team in terms of assigned full-time equivalents, not teamwork as true collaboration. Staffing ratios were noted to be potentially misleading if, for example, losing a provider artificially improved support staff ratios. Participants suggested that staffing outputs be shown per size of the patient panel to enable more accurate comparisons across clinics. They also endorsed the inclusion of context measures, agreeing that accounting for patient complexity increased the validity of comparisons across practices.

Participants recognized the measure’s potential for quality improvement but voiced concerns about its impact on team morale and use in performance evaluation. Several participants expressed apprehensions regarding potential unintended consequences, particularly if the measure was used to penalize poor performance. A primary care physician emphasized the need to reassure providers that the measure would not be used against them, noting that data can feel like a tool for punishment on the front lines. A nurse practitioner raised concerns about maintaining psychological safety within teams, especially if individual staffing categories were highlighted in negative performance quartiles.

The study team plans to make only three changes to ITEM itself in response to participant feedback, while addressing other concerns through the development of supporting materials. These materials include a user-guided dashboard that displays ITEM results and supplemental measures suggested by users, as well as an efficiency improvement toolkit. The team is testing changes to ITEM’s core clinical primary care team definition and considering how to integrate patient experience-based and timeliness-based access measures. Further testing of the effects of updating the measure more frequently is also feasible, although prior testing showed that ITEM requires a one-year data look-back to achieve strong reliability.

Strengths of the study include recruiting interprofessional participants from diverse roles and geographic regions who reflected expected user groups and testing a visual data display appropriate for busy clinicians. Limitations include the use of rapid qualitative methods, which precluded in-depth analysis and formal data saturation assessment. The study reflects only the perspectives of potential direct users of ITEM as a performance improvement measure and used convenience sampling, which limits transferability to non-VA settings. The research was based on a single fiscal year of data, and some users perceived the lack of inclusion of measures of team functioning or burnout as a limitation, whereas the study team viewed these as mediating variables.

In summary, the findings support the value of continued development and testing of ITEM as a promising approach for primary care practice efficiency improvement. The study highlights the broader need for economics-based measures of primary care productivity and efficiency that integrate team-based models and goals. By providing an integrated, transparent practice efficiency measure, ITEM aims to support the achievement of high-value primary care that accounts for the efficiency with which practices achieve both cost-related and health-related care goals.

Subject of Research: Qualitative evaluation of the Interprofessional Technical Efficiency Measure (ITEM) for primary care practice productivity and efficiency in the Veterans Affairs system.

Article Title: Primary Care Practice Productivity and Efficiency: Qualitative Evaluation of a Novel Clinic-Based Measure

Article References: McCleskey, S. G., Khodyakov, D., Nelson, K. M., Curtis, I., Newberry, S. J., Tran, L. D., Fihn, S. D., Wagner, T. H., & Rubenstein, L. V. (2026). Primary Care Practice Productivity and Efficiency: Qualitative Evaluation of a Novel Clinic-Based Measure. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10789-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10789-6

Keywords: primary care, efficiency measure, VA health system, qualitative research, productivity, clinical quality, interprofessional teams, data envelopment analysis, healthcare management, patient experience, Primary, Care