#1 The really good VAs are almost always associated with a top-flight teaching hospital. These VA hospitals share staff (residents and attendings) with the teaching hospital and indirectly benefit from the standards set at the non-VA hospital. The residents and attendings just won't accept second rate care (staff who say, we'll do it tomorrow, that's not in our contract, we go home at 4:30, we only do 2 cases a day) for their VA patients when the patients they treat a few blocks away get higher quality, faster care. So what do those residents and attendings do to get their patients the same standard? Complain, demand, transfer, whatever it takes. Bottom line is that the outcomes at the academic associated VAs are improved because of the shared resources (aka round the clock cath lab a short gurney ride away) and medical staff.

#2 Even at those high quality VAs you hear the horror stories of staff protected by union contracts or whatever who won't do their job and are never held accountable because the paper work is to hold them accountable is too daunting: People found in rigor who according to their charts were 98 degrees, 120/80 BP half an hour ago (yeah right, why check on patients if you don't get in trouble when you don't go take their vitals?).

#3 That doesn't mean the teaching hospital couldn't learn a thing or two from the VA across the street and do less CYA medicine and have better outcomes, but still don't imagine the VA outcomes are not impacted for the better by the standard of care set at non-VA institutions.