#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.

Just for the record:

1. While it is true the many VA hospitals are associated with academic institutions and share some faculty, patients do not get shuttled back and forth between those hospitals if the VA does not have the equipment or facilities to treat the patients. If the VA needs to transfer the patient they go to another VA facility. For example, if a patient needs a particular operation not provided at the Northport VA on Long Island (associated with Stony Brook Hospital), he gets transferred to the Manhattan VA, not the university medical center. Most of the physicians who are faculty at the academic medical center are voluntary faculty at the VA. They may practice medicine or even do elective surgery there, but it is unlikely that they show up for emergencies. For that the VA must have its own staff.

2. The support staff at the VA are just like nurses and therapists everywhere else and function at the same level of quality. Even nurses at big medical centers are protected by union contracts.

3. There's plenty of CYA medicine practiced at VA hospitals.

I worked in a VA as a resident, and worked really, really hard to provide quality medical care to the vets. Unfortunately, the VA system stood in the way at every corner. It was frequently impossible to get a patient to the OR for a needed procedure (for example, patients with laryngeal cancer would have their case cancelled by a secretary because the health demographics form was not properly filled out... what happened to these forms??? there is probably a large warehouse in washington somewhere that is chock full of these forms.) Postop care was generally abysmal. For example, one flow sheet had the patients temperature charted beautifully every two hours, just as ordered... unfortunately, the temperatures started at 98.6F and slowly drifted down to near room temperature. The patient had died during the night and no-one had noticed. The nurses excuse: the orders say to call the physician for a temperature greater than 100.6, nothing about low temperatures. And this was one of the high quality VAs associated with a major teaching hospital.

Imagine your local department of motor vehicles running a hospital... that is the VA.