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VA Transforms Health Care Service to Veterans

Nurse Anne Hooper, walking down a hall at the Memphis Veterans Affairs Medical Center, catches sight of a woman pushing her elderly father in a wheelchair. "Need some help?" she asks. A keen eye for customer service by Hooper, and VA employees everywhere, is one of the hallmarks of the "new VA."

Customer service standards have taken such hold in VA medical centers that some are gaining private-sector recognition. The Memphis hospital recently won the Greater Memphis Award for Quality, having competed with large and small companies that excelled in performance improvements, primarily in customer satisfaction.

Health-care reform activities in 1993 may have jump-started the Department of Veterans Affairs customer focus as VA began to rethink its place in the health-care market, but the restructuring of its system over the past two years provided the impetus for the accelerating changes. Improving customer service along with simplifying eligibility rules, expanding contracting authority, improving information management and institutionalizing the best clinical practices are only some of the many changes in the restructured VA that might surprise and inspire disciples of government reinvention.

Creating Integrated Networks

Beginning in October 1995, the VA health-care system began transforming itself from a confederation of more than 170 medical centers and nearly 400 clinics into 22 integrated networks (Veterans Integrated Service Networks) of care. The idea was to move from focusing on in-hospital treatment to expanding primary and ambulatory care in an effort to coordinate a patient's use of specialized services. These changes came about by decentralizing authority and consolidating services at local hospitals and clinics; allowing hospital action teams to redesign procedures; rechanneling money and staff away from bed-based care to outpatient care and primary, coordinated care; and, shifting budgeted funds to areas of the country facing the greatest consumer demand.

The networks each comprised of several medical centers and related facilities take a patient-centered approach to health care by taking advantage of decentralization, creating smaller regional management staffs, and giving those staffs authority to pool the resources of the hospitals within their groups to use their services more efficiently. Network directors not only have budgetary authority for their groups' hospitals, but also the responsibility of meeting the unique needs of the veterans living in the communities the hospitals serve.

Dr. Kenneth Kizer, Under Secretary for Health, says the consolidation of resources within the network structure improves services for patients. "We have some data that show improved customer satisfaction although we are not yet at the level we have to reach." VA's efforts are, however, beginning to pay off.

Networks can contract with private medical providers and enter sharing agreements with local governments or DoD installations. These sharing agreements help meet veterans' needs, can save money, and often improve access to care for veterans and even active-duty military and their families.

Philadelphia Team Wins Hammer Award for Partnering

A reinvention team at the Philadelphia VA Medical Center recently won a Hammer Award for forging an agreement with the Coast Guard that permits veterans to receive optometry, orthopedic and women's health care among other services on a base in Cape May, N.J. Southern New Jersey veterans now have several kinds of medical care available close to home, and Coast Guard members have additional medical care providers. The Coast Guard saved over $1 million last year because of reductions in the cost of care and off-duty time.

Coatesville, PA, Team Partners with Community--and Wins Hammer

The Coatesville, Pa., VAMC another Hammer Award winner eliminated some sewer construction costs for neighboring communities and saved federal taxpayers money in the process. Nearby subdivisions and non-profit institutions in West Brandywine Township faced possible easements and construction to connect a sewer line to a new treatment plant in Coatesville. VAMC Chief Engineer Steve Blanchard and his staff proposed that the township route the line through an existing sewer line on VA grounds. It saved local taxpayers $250,000 and the medical center another $250,000, the cost of its own tie-in to a separate line. The federal savings will continue because the township took over maintenance of the line.

Parallel to all of the local decisions to share and save resources are many top-management decisions, such as integrating medical facilities, which give still more authority to local managers. In the past two years, 34 VA medical facilities merged into 16 partnerships to better allocate scarce medical dollars and improve management. The effect is to improve the delivery of health care, both primary and specialized. The mergers have also helped remove duplicative administrative costs.

Dallas and Bonham Centers Coordinate Psychiatric Services

The Dallas VAMC, a large, acute-care hospital 90 miles from the Bonham VAMC, which provides primary, geriatric and extended care, now coordinates the psychiatric services for patients at both hospitals and handles fiscal matters, with only one director over both centers. According to Alan Harper, director of the new VA North Texas Health Care System, Dallas always was the primary referral hospital for Bonham patients. "So this administrative streamlining is a natural for us, but it's also improving continuity of care for the patients." Future savings, said Harper, will expand patient care.

New Funding System Asssures More Equitable Access to VA Services

To ensure that VA's national spending for health care maximizes its value, VA changed its medical funding allocation to support similar access to care for eligible veterans no matter where they live and to eliminate its unexplained cost differences across the country. Congress had recognized the need for reform and required VA to develop a new system in 1997. On April 1, VA implemented a system to reallocate funds reflecting the number of veterans treated at each medical center who have high-priority eligibility status. The new funding allocation system should give veterans more equitable access to VA services and will bring more money to facilities in the Sunbelt. The network headquartered at Bay Pines, Florida, comprised of eight VA medical centers and nine outpatient clinics in Florida and Puerto Rico, will gain $57 million this year, a six percent increase over last year, and probably incremental additions in the next few years.

Dr. Robert Roswell, network director, says the additional dollars will improve patients' access to care. His network will establish four more community-based clinics reducing travel by patients to metropolitan areas and will purchase a telemedicine system to link the medical centers and clinics. Telemedicine consultations will bring specialty treatment to patients far away from the VAMCs the same day they visit outpatient clinics. "We will offer treatment to 8,000 more Florida veterans and, for many, right in their own backyards," boasted Roswell.

Redirecting funds and decentralizing authority has not stopped at management in VA medical facilities. Newly empowered action teams have won Hammer Awards for changing medical-care delivery in ways that please patients.

Topeka Introduces Barcode Readers to Assure Timely, Accurate Medication

Hospitals increasingly are using sophisticated computer systems to reduce errors in administering medication. At the Topeka, Kansas, VAMC, a team of computer programmers, nurses and pharmacists decided that the commercial systems available were too costly and not reliable enough. They developed a point-of-care system that uses a hand-held, wireless barcode reader to scan medical information. The traditional system for administering medication required two nurses to record medication manually in the patient's paper chart. The new system, transmitting data by radio frequency to a mainframe computer, alerts nurses to missed doses and ensures medication is not administered at the wrong time. It also flags any attempts to administer either the wrong medication or the wrong dosage. Using the system, the staff have administered 500,000 doses of medication without error and reduced charting time.

Industry Standards and Methods Dramatically Improve Services

The Spokane, Wash., VAMC redesigned the entire patient care delivery system so patients would no longer have to make several visits for various kinds of treatment and, if admitted, would not have to stay longer than necessary. The staff decided to coordinate services in advance for patient visits and to use industry standards to target lengths of stay for inpatients. They formed three teams, one of which researches and incorporates customer preferences as they are discovered. Staff also designed a cross-discipline form to help plan discharges efficiently while ensuring against premature discharges.

Among the results: excess inpatient capacity redirected to outpatient services; average lengths of stay reduced from 7.2 to 5.1 days; savings in laundry of 200,000 lbs. a year; and a 30-percent reduction in the number of patient meals, resulting in a 30-percent reduction in total cost of subsistence operations achieved by reassigning employees to other positions. On top of that, Spokane VAMC strengthened patients' positive perceptions of their experience. Using Gallup organization data on customer satisfaction markers developed for private hospitals in the area, the customer feedback team identified patient preferences. Following restructuring, they found that patients showed increased satisfaction with coordination of their care, emotional support and improved timeliness of primary care service ranging from 14 to 34 percent. Said Ron Porzio, associate director, "Our staff supports the changes because they see favorable outcomes and our patients want to come back."

Such high marks from patients are showing up more and more at VA medical centers. Getting regular feedback from patients is required of all VAMCs under national and local customer service standards. Getting a nationwide picture of these findings is the job of the National Customer Feedback Center. In 1995, VA surveyed a sample of outpatients about the continuity of care they received after conducting focus groups in which patients said it was important to them. In that 1995 survey, two-thirds of respondents said they had one medical professional or team take responsibility for their care.

At the same time as the survey, more and more VAMCs were beginning to emphasize primary care, with interdisciplinary medical participation in teams that see the patient on each visit. By the next year, a similar survey found 72 percent of respondents reporting coordinated care. The higher number also correlated with increased satisfaction levels registered by surveyed patients.

Feedback such as this is encouraging, but much remains to be done to reengineer the veterans health-care system, a task Dr. Kizer describes as "one of the most profound transformations of any organization -- public or private -- in American history." Contact Gregg Pane, MD Chief Policy, Planning and Performance Officer, Veterans Health Administration at (202) 273-8932.

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