As the former representative of the Disabled American Veterans (DAV), one of the country's largest veterans service organizations, Secretary of the Department of Veterans Affairs (VA) Jesse Brown brings to VA an understanding of the problems facing veterans. He has begun to lead the department into a new era in which veterans' groups are explicitly a part of the policymaking process.
The transition to a new VA will not be easy because of the breadth of the organization and its connections to a wide range of communities of interest here and abroad. Still, VA has a long history of successes and Secretary Brown hopes to build on them.
For example, VA's medical research has produced two Nobel Laureates and sparked the seminal thinking on such issues as spinal cord injury and prosthetics. It administers an educational program--the G.I. Bill--that is one of the most successful domestic policy initiatives ever implemented.
The VA has conducted several pilot studies of its operations to determine how they might be made more effective and efficient. A wealth of data exist to help determine what needs to be done. The department's leadership has committed VA to the pursuit of new standards of accomplishment.
Even before the National Performance Review (NPR) was officially launched, VA had established an executive-level task force to find new ways of doing business and of providing service. VA was also an important participant in the White House Task Force on Health Care Reform.
An early cross-cutting theme at the department was that every dollar spent unnecessarily by VA was a dollar that could have been spent meeting the needs of veterans. With this in mind, Secretary Brown undertook to eliminate any perception of elitism by closing executive dining rooms, prohibiting first-class travel, and freezing executive furniture purchases.
With the start of the NPR, VA established a 15-person steering committee to coordinate departmental reinvention activities. The committee is chaired by the deputy chief of staff, and consists of senior executives from VA's principal operating units and staff offices. A full-time staff was assigned to support the committee, and the NPR reinvention projects were announced to all 260,000 full- and part-time VA employees.
The department established three reinvention laboratories that go a long way toward improving the department's direct contact with veterans and their families. In every case, a person--not a process-- will be the caretaker of veterans' concerns. Experience gained from the laboratories will guide other efforts to refocus VA's operations. Other, more sweeping changes in the department, however, will require basic structural changes in VA and the government as a whole, consistent with recommendations made by the NPR in this report. For example:
--- Some changes required to make VA facilities responsive to veterans' needs cannot be made departmentwide because of legislative constraints--these are addressed in Issue DVA03 of this report.
--- Some changes required to make VA facilities responsive to veterans' needs cannot be made departmentwide because of VA's self- imposed constraints--these are addressed in Issue DVA08 of this report.
--- Some changes required to enable the VA facilities to be responsive to veterans' needs are constrained by the VA system and its underlying business practices--these are addressed by several NPR recommendations elsewhere in this report, and include consolidating operations; leveraging scarce assets better; and augmenting the use of modern technologies for processing veteran information received by the department, paying bills, and making benefit payments.
The department is actively looking to VA employees in the field, who work directly with veterans on a daily basis, to provide a major impetus to reinvention efforts. For that reason, VA has chosen two of its 171 medical centers, and one of its 58 regional offices, as reinvention laboratories. The laboratories are focused on making the VA more veteran-centered and service-oriented.
The department's reinvention laboratories consist of the New York Regional Benefits Office, the Baltimore VA Medical Center, and the Milwaukee VA Medical Center. Reinvention initiatives at these facilities are being coordinated with representatives of veterans service organizations and union officials to address the full range of VA staff and veteran concerns as the initiatives evolve.
The Regional Benefits Office administers veterans benefits such as disability compensation, pensions, education, vocational rehabilitation, and home loan guaranties to veterans and their families in the New York area. The regional office has pursued total quality management principles for some time, and its reinvention laboratory is expanding an effort to reengineer the services provided to veterans.
The claims adjudication process in VA regional offices is very fragmented, consisting of some 20 to 30 steps spread among about a dozen employees. Staff in the New York office have reengineered the entire service concept, turning instead to a more integrated case management approach. The goal of this approach is to personalize the claims process and empower employees to handle veterans' claims from start to finish, interacting with them and their families more frequently to improve communications and clarify expectations.
The reengineered process uses teams of 12 employees, with each individual team responsible for all elements of a claim. Specialization is deemphasized, and overlapping knowledge among team members is promoted. The teams are essentially self-directed and a sense of ownership of the claims cases is encouraged. VA expects to cut disability compensation processing time significantly, possibly by as much as 50 percent. Faster decisions and more personal attention will mean more satisfied beneficiaries. The results thus far are encouraging.
The Baltimore Medical Center is giving the concept of managed patient care its most visible trial, and both patients and staff are benefiting. The center is the newest VA hospital and employs the latest in technology and facility design to demonstrate what the VA medical system is capable of doing. As such, it is a natural reinvention laboratory.
The Baltimore center has developed a hospital inpatient care model that makes extensive use of patient care assistants (PCAs). These individuals cross-train in nursing, laboratory, pharmacy, respiratory therapy, and cardiology skills to perform a variety of patient care functions at the patient's bedside. With PCAs to help them, clinical professionals have more time to devote to the patient care tasks that they are uniquely suited to perform. As a consequence, the overall quality and timeliness of patient care is enhanced.
As funding permits, ambulatory care for outpatients is being organized around a primary care model. Under this model, every veteran is assigned to a primary physician to increase patient access to, and communications within, the health care delivery system.
Baltimore is also emerging as a leader in the management of patient information. Patient data are readily available throughout the hospital, and information-gathering devices in patients' rooms and service areas are integrated to give staff ready access to patient data.
The radiology department also uses a state-of-the-art computer system that allows physicians to manipulate x-ray images in three dimensions--enabling them to more easily detect abnormalities or conditions that would be difficult, or even impossible, to diagnose using traditional two-dimensional x-rays.
This VA Medical Center seeks to identify the needs of veterans and their families through surveys of patients and center staff. The medical center is using this information to better focus its health care delivery practices. Several early successes have already been attributed to this technique.
Home oxygen therapy presented a problem of coordination between the providers of the equipment and the caregivers responsible for patients. A home oxygen team was established to address this problem. The teams now track clinical concerns--including patient compliance-- while monitoring the timely, adequate provision of service by vendors. This initiative has resulted in better continuity of care at an estimated annual savings of $90,000.
Kidney dialysis is monitored through laboratory analysis of blood samples. In too many cases, laboratory results were being received at the dialysis unit after the procedure was done. By working together, the nursing and lab clinical professionals involved solved the problem. Their solution combines better preparation of specimens by nurses, adjusted priorities in the lab, and the use of a pneumatic tube delivery system. This initiative resulted in reduced turn-around time, better use of staff time, and more timely response to patients' needs.
Milwaukee is also the site of VA's national center for cost containment, which studies service delivery enhancements and cost- saving approaches. It bases its work on the active involvement of the clinical staff and disseminates worthwhile findings to VA medical centers nationwide. VA estimates that it saved at least $30 million in fiscal year 1992, based on Milwaukee's initiatives. Through these and other innovations, Milwaukee is reinventing the way it does business.
The foundation of a successful plan for the future is an understanding of what has happened in the past--whether successful or not. The NPR has served as a catalyst. The relationship between NPR and VA staff has resulted in the identification of measures and possible experiments to help redirect energies toward VA's primary mission--service to veterans and their families.
As word about the results from the reinvention laboratories gets out, more employees are coming forward with proposals that will allow them to do their jobs better or faster. VA is committed to reinventing its basic service of providing health care and benefits for almost one- third of the U.S. population, and serving as a model for experimentation in arenas that will have positive ramifications for the private sector.
These goals, however, are not attainable by VA and the NPR alone. They require the support of Congress, veterans service organizations, labor unions, and veterans themselves in a national effort. Anything less may fail to produce the greater successes that can be achieved with cooperative action.
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