Department of Veterans Affairs

Recommendations and Actions

DVA10: Serve Veterans and Their Families as Customers

Background

Unlike any other federal organization, the Department of Veterans Affairs (VA) is responsible for fulfilling obligations of the United States that were incurred in exchange for earlier national service, often at great risk. Military service in many respects represents the most fundamental form of national service.

VA affects veterans' lives in very direct ways. With its vast network of employees and facilities, VA employees assist between 5 to 10 million veterans annually, including those who receive disability compensation or pension benefits, vocational rehabilitation, education, home loan guarantees, life insurance, and burial services. Each year VA handles in excess of 15 million telephone calls and processes over one million hospital admissions and 25 million outpatient visits.

VA's customer base includes approximately 27 million veterans (almost 21 million of whom served during at least one war period), 42 million dependents, and 1.6 million survivors of deceased veterans. Thus, VA's customer base comprises approximately one-third of the U.S. population.

All of VA's activities should be focused on putting its customers first, and the department is attempting to place a renewed emphasis on service. Through its quality management efforts, VA is undertaking five important new initiatives to improve the delivery of services to those for whom the VA and its mission exists--the veterans.

Courtesy and Caring. Service starts with courtesy. In July 1993, Secretary Brown inaugurated a new nationwide awareness campaign among VA's 260,000 employees, emphasizing the themes of caring and courtesy. The motto of the campaign is "VA--Putting Veterans First." Every VA employee will participate in courtesy training and orientation programs. In announcing the program, Secretary Brown said:

Because we are undoubtedly the government's largest single employer of direct public contact personnel, we have a special need to emphasize customer service. The tone we establish with our veterans in their encounters with VA must communicate a total sense of caring and courtesy . . . We want to provide clear guidelines to our employees not only to reinforce a sense of responsibility for being pleasant and helpful, but also to demonstrate that in the long run it helps us to be efficient.

The Secretary explained that by reducing time spent on consumer complaints and by taking an early interest in individual concerns, VA could increase its productivity.

Listening to Customer Feedback. Since most public agencies do not get funds from their customers as businesses do, and since most public programs are monopolies whose customers cannot go elsewhere for a better deal, agencies can easily become customer blind rather than customer driven.(1) VA can learn from companies such as Xerox, which requires its senior managers to spend one day a month taking phone calls from customers.(2) Says former Xerox Chief Executive Officer David Kearns, "There is simply no substitute for direct access. It keeps managers informed, it keeps them in touch, it keeps them honest."(3)

VA needs more flexibility in reaching and hearing directly from veterans and their families on their perceptions and expectations. VA employees must have an opportunity to respond quickly to any concerns or meet the changing needs of their customers. Adding to this urgency is the fact that VA's customer base is increasing with the current downsizing of the military.

Customer feedback within VA is being offered in several ways, including surveys, personal one-on-one telephone interviews, and focus groups. The extent of direct and indirect involvement with customers in each feedback situation varies, depending especially on whether the feedback is conducted at the local or national levels.

In almost every case, VA must receive approval from the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1980 to survey veterans and their families. The approval process is cumbersome, lengthy, and restricts VA's ability to collect customer data. VA should have the authority to collect customer data. Along with that authority must be the responsibility to have trained personnel who can design, develop, and interpret surveys.

Customer Representation. VA is improving its services by emphasizing direct service contact with veterans and their families. One initiative involves the enhancement of the customer representative function, coupled with the establishment of ombudsman activities. The actual design and implementation of this initiative will vary within each of VA's three primary organizations, the Veterans Health Administration, the Veterans Benefits Administration, and the National Cemetery System.

Although the roles and responsibilities of the customer representative and ombudsman are similar, differences do exist between these functions. The customer representative is often an employee of an organization, whereas an ombudsman frequently is not. For example, there are patient representatives at most VA medical centers. These employees, on behalf of the facility, assist patients, family members, veterans service officers, and other involved individuals to answer their questions and concerns about the medical care experience and project a positive image for VA. In the private sector, the Ritz Carlton Hotel in Washington, D.C., resolves customer problems on the spot by authorizing all employees to make decisions, even writing checks of up to $2,000.

In contrast, an ombudsman serves as an advocate for the veteran, and is not necessarily restricted by internal VA rules and constraints. An ombudsman can be thought of as an individual who facilitates resolution of customer complaints. For example, an ombudsman will investigate the circumstances surrounding the complaint and recommend a course of action to resolve it.

Partnership with Veterans Service Organizations (VSOs). VSOs, in effect, represent VA's customers. Concurrent with the creation of veterans programs and benefits in the formative years of the United States, veterans were organizing to help one another--the forerunners of today's VSOs. Following World War I, the number of VSOs grew dramatically. With that growth, VSOs became very active in affecting policy making at the federal level.

Today, there are more than 8 million veterans who are members of VSOs that are federally chartered or recognized and approved by the VA secretary to prepare and present veterans claims under laws administered by VA. More than 6 million of these veterans are represented by the three largest organizations--the American Legion, Veterans of Foreign Wars of the United States, and Disabled American Veterans.(4)

Being thoroughly familiar with VA programs, the VSOs are very sophisticated advocates for veterans. Uniquely, the VSOs prepare an annual independent budget, endorsed by about 38 organizations, based on what they believe veterans need.(5) Since a major focus of reinventing government is listening to the customer, it is to VA's advantage to include such organizations, at least in a consultative sense, in its decisionmaking on policy.

Patient Bedside Telephone Access. VA can establish itself as a customer-driven organization by acting on a measure that stresses the dignity of patients in VA medical centers and respect for their families: patient bedside telephones. VA has historically not provided patients with direct bedside access to telephones. Veterans have had to rely on pay telephones to make and receive telephone calls, causing great inconvenience, especially for those with severe disabilities.

To be more sensitive to veterans' needs for telephone access, VA has required nursing staff to devote time to assist patients in making telephone calls to and receiving calls from their loved ones. Bedside telephones are ordinarily found in other hospitals across the country.

The General Accounting Office conducted an audit on the effective use of nursing skills and recommended that VA provide telephone access for patients.(6) Following that review, the Veterans Health Care Act of 1992 (Public Law 102-585, enacted in November 1992), directed the secretary to evaluate the feasibility and desirability of patient bedside phones. In 1993, the undersecretary for health developed a plan for placing patient telephones at all 171 VA medical centers within five years.

The VA Medical Center in Castle Point, New York, was the first to receive patient phones. VA accomplished this through donations from the veterans service organization known as PT Phone Home. At no cost to VA, PT Phone Home coordinated the donation of funds, equipment, and labor necessary to complete the installation and to pay the monthly costs.

In summary, being courteous and caring, listening to the customer and acting on customer feedback, enhancing customer representation, forming a partnership with the veterans service organizations, and stressing the dignity of patients in VA medical centers through bedside telephone access are important initiatives that will enable VA to achieve its goals as a customer-driven organization.

Actions

1. The Department of Veterans Affairs (VA) should implement a courtesy and caring initiative throughout VA.

Since this initiative concerns effective communications, some form of training and feedback mechanisms should also be developed to determine the effectiveness of the courtesy and caring effort from both employee and veteran perspectives.

2. VA should develop a departmentwide policy for collecting and responding to veterans' suggestions and concerns.

The policy should encompass a strategy to (1) obtain blanket authority approved by OMB for conducting recurring surveys, and (2) provide a centralized clearinghouse on feedback lessons learned.

3. VA should develop a comprehensive approach for improving its capacity to respond to its customers' concerns, inquiries, and complaints.

One way to accomplish development of such an approach would be to use a working team composed of VA and VSO representatives. Their purpose would be to develop and implement a plan for establishment of customer representatives, ombudsmen, or case managers at VA medical centers, regional offices, and cemeteries as appropriate at each particular facility.

4. VA should develop a comprehensive approach for providing the VSOs with a stronger consultative role in policy making and decisionmaking.

This initiative would build on existing relationships and greatly strengthen them.

5. VA should provide patient bedside telephone access at its medical centers as soon as possible.

VA should continue to work aggressively with community organizations (e.g., PT Phone Home), VSOs, and telecommunications firms to obtain telephones and have them donated as a community service.

Implications

VA can better serve veterans and their families by putting its customers first. Effective training for and implementation of a courtesy and caring program should improve the quality of service and customer confidence. Without systems in place to ensure two-way communication with veterans and their families, VA will continue to reflect a bureaucratic perspective, rather than a customer orientation.

Customer service--already a critical need for VA from a government reinvention perspective--will become more so in an increasingly competitive environment (e.g., with national health care reform) with rising customer expectations. VA will need to increase its emphasis on human resources development. The implementation of a viable customer representative program is consistent with the Alternative Dispute Resolution Act of 1990, which requires VA and other federal agencies to develop policies for implementing alternative means of dispute resolution in their administrative programs.

Unlike most cabinet departments, which have regulatory or oversight responsibilities, VA is a service organization. As such, its decisions should focus on veterans and their families. Creation of a partnership with the organizations representing these VA customers has great potential for more responsive services and better informed policies.

The installation of bedside telephones will bring VA hospitals up to the standard in most other hospitals across the country and permit nurses to spend more time on direct patient care.

Fiscal Impact

VA anticipates that no new budget authorities will be needed to implement the initiatives described above. The department will make every effort to secure funding for the patient bedside telephone initiative through community organizations, VSOs, and private businesses.

Endnotes

1. Osborne, David, "Reinventing Government: Creating an Entrepreneurial Federal Establishment," in Will Marshall and Martin Schram, eds., Mandate for Change (New York: Berkley Books, 1993), p. 264.

2. Osborne, David, and Ted Gaebler, Reinventing Government: How the Entrepreneurial Spirit is Transforming the Public Sector (New York: Plume Books, 1993), p. 170.

3. Ibid.

4. U.S. Department of Veterans Affairs, 1993 Directory of Veterans' Service Organizations (Washington, D.C., 1993), pp. 5, 16, and 36.

5. Kenney, James J., et. al., The Independent Budget for Veterans Affairs: Fiscal Year 1994 (Washington, D.C., undated).

6. U.S. General Accounting Office, VA Health Care: Telephone Services Should be More Accessible to Patients, GAO/HRD-91-110 (Washington, D.C.: U.S. General Accounting Office, July 31, 1991).

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