VHA's Priorities for Strategic Action
Spotlight: Employee Engagement in Depth
Strategic Priority Awareness VA Healthcare System
VA's Office of Patient Centered Care and Culture Transformation (OPCC&CT) has endeavored to institute a culture of patient-centered care throughout the VA healthcare system - a key priority within VA's strategic plan. This strategic priority has been called an effort to institute personalized proactive patient-driven care (PPPD). OPCC&CT's efforts have included:
- Clinician education in a "whole health" approach to patient care,
- Funding of Centers of Innovation in Patient-Centered Care and patient-centered care pilot projects in general, and
- Deployment of Field Implementation Teams to help medical centers move toward providing PPPD healthcare.
A team of investigators from the Center for Evaluating Patient Centered Care, (EPCC-VA; Director, Barbara Bokhour, PhD), funded by OPCC&CT and VA HSR&D's Quality Enhancement Research Initiative (QUERI), assessed VA employees' degree of awareness and involvement in these efforts.1 Those investigators, led by Mark Meterko PhD, examined the:
- Level and variation of VA staff awareness and activity related to the strategic priority goal of providing PPPD healthcare within VA care facilities and across organizational boundaries within facilities;
- Relationship between the degree of strategic priority awareness and activity and two potential facilitating factors - civility and organization learning; and
- Relationship between degree of strategic priority awareness and activity and two major workplace outcomes - overall job satisfaction and burnout.
To accomplish these goals, investigators analyzed data from more than 135,000 respondents who answered six questions regarding VA staff awareness of and participation in activities related to the provision of PPPD that were included in the FY2014 All Employee Survey (AES). Responses ranged from "strongly disagree" to "strongly agree" on a Likert-type scale.
Overall, study findings indicated that awareness of and involvement in efforts to implement PPPD was high. Approximately two-thirds of respondents agreed or strongly agreed with each of the PPPD module questions concerning efforts to provide and support PPPD healthcare in their facility and workgroup. On the most widely-endorsed item, just over 83% agreed or strongly agreed that they understood their own role in providing Veterans with PPPD healthcare. Nonetheless, there was substantial variation in the level of perceived PPPD-related activity among VA facilities. For example, at some facilities 62% of all respondents agreed or strongly agreed with all six PPPD questions, while at other facilities, this was only true for about 31% of all respondents. Moreover, at one facility with a high overall level of perceived PPPD-related activity, the percent of respondents who answered "agree" or "strongly agree" to all six SPA questions ranged from 6% to 91% across 54 workgroups with 10 or more respondents - a spread of 85%.
Substantial variation in PPPD across facilities also was evident even when comparing responses within one particular service or department. For instance, based on responses from primary care staff only, the percent of VA employees who agreed or strongly agreed with all six PPPD questions ranged from 26% to 72% at the 141 facilities with 10 or more primary care respondents. Other findings indicated that:
- Higher levels of work group civility were associated with higher levels of SPA.
- Higher levels of organization learning climate were associated with higher levels of SPA.
- Higher levels of SPA were associated with high levels of overall job satisfaction.
- Higher levels of SPA were associated with lower levels of burnout.
Although the direction of causality in these relationships cannot be determined from the cross-sectional data in these analyses, one interpretation of this constellation of findings is that civility and organizational learning facilitate the implementation of PPPD - and that working as a member of a team focused on providing PPPD, in turn, increases job satisfaction and reduces burnout.
These initial findings raise many interesting questions. What organizational factors account for the variation in PPPD across VA medical centers? Why is it that 70% of staff answered all six SPA questions favorably at some facilities, and at other facilities the "percent positive" was less than half that rate? Study investigators suggest that further examination involving additional data could examine the direction of causality in the relationships between PPPD, civility, organization learning climate, job satisfaction and burnout as well as identify other possible impacts of PPPD on the work experience of VA staff. In addition to more extensive quantitative analyses, qualitative methods including interviews by telephone and/or in-person could contribute to a better understanding of the organizational factors that characterize "high outlier" PPPD sites - and shed light on the impact of PPPD on the work life of VA staff and the healthcare experiences of Veterans.
Mark Meterko, PhD
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
1. Meterko M, Charns M, Mohr D, and Bokhour B. Strategic Priority Awareness and Activity in the Veterans Health Administration: Analysis of Data from the FY14 All Employee Survey - Final Report. White Paper. 2015.
Implementing BREATHE in the VA Healthcare System
Angela Rollins, PhD
Burnout and employee engagement are an obvious focus of attention in VA and other healthcare settings. Staff burnout can have a detrimental impact on employees, organizations, and the clients they serve. Employees experiencing burnout can demonstrate problems with physical and emotional well-being, work-life balance, and personal relationships. At the organizational level, burnout and reduced employee engagement can lead to reduced commitment to the organizational mission and staff turnover. Burnout can also lead to poor quality of care, as disengaged employees resist learning innovative practices and struggle to provide compassionate, person-centered care in the midst of overwhelming demands.
Although some interventions aimed at helping individual staff address burnout on their own have shown promise, a potentially stronger approach would also target the organizational contexts that impact burnout. Our study aimed to identify organizational contexts of both burnout and work engagement in mental health settings that might be used to inform organizational-level interventions. To do so, we interviewed 40 mental health managers and staff from two VA facilities and two non-VA social service providers regarding their thoughts on organizational elements that contributed to either burnout or employee engagement.
Addressing Work Inefficiencies
Either derived directly from participant suggestions or through inference about facilitators and barriers to employee burnout and engagement, we identified several potential categories of organizational interventions, primarily centered around:
- Addressing factors that contribute to work inefficiencies, and
- Supporting employee wellness and professional development.
A prominent idea for addressing work inefficiencies included close examination of performance metrics to refocus the organizational culture on high-quality, person-centered care over outdated performance metrics. We repeatedly heard study participants voice concerns that pursuing performance metrics actually undermines high quality care rather promoting it. Other suggestions included addressing burdensome administrative functions and regulations that delay filling needed positions or result in constant detailing of staff from one service to another. Others suggested streamlining administrative tasks and meetings (e.g., huddles where no one who attends has authority to address critical issues), as well as reducing documentation burden (e.g., unnecessary clinical reminders). Another subtheme of suggestions revolved around encouraging managers to get more "in touch" with direct clinical care, such as having a physical presence in direct care settings. Addressing communication gaps both within a workgroup and across workgroups was also seen as essential in achieving efficiencies (e.g., conflict resolution).
Another subtheme involved evaluating personnel accurately so that the system works well.
Perhaps on the "easier" end of this spectrum, several participants suggested recognizing high performance from employees with informal but genuine recognition over more formal mechanisms likely to become bogged down by bureaucratic processes. On the more difficult end of the spectrum, several respondents spoke of the need to hold poor performers accountable via either constructive feedback or formal administrative steps (e.g., performance improvement plans, termination for those who refuse to improve). Lastly, several participants highlighted the need for management to actively address bureaucracy, rather than simply accept it as the normal way of doing business (e.g., avoid requiring decisions to be approved at multiple levels of facility). Several participants cited the benefits of autonomy and trust from their management to schedule their own patients or utilize more flexible work schedules. We should note that managing for maximum autonomy also assumes that organizations can legally and skillfully address poor employee performance when that trust is violated. Lastly, some VA staff found the alignment of management structure by discipline (e.g., social work, nursing) rather than by the often multidisciplinary programs that serve Veterans (e.g., mental health intensive case management, psychiatric rehabilitation and recovery center) produced a convoluted reporting structure frustrating to both clinicians and managers alike.
Prioritizing Worker Well-Being and Professional Development
Several suggestions for improving employee engagement involved organizations prioritizing worker well-being and professional development. Some participants felt managers could recognize and address burnout by encouraging self-care strategies amongst employees (and employing strategies for themselves). Other participants, particularly VA professionals, endorsed professional development in key skill sets as an attraction to VA employment. Some expressed concerns that those opportunities had diminished in recent years, citing travel bans and regulations on training session attendance. Some participants endorsed the value of opportunities to lighten monotonous clinical duties via diversifying work tasks (e.g., committee work, mentorship). Many participants also highlighted the benefits of social cohesion with their work group or other coworkers for keeping them engaged at work, such as informal activities (e.g., lunch with coworkers) and retreats.
In conclusion, burnout has serious consequences for organizations. VA and other healthcare organizations could focus on management structure and skills, as well as streamlining bureaucratic policies and processes to support staff in reclaiming their mission to provide high quality care to Veterans. Many of our findings are potentially generalizable to a variety of VA service settings.
Angela Rollins, PhD
HSR&D Center for Health Information and Communication
Improving Care Coordination within VA Patient-Aligned Care Teams
Sylvia Hysong, PhD
Poor care coordination is pervasive and a principal cause of avoidable morbidity, mortality, resource use, and patient and health care team dissatisfaction. Veterans are in particular need of optimal care coordination, given that many suffer from comorbid conditions, mental health problems, and a challenging socioeconomic environment. Multidisciplinary care teams, such as VA Patient Aligned Care Teams (PACTs), have been proposed as one of multiple strategies to improve care coordination in the primary care setting. For such a strategy to succeed, PACT members must excel at the act of coordinating, including working collectively on interdependent tasks to deliver evidence-based care that could not be accomplished as effectively by a single provider. However, the ability to monitor team coordination is still in its infancy; current measures of care coordination focus primarily on utilization outcomes, such as hospitalization or Emergency Department utilization. A clear understanding of the objectives and standards of coordination, as well as the information needs at the point of care, are essential to successfully coordinating care.
The objective of this study was to determine the point-of-care information PACT members need to successfully coordinate care. As part of our VA HSR&D funded Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) project - Improving Quality and Safety through Better Communication in PACTs - we partnered with clinicians and leadership in the Great Lakes VA Healthcare System (VISN 12) to accomplish the following objectives:
- Develop a system of objectives and prioritized performance metrics specific to coordination in primary care;
- Assess the effect of using this measurement system on clinicians' coordination behaviors; and
- Determine the specific information needed at the point-of-care to improve coordination and recommend point-of-care aids for delivering the information.
Laura Petersen, MD, MPH, FACP
The study consists of three phases. In phase 1, we employed the Productivity Measurement and Enhancement System (ProMES),1 a structured approach to performance measure creation from industrial/organizational psychology, to develop coordination measures with a design team of 6-10 primary care personnel. The ProMES method is unique in engaging actual frontline workers in developing measures of their own work effectiveness. We partnered with a design team of primary care clinicians from the Union Grove Community-Based Outpatient Clinic and the Milwaukee VA Medical Center, and an advisory team of clinicians and leadership from multiple facilities within VISN 12 to identify two objectives PACTs are trying to ultimately accomplish through their coordinated efforts:
- Support and foster Veteran engagement in their wellness by being patient-centered, and
- Ensure that Veterans receive high-quality, efficient care.
Based on these objectives, the design and advisory teams identified and prioritized a set of eight indicators intended to measure the PACTs' effectiveness at achieving these two objectives; each indicator is prioritized by the degree to which it contributes to effective coordination.
In phase 2, we conducted focus groups with the phase 1 design team to identify point-of-care information needs. We are in the process of analyzing the learnings from these focus groups to develop recommendations. Phase 3 is a two-arm field experiment. PACTs receiving the intervention will receive monthly, tailored, web-based feedback reports of their scores on the measures developed in phase 1. In addition, PACTs will meet monthly to reflect on the feedback and identify solutions to improve coordination broadly, rather than improvement on individual scores. Control arm PACTs will receive no intervention. We are currently recruiting PACTs to begin this phase.
Our partnership with VISN 12 has truly highlighted the engagement of the clinicians who gave hundreds of hours of their collective time to help develop this metrics system. They are eager to see the results of their efforts through their participation in Phase 3. Our partnership has also borne additional scientific fruit, including a peer-reviewed publication proposing reporting standards for partnered research,2 co-authored by VISN 12 leadership and our research team.
This model of partnership facilitated by HSR&D CREATE funding between research and operations - during the research and implementation process - has the potential to result not only in new clinical innovations, but also in a heightened level of employee engagement that will improve the VA experience for employee and patients alike.
Sylvia Hysong, PhD and Laura Petersen, MD, MPH, FACP
Principal Investigators: Improving Quality and Safety through Better Communication in PACTs
1. Pritchard R, Weaver S, and Ashwood E. Evidence-based productivity improvement: A practical guide to the productivity measurement and enhancement system. 2011. New York: Routledge Academic.
Hysong S, Woodard L, Garvin J, et al. Publishing protocols for partnered research. Journal of General Internal Medicine. 2014;29(Suppl 4):820-824.