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Change in Health Care

The Imperative

The national consensus for change in health care comes from increasing awareness of inadequate access, variable quality, high costs, and mediocre outcomes, as well as the realization that economic stability requires we address these shortcomings. While VA may have demonstrated superior performance in access, quality, and outcomes, we are not exempt from this imperative. In areas such as polytrauma, advanced prosthetics, and comprehensive mental health services, the pace of change in VA has been significant. Yet, in January 2009 testimony to the Senate Veterans Affairs Committee, Secretary of Veterans Affairs, Eric Shinseki emphasized the need, not simply for more of the same, but instead for fundamental transformation into a "21st Century Organization." He characterizes this as:

• Centering on Veterans as clients, not simply users. We design, implement, and evolve our services to meet the changing needs of Veterans through an engaged, inspired, and empowered workforce.
• Focusing on results, particularly the timeliness, quality, and consistency of our services We set and meet objectives for improved access, high-quality care, and exceptional client relationships, using world-class technology and business processes, leadership, accountability, and attention to effectiveness.
• Forward looking. We anticipate Veteran needs and are proactive in meeting them, through an innovative, Veteran-focused culture, effective communication, and systematic outreach and collaboration.

As Army Chief of Staff from June 1999 through June 2003, General Shinseki transformed a high fixed-cost, Cold-War legacy into an agile, versatile, and flexible fighting force able to respond rapidly to emerging threats. Many parallels to health care can be drawn from the Army's transformation.¹

A Compelling Vision

Those that study organizations closely have observed that change is less about data, analysis, and strategic planning than about a compelling truth that shapes feeling and motivates action. We appreciate as much in clinical practice--the smoker won't quit by being presented statistics, but only after seeing the benefit that quitting produces.

Within VA, the vision for change takes the form of Veteran Centered Care. This involves anticipating patient needs by defining the delivery system and aligning our services around mutually negotiated needs and goals. The care we provide, whether local or regionalized, in-house or purchased, will reflect the longitudinal needs of patients rather than the expertise of specialized clinicians. As a result, VA will increasingly orient care around interdisciplinary teams that share decision-making with patients and families. Among the key principles of such care are:³

• Honoring the Veteran's expectations of safe, high quality, accessible care.
• Enhancing the quality of human interactions and therapeutic alliances.
• Soliciting and respecting the Veteran's values, preferences, and needs.
• Systematizing the coordination, continuity, and integration of care.
• Empowering the Veteran through information and education.
• Incorporating the nutritional, cultural, and nurturing aspects of food.
• Providing for physical comfort and pain management.
• Ensuring emotional and spiritual support.
• Encouraging the involvement of family and friends.
• Providing architectural layout and design conducive to health and healing.
• Introducing creative arts into the healing process.
• Supporting and sustaining an engaged workforce.

The success of this vision will require exceptional attention to coordination of care. In health care, coordination means connections among interdependent people who transfer information toward the goal of advising and enabling the patient and organizing care for the purpose of optimizing the patient's health status. Despite many strengths (including computerized health records and primary care teams), coordination of care remains imperfectly realized within VHA. Key challenges include strengthening primary care teams, establishing new systems for information exchange for Veterans that get part of their care in the private sector, assigning care coordinators for high risk Veterans, and fully leveraging information technology to enhance communication.

This vision also involves significant rethinking of access to care. Veterans deserve timely access to quality health care which meets or exceeds internal and community standards and is measured by their expectations. Such access should not depend on proximity of fixed infrastructure such as hospitals, but rather utilize new modes of care delivery supported by technology.

Inquiry and Learning

The weight of experience makes it harder to change. This includes past VA transformations. Lifelong learning demands we shed old habits and question our assumptions. For the health services research community, old patterns include the three to five year duration of projects (the window for transformation will be shorter than 36 months), the selection of "safe" hypotheses and methods (peer review may need to be recalibrated toward risk-taking and speed), and a predilection for analyzing the past rather than creating the future (rapid cycle, actionoriented research is more needed than ever). Shedding these old habits will require unprecedented speed and agility as well as the willingness to roll up sleeves and learn through our actions, successes, and failures. This won't be easy for a number of reasons, yet our Veterans deserve nothing less.

References

1. Frontline documentary, "The Future of War," October 24, 2000.
2. Kotter JP. "The Heart of Change." Boston: Harvard Business School Press, 2002.
3. Department of Veterans Affairs. Veterans Health Care: Leading the Way to Excellence. Report of the Universal Services Task Force. April 2009.
4. Suzuki S. Zen Mind, "Beginner's Mind." New York: Weatherhill, 1970.