Health Services Research & Development

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Practicing, Teaching, and Researching in an Era of Transformational Change

Since publication of the Institute of Medicine (IOM) report titled Crossing the Quality Chasm, much attention has focused on change within the culture of health care delivery systems. Within VHA, the culture shifts may be characterized as transformational. The shifts influence not only the larger VHA health care delivery system but also the changes required by individual providers in the delivery of health care, and in our medical education and research priorities. Importantly, our culture must also address the changes occurring to our Veterans themselves, both as individuals and as a population.

During the latter part of the 20th century, organizational change emerged as a science unto itself. Much has been written about the need to manage and lead change; this work has made clear the role of leaders in championing change and the need for proven methodologies in instituting change. During the same time, system management and change emerged as a core component of graduate medical education.

In 2007, VanDeusen Lukas et al published findings critical for success in health care system change within VHA. 1 Their work demonstrated not only consistency between change in VHA and other health care delivery change models but also highlighted the required components of effective organizational transformation. These components include communicating the need for change, aligning and integrating change activities across all levels of a health care organization, and pairing leadership engagement with process improvement activities.

The changes in the health care delivery system motivated by the Affordable Health Care Act, combined with the continued evolution of health care technologies such as e-connected medicine and the growth in patient engagement and expectations, have all contributed to a rapidly changing environment. In recent years, numerous initiatives have led to improvement and cultural change throughout VHA. As a result, VHA, in partnership with Veterans' families, our students, and our trainees, is now engaged in building a culture of data-based continuous improvement to meet the ever-evolving needs of our Veteran patients.

Of equal importance to the system-wide and cultural changes occurring within VHA, changes are taking place in the individual- and population-based care of our Veteran patients. Dougherty and Conway outlined the 3Ts of transformative change, providing insight into the characteristics of such change. 2 The practice of medicine continues to move toward biomedical research strongly linked to clinical efficacy research (T1), thereby better defining the knowledge used in individual care decisions. T1 is balanced by improved population health achieved through outcomes, comparative effectiveness, and health services research—and translation of research into evidence-based tools for both clinicians and patients (T2). These practices, accompanied by effective measurement systems based in the domains of health care value (technical quality, access, satisfaction, and efficiency), comprise the third component (T3) of a culture that is able to adapt to and satisfy the requirement for continuous improvement.

By applying the 3Ts across VHA practices, we can improve the care of our patients while aligning our research and educational missions. In fact, the 3Ts are reflected in our transformational initiatives around the Patient Aligned Care Team, Mental Health Integration, and E-Health initiatives'and through new sources of feedback, such as Patient Almanacs, Inpatient Evaluation Center, and Corporate Data Warehouse reports. Creating a culture of patient care decisions at the individual level, or an N of one patient, supported by population analytics or an N of 1,000, defines the proactive, patient-centered culture envisioned by large integrated health care delivery systems.

Change throughout the broader health care delivery system and research-driven individual patient care plans are necessary components of a successful organizational culture. Changes in our Veteran patients' attitudes and expectations will more clearly refine both present and future culture changes. Enhanced engagement of patients in their care planning and self-management decisions will be central to reaching VA's goal of improved Veteran well-being and improved population health.

New educational methods and research efforts, such as those described by Dr. Weiner, are needed to understand this new dynamic and are important to effective organizational change. System and individual changes associated with an increased awareness of health care equity and literacy are key to achieving the desired care outcomes. Furthermore, these changes are necessary if VHA is to continue providing the high-quality medical education needed to develop the workforce to sustain a new culture. Through improved analytics, individualized care plans will change how we measure and achieve enhanced patient wellness, shifting from an absolute process-based outcome to an individually tailored outcome. "Patient centeredness" will redefine the journey of improvement from one that not only focuses on the application of evidence-based information but one that also addresses how such information is delivered and aligned with individual goals.

Culture change is complex, continuous, multivariate, and essential to the effective delivery of health care services within VHA. The continued evolution of culture and practice is the only component of our system and practice that will not change. New models, methods, measures, technologies, and expectations are constantly emerging. VHA welcomes innovations in a culture that values safety, understands risk, redesigns systems, improves care based on data, and engages patients while honoring their preferences. At the same time, VHA will integrate leading-edge research and effective medical education to ensure that future generations effectively serve those who have served.

  1. VanDeusen Lukas, C. et al. "Transformational Change in Healthcare Systems: An Organizational Model," Health Care Management Review 2007; 32(4):309-20.
  2. Dougherty, D. and P. Conway. "The '3T's' Road Map to Transform U.S. Health Care. The How of High-Quality Care," Journal of the American Medical Association 2008; 299(19):2319-21.