A Journey Toward Quality, Performance for Maryland VA

A Veterans Affairs health system identifies its weaknesses and rebuilds itself using a multifaceted, team-based approach grounded in engaged, thoughtful leadership.

ABSTRACT: In 2014, the VA Maryland Health Care System was one of the lowest-performing health care organizations in the Veterans Affairs Health Administration. Low employee morale, significant employee turnover, long-term patient dissatisfaction, low quality indicators, underfunding and a lack of organizational focus and priorities all demonstrated the need for leadership, vision, priorities and organizational focus. The authors describe a two-year process to achieve a high-quality, high-performance organization through key leadership changes, critical decisions and cultural initiatives, and the outcomes they realized.

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In late 2014, the Veterans Affairs Maryland Health Care System successfully passed its triennial accreditation survey, but January 2015 brought the system a series of unplanned executive personnel changes that accompanied long-term staffing shortages, low employee morale, significant employee turnover and long-standing patient dissatisfaction. That led to a two-year journey toward creating a high-quality, high-performing organization — which emphasized the leadership changes, critical decisions and cultural initiatives aimed toward creating organizational excellence.

The system consists of the Baltimore VA Medical Center, an acute-care hospital that also serves as a primary medicine and surgery residency training site for the University of Maryland Medical School and several other affiliates; the Perry Point VA Medical Center, which has mental health programs, a nursing home, subacute rehabilitation beds, and 20 acute/subacute medicine beds; the Loch Raven VA Community Living and Rehabilitation Center, a nursing home and acute/subacute rehabilitation facility; and five geographically distributed out-patient clinics.

The system includes the Baltimore VA Medical Center, an acute-care hospital that serves as a primary medicine and surgery residency training site for the University of Maryland Medical School. | va.gov

In December 2014, the system had approximately 3,490 employees, or 87 percent of the authorized 4,000, after years of hiring freezes, budget shortages and budget cuts.

In fiscal year 2015, access to VA Maryland Primary Care services was challenging; it was not unusual for veterans to wait more than 30 days for their scheduled appointments. The system’s quality and patient-safety programs were experiencing long-term personnel and leadership shortages, and organized medical staff participation in quality and safety activities was lacking.

While root cause analyses were being performed, they seldom identified systems issues needing correction. Employees rarely stopped unsafe acts or questioned breaches in safety protocols that were designed as safety nets for patients and employees. Preventable errors and near misses were occurring, but the system's employees were either afraid to file incident reports or apathetic about filing them. Many system employees, including residents and their attending physicians, believed there was no credible culture of safety.

In fall 2014, the VAMHCS scored in the fifth quintile — the lowest — for employee satisfaction. Teamwork and collaboration suffered because of chronic personnel shortages, a lack of leadership emphasis, and a lack of interdisciplinary communication and cooperation. Veterans routinely and formally informed system leaders of their sustained dissatisfaction; this dissatisfaction was documented over years of patient satisfaction surveys. In 2014, scores across care sites ranged from 14 percent to 86 percent for 14 key outpatient measures.1

There also were frequent conversations regarding safe nurse staffing levels, but even if the staffing model could have been adjusted upward, nursing shortages would not have allowed a significant increase in skilled nursing coverage. Although the chief nurse executive previously established committees for quality/performance and senior nursing leaders, the health care system never formally recognized either of these entities. As a result, nursing issues were not formally or routinely addressed by the system’s governing body.

By December 2014, there were pervasive clinical and satisfaction issues among employees and patients. However, like most health systems, there were pockets of dedicated staff and superb customer service throughout the VAMHCS.

A New Start: Leadership Matters

After serving as the 34th U.S. Army Chief of Staff and retiring, Gen. Eric Shinseki returned to federal service in 2009 as the Secretary of Veterans Affairs. His experiences in a values-based organization motivated him to establish the VA’s ICARE (Integrity, Commitment, Advocacy, Respect and Excellence) value program.2 These values aimed to define the VA’s culture and strengthen its dedication to those it served. They also were designed to provide baseline behavior standards expected of all VA employees. The values were briefly discussed during the system’s new-employee orientation, but the core values were not routinely discussed, emphasized or demonstrated by system leaders or employees.

Key leadership changes provided the opportunity for the system to begin a journey toward becoming a high-performing organization; three new physician leaders and a current nursing leader were integral to these change management efforts.

In January 2015, two new physician leaders were placed into the system’s top two positions — one as the director/CEO (a career Navy Medical Corps officer and a Certified Physician Executive) and the other as the chief of staff/chief medical officer (a career VA physician and leader). A non-VA physician, also a Certified Physician Executive, was hired to lead the system’s quality, patient safety and performance improvement programs. The system’s chief nurse executive was a valuable resource in this work, given previous success in establishing credible quality and performance improvement programs for nursing units and for the system’s two nursing homes.

In true military fashion, the new CEO took charge and quickly established a collaborative, accountable senior leadership team that included the new CMO, the CNE (a certified/advanced nursing executive with many years of civilian and VA leadership experience), and the associate directors for operations and finance. This leadership team's initial priorities included demonstrably delivering on the promise to provide high-quality health care in a reliable and safe environment; ensuring C-suite members were routinely visible to the system's patients and staff; and soliciting, listening to and understanding the constructive and actionable feedback provided by patients and employees.

The CEO instituted a “don’t wait for permission, just do the right thing for our patients” management philosophy that empowered leaders at every level and site of the organization. The new leadership team also adopted and embraced the VA’s ICARE Values as the basis for leader and employee performance and behavior expectations, especially as it pertained to the treatment of patients, their family members and fellow employees.

Organizational Quality and Patient Safety

The newly hired physician leader quickly transformed the Quality, Safety and Improvement service, reorganizing and refocusing staff and efforts. It focused on the key characteristics of high-performing, highly reliable health care organizations and on the importance of making “improvement” both an organizational priority and a performance expectation. Foundational to these discussions was the importance of the VA’s ICARE values.

Delivered throughout the organization, these discussions consistently ended with an “encouraging invitation” for all employees to serve as quality and safety officers. The senior leadership team became transformational partners by frequently discussing and encouraging quality, patient safety and performance improvement concepts and behaviors. The QSI director began rebuilding his own service while also encouraging fellow physicians to begin participating in the system’s quality, patient safety and PI programs.

Working closely with the chief of risk management/patient safety, the CMO and the CNE, the QSI director renewed a system focus on health care activities. He also encouraged incident reporting to identify errors and variances that could lead to patient or staff harm. The team implemented a nonpunitive, post-incident, post-near-miss “huddle” that clarified the facts and correctly identified incidents before their formal reporting. The QSI director also instituted a management review of all root cause analyses to ensure systemic causes of incidents were identified and addressed.

One important area of discovery was the supervision of medical and surgical residents and clinical fellows. Attending physicians seldom were present beyond the time allocated for formal attending rounds, and they seldom were called for assistance outside of rounds. Residents were independently managing VA patients most hours of the day, placing patients at unnecessary risk.

The QSI director and the CMO quickly published and maintained a dynamic list of criteria that man-dated a verbal discussion between residents and attending physicians, regardless of when the criteria were recognized.

Governance Observations

Complicating the quality and safety issues was a governance structure that was poorly organized for success. Each month the same lengthy monitoring reports were provided to every executive-level committee and to the health care system’s governing body and senior leadership team — but seldom did these reports include identification of key issues or recommendations for corrective action.

The system’s executive governing body committee also wasn’t routinely reviewing or assessing the effectiveness of the health care system’s quality, PI and patient-safety programs. Because of the “monitor and report” approach, the governing body and senior leadership team infrequently were informed of system-level issues requiring executive leadership intervention. The governing body similarly did not have a routine forum for formally discussing strategic objectives, milestones or the desired future of the system. The QSI director began sharing these governance observations and potential solutions with the CMO, the CNE and the CEO’s senior adviser.

The 2014 crisis that surfaced at the VA system in Phoenix, Arizona — which included months-long waits for veterans seeking health care — motivated Congress to provide additional budgetary resources to VA health care facilities. The new Maryland CEO approved hiring clinicians and support personnel to solve the system’s long-standing access issues.

In addition to focusing on cultural transformation, the new QSI director spent the first six months observing the demonstrated leadership capabilities and competencies of the organization’s clinical leaders while also reviewing the content of the system’s clinical leader development program. He identified a significant knowledge and experience gap caused by an inadequate clinical leadership development program — many clinical leaders lacked basic knowledge of health care management, and most were untrained in the art of leadership. The QSI director shared his clinical leadership competency observations and recommendations with the CMO and the CEO. The CNE, realizing there was inadequate leader development within the nursing ranks, created a “boot camp” for front-line nursing supervisors. But there was no equivalent national, regional or local training program for the VA’s clinical leaders.

Equally apparent was an inadequate understanding by medical and surgical residents of the system's renewed trans-formational efforts in quality and patient safety. The QSI director empowered a new chief resident for quality and safety to resolve this gap. The chief resident routinely trained rotating residents on the system’s requirement for verbal discussions with their attending physicians, and educated residents on the system’s new quality and patient safety expectations. These efforts had an immediate and sustained impact on improving communication between residents and VA employees, on in-creasing their participation in quality and patient safety activities, and on increasing their incident and near miss reporting.

With the invigorated emphasis on quality and safety, there were renewed discussions about nurse staffing levels and the adequacy of nationally recognized nurse staffing models for providing a safe care environment. The CNE began exploring staffing options when the CEO was ready, in the interest of quality and safety, to hire additional nursing staff.

Meanwhile, the CEO remained concerned about the system’s historically poor performance on patient satisfaction surveys. The CEO and the CNE were concerned equally about the high rate of nursing turnover. To improve these areas, the CEO established patient and staff focus groups in summer 2015. These groups provided system leaders with an understanding of the current condition of the system; they also articulated their recommendations for making the system both a great place to receive health care and a great place to work. One key issue articulated by both employees and staff was the need for leader and staff accountability.

Equipped with this fresh information, the leadership team had a clear understanding of the major issues preventing organizational excellence; the team quickly began implementing additional changes designed to create a high-quality, high-performing organization.

System Initiatives and Programs

By the end of 2015, focused hiring and onboarding efforts allowed the system to transition from 40 partially filled primary-care teams to 50 fully staffed teams. Simultaneously, clinical leaders began standardizing clinical templates and articulating clear productivity expectations.

Working with the CEO’s senior adviser and the CMO, the QSI director reorganized the system’s governance structure. The CNE’s nursing quality and performance improvement committee was formally recognized, defined and included in the system's overall quality program. The senior nursing leadership committee also was formally recognized, defined and required to routinely report to the governing body. Similarly, the executive quality committee was directed to begin routinely reporting all outstanding accreditation and regulatory issues to the governing body, as well as the planned actions for resolving them. These changes resulted in meetings becoming productive, efficient and resolution-defining — and they ultimately allowed the governing body a formal opportunity to review and discuss strategic issues and objectives.

Using core competencies defined by the American Association for Physician Leadership®,3 the QSI physician leader developed and proposed implementing a training program to fill the knowledge gap identified in the system’s clinical leaders. The CMO and the CEO endorsed the QSI director’s clinical leadership training recommendations. The result was a six-day didactic and experiential clinical leadership skills academy that was implemented in a full day of training each month over the course of six months. Upon completion of this academy, a quarterly professional development program was established for all leaders, conducted by the system’s executive leadership team and facilitated by the QSI director.

Based on overwhelming feedback about comparatively low nursing salaries, the CEO initiated a formal nurse salary survey designed to identify fair pay based on geographical areas of work. Simultaneously, the CNE implemented a new methodology that increased overall staffing and ensured safe levels were consistently calculated, planned and provided on the system's inpatient and extended care nursing units. To ensure a common understanding of nursing leadership goals and expectations, a monthly nurse leaders’ professional development forum, designed to address and improve the core competencies identified and defined by the American Organization of Nursing Executives, was established. To improve patient satisfaction and ensure timely service recovery, the CNE adopted, implemented and required the routine use of Studer principles by the system’s nursing leaders.4

Establishing an Organizational Vision

The CEO understood the importance of establishing a common vision when beginning a journey toward organizational excellence. After sharing his initial ideas, the CEO, the CMO and the QSI physician leader collaboratively created an organizational vision for patient and family-centered care based on the VA’s ICARE values. Each value was clearly defined, and the vision was graphically designed to simplify understanding.

Senior leaders began discussing and explaining the importance of the organizational vision during leadership meetings, during clinical and nursing leadership training forums, and during newly established patient and employee town hall meetings. Almost every staff member learned to explain the equal importance and prioritization of patients, patients' families, and staff, and they were also able to explain the importance of staff members demonstrating the system's core values as a foundation for achieving the vision.

Believing the system's chronically poor patient satisfaction scores represented an ethical leadership issue, the CEO directed the system's designated clinical, clinical support, nursing and administrative senior leaders to begin discussing their action plans and milestones for improving satisfaction in their areas of responsibility. These presentations were facilitated by the QSI director, and they occurred during the system's Integrated Ethics Council meetings, routinely attended by the entire executive leadership team and senior leaders.

Organizational Outcomes

All of these actions have been sustained since implementation. The overall result of the clinical and clinical support-focused hiring effort, standardizing clinical templates and articulating clear productivity expectations was the attainment of same-day primary-care access, and the reliable scheduling of primary-care appointments within 30 days, both by the end of 2016, and sustained over time.5

As a result of this improved and sustained access, the system is projected to realize a reduction of 7,739 emergency department visits and 232 preventable hospital admissions in fiscal 2017. These tangible improvements equate to a cost savings of nearly $11.8 million for the VA Maryland Health Care System.

Clinical and nursing leaders consistently demonstrate improved business acumen and the ability to appropriately manage common personnel issues. This was due in large measure to the clinical and nursing professional development programs administered by the CNE and the QSI physician leader.

The CNE's decision to revise the nurse staffing model resulted in increased nurse staffing levels throughout the system. These staffing changes directly correlated to an overall increase in reported errors, near misses and incidents by all staff members — but a decrease in errors, incidents and near misses directly attributable to nurse staffing shortages.

The 2015 nurse salary survey demonstrated the system had a significant salary gap for the central Maryland region. Despite the budget impact, the CEO implemented an un-planned, across-the-board nursing pay raise to correct the salary gap. These focused improvements resulted in the lowest nursing turnover rate in years. Most of the VAMHCS nursing turnover is now caused by retirements and transfers rather than resignations or removals.

System leaders and employees now are consistently held accountable for their performance and behaviors at all organizational levels. Accountability has become a system that is reviewed and assessed during root cause analyses. Performance bonuses and awards are linked to staff consistently achieving performance goals and expectations.

The system’s last two employee surveys demonstrated significant and sustained improvements. The results of the fall 2015 survey demonstrated an overall increase from the fifth (worst) quintile to the third quintile, and these improvements were sustained in fall 2016. Some employees chose to leave the system soon after accountability became an expectation, but most stayed. Most of them are committed to the organizational vision and core values. Patients also are articulating satisfaction in surveys.6

System physicians are actively involved in quality and PI activities, and they have become enthusiastic members of interdisciplinary teams dedicated to delivering quality care in a reliable and safe manner. Organizational quality and performance improvement committee meetings are now filled with discussions of relevant clinical projects, and the project owners and committee leaders consistently address, track and correct system issues. New endeavors include nursing-sensitive measures, such as falls and pressure ulcer prevention, post-operative wound-infection prevention, and the diagnosis and management of chronic lung disease.

The system’s two medical centers began the journey toward excellence as one-star facilities, with many significant health care measures performing at the 30th percentile (or lower) compared to other VA facilities. However, after two years of focused leadership actions, employee buy-in, and high-quality and sustainable interventions, the majority of these performance measures now register between the 50th and 90th percentiles — with some at the top, compared to similar VA facilities. Both medical centers became three-star facilities in 2017.7

The governing body is now consistently provided with analyzed and actionable information, and corrective actions are tracked to completion in all system committees and subcommittees. The governing body routinely reviews and assesses the effectiveness of the quality, PI and safety programs — and finally is able to focus on strategic priorities, establishing strategic objectives and defining achievable completion milestones.

Conclusions

The system’s quantifiable and sustained success results from a multifaceted, team-based approach grounded in engaged and thoughtful leadership. The CEO is a physician leader who understands success and the necessary changes to create a high-performing organization. The CEO built and empowered an effective senior leadership team and held leaders account-able for outcomes. He also understood the importance of establishing an organizational vision that was simple, effective and grounded in core values — and this vision became a rally flag for organizational success.

The CEO also understood the value of physician leadership; he broke several VA traditions by hiring a Certified Physician Executive to serve as the leader of the quality, patient safety and performance improvement service. Hiring a physician leader became a strategic investment that paid significant organizational dividends — the organization's quality, patient safety and PI programs have become models of collaboration and sustained performance. The system's culture of quality, safety, performance improvement and employee investment are palpable to staff, patients and visitors alike.

The CNE is a nursing leader who also understands success and how to implement effective changes — she developed her leadership team, implemented action plans and held her leaders accountable for the performance of their areas of responsibility. Her collaboration with the QSI physician leader magnified the system’s ability to produce positive clinical out-comes, patient satisfaction and employee retention.

Leadership made a positive difference for the system, and it will be key to sustaining these improvements. The system’s journey is not yet complete, however; its overall goals for organizational success include recognition as a five-star health care entity, achieving and sustaining total patient satisfaction, and reaching the first quintile in employee surveys. Sustained excellence will require competent, caring, engaged and visible leaders who consistently demonstrate their ongoing commitment to an organizational vision, core values and accountability.

James Gregory Jolissaint, MD, MS, CPE, FAAPL, is vice president of military and veterans health for Trinity Health and Holy Cross Health System in Maryland. He is the former director of quality, patient safety and performance improvement for the VA Maryland Health Care System. He is also chairman of the American Association for Physician Leadership's board of directors.

Sheila Bryson-Eckroade, RN, MEd, NEA-BC, is associate director for patient care services and chief nurse executive for the VA Maryland Health Care System.

Adam M. Robinson Jr., MD, MBA, CPE, is chief executive officer of the VA Maryland Health Care System.

Vamsee Potluri, MHA, MBA, is the ambulatory care operations director-group practice manager for the VA Maryland Health Care System.

REFERENCES

1. VHA Office of Analytics and Business Intelligence – Patient Experience. U.S. Department of Veterans Affairs, vaww.car.rtp.med.va.gov/programs/shep/shepreporting.aspx. Accessible via Veterans Affairs networks.

2. VA ICARE Values, va.gov/icare .

3. American Association for Physician Leadership website, physicianleaders.org.

4. Studer, Quint. Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference. Fire Starter Publishing, 2003 (first edition).

5. VHA Office of Analytics and Business Intelligence, Access/completed appointments cube. U.S. Department of Veterans Affairs, bioffice.pa.cdw.va.gov/default.aspx?bookid=feed0662-25f3-4e84-832c-66b859eb8eb8|ispasFalse|report586c0ec4-3a8a-4923-a543-7d76269efbd4|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue. Accessible via

6. Veterans Affairs networks.

7. VHA Office of Analytics and Business Intelligence – Patient Experience. United States Department of Veterans Affairs, vaww.car.rtp.med.va.gov/programs/shep/shepReporting.aspx. Accessible via Veterans Affairs networks.

8. Strategic Analytics for Improvement and Learning. VHA Support Service Center. U.S. Department of Veterans Affairs, https://www.va.gov/QUALITYOFCARE/measure-up/Strategic_Learning_SAIL.aspAnalytics_for_Improvement_and_