1. VA Psychology Leadership Conference
Jill J. Draime, Psy.D.
VHA National Center for Organization Development

2. Flow of Today’s Presentation
Share the current context and realities for VHA as an organization and VHA leadership specifically
OIF/OEF and Mental Health
VHA’s Performance Management System
Who is NCOD and what have we learned about the organization that might be helpful to you?
How can psychologist leaders “Manage Up”?

3. VHA Current Reality

4. Veterans Health Administration
VHA Mission Statement
Honor America’s veterans by providing exceptional health care that improves their health and well-being
VHA Vision Statement
To be a patient-centered integrated health care organization for veterans providing excellence in health care, research, and education; an organization where people choose to work; an active community partner and a back-up for National emergencies

5. Veterans Health Administration
VHA Core Values
Trust
Respect
Excellence
Compassion
Commitment
VHA Domains of Value
Quality
Access
Function
Satisfaction
Cost Effectiveness
Healthy Communities

6. A Framework for Understanding VHA

7. Dynamics of the Enrollee Population – Growth Slows
VA is experiencing a dramatic slowdown in the growth of the enrollee population due to
Declining veteran population
Deaths in the Priority 8 enrollee population since the suspension of enrollment
Deaths in the pre-enrollee population (Enrollees who used VA prior to Eligibility Reform)
New enrollment of OIF/OEF veterans does not reverse the trends

8. Dynamics of the Enrollee Population – OIF/OEF Veterans
Many unknowns will influence the number and type of services that VA will need to provide OIF/OEF veterans
Duration of the conflict, when they are demobilized, impact of outreach efforts
Currently, OIF/OEF have different utilization patterns than non-OIF/OEF enrollees
They use about half as much inpatient acute medicine and surgery as non-OIF/OEF enrollees
They are expected to need three times the number of PTSD residential rehabilitation services as non-OIF/OEF enrollees
They have greater needs for physical medicine, prosthetics and outpatient psychiatric and substance abuse services

9. VA is requiring Significant Annual Increases in Appropriations for Medical Care
Like the broader health care community, VA health care costs are growing significantly
FY 2008 Budget submitted to Congress totals $36.5 billion, for a 8% increase over FY 2007
Significant annual increases in expenditures are projected to continue into the future
It is questionable whether these large annual increases are sustainable
Continued improvements in our health care management are critical in controlling these increases

10. Broader Health Care Industry Trends Driving the Increase in VA Expenditures
Trends impacting the entire health care industry account for the majority of the increase in expenditures from FY 2007 to FY 2008
Health care inflation
Advances in medical practice that impact the cost and utilization of services
Adoption of new, more expensive drugs and technologies

11. VA-Specific Trends Driving the Increase in VA Expenditures
Dynamics within the enrollee population drive almost a third of the increase
Aging of the enrollee population
Impact is somewhat dampened by enrollees’ declining reliance on VA after they qualify for Medicare
Enrollees transitioning to higher enrollment priorities
This trend is expected to increase due to the large number of veterans requesting reviews of their disability rating
Without VA’s efforts to efficiently manage health care utilization, the increase would be even higher
Continuous System Redesign/ACA, FIX (Flow Improvement Inpatient Initiative) critical as move forward

12. OIF/OEF and Mental Health Utilization
VHA Current Reality
OIF/OEF and Mental Health Utilization

13. Diagnoses by Broad ICD – 9 categories for 205,097 OIF/OEF veterans evaluated at a VA healthcare facility during FY
Diagnosis (ICD – 9 categories) Percent
Disease of Musculoskeletal
System of Connective Tissue
Mental Disorders
Symptoms, Signs, and Ill-Defined
Categories
Diseases of Digestive System
Diseases of Nervous System/
Sense Organs
Diseases of Endocrine/Nutritional/
Metabolic Systems

14. OIF/OEF Veterans Evaluated at VA Facilities Ranked by the Frequency of 3-Digit ICD-9 Diagnostic Code for the 10 Most Frequent Mental Disorders
Disease Category (ICD-9 Code) # of OIF/OEF Veterans
Adjustment reaction 42,543
Nondependent abuse of drugs 28,732
Depressive disorder 23,462
Neurotic disorders 18,294
Affective psychoses 12,386
Alcohol dependence 5,413
Sexual deviations and disorders 3,239
Special symptoms, not elsewhere 3,178
classified
Drug dependence 2,387
Acute reaction to stress 2,273

15. Mental Disorder Patients by Demographics
Percent

16. PTSD Patients by Demographics
Percent

17. Prevalence of Potential PTSD among New OIF/OEF Veterans Treated at the VA, FY 02-06
Percent

18. VHA’s Performance Management System
What is being asked of VHA Leaders?

19. Base
Camps
Congress
Budget
Patient Centered
Integrated Care

20. Future: Quest for the Summit
In preparation for the National Leadership Board’s Strategic Planning Summit, VHA Leaders were asked to identify the major challenges and barriers to moving to the next level of excellence
They identified the following 8 themes:
Service Delivery Logistics/Business
HR/Workforce Financial
Capital Infrastructure Info Systems/IT
Performance Measures Cultural Influences

21. Future: Quest for the Summit 4 Required Tools for the Quest for the Summit from Dr. Kussman
Transformational Leaders and Leadership
Shared vision
Common commitment to ethical leadership and VHA’s values
Accountable leaders with integrity, willing to take appropriate risks, competent in change management
Succession planning and developing our future leaders

22. Future: Quest for the Summit 4 Required Tools for the Quest for the Summit from Dr. Kussman
Unsurpassed Quality Patient Care
Industry leader in performance
Innovative clinical care and research (genomics, molecular medicine)
Cutting edge information systems and technology

23. Future: Quest for the Summit 4 Required Tools for the Quest for the Summit from Dr. Kussman
Coordinated Business Process Improvements
Coordinated initiatives to enhance the quality of patient services and to foster business integrity and compliance
Performance Measurement
Assess the outcomes of care provided to patients and the quality of our enabling infrastructure (e.g., IT, Business)
Provide an accountability framework for assessing the performance of the leaders, clinicians, and managers in VHA
To improve care by reducing variation across the system

24. Align Performance Organization Goals Dept F Dept F Dept E Dept C
Dept A
Dept D
Dept B
Dept F
Dept G

25. Align Performance Organization Goals Dept G Dept C Dept A Dept E
Dept D
Dept B
Dept F

26. Align Performance VA Strategic Plan VHA Strategic Plan
VHA Performance Measures
Network Director Performance Plans
Medical Center Director Performance Plans

27. Critical Elements (60% of the SES performance assessments)
Networks
Program Offices
CFO 6
COS
1-3
Surgery
1,3,4 MH
1,4,5 PC
1,2,4 PC
1,2,4 O
1-3 MH
1,4,5
Network Director / Program Officer
Responsible for
1. Pt Satisfaction-overall (PM)
2. Quality: HEDIS/ORYX
3. Access – no OIF/OEF on wait lists; no50%SC>30days on EWL
4. Mental Health – Initial Screen for PTSD, DEP, SUD & TBI
5. Business Operations (2 measures)
6.IT Security-vulnerabilities resolved
7. Environment of care – Actions Plans implemented based on EOC rounds, IG reports and Jt Comm, no serious findings
8. Organizational health – Actions Plans implemented on EmpSur
9. Org contribution/ collaborations
Network
Director
Resp. for
1 thru 9
Surgery
1,3,4
PCS
Program
Heads &
Chief
Consultants
Resp. for
1 – 5,
8 & 9
Card
1,3,4
Critical Care
1,3
Critical Care
1,3
Card
1,3,4
CFO 6
CFO 6
Facility
Director
Resp. for
1 thru 8
OQP
Prgogram
Leads
Resp. for
1 – 5,
7 - 9 PC
1,2,4
COS
1-3 MH
1,4,5
Surgery
1,3,4
Card
1,3,4
Critical Care
1,3
Critical Care
1,3
Surgery
1,3,4 MH
1,4,5
Card
1,3,4

28. Proposed Critical Performance Measures

29. Proposed Critical Performance Measures

30. Who is the VHA National Center for Organization Development and What might we have to offer you?

31. Definition of Organization Development
OD is a planned, long-range, systems and primarily behavioral science strategy for understanding, changing, and developing organizations and improving their present and future health and effectiveness.
Larger stated purpose of supporting overall ‘organizational health’
Often considered a subset of industrial/organizational psychology
NCOD has 18 psychologists on staff (clinical, social, etc.)
Nurse Executive
HR Specialists
Health Administration
Many current Executives want to work with us post-retirement
While it is listed as being a ‘primarily behavioral science’, it is also deeply rooted in focusing on systems – whether it is a small system (workgroup), a large system (medical center), or a significantly large system (VHA)

32. Process Consultation
The detailed exploration, analysis, and assessment of what is happening as group members work in the moment
The formulation of immediate interventions, putting them into action, while considering what form they should take and with what desired impact
The reasoned and intentional interventions by the consultant, into the ongoing events and dynamics of the group with the purpose of helping that group effectively attain its agreed-upon objectives

33. Process Consultation Content (role as an ‘Expert Consultant’)
The “What”
The work to be done; the Product; the Goal/Objective
Process (role as a ‘Process Consultant’)
The “How”
The approaches, procedures, rules, group dynamics, and styles of interaction
The Content can be viewed as the words; the Process as the music
In this role, you are coming in to assist the group in determining new ways of working together to achieve goals.
You always assume the have the answers to solve basic problems.
You remove (or address) the emotion from the situation.
Example: Physician in Northern California who openly stated that the problem with the organization is that too many administrative, non-essential persons were in decision-making situations and not enough persons who actually put their hands on patients. This happened at the onset of a two day retreat and people were immediately disengaged and ready to leave.
This is an example of our role as process consultant. We were not there to design for them a new organizational structure, but rather to identify underlying obstacles that were getting in the way of their moving forward as a high functioning organization, and then supporting an environment that allowed them to address these issues.
It does help to have a greater understanding of health systems. This builds credibility and facilitates your being able to engage members of the group.

34. VHA National Center for Organization Development
Organizationally, report to the VHA Management Support Office (MSO) in Washington, DC.
Oversee all VHA Human Resource policy activity
Oversee all VHA Leadership Development activity
Oversee all VHA Executive Leadership selections
Results in a position of being both an internal and external consultant to VHA entities
NCOD is funded directly at the onset of each fiscal year from VHA
Removes the financial limitation away from a Medical Center
Eliminates the need to financially contract on a case by case basis

35. VHA National Center for Organization Development
Assessments
VHA All Employee Survey
360/180-Degree Assessment
ECF Feedback and Critical Skills Assessment Center
Customized Assessment Instruments
Interventions
Civility, Respect, and Engagement in the Workplace
Executive Coaching
CO, VISN, and Facility interventions

36. VHA National Center for Organization Development
Research
Management Studies
Workforce and Leadership Development
Succession Planning
Leadership Transition Briefings

37. Scope of Work: Service, Workgroup or Program Office Intervention
Invitation, Contract
Leadership
Union
Client - Supervisor
Assessment
Standard instruments (surveys)
Confidential interviews
Observation
Feedback of data
Action planning (Role of process consultant vs. expert)
Ongoing follow up
Average contract is 6 months
Or mutual terminations

38. Scope of Work: National VHA Policy Support
Organizational Research:
Employee civility in the workplace; impact on patient satisfaction and clinical outcomes
Executive tenure at a Medical Center; impact on organizational outcomes (clinical, financial, employee satisfaction)
Executive Leadership Developmental Program effectiveness
Impact of organizational structure on outcomes
Effectiveness of various organizational interventions

39. Importance of Organization Development in Healthcare
Systematically, technically, politically complex organizations
All workgroups/programs are reliant on others within the system
Organizations of great diversity (that are not exclusive)
Professional training
Technical training
Overall scope and purpose
Stressful, emotionally charged work environments

40. THE MOST IMPORTANT THING ABOUT US IS...
We have a dream about employees coming to work with anticipation of personal growth, excitement, and the deep sense of accomplishment that results from being the VERY BEST

41. Fundamental Rules of Interaction
CIVILITY
Baseline Expectation
Fundamental Rules of Interaction
On-stage Behavior
Courtesy
RESPECT
Trust
Compassion
Ethics
Listening
Honesty
ENGAGEMENT
Authorized to act
Accountable

43. 2006 Relationship of Workplace Civility to Employee Overall Satisfaction (Black) and Intent to Stay with VA (Blue): Quartile Utility Analysis

44. CREW I Results

45. CREW II Results

46. Job Satisfaction Index

47. Organizational Assessment Inventory

48. Civility Index

49. Culture Survey

50. What are Psychologist Leaders facing in the current VHA environment?
What are the expectations going to be going forward?

51. Growth of Mental Health Programs
The mental health of veterans, especially OIF/OEF, is a major concern of our Congressional partners, the Secretary, and the leadership of VA and VHA
This has resulted in massive recruitment efforts for mental health professionals
This has resulted in significant funding increases earmarked for specific mental health initiatives

52. Growth of Mental Health Programs
Change in Expectations: How we do business will have to change
Care is being monitored by Congress
Provide best and most timely care to veterans, including contacting veterans returning who have not yet come into the VA
Responsiveness to veterans and their perceived needs
Increased scrutiny
Contact with and responsiveness to families

53. Growth of Mental Health Programs
Change in Expectations: How we do business will have to change
Will have to anticipate needed services
Will have to provide more services within an integrated system
Within Mental Health
With Primary Care
Will continue to get mandates to meet in a timely way
E.g., 100 OIF/OEF transitional patient advocates

54. One Example of Increased Scrutiny
In an article carried by 120 media outlets nationwide, the AP reports (5/10, Yen) “Veterans returning from Iraq and Afghanistan are at increased risk of suicide because not all Veterans Affairs health clinics have 24-hour mental health care available”, an internal review says. “An OIG report, the AP continues, found that nearly three years into the VA’s broad strategy for mental health care, services were inconsistent throughout the agency’s 1400 clinics… With about one third of veterans reporting symptoms of post-traumatic stress disorder, it is incumbent upon VHA to continue moving forward toward full deployment of suicide prevention strategies for our nation’s veterans”, the report stated. In a written response, the VA’s acting undersecretary for health agreed with many of the recommendations. Michael Kussman noted that the VA recently has placed suicide prevention coordinators in each medical center. The AP also notes the release follows high-profile suicide incidents in which families of veterans say the VA did not do enough to provide care.

55. Comments by Dr. Kussman at his Confirmation hearing
“I believe VHA has done an exceptional job of meeting the needs of our newest generation of veterans. But we still face many challenges. Among them are:
To improve our level of collaboration with our partners at the Department of Defense;
To enhance our ability to treat veterans with severe traumatic brain injuries, and to detect mild to moderate TBI where brain injuries are not immediately apparent;
To continue our search for the most effective therapies for Post-Traumatic Stress Disorder, and ensure those therapies are quickly distributed throughout our system and elsewhere;
To improve access for all enrolled veterans to our world-class care, from our newest veterans to our oldest; and
To meet the goal of the President’s New Freedom Commission on Mental Health to emphasize recovery, not stabilization, for every mentally ill veteran.”

56. What does this all mean for Psychologist Leaders?
Ways to “Manage Up”

57. Managing Up
Both Nationally and Locally, with the significant increased funding for mental health initiatives, comes accountability and responsibility
For outcomes
For sound financial practices
If you don’t have a strong relationship with your local leadership, you will need to work on developing one

58. Managing Up
We’ve talked about: What leaders are being asked to do (from the USH); What they are being held accountable for (PM system); The level of scrutiny they are under (AP article)
Your job is to have the local conversation
What do they want to hear?
How often?
In what format?

59. Managing Up
Psychologists have skills that make you indispensable to the organization and to leadership
Research expertise
Understanding of statistics
Being evidence-based and data-driven
Understanding of individual and group dynamics
Understanding of change management
Showing you can add value is the best way to manage up

60. In Closing…
Let’s return to VA/VHA’s current and emerging issues and ask ourselves “What role can Psychologist Leaders play in carrying out the strategic goals of the organization? How do we best position ourselves to do that?

61. Emerging Issues with Unknown Impacts – Broader Health Care Community
Unsustainability of rising health care spending
How will the unsustainable increases in health care spending in the United States be brought under control and when?
Impact of potential legislation proposing universal access
Possible coordination of federal health care benefits
Demand for long-term care services
How will the current emphasis on end-of-life issues impact demand for institutional long-term care?

62. Emerging Issues with Unknown Impact - VA
OIF/OEF
When will the conflict end and what is the total number of OIF/OEF veterans?
How will the new approach to PTSD treatment impact the level of disability of OIF/OEF veterans in the long term?
Will their reliance on VA health care change over time?
Traumatic Brain Injury
How will the evolving view on how to care for veterans with TBI impact the types of services VA will need to provide?
Legislation and policies that propose alternative ways of providing care rather than an integrated health system
How would a Congressional proposal to voucher out care for service-connected veterans change the VA health care system?

63. Future Direction: Assumptions
Health care reform will be a major issue in the 2008 election and will impact VHA
Current health care spending, including VA, will be deemed unsustainable and will give rise to policy interventions
Consumer choice will continue to be a driver in American health care
Health care transparency requirements will increase and create a more competitive environment
VA will be held to evolving health care industry standards

64. Table Discussion From a Local Mental Health Perspective:
How do you position VHA and your local site to be attractive to veterans going forward?
What makes your model of care for Mental Health distinctive?
How will you manage cost to create greater value?
What proactive role can you play to position your local site to meet these strategic challenges? How do you best position yourself?
What specific actions will you take when you return to your local site, given what we have talked about today?

65. Contact the National Center for Organization Development
Questions?
Contact the National Center for Organization Development