VA Psychology Leadership Conference

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

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. 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 2002-2006 Diagnosis (ICD – 9 categories) Percent Disease of Musculoskeletal 42.7 System of Connective Tissue Mental Disorders 35.7 Symptoms, Signs, and Ill-Defined 33.0 Categories Diseases of Digestive System 30.7 Diseases of Nervous System/ 30.0 Sense Organs Diseases of Endocrine/Nutritional/ 17.8 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. Patient Centered Integrated Care Budget Base Camps Congress Base Camps Base Camps Base Camps

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 Summit4 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 Summit4 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 Summit4 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.

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

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

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?