The VHA has come under increasing public scrutiny in recent years because of the significant backlog of patients waiting for appointments. A recent Washington Post article highlighted the problem: "Many veterans must wait more than a year for an appointment with a primary care doctor at Veterans Affairs health facilities. Some die before even being seen by a physician," began the article.
Unfortunately, the article did not then go on to tell the good news: that the VHA’s intensive effort to reduce waiting times for appointments, begun four years ago in collaboration with the Institute for Healthcare Improvement (IHI), is yielding impressive results. In the six specialties targeted for access improvement, average system-wide waiting times for initial appointments are down dramatically, even as the system was able to meet the demand for services for approximately 900,000 new patients between fiscal years 2000 and 2002. The biggest gains during that time period were made in primary care where national waiting times for the next available appointment decreased by 53 percent, from 60.4 days to 28.2 days.
Change in Average Next Available Appointment Waiting Times, Veterans Health Administration (VHA)
"We have turned a major ocean liner around," says Odette Levesque, RN, NP, project coordinator for the VHA/IHI Advanced Clinic Access Initiative. "We feel we are at the tipping point."
The six clinics — primary care, audiology, cardiology, eye care, orthopedics, and urology — were targeted because approximately 80 percent of veterans are seen in those clinics, says Levesque. She adds that plans are in place to focus next on mental health and gastroenterology.
The Veterans Health Administration, part of the Department of Veterans Affairs (VA), is the United State’s largest integrated delivery system, caring for some six million patients. In 1996, the US Congress signed into law the Veterans Health Care Eligibility Reform Act, which, among other things, opened up the VA health system and benefits to all veterans, not just those suffering from service-related health problems. And so the floodgates opened.
A Huge Job
In 1999 the VHA enrolled teams from 134 sites in an IHI Collaborative on Reducing Delays and Wait Times. Through the Collaborative the participants learned about advanced access scheduling, which, once the backlog of patients is reduced, allows most patients to be seen on the same day they call. Working at their own clinics, these "early adopters" were able to bring the average waiting time for an appointment down by 54 percent.
But as great as this success was, in a system with 22 Veterans Integrated Service Networks (or VISNs) and literally thousands of locations, it is a drop in the bucket. Meaningful success will only come from improving access system-wide, a job that is far easier said than done.
"We tried to spread these new ideas throughout the system, but we found it was a huge job," say Robert Petzel, MD, network director of VISN 23 in Minneapolis and chair of the VHA’s Advanced Clinic Access Steering Committee. "So we contracted with IHI to help us spread advanced clinic access to all our target clinics." That includes 1,826 clinic sites and over 4,500 individual providers.
"Our first step was to develop a national infrastructure that would support this work at every level," says Levesque. They created a National Leadership Team, an Advanced Clinic Access Steering Committee, a network of Points of Contact at each VISN, and a group of leading clinicians who agreed to serve as National Coaches on advanced clinic access.
"Getting the commitment of national, regional and facility leaders was key to spreading our successes," says Levesque.
Building Relationships
Equally important was creating effective means of communication, says Renee Parlier, RN, MPA, recently appointed national program manager for the VHA Advanced Clinic Access Initiative. Instructive information was provided through videos, posters, reports, and an internal website.
But in a system so huge, advanced clinic access is not a "cookie cutter" solution to access problems. "There is room for variation," says Parlier, "and what works for one site won’t work in exactly the same way someplace else." She says sites must experiment and customize solutions to their needs, but must use three principles in their access improvement work. "Each site must measure supply and demand; examine the gap between supply and demand; and redesign the system accordingly," she says. But there is "wiggle room" in the details of implementation.
For this reason, among others, internal communication among those working on access was a critical factor in spreading knowledge. The VHA made sure that interactive communication would occur regularly through nearly every means available: conference calls, email, regional meetings, and, in March 2003, at a national meeting in Boston.
"There were upwards of 300 people at that meeting," says Parlier," and we are still getting incredible energy from so much face-to-face contact."
Parlier says the meeting reinforced an important factor in successful "spread" efforts. "It’s not enough simply to communicate information," she says. "It is important to support that communication by helping to build relationships. People trying to implement advanced clinic access need to be comfortable getting on the phone and calling the internal experts who’ve already done it."
Parlier says that because the meeting brought together people who were at all stages of progress on advanced clinic access, many formerly skeptical participants were convinced and energized by the progress others reported. Says Parlier, "On our conference calls, I no longer hear, ‘This won’t work for us,’ or ‘This doesn’t make sense,’ but rather, ‘How did you solve this problem or that problem?’ There is tremendous sharing of information."
Regular communication also helps keep people focused and committed to the work, which can seem overwhelming and endless at times, says Parlier. "People have to stay focused in order to continue making progress. But that doesn’t mean it is easy."
Keys to Success
Petzel says that continuous communication is also key because people are at different stages of awareness and knowledge. "The need for improvement is not evident to everyone," he says. "Continuous communication is essential, especially in such a huge system, because people are at different stages of understanding and acceptance."
Indeed, says Levesque, it is hard to understate the culture change this represents. Complaints about waiting times notwithstanding, some clients liked the old VHA mindset and the slower pace of things. "Our system has always been very social," she says. "Clients would often come in hours before their appointment so they could spend the day visiting with friends, telling war stories." Today, the VHA is endeavoring to keep the friendly atmosphere, but infuse it with efficiency.
Though it is hard to measure how far along the VHA is in its effort to spread advanced clinic access to the entire system, Petzel estimates the project is about 10 to 15 percent complete. That may not sound like much until you remember the size of the system, he says. "It is huge from a number of perspectives. Not only is the system itself big, but the resources are really limited, and there is regular turnover in a staff this big."
But despite the obstacles, progress is measurable. Petzel cites a couple of factors as key elements in any effort to spread success throughout a system, large or small. "You have to have a plan," he says, a blueprint for spread. "You’ve got to have senior leadership that is invested, interested, knowledgeable, and willing to reward success. And you’ve got to have clinical champions that are supportive and engaged."
Parlier adds to this list the need to keep the work visible at all levels through newsletters, conference calls and meetings, and to work continuously to connect people with one another for knowledge sharing and support.
Levesque points to the importance of effective leadership at two levels. "Senior VHA leaders demonstrate ongoing commitment to this effort, and are critical factors in keeping the momentum going. And the Points of Contacts (POCs) in each VISN are key because they really manage the day-to-day tactics of spreading this initiative to the local clinic level."
Parlier agrees that the POCs are the lynchpins of the access initiative. "They are the people who create the implementation plans and identify the people responsible for doing the work."
Parlier admits she gets impatient that progress isn’t faster, but she remains enthusiastic about her work. "This idea that we’re going to change the way we deliver care to our outpatients, and use continuous improvement to gain ultimate efficiency, is the most exciting thing I can think of. It’s not just about reducing waiting times. It’s about improving the whole system. It just doesn’t get any better than that."
