Case: Cincinnati Veterans Administration Medical Centeri

The Cincinnati VA Medical Center (CVAMC) provides health care to eligible veterans in Ohio, southeast Indiana, and northern Kentucky. The CVAMC is an acute care, university affiliated 220-bed facility. It is a part of the Veterans Healthcare Administration of the Department of Veterans Affairs. It comprises one of five medical centers within the Veterans Integrated Services Network 10 (VISN 10). The CVAMC works to provide a variety of services as needed across the continuum of care for veteran patients, as well as trainee education and the pursuit of new knowledge through research. The mission arises from Federal mandates to support health care, education and research. CVAMCs vision is to shape our future by breaking the traditional VA mold, building on our strengths, and emerging as the health care center of choice for all Veterans. As pioneers of change we will: 1. Establish the patient at the core of all processes with the focus on continuity of care leading to optimal patient outcomes. 2. Develop a united team of competent, caring, empowered employees committed to providing service that exceeds expectations. 3. Foster unprecedented labor/management trust and cooperation. 4. Create a proactive organization that is responsive, streamlined, and personal. 5. Be recognized as an innovative, vital health care leader and educational resource in our VA system and the Greater Cincinnati community. The CVAMC is able to offer a variety of inpatient and outpatient healthcare services. The Medical Service staff offers services in primary care, general internal medicine, and in multiple medical subspecialties such as cardiology, nephrology, pulmonary, and gastroenterology. The Surgery Service offers general surgical care and specialty care in such areas as urology, orthopedics, vascular surgery and neurosurgery. The Mental Health Service provides psychiatric and psychological support care for patients with a variety of programs including care for patients with post-traumatic stress disorder, substance abuse, and serious mental illnesses. The Neurology Service cares for patients with disorders of the nervous system. It has special programs in epilepsy, neuromuscular disease, stroke, and movement disorders. Physical Medicine and Rehabilitation Service offers support for patients with acute and chronic debilitating conditions. It offers

programs in occupational, physical, and speech therapy as well as chronic pain management and prostheses. The CVAMC also provides specialty services in support of other medical centers within the VISN. This includes surgical, psychiatric, neurological, and medical specialty care to patients at Dayton, Chillicothe, and Columbus. Additionally, some specialized care is offered for veterans from other areas of the state and country, including the production of special limb prostheses. The primary customer is the veteran patient. Highest priority is given to veterans with medical conditions or injuries related to their service in the military, and to those veterans with limited resources who otherwise would have difficulty obtaining the care they need. CVAMC offers a broad range of services to other eligible veterans as well. Other customers include the families of veteran patients, the veterans support organizations (VSO), the trainees including residents and medical students, and the staff at the other VISN facilities. There is a special relationship with the University of Cincinnati. This involves all three major missions of this medical center. The majority of the staff physicians have joint appointments with the University. Some specialized care is provided through sharing agreements with the University, including radiation therapy, special radiological studies, and cardiac surgery. The CVAMC is a major teaching center for many of the University's residents and medical students. The CVAMC also supports researchers with joint appointments at the University. There is a partnership between the unions and the Medical Center. Finally, there is a partnership between the Medical Center and a local elementary school. The 1,100 employees of the CVAMC include physicians, nurses, psychologists, dieticians, social workers, therapists and other health care professionals. This number also includes those members of the services that support the delivery of care including environmental management, security, medical administration, finance, and acquisition personnel. Physicians represent approximately 10% of the full-time work force, while nursing personnel account for about one-third. The main facility for the CVAMC includes the acute care bed services and clinic areas housed in one building in Cincinnati. The inpatient facilities include two intensive care units, acute medical and surgical services, and acute and intermediate term

psychiatry services. Outpatient facilities include clinics on three floors and a Patient Evaluation Area for patients with emergencies. Full-scale laboratory, clinical pathology, and radiological services are available on-site. There are facilities for computerized fabrication of artificial limbs for patients with amputations. Day treatment facilities are also available for patients with PTSD and substance abuse. The CVAMC operates a nursing home and a domiciliary for homeless veterans at its Fort Thomas location. The CVAMC also supports an outpatient facility in Bellevue, KY for easier access for veteran patients in northern Kentucky. The CVAMC also offers specialty services to other VAMCs in VISN 10 through out reach programs at those facilities. One major regulatory body is the Joint Commission for Accreditation of Healthcare Organizations. Other regulatory bodies that review the activities of the CVAMC include the Nuclear Regulatory Commission, the College of Pathology, The Environmental Protection Agency, and OSHA. Veteran patients require accessibility to care. This includes the need to be seen at a location convenient to them, as much as possible. Additionally, they must be able to get an appointment with their clinicians within a reasonable period of time. A thirty-day limit for specialty clinic consultation has been targeted as a key customer service standard. Patients do not want to have to wait for long periods on the day of their appointments. They need access to the latest technology and specialty skills as appropriate for their medical conditions. This is important even if the CVAMC does not have the necessary equipment or personnel on site. The CVAMC must then contract for those services. Veteran patients need to have continuity of care. They want to see the same clinician each visit to develop rapport with someone who understands their particular needs. They want that provider to be aware of the results of any specialty consultations or hospitalizations. These patients deserve the availability of a range of services to meet their needs. They recognize the need for interdisciplinary approaches to solve some of their health problems. They demand to be heard during medical decisionmaking and want their end-of-life wishes respected. The families of veteran patients need to be informed about the care of their loved ones. They want to be able to participate in educational activities. They wish to be able to support the patient when treatment decisions are being made. They want convenient

access to care for the veteran patients, as they are often responsible for getting the patient to the appointments. The veterans services organizations play a key role in supporting veteran patients. They demand that the veterans needs be met. To this end, they require access to top management of the CVAMC in order to discuss their concerns. The trainees demand access to teaching facilities. They want to be able to assist in the care of patients with a variety of health conditions. They want to be able to discuss issues with experienced staff. They demand access to the latest technology and treatments. They want to be able to interact with researchers to gain a better understanding of their patients conditions and options for care. The staff at other VISN facilities needs to be able to take advantage of the expertise and equipment at the CVAMC when these are not readily available at their own sites. They want access for their patients that is timely and convenient. They demand timely reports of these evaluations and wish to be included in medical decision making. The University demands satisfaction of its teaching requirements for the trainees. The University requires regular monitoring of the trainees progress. University staff also monitors the trainees evaluation of their experience while at the CVAMC. The University requires payment for clinical services provided. The CVAMC holds a special place in the competitive healthcare market in the region. It is the only hospital in its service area dedicated to veterans. While this limits the number of potential customers, it can use this in its pursuit of its targeted customers. It is relatively small compared to the areas major medical centers, but it can take advantage of its membership in the very large chain of medical centers in the VHA when purchasing medications and equipment. It can also take advantage of its ties with the University and nationally funded research programs to lend an aura of quality. It also provides the most vertically integrated health care delivery system in the market, with a variety of services for its veteran patients across the continuum from outpatient to inpatient. It currently provides care to approximately 21,000 veteran patients, but this represents only about a 10% penetration of its target market. This limited penetration is due in part to years of restricted eligibility to receive care at this facility. Because of its role of supporting veterans with limited resources, it has been viewed at times as a

provider of last resort. Federal regulations restrict the ability to advertise, limiting the ability to market its services. The CVAMC also faces a declining population of veterans in its service area. The CVAMC has a number of competitors in the region. These include all of the major medical facilities which provide inpatient or outpatient care. These compete with the CVAMC mostly for patients with insurance or Medicare coverage. Veteran patients with limited resources may also go to places other than the CVAMC, since some support for indigent care is available. Additionally, the other VA medical centers in the state can compete with the CVAMC for veteran patients. Funding of these centers depends in part on the number of veteran patients served. The CVAMC must be ready to compete with these other facilities, inside and outside of the VHA, if it is to succeed. There are several factors of importance when competing in this health care market. The reputation for quality may be a critical factor for some patients. Cost is a major factor for many veteran patients, since they have little or no out-of-pocket expenses for care provided at the CVAMC. Accessibility is critical, since patients are often unwilling to tolerate long waits for appointments or long delays on the day of their visits. Many patients show strong preferences for local access to care, the ability to avoid bridge or downtown traffic, and ease of parking. Continuity of care is important to many patients. Many patients want their providers to be able to coordinate their visits and tests, with good communication of results among their providers. Staff courtesy, empathy and efforts to educate the patients may also be factors of importance to health care customers. Change continues to affect the health care market. Recent changes in federal reimbursement of medical facilities under the Balanced Budget Act have caused financial strain among health care providers. The VHA is funded separately, but is not immune to budget cutting activities in Congress. The insurance companies have also been aggressively trying to reduce their expenses, impacting the revenues of medical facilities. The aging of the population has increased the demand for services. The costs of pharmaceuticals and medical technology continue to rise. Changes in coverage of medications have forced some patients to consider different sources for their healthcare. CVAMC must attend to these changes if it is to prosper in this changing health care environment.

The major new initiative for the CVAMC is to improve access to care by the placement of outpatient facilities at sites more convenient to veteran patients. This process started with the planning for and implementation of the community based outpatient clinic (CBOC) in Bellevue, KY. Analysis of zip code information for eligible veterans in the region showed that there is a high concentration of patients in the three counties of northern Kentucky. Focus groups were held with patients from this area that showed that these patients strongly disliked having to cross the Ohio River for their healthcare. An adequate site was found for a clinic in northern Kentucky. Since its opening, enrollment with patients new to the system has occurred rapidly. In view of this success, the demographic data was reviewed for consideration of two more veterans service centers. Sites in southeast Indiana and Clermont County have been approved. These should help the CVAMC to meet its targets of increased patient enrollment as well as improved access to care. The Mental Health Service has undertaken an initiative to improve access to its targeted group of veteran patients in the northern suburbs of Hamilton County. This will also improve access to care and utilization of CVAMC resources as these patients begin to use other services. The CVAMC has taken part in a new VISN case management program. This involves assigning a nurse to patients in certain high-risk categories. The categories of risk were determined by review of resource utilization including days of hospitalization. The case manager is trained to improve coordination of care and assure appropriate preventative measures are taken to improve the health state of the patient, limiting the use of scarce resources. Major research programs are helping the CVAMC achieve its missions. The medical center is one of three sites funded nationally as a Patient Safety Center of Inquiry to look at how mistakes occur and how they can be limited in the delivery of health care. The Mental Health Service has recently received further funding from the National Institutes of Health to study substance abuse management. These programs help to fund staff positions while improving the quality of care that we are able to offer to veteran patients.

The computerized system for automated production of prostheses represents a new service that is not available elsewhere in the VISN. Additionally, it is far superior in cycle time to any system available anywhere else in the region. This system allows the CVAMC to offer its patients with amputations unparalleled service. The shorter cycle time increases the chances that the veteran patient will be able to ambulate well after an amputation procedure. The system allows us to provide similar service for veteran patients at other facilities within the VISN and beyond, without the need for these patients to travel to Cincinnati. Another area receiving great attention at this time is achieving increasingly strict customer service standards. These help focus attention of all employees on the issues of importance to veteran patients. These standards have associated monitors and measures, with benchmarks from health care systems nationally. The major unique factor at the CVAMC is the strategic planning process. This occurs at the Quorum, a quarterly meeting of managers from all services as well as representatives of major customer groups. Results of prior initiatives are reviewed. The group decides whether the resources should continue to be assigned to those projects. New initiatives are considered in view of changes in the environment and customer needs. The large size of the group improves organizational buy-in for initiatives. The monitoring activities of this group has allowed the elimination of some committees including the Quality Assurance Committee. The size and nature of this strategic planning group is unusual for a health care organization. The quarterly meetings allow the medical center to respond more quickly to change. This process will be important in the future success of the CVAMC. Discussion Questions 1. Based on this background information about the CVAMC, propose a set of approaches that the medical center might pursue to help achieve its vision and truly be customer-focused. competition. Focus on the types of customers the CVAMC has identified, their needs, and the organizations role in the community and with respect to its

2. The Appendix to this case shows a patient satisfaction survey used at the CVAMC. Classify the questions according to the key dimensions of service quality described in this chapter. Analyze the questions as to their ability to determine actionable information for improvement, address key patient needs and expectations, and assess satisfaction and loyalty. Write a summary report of your conclusions.

Appendix: VA Survey

We thank our student team, William Cahill, Troy Hall, and Rachel Whitaker, and the Cincinnati Veterans Administration Medical Center for providing this case information.