Creating World-Class Care and Service for Our Nation’s Finest: How Veterans Health Administration Diffusion of Excellence Initiative Is Innovating and Transforming Veterans Affairs Health Care

Abstract

As the largest integrated health care system in the US, the Veterans Health Administration is dedicated to continually innovating its systems, technology, and practices to provide high-quality care to US veterans. In this article, I describe the Veterans Health Administration’s Diffusion of Excellence Initiative, which involves an annual, systemwide competition to recognize Department of Veterans Affairs employees and identify promising practices for implementation in other Department of Veterans Affairs facilities or Veterans Integrated Service Networks. To demonstrate the reach and impact of the initiative, I highlight practices that are being implemented in 4 areas: 1) direct scheduling, 2) access to health care in rural areas, 3) access to mental health care, and 4) interactive and patient-centered care. In addition, I outline the primary components of the current transition plan to elevate lessons learned and transform the initiative from a nascent start-up to a sustainable part of the Veterans Health Administration’s culture.

INTRODUCTION

As the Deputy Under Secretary for Health for Discovery, Education, and Affiliate Networks at the Veterans Health Administration (VHA), the largest integrated health care system in the US, my topmost priority has always been to improve the quality and consistency of care delivered to the 9 million veterans that the VHA serves. This supports the agency’s vision for providing veterans a consistent, seamless care experience at any Department of Veterans Affairs (VA) medical facility across the country. To that end, the VHA is constantly seeking to innovate its systems, technology, and practices to ensure that our veterans are receiving the highest caliber health care.

Through the Diffusion of Excellence Initiative, the VA has created a culture that is committed to identifying innovative and best practices that are employee driven and creating the pathway to standardize and spread these practices on the basis of proven success and outcomes. The Diffusion of Excellence Initiative is all about identifying, recognizing, and spreading best practices as the engine to drive continuous improvement across the VA and to change veterans’ lives for the better.

DIFFUSION IN ACTION: IMPLEMENTING PRACTICES, CHANGING LIVES

The VHA hosts an annual, systemwide competition to recognize top performers and to identify promising administrative and clinical practices and innovations that have been previously implemented in 1 or more VA locations. Inspired by the reality television series “Shark Tank,” the competition invites all employees via email, social media, and signage to submit innovations or practices on their own time that have demonstrated improvement in care delivery or operational processes across VHA priorities. As defined by VHA senior leadership, priorities are access, care coordination, employee engagement, medical-surgical nursing, clinician recruitment and retention for rural facilities, quality and safety, suicide prevention, and veteran experience.

Since late 2015, more than 1600 practices have been submitted during the course of 3 “Shark Tank”-style competitions. For each competition, subject matter experts from the field evaluated submissions using prespecified review criteria (eg, demonstrated impact of the practice, feasibility of replication, and alignment to VHA priorities) and selected semifinalists. The VHA program office leaders then evaluated the semifinalist applications on a scale of 1 to 5 using a standardized assessment tool based on the same review criteria. On the basis of the evaluation responses from program office leadership, finalists were selected for advancement in the competition by VHA senior leaders—the “sharks.”

In total, 47 practices have been selected and designated as Gold Status practices for facilitated implementation in other VHA facilities or Veterans Integrated Service Networks (VISNs). Diffusion focuses on spreading evidence-based best practices and innovative promising practices that have demonstrated outcomes. The Gold Status practices are currently at various stages of implementation, ranging from targeted implementation within a VISN to broad implementation at VA Medical Centers throughout the country within multiple VISNs.

Although there are many success stories that speak to the reach and impact of Diffusion of Excellence practices in making a difference every day for veterans, this article highlights 4 different practice areas: 1) direct scheduling, 2) access to health care in rural areas, 3) access to mental health care, and 4) interactive and patient-centered care. From improving audiology and optometry services to delivering mental health services to rural veterans, or engaging veterans in advanced care decisions, the Diffusion of Excellence Initiative is improving and fundamentally changing how the VA delivers care and service to its most important customer, the veteran.

Patient-Driven Direct Scheduling

Perhaps the greatest success story of the Diffusion of Excellence Initiative is the Audiology and Optometry Direct Scheduling Pilot, identified through the VHA “Shark Tank”-style competition and selected for a rapid, national rollout. An interdisciplinary clinical team at the Bay Pines VA Healthcare System in Bay Pines, FL, implemented a patient-driven, direct-scheduling process to address a bottleneck for audiometric and optometric services caused by the cumbersome and bureaucratic requirement for veterans to first see their primary care physician. These employees created standardized communications to eliminate scheduling confusion and delays, all to improve veterans’ access to primary care.

This practice has experienced a reported reduction in total wait times for new patient audiology and optometry appointments, as well as the number of audiology and optometry consultations, freeing up primary care staff time and clinic resources. Veterans have reported a positive experience and prefer the ability to schedule appointments directly with audiology and optometry clinics. Clinicians have echoed this positive sentiment; they report they are using their time more productively because of the streamlined scheduling process, according to postimplementation site analyses conducted in December 2016 by the team. This practice is now in place across the VHA.

Serving Veterans in Rural Areas

The Diffusion of Excellence Initiative has been particularly successful in identifying and supporting practices that target one of the VHA’s top priority groups: Veterans in rural areas. One-fourth of all US veterans—more than 5 million veterans—reside in rural communities and experience great difficulties in accessing care and services, stemming from geographic barriers, limited Internet access, and high poverty rates. Several Diffusion of Excellence practices specifically focus on rural veterans. One such practice, TeleWound, uses econsultations, clinical video telehealth, and store-and-forward telehealth, which eliminates travel burden and reduces the risk of infection and hospitalization for the VA’s rural population. Another practice, the Community Housing Fair, is a 1-day event during which homeless veterans collaborate with landlords, employers, and other community partners who can help provide same-day housing. This housing fair was especially useful for veterans in rural community-based outpatient clinics, where there are numerous barriers to adequate housing.

Improving Veteran Access to Mental Health Care

Identifying veterans at risk of suicide has typically been reactive, with interventions dependent on a veteran self-disclosing suicidal thoughts or intent or a clinician recognizing warning signs. The Suicide Prevention-Addiction Recovery Care group therapy model introduced a group therapy approach to proactively address suicide risk among veterans in the population receiving treatment for substance use disorder. Mental health clinicians provide education and help veterans identify plans and coping strategies during a session that is cofacilitated by a suicide prevention coordinator and a specialist in substance abuse disorders.

Interactive and Patient-Centered Care

Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses to complete oral care) encourages VA staff to perform oral care for and with veterans to reduce the risk of nonventilator (-associated), hospital-acquired pneumonia (NV-HAP). A lack of oral care causes bacteria to grow on teeth, which can be aspirated into the lungs and cause pneumonia. The practice ensures that inpatient, nonventilator-dependent veterans receive oral care by providing consistent staff training, educating patients on oral care and its association with pneumonia, and standardizing the procurement process for oral care supplies. Within the first 19 months of implementation, the NV-HAP incidence rate has decreased from 105 cases to 8.3 cases per 1000 patient-days, resulting in an estimated 13 lives saved and a cost avoidance of $2.8 million.

These practices show how innovation directly affects and benefits veterans nationwide and are only a few of the many examples of “diffusion in action.” But, the Diffusion of Excellence Initiative focuses on more than just improving systems and processes; it aims to inspire VA employees and leaders as active and valued contributors to the innovation process. The Diffusion model empowers VHA employees to engage in developing creative solutions to some of the agency’s most difficult challenges, which ultimately influences and helps shape the organization’s future.

FROM START-UP TO SUSTAINED

The Diffusion of Excellence Initiative provided the VHA with a framework that leverages the agency’s large scope and scale to deliver demonstrable improvements in the way we care for our nation’s veterans. It is also a framework that any health system can use to maximize innovation in providing high-quality and consistent health care. The initiative empowered employees by harnessing their ingenuity and bright ideas into actionable outcomes that provide invaluable benefits not only to the lives of veterans but also to their caregivers and supporters.

In the nearly 3 years since its inception, the Diffusion of Excellence Initiative diligently followed the innovation mantra, “Think big. Act small. Fail fast. Learn rapidly.” As with any new endeavor, there were missteps, missed opportunities, and flat-out failures, but the team behind the initiative learned ceaselessly, remained agile, and adapted as necessary (eg, using digital survey platforms to streamline the application process, and providing finalists with training on pitching their practices).

The next challenge, however, is elevating such lessons learned to transition the initiative from a nascent start-up to a sustainable part of VHA’s culture. There are 3 primary components of the current transition plan: 1) cultivate the culture, 2) build partnerships and encourage collaboration, and 3) embrace appropriate technology.

Cultivate the Culture

The Diffusion of Excellence Initiative tapped into something powerful: VHA employees are mission-driven. When given the opportunity, they jumped at the chance to improve and overhaul clinical and administrative processes, to adapt best practices from the private sector for VHA use, and to develop new products and practices from the ground up—all with the pure intention of improving the veteran experience. It will be important to maintain that energy and drive. To do that, the initiative will increase the amount of opportunities for learning, sharing, and collaboration among VHA employees by hosting virtual grand rounds sessions, offering implementation science training, and developing collaborative learning networks.

Build Partnerships and Encourage Collaboration

The VHA takes pride in providing the best care for veterans, particularly regarding health challenges prevalent in the population (eg, traumatic brain injury, posttraumatic stress disorder, and the need for prosthesis and assistive technology). However, there is much to learn from addressing those challenges in other federal and state agencies and the private sector. In the coming months and years, the team behind the initiative will actively seek opportunities to share what worked and did not work, while simultaneously endeavoring to learn from the successes and failures of colleagues seeking to identify, develop, and spread innovation outside the VHA. The initiative will also develop targeted collaborations with private sector health systems in an effort to educate community partners that provide care for veterans.

Embrace Appropriate Technology

Technology is an important part of the modernization process. It supports collaborative activity; encourages networking and sharing of information; and generally makes data collection, tracking, and analysis a less daunting process. In the next year, the initiative team will develop a centralized digital platform that supports all the promising and best practices in the VHA and creates a community with which to collaborate and share information and data.

Focusing on these 3 major components will enable the VHA to capitalize on the lessons learned over the course of the past 3 years and enable a smooth transition into the next phase of the Diffusion of Excellence Initiative. This evolution will not occur without additional failures and missteps, but I am confident that successes will outweigh these. We look forward to sharing our future learnings!