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BTOES Insights Official
September 21, 2020

BTOES Healthcare Live - SPEAKER SPOTLIGHT : Veteran’s Health Administration Scheduling System - The Pathway to High Reliability Realization

Courtesy of The United States Department of Veterans Affair's Jennifer Ford and George Washington University's Patricia MacTaggart, below is a transcript of his speaking session on 'Veteran’s Health Administration Scheduling System - The Pathway to High-Reliability Realization' to Build a Thriving Enterprise that took place at BTOES Healthcare Live - A Virtual Conference.



Session Information:

Veteran’s Health Administration Scheduling System - The Pathway to High Reliability Realization


Timely access to services is the gateway to patient safety and quality.  Scheduling is the foundational  step to providing access to care that is highly reliable.  The redesigning and reimagining of effective and efficient scheduling strategies are dependent on an evidence-based approach that focuses on the critical drivers of the scheduling system in supporting the needs of the Veteran and providers related to access, patient safety and quality.  

Understanding the opportunities and limitations of scheduling systems is critical to successfully enhancing access to services.     To move the maturity of the VHA healthcare ecosystem forward,  VHA measured and validated a scheduling improvement initiative to support the access to care strategic benefits. Predicated on the documented and deliberate transparent methodology use, VHA created the pathway to optimization for high reliability of delivery services for Veterans and providers.

  • Public and private health care system participants who seek to be highly reliable in their  operational as well as clinical efforts to improve access to care enterprise wide  will learn from the VHA scheduling continuous improvement initiative.
  • Participants will gain an understanding of the VA assessment methodology used to validate benefits realized and limit risks of scheduling system improvements.
  • Participants will understand the opportunities and limitations of scheduling systems critical to successfully enhancing access to services using a US Veteran Administration use case.
  • The enterprise wide measurement of highly reliable access to care at VA provides an approach for other healthcare systems to validate the foundational, operational and strategic benefits realized specialty by specialty, facility by facility.

Session Transcript:

And I'm very excited to welcome Jennifer Ford and Patricia Mctaggart for our very first presentation for beetles healthcare. So I'll do a brief introduction for Jennifer and Patricia. Hello, Jennifer. Jennifer has been working within the healthcare industry for almost 20 years as the Director of the Quality Measurement and Value Division which we've seen the Veterans Health Administration, VAT, which focuses on the effectiveness and value of all Z, H, A, major investments and interventions. These investments requires strategic direction and abstinence based assessment in order to maximize the value of the healthcare outcomes, Mrs., Ford specializing high reliability organizations, healthcare access care within the community knowledge management and health IT programs and products to include the electronic health record.

She also has been a professor for over six years and teaches at George Washington University.

And then we have Patricia Mctaggart with us. In addition to being a Master of Health Administration, Masters of Health Information Administration, and Masters of Public Health Teacher Instructor and Program Director at George Washington University. Ms. Mctaggart currently has an appointment as a program manager and the Veterans Health Administration an Executive's Public Service for over 40 years. Ms. Mctaggart has lead national efforts in the areas of data, quality, service, delivery, and information management. It's a real honor to have both of you with us and we're very much excited about watching your presentation today.

Thank you, GSA.

Welcome, World. It's exciting to be here, and I'm very pleased to be able to have the opportunity to speak with you over the next 40 minutes or so about BHA scheduling system, which we call the Pathway to access high reliability realization.

But first, before we get into that, I'd like to talk to you about how we transform our own organization To really be able to answer the question, how do you know, with all the billions, be billions of dollars we spend on healthcare within the VA.

Screenshot - 2020-09-18T211847.055The real question is, how do we know our transformations are effective and valuable to everyone, our veteran patients, our providers, our administration, in general?

So a little history.

So back in 2007, I was directly asked to create an organization that would help us understand, how do we know our health IT systems are yielding the benefits and the value that they were intended. We had about $350 million a year worth of enhancements, and over a half a billion dollars, a year worth of maintenance that we had on our EHR system.

So our roots were really in Health IT.

By 2010, interestingly enough, the VA went through 16 major transformation portfolios in which two of them were directly related to health care: one of the portfolio's healthcare efficiency was one of our major transformations to get us more towards higher efficiencies and effectiveness and value.

Even though our rates were in health IT, the Principal Deputy Deputy Undersecretary for our health had this vision that we really needed to focus on the business. I have healthcare as well, and asked me if our processes and prudent methodologies would work on other types of investments and interventions, such as, you know, revenue cycle management, Our beneficiary, travel systems, our operational excellence, and so on and so forth.

So I said, I don't see any reason why our premium methodologies couldn't work on all portfolios within the VA that include all people, processes, drive business drivers, and technology.

So, over the next few years, as the transformations were occurring, we were able to apply our methodologies and really gave that insight into how do you know your business transformations are happening effectively and of value?

So, that kind of is what leads me to my next slide and talking about access.

So, just a little bit of background here. What was the need for transformation and access? Some of you may have heard, back in 20 14, the VA had had major challenges with access, which reached congressional level.

Um, we really had a whistleblower at one of our sites that, that, that we had excessive timeliness issues to access for our veterans, which were directly causing patient safety and quality issues.

So, it was really the first demonstration on the International, or the Institute of Medicine had had had determined that access is a first entree into patient safety and quality, but really didn't have a lot of, the evidence behind that, as much as, in 20 14, VA. Really demonstrated that Act.

That was the pathway to patient safety and quality, and some of our challenges demonstrated that, what, what were our findings on? What was the what was the problem? Well, the first problem was we didn't really have an access definition, what there were so many to many relationship, when it came to act, that we really didn't define all of those relationships.

We also, um, we also I'm sorry. We also saw that access was the first step to determining patient care. It was the absolute first touchpoint and that our scheduling system was the foundational piece to that.

The other interesting thing is our delivery system. When you look at our delivery system, we have a closed system.

We have a finite budget.

We don't have a, no, eight an arm and extension of funding. That helps us with surges.

Many of you may not know that we are the largest integrated health care network in the country.

We have 172 hospitals and over a thousand community based outpatient clinics.

We have nine million plus veteran patients that are eligible and enrolled and eligible to use our system and about 5 to 6 million at any one time uniquely in multiples or accessing our system with multiple appointment.

Btog CTAWhat we did find is that also, our access is very complex.

You don't necessarily have, under one roof, every single specialty when it comes to outpatient consultation, outpatient surgery, an inpatient surgery, an inpatient unit.

We have all of that under one roof 172 hospitals across the entire United States. Whether it's rural, suburban, or city settings.

The other interesting fact of our system as our population our population is one of the thickest populations in the country. Several most of our veterans are elderly and have several comorbidities that are very complex in terms of the care plan of our patient.

Then we also ensure that we have the care for all the comorbidities integrated so that our patient is getting true patient centered care.

So, at the end of the day, what does this mean?

It means that really, when you act, when you look at the definition of access and you assess what access really means, it's one specialty at one facility at one point of time, and so What that means is that a facility could have, you know, 50 specialties that 48 of them, maybe no operating just fine. And two might be a problem, You know, whether you may not have the space or you may not have the number of providers needed. But unfortunately, for us, because we have a big public lens on us and congressional oversight, that is two specialties, will hit the, will hit the papers, and we will get recognized as having some issues with access Now. I'm not saying that. we shouldn't have those two specialties no operating excellently for access either, but the problem is, is that it's a lot, and it's very complex. Our healthcare delivery system from a timeliness perspective, it is very hard to track and understand the data.

But before I move on, I also want to talk about a personal situation that I, that I experienced directly.

So, this is also in the price, this is in the private sector, are very sick and I couldn't, it was, it was, it was a thickness that was kind of covert. Had some blood work done, my primary care doctor recognized that I need to see a specialist, recommended me to a specialist, that he knew very well, fax my paperwork, my blood work over. And I tried to get an appointment.

And I called every minute of the day. And the scheduler just kept telling me, No, we don't have any appointments. You're going to have to wait a week.

So, every day, I was going downhill, and at the end of the day, I did end up in the emergency room.

Unfortunately, that was an unnecessary visit, and once I did, I mean that there, because I was going downhill, but if the provider solving sooner that was going to be an unnecessary visit, I did get stabilized.

And I finally went to my doctor only to find out that when I asked about my paperwork, that was fact over, the scheduler literally went over to the fax machine and was sitting there.

So obviously, over a week, my paperwork was sitting on the fax machine, Finally got into the doctor's office, and he looked at my condition, not only my blood work, but how I looked, and his first words were, Why didn't you see me sooner?

After that situation plus the VA situation, I did have a passion to help transform this area of health care, which was the gateway, you know, into safety, patient, safety, quality, and value of care.

And at the end of the day, what we realized is the first step. The very first foundational piece was starting with the scheduling.

All right, so let's talk about our scheduling system for a second. Now, you have to understand that VA was the first organization to really put out an integrated electronic health record that had all the EHR modules necessary to function as a healthcare organization.

Our scheduling system was part of that EHR, and it's over 40 years old. Now, or scheduling system that is still in effect right now is antiquated. It actually has a blue screen, Roland scroll. We have put a QE graphic graphical user interface on top of that as as of today. But it still has very limited workflow in it, and very, very limited business roles to take you through the veteran patient pathway through access.

It's a clinic based system, which means that every single grade, every single resource in the organization, whether it be a provider meaning of a doctor or a nurse, a machine, a party of cardiology machine or an MRI machine, any type of equipment needs, it needs an appointment grid.

Then what makes it really difficult is the scheduler has to match up If the provider needs the other resource, the scheduler has to match up the provider with the resource at the same time. So that they are both available to the patient at the same time.

So our system was in dire need of an overhaul.

So you might say, Well, jeez.

That's, why did it take you this long to figure that out? We figured it out a while ago, and we've had many significant attempts to overhaul our system. But there was a couple of issues. Number one, for those of you who know legacy systems over 40 years, you know, much of the code is gone. There's a lot of intricacies that is embedded, that it's hard to uncover. You can't lose patient data, lose patient information. So it's very hard to overall Hall a system like that, especially when it's integrated.

32So, so, so deeply like ours, the other issue is that the cots products of the past, the commercial, off the shelf products didn't have all the functionality that the VA needed or the capabilities over any better than what we had in our system. So, unfortunately, their maturity in the industry took a while, too.

Just not even catch up to us, but surpass us enough to where we were able to take advantage of that new capability and technology.

So, there was a maturity in this system.

So, what we decided to do was acquire a commercial off the shelf system, and we called the project manager at that medical appointment scheduling system.

And if this was this, this was to be successful as an overhaul of our scheduling system, it would have been the first in our history to overhaul the legacy system with a class product.

So as we were acquiring our new system, we were really getting to work. What we did, was, we needed a baseline, How did our system operate today, and what was, what was good about it? Let's make sure we capture that, and what did we really, really need to change?

What kind of capability did we need in order to make it way better than what it was today? Besides the obvious of the roland's role in the GUI on top of that.

So what we did, was, we did a deep dive into a subset of specialties that were very critical.

And what we did was, we did a causation analysis of that.

Meaning when we did a deep dive, every time we found a pain point, every time we found a point of failure. And every time we found a best practice, we were, we were not only documenting that into a very concrete benefits realization framework, but we were also feeding the acquisition team to say, what was needed in our new system in order for it to be highly successful.

So, therefore, our Benefits realization framework ended up with over 300 measures and metrics.

That really looked to transform the areas of access, such as demand, supply, practice management, in other words, how we, how we function as an organization? What are our business drivers?

And our policies, our space, and equipment, because we have no limited space in our facilities, so we would have to acquire more space if we acquired more doctors as an example, and, of course, our budget was a big factor into our analysis.

And what that yielded, was measures and metrics that fell under each of those five major benefits, such as: satisfaction, utilization, timeliness to care, those types of things. And my colleague, Patricia ..., will talk to you about those results a little bit later in the presentation.

What we did was we then collected data from the benefits realization framework with all of these 300 metrics that were both quantitative and qualitative, and arrived at our baseline. And this was the also demonstrated the value for basically the business case of why our system needed to be overhauled.

And essentially, the business case was really the big need for change.

All right. Next slide, please.

Oh, sorry about that. I think are just talked about maybe one more slide, please.

Here's what the big two da was. Here's the big aha moment.

What does it really boil down to?

When we did, the baseline, was one major issue, is that our VISTA scheduling system did not answer, How do we know? How do we know we are achieving access to care?

How do we know we're doing it in a timely manner and in an effective and valuable manner?

The VISTA system, with all of it, functions, really boiled down to one thing. It was like a basic calculator.

So, as our schedulers, we're scheduling for very complex scheduling events, such as, you know, if you had diabetes and you needed to be able to, you had to go to your endocrinologists and you had to go to your podiatrist and ophthalmologists and make sure all of this appointments were scheduled.

And in the order that they needed to be in, none of that workflow, none of that business rule was in the VISTA system. So what was happening is, our schedulers were doing all of that. Business intelligence will be caught outside of the system.

So, we had no idea where the patient was in their path in their care plan. We had no idea except for when the scheduler recorded it.

So, just like a calculator, if you were to say 2 plus 3 equals 5, the input of two, and the input of three, we don't know how you arrived at those numbers. We just know that 2 plus 3 equals 5. Same type of thing with VISTA scheduling. There isn't much more complexity to it, obviously, but if it really had to boil down to it, there was no transparency in the system at all.

Math, on the other hand, provided all of that functionality that we acquired, it was, it demonstrated the many to many relationship, it took us through the workflow. It was able to guide us through those business drivers and business roles, and we were really able to pull all of the resources together. So, our scheduler would not have to check every single resource to schedule a one-time scheduling event.

All of it was pulled together from a resource, from a resource management perspective.

And, so, what it really, really did is, it not only provided us the capabilities that we needed, but, the transparency that we so desperately were yearning for, as well as the decision making capability.

So that we could ensure that our act, that was, you know, up to par being managed at the right time, at the right place in the right modality.

So now I have the privilege of turning over to my colleague, Patricia Mactaggart, and she's going to actually go through many of the results that we had that you are probably eager to hear about. Patricia.

Good morning, afternoon, evening. Depending on where you're at, unless you can validate the impact of the improvement, the benefit realization of the human, financial, and time investment is always in question.

The reasons the VA made the operational changes in the scheduling system are threefold.

And they are the same reasons you would consider a change.

The first is to meet clinical and operational strategic goals, and for the VA, that's improving sets and access to services and enhancing the Veteran's experience and engagement.

Sind scheduling is the first step to access and access the pathway to quality and patient safety.

one of the significant direct impacts of the VA's scheduling system redesign effort was the improvement to access.

The scheduling system enhancement processes included technology that was innovative and improve veteran access.

VA added my chart, which is the patient facing online portal that allows veterans to create, modify, and cancel a direct scheduling appointment, reducing the burden on schedulers, and allowing Veterans to select the appointment date and time that works best for them, potentially reducing no-show rates.

Screenshot (4)Some of the documented value impacts of the changes include the veterans are canceling their primary care appointments prior to the appointment, allowing the medical facility to rebook the appointment, making providers more productive, and avoiding wasted space and human resources.

The number of consoles that were open greater than 30 days decreased, providing better connectivity, continuity of care and less wait time to see the specialist, And most importantly, the number of completed appointments increased, validating that veterans are able to get the services they needed at the time they needed it for the best clinical outcomes.

The second reason any of us would undergo a change would to make the technology processes and people were efficient. So clinical and your operational staff can be more productive and able to serve more patients.

The VA's scheduling, this was accomplished to decreasing manual, paper driven processes, and enhancing the usability of the technology.

As a result of resource based workflow and process efficiencies, it now takes less time to schedule or cancel appointment and the timing of recall reminders has improved.

Console completions were improved to the use of an automated scheduler work queue that allows the scheduler, in real time, to know what tonsils and return to clinic orders have been acted on, and which ones need action.

Previously schedulers do use paper lists to track throughout the day.

Now, there is less potential for missed opportunities. Schedulers are more productive.

And the appointment wait times for Veterans has gone down.

one of the biggest impacts of the new system is that schedulers can schedule both personnel and non personnel resources, such as space and equipment, which the previous system would not do.

For example, a cardiologist may have multiple Clements pulmonary stress, tastemaker, EKG, arrhythmia on any given day.

In the previous scheduling system, each provider would have one schedule per clinic, and would need to print out, in the morning, each individual clinical schedule, track it in paper, compile the paper copies for each clinic schedule, and then manage his or her day, based on the schedule that existed at the time of the printing, which again, was at the start of the day.

With the new system, the same cardiologist has one schedule with the resources needed for the appointments attached for one consolidated, electronic provider's schedule.

Not only does that make it easier for the provider to identify where he or she needs to be, it allows the providers to accommodate changes in demand.

Mass also automated many manual processes, reducing potential points of failure in the scheduling process.

Another example of a positive impact of decrease manual processes was the reduction for some community caseworkers over time by 62%. Not only does that create staff satisfaction, administrative costs are reduced.

In addition, we have all seen how health care needs have become more complex and multi-faceted resulted in patients needing re-occurring appointments and inter-connected appointments, such as lab, an X-ray before a specialty appointment for diagnosis.

The new system is able to make these appointments more easily and without errors, reducing unnecessary variation and waste.

Think about the value to your organization. If you are you can reduce the time it takes to schedule or cancel appointments by up to three minutes per appointment.

Like D, A, your appointment staff would have more time to communicate with your patients.

Think about the value to your organization, if you can increase same day appointments across high priority specialties, such as ontology or cardiology physical therapy, and decrease the average wait time for mental health. And it's just an issue, that address, that is being addressed by both public and private healthcare deliveries.

This would be real business value, and it is a real business value for VA, improved access, improve clinical care, improve provider, and patient satisfaction.

The third reason for systemic operational change is to provide real-time data, and analytics, and real information to your administrative operational staff and your clinical staff, so they can gain a better understanding of supply, demand, and their needs.

Mass provided VA medical facilities, transparency, as well as evidenced based, real-time, actionable information To decision makers about productivity, quality of care, and the fiscal impact of the scheduling system transformation, which allowed them to optimize resource utilization, and enhance their decision making.

Screenshot - 2020-09-18T211847.055The results have validated the business value to date.

So what is the impact of future axis high reliability realization?


Thank you. That was great, Patricia. So where did we take this, though?

We took our rigorous analysis.

We had a incredibly complex 300 measure, benefits realization framework. We measured our baseline. We took the same framework and applied it to math.

And you just heard the results that Patricia explained from the comparison of the before and after.

And then and we had this huge success. We had the first time ever ability to change out a VISTA schedule a VISTA system with a cots product. And again, with huge success.

So where did we take this?

So we presented our findings to the undersecretary of Health, which actually created a, a monumental, immediate decision to then replace all scheduling systems in the VA.

Well ahead of and if you haven't heard, VA is replacing its entire EHR, um, with another with a cots product, an $18 billion venture over 10 years.

And instead of waiting for every facility to adopt the new EHR, the decision that we helped to create was to immediately change out the scheduling system first ahead of the EHR implementation. Because it was that critical to patient safety and quality of care to do So as we just demonstrated.

This decision was a multi-billion dollar decision on top of the $18 billion decision already to replace our AT, our EHR, making it, one of the largest business transformations in healthcare history today.

Congress took our findings and adopted them, overwhelmingly approved the ability for us to finance the new vision and direction to change our scheduling system first.

And we were basically on our way, to higher reliability, to access through our scheduling festa.

We are proud of our proven methodologies of how to optimize these systems and continuously improve our processes, becoming a major learning organization. Not just within the VA, but also in health in the healthcare industry. In general, we are proud to be able to present this to such a platform of leaders that are looking for this type of, how do you know, your business transformation is successful? That it's yielding the expected benefits that I really was able to optimize and claim success for the types of investments and interventions we're making on a daily basis.

I really thank you for taking the time to be with us this morning, and I'm excited to hear any questions that you may have for us today.

Thank you.

Jennifer, terrific presentation, Jennifer, and Patricia. Thank you so much. We have had a number of questions come up, and I'm going to relate those to you As, so, thank you again, for a terrific presentation. First of all, one of the first questions that has emerged in the comment and commentary as well, has to do with the scale of what you're doing here. I think it's hard for people to understand, especially those who are outside of the United States, kind of the order of magnitude scale of what you have. So, you talk about, I think, $18 billion implementation, or something like that. And then, that was a little bit about the scope of this thing. I mean, order of magnitude estimate how many people are affected here, who are participating in the scheduling system. You talk about 12 different areas of practice in multiple sites. Just give us kind of an order of magnitude scope of what this looks like.

Again, let's start high and drill down. We're the largest integrated healthcare system in the country in the country and probably rivals in the world.

We have 170, so we have 50 states plus Puerto Rico. We have 772 hospital, just the hospital facilities across the nation, which touch on city setting, suburban settings, and rural settings. Just because our veterans are in rural settings, we have to service them anywhere. Which makes it very unique, because we can, Again, we're not a profit center. We don't need to look at a profit and loss statement to understand how our reach have to affect all of our population, so that's kinda number one. Then we have chemical. That branch off of those facilities in each facility has at least probably 10 community based outreach clinics.

So those clinics have usually primary care, behavioral health and then several specialties, depending on, again, the population needs of the of that population. Location, location and catchment area. Now, within would also is very unique within each facility. Most of our facilities are of the highest complexity, what we call 1, 1, A, B, and C, which means it entails every single specialty, with the exception of a few specialties that are very specialized, but maybe certain universities like certain kind of, no brain surgeries and whatnot may entail.

But having that kind of reach across the United States, that many facilities, that many people, hundreds of thousands of appointments across the enterprise, per minute.

It becomes an enormous no, turning the Titanic. When you're saying, Well, why don't you just replace the scheduling system? It is a monument to not only Tasker, but the decision to do something like that is so highly disruptive and transformational that you really have to have your evidence based information, really, you know, tight so that when you make that decision, you can look Congress in the face and said this is why we made it. And this is the progress and this is how we know.

And I think to add to that, one of the risks that we find an enlarged transformations is that people try to roll things up and do it at a very high level, And as what Jennifer said earlier, this is specialty by specialty drilling down because how you do care for ecology and the resources involved in that are very different than what you're going to do for cardiology or physical therapy. So, the numbers may roll up, and you may not be able to identify that point of failure that is impacting your business processes and the clinical care you're providing your provider.

So, it's even more complex, because you need to drill down, and then bring it back up.

Fascinating, fascinating. The scope of this, of this transformation, and, you know, if you gotta eat analysis, then you gotta eat one bite at a time. And we look at this elephant, and I'm curious about even, how do you even create your core team? What does that look like in terms of your core team? How many people are participating in the very beginning, on the, on the Core team? What does that look like?

So, I have a core team of specialists that, that help with the measurement of this transformation. The transformation with themselves take no many core teams to actually implement. We actually don't do the implementation, we tag along with the implementation to provide the how do you know, how do you know, you know, this step was successful? And we build that, we don't just come in at the end. As I mentioned in the presentation, we make sure that we were feeding the acquisition team, what was necessary, so that when they finally acquire the system, they knew the pitfalls, they need to stop.

So, um, so, it is a very core team of specialists, that we also acquire other resources to come in and out, depending on the flavor of the day. Like I manage, like I mentioned, we do this across the board. You introduced with high reliability, access to care, and so many other types of health care. Delivery, in general, this was just an example with scheduling, one example of hundreds, you know, hundreds of assessments, thousands of assessments, tens of thousands of knowledge, artifacts that we have in this. how do you know you transformed effectively?

And I think one of the things is a skill sets. Jennifer's put together teams of people who have technology expertise. We have people who have business processes, expertise. We have measurement expertise. No one person has all the expertise, but it's putting that team together. And the approach is very much utilizing an observing the activities of the people doing it. We go out to the facilities and do on-site observations. We look at their data. We scrutinize the data and the data definitions to make sure that we're comparing apples to apples.

We have technology folks that go through the foundational and functional system processes, and then we go and look at the workflow and what they actually do and how they actually do it. That's where you fall, find the potential opportunities for improvement.

32Every family found entities. They would turn into a measurement in that overall framework.

Very good. Just one more question, kind of setting the stage that that has emerged has to do with just a rough timeline. Because this is such a large, complex transformation. When did you start? I mean, how, how, how, how it progressed over the months and years and then and then where are you at in that in that process? It completely done. And what does that look like from a timeline perspective?

If you see me looking down, I'm looking at Jones Day. So, I'm not looking away, I'm looking at you. Like I mentioned, you know, we, we've tried to transform scheduling for many, many years, and, like I said, there was many difficulties with it.

But back in 20 14, I'm sure many of you can go Google VA, 2014, scheduling or access issues that comes right up and it's no secret that, you know, we were in desperate need of transformation. So how do you even take on this? You know, this kind of enormity, It does take time. You have to have a, you know, I think that the proven methodology that we have, and the approach that we take is very effective, very efficient, because what we do is, like Patricia said, we go into every facility. at first. We were gonna look at every single specialty and found that that was just going to be way too daunting. So we did get a representative 12 specialty sample that were very complex. But, you know, had many of the comorbidities that are veterans had.

And we did a very rigorous, you know, 12 site process to make sure that we didn't uncover any, you know, significant nuances from site to site to site. And if we did, we documented it.

So we felt that we had a very good enough sampling, and that took probably a year to do all of that, because it is a lot of analysis. And one of the issues that we have an organization, is we have data, but we don't have a lot of business intelligence with that data. So that business intelligence, what we found had to be done manually and that was a very daunting over time. So, like Patricia said, we didn't have definition. We were rolling up specialty care and we were, you know, when you rolled it up, we were meeting our specialty care tenfold that then when you hold it, it was because maybe, you know, optometry we're seeing their patients 100% but others were seeing their patients out of 50% interval. And that was just not acceptable.

When you really unraveled, is the baseline to really a good year, which also, like I said, allowed us to feed the acquisition team and acquire, you know, certain acquisitions take time and then there was probably an 8 to 9 month rollout implementation rollout of the system Once.

And, actually, it was only within two weeks of the end date from when it was when the end date was identified from the start, which was pretty miraculous. It was about an 89 month rollout.

Once the rollout happened, you cannot measure right away.

You have to wait because there's kinks.

It has to normalize, there's gonna be people that don't understand the need to be retrained whatnot. But our leadership needed answers right away, I mean, this was being watched every minute of the day.

We did do a very quick four months, initial measurement, and comparative, back to VISTA scheduling. And there were some very significant business transformation, qualitative information that really did provide the evidence based and the evidence to move forward with the system.

But just to make sure, we did one more partial measurement at the seven month mark to make sure that we're not only confirming those initial measurements, but we're also gaining some of the more strategic benefits like to access and whatnot. So it is a process, and you do have to stay patient. Although some of our leaders aren't very patient, but we were trying to give them the best information. But what we didn't want to do is we did not want to compromise.

The quality of our assessment was a quick or maybe not, so analyzed, measure. So we were, you know, ensuring that what the information we gave them was real.

And to follow up on that, Jennifer, the very last stage of implementation, thereabouts what year did that take place?

Roughly, it was funny 18, 2018. So, you're looking for, you know, 2014 to 20 18, which is an incredible transformation at this magnitude and that timeframe. And it does take time for something of this magnitude to take hold. It's, it's really fascinating. Well, I want to go to very specific questions. I think we have enough questions. I'll talk all day long. So, I'm going to do this the best. Just to summarize some of the questions and the, and, again, for those of you who submitted questions are unable to get the answers, you can contact us, you can go on LinkedIn under the posting that we have for this, and both some of your questions there. And now, I'll certainly pass them onto Jennifer. I'm Patricia. But this comes from William Fuller and William Sass, first of all everybody, the same great presentation. Thank you very real about about and very well done, the transformation itself and the way you present it. Did the question from William is, did the ... use a static process maps, simulations?

What if scenarios, or a combination of tools in this transformation? And was integration done in-house, or by external suppliers?

So, the integration was done by the cost, the commercial off, the shelf, external suppliers. The people who provided the software, did do the integration, that they were one team.

We did not have an outside consulting team do the implementation. So, they were one team. So that, that actually, I think, was a benefit.

To the other question, is, yes, we did create scenarios. We called them with Veteran Pathways. We created a very complex represent representative scenarios that we, actually, on site, traveled through the process. As if we were the veteran, literally going from clinic the clinic to make sure that our information was transferring at the time through the clinic, and that, you know, what was expected to be there in terms of information was there. So we did do a lot of those process maps, and what we called the Veterans Pathways.

Very good. I have next question here from Camera, Jahan, Shahid. Good to see. Your camera. Camera has been a presenter in.

The conference is certainly one of a member of our audience, who was very engaged in our presentations. He says, Great presentation, Patricia. And Jennifer, I'm curious, do you also work on reducing less minutes cancelations by patients, and if so, can you elaborate on that? And then he has a follow up on what kind of training and change management was required to ensure that this new scheduling system sticks.

Yes, very to very complex and excellent questions in the question on everybody's mind. Well, let me answer the second one, just because that was the fresh, in my mind right now. But, from a training and change management perspective, the, the, the provide, the product provider did provide the training of this system.

And then, we did have, you know, super champions at the site to be able to understand what the new business processes were, the new business drivers to be able to do it, by train the trainer on a constant basis. And that was a critical change for success Now, one of the major issues, though, is that, again, this is why you have to look at it specialty by specialty.

Certain specialty said, this is great. I didn't know I had this capability and they were extremely innovative in their new processes.

Other specialties kinda just forfeited their old process into the new process and didn't really take advantage of new technology and that part of the transformation, and that's part of this measurement. We measure that to know who's kind of the leader of the innovative leader, and who are the ones that might need some help and adopting.

Screenshot (4)So we are, is that, again, just like any change, that's a process. That's going to be a 2 to 3 year process change over and over again, until all specialties are kind of up on the same floor in the elevator, and taking advantage of those capabilities. I'm sorry to say, what was the first question part of that question? Very good job in addressing that, and we are running against time here. So I'll ask for just the first portion of that question, if you can address that quickly. Had to do with the issue, got into last-minute cancelations by patients if that's an issue that you had to deal with or maybe attacked as part of this.

one of our issues is we don't charge a no-show fee. We there's no one.

Do you know, for our veterans, if they don't show up, they don't know? There's no penalty? So that is a really big issue for us. However, the new system, the old system, could, could do some of this tracking and tracing. The problem with that, though, is that, again, it was all manual business intelligence. You've had to really take months to dive into the data. The new system, However, that was one of the requirements. And it actually had AI tools to be able to track that. So that we might find that information out ahead of time and be able to really, you know, take those open slot and filled them quicker before it's too late. And the time slot and path. Because if you look at the VA were closed system, where basically firm fixed price, even at the average $175 an hour for each or a slot that, that it goes unused when you have.

At one point in 20 17, it was nine point two million, No shows, just do the math, and you're in the billions at this point in time, So that was a very big business driver for us to make this change, so that we could get that capability to determine those last minute slots, Not going filled or looking at kind of those offenders and and being prepared for that and, you know, understanding who we can put in those blocks ahead of time?

I also think one nuance to go to the person who asked the question specifically. We got down to the nuances of things like texting. There is a benefit of texting. A reminder. There is a real benefit of having a veteran or the patient commit to whether they're going to come or rescheduling ahead of time, so you can read book schedule. It's that level of detail. That allows you to know what works and what doesn't work, And that was a very specific example that relates to dealing with no shows.

Jennifer, I'm Patricia. Thank you so much. This is a wonderful presentation. Wonderful work, and your presentation reflects the, the great work and leadership that you have had on this incredible projects. Many, many people thankful for the work that you do for our veterans in society, and really creating an important, positive change in our world. So, thank you.

Probably a lot. more questions that we could ask. And they will follow those up on LinkedIn, and we'll get those to you, as well as as many as possible. Thank you so much for sharing your journey with us today.

Appreciate it. Thank you, everyone.

Ladies and gentlemen, that was just a flavor for the day. What an incredible, multi, billion dollar transformation in engaging, hundreds of thousands, if not millions, of patients in the United States, and improbably locations outside the United States as well. We didn't even get into that into that component. Terrific, terrific. And, at the top of the hour, we're going to be closing this segment now.

Then, the top of the hour, we're going to fold it up with two incredible thought leaders on healthcare as well. We're going to welcome doctor William maples and Jennifer ..., doctor William maples, the President and Chief Executive Officer of the Institute for Healthcare Excellence. And Jennifer ... is the Chief Experience Officer for the Institute of Health for Health Excellence Healthcare Axons, and they're going to talk about creating a culture to promote individual and team rising resiliency, and peak performance. So, we're gonna, again, hear directly from industry experts and on how to successfully transform our organizations, our healthcare organizations. So, look forward to see you back at the top of the hour. We'll take a quick break now. And I'll close the session, and I'll see you back soon. Thank you.


About the Author

more (94)-2Jennifer Ford,
Director of the Health Care Reliability and Value Division,
The United States Department of Veterans Affairs.

Jennifer Ford has been working within the health care industry for over 18 years. She is the Director of the Health Care Reliability and Value division within the Veterans Health Administration (VHA), whichfocuses on the effectiveness and business value of all VHA major investments. These investmentsrequire strategic direction and evidenced-based assessments in order to maximize the intended value ofthe health care outcomes. Therefore, Ms. Ford leads a team that measures the benefits of VHA’s investments to ensure that the Department’s leadership is optimizing the clinical outcomes andoperational productivity of the organization.

Ms. Ford specializes in High Reliability Organizations, Health Care Access, Care within the Community and Health IT programs and products to include theElectronic Health Record (EHR) which supports VHA’s health care model. In addition, she ensures tha health care organizations learn and adopt the products and programs in which they invest to achieve theexpected value, while maintaining a culture of continuous process improvement. Prior to the VA, shehad a successful career in the consulting industry, focusing on business development and programmanagement of Fortune 100 companies.

Ms. Ford is a graduate of American University and has an MBA from George Mason University. She has been a professor for over three years and teaches atGeorgetown University and George Washington University. Ms. Ford has earned a Project Management Professional (PMP) designation and is an expert in the Project Management, Business Management andHealth Informatics fields.


About the Author

more-Sep-21-2020-09-31-28-86-AMPatricia MacTaggart,
HealthInformatics@GWU Program Director and Health Services Policy and Management Teaching Instructor,
George Washington University.

Ms. MacTaggart is the HealthInformatics@GWU Program Director and Health Services Policy and Management Teaching Instructor at George Washington University (GWU).  MacTaggart has an appointment at the Veteran’s Health Administration. 

Professor MacTaggart previously completed a three-year appointment at HHS in the Office of the National Coordinator as a senior adviser in the Office of Care Transformation and has been a county, state, and federal public servant for over 40 years, including serving as Minnesota's Medicaid director. She has been an executive for a nonprofit insurance, an IT vendor, and a for-profit consulting firm. She is on multiple national advisory committees, including HIMSS, e-HI, NASI, and AcademyHealth Education Council.


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