Abstract
With a national priority to make the Veteran Health Administration (VA) a leading customer service organization and provide patient-centric services to veterans and their families, the Wilmington VA Medical Center (W VAMC) partnered with the University of Delaware’s Department of Hospitality and Sport Business Management at the Lerner College of Business & Economics to develop the VA Patient Experience Academy. The program focused on employee training and provided tools to enhance the veterans’ experience, operationalized the VA Way (VA Core Values, Service Behaviors, Service Recovery), and Own the Moment. Phase 1 of the VA Patient Experience Academy launched with 25 managers in February 2019 and were followed by 5 cohorts including physicians, nurse practitioners, registered nurses, licensed practical nurses, medical staff assistants, and staff. The participants were selected from the W VAMC and 5 Community-Based Outpatient Clinics. The results were measured on 3 levels: Learning outcomes, application of training to practice, and the veterans’ satisfaction scores. Scores in all 3 areas showed significant improvements.
Keywords
Introduction
The Veterans Health Administration (The VA) is America’s largest integrated health care system, providing care at 1454 health care facilities with varying complexity serving 9 million enrolled veterans each year (1). The VA’s definition of Patient Experience (PX) is similar to prevailing definitions (2) in the literature, “The sum of ALL INTERACTIONS, shaped by the organization’s culture, that INFLUENCE Veterans’ and their families’ perceptions along their healthcare journey.”
Patient Experience is the number 1 priority for many health care organizations followed by employee engagement. This has resulted in investment in PX staff, service excellence, and staff training and development with strong, visible support from leadership (3). Patient Experience is also a number 1 differentiator to attract and retain patients (4). Additionally, hospitals with better customer-reported experience perform better financially (5), and the resulting reimbursement associated with value-based contracting (6).
Consequently, health care leaders are compelled to focus on improving and investing in PX. As such, the veteran experience is a major priority for the VA. To ensure veterans, their families, caregivers, and survivors select the VA as their preferred health care system, the VA established a vision to be the leading customer service organization in government. This is accomplished not only by providing a focus on safety, but also timely access to high quality health care that is both compassionate and respectful (7).
To meet the challenge, The Wilmington VA Medical Center (W VAMC) partnered with the University of Delaware’s Hospitality and Sport Business Management at the Learner College of Business & Economics to develop the Veteran Patient Experience Academy (VA PXA). The program focused on employee training and provided tools to enhance how staff engage, communicate, and improve the veteran experience and care.
Leadership Support
A strong, leadership commitment is key for transforming the delivery of patient-centered care (8). Leaders must also be active role models, expound a clear vision, and include and empower all staff in their professional development (9). Leadership sets the culture, and the right leadership can create a more positive place for staff to work, leading to better ways of improved outcomes for patients (10). In sum, leadership role and training are facilitative factors for a patient-centered culture (11).
From the start, the VA PXA was strongly endorsed by VA leadership. During the preactivation ceremony that took place at the University od Delaware’s STAR Campus, the director of the W VAMC remarked, “I feel like we have not put in the time with training and investing in our staff by improving opportunities to learn from others,” Kane continued, “Training shouldn’t just be about the technical aspects of our jobs it should also be about improving the entire care experience” (12).
The W VAMC chief of staff at the time, Robert Boucher, reinforced the need for this new program. “We at the VA agree; we don’t teach the essentials of hospitality well; we don’t really understand all of the nuances. It is not because we as humans are not good at this. It’s that we are not learning in the right way. We are not learning and applying the right skills. That, from my perspective, is when you bring in the pros” (12).
Further evidence for leadership support came when Secretary of Veterans Affairs Robert Wilkie and Delaware US Senator Tom Carper, as well as Vincent Kane, director of the W VAMC all joined for a visit to a live session of the VA PXA. During the visit, the Secretary asserted, “The first step in the veterans process is to make sure that those veterans who come to us are welcome,” Wilkie continued, “If we don’t make them feel welcome that first time, all of the metrics, all the studies show us that we lose them. And it’s working here in Delaware” (13).
Description
With the goal of making hospitals truly hospitable and creating a culture of exceptional experience, the medical center, veteran community, and UD tailored and customized the VA Patient Experience Academy (VA PXA). Originally, the UD’s PXA was established in 2014 in conjunction with the Christiana Care Health System. As reported in The Beryl Institute Patient Experience Case Study (14), the goal of the program was to integrate healthcare and hospitality to create the PXA.
This innovative program was built through a multidisciplinary collaboration of the W VAMC and UD’s Healthcare Theatre in the College of Health Sciences, the Lerner College of Business & Economics’ Hospitality and Sport Business Management, and UD’s Division of Professional and Continuing Studies, leading to a UD PXA certification.
The Program
The VA PXA training sessions were held over a 5-week period, with a 2-hour workshop each week and were proceeded by a 60-day follow-up session. Each cohort was comprised of up to 25 VA participants. Weekly schedules provided trainees with the opportunity to apply what they learned and share feedback at subsequent sessions. The goals of the 60-day follow-ups were for participants to apply aspects of their learning or design innovative approaches to improving the veterans’ experience and share their achievement stories.
Participants
Phase 1
Participants of cohort 1 were managers (N = 25) from all locations. Launching the VA PXA with managers was a critical step. Their feedback was essential for the initial success and support of the program, as well as for long-term leadership and reinforcement. Additionally, managers participated in a coaching session that included effective goal setting, feedback, and coaching techniques to maintain engagement and accountability.
Phase 2
Participants of cohorts 2 to 5 (N = 209) included physicians (15), nurse practitioners (4), registered nurses (35), licensed practical nurses (28), and medical staff assistants (119) from various departments including 2 patient advocates and 6 social workers selected from the W VAMC and Community-Based Outpatient Clinics (CBOCs) at Cape May, Sussex, Atlantic, Cumberland, and Kent Counties.
Learning Methods
Novel approaches to training
Two unique approaches were selected to deliver the VA PXA: Bridging Hospitality to Healthcare and Healthcare Theatre:
Bridging Hospitality to Healthcare: Although we acknowledge that hospitals are not hotels, according to James Merlino, MD, health care is a unique service business, and we can learn from the hospitality field as to how we can better interact with patients and customers (15).
Healthcare Theatre: In a transformative approach to training, health care students and staff were taught by UD’s Theatre Department and College of Health Sciences to act as patients and family members so that participants could practice and apply their skills in a safe and realistic environment using the Freeze Frame method. In this technique, also known as live stage performance, actors freeze at a particular point to highlight significant learning topics. For example, participants interacted with theatre students (actors) portrayed as patients with Parkinson disease or an irate veteran, replicating real-life emotional situations.
Workshop design
We utilized: (A) cross-functional teams to inspire system-thinking; (B) simulations to practice skills; (C) achievement stories to apply learning concepts at work, design new processes, and share the results in 60-day follow-ups.
Operationalizing the VA Core Values, Service Behaviors, Service Recovery, and Own the Moment
The primary goals of workshops were learning and operationalizing the VA Way and Own the Moment. The Veterans Experience Office has a well-designed patient experience program that includes 2 major components: The VA Way and Own the Moment. Table 1 summarizes the highlights of the program.
The VA Way and Own the Moment.
Abbreviation: VA, Veterans Health Administration.
We utilized the best practices from the hospitality industry, such as anticipating the needs and weaving those needs into actions. What is to be a service employee? How to wow customers? How to have fun with excellent grooming, and so on were essential for operationalizing the VA Way and Own the Moment.
Measurements
Based on needs analysis, 3 criteria were selected to measure the success of training: Learning achieved, application of learning to practice, and patient satisfaction scores.
Learning achieved: All participants were administered a pre-and-postassessment during the first and the last workshops for all cohorts. The aims of these assessments were to quantify the extent to which providers and staff were already knowledgeable about the VA Way and Own the Moment and compare the results after training.
Application of learning to practice: We gathered feedback as to the degree to which providers and staff applied the VA Way and Own the Moment and that they helped to guide employee work at the VA. Simulations and achievement stories were designed to apply learning to practice.
Patient satisfaction scores: This was measured by using: (A) Survey of Healthcare Experiences of Patients (SHEP) and (B) The Veterans Signals (VSignals) before and after the intervention.
A. SHEP assesses patients’ perceptions of their health care experience similar to the Consumer Assessment of Health Providers and Systems (CAHPS) surveys—a health care industry standard. To evaluate the overall success of the training, we analyzed SHEP’s Office Staff results and Office Staff Composite scores—before the commencement of the intervention and 3 months after training to allow for completion of surveys by respondents. SHEP’s Office Staff variables included:
Employee helpfulness,
staff courtesy and respect, and
Office Staff Composite scores
B. VSignals is a customer experience survey used by the VA to gather feedback on patient experience via the veterans’ active emails. VSignals provides feedback on ease of appointment, meeting expectations, provider listening, explaining things that could be easily understood, what to do next after visit, and overall trust in VA.
Results and Analysis
Phase 1 and 2
The goals of the pilot project (phase 1, managers training and Phase 2, cohorts 1-5) were to test the success of the VA PXA and incorporate the VA Way and Own the Moment to the culture of the W VAMC and assess the degree to which the intervention will produce meaningful outcomes for the veterans. If so, the W VAMC will continue to enroll as many as providers and staff in the program as possible.
As shown in Figure 1, the pilot program resulted in significant improvements on all 3 criteria. (1) Pre-and-postassessment results increased (130%) more than doubled. (2) Participant feedback revealed that they now understood the VA Way and Own the Moment and that helped to guide their work at the VA (a 10-fold improvement). In addition, significant improvements and innovative approaches to patient experience and engagement were shared via achievement stories. (3) Leadership focus and commitment to provide a patient-centered approach resulted in clear increases in patient satisfaction scores. As shown in Figure 1, the VSignals trust score exceeded the goal of 90% at the Wilmington VAMC (2.5% above national average, and number 1 in the state of Delaware). VSignals trust scores for 3 of 5 CBOCs reached nearly 100%. We contributed the weaknesses of the other 2 clinics as possibly due to the fact not all providers and staff had yet completed the training sessions. Finally, SHEP Office Staff results for main campus improved in all 3 measures: courtesy/respect 8%, staff helpfulness 13.4%, and Office Staff Composite Scores 10%, respectively. The CBOCs’ overall scores in all 3 dimensions also increased significantly (courtesy/respect 53%, helpfulness 85.5%, and composite scores 35.4%).
Results.
Finally, as a result of significant improvements and success of the phase 1 and 2, the VA approved an expansion of the pilot program to an additional 10 cohorts (250) participants already underway during the drafting of this article but delayed due to the COVID-19 pandemic.
Lessons Learned
As we looked back on our intervention with the VA PXA and our past experience with the Christiana Care Health System PXA (16), we learned that establishing and publicizing mission, vision, core values, and service behaviors by themselves are not enough to be comprehended, appreciated, and/or applied by all organizational members. It was through the commitment of the VA leadership and a deliberate intervention that provided the opportunity for all participants to not only learn, but also operationalize their learning at all touchpoints with patients and colleagues.
Although other training interventions relating to PX have shown positive results (17), based on our observation, Bridging Hospitality to Healthcare introduced special touches that could not be easily quantified (experience). For example, training site was at the UD’s STAR Campus, yet it required some physicians to drive 4 hours and participate in learning sessions for additional 2 hours. This caused a provider to complain about the driving time. The instructor went beyond expectations and delivered a goody bag for the provider’s ride back home. That action alone wowed him, and the problem was solved.
UD’s Healthcare Theatre added another effective dimension. Simulations performed by trained actors truly resembled real-life scenarios and influenced learning outcomes.
Additionally, we learned that incorporating achievement stories is an effective method for shifting the responsibility of learning, application, and process improvement to providers and staff. This was evident as each participant or teams of participants shared their achievements during the 60-day follow-up presentations.
Finally, we felt no resistance to the intervention as the program began with illuminating the core values of the VA, the concepts, and ideals that every employee embraces and advocates for the veterans who have served this country. Teamwork and cross-functional approach to workshops reinforced the idea that the VA is an integrated system, and each part impacts the other.
Finally, we intentionally weren’t deliberate on measuring the participants’ reactions to training, whether they liked the training or not. The indirect message on this approach was that the VA Core Values, Service Behaviors, and Own the Moment were not negotiable. The outcomes measurements, such as pre-and-postassessments, patient satisfactions scores, and achievement stories provided sufficient feedback regarding the success of the training intervention.
Conclusions and Recommendations
This quality improvement initiative provides useful information to guide health care leaders on the relevance and importance of a well-planned intervention to improve patient experience. The intent of the initiative was to not only ensure that veterans received an exceptional experience, but that staff also felt valued and empowered to resolve issues at the point of concern and that providers felt their patients were getting exceptional care. The study demonstrated that in order for PX initiatives to be successful, they require significant investment, leadership commitment, and all-out participation, including physicians and frontline staff. Training had to go beyond imparting technical skills and needs to include demonstrating empathy, understanding the customers need, problem solving, active listening, a willingness to admit mistakes, and put the veterans first.
From an educational perspective, we recommend that learning be delivered in small cohorts and for an extended period so that participants have a chance to practice and apply their learning. Detailed attention must be made to include mission, vision, core values, service behaviors, service recovery, and key components of CAHPS surveys. Implement daily or weekly department huddles that reinforce skill development, support information sharing, and provide inspiration to sustain the culture and keep the training alive. Finally, the collation of achievement stories and measurement of results of learning, application, and patient feedback are all critical for determining success. Ultimately, based on the Academy’s remarkable results, we recommend this training to other VA and health care organizations.
Footnotes
Authors’ Note
This manuscript does not involve research on human subjects and meets criteria for exemption and approved by the institutional review board (IRB). Ali A Poorani was the principal investigator (PI) and the Faculty Director. Vince Kane was co-author and provided data and edits. The facilitators were from both the hospitality industry and academia. (6) • Kathy Smith, former senior vice president of human resources at The Ritz-Carlton Hotel Company. • Bill Sullivan, managing director of the Courtyard by Marriott – Newark at the University of Delaware. • Allan Carlsen, director healthcare theatre, UD assistant professor of theatre. • Sheryl Kline, UD deputy dean of the Alfred Lerner College of Business and Economics and professor of hospitality business management with years of experience in the hospitality industry. Other Support: • Michael Renfrow, deputy director VA Patient Experience (VEO/PX) provided the VA material and consultation support. • Robert Boucher, MD, MPH, otolaryngology-head & neck surgery, Lebanon VAMC, provided leadership support. • George Irvine, associate provost, Division of Professional and Continuing Studies (PCS) at the University of Delaware provided contracts and other support.• Patricia Allen, M.Ed., program coordinator, Division of Professional and Continuing Studies (PCS) at the University of Delaware, coordinated logistics. • Jessica Netta, CA, administrative assistant, Division of Professional and Continuing Studies (PCS) at the University of Delaware, assisted with logistics.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Veterans Experience Academy was fully funded by the Wilmington VA Medical Center.
