Casey ComprehensiveCare Center forVeterans Case Study

2015

Baldrige Performance Excellence ProgramNational Institute of Standards and Technology (NIST) • United States Department of Commerce

July 2015

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The Casey Comprehensive Care Center for Veterans is a fictitious Baldrige Award application prepared for use in the 2015 Malcolm Baldrige National Quality Award Examiner Preparation Course. The fictitious case study organization presents an integrated-services concept to provide comprehensive care to Veterans from all three Administrations within the U.S. Department of Veterans Affairs (VA). The case study illustrates the format and general content of an award application. However, since the case study serves primarily as a tool for training examiners to evaluate organizations against the 2015–2016 Baldrige Excellence Framework, the case study may not address all Criteria for Performance Excellence requirements or demonstrate role-model responses in all Criteria areas. Please refer to the Casey Comprehensive Care Center for Veterans Feedback Report to learn how the organization scored and to see its strengths and opportunities for improvement.

This case study was written in collaboration with and with the support of the Secretary’s Robert W. Carey Performance Excellence Award Program, a Baldrige-based national award program for all VA agencies. The Carey Award recognizes organizations within the VA that have implemented management approaches that result in sustained high levels of performance and service to Veterans. For more information, go to http://www.va.gov/.

This case study is a work of fiction, created and produced for the sole purpose of training regarding the use of the Baldrige Excellence Framework. There is no connection between the fictitious Casey Comprehensive Care Center for Veterans and any other organization, named either Casey Comprehensive Care Center for Veterans or otherwise. Any resemblance to any specific facility within or external to the VA is purely coincidental. The names of several national and government organizations, including the Administrations of the VA, are included to promote the realism of the case study as a training tool, but all data and content about them have been fictionalized, as appropriate; all other organizations cited in the case study are fictitious or have been fictionalized.

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Suggested citation: Baldrige Performance Excellence Program. 2015. 2015 Baldrige Case Study: Casey Comprehensive Care Center for Veterans. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. http://www.nist.gov/baldrige.

CONTENTS 2015EligibilityCertificationForm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E1 OrganizationChart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O1 2015AwardApplicationForm,pageA-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1 GlossaryofTermsandAbbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G1

Preface: Organizational Profile P.1 OrganizationalDescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i P.2 OrganizationalSituation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Category 1: Leadership 1.1 SeniorLeadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1.2 GovernanceandSocietalResponsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Category 2: Strategy 2.1 StrategyDevelopment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 2.2 StrategyImplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Category 3: Customers 3.1 VoiceoftheCustomer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.2 CustomerEngagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Category 4: Measurement, Analysis, and Knowledge Management 4.1 Measurement,Analysis,andImprovementof OrganizationalPerformance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4.2 KnowledgeManagement,Information,and InformationTechnology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Category 5: Workforce 5.1 WorkforceEnvironment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 5.2 WorkforceEngagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Category 6: Operations 6.1 WorkProcesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 6.2 OperationalEffectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Category 7: Results 7.1 ProductandProcessResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 7.2 Customer-FocusedResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 7.3 Workforce-FocusedResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 7.4 LeadershipandGovernanceResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 7.5 FinancialandMarketResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

2015 ELIGIBILITY CERTIFICATION

FORM

ORGANIZATION CHART

O1

Casey Comprehensive Care Center for Veterans (C4V)— Because I-CARE for Veterans

Organization Chart

Department of Veterans Affairs Central OfficeStaff Organizations Office of Regulation Policy and Management Staff OfficesAcquisition, Logistics, and Construction Inspector General Office of Congressional and Legislative AffairsAdvisory Committee Management Office Office of Employment Discrimination Office of Human Resources and AdministrationBoard of Veterans’ Appeals Complaint Adjudication Office of Information and TechnologyCenter for Faith-Based and Office of Small and Disadvantaged Office of Management Neighborhood Partnerships Business Utilization Office of Operations, Security, and PreparednessCenter for Minority Veterans Office of Survivors Assistance Office of Policy and PlanningCenter for Women Veterans Veterans Service Organization Liaison Office of Public and Intergovernmental AffairsGeneral Counsel

PAGE A-1 OF THE

2015 AWARD APPLICATION FORM

GLOSSARY OF TERMS AND

ABBREVIATIONS

G1

Glossary of Terms and Abbreviations

AABB . . . . . . . . .AmericanAssociationofBloodBanks FacWork . . . . . . .FacilityWorkACA . . . . . . . . . . . . .AffordableCareAct FAR . . . . . . . . . . . . . .FederalAcquisitionsRegulationsACO . . . . . . . . . . . .AccountableCareOrganization FCC . . . . . . . . . . . . . .FederalCoordinatingCenterACR . . . . . . . . . . . . .AmericanCollegeofRadiology FDA . . . . . . . . . . . . . .U.S.FoodandDrugAdministrationACSI . . . . . . . . . . .AmericanCustomerSatisfactionIndex FDC . . . . . . . . . . . . . .FullyDevelopedClaimADA . . . . . . . . . . . . .AmericanswithDisabilitiesAct FEMA . . . . . . . . . . .U.S.FederalEmergencyManagementAgencyAES . . . . . . . . . . . . .All-EmployeeSurvey FIM . . . . . . . . . . . . . .FunctionalIndependenceMeasureAGE . . . . . . . . . . . . .AssociatedGovernmentEmployees FMEA . . . . . . . . . . .FailureModeandEffectsAnalysisAHCG . . . . . . . . . .AccreditingHealthCareGroup FSS . . . . . . . . . . . . . . .FederalSupplyScheduleAHRQ . . . . . . . . . .AgencyonHealthcareResearchandQuality FTEE . . . . . . . . . . . .Full-TimeEmployeeEquivalentAMI . . . . . . . . . . . . . .AcuteMyocardialInfarction FY . . . . . . . . . . . . . . . . .FiscalYearANCC . . . . . . . . .AmericanNurseCredentialingCenter GAO . . . . . . . . . . . .U.S.GeneralAccountingOfficeAOS . . . . . . . . . . . . . .AvailableOn-Site GEMS . . . . . . . . . .GreenEnvironmentalManagementSystemAPS . . . . . . . . . . . . .ActionPlanningSystem GS . . . . . . . . . . . . . . . .GeneralSchedule:PredominantpayscalewithintheU.S.ARNP . . . . . . . . . . .AdvancedRegisteredNursePractitioner civilservice,includesthemajorityofwhite-collarpersonnelASPIRE . . . . . . .Web-baseddashboardthatdocumentsqualityandsafetygoals (professional,technical,administrative,andclerical)positionsAV . . . . . . . . . . . . . . . .AnnualVolume GuidingAWE . . . . . . . . . . . . .AnnualWorkplaceEvaluation Principles . . . . .People-Centric,Results-Driven,Forward-LookingBCMA . . . . . . . . .BarcodeMedicationAdministration HAI . . . . . . . . . . . . . .Hospital-AcquiredInfectionBID . . . . . . . . . . . . . . .BenefitsInformationDay HCAHPS . . . . . .HospitalConsumerAssessmentofHealthcareProvidersBMP . . . . . . . . . . . . .BasicMetabolicPanel andSystemsBOSS . . . . . . . . . .BurialOperationsSupportSystem HEDIS . . . . . . . . . .HealthcareEffectivenessDataandInformationSetBPTW . . . . . . . . . .BestPlacestoWork HH . . . . . . . . . . . . . . . .HollidayHospitalC4V . . . . . . . . . . . . . .CaseyComprehensiveCareCenterforVeterans HHS . . . . . . . . . . . . . .U.S.DepartmentofHealthandHumanServicesCAHPS . . . . . . . . .ConsumerAssessmentofHealthcareProvidersandSystems HICS . . . . . . . . . . . .HospitalIncidentCommandSystemCAM . . . . . . . . . . . .CommitteefortheAcquisitionofMaterials HIPAA . . . . . . . . . .HealthInsurancePortabilityandAccountabilityActCAP . . . . . . . . . . . . . .CollegeofAmericanPathologists HPDM . . . . . . . . . .HighPerformanceDevelopmentModelCARF . . . . . . . . . . .CommissiononAccreditationofRehabilitationFacilities HPEX . . . . . . . . . . .HealthcarePerformanceExcellenceCompositeCAUTI . . . . . . . . .Catheter-AssociatedUrinaryTractInfections HUD . . . . . . . . . . . . .HousingandUrbanDevelopmentCBC . . . . . . . . . . . . . .CompleteBloodCount I-CARE . . . . . . . . Integrity,Commitment,Advocacy,Respect,andExcellenceCBOC . . . . . . . . . .Community-BasedOutpatientClinic (VAvalues)CDC . . . . . . . . . . . . .CentersforDiseaseControl IDEALS . . . . . . . Identify,Design,Execute,Analyze,Learn,Sustain/ShareCDL . . . . . . . . . . . . . .CompetencyDevelopmentforLeaders IDP . . . . . . . . . . . . . . IndividualDevelopmentPlanCFR . . . . . . . . . . . . . .CodeofFederalRegulations IEC . . . . . . . . . . . . . . IntegratedEthicsCouncilCHF . . . . . . . . . . . . . .CongestiveHeartFailure IEP . . . . . . . . . . . . . . . . IntegratedEthicsProgramCLABSI . . . . . . .CentralLine-AssociatedBloodStreamInfection ILMS . . . . . . . . . . . IntegratedLeadershipandManagementSystemsCMS . . . . . . . . . . . .CentersforMedicareandMedicaidServices IRB . . . . . . . . . . . . . . . InstitutionalReviewBoardCO . . . . . . . . . . . . . . . .ContractingOfficer IRIS . . . . . . . . . . . . . . InquiryRoutingandInformationSystemCOR . . . . . . . . . . . . .ContractingOfficer’sRepresentative ISO . . . . . . . . . . . . . . . InternationalOrganizationforStandardizationCPEP . . . . . . . . . . . .CaseyPerformanceExcellenceProgram KIO . . . . . . . . . . . . . .KeyIntendedOutcomeCPOE . . . . . . . . . .ComputerizedPhysicianOrderEntry Key CPRS . . . . . . . . . . . .ComputerizedPatientRecordSystem Priorities . . . . . .VA-mandatedprioritiesaddressingissuesrelatedtoVeteranCREW . . . . . . . . . .Civility,Respect,andEngagementintheWorkplace access,claimsbacklog,andVeteranhomelessnessCRMS . . . . . . . . .CustomerRelationshipManagementSystem KMS . . . . . . . . . . . .KnowledgeManagementSystemCS . . . . . . . . . . . . . . . .CommunicationSystem KSA . . . . . . . . . . . . . .Knowledge,Skills,andAbilitiesCSU . . . . . . . . . . . . . .CaribbeanSeaUniversity LCMS . . . . . . . . . . .LearningContentManagementSystemCT . . . . . . . . . . . . . . . .ComputerizedTomography LEED . . . . . . . . . .LeadershipinEnergyandEnvironmentalDesignCWT . . . . . . . . . . . .CompensatedWorkTherapy LGBT . . . . . . . . . . .Lesbian,Gay,Bisexual,TransgenderDART . . . . . . . . . . .EmployeeDaysAway/Restricted/Transferred LinKS . . . . . . . . . .LinkingInformationKnowledgeandSystemsDataFACTS . .DataFind,Analyze,Compare,andTrendService LIP . . . . . . . . . . . . . . . .LicensedIndependentPractitionerDebil . . . . . . . . . . . . .Debilitating LTC . . . . . . . . . . . . . .Long-TermCareDEPS . . . . . . . . . . .DisasterandEmergencyPreparednessSystem LOS . . . . . . . . . . . . . .LengthofStayDHS . . . . . . . . . . . . . .U.S.DepartmentofHomelandSecurity LS . . . . . . . . . . . . . . . .LeadershipSystemDoD . . . . . . . . . . . . .U.S.DepartmentofDefense MCCF . . . . . . . . . .MedicalCareCollectionFund DRG . . . . . . . . . . . . .Diagnosis-RelatedGroup MHV . . . . . . . . . . . .MyHealtheVetDx . . . . . . . . . . . . . . . . .Diagnosis MoS . . . . . . . . . . . . . .Measure(s)ofSuccessEDM . . . . . . . . . . . . .ExecutiveDecisionMemorandum MOSS . . . . . . . . . .MeasuresofSuccessScorecardEEOC . . . . . . . . . . .U.S.EqualEmploymentOpportunityCommission MQSA . . . . . . . . . .MammographyQualityStandardsEMTALA . . . . .EmergencyMedicalTreatmentandLaborAct MRI . . . . . . . . . . . . . .MagneticResonanceImagingEOC . . . . . . . . . . . . . .EnvironmentofCare MRSA . . . . . . . . . .Methicillin-ResistantStaphylococcusAureusEPA . . . . . . . . . . . . . . .U.S.EnvironmentalProtectionAgency MSD . . . . . . . . . . . .U.S.VirginIslandsMonetaryServicesDivision

G2

MSN . . . . . . . . . . . .MemorialServiceNetworkMVV . . . . . . . . . . . .Mission,Vision,andValuesNCA . . . . . . . . . . . .NationalCemeteryAdministrationNEO . . . . . . . . . . . . .NewEmployeeOrientationNeuro . . . . . . . . . . . .NeurologicalNHPP . . . . . . . . . . .NationalHealthPhysicsProgramNOV . . . . . . . . . . . .NoticeofViolationNPSG . . . . . . . . . . .NationalPatientSafetyGoalsNRC . . . . . . . . . . . . .NuclearRegulatoryCommissionOAI . . . . . . . . . . . . .OrganizationalAssessmentandImprovementOCR . . . . . . . . . . . . .OfficeforCivilRightsOEF . . . . . . . . . . . . . .OperationEnduringFreedomOIF . . . . . . . . . . . . . . .OperationIraqiFreedomOIG . . . . . . . . . . . . . .OfficeoftheInspectorGeneralOMB . . . . . . . . . . . .U.S.OfficeofManagementandBudgetOMIS . . . . . . . . . .OperationsManagementandImprovementSystemOND . . . . . . . . . . . . .OperationNewDawnOPM . . . . . . . . . . . . .U.S.OfficeofPersonnelManagementOrtho . . . . . . . . . . . .OrthopedicOSHA . . . . . . . . . . .U.S.OccupationalSafetyandHealthAdministrationP . . . . . . . . . . . . . . . . . . .ProjectedPA . . . . . . . . . . . . . . . . .PhysicianAssistantPACT . . . . . . . . . . .Patient-AlignedCareTeamPAO . . . . . . . . . . . . . .PublicAffairsOffice(orOfficer)PAR . . . . . . . . . . . . .PerformanceandAccountabilityReportPATS . . . . . . . . . . . . .PatientAdvocateTrackingSystemPDSA . . . . . . . . . . .Plan,Do,Study,ActPENTAD/QUADRAD . .VHA-facilityleadership,basedonwhethertherearefouror

fivemembersoftheSLTPharmD . . . . . . . .DoctorofPharmacyPI . . . . . . . . . . . . . . . . . .PerformanceImprovementPII . . . . . . . . . . . . . . . . .PersonallyIdentifiableInformationPIT . . . . . . . . . . . . . . . .PerformanceImprovementTeamPIV . . . . . . . . . . . . . . .PersonalIdentityVerificationPMARS . . . . . . .PerformanceMeasurement,Analysis,andReviewSystemPneum . . . . . . . . . .PneumoniaPSI . . . . . . . . . . . . . . . .PatientSafetyIndicatorPT/OT . . . . . . . . .PhysicalTherapy/OccupationalTherapyPT/PTT . . . . . . . . .ProthrombinTime/PartialThromboplastinTimeQRCode . . . . . .QuickResponseCodeR&E . . . . . . . . . . . . .RequirementsandExpectationsRBO . . . . . . . . . . . .RegionalBenefitsOfficeRCA . . . . . . . . . . . . .RootCauseAnalysisRESOLVED . .Record,Empathize,Solve,OfferOptions,Listen,Verify,

ExpressAppreciation,DocumentRN . . . . . . . . . . . . . . . .RegisteredNurseROI . . . . . . . . . . . . . . .ReturnonInvestmentRSRR . . . . . . . . . . .Risk-StandardizedReadmissionRateSA . . . . . . . . . . . . . . . . .StrategicAdvantageSAIL . . . . . . . . . . . .StrategicAnalyticsforImprovementandLearning(VHA

standardizedreport)SAMHSA . . . . .U.S.SubstanceAbuseandMentalHealthServices

AdministrationSAW . . . . . . . . . . . . .SchoolatWorkSC . . . . . . . . . . . . . . . . .StrategicChallengeSHEP . . . . . . . . . . . .SurveyofHealthcareExperiencesofPatientsSIPOC . . . . . . . . . .Supplier,Input,Process,Output,CustomerMappingSLT . . . . . . . . . . . . . . .SeniorLeadershipTeamS.M.A.R.T.E.R. . .Specific,Measurable,Aligned,Realistic,Time-bound,

Evaluated,andReviewedSME . . . . . . . . . . . . .Subject-MatterExpertSMR . . . . . . . . . . . . .StandardizedMortalityRatioSO . . . . . . . . . . . . . . . .StrategicOpportunity

SOS . . . . . . . . . . . . . .Seeit,Ownit,SolveitSPC . . . . . . . . . . . . . .Suppliers,Partners,andCollaboratorsSPP . . . . . . . . . . . . . . .StrategicPlanningProcessSPS . . . . . . . . . . . . . .StrategicPlanningSystemSSA . . . . . . . . . . . . . .U.S.SocialSecurityAdministrationStandUp/StandDown . .Toformallyactivateandcommissionaunit,formation,or

commandstructure/TodeactivateordecommissionitSWOT . . . . . . . . . .Strengths,Weaknesses,Opportunities,andThreatsTBI . . . . . . . . . . . . . . .TraumaticBrainInjuryTAP . . . . . . . . . . . . . .TransitionAssistanceProgramTMS . . . . . . . . . . . .TalentManagementSystemTx . . . . . . . . . . . . . . . . .TreatmentU/UNIQUE . . .UniqueVeteransserved,numberof.EachindividualVeteran

iscountedonlyonetime,evenifreceivingmultipleservices,havingmultiplevisits,orutilizingmultiplefacilities.

UCR . . . . . . . . . . . . .UnitCostReportUA . . . . . . . . . . . . . . . .UrinalysisUC . . . . . . . . . . . . . . . .UrgentCareVA . . . . . . . . . . . . . . . .U.S.DepartmentofVeteransAffairsVA-OIT . . . . . . . .VAOfficeofInformationandTechnologyVAAR . . . . . . . . . . .VAAcquisitionRegulationVACO . . . . . . . . . .VACentralOfficeVALU . . . . . . . . . . .VALearningUniversityVAMC . . . . . . . . . .VAMedicalCenterVAP . . . . . . . . . . . . . .Ventilator-AssociatedPneumoniaVASH . . . . . . . . . . .VeteransAffairsSupportiveHousingVAVS . . . . . . . . . . .VAVolunteerServicesVBA . . . . . . . . . . . .VeteransBenefitsAdministrationVERA . . . . . . . . . . .VeteransEquitableReimbursementAllocationVHA . . . . . . . . . . . .VeteransHealthAdministrationVI . . . . . . . . . . . . . . . .U.S.VirginIslands:St.Thomas,St.John,andSt.CroixVICTARS . . . .VeteransInsuranceClaimsTrackingandResponseSystemViNF . . . . . . . . . . . . .VirginIslandsNetworkfortheFutureVIRBO . . . . . . . .VirginIslandsRegionalBenefitsOfficeVISN . . . . . . . . . . .VeteransIntegratedServicesNetworkVistA . . . . . . . . . . .VeteransHealthInformationSystemandTechnology

ArchitectureVIVC . . . . . . . . . . .VirginIslandsVeterans’CemeteryVeteran’sChoiceCard . .ForVeteransenrolledintheVAsystemasofAugust1,

2014,aswellasthosewhoservedincombat.MaybeusedbyVeteranswhoexperiencetimeanddistancedelaystoreceivecarefromnon-VAfacilities

VPN . . . . . . . . . . . . . .VirtualPrivateNetworkVSO . . . . . . . . . . . . .VeteranServiceOrganizationWEDMS . . . . . .WorkforceEngagement,Development,andManagement

SystemWG . . . . . . . . . . . . . . .WageGrade:federalemployeesintradeandlabor

occupations

Icons/Color Coding

Purpletextorshadingdenoteshealthcareoperations(VHA).

Greentextorshadingdenotesbenefitsoperations(VBA).

Goldtextorshadingdenotescemeteryoperations(NCA).

Gradientcoloringdenotesmultipleoperations,inclusiveofmorethanoneAdministration.

ORGANIZATIONAL PROFILE

i

Organizational Profile

P.1 Organizational DescriptionP.1a TheCaseyComprehensiveCareCenterforVeterans(C4V)isaninnovative,collaborativecenterforVeteranslivinginorvisitingtheU.S.VirginIslands(VI).C4Vwasstoodup(opened)in2010asthefirstU.S.DepartmentofVeteransAffairs(VA)facilityunderasingledirectorshipthatprovidesservicesfromallthreeAdministrationswithintheVA:theVeteransBenefitsAdministration(VBA),theNationalCemeteryAdministration(NCA),andtheVeteransHealthAdministration(VHA).Thisintegrated-servicesconceptwaspilotedbasedonthedesiretoprovidemorecomprehensive,effective,andefficientcaretoVeteransingeographicareasthatarenotsufficientlypopulatedtojustifyseparateservicesfromallthreeAdministrations.

SincetwoofthethreeprimaryC4VofferingsfallundertheBald-rigeExcellenceFramework(Business/Nonprofit),thisapplicationwilladdressthosecriteria,whilerespondingtothehealthcareversionasappropriate.BackgroundcolorsontablesandintextshowAdministration-specificinformation:VBA(green),NCA (orange),andVHA(purple) .

P.1a(1) Themainproductsandhealth care service offerings (FigureP.1-1) providecomprehensivecareforVeterans.Thedelivery mechanismsincludetheHollidayHospital(HH),theVI’sVeterans’Cemetery(VIVC),andtheVI’sRegionalBenefitsOffice(VIRBO),whichareallco-locatedon100acresofpropertyjustoutsideofthecapitalcityofCharlotteAmalieontheislandofSt.Thomas.Additionally,community-basedoutpatientclinics(CBOCs)arelocatedoneachofthethreemainislandsofSt.Croix(BrabsonCBOC),St.John(BurtonCBOC),andSt.Thomas(YoungCBOC).TheBrabsonCBOCalsohousesa24/7EmergencyDepartmentwithastaffedtelephonecrisislineandhelicoptertransportservice.TheCBOCsarenotnewfacilities.Previously,theseweresatellitefacilitiesoftheVHAhospitalinPuertoRico;whenHHwasbuiltandopened,affiliationwastransferred.HHisratedasacomplexity2healthcarefacilitywithintheVAsystem.Complexity1(a,b,andc)facilitiesmanagethemostdifficultclinicalconditions,whilecomplexity3facilitiesmanagetheleastdifficult.AlthoughHHissmall,itisstaffedasacomplexity2facilityduetotheremote,islandlocation.

TheSeniorLeadershipTeam(SLT)determinestherelative importanceofeachservicebasedon“demand”measures,either

intermsofannualvolume(AV)ornumberofunique(U)Veteransserved,aswellasfinancialaspects,measuredasapercentageoftheC4Vbudget.

VeteranstatuswithintheVIisslightlyhigherthantherestofthecountry.Approximately8%oftheVItotalpopulationhaswornanAmericanmilitaryuniform—atotalofabout8,500islandresidents.C4ValsoprovidesservicestovisitingVeterans—pri-marilythroughthemedicalfacilities,althoughtherearefrequentrequestsfromVeteranswhowishtobeinterredintheparadisethatistheVI.

Theislandswereparticularlyimpactedbytheeconomicdownturnofthepreviousdecadebecausetheirmainactivityistourism.EconomichardshipsintheVImeanthatmoreislandersdecidetoserveinthemilitarywhentheycan’tfindgainfulemploymentlocally,andmoreVIVeteransmeeteligibilityrequirementsforcare.Nationally,about42%ofVeteransareenrolledwiththeVHAforhealthcare,26%aretreatedannually,and7%arebelowthepovertylevel.IntheVI,over50%ofeligibleVeteransareenrolled,35%aretreatedannually,and32.5%arebelowthepovertylevel;C4Vhasjustover3,000“unique”Veteransenrolledforservices.

P.1a(2) TheSLTmadethestrategicdecisiontoaligntheC4V mission, vision, and values(MVV)withthoseoftheoverallVA,duetothecomprehensiveservicesprovided.C4Vembracesitsrole(initiallyasapilotprogram)toleadandguidetheVAthroughthis“unknownandintricatemodel”ofcomprehensive,integratedcare;tobetterserveVeteransintheVI;andtoleadthewayforotherunderservedandremoteareasofthecountry.

C4V’score competencies arebuiltaroundVeteransandtheirfamiliestosupporttheVAmission.ThecenterleveragestheBaldrigeExcellenceFrameworkasitsstrategicframeworkforintegratedleadershipandmanagementsystems,settingC4VapartfrommanyotherVAfacilitiesandprovidersofsimilarserviceswithintheVIandtherestofthecountry.EarlyadoptionofthesecorecompetencieshelpedC4V“hitthegroundrunning”whenitwasstoodupin2010,focusingonrecruitingVeteranstoservetheVeteranpopulation;buildingsystems,approaches,andprocesses

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aroundtheneedsoftheVeteransserved;andenablingittodesignandbuildfacilities,infrastructure,andprocesses,asneeded,inaVeteran-centric,systematicmanner.

P.1a(3) TheC4V workforce profile (FigureP.1-3)isrelativelysmall,with225atthehospital,10atVIVC,29atVIRBO,4eachattheYoungandBurtonCBOCs,and19attheBrabsonCBOC(whoalsostafftheEmergencyDepartment,crisisline,andflightcrew).

Inadditiontoemployees,theworkforceincludesmanydedicatedvolunteersinallhealthcarefacilitiesandthecemetery.TheworkforcealsoincludesthenursingstudentsatCaribbeanSeaUniversity(CSU)whouseC4Vasaclinicaltrainingsiteforassociateandbaccalaureatedegreesinnursing.

TheC4VworkenvironmentandmakingadifferenceforVeteransarethekey drivers that engage the workforceinaccomplishingthemissionandvision,inadditiontoprideinbeingpartofthisintegratedservice-deliverymodelforVeterans.TheC4VLeader-shipSystem(LS;category1)createsanenvironmentthatincludesfairandequitabletreatment,ethicalservice,andprofessionalgrowthopportunities.Theworkforcealsorequiresandexpectsteamworkandahealthy,safe,andsecureworkenvironment.

Approximately80%oftheworkforceisrepresentedbytheAssociatedGovernmentEmployees(AGE)collective bargain-ing unit . Special health and safety requirementsarenotedinFigureP.1-3.

P.1a(4) Primaryassets,inadditiontotheworkforce,aretheC4V facilities.HHisa25-bed,full-servicehospitalinabeauti-fultwo-story,102,500sq.ft.building,setonapproximately20park-likeacresofthe100-acrecampus.Allinpatientroomsare

privateandtelemetry-capable.C4Voffersthreesurgerysuites,aminorprocedureroom,afive-bedgeneralintensivecareunit,anda24-hourEmergencyDepartment,withsixcarestationsincludingtwotraumabays.Servicesalsoincludeimaging,includingCT,MRI,ultrasound,andmammography,andcardiovasculardiagnos-tics.C4Vintegratesitshealthcareofferingsthroughtelemedicineservices,providingexpertiseandguidanceinremotelocationstothethreeCBOCsandreceivingexpertiseandguidancefromotherVHAfacilitiesinthecontinentalUnitedStates.

VIRBOoccupiesspacewithinHHtofacilitateVeterans’accesstotheirbenefitsandenabletwo-waycommunicationbetweenVeteransandbenefitsofficers.

Thecemeteryportionofthecampusencompassesover50acres,including18,000unfilledgravesites,10,000columbarianiches,and2,500in-groundgardenniches.Webcamsandspeciallightingenablelovedonesto“visit”thecemetery24/7throughtheinter-net,andthenationalgravesitelocatorsystemensuresthatfamiliesandfriendscaneasily“find”theirlovedones,whethervisitinginpersonorelectronically.

OneoftheadvantagesofthecollaborativeintegrationofC4VisthesharedexpertiseamongtheAdministrations.Forexample,cemeterypersonnelmaintainthegroundsoftheentiremaincampus,ensuringthatpersonnelandequipmentareusedtotheirfullestcapacity,efficiently,andeffectively,maintainingtherespectful,park-likeatmosphereoftheentirefacilityfortheenjoymentandrelaxationoftheVeteranpopulationandtheentirelocalcommunity.

Throughsecurewebconnections,allthreeAdministrativefunctionswithinC4VarelinkedintotheVAcomputersystemsandsoftwareprogramsdescribedincategory4.

P.1a(5) TheVAhaspublishedspecialrequirementsbasedonthebusinessmodelforC4V(Figure2.1-4).Generalrequirementsincludetheregulatory environmentforVAfacilities(Title38oftheU.S.CodeofFederalRegulations);plusallgeneralregula-tionsforcemeteries,benefitsadministrations,theinsuranceindustry,andhealthcareapply(FigureP.1-4).

P.1b(1) Theorganizational structure isamatrixreportingformat,ledbyasingleDirector,whointurnreportsseparatelytothegovernance systemoftheleadersoftheAtlantaMemorialServiceNetwork(MSN)forNCAactivities,theSouthernAreaOfficeforBenefitsandLoansforVBAservices,andVeteransIntegratedServiceNetwork8forVHAactivities.InadditiontotheDirector,theSLTincludestheDeputyDirector,AssociateDirectorforHealth,AssociateDirectorforMemorialAffairsandFacilities,AssociateDirectorforBenefits,andtheChiefsofPerformanceExcellence,HumanResources,andInformationTechnology.

P.1b(2) At C4V,eachmemberoftheworkforceandeachsup-plier,partner,andcollaborator(SPC)isabsolutelyclearthatC4V ismission-driven,andthemissionclearlydefinestheC4V key customer groups: Veteransandtheirfamiliesandsurvivors.Keymarket segmentsarealignedtothemainofferings(FigureP.1-1)andthethreeislands.

Oneadditionalmarketsegmentisnon-VI-residentVeteransseek-ingC4Vservices,usuallyforhealthcareormemorialservices.Otherstakeholders includetheworkforceandSPCs,theVI

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communitiesimpactedbyVeteranhomelessness,andtheentireVAsystem(becauseC4Vwasapilotformatforintegratedcare).Requirements and expectations(R&E)ofeachstakeholdergrouparenotedinFigureP.1-5,includingthedifferences in requirements forspecificsegments.

P.1b(3) EachoftheadministrativefunctionsofC4VhaveSPCs withspecific roles (FigureP.1-6).Suppliersaredesignatedas“key”iftheyreceiveover70%ofthespecificbookofbusinessfromC4V.InaccordancewiththeFederalAcquisitionRegulations(FAR),allsuppliers’servicesaremanagedthroughacentralizedcontractingprocess,withthekeycommunication mechanism forallbeingtheContractingOfficer(CO)and/orthetechnicalrepresentatives(COTRs).Additionally,allsuppliersaregivenaperformancereportatleastannually,asspecifiedbythetermsoftheircontracts.Thereportprovidesfeedbackaboutthecontrac-tualmeasuresofsuccessandhelpstocreateaccountabilityforallparties.

WithinC4V’sworksystems,SPCsarekeyenablersfordelivery ofservices,asC4VwouldnotbeabletoofferservicestoVeteranswithoutsuppliesandequipment.CollaborationwithCSUhelpskeephealthcareserviceofferingscurrentwithstandardsofprac-ticeandevidence-basedguidelines.PartnershipwiththeVeteranServiceOrganizations(VSOs)aidsinoutreachtoVeteransandhelpsVeteranstotrustanduseC4Vservices.

Supply chain requirementsfromC4Vincludeaccuracyandon-timedelivery.SupplierrequirementsforC4Vincludepromptpaymentandfairpricing.Two-wayrequirementsincludeopencommunicationchannelsregardingR&E,performance,andopportunitiesforimprovement.

P.2 Organizational SituationP.2a TheC4VSLTandworkforceembracetheincrediblemissionof“servingthosewhohaveserved.”Additionally,C4VhasthehonorandprivilegeofhelpingtoshapethevisionandforgeafutureinwhichmanyVeteranswhoarecurrentlyunderservedduetoremotegeographicregions,areasofsparsepopulations,andresourceconstraintsmayhaveaccesstohigh-qualitycareandservicesfromtheVA.

P.2a(1) C4VservesanichewithintheVI.Insomeregards,C4V competeswithlocalhospitals,insuranceproviders,andcemeteries,butinmostcases,C4Vprovidesservicestothosewhocouldnotpayotherproviders.Typically,theVeteransservedby C4Vwouldnotproducesignificantrevenueforotherlocalprovidersofsimilarservices,andtherefore,relationshipswithothersarecollaborativeratherthancompetitive.However,withtheexpansionofMedicaidservicesundertheAffordableCareAct(ACA)andthenewVeteran’sChoiceCards,manyVeteranswillhaveincreasedchoicesforhealthinsuranceandhealthcare,andrelationshipsmaybecomeincreasinglycompetitive.

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ThedecisiontopilottheC4VcollaborativedeliverymodelintheVIwasdrivenbythehighratesofVIunemployment(13.5%,morethandoublethe6.1%averageforthecontinentalUnitedStates),theassociatedhighratesofpeoplelivingbelowthepov-ertylevel(32.5%,comparedwith15%averageforthecontinentalUnitedStates),andhomelessness(0.5%,comparedwith0.2%averageforthecontinentalUnitedStates).ThesestatisticstendtostrikeVeteransparticularlyhard,duetotheirrelativelyhighratesofdisabilityfromphysicalandemotionaltraumaincurredwhileservingourcountry.

With25inpatientbeds,HH’srelative sizeismuchsmallerthantheotherVIhospitals;St.Croixhasahospitalwith188beds,andSt.Thomashasahospitalwith194beds.Eachhasassociatedoutpatientservices,includingpsychiatricservices.BothoftheselargerfacilitiescollaborateandpartnerwithC4VbyofferingservicesthatarenotavailablefromC4VandarepaidbyC4V underfee-basisprovisionsofthe“Non-VACare”programforVeterans.BothlocalhospitalsalsoprovidetelemedicineandconsultativeresourcesforC4V,inadditiontothetelemedicineservicesavailabletoVeteransfromotherVAfacilities.

Similarly,whilethereareothercemeteriesonallthreeislands,VIVCprovidesservicesatnochargetotheVeteran’sfamily,includingopeningandclosing,perpetualcare,amarkerorheadstone,aburialflag,andaPresidentialMemorialCertificate.FamiliesofmanyVeteranscouldnotaffordservicesatotherlocations,andmanyselectC4VservicestoprovidetheirfamilymemberswithafinalrestingplacemeetingNationalShrineStandards,withlastingtributesthatcommemoratetheirserviceandsacrificetoournation.

ServicesprovidedbyVIRBOarealsounique.HealthinsuranceisofferedtoeligibleVeteransatnocharge,andotherbenefitsincludeloanguarantees,low-interestloansforhousingand

education,vocationalrehabilitationandeducation,lifeinsurance,anddisabilitybenefits.Aswithhealthcare,theACAisincreasingthecompetitivenatureofVIRBO,asVA-eligibleVeteransmayalsobecomeeligibleforMedicaidservices.

Therearenoplansatthepresenttimeforfacilityorserviceexpan-sion.HHtypicallyhasinpatientsin20ofthe25availablebeds,andmostVeteransareabletoobtainanoutpatientappointmentontheirfirstorsecondchoiceofdatesandtimes.VIRBOhasoneofthebestclaimsprocessingtimesinthecountry,andVIVCisprojectedtohavespaceavailableuntil2050.

P.2a(2) Fewkey changes are anticipated to affect the competi-tive situationforVIVCorVIRBO,althoughtheACAandthenewVeteran’sChoiceCardswilllikelypromptchanges inthecompetitivesituationforC4V’shealthservices.TheissuesthatotherVHAfacilitiesfacedin2014relatedtotimelinessofaccessandVBA-relatedclaimbacklogsresultedinnewregulationstoenableVeteranstouseaVeteran’sChoiceCardtoreceivecarefromanyMedicareprovider,FederallyQualifiedHealthCenter,IndianHealthCenter,ormedicalcenterfundedbytheU.S.DepartmentofDefense(DoD).

P.2a(3) FigureP.2-1presentscomparative and competitor data,includinglimitationsonobtainingvalid,reliable,timely,andaffordableinformation.Themajorissueinobtainingcomparativedataandinformationistimeliness,particularlyfromdatasourcesexternaltotheVA.Additionaldatamaybeavailablemoretimelyfromtradeorganizationsandthird-partydatafirms,suchascom-mercialsatisfactionsurveycompanies;however,thesedatatendtobeveryexpensivetoprocure.

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Themyriadofvariablesingatheringandreportingdata,par-ticularlyinhealthandbenefitsoperations,presentschallengesensuringreliabilityandvalidityofcomparisonandbenchmarkinformation.

AsaFederalagency,C4VmustobtainOfficeofManagementandBudget(OMB)approvalwhenidenticalinformationistobecollectedfrommorethanninerespondents.TheVSOshelpfosterrelationshipswithVeteransandwithinthecommunitybysharingdataandinformationwithC4Vthattheyobtainthroughtheirsurveyprocesses.

P.2b C4Vhasthestrategic advantageofbeingperceivedasakeyresourceforVeterans.AsastrategicactiontakeninsupportoftwoofthethreeVA“KeyPriorities,”C4VwasstoodupinanareawhereresourcesforVeteranswerescarce.

LeadershipandtheworkforceatC4Vunderstandtheironythatmanyofitsstrategic challenges(FigureP.2-2)arethesamefactorsthatledtothecreationofC4VanditsuniqueinitialroleasaVApilotprogram.TheSLTcapitalizesonthisrolebycarefullymeasuringtheimpactonhelpingovercomethosestrategicchal-lenges.C4Visveryawareofthefactthatsuccessmaycreatetheincentiveforothersimilarcollaborativefacilitiestobestoodupinotherunderservedareasofthecountry,sothatoutreachtowardVeteransextendsbeyondtheVI’sshores.

FortheVI,inadditiontothedecreaseintourismassociatedwiththeeconomicdownturn,anadditionalhardshipoccurredinFebru-ary2012whenamajorVImanufacturerceasedoperations.Thiscompanycontributedabout20%oftheterritory’sgrossdomesticproduct,andtheclosureledtomajorjoblossesandadoublestrainonthelocaleconomyfromtaxlossesandsocialserviceneedincreases.HighunemploymentpromptedmoreVIyouthtoentermilitaryservice,andmanyofthemwillbedischargedinthenext12–24monthsduetotheDoDpersonneldrawdown.

ThesereturningVIVeteransfaceanevenhigherrateofunem-ploymentthanthegeneralpopulationduetothehighincidenceofphysicalandemotionaltraumaassociatedwithmilitaryservice.Currently,13.5%ofVIVeteransareunemployed,increasingtheireligibilityforC4Vservices,andthisrateisexpectedtogrowoverthenextfewyears.

ManysocialissuesfacingtheVIaremagnifiedintheVeteranpopulation.Forexample,thereisahighdegreeofcorrelationbetweenwarmerclimatesandhomelessness,aswellasbetweentraumaticbraininjury(TBI)andhomelessness,andbetweenTBIandjobloss/unemploymentleadingtopovertyandhomelessness.ThecommitmentoftheVAinhelpingtofindsolutionsiswel-comedbytheVIgovernmentanditscitizens.

P.2c TheSLThadstrategicdiscussionaboutthedesignandimplementationofitsperformance improvement (PI) system(s) . SeveralkeystaffmembershadexperienceusingtheBaldrigeCriteriaasastrategicframeworkforleadershipandmanagement.ThedecisionwasmadetodesigntheentireorganizationusingsystematicapproachespromptedbytheBaldrigeCriteriaques-tions;thisledtoC4VwinningtheCPEPtrophyin2014.

Tofosterinnovation,ongoinglearning,andwisestewardshipofresources,seniorleadersevaluatedseveralPIsystemstoadoptanddeploytotheC4Vworkforce.EachSLTmemberhadexperi-enceusingplan-do-study-act(PDSA)andsystemsredesign.Aftercomparingtheadvantagesanddisadvantagesofthesemethodolo-gies,SLTmemberschoseIDEALS(FigureP.2-3),whichtheylearnedaboutataBaldrigeQuestforExcellence®Conference.Thisapproachencompassesawidevarietyofothertools,toincludePDSAasthe“bigDEAL”loopinthecenter.IDEALSispromotedtotheworkforceas“simplyawayoflife,”withtherecognitionthatthefirststeptowardanyimprovementisidentify-inganeedforchange,andthatimprovementsneedtobesustainedinordertobesuccessful.BenefitsoperationsarealsopursuingISOcertification,inalignmentwiththeVBAinitiativetoenhanceclaimsefficiencyandaccuracy.

IDEALSolutionsincludetoolsfromLean,theoryofconstraints,SixSigma,appreciativeinquiry,andotherimprovementmethod-ologies,whicharedeployedthroughPerformanceImprovementTeam(PIT)crews,particularlyduringthe“design”and“execute”phases.Statisticaltoolsareusedto“analyze”findingstodrivefurther“learning.”IDEALShasthreekeyadvantages:it’seasilyunderstoodandremembered,itpermits“steppingout”oftheimprovementcyclewhenresourceswouldbebetterusedelsewhere,anditsystematicallypromoteseffortsto“sustain”andshareprocessesthatareproventobeeffectivebytheresultsachieved.The6-Ps of Leadershipandthe6-E Leadership Tool,describedin1.1a(1)and1.1b(1),arealsokeyelementsofthePIsystem.

Figure P.2-3: IDEALS Performance Improvement System

RESPONSES ADDRESSING ALL CRITERIA ITEMS

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Category 1 Leadership

1.1 Senior LeadershipSeniorleadersatC4VhavedevelopedasetofIntegratedLeader-shipandManagementSystems (ILMS)toleadtheorganization.TheILMScomprisetheLS(Figure1.1-1);CommunicationSys-tem(CS;Figure1.1-2);StrategicPlanningSystem(SPS;Figure2.1-1);ActionPlanningSystem(APS;Figure2.2-1);CustomerRelationshipManagementSystem(CRMS;Figure3.1-1);Per-formanceMeasurement,Analysis,andReviewSystem(PMARS;Figure4.1-1);KnowledgeManagementSystem(KMS;Figure4.2-1);WorkforceEngagement,Development,andManagementSystem(WEDMS;Figure5.1-1);OperationsManagementandImprovementSystem(OMIS;Figure6.1-1);andDisasterandEmergencyPreparednessSystem(DEPS;Figure6.2-2).AllarestructuredaroundtheIDEALSsystemnotedinP.2c,andeachkeytask(e.g.,“deployvisionandvalues”)identifiedineachsystemisadefinedandsystematicapproach.

TheDirectorusedtheBaldrigeCriteriaandILMSatapreviousfacilityandbroughtthemtoC4V,wheretheSLThasusedandrefinedthemsince2010.EachoftheILMSisdesignedtoaddressthebasicandoveralllevelsoftheBaldrigeCriteria,andtheyarereviewedduringeachstrategicplanningcycleandalsowitheachself-assessment/applicationcycle.In2013,theSLTevaluatedthesystemsanddecidedtoprocessmapeverykeytaskidentifiedineachoftheILMStoensurethatthesystemsweresystematicandadequatelyaddressedthemultipleareasoftheCriteria.Theprocessmaps,suchastheStrategicPlanningProcess(SPP)inFigure2.1-2,furtherintegratetheILMSandarereviewedtwiceperyear.TheSLTreviewsthepublicapplicationsofeachBaldrigeAwardrecipientandtheBaldrigecasestudy,lookingforideasforpotentialenhancementstotheILMSanditsassociatedprocesses.

TheLS(Figure1.1-1)usestheCS(Figure1.1-2),communicationmechanisms(Figure1.1-3),andtheCRMS(Figure3.1-1)asinputstoidentifyandunderstandstakeholderrequirementsandexpectations.Processesaredeployedthroughplanning,policies,andprocedures;evaluatedusingthePMARS(Figure4.1-1);andimprovedthroughtheOMIS(Figure6.1-1).

1.1a(1) Seniorleaderssetthevision and valuesthroughtheSPP(Figure2.1-2),inalignmentwiththeVAanditsthreeAdministra-tions.ThemissionandvaluesareidenticalthroughouttheVA;whilethevision,designedtocreateafocusonperformanceexcellence,isspecifictoC4V .

SeniorleadersdeploythevisionandvaluesthroughtheLS.First,theworkforce,includingemployees,volunteers,students,andcontractors,aswellassuppliers and partners,areaskedtocom-mittotheMVVpriortobeginningtheirengagementwithC4V . Then,throughsignage,posters,screensavers,andwrittenmateri-alsasremindersofexpectedbehaviors,theMVVaremadehighlyvisibleto the workforce, customers,andotherstakeholders whovisitthefacilities.Next,theSLTfurtherdeploystheMVVthroughpersonal actions thatrolemodelexpectedbehaviors,reviewsofperformance,discussionsabouttheimportanceofthebehaviors,andpersonalparticipationinrecognizingandreward-ingexemplaryactivities.Forexample,in2013,C4Vupdatedand

refreshedtherecognitionsystembasedontheDr.Seussquotethat“to the world you may be just one person, but to this one person you may be the world,”toemphasizethecommitmenttoworld-classcare.ExemplaryactionsarecommunicatedtotheSLT,oneofwhompersonallysendsanotecardtotheemployee’shome,expressingappreciationfor“goingoutofthisworld”toimprovethelifeofaVeteran.Notesincludethequote,depictaglobe,andspecifyhowtheactionlinkstoC4Vvalues.

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SLTactionsreflectacommitment to the valuesthroughsystem-aticuseofthe6-Ps of Leadership:Purpose,Passion,Planning,Persistence,Patience,andPresence.TheSLTconsidersanddiscusseseachofthe6-PsasitrelatestoeachoftheIDEALS-basedsystems,particularlytheLS(Figure1.1-1).Deploymentofthe6-Ps of Leadership beginswithpersonalparticipationinNewEmployeeOrientation(NEO)andcontinuesthroughleadershiprounding,morningSLThuddles,rewardandrecognitionsystems,anduseofthe6-E Leadership Tool(1.1b[1])inprovidingresourcesthateducate,equip,empower,engage,andencouragetheentireworkforcetolivetheMVVandtoevaluateprogresstowardbecomingaworld-classorganization.In2014,C4Vimple-mentedanewcampaignSee it, Own it, Solve it(SOS),whichisfocusedonaccountabilitytohelpengageallmembersoftheworkforceinseekinginnovativesolutionstobetterserveVeterans.

1.1a(2) SLTmembers’actions demonstrate their commitment to legal and ethical behavior,andtheypromote anorganiza-tionalenvironmentthatrequiressuchbehaviorinaccordancewiththeVANationalCenterforEthicsFourCompassPointsforEthicalLeadership.First,SLTmembersdemonstratethatethicsisaprioritybytalkingaboutethicsandprovingthatethicsmatterstoeachofthempersonally,byencouragingdiscussionsofethicalconcerns,andbyparticipatingontheIntegratedEthicsCouncil(IEC).Second,theycommunicateclearexpectationsforethicalpracticethroughpolicies,procedures,andeducation,beginningwithSLTpersonalparticipationinNEOandreinforcedthroughannualtrainingfortheentireworkforceandcontractors.Theyrecognizewhenexpectationsneedtobeclarifiedbythequestions,scenarios,andsituationsthatcomebeforetheIEC,PeerReviewCommittee,orotherlisteningmechanisms,includingtheEthicalConcernsReportingToolandthehelpline.Communicationsaboutethicalexpectationsareexplicit,identifyingexamplesofconcernsandlinkingrecommendationstostoriesofpersonalexperiencesandtheunderlyingvalues.Asmuchaspossible,seniorleadersanticipatebarrierstomeetingexpectationsandallocateresourcesaccordingly.Third,theyrolemodelethicaldecisionmaking,identifyingdecisionsthatraiseethicalconcernsandincludingtheperspectivesofkeystakeholdersinthedecision-makingprocess,clearlyexplainingdecisionsandrecommendations.Finally,theysupporttheIntegratedEthicsProgram(IEP)describedin1.2a(1).Theyareengagedinallaspectsoftheethicsprogram,encourag-ingtheraisingofconcerns,havingcourageousconversationsaboutconcerns,reachingconsensusaboutthebestmannertoaddressaconcern,andencouragingauditsrelatedtohigh-riskissuestoensurethatbehaviorsareappropriate.In2012,C4V determinedthatscenario-basedtrainingwouldbemorerealisticandmemorable,sothetrainingwasrefreshedandupdated,andin2014,ethicswereintegratedintothenewSOScampaign.

1.1a(3) Seniorleaderscreate a successful organizationthroughdiligentallocationofresources,alignedtothemission,throughtheintegratedplanningandbudgetingprocesses.DeploymentoftheI-CAREvaluescreatesanenvironmenttoachieve the missionandimprove performancetoworld-classlevelsthroughorganizationalandpersonallearning.WhentheI-CAREvaluesofIntegrity, Commitment, Advocacy, Respect, andExcellence wereadoptedbytheVAin2011,theSLTspentadayoff-site,focusedonhowtobestintegratethemintoC4V,alongwiththeVA

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characteristicsofbeingTrustworthy, Accessible, Quality-Oriented, Innovative, Agile, andIntegrated.

TheSLTsystematicallyusesmanymethodstokeepthevaluesandcharacteristicsattheforefrontofeverydayexperience.Forexample,I-CAREcertificatesareavailablefromtheVAfortheworkforcetorecognizeeachother’snoteworthywordsoractionsthatmakeapositivedifferencetotheworkplaceandtheVeteransserved.Everymeetingagenda,newsletterarticle,webpage,andotherC4Vcommunicationmustbespecificallylinkedwithatleastonevalueorcharacteristic.Thelinkagesheightenawarenessandfocusandhelpcreateaworkforce culturethatisVeteran-centricandvalues-driventodeliveraconsistently positive customer experience.WhenSLTmembersevaluatedthisprocessofalways linkingavalueand/orcharacteristic,theyfoundthatlinkageswereusuallyobvious,andwhenalinkagewasnotreadilyapparent,theactivitywasusuallynon-value-added,ormisaligned,andshouldbestopped.

TheVAvaluesandcharacteristicsarealsointegratedintotheprocesstodevelopplans,training,andimprovementinitiativesbyusingaweightedprioritizationmatrix.EachplanorinitiativeincludeskeyMeasure(s)ofSuccess(MoS)tofocusonmanage-mentbyfact,andisassignedtoasingleowner(notacommitteeorgroup)tocreateaccountability.Clearcommunicationsregard-ingexpectationsforperformanceanddevelopingtheSOSculturehelpleaderscreateanenvironment for innovationandintel-ligent risk taking,aswellashelpthecenterachievethestrategicobjectivesandpromoteorganizationalagility.

DrivenbyuseoftheBaldrigeExcellenceFramework,theSLTconsiderstheBaldrigeconceptsofVisionary LeadershipandOrganizational LearningtosupplementtheI-CAREvaluesandVAcharacteristicswiththecorevaluesofBaldrigethatdonotoverlap.Useofallthirteenvaluesandcharacteristicshelpscreatebalanceamongsustainability,improvement,agility,stability,andinnovation,anddrivesorganizationalandpersonallearning.

C4V’sBaldrigejourneyhashelpedpromotesustainabilitybyenhancinganalysisofdatatoolsandanalytics.UsingtheNCA’sOrganizationalAssessmentandImprovement(OAI)Programasamodel,C4Vestablishedastandardizedprocesstoassessperfor-manceandoverallorganizationalhealth.Standardmeasures,whichincludearobustdatadictionaryandpresetcontrollimits,helpthecenterevaluatewhenmetricsareinneedofattentioninordertoachievehighperformanceandfocusresourcesforimprovement.Thepresetlimitsincludespreadsheetconditionalformattingtoautomaticallyaddred,yellow,green,andbluecolor-coding.Onthesecolor-codedstoplightcharts,leadersencouragetheworkforceto“gofortheblue”—levelsofperformancethatareworld-classincomparisontootherorganizationsperformingsimilarservices,typically90thpercentileorabove.“Green”statusrepresentsthe60thpercentile,with“yellow”indicating50thpercentile,andanythingbelowthe50thpercentile(averageperformance)isconsidered“red.”Additionalupperandlowercontrollimitswereaddedin2012toalerttheSLTtotakeaction,andslopecontrolsnowtriggeranauditwhenaperformancechangeseemsunrealistic.InresponsetoinaccuratewaittimereportingidentifiedelsewhereinVHA,C4VwasauditedinJune2014withnoirregularitiesfound.In2012,C4VimplementedanewserviceknownasDataFACTS:Find,Analyze,Compare,and

TrendService.TheDataFACTSTeamincludesabiostatisticianwhosupportsallthreeC4VAssociateDirectorsinconvertingthebig dataintoinformationtoguidedecisionmaking(specificsupportisdescribedincategory4)andresourceallocation.ThismodelisbeingdeployedthroughouttheVA.

TheSLTparticipatesinsuccession planninganddevelopmentoffutureorganizationalleadersinaccordancewithVApolicies.SuccessionplanningandappointmentsfortheDirector,Deputy,andAssociateDirectorsaremadeattheAdministrationlevel.OtherSLTmembers’successionplanningisaccomplishedbyC4V . Topreparefutureorganizationalleaders,C4Vstrivestodevelopeachmemberoftheworkforcetohis/herfullestpotentialthroughtheWEDMS(Figure5.1-1).

AlloftheSLTmembersandmanyoftheotherleadersserveasVA-certifiedmentors.TheysupportVAemployeedevelopmentthroughmentoringandcoachingparticipantsintheLeadershipVAandCompetencyDevelopmentforLeaders(see5.2b[3])pro-grams.Theyalsosupportavarietyofinternprogramsandmentorgraduate-levelstudentsinrelatedfieldsofstudy.SLTmembersprovideexpertiseandfundingforleadershipdevelopmenttrainingatalllevels,asdescribedincategory5,andpromotegrowthanddevelopmenttoensurecontinuityofoperationsduringtheirabsencesbyassigninginterimcoveragetosubordinates.

TheSLTcreatesacultureofpatient safetybysettingclearexpectationsandrewardingsafetyinitiatives,embracingtheJust CultureandSpeak UpinitiativesoftheAgencyonHealthcareResearchandQuality(AHRQ)andtheAccreditingHealthCareGroup(AHCG).TheSLTusestheGood Catch! awardprogramtoencouragereportingofinstanceswhereapotentiallyharmfuleventwasaverted.Amultidisciplinarycommitteedeterminesawardlevels,rangingfromacertificatetocash,dependingontheseverityofthepotentialforharm.Initiatedinhealthcareopera-tions,theseprocessesarenowdeployedthroughoutC4V .

1.1b(1) TheSLTcommunicateswithandengagestheentireworkforceandkeycustomersthroughtheCS,showninFigure1.1-2,usingthemultiplecommunicationmechanismslistedinFigure1.1-3.Manyofthemechanismsshownaredesignedtoencouragefrank,two-waycommunication,includingeffectiveuseofsocial media.Whenfeasible,key decisionsarecommunicatedinpersontoallowforclarificationandhelpensureunderstanding.Basedonfeedbackfromfocusgroups,follow-uptalkingpoints arenowprovidedinwritingtoallseniorleaderstoensurethataclearandconsistentmessageisliterallycarriedforth.Communi-cationsaboutkeydecisionsarealwaysalignedtotheC4Vvaluesandcharacteristics.

Theanalyze phaseoftheCStakesonmanyforms.BasedonaninnovativeideafromtheTrainingDepartment,C4VnowappliestheKirkpatrickModelforevaluationoftrainingtothecom-municationprocesses.Thefirstlevelistoensurethattheintendedrecipientsreceivedtheinformation.Thesecondlevelevaluateswhethertherecipientsactuallyunderstoodthecommunication.Typically,thisisevaluatedthroughtheconversationsheldduringleadershiprounds,givingtheleaderssomethingspecifictodiscuss.Thethirdlevelrequiresthattheimmediatesupervisororanotherobserverensurethatthedesiredbehaviorsrequestedinthecommunicationarebeingfollowed.Thehighestlevelisto

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evaluateorganizationalperformancerelativetothetopic.Basedontheimmediatepost-disseminationanalysis,theDataFACTSTeamevaluatesperformancerelativetothespecifictopic,asappropriate,aswellasresultsrelatedtotheassociatedvalue/characteristic.Thefirstlevelevaluatestheeffectivenessofthemechanismsfortransmission,whilethehigherlevelsevaluatetransmissionof,receiptof,andactiononthemessage.Levelfouralsoevaluatesorganizationallearningaboutthetopic.

TheSLTtakesaveryactiveroleinmotivating the workforce,primarilythroughparticipationinreward and recognition programs.Rewardandrecognitionareembeddedintothe6-E Leadership Tool.First,seniorleadersEducatetheworkforceaboutrequirementsandexpectations,carefullyaligningrewardandrecognitiontothekeyintendedoutcomesandassociatedMoS.Next,theyEquiptheworkforcewithinformationaboutcurrentandbenchmarkperformancelevelstohelpidentifyopportunitiesforimprovementandinnovation.Then,seniorlead-ersEmpowerworkforcememberswiththenecessaryresources,Engagingthembyshowingtheintegrationof(1)theMVV,(2)theirabilitytomean the world topeoplebyimprovingprocesses,and(3)bothintrinsicandextrinsicmotivation.Finally,C4VusesmultiplemechanismstoEncouragethedesiredbehaviorsthroughrewardandrecognition,basedonperformanceEvaluatedthroughMoS.Acycleofimprovementlastyearwastomoretightlyintegratetherewardwiththedesiredbehavior,asshowninFigure1.1-4,toreinforce high performanceandapatient and other customerfocus.

1.1b(2) TheSLTcreatesafocus on actionalignedwithorga-nizationalobjectives andthe MVVandencourageshighper-formance,innovation,andintelligent risk takingthroughuse

oftheILMS,BaldrigeCriteria,andthe6-Ps of Leadershipandthe6-E Leadership Tool.WhilepreparingtostandupC4V,SLTmembersattendedateam-buildingandproblem-solvingcourse.Theyusedprinciplesofappreciativeinquirytoidentifythemostdesirablecharacteristicsofleadersbasedonpersonalexperienceandhistoricalfigures.Theythenfocusedonhowtosystematicallyincorporatethesecharacteristicsintodailyactivities.WhentheVAmemorializedcharacteristicsandvalues,C4Vsuggestedmanyoftheattributesthatmadethelist.LeadershipbehaviorsembeddedatC4Vforeachcharacteristicinclude

■ Trustworthy=Integrity+Capability+Capacity.Keepourword,treatothersfairly,balancevalue,andbasedecisionsonfact.

■ Accessible=Physical+Emotional+Logical.Beapproach-ableandopentoideasandsuggestionsbybeingpositiveandproactive.

■ Quality-Oriented=Inputs+Processes.ContinuouslyevaluatetoidentifytheIDEALSolutionwithinthecurrentresourceconstraints.

■ Innovation=Need+Knowledge+Creativethinking.Neverbecontentwiththestatusquo,nordesirechangejusttochange.SeekalwaystobetherolemodelinenhancingtheVeteranexperience.

■ Agility=Flexibility+Sustainability.Seektobereactiveinaproactivemanner.Createthefuture!

■ Integrated=Me+You+Othersaremorethanthesumoftheparts.Embracethechallengesandadvantagesofbeingpartofalargerwhole,andseektobebothadisruptiveandstabilizinginfluence.

ThereisacommonsayingwithintheVA:“Ifyou’veseenoneVAfacility,...you’veseenoneVAfacility.”Recentchallenges—withinVHAregardingaccess,withinVBAregardingbacklog,andwithinNCAregardingcorrectidentificationofgravesites—remindtheworkforcethat“whensomethingbadhappensatoneVAfacil-ity,ithappenedintheVA,”andalloftheVAfeelstherepercus-sions.Leadership’sfocusonmanagement by fact promotestheconfidenceofallkeystakeholders—especiallytheworkforce,taxpayers,andVeterans—inC4V’squalityandperformance.

TheSLTidentifies needed actionsbasedonperformancemea-sures;thisidentificationincludescarefulselectionofSMARTERgoalswhensettingexpectations for organizational perfor-mance . C4VformerlyusedtheacronymSMARTbutthenaddedthe“ER”toensurethatallofthegoalswereSpecific,Measurable,Aligned,Realistic,Time-bound,Evaluated,andReviewed,asdescribedin2.2a(1).EnsuringthatgoalsarealignedandrealisticenablestheSLTtofocusoncreating and balancing valueforpatients,othercustomers,andotherstakeholders.Includingshort-andlonger-termplanninghorizonsforeachgoalhelpstoensurethatitisrealistic.Asdescribedin1.1a(3),C4Vusesmultiple“presetpoints”topromptactionsatvariouslevelsofleadership.Lowerintheorganization,theperspectiveisneartermandmorenarrowlyfocused,asshowninFigure1.1-5.Middlemanagementisfocusedonthe“operationalzone”coveringthe1–12monthtimeframe.Higherintheorganization,theperspectivebecomeslongertermandmorebroadlyfocused.Allworkforcemembersareexpectedtospendsomeoftheirtimeinboththeshort-andlonger-termdomains.Leadersdrilldownandtakeimmediate

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actionwhenaperformancepresetpointistriggered;actionsmayincludementoring,brainstorming,orreallocationofresources.Thisapproachhelpstheentireworkforcetoremainfocused on success andinnovativeaboutreachingthevision.

1.2 Governance and Societal ResponsibilitiesTheC4Vapproachtoresponsible governanceandleadership improvement isrootedintheMVVandVAcharacteristicsandbeginsattheverytop.TheVASecretarystates,“TheVACoreValuesandCharacteristicsapplyacrosstheentireVAorganiza-tion.”TheyarethefoundationofVAcultureandsupportVA’smissiontoprovidethebestcareandservicestoVeterans,theirfamilies,andbeneficiaries.Theyfocusmindsonthemissionofcaringandtherebyguideactionstowardservicetoothers.Thesevalues—Integrity,Commitment,Advocacy,Respect,andExcellence—definethecultureandstrengthenthededicationtothoseserved.Theyprovideabaselineforthestandardsofbehav-iorexpectedofallVAemployees.Theyremindtheworkforceandothersthat“ICARE.”

VeteransmustknowthatC4Vis“allin”whenitcomestoaccomplishingthemissionandlivingbythevalues.TheSLTusestheAnalyze andLearn phasesoftheLStomeasure,monitor,review,andanalyzetheeffectivenessofthesystemsandactivities,basedontheirimpactonresults.The6-Ps of Leadershiparethedailyguidetoleading:

■ Purposeisprovidingotherswithaclearvisionanddirec-tiontofosterindividualandorganizationalalignment.Purposealsoprovidesasenseofsecurityinthefutureandintheleader.

■ Passionisthepersonaldrivetorealizethevisionforthefuture.TeamsandorganizationssensethecommitmentandengagementbytheSLT,andpassioniscontagious.

■ Planningunderstandsthatpurposeandpassionneeddirectionandfocustomoveefficientlyandeffectivelyalongthepath.

■ Persistenceisthewillingnesstostaythecoursethroughthetoughtimes—stayingfocusedonthevisionandneverwavering,evenwhenthegoinggetstough.

■ Patiencemeansnevergivinguponthejourneyorthepeoplewhomaynotprogressasquicklyasdesired,whilerecognizingthatsomemayneedadifferentseatonthebusortogoonadifferentbus.

■ PresenceisthecommitmentoftheSLTtobevisibleandapproachableonthefrontlinesoftheorganization,listening,caring,andseekingtounderstand,includingcaringenoughtotakeaction—eveniftheactionisnoteasy.

IncorporatingtheBaldrigeCriteriaasakeyelementofthePIsystem,theSLTusestheCriteriaquestionstoevaluateandimproveprocesses,aswellasitsownleadershipeffectiveness.SLTmembersusetheMVV,characteristics,6-E Leadership Tool,and6-Ps of Leadershiptoguidebehaviorstoensurelegalandethical behavior,fulfillsocietal responsibilities,supportkey communities,andcontributetocommunity health .

1.2a(1) Theprocessesto review and achievegoodgovernanceareshowninFigure1.2-1.Thereisnotraditionalgovernanceboard.C4VreportstoallthreeAdministrationswithintheVA,soitissubjecttoreviewfromeachoneandhasthebenefitoflearningfromallthree.Forexample,C4VadoptedtheuseofstandardizedmeasuresetspatternedaftertheOAIprogramusedtodesignatenationalshrines;VIRBOandVIVChavebeenintegrated intotheIEP;andfulldeploymentoftheSharedGovernanceCounciltomovetowardMagnetstatus,aswellasuseofadvisorycouncilsthatincludeVeteransandtheirfamiliestoprovideinputtokeydecisionsbeingmade,arecommonpracticesintheVHA,butnotyetwithintheVBAorNCA.

1.2a(2) TheperformanceoftheDirector is evaluatedjointlybytheVISN8NetworkDirector,theAtlantaMSNDirector,andtheSouthernAreaOfficeBenefitsandLoansDirector.For

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threequartersoftheyear,eachofthemrotatestakingtheleadonprovidingfeedbacktotheC4VDirector,whileseekinginputfromtheothertwo.Fortheannualappraisal,a360-degreeevaluationisconductedbyoneofthehigher-leveldirectors,incorporatinginputfromtheothers,inputfromthemembersoftheSLT,andaself-evaluation.Organizationalperformanceisevaluatedateachquarterlyreviewsessionasoneelementoftheoverallappraisal.TheC4VDirectorevaluatestheDeputyDirectorandAssociateDirectorsinthesamemanner,andtheDeputyDirectorevaluatestheother members of the SLTusingthesameprocess.

Performanceevaluationsareonepartofdetermining executive compensation.ExecutiveandorganizationalperformancearetheprimarydriversoftheSLTbonuspackage,andratingsarethebasisfordevelopmentalopportunitiesandcareergrowth.DuetoissuesarisingfrominappropriatereportingofperformanceregardingVeteranaccesstocareatmanyfacilities,bonuseswerewithheldthroughouttheVHAin2014.TheSLTisincludedinanydisciplinaryactionfromanyAdministration.

ThemostrobustevaluationsderivefromthereviewsofC4V’sownperformancecomparedwithBaldrigeAwardrecipientsandotherbenchmarkedorganizations,bothinternalandexternaltotheVA.TheSLTandotherleadersuse performance evaluations,organizationalperformancemetrics,andfeedbackregardingleadershipfromtheAll-EmployeeSurvey(AES),IndependentPractitionerSurvey,andVolunteerSurveytoidentifypersonalandorganizationalareasofstrengthandopportunitiesforimprove-mentordevelopment.Theseperformancereviewsandaggregateinformationfromindividualdevelopmentplans(IDPs)informthetrainingplansfortheupcomingyear.Recentexampleshaveincludedleadershipdevelopmentregardingcreatingasafeenvi-ronmentforinnovation,evaluatingandimprovingcommunicationeffectiveness,andimplementingprinciplesofappreciativeinquirytofocusmoreonthepositiveandidentifybehaviorstorecognizeandencourage.TheseareasofdevelopmentalfocushavealsoresultedinupdatestotheLSsuchastheexpressedrequirementtoprovidea“safe,secure,andhealthy”environment.

1.2b(1) Whiletherearefewadverse impactsofC4V’sservicesandoperationsonsociety,itaddressesthemproactively.Adverseimpactsgenerallyarerelatedtotheconsumptionofnatural resourcesorpreservationoftheenvironmentthroughwasteregulation.C4Vhasmultiplemechanismstoreduceconsumptionofresources,rangingfromelectronicrecordscuttingdownonpaperuseinhealthcare,benefits,andcemeteryoperations;tothecarpoolprogram,managedthroughthe“employeeself-serve”electronicplatform.Ridersrecordtheirsharedtripselectronically,andwhentheyaccumulate10round-trips,theyreceivea$10gasolinegiftcard.Periodicauditsareperformedtoensurethatridesharesarerecordedaccurately.

Useofelectronicmediaalsohelpsconservenaturalresources,reducingphysicaltripsamongthefacilities.ThisprogrambeganwithtelehealthservicesandquicklyexpandedtotelevisitationatVIVCthroughtheinnovativeuseofwebcamtechnology.C4VnowofferstelevisitationasappropriateforinpatientsatHH throughtheuseofportablecomputersande-visitvideocom-munication.Electronicmediainitiativeshaveenhancedpatientsatisfactionbyincreasingvisitationwhilereducingthecarbonfootprint.SuchinitiativeswererecognizedthroughC4V’sSee

the Green campaignwithcashawards;Veteransarenowabletovideo-chatwiththeBenefitsOffice,enhancingrelationshipbuildingbyimprovingcommunication.

AllofC4V’sfacilitiesareLEED-verifiedas“green,”incorporatingsolarpowerforheating,ventilation,andairconditioning;waterheaters;andparkinglotlights.C4Vinstalledverticalaxiswindturbinesatallfourhealthcarelocationstogenerateelectricpower.Tosustainboththeenvironmentandemergencyoperations,thesetechnologiesaretiedtothemainpowergridandemergencygenerators.

Regardingwastereduction,C4Vhasanavidculturetoreduce, reuse, and recycle,whenpossible.C4VinstalledtheinnovativeGreenMachine technologythatusesozoneinazero-emissionsprocesstosterilizebiohazardouswaste,reduceemissionsbyover90%,andreplenishtheearth’sozonelayer.GreenMachine alsorepresentsastrongbusinesscaseforintelligentrisk—thereturnoninvestment(ROI)wasinitiallycalculatedat2.7years,butwithexcesscapacityforwasteprocessingandapartnershipwiththeVIWasteManagementAuthoritytoprocessotherislandwaste,theactualROIwasreducedto2.1years.ThisgaveC4Vanopportunitytocontributetothecommunityinitiativeofpreserving paradise. C4Valsohasaveryactiverecyclingprogramforpaper,plastics,andmetal.

C4Vencouragesefficienciesandconservationthroughitssupply-chain management processes,asappropriate.Bulkquantitypurchasesaremadewhenpossibletoreduceshippingcoststotheislands,andvolunteersorCompensatedWorkTherapy(CWT)employeesrepackageor“kit”supplieswhenneeded.SuppliersarealsoeligiblefortheResourcefulnessAwardProgram.Forexample,C4VrecentlyimplementedaprogramwithVIGraniteWorkstousethescrapfromitsheadstonemanufacturingasthegravelforSerenityGarden’swalkingpathwaysandlabyrinth,creatingabeautifulappearancethatattractsvisitors.

Theprimary concern ofthegeneral public withC4V’soperationsislocalizedtrafficflow,particularlyonVeteran-relatedholidaysorduringmemorialservices . C4V preparesfortheseimpactsandconcernsbypublicizingtheplannedeventsandinvitingthecommunitytoparticipate.TheVSOsandlocalmediaareverysupportiveinalertingthecommunity.Theconcerns oftheVeteran-specific publicrelatetoaccess,quality,safety,andcustomerexperience—allstrategicobjectivesofC4V.EstablishingMoSforeachobjectiveandtransparencyinreportingresults,integratedwiththeSLT’saccessibility,addresstheseconcerns.Whenaparticularconcerniselevated,suchastheaccessissuewithintheVHAin2014,C4VpartnerswithlocalVSOsandthemedia,andusesmultiplecommunicationmechanismstoinformandreassurethelocalpopulationaboutitsperformance.ArecentC4VmessageremindedVeteransthattheycanaccessimmediatecarethroughtheEmergencyDepartment,ifneeded.Inaddition,anotherpatientadvocatepositionwasadded,andadvocateserviceisnowavailabletoalllocalVeterans,notjustinpatients.WhentheVAwasinthenewsin2014,theoutreachcoordinatoralsohelpedtakecallsandrespondtoconcerns.C4VencouragesVeteranstoreachouttootherVeteransandthegeneralpublicpersonallythroughtraditionalandsocialmediatosharetheirexperiences,whichhelpsalleviateanxiety.

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Key compliance processes, measures, and goalsformeetingorsurpassingregulatoryandlegalrequirementsareshowninFigureP.1-4,withassociatedreferencestoresults.Keyrisksassociatedwithoperations,fromtheVeteranperspective,andthe processes toaddresstheserisksareshowninFigure1.2-2.Measures and goals areshowninFigure2.1-5,astherisksareaddressedinthestrategicplan.

1.2b(2) SLTmemberspromoteandensureethical behaviorinallinteractionsthroughthe6-E Leadership Tool.First,theyEducatetheentireworkforceregardingexpectations,beginningwithNEOandonanannualbasisusingscenario-basedtrainingandthemandatedNo Fear training.Next,theyEquipandEmpowerworkforcememberstodotherightthingthroughguidelines,policies,andprocedures.SLTmembersEngagetheworkforcethroughconversationsaboutethicsandcommunicationsfromVeteransaboutwhatC4V’sserviceshavemeanttothem.SLTmembersEncourageethicalbehaviorthroughtherewardandrecognitionsystems.TheAdvocacyAwardrecognizesanyonewhobringsforwardanethicalconcernfordiscussion,delibera-tion,anddecision,andC4Vembracesanddiscusseswhistleblowerprotectionprovisions.TheSLTEvaluatestrainingeffectivenessandtheIEPthroughissuesraisedandaudits,asappropriate.

Keytopromoting and ensuring ethical behavior istheIECstructurethatintegratesethicalleadership,preventiveethics,andethicsconsultationintoacomprehensiveprogramcoveringbothmedicalandbusinessethics.Veterans,familymembers,beneficiaries,oranymemberoftheworkforcemayaskforanethicsconsultationatanytimeregardinganybusinessorpatientcareconcern.ThecouncilischairedbytheComplianceandEthicsOfficerandincludeslegalcounsel,physicians,clinicalandnonclinicalemployees,administrators,andrepresentativesfromtheVeterancommunity.Duringtheannualprocessreview,theIECadoptednewreviewmethodstobetterprotectidentities.IECmembersalsocreatednewguidancedocumentsandpatienteduca-tionmaterials.VeteranswerepreviouslygivenaPatient’s Bill of Rightsonadmission.TheyarenowgivenaVeteran’s Rights and Responsibilities documentonenrollmentforanyC4Vservice.ThenewdocumentisalsoprintedinthePatient Information Booklet providedonadmissionandispostedinkeyareasthroughoutthefacilities.

Key processesbeginwithanannualriskassessmentaspartoftheenvironmentalscanintheSPP.Aninternalauditworkplanisdevelopedannuallytoaddresshigh-priorityissuesbasedonrankingsoflikelihood,impact,andalternativemeansofpotentialdetection.Theriskanalysisandauditplandriveauditingactivi-tiesandtheeducationplan,aswellasthecreationoreditingofpolicies,procedures,andguidancedocuments.EverymemberoftheSLT,theCOandCOR,aswellaseveryonewithpurchasingauthority,signsaconflict-of-interestdisclosureannually.

PriortoengagementwithC4V,allnewworkforcemembersundergoacriminalbackgroundcheckandsignaStatement of UnderstandingoftheC4V Behavior Standards,whichareaddressedintheworkforcehandbook.EveryoneontheworkforcesignstheStatement of Understanding annuallyduringtheirperfor-manceappraisals.Thiscreatesanopportunitytodiscussconcernswiththerater.TheComplianceandEthicsOfficerisavailableforraisingconcernsoutsideofthechainofcommand,anda

confidentialhelplineallowsanonymousreports.Allconcernsareinvestigated,logged,andtrackedbytopictoidentifyopportunitiesforeducationorpolicyrevisionbasedonpatternsortrends.Thisdatabaseisnowcross-referencedwiththeJustCultureSurveyandSpeak Up! initiative,describedin1.1a(3),tobetteridentifypatternsandtrends.

MeasuresorindicatorsofethicalbehaviorsthroughoutC4V,includinginteractionswiththeworkforce,Veteransandothercustomers,partners,suppliers,andotherstakeholders,includesurveytoolsaskingforaratingofC4Vas“anethicalorganiza-tion.”ThisquestionisaskedontheAES,VolunteerSurvey,VendorSurvey,AmericanCustomerSatisfactionIndex(ACSI),andIMPressSurveyofVeterans.Auditfindings,bothinternalandexternal,arealsousedasindicatorsofethicalbehavior.Newworkforcemembersareaskedtohelpidentifyethicalopportuni-tiesforimprovementduringthe30-,60-,and90-dayevaluationprocesses,anddepartingworkforcemembersareaskedaboutanyethicalconcernsduringtheirexitinterviews.Programevalua-tionin2013uncoveredagapinsurveyingVeteransspecifictobenefitsfunctions,sopartnerVSOsimplementedaprocessusingSurveyGorillatofillthegap.Thisapproachwaslaterexpandedtoincludethecaptureofsatisfactiondataonlimitedfocusareas.

Monitoringbreachesofethicalbehaviorisintegratedformallyintotheauditprocessandinformallybytrainingallofthework-forceandtheVeteranstoserveastheeyesandearsofVeterans andtoadvocateforthemiftheyseeaconcern.Responsetobreachesofethicalbehaviorisbasedonthejust culture premise,whichisnonpunitiveintheabsenceofintent.Azero-tolerance policyisinplaceforwillfulbreaches.Actionmayincludere-educationandprobationwithheightenedoversight,disciplin-aryactionuptoandincludingterminationofemployment,andcriminalprosecution,asappropriate.

1.2c(1) C4Vconsiderssocietal well-being and benefitaspart of strategydiscussionsduringtheenvironmentalscanandactionplanning,inalignmentwiththeMVV.C4Vcontributestothewell-beingoftheenvironmentalsystemthroughtheimplementa-tionoftheGreenEnvironmentalManagementSystems(GEMS)Program,asystematicapproachtoenvironmentalmanagementwithintheVHAEnvironmentofCare(EOC)managementprocesses.GEMSguidanceensuresenvironmentalregulatory

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compliancewithExecutiveOrder13148throughpoliciesand screeningsforhighbloodpressure,highbloodsugar,andotherauditingprocesses.AtC4V,GEMSwasexpandedintothebenefits health-relatedissues.andcemeteryoperations,usingtheprogramandexpectationsto C4

4 4 VcollaborateswithcommunitypartnersforemergencycreateC V-widecompliance.C Vmodifiedtheprogramfrom management.ThispartnershipisdemonstratedthroughannualPDSAtobeIDEALS-based. community-widemasscasualtyexercisesandresponsestoactualDaily operations,guidedbytheMVV,enhancesocial and events.C4VisthedesignatedFederalCoordinatingCenter(FCC)economic systemsbycaringforVeteransandtheirfamilies; fortheislandsandanycruiseshipsatVIportsofcall.TheFCCaddressingissuessuchashomelessness;andovercomingbarriers roleistoreceive,triage,stage,track,andtransportpatientstothephysical,mental,andemotionalhealthandwell-beingof affectedbyadisasterornationalemergency,withthefullsupportthosewhoserved.Asamajoremployerinthearea,C4Vsupports ofstate,regional,local,federal,andnongovernmentorganiza-thelocaleconomy.C4Valsocontributestopreserving paradise,as tions.TheFCCwasactivatedshortlyafterC4Vopenedin2010,describedin1.2b(1). providingsupporttoover300victimsaffectedbysevereflooding

intheislands.Hurricanesarethemajorthreat,buttheVIhasnot1.2c(2) Key communitiesincludetheVIandtheVeteranpopula-hadamajorstormsince2010.tion,basedonregulatoryauthority.Thereisaspecificfocuson

wherethosetwogroups—eligibleVeteranswhoresideinorvisit C4VpartnerswithCSUfortraining,anditsInstitutionalReviewtheislands—intersect.C4Vactivelysupports and strengthens Board(IRB)isformallydesignatedtoapprove,monitor,andkeycommunitiesthroughprovidingservicesandsponsoring reviewC4Vresearch.C4Vsupportsthecommunitythroughactivities.TheSLTsolicitsideasforinvolvementandprioritizes fundraisingfortheCombinedFederalCampaign,participationsupportbasedonthecore competencies,MVV,beststeward- intheannualHeartWalk,andhostingfrequentblooddrives.shipofresources,andvalue-addedfactors.AnSLTchampion Communityoutreach,suchassuicidepreventionandeduca-isnowassignedtonurtureandcoordinateeachareaofsupport. tionaboutalltypesoftrauma,isusuallyrelatedtoC4VcoreForexample,aspartoftheOEF/OIF/ONDSeamlessTransition competencies.C4VprovidesFederalEmergencyManagementOutreach,teamsconductpost-deploymenthealthassessmentsfor Agency(FEMA)-certifiedcrisiscounselorsintheeventofanythosereturningfromcombat;assessmentsincludethepresenta- disaster.Cross-trainingamongtheSubstanceAbuseandMentaltionofallavailablebenefitsandopportunities.“Welcomehome” HealthServicesAdministration(SAMHSA),EmergencyMentalevents,collaborationwiththeHomelessCoalitionforstand HealthandTraumaticStressServicesBranch,FEMA,andthedowns,participationinCongressional-sponsoredoutreachfairs, VAenhancesoverallservicesandprovidesbettersupporttoandhealthscreeningsatmanyVeteran-centriceventsarekey Veterans.TheentireSLTandothersfromtheC4Vworkforceoutreachmechanisms.Forexample,C4Voutreachandclinical participateintheVISpeaker’sBureautocontributetoenhancingteamsattendlocalGreasedLightningmotorcycleridesandVI knowledgeofthelocalcommunityandpromotingthehealthofsportingeventstogiveinformationtoVeteransandconduct theVeterancommunity.

Category 2 Strategy

2.1 Strategy Development C4Vestablishesstrategy andgeneralobjectivestoaddresschallengesandleverageadvantagesandopportunities throughtheSPS(Figure2.1-1),asoneelementoftheoverarchingILMS.TheSPSreceivesinputsfromtheLS(Figure1.1-1),PMARS(Figure4.1-1),andtheCRMS(Figure3.1-1).StrategyisdeployedthroughtheAPS,showninFigure2.2-1.Dataandinforma-tionarecollectedfromandtransferredtokeystakeholdersforsharingandimplementingrole-modelpracticesthroughtheKMS(Figure4.2-1).TheOMIS,showninFigure6.1-1,providesC4V leadersatalllevelswithagilityandpromoteslearningandinnova-tionthatisincorporatedintothenextstrategicplanningcycle.

TheC4Vstrategicplanisaone-pagedocumentprintedonfoldedheavy110 170paperthatisspecificallydesignedtobecarriedwithleadersandmanagerstoassistthemintheirday-to-dayactivities.Insidethecover,itcontainstheMVVandcharacteris-tics,allderiveddirectlyfromthe2014–2020VAStrategicPlan,theC4Vcorecompetencies,thekeyintendedoutcomes(KIOs),thekeystrategicobjectivesandmostimportantgoals,andthekeymeasureswithperformanceprojectionsforthecomingyearandthenextthreeyears.Duringtheannualretreattobeginthe

SPP,theSLTreviewsthemissionandvalues,updatestheILMSasneeded,evaluatesthecorecompetenciesandservicesoffered,andrefinesthevisionforthefuture,asappropriate.Thisisaccomplishedthroughafacilitatedholisticreview,dialogue,andconsensus,whichisanimprovementoverthepreviousprocessthatrequiredmoretimeandwasalesscollaborativeprocessofseparatelyreviewingeachitemandrequiringunanimousvotingbyallseniorleaderstomakeanychange. ThemissionandvaluesarethesamethroughouttheVAandwouldonlyberevisedattheVACentralOffice(VACO).

TheILMSwererevisedin2011toincorporatetheintegrationofallC4Vservices,andthevisionwasrevisedin2012.Ratherthankeepingthreeseparatevisionstatements,C4Vbroadenedthevisioninscopetocoverbenefits,health,andmemorialservicesandtobemoredirectlyalignedwiththestatedvisionoftheVA.TheILMSwererevisedagainin2013and2015toalignwithBaldrigeCriteriachanges.

2.1a(1) TheSPS,showninFigure2.1-1,identifiesthemajorsystematicapproachesusedforstrategicplanning.Detailsofthekey process steps oftheexecutephaseoftheSPSandAPSarecontainedintheSPP,showninFigure2.1-2.

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Figure 2.1-1: Strategic Planning System

Figure 2.1-2: Strategic Planning Process

Representativesofeachkeystakeholdergroupparticipate intheplanningprocess,ortheirrequirementsandexpectationsarediscernedthroughthemultiplecommunicationmechanismsshowninFigure1.1-3.TheentireSLTparticipatesintheSPP.LocalVSOmembers,communityleaders,andAGErepresenta-tivesareinvited.DraftplansaresharedwiththeAtlantaMSN,theSouthernAreaOffice,andVISN8 forinputandtocheckalign-mentpriortofinalization.

Theshort- and longer-term planning horizons areoneyearandthree years,respectively,basedontheassessmentofthechangingregulatoryenvironmentandneedsofVeterans.Priorto2011,strategicplanningwasconductedandplanswerepublishedpriortothebudgetingprocess.Theone-yearplanningcyclenowalignswiththebudgetcycle,givingC4Vtheabilitytoensurethatappropriateresourcesareavailableandtheagility toadjustappro-priatelyasregulations,requirements,andexpectationschange.Thethree-yearplangivesC4Vadegreeofstabilityandkeepsthelonger-termfocusonreachingthevision.TheSPPaddresses the time horizons byestablishingobjectivesandmeasuresofsuccessforeachhorizon,andreviewofthehorizonsthemselvesarenowpartoftheplanningprocess.

2.1a(2) Thestrategydevelopmentprocessstimulates innovationthroughtheestablishmentofstretchgoalsthatrepresenttargetsforthethree-yearplanninghorizon,tyingrewardsandrecognitiontotheearlyattainmentofstretchgoalsandincorporatinginnova-tionthroughthe6-E Leadership Tool.First,C4V Educatestheworkforcethroughvarioustrainingcoveringprocessimprovementmodelssuchastheoryofconstraints,appreciativeinquiry,Lean,

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andSixSigma,anddiscussingtheimportanceofinnovation,whileemphasizingthethree“must”criteriatoevaluateinnovativeideas:mustnotcompromisesafety,mustaddvalue,andmustbereasonable.

Next,C4V Equipsworkforcememberswithinformationaboutthecurrentandbenchmarkperformancelevelstohelpidentifyopportunitiesforinnovation.Then,theyareEmpoweredwithnecessaryresourcesandEngagedintakingonprojectstomakeimprovements.Finally,C4VusesmanymechanismstoEncourageinnovation.Onecycleofimprovementin2012wastorewardthedesiredbehavior—thesubmissionofideas—ratherthanonlyrewardingandrecognizingideasthatwereadopted.ThePenny for Your Thoughtscampaignrewardseverysubmissionofasuggestionforimprovementwithapennyattachedtoacertificate.Theemployeemaychoosetoenterthecertificateintoamonthlydrawingforprizesrangingfromgiftcardstoatime-off-with-payaward.Themostrecentimprovementwastheadditionofthe6thE—EvaluatetheimpactonC4Vkeymeasures(Level4oftheKirkpatrickModel)suchassafety,cost,efficiency,andeffective-ness. ThisenablestheSLTtoshowworkforcemembersthemajorimpacttheymakewhenthey lend a hand toimprovement.

Strategic opportunities andopportunitiesforinnovationareidentifiedduringSteps1through4oftheSPP,showninFigure2.1-2.Theinternalperformancereviewandexternalenvironmen-talscan(Step1)aswellastheSWOTanalysis(Step3)uncoveropportunitiestoevaluateforinnovationpotential.C4Vusesprinciplesofappreciativeinquirytoimaginean“ideal”futureduringSteps2and4oftheSPPandcapitalizeonthestrategicadvantages,andtoensurethatcorecompetenciesenablepursuitofopportunities.

C4Vleadershipdecideswhichstrategic opportunities are intelligent risks topursuethroughthestrategicplanningandactionplanningsystemsdescribedthroughoutcategory2andacost:benefitanalysis,asdescribedin2.2a(3).Thebusinessplanandactionplantemplatebothrequireidentificationoffinancial and other resources needed topursuetheseopportunities,sothatresourcescanbeallocatedthroughthebudgetprocessorcontingencyfunds.Large-scaleorhigh-costchangesrequireafullbusinessplan,whereassmaller-scopechangesrequirecomple-tionoftheactionplantemplate.TheSLTrecognizesthateachcommitmentcreatesanopportunitycost,drawingresourcesawayfromotherprograms,activities,andresourceinvestments.Thisawarenesshelpsguidefact-andcriteria-baseddecisionsregardingwhentodiscontinue pursuing opportunitiesattheappropriatetimetoenhancesupporttohigher-priorityopportunities.ThecriteriathatserveasthebasisforthesedecisionsincludevaluetoVeterans,supporttoC4Vasawhole,anddeterminationofthebestcourseofactiongiventheC4VMVV,strategicobjectives,actionplans,worksystems,andcorecompetencies.

Themajorstrategic opportunity(SO1)istoidentifyandenrollalleligibleVeterans,withaparticularemphasisonthosewhoarehomeless.WiththemandateoftheACAthatallU.S.residentshavehealthinsurance,C4VintensifiedoutreachtoensurethatallVeteranseligibleforVAservicesareenrolled.ThisaddsvaluefortheVeteransandalsosupportsC4Vfinancialsustainability,asVHAfundingisdrivenbythenumberof“unique”VeteransunderC4Vcare. DataFACTSnowhasastatisticallyvalidformula

tomoreclearlyestimatetheeligiblepopulation,basedupondischargedata,incomelevels,recentcombatdeployment,andotherfactors.Usingthisasthedenominatorforthemarketsharecalculations,ratherthanthetotalnumberofVeteransinthearea,providestheSLTwithbetterinformationonwhichtobaseoutreachactivities.Thesecondarystrategic opportunity(SO2)istheanticipatedincreaseintheVeteranpopulationoftheVI,astheDoDdownsizes.

OtherinnovativeapproachesC4VusestointensifyoutreachincludepartnershipswithhomelesssheltersandsocialserviceagenciesandvisitstoareasaroundtheVIwherethehomelesstendtostay.C4VexpandedthePatient-AlignedCareTeams(PACTs)toincludeabenefitsrepresentativetocreateanexpeditedandsmootherprocessforVeteranstoenrollandengagewithaPACT.Thisintegrationhasimprovedsatisfactionwiththeenroll-mentprocess(Figure7.2-13)acrossallsegmentsandsupportstheVAmajorinitiativetoeliminateVeteranhomelessness.C4Vini-tiallyplannedtorolloutonePACTdesignedtospecificallyservethespecializedneedsofthehomelessbutlearnedthatadesignatedteamwouldactuallybeabarrierinservingthissegmentduetotheassociatedstigma.AllPACTsaretrainedtodiscusshomeless-nesswithCompassionandRespectandtobealerttosignsthataVeteranmaybe—orisabouttobe—homeless.

2.1a(3) Dataarecollected throughtherobustenvironmentalscan andscorecards,and analyzedtodevelop information by theDataFACTSincollaborationwithsubject-matterexperts(SMEs).Previously,ninekeyfocusareasincludedVeteransandtheirdemographics,economyandfinance,humanresources,ITande-health,insuranceandcoverage,politicalissues,providerorganizationsandphysicians,qualityandsafety,andscienceandtechnology.Thesewerelatermodifiedtoalsoaddressmemorialandbenefitsservices.Thecomprehensiveservicescreatetheneedformorecomprehensivedata,sothescannowincludesthosefactorslistedinFigure2.1-3andconsiderslinkagestoallstrategicchallenges,advantages,andopportunities.

Satisfactionanalysisincludesformalandinformaldatagatheredfrompatients,othercustomers,andstakeholders(seecategory3),

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aswellasfromphysicians,employees,volunteers,andstudents(seecategory5).TechnologyadvancesincludechangesinIT.Robustdataanalysishelpsidentifyblind spotsandmitigatepotentialrisks to sustainability.Integrationofthebudgetprocess(SPP,Step7),includingworkforce,operations,andcapitalbudgets,helpsensuretheability to executetheplan.

2.1a(4) TheC4Vthreeservices-basedwork systemsareshowninFigure2.1-4.Worksystemdecisions,includingwhichkeyprocesseswillbeaccomplished by externalsuppliersandpartners,areincludedintheSPP,Step9.Theprimaryevalua-tionfactorishowtoaddbestvalueforVeterans—consideringcapability,capacity,core competencies,andrelevanceofthetasktotheMVV,comparedandcontrastedagainstpotentialsuppliersorpartners.

WhentheanalysisshowsthatthecorecompetencyisMVV-criticalorwouldaddmostvaluetoVeteransasaninternalprocess,itisdevelopedasafuture organizational core competency andnotoutsourced.Thecore competencies weredeterminedduringthe2011strategicplanningcycle,identifyingstrategicallyimportantcapabilitiescentraltofulfillingthemissionafterthefirstyearwascomplete.Thecorecompetencies, alongwiththeMVVandILMS,areevaluatedandvalidatedorrefinedduringStep2oftheSPPcycletoensurethattheyremaincurrentandappropriate.Forexample,Baldrige-based leadership and management systems wereaddedasacorecompetencyin2012,whenthesecondyearofexperienceshowedthatasystems perspectivewouldbetteralignandintegratethecomprehensivemodelofcareforVeterans.TheSLTrefinedandredeployedtheILMStobemoreinclusiveofVIRBOandVIVC .

2.1b(1) InordertoattaintheC4Vvisionof“thehighestqualityofcareandsupportservices,”theSLTselected“world-class”strategicobjectives (90thpercentileperformance).Theirassoci-atedgoalsandthetimetable for achievementareshowninFigure2.1-5,alongwiththeassociatedkeyaction plans(2.2a[1]).Therearenoanticipatedchangesinproducts/services,suppliersandpartners,oroperations.Primarykey changesinthecustomersandmarketsincludeanincreaseineligibleVeterans,astheDoDdownsizesmilitaryoperations.Thisanticipatedincrease,coupledwiththerecentaccessissueswithinVHA,hassharpenedthefocus

onensuringthatVeteransservedbyC4Vreceivetheirservicesasdesired.TheeconomicrecoveryfortheVIisexpectedtolagthemainland,astheprimaryeconomicdriverintheVIistourism.IncidentsaboardseveralcruiseshipsrecentlyhavehadanegativeimpactonthenumberoftouristsvisitingVIportsofcall.ThevolumeofburialsandintermentsatVIVCisalsoanticipatedtoincrease,duetothe“baby-boomerbubble”enteringtheendstagesoflife.

2.1b(2) Thestrategicobjectivescomprehensivelyaddress all of the strategic challenges and leverage the core competen-cies and strategic advantages,asshowninFigure2.1-5.AllVeteransareeligibleforintermentatVIVC,butthecommitmenttoprovidingVeteranswithaccesstoworld-classcareandservicesleverages the strategic opportunityofenrollingallVeteranswhoareeligibleforbenefitsandhealthcareservices,whichaccountfor99%ofthebudget.EnrollmentenablesC4Vtoprovideworld-classservicetothosewhohaveservedthecountrysowell,helpseliminateVeteranhomelessness,andpreservesC4Vfundingbyincreasingthecountof“uniques.”UndertheVeteranEquitableResourceAllocation(VERA)model,additionalhealthcarefundingisgiventoC4VforeachuniqueVeteranwhois”vested,”meaningthathe/shehasreceivedaqualifyinghealthassessmentandrecommendedhealthscreeningswithinthepreviousthreeyears.ThefundingincentiverelatedtovestingalignsthebudgetwithafocusonwellnessasanAccountableCareOrganization(ACO),promotesVeteranwell-being,andhelpsrelationshipdevelopmentbetweenPACTsandtheVeteranstheyserve.

C4VfundingforNCAandVBAactivitiesismanagedthroughtheResourceManagementTool.ThroughouttheVA,directorsinputworkactivitiesandVeteranpopulationdemographicsintothisstaffingmodel,andthesystemprojectsworkloadtodrivebudgetsandallocateFull-TimeEmployeeEquivalent(FTEEs)andotherresourcestothelocallevel.

Thetargetsfortheshort-andlonger-termtimehorizonsarealsoshowninFigure2.1-5.TheSLTbalances time horizons bysettingitssightsonthevisionofworld-classperformance(topdecile)inallmeasureswhilesettingrealisticinterimgoals.Althoughfrequentlytemptedtoset“big,hairy,audaciousgoals,”workforcemembersprovidedtheSLTwithfeedbackandsolidevidencethatbeingrealistic,yetstretching,promotestheirengagementinachievingthegoal.ThiscommitmentbytheSLTwasthefirstsystematiccommunicationusingYou had a Hand in This—anicondepictingahandholdingaglobe,nowbroadlydeployedtoinformtheworkforceandotherstakeholdersthattheSLTdecisionincludedtheirinput.ThiscycleoflearningalsostrengthenedtheresolvetoalwaysrequireSMARTERMoSwitheverykeyprocess,requirement,andactionplan.

Therootcauseanalysis(RCA)ofVHAaccessissues,VBAback-log,andNCAinaccuraterecordsindicatedthatSMARTERgoals,aswellastheBaldrige-styleassessmentofperformancelevels,trends,comparisons,andintegration,mayhaveuncoveredissuesandundesirablebehaviorsbeforetheygrewtonegativelyimpactVeteransanddamagethereputationandcredibilityoftheentireVA,includingC4V.Theplansconsiderandbalance the needs of stakeholders byincludingtheirrequirementsandexpectationsintheplanningprocessandusingamatrixtoolforprioritization,basedonresourcesneededandprobableimpact.

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2.2 Strategy ImplementationC4Vconvertsthestrategic objectives into action plansusingtheAPS,showninFigure2.2-1,anintegralelementoftheILMS.Thesummariesofkeyactionplans,includingthekeymeasures/indicators of progress,areshowninFigure2.1-5.TheactionplansareSMARTER—Specific,Measurable,Aligned,Realistic,Time-bound,Evaluated,andReviewed—whichmeansthattheprojectionsforfutureperformanceonthesemeasuresorindica-torsareequivalenttothetargetsshown,becausethetargetsareestablishedconsideringtheprojectedimpactoftheplans.Mostofthetargetsarepercentilerankingstoincorporatekeycompari-sons.AfunctionofDataFACTSisnowtohelpprojecttheshiftinactualperformancethatwillequaltopdecile,basedonhistoricaltrendsandknownimprovementactivitiesinthesectors.

2.2a(1) ActionplansaredevelopedusingtheAPS(Figure2.2-1).Allkeyaction plans are relatedtothestrategicobjectivesandhaveshort-andlonger-termtargetslistedinFigure2.1-5.

ParticularattentionisgiventoensuringthatkeyactionplansareSMARTER:

■ Specificmeansthatthedeliverableisveryclear.Plansalwaysbeginwithanactionverbselectedtofacilitatemovement.

■ MeasurableincludestheBaldrigeevaluationfactoroflevels—evaluatingprogressbasedonameaningfulmeasurementscale.Asacycleoflearning,plansmayciteintangible results, butallplansmustincludeatleastonequantifiableMoS.

■ Alignedmeanseachplanmustsupportoneormorestrategicobjectiveorgoal.In2011,astepwasaddedtoensurethateverygoalandobjectivehadsufficientactionplansupport.

■ Realisticincludesclearunderstandingofcontextbasedoncomparisoninformationandevaluatesresourcesnecessarytomoveatthedesiredrate—suchaspeople,finances,space,equipment,andideas.

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■ Time-boundincludestheaccomplishmentofshort-andlonger-termgoalsbyaspecificdate,typicallyalignedtotheplanninghorizons.

■ EvaluatedisnowdrivenlargelybyDataFACTS.Asdescribedincategory4,DataFACTSensuresthatdatacanbeconvertedtoreliable,validinformationuponwhichtobasedecisions.

■ ReviewedmeansensuringacultureofaccountabilityandcommitmentbyidentifyingarecurringvenuewheretheSLToragovernancecommitteereviewsperformance.Incorporatingthisstephasstreamlinedthedashboardsanddatacollection.

In2013,anactionplantemplatewasdevelopedtoensurethatallSMARTERelementswerefullydeployedanddocumentedineveryplan.Effectivenessofthetemplateswasevaluatedin2014,andtheywererevisedtoincludeDataFACTsandAGErepresentativesign-offsoneveryplantoensurethattheMoScanbecollectedandthatallmeasuresareincludedintheC4Vdatadictionary.AGEalsohelpstocommunicateanddeploytheplanstotheworkforce.

2.2a(2) Actionplansaredeployedtotheworkforceandtokeysuppliersandpartners,asappropriate,byconsideringtheirrequirementsandexpectationsinallplans.The“peopleandplans”-orientedsystemsintheILMS,includingtheLS(Figure1.1-1),SPS(Figure2.1-1),APS(Figure2.2-1),CRMS(Figure3.1-1),andWEDMS(Figure5.1-1)allincludeasteptoIdentify stakeholder requirements and expectations.TheCSandcom-municationmechanismsshowninFigures1.1-2and1.1-3areusedtoidentifyrequirementsandexpectationswhenastakeholdergroupisnotdirectlyincludedintheplanningprocessestoensurethatkeystrategic objectivesareachieved.Typically,whenaplanhitsabarrieror“speedbump,”arootcauseisfoundtobethatastakeholderorhis/herrequirementsandexpectationswerenotadequatelyaddressedorconsidered.Toenhancetheidentificationprocessespriortofinalizinganactionplantemplate,theplanownermustnowconductabrainstormingsessiononthistopic,

withoutlookingattheplan.Thishelpsencouragenewthoughtsandideas,ratherthansimplygoingalongwiththewrittenplan.

PlanownersandC4Vleadershipensuresustainable key out-comesoftheactionplansbymakingplansthatareRealistic andincludeamechanismforEvaluation and Review. IntegrationofDataFACTSintotheplanningprocesshasgreatlyenhancedtheabilitytosetrealisticgoalsandobtaincomparativeandbench-markdata.

2.2a(3) Theactionplantemplaterequiresidentificationofneces-saryresourcesofalltypestoaccomplishtheplan.IntegrationoftheStrategicandActionPlanningProcesseswiththebudgetingcyclehelpstoensurethatfinancialandotherresourcesareavail-abletosupporttheplanswhilemeetingcurrentobligations.Thebudgetprocessincludespersonnel,equipment,capital,facilities,andotherresources,inadditiontofinancialconsiderations.In2014,C4Vaddedamasterfacilitiesplantoensurethatplansconsiderspaceasaresource,particularlywithchangesintechnol-ogyandthespacere-allocationpotential,basedontheimpactoftheincreasinguseoftelehealthcareandeBenefits .

Actionplansaresegmentedaccordingtoscope.Personal Plans areownedbytherespectiveindividualandincorporatedintotheperformancemanagementsystemdescribedin5.2a(3);theymustaligntodepartmentandoverallC4Vgoalsandobjectives. Department/Service PlansareownedbytherespectivemanagerandareestablishedtosupportoverallC4Vgoalsandobjectivesandmustbeimplementedwithinthescopeofthemanager.MultipleareasmayhavesimilarDepartment/Service Plansandareencouragedtosharedetailsandprogressinformallyaswellasformallyduringcommitteemeetings,recurringreportingvenues,andimprovementfairs.Strategic Action Plans arethosethatinvolvemultipleareaswithinC4V,whereresource allocationiscrucial.Fortheseplans,anSLTmemberisassignedresponsibilityasthe“champion”toensureadequateresourcingandcompli-ancewithtimeschedulesandperformance.Forexample,manystrategicactionplanscommonlyinvolvethePublicAffairsOffice(PAO),volunteers,VA-OIT,orDataFACTS.ChampionoversighttocoordinationattheStrategic Action Plan levelenablestheseareastobetterplanandallocatetheirtime.

OneelementindeterminingthataplanshouldbeaStrategic Action Plan isthedegreeofrisk/impact.Therefore,thetemplateforthislevelofplanincludesaBusiness Impact Analysis compo-nenttomanagethefinancialandotherrisksassociatedwiththeplansandtoensure ongoing financial viability andstewardshipoftaxpayerresources.

2.2a(4) Thekeyworkforce plans tosupportshort-andlonger-termstrategicobjectivesandactionplansareincorporatedwiththemasterstaffingplan, describedin5.1a(1).Eachactionplanningtemplateaddressespotential impacts on workforce membersandpotentialchangesincapacityneeds.Theseanticipatedchangesarefactoredintothemasterstaffingplanandjustifiedthroughthebudgetingprocesswhenplanscreatechangesinpersonnelrequirements.Anticipatedworkforcecapability changesareaddressedthroughtheeducationalneedsassessment.

2.2a(5) Thekey performance measuresandindicatorsC4V usestotracktheachievementandeffectivenessofactionplansareshowninFigure2.1-5.Theactionplan measurement system

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reinforces organizational alignmentbyincludingatleastone resultsfiguresincategory7.Ifthereareanykeygapsinperfor-MoSwitheachactionplan,andeachactionplanmustalign manceidentifiedagainstcompetitorsorcomparableorganizations,toC4Vobjectives.DataFACTshasenhancedthecapabilityto DataFACTSprovidesthisinformationtotheSLTfordiscussionidentifyrelevantdataandcomparativeinformation.C4Vincludes anddecisionmakingregardingagileactionplanningorinclusionitsmeasuresontheVAPerformanceandAccountabilityReport inthenextsystemicperformancereview.(PAR),asreportedtoCongressannuallyandpubliclyposted.C4V 2.2b TheactionplanownersorotherC4Vleadersestablishandalsostrivestoavoidmeasuresofvolumes—preferringratesor implementmodified action plansifcircumstancesrequirearatiosasbettermechanismstoevaluateperformanceandprogress. shiftinplansandrapidexecutionofnewplans.TheneedforplanWhenpossible,measuresarerisk-orseverity-adjustedtoenable modificationsmid-cycleisusuallyidentifiedbasedonperfor-morevalidcomparisons. mancebelowexpectationsorchangesintheregulatory,human2.2a(6) Performance projectionsareequivalenttotheshort-and resource,operational,orotherenvironmentfactors.Aswithinitiallong-termtargetsinFigure2.1-5(discussedin2.2).Projections plans,thescopeoftheplandetermineswhethertheplanwillforcompetitorsorcomparableorganizations,alongwithkey remainservice/departmentspecificormorestrategicinnature.benchmarks(measuresofsuccess),areshownintherespective Thesameplanningtemplateandprocessesareused.

Category 3 Customers

3.1 Voice of the CustomerTheCRMS(Figure3.1-1)isdeployedthroughoutC4Vandincludessystematicapproachesfor listening to customers andmultiplemechanismsforgaining information regarding satisfac-tion, dissatisfaction, and engagement.AswiththeothersystemsoftheILMS,theCRMSbeginswith“identification,”whichisbasedondataandinformationgatheredthroughtheCS(Figure1.1-2).DataandinformationareanalyzedthroughthePMARS(Figure4.1-1),whichaddstotheknowledgeassetsthroughtheKMS(Figure4.2-1).TheCRMSisdeployedprimarilythroughtheexecute and analyze phasesoftheLS(Figure1.1-1),andtheanalyze phaseofWEDMS(Figure5.1-1).

3.1a(1) C4V listens to customersusingthemultipletwo-waycommunicationmechanismslistedinFigure1.1-3.Auniqueandinnovativeaspectofdiscerningcommunicationandlearningpref-erencesinvolvesusingwhatwaslearnedtotake action andbuildrelationships.WhenVeteransareenrolledforbenefits,informationisrequestedaboutvariouspreferences.Topicsincludehowtheyprefertobeaddressedandpreferencesforcommunicationandlearning,food,hospitalroomtype,religion,etc.—evenensuringthattheVeteranisawarethatthereareover60emblemsofbeliefthatcanbecarvedintoNCAheadstones .

ThisprocessevolvedfrombenchmarkingwithFrish-Martinhotels.Itwaspilotedinthehealthcareoperationsasa“prefer-encespage”ineachpatientrecord.VeteransandothersseethatC4Vlivesthevalues,specificallyCommitment, Advocacy, Respect, andExcellence,through“seeminglysimple”taskssuchasservingtheircoffeeandothermenuitemstailoredtotheirpreferences,orplacingtheminabedbyawindowwithasofterpillow.Givingpeopleexactlywhattheywantalsogreatlyreducedwaste .

Asacycleofimprovementin2013,thepreferencepageinforma-tionnowincorporatesadvanceddirectives,languagepreferences,andlearningstyle,andVeteransareofferedanopportunitytoupdatepreferencesateachencounter.Additionally,thepreferencepagehasbeenupdatedtoallowcomplaintinformationtobeincluded(see3.2b[2]),whichautomaticallyinformstheVeteran’sPACT.Learningstyleandotherpreferenceshavebeenparticularly

helpfultotherehabilitationcounselingprocesstoevaluateeduca-tionandjobdevelopmentopportunities .

DeterminingpreferencesandkeepingcontactinformationupdatedareparticularlycriticalforhomelessVeterans.Initially,aPACTwasplannedtospecificallyaddresstheneedsofthehomeless,buttheassociatedstigmaandgeographiclimitationswereidentifiedasbarrierstoaccess.PACTsarenowstrictlygeographicallyfocused,withstaffcross-trainedtounderstandtheriskfactorsassociatedwithTBIandothercombat-relatedissuestopreventVeteransfromlosingtheirhomes.

Asdescribedin2.1a(2),the6-E Leadership ToolfocusestheC4V workforceoncapturingandcommunicatinginformationgainedduring interactions with, and observations of, customers.Asanexampleofarecentinnovationfromvolunteers,whenaVeteranisadmittedtoHH,avolunteerstopsbywithan“artcart”toseeifthenewpatientwouldpreferadifferentpictureonthewall.VolunteersselectedforthisroleareallVeteransandhavereceivedspecialtraininginrelationshipdevelopmentandstressmanage-ment—includingrecognizingsignsofstressintheVeterans,whoaretypicallyverystoic.Volunteersusethistimetoconnectwiththepatient;offerthemyriadofrelaxationservices,includingmassage,musictherapy,animalvisitation,spiritualcare,andsupportgroups;anddemonstrateI-CARE.EmployeesalsooffertheseservicestoVeteransthroughouttheirhospitalencounters,andthevolunteercanberequestedtore-visit,ifthecaregiversseetheneed.Constantvigilanceandre-visitsarecrucialtoeffectivestressmanagementandrelationshipbuilding,asmanyVeteransneedtodevelopasenseoftrustandemotionalsafetybeforetheywilladmittheyhaveaneed.Stressmanagementmodalitiesenhancesatisfaction(Figure7.2-1),helpwithpaincontrol(Fig-ure7.2-8),anddecreaseuseofopiates.StressreductionservicesarenowofferedwithoutchargetononhospitalizedVeteranswhoarevested,asexplainedin2.1b(2).Thisstrengthenstheirrelation-shipwithC4V,servesasincentiveforthemtoremainvested,andengagesthemwithotherVeteransthroughusingthesemodalities.

Workforceeducationaboutbuildingrelationshipsandthecus-tomerexperiencestandardsbeginsduringNEO,isupdatedduring

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annualrefreshers,andisreinforcedbyunit-baseddiscussionsandroleplayduringstaffmeetings.NEOandmosttrainingareintegratedforNCA, VBA,andVHA personneltopromotelearn-ingandstimulatenewideasandinnovationacrossthevariousservices,asdescribedin5.1a(2).ManyoftheworkforcemembersareVeterans,soC4VnowsystematicallyengagesthemduringNEOandperformanceevaluationmeetingsindiscussionaboutVeteranrequirementsandexpectations,andhowC4VcouldbetterdemonstrateI-CARE.ThesuggestionstheymakearerecognizedwithYou had a Hand in ThistoEngagetheminmakingadditionalsuggestions.Alleducationalofferingsareevaluatedbasedonperceptionsofthelearners,impactonbehaviors,andresults—atallKirkpatricklevels,asdescribedin5.2c(2)—andimprovedwithIDEALS.

Accordingtoexpressedpreferences,thelisteningmethods aretailoredtotheindividualand vary for different customers, customer groups, or market segments. Forexample,bydirectionoftheVACO,theSurveyofHealthcareExperiencesofPatients(SHEP)questionnairesareonlyconductedforVHA andonlybymail.ACSIandConsumerAssessmentofHealthcareProvidersandSystems(CAHPS)surveysareusedformemorialandinsuranceservices.Toaddresstheotherstakeholdergroupsandgatheradditionalinformation,C4VpartnerswiththelocalVeteranServiceOrganization(VSO)touseSurveyGorillato

askadditionalquestionsandgathersegment-orservice-specificinformation.Forexample,10%ofVeteransreceivingoutpatientcareeachmontharerandomlyselectedtoreceiveasurveylink,limitedtoonesurveyeverysixmonths.Veteransreceivingrecurringservicesaresentasurveylinkonaquarterlybasis.Sincethesesurveyscan’tincludecomparisondata,C4VincorporatesquestionsaboutotherinstanceswheretheVeteranhasusedasimilarprovidertoascertainrelativeperformance.DataFACTSdeterminedthatinformationregardingcompetitorsandothersofferingsimilarservicesthatcouldbeobtainedthroughtheseprocessesdidnotadequatelyaddressthechallengeoftheimpactofhealthcarereform,andresultswerenotreceivedinatimelymanner,soC4VcontractedtheservicesofIMPress,anationalhealthcaresatisfactionsurveyprovider.Asanadditionalcycleofimprovementin2014,surveyscanalsobeaccessedthroughtheinformationkioskslocatedineachfacilityforthosewhomaynothavecomputer/internetaccessreadilyavailable.

C4V uses social media suchasAppearanceBook,BirdCall,PinBoard,andSpinPaneltomonitorandaggregatecustomercomments.HIPAAandVAregulationsprecludetheabilitytosharesomeinformation,andso,asaninnovativesolution,C4V activelyencouragesVeteransandfamilymemberstosharetheirexperienceswithC4VandotherVeteransonPinBoard.ThePAOmonitorswhatis“pinned”and“re-pinned.”Veteransusethesesocialmediatoenterreviewsoridentify“bestpractices”tohelpotherVeteransnavigatetheoftencomplexVAprocesses.Whenthishappens,processownersuseappreciativeinquirytoconductapositiveRCA(RCA+)tolearnwhytherecommendationworkswellandusetheAPS(Figure2.2-1)tomaketheprocessmoresystematic.TheseimprovementsarealsocommunicatedusingtheYou had a Hand in This programandicon,describedin2.1b(2).

C4Vusesmanyweb-based technologies,withthemostvisiblebeingthe(publicaccess)website.C4VislinkedtotheVAadmin-istrativewebsitesofNCA,VBA,andVHA,andeachwebsitehasa“contactus”link.VAalsohoststheInquiryRoutingandInformationSystem(IRIS)forthepublictoobtaingeneralinfor-mationandasasecurewaytosendqueriesthatcontainpersonallyidentifiableinformation(PII).Usersmaysubmitcompliments,complaints,andsuggestionsviaIRIS,whichroutesthemessagetotheappropriatestation,service,and/orteam.Additionally,theVAoffersMyHealtheVet(MHV)andtheeBenefitsportalassecuremessagingsystemswiththerespectivehealthandbenefitsfunctionsatC4V.RecognizingthatnotallVeteranshavecomputeraccessorarecomputer-capable—particularlyhomeless,disabled,andelderlyVeterans—C4VcollaboratedwiththeVIDivisionofLibraries,Archives,andMuseumsontheVINetworkfortheFuture(VINF).Beginningin2013,C4Vlaptopcomputersbegantoreachtheirreplacementschedule,sotheC4VITDepartmentsuggestedaninnovation:deletedatafilesanddonatethecomput-erstoVINFforrelocationintolibraries,museums,andVSOs.RecipientfacilitiesagreedtoprovidecomputersupporttoanyVeteranuponrequesttoenhanceVeteranaccesstoC4Vservices.

Inacycleofimprovementtwoyearsago,allcommentsreceivedthroughNCA,VBA,andVHA linksareroutedintothePatientAdvocateTrackingSystem(PATS)andcommunicatedtothePAO.ThePAOaggregates,reviews,andanalyzesthedata tobetterdiscernsatisfactionanddissatisfactionpatternsandtrends.

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TrendsandsignificanteventsarereportedtoSLTmembersattheirdailyhuddleandreportedtothePITCrewmonthly.Additionally,thePAOprepares“walkingandtalking”pointsfortheSLTtodeployduringdailyleadershiprounds.Keylearningsareincor-poratedintotheannualrefreshertrainingthefollowingyearorescalatedasadditionaltraininginthecurrentyear.

In2013,C4Vinstalledwebcamsinsomekeyareasofthecampus.Throughthisweb-based technology,familiescan“visit”thefinalrestingplacesoftheirlovedonesfromanywhereintheworld,andanyonecansitandrelax,watchingthewavescomeashoreonthepropertyorseethetropicalbirdsandplantsintheC4V SerenityGarden.Earlyin2014,theserelaxingvenuesweremoresystematicallyincorporatedintothestressmanagementprograms,withaudiorecordingsandvideodisplaysavailablethroughtheclosed-circuittelevisionsystemasrelaxationmodalities.

QuickResponse(QR)codeswereinitiallyaddedtoC4Vinforma-tionkiosksandsignagetohelpfamiliesusetheNCAgravesitelocatorservice.QRcodesarenowusedtoenabletheVeteranstomorereadilylinkwithsocialmediawebsites,andDataFACTSmonitors“pageviews”asalisteningmechanismtoevaluateengagementandinvitesgueststothesepagestolinkwiththeAppearanceBookpageto“like”C4VorpinC4VonPinBoard.ArecentinnovativeuseofQRcodesenablesVeteransandfamiliesto“requestasurvey”fromtheVSOtoprovideC4Vwithfeed-back.Aninteractivesiteprovidestheappropriatelinktoasurveyspecifictoservicetypeandcustomersegment.ThemostrecentQRcodeideawastolinktointeractivemapstohelpVeteransandvisitorsfindtheservicestheyareseekinganywhereonthecampus,notlimitedtothecemetery.Asmartphone“app”isunderdevelopmenttohelpVeteransnavigateparkingandphysicalaccesstoC4Vfacilities.AftertheC4Vpilotoftheappiscomplete,itwillbedeployedtolarger,morecomplexVAfacilities.

Todeterminehowperceptionsvary across the customer life cycle,oneofthedemographicquestionsoneachoftheSurvey-Gorillasurveysaskswhethertherespondentisnewtothesystem,visitingtheVI,orhasexperiencedcareatC4Vpreviously. Togainbettercomparativedata,surveysnowaskiftherespondenthasexperiencedcareelsewherewithinthepastyearand,ifso,offersthemtheopportunitytocompleteanadditionalsurveyregardingthatexperience.Althoughnotprovider-specific,thismechanismobtainsgeneralcomparison/competitorinformationtouncoverpotentialopportunitiestoimprove.

Byregulation,theSHEPsurveyisnotcustomizable,buttheIMPresstool,SurveyGorillasurveys,andthecompliment/com-plaintsystemareapproachestoseek immediate and actionable feedbackfromcustomersonthequalityofproducts,customersupport,andtransactions.AfterbenchmarkingwithapreviousrecipientoftheCaseyPerformanceExcellenceProgram(CPEP),C4Vpostedcollageframeswithpicturesofthecurrentworkforceineachareaabovea“commentcard”box,invitingimmedi-atefeedbackaboutspecificcustomer-workforceinteractions.Managerschecktheboxesbeforetheendofeachshift,enterthefeedbackintoPATSandwriteaffirmingnotes,ortalkwiththosenamedinnegativefeedback.AfterapilotperiodinVHA,thisprocesswasdeployedtotheNCAandVBAoperations.EntryintoPATSenablessharingofstrongpracticesandopportunitiesforimprovementandinformsthetrainingforthenextyear.

3.1a(2) C4Vlistenstoformer customers, potential customers, and competitors’ customerstoobtainactionableinformationandfeedbackusingthemechanismslistedinFigure1.1-3.OnceengagedwiththeVA,mostVeteransuseVAservicesexclusively.IntegrationofbenefitsoperationswiththePACTsenablesC4V toknowwhenaVeteranreceiveshealthservicesfromanon-VAprovidertofollowupanddeterminethereason.Similarly,integratedservicesenableC4VtocontactthefamiliesofVeteranswhoreceivenon-VAmemorialservicestolistenandlearnwhytheydidnotselectC4V.Themostfrequentreasoncitedislackofawarenessofbenefitsandservices.

Thisfeedbackpromptedactionplanningtoincreaseeffortsatoutreachtopotentialcustomers.Ina2014cycleofimprovement,SurveyGorillalinksaresenttoanyVeteranwhohasreceivedfee-basedservicestodeterminerelativesatisfactionwiththealternativeproviderandrequestsuggestionsforimprovementstoC4Vservices.A2014suggestionfromaVeteranvolunteeratC4V resultedincommunicationswithanyVeteranwhoselectstousetheservicesofotherprovidersbeingclearlyfocusedon“helpVAimprove,sothatthenextVeteranreceivesevenbettercare.”Thisapproachhasimprovedresponseratesandidentifiedopportunitiesforservicerecoverythatincreasedengagement,measuredby“willingnesstorecommend.”

C4VincorporatesthereasonsthatVeteranscurrentlyreceivingservicesare“highlywillingtorecommend”intotheapproachesforofferingservicestopotential customers.First,participationinDoDprogramsproviding“transitionassistance”toactivedutymilitarywhoaregettingreadytotransitionto“Veteranstatus”identifiespotentialcustomers.Next,thosewhoclaimtheVIastheirhomeofrecordareproactivelycontactedandinformedofC4Vservicesandofferings.Withintwoweeksofofficialdischarge,servicemembersarecontactedbyeithertheBenefitsOfficerorsocialworkerofaPACTtoensurethateligibilityisunderstood.Outreachstaffrecognizedlastyearaneedtoimprovetheprocess,sotheybeganofferingBenefitsInformationDays(BIDs)toinformVeteranswhoarenotnewlyseparatedabouttheirpotentialeligibilityfortheservices.Thisdayisofferedasa“fair”atmosphere,includingrefreshmentsandtoursofthestation.BIDsalsoserveasanopportunitytoengageVeteransinbecomingvolunteersoremployeesatC4V.BIDshavehelpedtheoutreachtothehomeless,specificallyprovidinginformationtosheltersandknownhomelesslivingareasabouttheseevents.In2014,C4Vofferedthefirst“off-site”BIDinaparkdowntownneartheSt.Thomashomelessshelter,yieldingtheenrollmentof17VeteransforC4Vservices.

C4VrecognizesthatVeteranswhoareC4Vemployeesorvolun-teersarelikelytobepotentialcustomersofC4V,andnon-Veter-ansarelikelytobecustomersofcompetitorsorothersprovidingsimilarservices.CapitalizingontheYou had a Hand in This program,patientadvocatesfrequentlyaskworkforcememberstosharetheirownexperiencestohelpC4Vlearnandimprove.Manywelcometheopportunity.

3.1b(1) C4V determines customer satisfaction, dissatisfaction, and engagementprimarilythroughintegrationofinformationgainedfromsurveys,focusgroups,andcommentcards.Asnotedin3.1a(1),methodsdiffer among customer groups and market segments.Dissatisfactionismeasuredprimarilythroughlow

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scoresonsatisfactionsurveys,complaintsreceived,andnegativityonsocialmedia.MemorialspersonnelarethebenchmarkforsatisfactionwithinC4V,andVIVCpersonnelengageasinstructorsfor“TheExperienceoftheVeteran”classes.AllresultsflowintotheC4VDataWarehousetocapture information, andPMARSenablesanalysisbyDataFACTSandprocessowners.Inadditiontothecodingsystemusedtonotesource,type,andtopicoffeedback,thesystemalsopromptsentryofthetypeofserviceandwhetherthecommentisnegative,neutral,positive,ormixed.Animprovement,basedontheIDEALSanalysisofbothCRMSandPMARS,incorporatedathesaurusdatabase,sothatfeedbackcanbeaggregatedbykeywordsor“closematches”tobetteridentifytrends.

Thisrobustanalysismakesthedataactionable foruseinexceed-ingcustomers’expectationsandsecuring long-term engage-ment.Thetrainingfocusfor2013–2014wasdeploymentofthePlatinum ruletoensurethattheCRMSisusedtounderstandrequirementsandexpectationsofcustomers.ThePlatinum rule goesbeyondtheGolden rulethatstates“doforothersasyouwouldhavethemdoforyou”—encouragingtheworkforceto“doforcustomersaccordingtothecustomer’spreference.”Theprefer-encedatabasewasfullydeployedthroughoutC4VtoallNCA,VBA,andVHAservicesandfacilitiesduringthiscampaign.

C4Vdeterminesdissatisfactionandcapturesactionableinforma-tionfor future usebyanalysisofthe“bottom-box”scoreswithinthevariousmechanismsdescribedabove,aswellasthroughthecomplaintmanagementprocessdescribedin3.2b(2).Thisinformationisusedtodetermineprioritiesforcustomerexperi-encetrainingandprocessimprovements,anditdrivesupdatestopoliciesandprocedures.

3.1b(2) C4V obtains informationonVeteranandothercustomersatisfactionrelativetosatisfaction with competitors, otherorga-nizationsprovidingsimilar products and services,andindustry benchmarksdirectlythroughaskingthem,asnotedin3.1a(1).Additionally,processownersandDataFACTSanalyzepubliclyreporteddataasavailable,includingHCAHPSforVHA,CAHPShealthplancomparisonsforVBA,andACSIforNCA, inadditiontocomparisoninformationavailablefromwithintheVA.

3.2 Customer EngagementC4V determines product offerings tosupportcustomersinaccordancewithTitle38oftheCodeofFederalRegulationsthatgovernsbenefitsprovidedtoVeteransthroughtheenvironmentalscanoftheSPPandongoingmonitoringandanalysisofdataandregulationschanges.Communication mechanisms aredeter-minedbytheprocessownerusingtheCS(Figure1.1-2),basedondemonstratedeffectivenessasdescribedin1.1b(1)andexpressedpreferencesofVeterans,theirfamilies,andsurvivors.C4V builds relationshipswithpatientsandothercustomersthroughtheuseoftheCRMS(Figure3.1-1).

3.2a(1) Manyaspectsofthemarket requirementsfortheproduct offeringsandservicesofC4Varebasedonlaws,rules,andregulationsthatarecommunicatedthroughtheorganizationalstructureoftheVAandlegalcounsel.C4Vdeterminescustomer requirementsforproductofferingsandservices bythelisteningmechanismsshowninFigure1.1-3anddescribedin3.1a(1).InadditiontotheCRMS(Figure3.1-1),studyandanalysisof

externalandinternaldata,asdescribedin2.1a(3),4.1,and4.2a,alsocontributetounderstandingrequirementsandexpectationsofstakeholders,aswellasavailableproducts,technologies,services,andevidence-basedcaretoidentifyandadapt C4Vofferingstomeet the requirements and exceed the expectationsofcustomergroupsandmarketsegments.

Forexample,toexpandaccesstoservices,aC4VPITCrewconductedresearchandbenchmarkedwithintheVA,withotherhealthcareproviders,andwithotherindustries.C4Vimplementedamyriadofinnovativeideasandisstillseekingsolutions.Examplesofnewprocessesincludeexpandedhoursofserviceandadditionalgroupappointments.DataFACTSalsobenchmarkedwithairlinesandhotelstoexplorethefeasibilityofoverbooking.Patternedafterthese,aswellastherestaurantindustry,C4Voffers“standby”appointmentswheretheVeteranisguaranteedtobeseenonaparticularlydaybutnotataspecifictime.Veteransareprovidedwithfoodvouchersandinvitedtowaitinacomfortableloungearea,withstress-managementmodalitiesdescribedin3.1a(1),TV,games,internet,andhealth-relatedreadingmaterials.TheyaregivenapagerthatonlyworksonC4Vpremisestoalertthemaboutanopeningintheschedule.AnunexpectedbenefitfromthisapproachwasthatsomeoftheseVeteransofferedtoprovidevolunteerserviceswhilewaitingfortheirappointment(theseservicesaregratefullyacceptedbyC4V),andmanyoftheseVeteranshavenowbecomeengagedasregularvolunteers.

C4V identifiesproductandserviceofferingstoenter new markets, attract new customers,andcreate opportunities to expand relationships with current customersprimarilythroughhigher-headquartersinitiativesandplansandbythegatheringofdataondiseaseincidenceandneedsoftheVeteranpopulation.Statisticalandactuarialdataanalysis,projectionsofDoDperson-nelleavingactivedutyandbecomingVeterans,andeconomicinformationfortheVIhelppredicteligibilityandthespecificneedsforhealthcare,benefits,andmemorialservices.ThisrobustanalysisisconductedannuallyaspartoftheenvironmentalscanintheSPP.DataFACTS,processowners,clinicians,andleader-shipmonitordataandcommunicationchannelstodeterminewhenoff-cycleadjustmentsmaybeneededtoadaptcurrentservicestobetteraddressVeteranneeds.ThePACTmodelofcaredeliveryfostersrelationships,sothatteamscanreachouttoVeteranswithnewbenefitsandhealthcareservicesastheybecomeavailable,ratherthantheVeteranneedingtoseekinformationfromC4V . ThissupportstheC4VcorecompetencyofVeteran-centriccare.

Mostrecently,atthesuggestionofsomeVeterans,C4Vhasbeguntoincorporatemorecomplementaryandalternativemedicine(CAM)methodologiesintotherepertoireofhealingmodalities.SomeoftheC4VpractitionersandvolunteershavebecomeskilledatReiki,acupressure,andacupuncture,aswellasmusic,art,andaromatherapies.Intriguedbythesetreatmentmodalities,oneofthecemeterygroundskeepersproposedincludingalabyrinthmeditationwalk,usingthecrushedwhitegraniteleftfromcuttingcemeteryheadstonesandmarkers.Atthecenterofthelabyrintharemarkers,notingthehistoryoftheVIinvariousmilitaryconflictsovertime,connectingthepresent-dayVeteranstotheirmilitaryancestors.Thewebcamnetworkenablesa“virtualwalk”throughthelabyrinthwhenaphysicalwalkisnotpossible.

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3.2a(2) C4V enablescustomerstoseek information and support andto conduct businessthroughthemultiplecommunicationmechanismsinFigure1.1-3andthroughthePACTstructure.AtypicalPACTincludesalicensedindependentpractitioner,suchasaphysician,nursepractitioner,psychologist,dentist,etc.,supportedbyanurseand/orsocialworker,administrativesupportstaffmember,benefitscoordinator,andvolunteers.ThePACTisthemedicalandbenefits“home”fortheVeteranandcoordinatesVeterancareandbenefitstosupportphysical,mental,andfinancialwell-being.ThePACTfocusesonholisticcareandlife-longhealthandwellness.Forexample,inadditiontotreatmentofillnessandinjury,PACTsoffernutritioninformation,smokingcessationguidanceandsupport,immunizations,andtheMOVE!weightmanagementprogram.ManyservicesareofferedelectronicallyoringroupsettingsbasedonVeteranpreferences.

TheC4Vinnovationofaddingabenefitscoordinatorandvolun-teersintothePACTsalsoprovidesaccesstoadditionalsupportandassistance,suchaseducation,homeloans,disabilitycompen-sation,jobcounseling,rehabilitation,pension,andlifeinsurance. ThePACTensuresthatVeteransandfamiliesareawareofthevariousservicesofferedbyVIVCatnocharge,includingburial,columbaria,honorguardservices,andperpetualcare.

Veteransgive feedbackonservicesandsupportthroughtheirPACT,throughthemultiplesurveysavailable,throughVSOs,orlessformally,throughanyofthecustomer support andcom-munication mechanismsdescribedinFigures1.1-2and1.1-3.Figure1.1-3notesthevariety incommunicationmechanisms for different customers, customer groups, or market segments,aswellaswhichmechanismsarefordisseminatinginformationorlistening,orboth.BasedontheincreasedworkforceengagementinmakingimprovementsuggestionswhentheYou had a Hand in This programwasimplemented,C4Vstartedanewcustomer-relatedcampaignin2013calledWe’re Listening! Internalandexternalcommunicationsrelatedtosomethinglearnedfromcustomerlisteningmechanismsarenotedwithanearicon.ThishelpsVeteransandothercustomersknowthatC4Vtakeswhattheysayseriously.In2014,thecampaignwasintegratedwiththeSpeak Up! initiativefromAHCGrelatedtopatientsafety.Thisre-energizedbothprograms,remindingtheC4VworkforcetoactivelylistenanddemonstratingtoVeteransandothercustomersthatthereisvaluetothemandothersingivingfeedback.

C4V determinescustomers’key support requirementsfromitslisteningmechanisms.Forexample,inearly2014,aVeteranC4VemployeecommentedhowmanycommunitygroupsandprogramsarenowavailabletosupportVeterans,andhowmuchdifferentthisisthanduringtheVietnamerawhenheserved.TheSLTsystematicallyresearchedtheVIandaskedVeteranstohelpidentifypublicandprivategroupsthatsupportVeterans.Theyfoundchurchgroups,othergovernmentagencies,Veterangroups,socialactiongroups,communityservicegroups,andsupportgroups,inadditiontoprograms,services,initiatives,andoffersfromlocalattorneys,retailestablishments,restaurants,andotherbusiness—manydozensoverall.C4VapproachedallofthemaboutcreatingamoreintegratednetworkforVeteransupport,andVETBasewasborn.

TheC4VoutreachcoordinatormaintainsVETBase,whichincludesdataonorganizationalfocusareas,typesofsupport,

specificrequirements,andcontactinformation.ThisinformationinthisdatabasewasinitiallysharedwithVeteransandotherorganizationsuponrequest,butin2014itwasmadeavailableasasmartphoneapp.VeteranscanalsowritereviewsofservicestohelpguideotherVeteranstohigh-qualityservicesandhelptheseorganizationsidentifyopportunitiesforimprovement.VETBasehasreducedduplicationofeffortsandenhancedthevisibilityofalloftheprograms;plus,itclearlydemonstratestoVeteransthevaluethattheVIcommunityplacesonthemandtheirservice.C4Visnowexpandingthedatabasetoincludenon-localprogramsfromwhichVIVeteranscouldbenefit,despitethedistancetoevaluatetheopportunitytousetelehealthconnectivityresourcesasanintelligentrisk.

C4Vensuresthatrequirements are deployedtoallpeopleandprocessesinvolvedincustomersupportthroughthe6-E Leader-ship Tool describedin1.1andthe6-Ps of Leadership describedin1.2.ThesetoolsweavetheMVV,corecompetencies,andcharacteristicsintothefabricoftheC4Vculture.Veteran-centriccareisdeployedfrompriortohirethroughpost-separation,asmanyretiredemployeesreturnasvolunteers.Specificdeploymentmechanismsincludetrainingevents;policiesandprocedures;con-tractsforcustomer-facingsuppliers,collaborators,andpartners;andevaluationofassociatedresults.TheC4VtrainingteamisparticularlyattentivetoKirkpatricklevels3and4evaluations,asdescribedin5.2c(2),ensuringthatallrequirementsareknownandmet,andthatexpectationsareunderstood,negotiatedasappropri-ate,andmetorexceeded.

3.2a(3) C4VdeterminesitscustomergroupsandmarketsegmentsfirstbyTitle38regulatoryrequirementsthatdesignatewhomayreceivebenefitsandservices,thenthroughtheuseoftheDataFACTsformuladiscussedin2.2a(2).ThenC4Vusesinforma-tiononcustomers,markets,andproductofferingstoidentify current and anticipate future customer groups and market segmentsbasedondataandinformation.ThePMARS,showninFigure4.1-1,andDataFACTSpromoteunderstandingofcurrentneedsforservicesandspecificrequirementsandexpectationsuponwhichtomakeprojections,asdescribedin2.2b.Offeringsfrequentlyaddresstherequirementsandexpectationsthatdefineasegment,andoncedeveloped,theyofferopportunitiesforlearninganddeploymenttoallcustomers.Forexample,socialmediamechanismsofcommunicationwereenhancedtoaddressidentifiedneedsoftheyoungerOEF/OIF/ONDVeteransegmentsandareopentoanygenerationorconflict-eraVeterans.FemaleVeteransalsohavespecificneeds,requirements,andexpectationsaroundwhichC4Vhasdesignedspecificprocessesandofferings.You had a Hand in This andWe’re Listening! programspromotecommunication,whichpromotesidentificationofspecificneedsandunderstandingandbuildsrelationships.

TheSLTunderstandsthatlocalhealthcareorganizations,ceme-teries,andbenefitsprovidersmaybecompetitorsattimesandcol-laboratorsinotherinstances,particularlyforhealthcareservices.TheC4VfocusisonensuringthebestserviceforVeterans,whilerecognizingthatVAoffersthelowest-costoptionbecauseVeteranshavealreadypaidtheprice.C4V considers competitors’ custom-ers andother potential customers and marketsinsegmentationbyevaluatinghowbeingVeteran-centricissimilarto,ordifferentfrom,beingpatient-orcustomer-centric.Forexample,51%ofthe

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populationintheUnitedStatesarefemale,whileonly10%oftheVeteranpopulationarewomen.C4Vcustomerexperiencetrainersfocusonthisdifference,notingthatparticularcaremustbetakentonotassumeawomanis“herewithaVeteran,”ratherthanbeing theVeteran.Otherorganizationsmaysegmentbygeneration;intheVeteranpopulation,segmentingbyeraofconflictmaybemorerelevantthanbyeraofbirth.

C4Vdetermineswhichcustomers,customergroups,andmarketsegmentstoemphasize and pursue for business growthbasedonTitle38regulatoryrequirements.TheC4VgoalistoprovideallservicesforwhichaVeteraniseligibletothefullestextentpermissiblebylaw.

3.2b(1) C4V acquires customers andbuilds market share throughtheoutreachactivitiesdescribedin3.2a(1).BecauseoftherelativelysmallvolumeofVeteransservedbyC4VcomparedwithotherVAfacilitiesandtheintegrationofservices,theTransitionAssistanceProgram(TAP)atC4Visnotoutsourcedtoacontractor,asatotherfacilities.Thisweek-long,mandatoryprograminformsseparatingactivedutymilitaryabouttheVAbenefitsandservicesavailabletothem,facilitatingenrollmentforeligibleVeterans.AtC4V,TAPisconductedbytheoutreachcoordinator,includesthePACTs,andistheprimarymechanismtointroduce,build, and manage the C4V brand.Initially,oneofthePACTsonSt.ThomaswouldattendTAPasateam,butfeedbackfromVeteranswasthatwhiletheybegantoengagewiththePACTatTAP,theywerethenoftenassignedtoadifferentPACTforcare.C4VnowhasonePACTrepresentativefromeachteamattendeachTAP,sothatVeteranswillmeetsomeonefromtheteamwhowillbeengagedintheircare.PACTassignmentsaremadeassoonaseligibilityisdetermined,usuallybeforeTAPiscomplete.ThisenablesC4VtoofferenrollmenttoalleligibleVeteransastheyseparatefromactiveduty.OtheroutreacheffortsaredesignedtoenrollVeteranswhoarecurrentlyeligiblebutwerenoteligiblewhentheyseparatedfromservice.

PACTsaretheprimarymechanismto buildandmanage relationshipswithcustomersto meet their requirementsandexceed their expectationsineachstage of the customer life cycle; increase their engagementwithC4V;andretain themas customers.EachVeteranisassignedtoaPACT,whichmanagesandcoordinatesallcarefortheVeteranforlifewhileatC4V.Asaninterdisciplinaryteam,withtheVeteranandfamilyatthecenter,thePACTstrivestoprovideholisticcarefocusedonwellness,includingphysical,mental,andemotionalhealthandwell-being.WhenallaspectsofcarearecoordinatedthroughPACTs,continu-ityofcareisenhanced,andtheVeteranisempoweredthroughinformationandeducation.C4VhasfourPACTs—oneateachlocation,andeachwithamaximumpanelsizeof1,000Veterans,whichisslightlysmallerthantheaverageVAPACTsizeof1,200uniqueVeterans.

C4V leverages social mediatoenhancecustomerengagementandrelationshipsingeneralthroughthemechanismsdescribedin3.1a(1).Additionally,C4VhasaneducationandoutreachchannelonYourConduit,withvideomessagessharingrole-modelpracticesontopicsthatincludeenrollment,thefilingofappealsandclaims,selectionofmemorialoptions,andavarietyofhealth-relatedtopics.C4V leverages social mediatoenhancetheVeterans’relationshipswiththeirPACTsthroughsecure

messagingsystemswithinMHV andtheeBenefitsportal.AllprimarycarestaffmembershavebeentrainedtopromoteMHV toVeterans,androle-modelpracticesaresharedregularly.

Veteranshavetheopportunitytoregisterandbecomeauthen-ticatedinthepatientlibraryatHH,atallthreeCBOCs,fromhome,oratanyVIpubliclibrary.BasicfeaturesofMHVenableVeteranstoaccessgeneralinformation;theAdvancedoptionenablesthemtoaccesstheirownrecords;andPremiumaccessallowssecuremessagingtocommunicateonlinewiththeirPACToranyspecialist.Togainhigher-levelaccess,patientsmustcompleteanin-personidentificationauthenticationprocess.MHValsogivesVeteransaccesstothe“bluebutton,”aone-clickportaltoaccesstheirownhealthrecords.AnyMHVuserisabletodownloaddataandresultsfromtheVAelectronichealthrecord,andonceaVeteranhasPremiumaccess,he/sheisabletoenterinformationintohis/herMHVpersonalhealthrecord.BasedonaVeteranemployee’ssuggestion,C4VisworkingwiththeVHA SupportServiceCentertointegrateVBAinformationandenablethetrackingofeducationloans,homeloans,andotherbenefits.

AtanyC4Vlocation,volunteerfacilitatorsassistpatientsinregistering,asneeded.Atpubliclibraries,supportisofferedthroughVINFvolunteerswhohavebeentrainedonthesystemandalsoonHIPAAprivacyregulations.Providersrespondtopatientquestionswithin72hours,orthesystemautomaticallyescalatesthemessage.ActivelypromotingMHV,guidingVeteransthroughtheprocess,andexplainingthesystemadvantagesduringavisithaveledtoC4Vleadingthenationregardingauthenticationrates.C4VisnowpilotinganintegrationinitiativebetweenMHVandtheeBenefitsportal,withasinglesign-onandauthenticationprocessgivingVeteransseamlessaccesstobothsystems.

3.2b(2) C4V manages customer complaintsconsistentlywiththeVA,althoughC4Vintegratesanybenefitsorcemeterycom-plaintsintothesamePATS,asshowninFigure3.2-1.C4VcreatedtheacronymRESOLVEDtohelptheworkforceensurethatallappropriatesteps,includingdocumentation,aretakeninresolvingcomplaintspromptly andeffectively.Timely,effective,andcon-sistentcomplaintmanagementandincorporationoftheissueinto

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theVeteranpreferencedatabaseenableC4Vtorecover custom- theVeteran’srecordwillseeaflaggedentryassociatedwiththaters’ confidenceandenhance their satisfaction and engagement . encountersothatallappropriatemembersoftheworkforcecanbeMonthlyaggregation,review,andanalysisofcomplainttopicsby madeawareoftheissue.ThePACTstructureandtheintegrationthePAOhelptoidentifysystemicissuesforactionplanningin atC4Venablecaregiversfromallservicestoenterandviewinfor-ordertoavoid similar complaints inthefuture. mationaboutVeteranpreferences.PACTmembersuseencounters

asopportunitiestodiscussadditionalbenefits,asappropriate,asAnycomplaintsreceivedarealsonotedbystaffontheVeteranwellasadvancedirectives,finalrestingplacepreferences,andpreferencepage,whichautomaticallysendstheentryintoPATS,beneficiaries,whichhelpsthecemeteryoperationswithlonger-whichenablestrackingofpatternsandtrendsincomplaints,andtermplanning.ensuresthattheworkforce“remembers”anycomplaintstoensure

thatissuesarenotrepeated.Additionally,anypersonthatlogsinto

4.1 Measurement, Analysis, and Improvement of Organizational PerformanceC4V measures, analyzes, and improves performanceusingdataandinformationatalllevelsandinallpartsoftheorganizationusingthePMARS,showninFigure4.1-1,oneoftheILMS.PMARSassistsC4VinconvertingtheplethoraofdatawithintheVAintoinformationtousetoguidedecisionmaking,resourceallocations,andtheidentificationofopportunitiesforimprove-mentandinnovation,alongwiththeguidanceandsupportofhigherheadquarters,DataFACTS,andotherknowledgeassets.CreatingandsustainingthecorecompetencyofusingtheBaldrigeframeworkpromotesC4V’suseofcomparative and customer data to support decision making.TheSLTandDataFACTSusethe6-E Leadership Tool, describedin1.1b(1),tofosterconsistentunderstandingoftherelativeperformanceofC4V .

4.1a(1) C4V selects, aligns, and integratesdataandinformationtouseintrackingdailyoperationsandoverallperformance,includingprogressonachievingstrategicobjectivesandaction

plans,basedonmeasurementrequirementsfromthethreeVAAdministrations.Asdescribedin1.2a(1)andshowninFigure2.1-5,C4VfollowedtheleadofNCA,whichhasstandardizedmeasurestodesignatecertaincemeteriesasNationalShrines.Thisprogramclearlyarticulatesthedesiredmeasuresofperformanceandstandardstoachievethishighlycovetedstatus.C4Vhealthcareoperationsareobligatedtoincorporatethestandardin-pro-cessandoutcomemeasuresetsoftheCMStocomplywithAHCGstandardsandVHAregulations.Additionally,standardmeasuresfromHEDISareusedjointlybybenefitsservicesandPACTteams toprovidepreventiveandchroniccareandtopromotewellness.VHAandVBA haveadditionalstandardmeasuresets,basedonstrategicinitiativesofeachAdministration.TheseincludetheASPIRE-healthdashboardthatdocumentsqualityandsafetygoalsforVHA;LinkingInformationKnowledgeandSystems(LinKS),adashboardthatdocumentsoutcomemeasuresforacutecare,intensivecareunit,outpatient,andsafetymeasuresannually;andtheStrategicAnalyticsforImprovementandLearning(SAIL)report.Inaddition,ASPIRE-benefitsisadashboardfortrackingprogressongoalsforbenefits,compensation,pension,education,loanguaranty,andvocationalrehabilitationandemployment . PerformanceispostedpubliclyontheHospitalCompareVAwebsite,whichisupdatedquarterly,andtheVBAPerformanceReportswebsite,whichisupdatedweekly .

At C4V,dataarecollectedautomaticallywheneverpossible.TheVeteransHealthInformationSystemsandTechnologyArchitec-ture(VistA)fromVHAincludesnearly160integratedsoftwaresystems,includingcomputerizedorderentry,barcodedmedicationadministration,clinicalguidelines,coding,andMHV.C4Vpullsinformationfromeachofthesesystems,aswellasfromkeysys-temsfromVBAandNCA.Dataflowsfromeachofthesystems,particularlythoseshowninFigure4.1-2,intotheC4VDataWare-house,thecentralrepositorythatenablesDataFACTStoperformqueriesacrossallsystemstoextractmeaningfulinformationfromthedata.AutomatedqueriesprovidethereportsupthechainofcommandtoeachAdministration,andreportsareauditedinter-nallyandexternallyforaccuracyonaregularbasis.Frequencyofauditsisdeterminedbyariskmatrixdependingonthepossibilityofmisinformationandthepotentialimpactthatmisinformationwouldhaveonoperationsand/ortheVeteranpopulation.

TheregulatoryandVACO/Administration-imposedstandardizedandrequiredmeasuresforC4Vnumberinthehundreds,andthe

Category 4 Measurement, Analysis, and Knowledge Management

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SLTdeterminedtheneedtosharpenthefocusonthosethatarekeytoVeterancareandorganizationalsuccess.C4Vnowsegmentsdataintotwotypes:Measures of Success andMetrics to Monitor. Thelatteraremonitoredbytheautomatedsystemsandreceivepersonalattentiononlywhenpre-setcontrollimitsarebreached.

Measures of Success areactivelyreviewedonaregularscheduleinatleastonevenuetofocusattentionontheneedforimprove-mentandinnovation,andtocreateopportunitiesfordiscussion.Measures of SuccessareincludedontheC4VMeasuresofSuccessScorecard(MOSS)showninFigure4.1-3anddemonstrateactualcolor-codingofperformance(seeFigure2.1-5forresultsfiguresreferences).

TheMOSSincludesleadingindicatorsofkey performance measuresrelatedtotheC4Vstrategicplanandassociatedactionplans,includingsomeaggregatemeasuresfromstandardreportsandC4V-identifiedcriticalopportunitiesforimprovement.Thesemeasuresaretracked in realtimethroughautomatedsystemsandtheC4VDataWarehouse,fedbyintegratedelectronicsystems.

MOSSmeasuresarequicklyreviewedatthedailySLThuddle,discussedanddecideduponasappropriate,andadditionaltopicsarereviewedweekly,monthly,andquarterly,asnotedonFigure4.1-3.Twiceperyear,theSLTreviewsthestatusandprogressoncompletionofworkforceperformanceevaluationsanddevelopmentplans.TheMOSSappearsonthedesktopofeachmemberoftheSLTandisavailabletoallworkforcememberswithaccessthroughtheC4VShareSpotsite.Clickingonanycolor-codedmeasureprovides“drill-down”capabilityintothevarioussegmentstofacilitateanalysisofrelativeperformanceinternally,asappropriate.

Dataandinformationareused to support decisionmaking,continuousimprovement,andinnovationbyincorporatingMoSintoeveryactionplanatalllevelsoftheorganization.The

detailandtimehorizonsofthemeasuresarestructuredtoalignwiththemanagement zonesshowninFigure1.1-5.Inabureau-craticorganizationofthesize,scope,andcomplexityoftheVA,thisalignmentandappropriatefocalpointarecrucialtosuccess.Asleadersofapilotcomprehensivecarecenter,C4Vleadersformalizedthemanagement zoneconceptandtrackthetimethatupper-andmid-levelleadershipspendineachzone.Withthisintegratedstructure,whenthenear-termperformanceineachseg-mentofC4Vis“runninggreenorblue,”SLTmembersareassuredthattheydonotneedtospendmuchtimeintheoperationalmanagementzoneandcanremainfocusedonthelongerterm.TheSLTfocuson“red”isnotpunitivebutacknowledgesthatresources,suchasideas,training,additionalstaff,orequipment,arerequiredtoimprove.Yellowmetricsarecarefullymonitored.

DataareusedasthefirststepintheSPP,showninFigure2.1-2.Theenvironmentalscanincludesexternaldataandthesystematicreviewofinternalperformancemeasures.Asmeasuresareselectedduringthisreview,theyaresegmentedintoMoS and

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Metrics to Monitor, basedoncurrentcomparativelevelsofperformance,alignmenttothestrategicplan,andrequirementsofhigher-headquartersorganizations.

4.1a(2) C4V selects comparative datainaccordancewithVAguidelinesandbasedonfivekey considerations.ThefirstconsiderationisthecurrentC4VlevelofperformancewithintheVA,basedoncomparisondatatypicallybeingreadilyavailableinternally.WhenC4VlevelsofperformancehavereachedtopquartilewithintheVA,DataFACTScollaborateswiththeSLTandprocessownerstomakeadeterminationregardingwhethertoseekexternalcomparisons,basedontheadditionalfourconsider-ationsshowninFigure4.1-4.

C4ValsoconsidersthegoalsofHealthy People 2020whensettinginternalgoals,althoughthesearenotconsideredtobecompari-sonssincetheyarenotactualperformancedata.

Formerly,decisionsaboutobtainingcomparisondatawereonlybasedonwhetherthedatawereavailableandaffordable.SincetheinceptionofDataFACTSandformalizationoftheC4Vdatadictionary,additionalemphasisisplacedonensuringthevalidityandreliabilityofdatabeforeincorporatingthedataintouseasinformationtohelpC4V.LimitationsinobtainingdataarenotedinP.2a(3),andthehierarchyofcomparisoninformationshowninFigure4.1-5isusedtodrivehigher-performancemeasures.

C4V ensurestheeffective useofkeycomparativedataandinformationtosupportoperationalandstrategicdecisionmakingandinnovationbysystematicallyincorporatingcomparisonsintoallgraphsandchartsusedtoanalyzeperformance.Comparisondatawerealsousedtodeterminethesetpointsdescribedin1.1a(3)toestablishthelevelsofperformancetobedesignatedbycolor-coding.Risk-adjustedmeasuresareused,whenavailable,toincreasevalidityandreliability.

Whencomparativedatacannotbeobtained,C4VusestheapproachofaskingsurveyrespondentstocompareC4Vserviceswithothersimilarproviders.Forexample,funeraldirectorsmaybeaskedtocompareVIVCservicesandsupporttoothercemeter-ies.SurveyGorillafrequentlyincludesquestionsabouthowC4V compareswithotherproviders.

4.1a(3) C4V selectsandensures effective useofdataandinfor-mationspecifictothevoice of the customerandmarketinmuchthesamemannerasgeneralinformationdescribedin4.1a(2).Additionally,voice-of-the-customerinformationisincorporatedintoprocessredesignandworkforcetrainingtobuildamorecustomer-focusedculture.ThisconstantfocusbuildsontheC4V corecompetencyofVeteran-centric care, including and especially treatment of war-related injuries that are physical, mental, and/or emotional. Thesystematiccapture,aggregation,andintegrationofdatafromthewiderangeofC4Vlisteningmechanisms(includingcomplaints)supportoperationalandstrategicdecisionmaking

andinnovationthroughalloftheILMS,byhelpingtoidentifyrequirementsandexpectationsastheychange.

C4Vusesdataandinformationgatheredthroughsocial mediaasoneaspectofvoice-of-the-customerfeedback.Associalmediahasmatured,C4Vhasbecomemoreactiveinanalyzingandusingsocialmediaratherthansimplymonitoringthem.Forexample,SpinPanelhelpsDataFACTSaggregateandtrackthementionsofC4Vinvarioussocialmedia;correctpossiblemisinformation;dis-tributeaFACTSheet;andidentifytheneedtocharteranewPITCrewtoredesign,improve,orinnovateaprocess.Periodically,C4VwillactivelycampaignforVeterans,families,andsurvivorstoshareexperiencesthroughsocialmedia,writingreviews,givingaThumbsUponAppearanceBook,orsharingonPinBoardtohelpotherVeteransunderstandtheresourcesthatC4VprovidesandtohelpC4Vimprove.

4.1a(4) DataFACTShasgreatlyenhancedthecapabilityofC4Vtoensurethattheperfor-mance measurement system can respondtorapidorunexpectedorganizationalorexternalchanges.DataFACTScanaddMetrics to MonitortotheMOSSimmediatelytosharpenthefocuswhensetpointsarereached.Simi-larly,MoScanbedeletedfromMOSSwhenperformancelevelsarestableandpriorities

shift.DatafromeachITsystemshowninFigure4.1-2rollupintolargerVHA,VBA,orNCAdatabasestoproactivelyenableDataFACTStonotewhenperformanceelsewhereintheVAmayrequireaC4Vresponse.

4.1b C4Vreviewsperformance and capabilitiesprimarilythroughMOSS.Priorto2012,thisscorecarddisplayeddatainspreadsheetsthatwerecolor-codedred,yellow,green,orblue.In2012,theSLTchangedtousinggraphsinalignmentwiththeBaldrigeevaluationfactorsoflevels,trends,comparisons,andintegration.Inanothercycleofevaluationandimprovementin2013,C4Vchangedagaintodisplayingperformanceusingbothmechanisms,insertingcolor-codeddatatablesintoeachMOSSchart.MOSSincludesonlykey performance measures,althoughleadersandmanagersmayaddmetricstotheirownpersonaldashboard,asdesired.Tomaintainfocus,managersareaskedtonotexceed10additionalmetrics. Basedonprocesscycletime,datapointsareaddedtoMOSSonadaily,weekly,monthly,

Figure 4.1-5: Hierarchy of Comparison Information

World- class

Competitors

Industry standards

Similar processes from all VA providers

Internal comparison against targets, projections, and other similar segments

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orquarterlybasis.Whenatimeframeiscomplete,thedataareaggregated(packedup)intothenexthighertimeframeforreviewpurposes.Forexample,whenaweekiscomplete,thedailydataaredisplayedasaweek;whenamonthiscomplete,weeklydataaredisplayedasthemonth,etc.

DataFACTSperformsvariousanalysestohelptheC4VSLTbeconfidentthatreviewsarecomprehensiveandconclusions are valid. Analyses includecorrelationandregression;comparativeanalysisfromdifferentdatasources;androbustuseofcomparisondata,periodicaudits,andconversationsduringleadershiproundstoensurethatthedatadictionaryisproperlyunderstoodandapplied.MOSSwasinitiallyconceivedinabalancedscorecardformat,focusedonfinancial,customer,internalprocess,andlearn-ingandgrowthmeasures.ThedesignwaschangedpriortobeingimplementedtoreflecttheBaldrigecategory7itemsinordertosupporttheC4VcorecompetencyofBaldrige-basedleadershipandmanagementsystems.MOSSnowincludesmeasuresalignedtoeachstrategicobjective—access,quality,safety,customerexpe-rience,workforceengagement,andvalue—andthesestrategicobjectivesaredesignedtoincludemeasuresfromeachcategory7itemandareatoaddress.

ThisenablestheSLTtouse the reviewdatafromMOSStoassessorganizationalsuccess,competitiveperformance,financialhealth,andprogressonachievingstrategicobjectivesandactionplans.ThestructureofMOSS—displayingnear-timedata(today,yesterday,lastweek),whicharethenrolleduptoshowtrends(monthly,quarterly,annually),includingcomparisondata,anddisplayingbothgraphsandcolor-codedcharts—enablesC4V’sSLTandotherleaderstousethesereviewstorespond rapidlytochanginginternalneedsandchallengesintheoperatingenviron-ment.ColorcodinghelpstheSLTandotherC4Vleadersidentifytheneedfortransformational change.Forexample,performancelevelstrendinginanadversedirectionformorethanonedefinedperiod,levelsthatare“red,”orlevelsthatviolateanupper-orlower-controllimitwillcauseashiftofleadership’sfocalpoint(Figure1.1-5).

LeadersfromtheAtlantaMSN,theSouthernAreaOffice,andVISN8reviewC4V performance and progress on strategic objectives and action plansonaquarterlybasis.ThedialogueduringtheevaluationoftheDirectordescribedin1.1a(2)focusesonleadershipbehaviorsthatmayimpacttheperformancedisplayedonMOSS.ThishelpstheSLTtoassessandenhancepersonalandorganizationalagilityandtohavetheabilitytorespondtochangingneeds.

4.1c(1) MOSS,withDataFACTSsupport,enablesC4Vleadersatalllevelsto“drilldown”intodatatoidentifyorganizational units or operations that are high performing. DataFACTSalsoextendsthiscapabilitybeyondC4V,identifyingpracticesinVBA,VHA,orNCAtoshareorincorporatewithinC4V,providingoneoftheadvantagesofbeingpartofanorganizationthesizeoftheVA.

4.1c(2) C4V uses performance review findingsandkeycom-parativeandcompetitivedatainprojectingfuture performance,asdescribedin2.2a(6),consideringbothtrendsandtheimpactofactionplanstoreconcileanydifferencesamonggoals,projections,andprojectionsforcomparisonorcompetitorperformanceforeachmeasureonMOSS.Additionally,thesefindingshelpidentify

opportunitiesforcontinuousimprovementandinnovationusedin4.1c(3).

4.1c(3) C4Vusesperformancereviewfindingstodevelop prioritiesforcontinuousimprovementandopportunitiesforinnovationbasedongapanalysisbetweentrendprojectionsandgoals,factoringinconsiderationssuchasalignmentwiththeC4V strategicplanandtheplansandprioritiesofVBA,VHA,NCA,ortheVAoverall.Highestpriorityforimprovementandinnovationisgiventoanareaofperformanceshowingabroadgapbetweentrendanalysisandtheestablishedgoalinanareaofstrategicimportance.Asdescribedin2.1b(2),theprioritizationmatrixtoolisusedtodetermineanddocumentpriorities.

Priorities and opportunities are deployedtoworkgroupandfunctional-leveloperationsthroughoutC4VprimarilybycharteringPITCrewsthataresupportedbyDataFACTS.AnexampleofPITCrewworkisdescribedin3.1a(1).AnalysisofsegmenteddatawithinC4V,throughouttheVA,andexternaltotheVAinformsleadership,PITCrews,andSMEsofstrongpracticesforbench-markingpurposes.Prioritiesandopportunitiesaredeployed to suppliers, partners, and collaboratorsbyincludingthemonPITCrewsorbyaskingfortheirideas,experiences,andsuggestions,asappropriate.ThesupportofDataFACTShelpstoreinforcetheC4V management by cultureandensureorganizational alignment towardstrategicobjectivesandperformancegoals.

The6-E Leadership Tool and6-Ps of Leadership areusedtosup-portcontinuous improvement and innovation throughmanyoftherewardandrecognitionsystemsshowninFigure1.1-4.Theseincludenoncompetitiverecognition,suchasgivingeachpersoninanareaachieving90th-percentileperformancearecognitionglobepintorecognize“world-class”performance,andfrequentuseofpubliclydisplayed“blue-ribbon”certificatestonotehigh-performanceresultsfromimprovementactivitiesorteamefforts.

TheSLTalsopromotescontinuous improvement and innova-tion byteamrecognition,includingVIVA!Quality,afunplayonwordsfortheVIVeteransAffairsQuality,andthe“longesttimesince”anadverseeventofvarioustypes,suchasaworkforceinjury,ahospital-acquiredinfection(HAI),oraclaimserror.CapturetheFlagenablesthehealthcareareawiththehighestsatisfactionleveltoproudlydisplayabannerproclaimingthatfactforthefollowingmonth.

4.2 Knowledge Management, Information, and Information TechnologyC4V manages and grows knowledge assetsandlearnsusingtheKMS,showninFigure4.2-1,oneoftheILMS.C4Vdistinguishesamongdata,information,andknowledge.TheKMSenablesthemyriadofdataavailablethroughC4VITsystemsanddatabasestobetransformedintoinformationtogrowknowledgeassetsandlearn.Management by fact informsdecisionmakingandprovidesinputintoorganizational learning,whichinturnsharpensthefocus on delivering value and results fortheVeteransserved.DataFACTSperformsvariousanalyses,andcross-referencedITsystemsensurethequalityandavailabilityofdataandinformationneededbytheworkforce,suppliers,partners,collaborators,andcustomers.Software and hardwarearemaintainedaccordingtoVApolicies,procedures,andregulations.

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4.2a(1) C4Vhasmultiplemechanismstocollect and transfer workforce knowledge,primarilyusingwrittenpoliciesandproceduresascommunicationmechanisms,aswellasformaltrainingandlessformalizedpersonalinteractions.Communicationmechanismshaveallbeenimprovedovertime,basedonwork-forcesuggestionsandbenchmarkingactivities.Asdescribedin5.1a(2),themostknowledgeableworkforcemembersareselectedtoprovidementoring,coaching,andtrainingtolessexperiencedornewerworkforcemembers,aswellastomentorstudents.Mentorsareselectedbasedontheirknowledgeandskills,aswellastheirattributesandabilitiestoteachandcommunicate.

High-performingemployeesfromalldisciplinesareenrolledintheNationalCertifiedMentorProgramatVACO.Certificationbeginswithafull-day“CoachingforHighPerformance”class.Aftercompletion,mentorselectronicallyloghoursintoanationaltrackingsite.Uponlogging25hours,thementorearns“resident”-levelcertification,andafterlogging50hours,thementorreceives“fellow”-levelcertification.Oncecertified,thementorcontinuestologhours,includingformalandinformalcoaching.Basedonreviewofthisprocess,C4Vhasbeguntwopilotprograms.FirstisfulldeploymentofsimilarprocessesforVIRBOandVIVCpersonnel.Secondisasupplementalpeermentoringprogramtoenableleaderstoidentifyspecificskillswheretheydesireformalmentoring,andthenpairthemwithacertifiedmentoratleasttwogradesabovewhowillprovidetoolsandresourcestobuildtheirskillsandcompetenciesinthespecificareasidentified.

FollowingtheexampleofapreviousBaldrigeAwardrecipient,C4VimplementedCaseypedia,auser-contributionintranetsitetopromoteknowledgesharingofstrongpractices,tips,and

techniquesassociatedwiththeworkenvironment.Anymemberoftheworkforcecanaddtothisknowledgerepository,andnowDataFACTSverifiesandvalidatestheinformationpriortopost-ing.ContributorstoCaseypediareceiveatleastoneoftherewardandrecognitionmechanismsshowninFigure1.1-4,dependingonthedetailsofthecontribution,evenifthecontributionisnotposted.Themostexperiencedworkforcememberswhoactuallycarryoutpolicies,procedures,andpracticeshelpwiththeongoingreviewandupdatingofdocumentation,whichisavailableonlinethroughaC4VShareSpotsite.Policiesandproceduresaremain-tainedinadatabasesearchablebykeywordforeasyreference.Afterthesuccessofusingathesaurusdatabasetoeaseanalysisofcustomerfeedbackforpatternsandtrends,thethesauruswasexpandedanddeployedtothepolicyandproceduredatabasetofacilitatesearching.TheelectronicsystemsinFigure4.1-2aretheC4Vdatarepositories.Caseypedia,thepolicyandproceduredata-base,andtheworkforcearetheprimaryknowledgerepositories.

SharedgovernanceatC4Vbeganinnursingasastaff-leaderpartnershiptopromotecollaboration,shareddecisionmaking,andaccountabilityforimprovingqualityandsafety.SharedgovernanceisnowdeployedthroughoutC4Vasamechanismtodevelopandshareworkforceknowledgeandexpertise.Gover-nancecouncilsconductresearchintobestpracticesandpromotenetworkingamongcolleaguesandmentors,aswellascollabora-tionamongdepartments.Inadditiontothereal-timesharing,governancecouncilsstandardizeprocessesthroughpoliciesandprocedures,helpdeployevidence-basedpracticesthroughtrainingandobservationsofcolleagues,andincorporatediversityintoimprovementteams.ThisprocessnowempowerstheentireC4Vworkforcetousethe6-E Leadership Tool, whichenhancesworkforcesatisfactionandengagementandtransfers knowledge amongtheworkforce.

DataarealsocollectedautomaticallythroughITplatformstoaddtoC4V knowledge assets.DatacollectionandanalyticssystemsincludetheITknowledgeassetsshowninFigure4.1-2,aswellastheVAandnon-VAstandardizedreportsandsourcesofcompari-soninformation.DatafromthesestandardizedreportsthatarenotincludedintheMOSSaretheMetrics to Monitor describedin4.1a(1)andFigureP.2-1.

Dataareobtainedfrom customers, suppliers, partners, and collaborators throughthevariouslisteningandcommunicationmechanismsinFigure1.1-3,theCS,andtheCRMS,andtheyareconvertedintoinformationandknowledgethroughthePMARSandtheKMSbyanalysis,principallyledbyDataFACTS.Informationandknowledgearetransferredto thesestakeholdersthroughtheCS.Customers, suppliers, partners, and collabora-tors areincludedinimprovementprojectsandmeetingstoshareinformation.Additionally,customersareprovidedwithwrittenmaterialsandgivenmanyopportunitiestoaskquestionsandgetclarification.ThisinformationsharingaboutallC4VservicesbeginsduringtheTAP,describedin3.1a(2)and3.2b(1),andcon-tinuesthroughrelationshipbuildingwiththePACTandthefamilythroughmemorialservicesandperpetualcare.Oneexampleofanewsystematicapproachtotransfer relevant knowledge relatestoinformationaboutprescriptionmedications.Thecomputerizedpatientrecordsystem(CPRS)identifieswhenanewmedicationisprescribedforaVeteran.DataFACTShascreatedadatabaseof

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medicationinformationsheets,writteninplainlanguage(definedascommunicationtheintendedaudiencecanunderstandthefirsttimetheyreadorhearit).TheproviderfromthePACTorinpa-tientcareteamgivestheinformationtotheVeteranandrequeststhathe/she“teachback”theinformationtotheprovidertoensurethatknowledgewastransferred.ThisprocessisnowdeployedwhenaVeteranreceivesaprescriptionfromoutsideoftheVA.WhenarequestforpaymentismadetotheVIRBO,amemberofthePACTcontactstheVeterantoensurethatinformationaboutthemedicationisunderstood.

AllofthedataareintegratedthroughtheDataWarehouse,asshowninFigure4.1-2.TherelationaldatabasestructureenablesDataFACTStoblend and correlate datafromthevarioussourcesinordertovalidateinformationandcreatenewknowledgefromdisparatedatasources.Forexample,anursebelievedthatpatientsonacertainmedicationweremorepronetofalling.CorrelatingdatafromtheBCMAsystemwiththeincidentdatabaseshowedthesameincidenceoffalls,butamuchhigherfall-with-injuryrateforVeteranstakingthatmedication.Thenewknowledgewasusedtochangeprescribingpracticestoanalternatemedicationandpromotedpatientsafety.

TheintegrationofVIRBOintothePACTmodelhasalsohelpedkeepcareintegratedsincetheinceptionofVeteran’sChoiceCards.ExternalprovidersofcaretoVeteransmustsubmitavisitsummarytohavethepaymentreleased.ThissupplementalrecordisscannedintoCPRSandreviewedbythePACT,whichhashelpedthePACTaddresssomeissuesofVeteransseekingtoobtainduplicateprescriptions,particularlyforopiates.

CustomerscanopttosendorreceivesecurecommunicationsthroughMHVandtheeBenefitsPortaloncetheycreatethecon-nection.Suppliers,partners,andcollaboratorsmaybeprovidedaccesstodataandinformationthroughsecurevirtualprivatenetwork(VPN)accessbasedonneed.

CaseypediaandtheC4VDataWarehousearethecollectionpointsfordata,andtheC4Vteams,supportedbyDataFACTS,convertthedatatoinformationandenabletransferofrelevantknowledge.The6-E Leadership Toolandthe6-Ps of Leadershipcreatetheconditionsforinnovation,andthedata,information,andknowledgeareincorporatedintothestrategic planningprocessesduringtheenvironmentalscan.

4.2a(2) C4V uses knowledge resourcestoembedlearningintooperationsthroughPMARS,showninFigure4.1-1.Thecapabilitytoeasilyqueryelectronicdatabasesandknowledgerepositorieshelpsensureamanagement-by-factcultureanddrivesfutureinnovation.Historically,findingananswertoa“whatif ”questioncouldrequirebeginningaresearchstudy;nowData-FACTScansetqueryparameterstolookbackandhaveananswermuchmorequickly.Rapidanswershavebeenshowntopromptmorequestions,whichhasfosteredinnovation.Variousdiscussionforumstransformdataandinformationintoorganizationalandpersonalknowledge.Forexample,theSLTdailyhuddleshavebeenrestructuredaroundMOSStomakepromptdecisionsaboutresourcereallocation,asnecessary.RCA,RCA+,andfailuremodeandeffectsanalysis(FMEA)alsofacilitatedata-drivendecisionsaboutimprovement.

4.2b(1) C4Vusesarobustdataandinformationvalidationprocess,managedbyDataFACTS,toensureaccuracy, integrity, and reliability.Thesefactorsareevaluatedonanongoingbasisthroughreportingandauditingfunctions,bothinternallyandexternally.AdatadictionaryincludesinformationaboutallC4V dataincludingspecificmeaningsofdataandterms,relationshipstootherdata,origin,usageguidelines,andformat.ManyITsystemsusedata-entrycontrols,suchas“picklists”fromdrop-downmenustominimizetypographicalerrorsandstandardizeterminology.Whenfree-formtextisdesirable,thenewthesaurusdatabase,describedin3.1b(1),assistsinanalysis.Whenpossible,queriesareconductedacrossmultiplesourcestocross-verifyandvalidatetheresults.Othercontrolsincludesamplecheckingofentereddata,verificationofthedatathathavebeenentered,constanttrainingandretrainingofthoseenteringdata,andentriesbeingmadeonlybytrainedandauthorizedusersofeachsystem.

Automatingtheflowofdataamongelectronicsystemsenhancescurrency.Cliniciansareexpectedtocompletenotespriortoconcludingtheirworkday.Benefitsworkerscompleteclaimsandcalllogsin“realtime,”andVIVCentersdataasintermentsarescheduledandcompleted.

4.2b(2) TheentireworkforcereceivestrainingonpoliciesandregulationsrelatedtoprivacyandconfidentialityinaccordancewithHIPAAprovisionsduringNEOandannuallythereafter.Securityapproachesincludetheuseofthelatestsecuritysoftware,firewalls,andmalwaredetectionsystems,aswellasfrequentbackupandencryptiontechnologies.Computersrequirepersonalloginandpasswordsaswellasapersonalidentityverifi-cation(PIV)cardsystemforaccess,anduseraccountsareauditedperiodicallyforinappropriateconfidentialinformationaccess.

Accesstosensitivedatarepositoriesispredefinedbyregulatoryrequirementsforprotectedhealthandbenefitsinformationandgrantedaccordingtofunctionalcategories.Securityaccesscontrolforallusersisreviewedquarterly.Annually,onlinetrain-ingregardingpersonal,protectedhealthinformationprivacyandcybersecurityismandatoryforallemployeesandforvolunteersandstudentswhoaccessconfidentialinformationbasedontheirroles.

Workforcememberswhotelecommutearegivensecuresys-tems,includingVPNaccess.Asanadditionalsafeguard,someinformationisnotavailableoff-site.AllC4Vcomputersaresecuredagainstfilesbeingtransferredbyportablemediasuchasflashdrivesanddisks.E-mailmessages,particularlythosewithattachments,aremonitoredelectronicallyforprotectedhealthinformation,andthesenderisnotifiedtouseasecuretransmissionmode,asneeded.

4.2b(3) C4Vmakesneededdata and information available inauser-friendlyformattotheworkforce,suppliers,partners,collaborators,andcustomers,asappropriate,throughsecuremes-saging,productionofreportswithappropriateinformation,andVPNaccesswhennecessary.Policiesandproceduresareevalu-atedtoensureregulatorycompliancewithVAhandbook6500;VA’sinformationsecuritystatutes,38UnitedStatesCode(U.S.C.)§§5721-5727,theFederalInformationSecurityManagementActof2002,44U.S.C.§§3541-3549,CoordinationofFederalInformationPolicy,InformationSecurity;andOMBCircular

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A-130,AppendixIII,SecurityofFederalAutomatedInformationResources.C4Vseekstobalancetheneedforaccesswiththeneedforsecurityandconfidentiality.

4.2b(4) C4Vhaslimitedinputintotheselectionofhardwareandsoftware.ITsupportservicesensurethathardwareandsoftwarearereliable, secure, and user-friendlyprimarilybyprovidingtraining,guidancethroughpoliciesandprocedures,anda24/7helpdesktoanswerquestions.InanorganizationthesizeoftheVA,withtheintegrationofCPRS,BOSS,andothernation-widesystems,being“user-friendly”focusesmoreonensuringthatusershaveinformationneededtousethesystemwellthanonthesystemitself.C4Videntifiesandtrainsselectedpersonnelas“super-users”foreachITsystemtoprovideadditionalsupportandguidance.

4.2b(5) Intheeventofanemergency,C4Vensuresthathardwareandsoftwaresystemsanddataandinformationcontinuetobeavailabletoeffectivelyservecustomersandbusinessneedsbyfol-lowingtheprocessesestablishedfortheentireVA.Theseincludeplannedcommunications,contingencyplanning,andredundant

systems.A“CodeZ”iscalledasthecontingencycodeintheeventthate-mail,telephone,VistA/CPRS,ornetworkaccessareunavailable.Intheeventofa“CodeZ,”anoverheadannounce-mentisbroadcasttoallstaffalertingthemofthecriticalsoftwarecomponentthatiscompromisedandtheexpectedduration.EachservicehasaCodeZcontingencyplanwithspecificproceduresforcontinuityofoperationsduringdowntimeanddata-recoveryprocedures.VistA,VICTARS,andBOSSarebackedupnightlyandsavedintwomedia(magnetictapeandinternalhard-drive)inaseparate,firewall-protectedpartition.TapesareimmediatelysenttoasecurevaultinabankonSt.ThomasIsland.DataarealsosentviaasecureconnectiontoaremoteVADataCenter.

IfCPRSisindowntime,VistAisusedtoprovide“read-only”accesstoinformationthroughthenetwork.Thisweb-basedsys-temisanationallymaintainedcontingencydatabaseofreal-timepatientchartsindependentoflocalsystems.Thecontingencycom-putersareupdatedhourlyforthehospitalanddailyattheCBOCs.Fullgeneratorpowerisavailableforthehospitalasanemergencypowerbackup.Thehospitalhascellphonesforregularcommuni-cations,andsatellitetelephonesareavailableatallfourfacilitiesintheeventofcellulartowerfailure.Staffcanalsoreverttopaperformatforcontinuousmedicalcareandbusinessoperations.

Category 5 Workforce

5.1 Workforce EnvironmentC4VleadershipmaintainsasupportiveandsecureworkclimatethroughtheLS,showninFigure1.1-1,the6-Ps of Leadershipandthe6-E Leadership TooldeployedthroughtheWEDMS,showninFigure5.1-1.

C4Vmanagesworkforce capacitytoaccomplishworkthroughthemasterstaffingplanandassociatedpositioncontroldatabase.Workforce capabilityismanagedthroughtheperformanceappraisalprocess,whichincludesanIDPforeachmemberoftheworkforce.AtC4V,basedonapriorfeedbackreport,theseprocessesarenowdeployedtothevolunteermembersoftheworkforce—aposition-controlmasterlistmatchestalentswithspecificneeds,andvolunteersareencouragedtodevelopnewtalentsandskillsthroughparticipationinon-sitetrainingevents,asappropriate.AllemployeesandsomevolunteerpositionshaveaccesstotheTalentManagementSystem(TMS),thetraininganddevelopmentprogramoftheVA,offeredbytheVALearningUniversity(VALU).

5.1a(1) C4Vusesthreemajorprocessestoassess workforce capability and capacity needs,includingtheneededskills,com-petencies,certifications,andstaffinglevels.First,amasterstaffingplaniscreatedorvalidatedasanelementoftheSPP(Figure2.1-2)duringthesteptoobtainapprovalsandfunding.TheworkforcebudgetisbasedonFTEEcalculations.Underthismodel,anemployeeworking40hoursperweekisoneFTEE,whiletwoemployeeseachworking20hoursperweekwouldstillbeconsid-eredoneFTEE.Second,atthepre-standupmanagementretreatin2010,theSLTresearchedVAworkload-basedstaffingguidanceaswellasprofessionalworkloadstandards,suchasthosefromtheAHRQ,tovalidatetheoptimalworkloadforeachtypeofworkthatwouldberequiredatC4V.Theseincludednurse:patientratiosinvariouscaresettings,appropriatePACTsize,claims:processor

ratio,squarefootofbuildingspacepermaintenanceandhouse-keepingstaff,burialsandacreagemaintainedperworker,etc.CalculationsandanticipatedshiftsinworkloadareconsideredduringtheenvironmentalscanoftheSPP.RepresentativesfromtheAGEworkwiththeSLTandDataFACTStoverifythereasonablenessoftheworkload.Changesinprojectedvolumes/workloadorthecomplexityofthetaskspromptadjustmentsinthemasterstaffingplan.Third,“in-quality”staffinglevelsaredetermined,basedontheratiosabove,typically+/–10%ofthecalculatedneed.Managersareheldaccountableformaintaining“in-quality”staffing,whichisreviewedfromtheMOSSattheSLTdailyhuddle.Whenthemonthlyaggregateforaworkareaisnot“in-quality,”themanagersubmitsavariancejustification,whichmaypromptachangeinstaffingallowance,assignmentofaPITCrewtoenhanceefficiency,orotherSLTaction.In2013,volunteerpositionswereaddedtothemasterstaffingplantoensurethatvolunteerswerematchedtoworkbasedonknowledge,skills,andabilities(KSAs)andthatthevolunteercoordinatorcouldactivelyrecruitaccordingtoidentifiedneeds.

CapabilityisevaluatedduringtheSPPbyassessmentofbothcurrentandprojectedperformancelevelsoneachoftheC4V MoS.BasedonAHCGaccreditationstandards,cliniciansareobservedforcompetencyinvariousskillsonanannualbasis.C4Vdeployedthisprocesstoidentifycriticalorhigh-riskskillsfromeachpositiondescriptiontoverifycompetencyannually,includingvolunteers.Competencyobservationsaredonebypeerobservation;certifiedmentors,asdescribedin1.1a(3);thestaffdevelopmentdepartment;orasupervisor.The6-E Leadership Tool isusedbytheSLTandtheWorkforceDevelopmentOfficetoestablishaneedsassessmentandplantheeducationofferingsfortheupcomingyear.TrainingtoaddressmanyeducationalneedsisavailablethroughtheTMS,whichhelpsfosteralignment

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throughouttheVAandenablestheWorkforceDevelopmentOfficeatC4Vtofocusonlocalneeds.Competencyevaluationsarealsoinplaceforcertainvolunteerpositions.SomevolunteerpositionsarerequiredtoenrollinTMSandtakedesignatedofferings;TMSisopentoanyvolunteer.

5.1a(2) C4V recruits new membersoftheworkforceusingtraditionalgovernmenthiringprocessesthroughtheOfficeofPersonnelManagement(OPM).Whenapositionisapprovedforhire,theopeningiscommunicatedbyOPMusingmultiplechan-nels,includingtheintranet,internet(USAJobs,USAStaffing,andVACareers),delegatedexaminingunit(whenpositionsareopentoallU.S.citizens),jobfairs,andschoolcareerdays.RecruitersparticularlyseekvenueswherequalifiedVeterancandidateswouldlikelybeseekingpositions,suchasmilitary-specificjobfairs,militaryeventsinthearea,andpartnershipswithVSOs.VETBase,describedin3.2a(2),wasrecentlyaddedasadistribu-tionchanneltoensureoutreachtoasmanyVeteransaspossible.Similarresourcesareusedtorecruitvolunteers,withakeenfocusonVeterans.VolunteerrecruitmentinitiativesincludeuseoftheVolunteerMatchwebsite;attendanceathealthfairs;anduseofpartnerships,particularlywithVETBaseandCSU.

C4VbenefitsfromanumberofFederalandVA-specificfellow-shipandinternshipopportunitiesthatattracthighlyqualifiedadministrativeandtechnicalstaff.PrimaryexamplesincludethePresidentialManagementFellowsProgram,whichisavailabletoallFederalagencies,aswellasVA-specificprogramssuchastheTechnicalCareerFieldProgram(e.g.,biomedengineering,businessoffice,finance,publicaffairs,logistics,IT,andmore)andtheGraduateHealthcareAdministrationTrainingProgramfor

hospitaladministration/managementpositions.Theseprogramsalsosupportsuccessionplanningapproaches.

Thepositiondescriptionisusedintherecruitingmaterials,whichoutlinesthedutiesandresponsibilitiesofthejobandtheKSAsneeded.TheKSAsidentifiedforthepositionareusedtoevalu-atecandidatesforjobopeningstohelpensureagoodmatch.In2013,theChiefofHumanResources,thevolunteercoordinator,anddepartmentmanagersworkedwithaPITCrewtoredesignsystemstoimprovehiring,placement,andon-boardingprocesses.Theystreamlinedthehiringprocess,reducedthehiringtimeline,updatedNEO,andformalizedthementoringprocessdescribedin4.1a(1)tocreateamorepositiveexperienceandfirstimpressionfornewemployees,volunteers,andstudents.Successistrackedbyevaluatingtheone-yearretentionrate.

Thisteamimplementedatooltoassistwithbehavior-basedinter-viewingforpotentialcandidatestoelicitresponsesthatenabletheinterviewertobetterevaluateKSAsandpriorperformancetomatchskillsetsandcompetencieswithspecificjobrequirementsandtoidentifyhighperformers.ThetoolisalignedwiththeHighPerformanceDevelopmentModel(HPDM)competenciesandskillsusedthroughouttheVA.ThisVeteran-centricmodelfocusesoneightcompetencies—organizationalstewardship,systemsthinking,creativethinking,flexibility/adaptability,customerservice,interpersonaleffectiveness,personalmastery,andtechnicalcompetency.First,interviewsareconductedbythemanageroftheareawiththeopenposition.Peerinterviewsarethenconductedfortopcandidates,andallinterviewersparticipateinthesubsequentselectiondecisions.

Athoroughbackgroundcheckisconductedforanyprospectivememberoftheworkforce.Timingofthecheckvariesbyseg-mentbecauseoftheapplicant-to-selectionratio.Volunteersarecheckedpriortointerviewing,asmostvolunteerswhoapplywillbeacceptedforservice.Paidemployeesarecheckedafterinterviewing,basedontheexpenseofthebackgroundcheckandtheselectionratio.

VolunteersareplacedbasedonKSAsandtheirdesiresfortypeofwork,matchedtotheneedforthoseattributesinspecificareastoaugmenttheworkcapacityandcapabilityofthepaidworkforce.Employees’placementisbasedonthespecificpositionforwhichtheywerehired.Students’placementisdeterminedbytheirspecificlearningneeds,incollaborationwithacademicaffiliates.

Allnewworkforcemembersareorientedtotheirpositionandresponsibilities.NEOprovidestrainingtonewemployeestointroducethemtoservices,culture,andthecorevaluesofC4V,followedbyaservice-specificorientationtofamiliarizethenewemployeetohis/herappointedservicearea.Mentorsandtrainedpreceptorshelpintegratethenewemployeequickly,whichhelpswithretention.

C4Valsousesthe6-Ps of Leadershipandthe6-E Leadership Tool toquicklyfocusonemployeesatisfaction,encouragingemployeeinvolvementinpersonaldevelopmentthroughlearninganddevelopmentopportunitiesandserviceonimprovementteams.Newworkforcemembersfrequentlybring“fresheyes”thatseeopportunitiesforimprovementthatlonger-tenuredemployeesmaynolongernotice.Retentionincentives,suchastuitionassistance,repaymentofstudentloans,andflexiblescheduling,areoffered.

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C4VparticipatesintheVHAEducationDebtReductionProgramtofillpositionsclassifiedas“hardtorecruit”(particularlyphysi-ciansandnurses).Thisprogramrepaysupto$60,000ineducationloansfornewlyappointedhealthcareprofessionals. Fornonclini-cal/hard-to-recruitpositions/highlyqualifiedemployees,staffmaybeeligiblefortheFederalStudentLoanRepaymentProgramasarecruitmentorretentionincentiveforagencyemployees.Recruit-mentforspecificworkanddiversitysegmentsismanagedthroughjobfairs,specialty-specificrecruitmentfliers,advertisementsinapplicablespecialtyjournals,andpublicationsforspecificprofes-sionalassociationsandorganizations.

Volunteerorientationincludesthesamekeytopicsastheemployeeorientationandaservice-specificorientation,althoughcondensedintoashortertimeframewithalesserdegreeofdetail.Particularemphasisisplacedonregulatoryandsafetyrequirements,suchasprivacy,infectioncontrol,androle-basedinformation.Volunteersareprovidedwithahandbooksothattheycanreadilyreviewandreferencethecriticalinformation.StudentorientationalsocoversthesetopicsandmaybeofferedattheC4V campusorbythetrainingaffiliatepriortothestudentarrival.Studentpositionsthatincludecompensationandinternsattendthesameorientationasnewemployees.

FocusedrecruitmenteffortsensurethattheC4Vworkforcerepresents the diverse ideas, cultures, and thinking of the hiring and customer community.Thehiringsystemredesignteamintegrateddiversityconsiderationsintothehiringprocess.Allemployeesattendannualtrainingregardingculturalcompe-tencyandplain-languagecommunication.Healthliteracytrainingisrequiredforbenefitsandhealthservicesworkers.Dependingontheirrole,volunteersmaybeincludedinthesetrainingrequirements.

C4V retains theworkforceprimarilybyconstantfocusonthe6-E Leadership Tool, describedin1.1,andthe6-Ps of Leadership, especiallyEngagementinthecareofVeterans.Serviceanniver-sariesarerecognizedbytheDirectorwitha“thankyou”card,andgiftsofappreciationarepresentedinrecognitionof5,10,15,20,and25yearsofservice,aswellasannuallyafter30years.Peoplewith25+yearsofservicearepersonallyrecognizedbyanSLTmemberoftheirworkunitinthepresenceoftheirpeers.Inrecognitionofthediversityofpreferences,individualscanselectfromacatalogofgifts.In2012,thisprocesswasdeployedtovolunteerswhoprovideatleast400hoursofserviceperyear.

5.1a(3) C4V organizes and manages the workforcetoaccomplish work,capitalize on core competencies,reinforce a customer and business focus,andexceed performance expecta-tionsusingavarietyofprocesses.MostoftheC4Vworkforceisorganizedinatypicalorganizationalstructurehierarchy,includingsupervisorsandmanagersforallpositionsandallshifts,aswellasvolunteers.

PACTsmanageoutpatienthealthcareasteams,withthelicensedindependentpractitioner(LIP)intheroleofteamleadandtheVeteranatthecenter.PACT1,locatedatHH,andPACT3,alsoonSt.Thomas,arepartneredtoallowthePACT1physiciantoprovidemedicalsupervisionfortheadvancedregisterednursepractitioner(ARNP)leadingthePACT3team.PACT2,locatedattheBrabsonCBOConSt.Croix,ispartneredwithPACT4,

locatedattheBurtonCBOConSt.John,whichisledbyaphysicianassistant(PA).ThenonphysicianPACTs(3and4)haveslightlysmallerpanelsizes.

5.1a(4) C4V prepares the workforceforchangingcapabilityandcapacityneedsthroughtheworkforceplanningprocessesembed-dedintheSPS.Themasterstaffingplanisupdatedaccordingtoprojectionsofvolume,andthehiringprocessisinitiatedwhenincreasesareanticipated.Shouldadecreasedneedbeprojected,reductionswouldbemanagedinaccordancewiththeMasterAgreementbetweentheVAandAGE.Changesincapability areaccomplishedthroughtheeducationalneedsassessmentandsubsequenttraining.C4Vhasnothadanyreductionstodateasneedshaveincreasedsince2010.

C4Vdoesnotanticipateanyworkforce reductions,butbeingpartoftheVAsystemenablesemployeestotransitionseamlesslytootherVApositions,tominimizetheimpactofsuchreductions,iftheybecomenecessary.Periodsof workforce growth arepreparedforandmanagedthroughthehiringanddevelopmentprocessesdescribedin5.1a(1).

Veryshort-termchangesinneededcapacityaremanagedincollaborationwithAGEbyprocessestorewardthosewhocomeinextraonshortnoticewithgasolinegiftcards,asnotedinFigure1.1-4.Workforcememberswhoarecross-trainedtoalternateareasreceivebonusesundertheFederalOPM“pay-for-performance”processesandaregivenanadditionalbonusifthey“float”toanotherarea.Thisprocessforcreatingcapacitybeganinnursingandwasdeployedtoallotherappropriateareasin2011.In2013,theprocesswaschangedtoalsogiveabonustothesupervisorwhenamemberofhis/herareaworkselsewheretoencouragethesharingofresources,fosterasystemsperspec-tive,andbreakdownsilos,whilestillensuringaccountabilityfordepartmental-levelperformance.

TherobustITsystemsoftheVAhelptoensure continuityforthecustomerandworkforcestakeholders.Caseypediaandonlinepolicies,procedures,guidancedocuments,andjobaidshelpcreateconsistencyandcontinuityfortheworkforce,whiletheCPRScreatescontinuityforVeteransbyenhancingcareteamcommunications.

5.1b(1) C4Vaddressesworkplace environmental factorstoensureandimproveworkforcehealthbyembracingtheconceptthathealthcareprovidersshouldberolemodelsforhealthcarereceivers.AtC4V,wellnessprogramsofferedtoVeteransarealsomadeavailablewithoutchargetotheC4Vworkforce,incollabora-tionwithAGE.AvailableprogramsincludetheMOVE!healthyweightprogram,smokingcessation,stressmanagement,angermanagement,effective-parentingseminars,wellnesscoaches,andhealtheducation;thesearealsoavailablewithoutchargetovolunteers.Integratedwellnessactivitiespromoterelationshipbuildingamongemployees,volunteers,andVeterans.

Workplacesecurity isensured bynumerousapproaches:

■ Backgroundinvestigationsandfingerprintanalysisareperformedonallstaff,priortohire,toensuresafetyofcoworkers,Veterans,andvisitors,asdescribedin5.1a(1).

■ HazardSurveillanceInspections,commonlyreferredtoasEOCrounds,areheldsemi-annuallyinallareas.Quarterly

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inspectionsareconductedinhigh-hazardareas,includingHH,duetoitsovernightaccommodations,radiology,warehouse,laboratory,etc.

■ TheGEMScommitteeassessesenvironmentalfactorstoimprovequalityandstewardshipofnaturalresources.

■ TheC4VPoliceServicecontinuallymonitorssafetythroughsecuritycameras,training,presenceinentranceareas,andregularwalksthroughthebuildings.Specialfocusisplacedonnonpublicentrancestoensurethattheyaresecured.

■ WorkforcemembersuseaPIVcardtoaccesssecuredentrancesandcomputers.

Physicalaccessibility for the workforceandcustomersisensuredthroughappropriateconstructiondesignefforts,includingLEEDverification,andfullcompliancewiththeAmericanswithDisabilitiesAct(ADA);technologicalaccessibilityisensuredthroughthevarioussystemsdescribedincategory4,includingteleworkprocessesandprocedures.

Thekeyperformance measuresfortheseworkforcefactorsareidentifiedandtrackedthroughMOSS(Figure4.1-3),asappropri-ate;improvement goalsassociatedwithspecificworld-classstrategicobjectivesarenotedinFigure2.1-5,withothersnotedonthevariousgraphsincategory7.

5.1b(2) C4V supports the workforce viaservices,benefits,andpoliciesconsistentwithfederalemploymentguidelinesandpolicies,includingfederalpaytablesforwagegrade(WG)andgeneralschedule(GS)employees,tuitionsupport,healthbenefits,andleave.CSUistheonlyuniversityintheVI,withcampusesonSt.CroixandSt.Thomas.Nursingistheonlyclinicalprogramoffered,althoughstudentsinterestedinmedicalschoolcanstudyfortheirfirstthreeyearslocallyandthentransfertooneofthreeapprovedmedicalschoolsfortheirsenioryear.C4Valsoprovidesacomprehensivewellnessprogramfortheentireworkforce,includingvolunteers,withfreeaccesstofitnessfacilitiesandcoachesfornutrition,exercise,andotherhealthissues.Services,benefits,andpoliciesarerevisedataminimumofeveryfiveyearsorasneeded,usinganautomatedShareSpotsite.

Whenappropriate,specificworkforceneedsareaddressedthroughbenefits,services,andotherprogramstailoredtovariousemployeesegments.Forexample,teleworkisaninnovativemanagementtoolthatallowsmanyemployeestheopportunitytoworkatalternativeworksites,althoughdirectcaregiversinVHA andNCA mustworkon-site.CWTisavocationalrehabilitationprogramofferedbytheVAthatmatcheswork-readyVeteranswithcompetitivejobsandprovidesadditionalsupportduringthetransitiontowork.

Themultiplework-lifeandbenefitprogramsofferedtoallC4V employeesinclude

■ TheFederalEmployeeRetirementSystem ■ TheCivilServiceRetirementSystem(pre-1987hires) ■ Flexiblespendingaccounts ■ Federallong-termcareinsurance ■ ChildCareSubsidyProgramandThriftSavings ■ Observanceoftenfederalholidaysannually ■ Tuitionassistanceprograms ■ Employeeassistanceprogramcounseling

■ Healthinsuranceanddisabilityinsurance ■ Participationinwellnessprogramsnotedpreviously

5.2 Workforce Engagement5.2a(1) C4Vleadershipfostersanorganizational culture characterizedbyopencommunication,high-performancework,andanengagedworkforceusingthe6-Ps of Leadershipandthe6-E Leadership Tool.Specifically,MoSandleadershipattentionarefocusedonhighperformance,definedas“world-class,”usuallymeaning90th-percentilescoresorbetter.Theattitudes,behaviors,andbeliefsthataretheC4VculturearenurturedbytheSLT’sattentiontothe6-Ps of LeadershipandreinforcedthroughtherewardandrecognitionmechanismsshowninFigure1.1-4.Civility,Respect,andEngagementintheWorkplace(CREW)isaVA-wideculturechangeinitiativebytheVHANationalCenterforOrganizationalDevelopmentinresponsetoemployeefeedbackthatlowlevelsofcivilitynegativelyaffectedemployees’levelofjobsatisfaction.CREWtrainingisusedtoestablishacultureofrespectandcivilityintheorganizationandisbasedonlearningfromtheaviationindustrythattheprimarycauseofmostavia-tionaccidentsisduetohumanerrorandtheleadingcauseoftheerrorswerefailuresofinterpersonalcommunication,leadership,anddecisionmakinginthecockpit.Inthehealthcaresetting,CREWfocusesonthecognitiveandinterpersonalskillsandthesituationalawarenessandbehavioralactivitiesassociatedwiththeteamworkneededtoeffectivelymanagehigh-riskactivity.CREWwasinitiallyimplementedinsomeclinicalareasandthenexpandedtoothertypesofteams.ItwasdeployedasavoluntaryinitiativeandisnowpresentacrossallfunctionalareasatC4V . TrainingandCREW-basedteamsincludevolunteersandstudents,asappropriate.

C4Vleadershipensuresthattheorganizationalculture benefits from the diverseideas,cultures,andthinkingoftheworkforcebybuildingdiverseteamsandworkgroups,withthesupportofAGE.First,theworkforceiseducatedaboutvariouscultures,personalitytypes,andvariousstylesofthinking/learningthroughmanyfunevents,includingfairs,festivals,events,andopenhouses.Second,workforcemembersareencouragedtoparticipateinvariousper-sonalityassessmentsandlearningstyleevaluationsandtosharetheirfindingswithcoworkersandteammates.Third,diversityofideas,cultures,experience,andthinkingareconsideredwhenformingteamstomaximizeteameffectiveness.

5.2a(2) C4Vdeterminesthekey drivers of workforce engage-ment,includingthosefordifferent workforce groups and segments,throughvariousworkforcelisteningandassessment mechanisms.First,someofthequestionsintheAESaredesignedtounderstandandevaluateengagement,differentiatedfromsatisfaction,andregressionanalysisisconductedtohelpidentifykeydrivers.Second,specificquestionsrelatedtoelementsthatfosterengagementareaskedduringtheDirector’stownhall,focusgroups,theDirector’shuddle,andleadershiprounds,asshowninFigure1.1-3.Third,leadersobserveworkforcebehaviors,suchasparticipationwithvarioustypesofteams,workactivities,socialevents,absenteeism,injuries,etc.TheseprocessesarereviewedyearlywiththeAGEtoensurecomprehensiveandaccurateinfor-mationandtoidentifypotentialsourcesofadditionalknowledge.

5.2a(3) C4V assesses workforce engagement and satisfac-tion formallythroughemployeesurveys,thetrackingofIDP

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accomplishment,andworkforceparticipationinimprovementeventsandteams.Informal assessment methods and measures includeparticipationinemployeeevents.Methodsandmeasuresarerelativelyconsistentamongemployeegroupsandsegmentsbutdiffersomewhatforvolunteerandstudentsegments.Keymeasuresforthesegroupsincludedonatedvolunteerhoursandstudentgrades.C4Vusesotherindicators,suchasworkforceretention,absenteeism,grievances,safety,andproductivityasindirectmeasuresofworkforceengagement.Workforceengage-mentisevidencedthroughallC4Vresults,giventhatworkforceengagementfostersVeteranandothercustomersatisfactionandorganizationalsuccess.C4Vleadersatalllevelsusethe6-E Leadership Tooland6-Ps of Leadershiptoimprovework-forceengagement.DataFACTSusesstatisticalcorrelationandregressionanalysistoidentifyimprovementopportunitiesforbothworkforceengagementandbusinessresultsthatfrequentlybegintheIDEALScycle.

5.2a(4) TheC4VWorkforcePerformanceManagementSystemsupports high performance and workforce engagement by tightintegrationamongstrategicplans,departmentplans,andIDPstolinkindividualsuccesswiththesuccessofC4Vtowardmissionaccomplishment(seeFigure5.2-1).TheprocessbeginswithhiringforKSAsandthenusesWEDMSandIDPstodevelopdesiredpersonalattributes—keytocreatingthedesiredculture.Theperformancemanagementsystemandemployeeperformanceappraisalprocessincludemonitoring,developing,andreward-ing/recognizingdesiredbehaviors.PerformanceappraisalsarestructuredaroundtheMVVandstrategicobjectivesofC4V,andtheyfosterformaldiscussionsbetweenemployeesandsupervi-sorsatleasttwiceperyear.Duringthemeetings,theemployeeandsupervisorformulatetheemployee’sIDPtoidentifyspecificindividualgoalsthatalignwithC4Vstrategicobjectivesandgoals.Theperformanceappraisalsystemfocusesontraininganddevelopmentneedsanddesires,aswellasimprovementandenhancementofemployeeworkskills,ratherthanbeingapunitivesystem.IDPsfrequentlyincludeparticipationonimprovementteamsorotherpersonalactivitiesthatsupportspecificstrategicobjectives.Theseidentifiededucationandtrainingneeds“rollup”intotheWorkforceDevelopmentPlan.ThevolunteercoordinatorandareamanagersworkwithvolunteerstocreateIDPsforanyvolunteerwhodesirestoparticipateintheprocess.

Theperformancemanagementsystemincludesworkforcecompensationprimarilythroughrewardsandincentiveprogramsbecausemostpayincreasesformostoftheworkforcearedrivenbyfederalpolicies,andmostbonusincentiveshavebeenwith-heldduetorecentVHA orVBA performanceissues.Financialawards,rewards,andincentivepracticesincludethoseshownin

Figure1.1-4,suchaspay-for-performanceincentives,individualcashawards,groupcashawards,specialtycertificationawards,exemplaryjobperformance/achievementawards,individualtime-offawards,andgrouptime-offawards.

TheC4VWorkforcePerformanceManagementSystemreinforcesintelligent risktakingtoachieveinnovationbycreatingSMARTERactionplans,withgoalsthatcreatestretch,whilebalancedwithrealism.PITCrewsandCREWteamsarecharteredtobenchmarkprocesseswithinandoutsideoftheVA,andtheyarerewardedforcreativityandsuggestions,aswellasactualimprovements,asdescribedin1.1b(1).Publicrecognitiontendstostimulatemoreideasandsuggestionsandengagemoreoftheworkforceinseekingcreativesolutions,creatingavirtuous cycle—theoppositeofaviciouscycle—ofincreasingenthusiasm,engagement,improvement,andinnovation.Asnotedin2.2a(2),C4Vleadershipemphasizesthethreekey“must”criteriausedtoevaluateanidea:mustnotcompromisesafety,mustaddvalue,andmustbereasonable.Twiceperyear,C4V’sSLTsponsorsa“SpotlightonInnovation”eventwithstoryboardsandmulti-mediapresentationsofinnovativeprojectsaccomplishedbytheworkforce.Theeventisopentothepublic,withacelebrationatmosphere,includingrefreshmentsandhealth-relateddoorprizedrawings.TheeventispromotedbylocalmediaandVETBasepartnersandtypicallyreceivesverypositivemediaandpublicattentionlocally.A multidisciplinaryworkforcecommitteeselectsthetopinnovationprojectannuallyforsubmissionintheEmployeeInnovationCompetitionheldbytheVA.

Thefocusonaddingvalue,coupledwiththeVAprinciplesofbeingpeople-centric,results-driven,andforward-looking,rein-forcesacustomer and business focus.Alignmentandintegrationofplans,fromthestrategicplanthroughtheIDPs,fosterachieve-ment of action plans.TheSLTsetstheexpectationthatanactionplanrepresentsacovenantthattheplanwillbeaccomplishedbasedontheresourcescommitted.In-processmeasureshelpdeterminetheneedtorenegotiatetheagreementifthegoalswillnotbeachieved—eitherbyaddingresourcesoradjustingthegoals.Integrationofplans,resources,andaccountabilityhelp reinforce achievement of action plans .

5.2b(1) WEDMSsupports both C4V needs and personal development oftheworkforce,managers,leaders,andvolun-teersthroughalignmentandintegrationofplans,asshowninFigure5.2-1.Thisalignmentandintegrationcreatesynergyandenergybynotdrawingoffresourcestoanyunalignedordisinte-gratedactivities.AsshownintheSPSinFigure2.1-1andtheAPSinFigure2.2-1,C4Vplansatalllevelsaddress strategic chal-lengesandfosterachievement of short- and longer-term action plans.Additionally,plansatalllevelsaredesignedtocapitalize

onstrategicadvantagesandcore competen-cies,aswellasdeterminewhichstrategicopportunitiesrepresentintelligentrisk.

TheC4Vlearninganddevelopmentsystemappliestoallmembers,managers,andleaders,andispartoftheWEDMS(Figure5.1-1),beginningduringthehiringprocessandprogressingthroughintegrationintotheworkforce,facilitationoflearning,growth,reinforcementofnewknowledgeandskills

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onthejob,andassessmentoftrainingrequirements.Personalgoalsettinginalignmentwiththeorganization’sstrategicobjectivesandgoalsduringtheIDPprocessensuresthatactionplansandtheorganization’sstrategicchallengesareaddressedwhilecapital-izingonitscorecompetencies.OtherILMSsupportperformance improvement, organizational change, andinnovation (OMIS;Figure6.1-1);ethicsandethical business practices areaddressedbytheLS(Figure1.1-1);andimprovementsincustomer focus arecoveredwithintheCRMS(Figure3.1-1).

Totransfer knowledgefromdepartingorretiringworkers,C4V deploysnumeroussystematicapproaches,suchasover-hiringwhendeparturesareanticipatedorplacingaqualifiedcandidateintoapositiononapermanentorinterimbasispriortotheplanneddepartureforkeypositions.Informalknowledgesharingisfosteredthroughmentoringandpreceptorprograms,promotingcross-trainingandon-the-jobtraining,andengagingthehighlyexperiencedworkforceincreatingjobaids,policies,andproce-dures.C4Valsofrequentlyhiresretiredemployeesascontractorsorrecruitsthemasvolunteers.C4Valsopromotesprofessionalspecialtycertification,asavailable,andprovidesmentoring,studysessions,andfundingforongoingcontinuingeducation.

5.2b(2) C4Vevaluatestheeffectivenessofthelearninganddevelopmentsystemacrosstheorganizationusingthefour-levelKirkpatrickmodel,showninFigure5.2-2.Courseevaluationsaregeneratedforeachformaltrainingevent.Dependingonthetopicbeingpresented,pre-andpost-testingmayevaluatethetransferofknowledge,whichisparticularlyimportantwithtechnicalskillsandwhenonlinetrainingmechanismsareused.Supervisorsmonitorchangesinbehavior,particularlyforbehaviorsassociatedwiththepersonalimprovementplancomponentoftheformalperformanceappraisalprocessortoevaluatecompetencies.WiththeassistanceofDataFACTS,C4Valsolinkstrainingwithchangesinorganizationalperformanceresults.

Thechangeinorganizationalperformancealsoenableslead-erstoevaluatetheROIintraining.TheC4VEducationOfficeestablishedcriteriatopromoteandevaluatetheefficiencyoftheLearningandDevelopmentSystem,specificallydetermin-ingwhethertrainingeventswillbeinstructor-ledoronlineandwhetherexternaltrainingresourceswillbeusedoriftheneces-saryexpertiseisavailablein-house.

5.2b(3) C4Vmanageseffective career progressionforworkforcemembersandeffectivesuccessionplanningformanagementand

leadershippositionsthroughdevelopmentofthefullpotentialoftheentireworkforce.TheIDPsguidethedevelopmentofeachworkforcemember.

TheSchoolatWork(SAW)programservesasastepping-stoneforGS-5employeesandbelowtoenterintoacertificateordegreeprogram.Thissix-monthcareerdevelopmentprogramisdesignedtoimprovecareerprogressionopportunitiesforthoseemployeeswhooftendonothaveacareerpathfromentry-levelpositions.TheSAWprogramprovideslearningopportunitiestodevelopcomputerskills,math,reading,grammar,writing,medicalterminology,principlesofpatientsafetyandsatisfaction,andorganizationalskills.IDPssupportbaccalaureateandgraduatedegreeseitheronlineoratCSUprogramsforGS6–8membersoftheworkforce.

TheCompetencyDevelopmentforLeadersinthe21stCentury(CDL)isasix-monthleadershipprogramthatseekstopromotepersonalandprofessionalleadershipdevelopmentwithintheVAleadershipcompetencies,targetingintermediate-levelbehaviors.CDLdirectlysupportsC4Vsuccessionplanswiththeintenttopromotepersonalandprofessionalleadershipdevelopment,buildingonVAleadershipcompetencies.ThesetrainingeffortsarefundamentaltothepreparationofemergingleadersinhealthcareandVeteranservices.ThisprogramtargetsemployeesatlevelsGS9–14ortheequivalentwiththeintenttopromotehigh-potentialleadersintotheSeniorExecutiveService.

Figure 5.2-2: Hierarchy of Learning Evaluation—Kirkpatrick Model

Change in results

Observed change in behavior, related to new knowledge

Formal assessment of knowledge gain; pre-test/post-test

Participant satisfaction survey, self evaluation of learning

Category 6 Operations

6.1 Work ProcessesC4V designs, manages,andimproveskeyworkprocessestodeliverservicesthataddcustomervalueandcontributetoorganizationalsuccessandsustainabilityusingtheOMIS,showninFigure6.1-1.AswiththeotherILMS,theOMISisstructuredintheIDEALSformat.Tomaximizeefficiencyandeffectiveness,thefirststepinOMISistoidentifythekeyrequirementsofallstakeholders,followedbystepstodesigntheprocessorimprove-mentchangeaccordinglyandtoevaluatetheimpactofthenew

orimprovedprocess.OMISsupportsthethreeguidingprinciplesoftheVA:thateveryVAorganizationbepeople-centric,results-driven,andforward-looking.

6.1a(1) C4V determines key work process and service require-mentsatStep1oftheOMIS:identifyingthekeystakeholdersforaprocessandthenunderstandingtheirrequirementsandexpectations.ThisunderstandingisgainedthroughthelisteningandlearningmechanismsinFigure1.1-3andtheCRMSinFigure3.1-1.Whennecessary,therequirementsandexpectations

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ofthestakeholdersarebalancedthroughnegotiation,keepingthebestinterestsoftheVeteranasthecentralconsideration,andprocessesarethendesignedaccordingly.KeyworkprocessesandtheassociatedrequirementsarenotedinFigure6.1-2.

6.1a(2) C4V designs service offerings and work processes to meet all key requirementsusingIDEALS.First,requirementsandexpectationsareidentifiedusingthevariouslisteningandlearningmechanismsdescribedincategories1,2,3,and5.Particularemphasisisplacedonensuringthatregulatoryrequire-mentsaremetandbalancingalignmentwithhigher-headquartersplansandinitiativeswiththeagilityneededtoaddressindividualVeteranneeds.TheSLTconstantlyremindstheworkforcethata“uniqueVeteran”isnotsimplyanumberusedtocountdeliveryofservicesandreceivefundingallocations,butthateachVeterancomingtoC4Vforcareisauniqueindividualwithuniqueneeds.EspeciallybecauseC4Voperateswithinalargebureaucracy,processdesignincludesconsiderationthatC4VVeteransarepeople—notnumbers.AssociatingMoSwitheachplanhelpscre-ateaccountabilityforidentifyingrequirementsandexpectations,andtrackingperformance.

ProspectiveservicesorsystemsareevaluatedbytheSLT,basedonacomprehensivebusinesscaseanalysisthatexaminestherisksandbenefitsofimplementation,aswellastherisksandbenefitsofnotimplementingthechange.ThecompletionofanExecutiveDecisionMemorandum(EDM)ensuresthattheproposedsystem,service,orprocessisalignedwiththestrategicdirectionofC4V;theVISN,MSN,orBenefitsRegion;theAdministration(s);andtheVA,asalignmentwitheachofthesefacetsmustbedemonstratedintheEDM.TheEDMisthensubjectedtoafullandsystematicevaluationofintelligentrisk,includingthe“must”criteria.Implementationistypicallymanagedbyateam,frequentlythroughsmalltestsofchange,startingwithoneunitorgroupandmakingcoursecorrectionsbasedonlearninguntilthedesiredresultsareachieved.

C4Vincorporatesnew technology,organizational knowledge,product excellence,andthepotentialneed for agilityintoservicesandprocessesthroughthePMARS,KMS,andOMISsystems.TheVAandDoDarekeydriversofnewtechnologyandinnovation,withmajorinvestmentsofresearchfundingforhealth

caretechnology,IT,facilitiesandequipment,andprocess/systemredesign.AtC4V,processownerssearchtheexistingknowledgerepositories,includingCaseypedia,tobuildonexistingknowledgeratherthan“recreatingthewheel.”Capitalizingonpriorlearninghelpsbuildtimelinessandagilityintoanyprocessdesignorredesign.Approvalsandtimelinessarefrequentlyachallengeinalarge,bureaucraticorganization.AtC4V,theactionplantemplateincludesasectiontodocumentcurrentknowledge,evidence-basedbestpractices,newtechnology,andresearchintoallplans.

C4VactivelyrecruitsVeteransintoresearchanddevelopmentprojects,programs,andstudies,followingallregulationspertain-ingtohumansubjectsinresearch.PartnershipswithCSUandotheruniversityandindustryleadersgiveVeteransaccesstothemostcurrentbionics,prosthetics,hearingandvisionassistivetechnologies,andothermedicaldevices.

ProductsthatarenotassociatedwitharesearchprojectaresubmittedtotheClinicalProductReviewCommittee.Allstakeholdersarepresentorrepresentedatthemeeting,andthecommitteemaydecidetopilottesttheproductorapproveitforfullimplementation.Thisprocesshashelpedstreamlineinventoryandtrainingthroughstandardizationofproducts.Asubmissiontemplateconsiderscost,safety,feasibility,reprocessing,infectioncontrol,trainingrequirements,andcurrentinventorythatmaybeabletobereplaced.End-usersareinvolvedinthedecision-makingprocess,andvendorrepresentativesmaybeinvitedtomakeapresentation(butleavepriortodiscussionordecision).A2014reviewoftheprocessledtoanelectronicsubmissionforapproval,whichenablesbettertrackingofitems.

6.1b(1) C4Vensuresthatday-to-day operations ofworkprocessesmeetkeyprocessrequirementsthroughtraininganddocumentationofstandardoperatingprocedures.Policies,procedures,jobaids,andjobdescriptionshelptoensurethateveryinteractionandactivitymeetkeyprocessrequirements.Asappropriate,internalandexternalauditsareconductedtoobserve

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andevaluatetheconsistencywithwhichactualoperationsmeetkeyrequirements.Feedbackfromstakeholdersprovidesinsightintoanygapsbetweenintendedoperationsandactualbehaviors.

Figure6.1-2showsthekey performance measuresorindicators,alongwiththeassociatedresultsfigures.ManyofthesemeasuresareincludedintheMOSS,strategicplan,andmeasuresdescribedin1.2a(1),2.1a(1),and4.1b,andasshowninFigures1.2-2,2.1-5,and4.1-3.Mostoftheoutcome,servicequality,andperformancemeasureshavein-processmeasures,leadingindicators,orotherassociatedmeasurestopromoteorganizationalagility.Forexample,theAESisonlyconductedannually,soDataFACTSdeterminedthatabsenteeism,participationwithimprovementteams,andrewardandrecognitionactivitiesarevalidleadingindicatorsthatpredicttheresultsoftheAES.

6.1b(2) (HealthCare-SpecificCriteria)C4Vaddressesandconsiderseachpatient’sexpectationsandpreferencesthroughtheCRMS,showninFigure3.1-1.Considerationofindividualneedshasbeengreatlyenhancedbythepatientpreferencedocumentationprocess,describedin3.1a(1).Duringoutreachandenrollment,theoutreachcoordinatororthebenefitsrepresentativeonthePACTexplainshealthcareservice-deliveryprocessesandlikelyoutcomestotheVeteran.Duringthefirstvisitandeachvestingvisit,thecliniciansonthePACTreviewthehealthandwellnessstatusoftheVeteranandhelptosetrealisticexpecta-tions.IncollaborationwiththeVeteranandfamilyorothercaregiversoftheVeteran’schoice,aplanofcareisdocumentedinCPRS.TheVeteranthenreceivessecuremessagesandremindersthroughMHVtohelpstayontrackwiththeplan.Patientdecisionmakingandpreferencesarefactoredintothedeliveryofhealthcareservicesateachencounterthroughthepatientpreferenceprofileandclearcommunicationwiththecareteam.

C4V determines key support processesbyidentifyingthoseprocessesthatarekeytoenablingtheprimaryoperationsofeachofthemainproductandserviceofferingsshowninFigureP.1-1.Thesekeysupportprocessesareshownasthe“enablers”inthekeyworksystemdiagramshowninFigure2.1-4andshownwiththeirrespectiverequirementsandMoSinFigure6.1-3.Theseincludepublicrelationsandoutreach,security,humanresources,financialmanagementandbudgetingsupport,facilitiesandequipmentmaintenance,recordsmanagement,contracting,andITascommonacrossallfunctionalareasofC4V;whilefacilitiesandequipment-relatedsupportprocessesareprimarilyinthedomainofmemorialoperations,andmaterialsmanagementisprimarilytheresponsibilityofhealthcareoperations.

Day-to-dayoperationofthesekeysupportprocessesensuresthattheymeetkeybusinesssupportrequirementsinmuchthesamemannerasthekeyworkprocessesdescribedin6.1a(2),primarilythroughpolicies,procedures,andjobaids.

6.1b(3) C4V improvesworkprocessestoimproveproductsandperformance,enhancecorecompetencies,andreducevariabilitythroughsystematicuseoftheOMIS,showninFigure6.1-1.ThebroadscopeoftheIDEALSperformanceimprovementsystemandBaldrigeframeworkenablePITCrewstoselectthebestimprovementtoolsforeachproject,includingLean,SixSigma,appreciativeinquiry,orothermethodologies.Consideringtheseimprovementmethodstobe“tools”fromwhichtoselectthebest

optionforanygivenprojecthashelpedC4Vavoidthecommonperceptioninlargerorganizationsofhavinga“flavorofthemonth.”Criteriaareestablishedtoguideteamsinsystematicallyselectingappropriatemethodologiesandtools.Forexample,larger-scopeprojectswithmultiplestakeholdersmayrequireafullsystemredesignteam,whileotherchangesmaybebetterimplementedthrougharapidimprovementevent.ChangestobeimplementedafteranRCAmayundergoaFMEApriortoimplementation.

Byusingthe6-Ps of Leadershipandthe6-E Leadership Tool, theSLThasmadeasolidcommitmenttotheentireworkforcethatiscommunicatedfrequently:animprovementinitiativeandgaininefficiencyoreffectivenesswillabsolutelyneverresultinjobloss.TheleadershipofAGEisalwaysakeystakeholderinanyimprovementinitiativetoensurethattheworkforceclearlyunderstandsthatanyimprovementisVeteran-centricandworkforce-secure.AGErepresentativesign-offisnowincludedontheactionplantemplate,andAGEleadershiphelpscommunicatewiththeworkforceaboutnewprocessesandwhythechangeshouldbeembracedbytheworkforce.The6-Ps of Leadership andthe6-E Leadership Tool alsohelpfocusandprioritizeimprovementsbasedonstrengthening core competencies, andclearunderstandingoftheimportanceofthecorecompetenciesbytheentireworkforcehelpstodeployandsolidifythechangesandimprovements.

6.1c C4V manages innovation throughavarietyofmechanisms,allfueledbythe6-E Leadership Tool andthe6-Ps of Leadership, asdescribedin2.1a(1). C4Vbuildsinnovationusingtheequationshownin1.1b(2)fortheVAcorecharacteristicofinnovation=need+knowledge+creativethinking.NeedsareidentifiedbytheSOSculturethroughclearunderstandingofrequirementsandexpectationsbasedonthemultiplelisteningmechanisms,aswellasrobustsystemperformancemeasuresandcomparativedataandinformation.Knowledgeisenhancedthroughbenchmarkingactivitiesandtheworkforcedevelopmentprocessesdescribed

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incategory5,supportedbyleadershipbehaviorsdescribedin1.1b(2).Perhapsthemostimportantaspectisleadershipcreatingasafeenvironmentforcreativethinkingbyestablishingclear“must”criteriaforacceptabilityandintelligentrisk,asnotedin2.1a(2).TherewardandrecognitionmechanismsnotedinFigure1.1-4alsohelpreinforcethecultureofinnovationandintelligentrisk.

6.2 Operational EffectivenessDeterminingthekeyMoSforeachkeyprocessandacontinuousfocusontheMVVtopromotealignmentandintegrationarekeytothesynergythatdriveseffectivemanagementofoperations.

6.2a C4Vincorporatesmethodstocontrol costsintoprocessdesignandredesignduringtheOMIS.Theactionplantemplateincludesidentificationofneededresourcestoimplementchanges—consideringfunds,personneltime,equipment,space,utilities,andideas.Processmeasures,suchasserviceturn-around(efficiency),accuracy,costperserviceunit,andproductivity,aremethodsusedtomonitorcostsduringserviceandprocessdesignandimprovement.

Specificmethodstocontrol costs;prevent errors and rework; and minimize the costs of inspections, tests, and auditsinclude

■ Implementproactiveauditsonregulatoryrequirements,particularlyaschangesoccur.

■ Usetoolsincludingdesignofexperiments,RCA,FMEA,IDEALS,pilottesting,andsimulationstotestforerrorsandissuespriortolarge-scaledeployment.

■ Inviteinternalauditorstomonitorprocessdesign,redesign,andimplementationtobuildincontrols,andconcurrentlywriteorrevisepolicies,procedures,andjobaids.

■ UseinternalandexternalknowledgerepositoriesintheKMStoidentifyevidenced-basedpracticesandprotocolstoaddvalueandimprovetheprocessesandoutcomes.

■ Effectivelyusedatatodriveperformancebycarefulselec-tionofMoSandanalysisofdatabyDataFACTSandotherstakeholderstoensurethatdesiredbehaviorsarebeingrewardedandrecognized.

■ Encourageuseofinprocessmeasuressuchascycle time, productivity, etc., topromoteagilityandoutcomes.

■ Seekcomparativedata,particularlyworld-classortop-decilelevelsofperformance,beforesettingstretchgoals.

■ Incorporatetechnologies,suchastelehealth,webcams,smartphoneapps,etc.,toaccelerateimprovementsinquality,access,andaffordability.

■ Reducewaste,improveefficiency,decreasecost,andaddvaluethroughtheengagementofPITCrewsandtheentireworkforcebyreward,recognition,andthe6-Ps of Leader-shipandthe6-E Leadership Tool.

■ Monitorresultsandobserveactivitiesmorefrequentlyafterachangetoensureprocessesperformtotargetsandareagileandresponsivetochangingconditions;identifyadditionalopportunitiesforimprovement.

■ Decreasefrequencyofmeasurementand/orsamplesizesasprocessesstabilizetoreallocateresourcestootheractivities.

■ Useautomatedsystemsformonitoringwhenpossible.

C4V balances the need for cost control with the needs of cus-tomers and other stakeholders bydeploymentoftheC4Vvalueequation,assistedbyDataFACTS.Projectorchangevalueequalsthebenefits,dividedbythecost.Thevalueequationsystemati-callyconsiderstheROIandthecostdefinedastheresourcesidentifiedontheactionplantemplateandthebenefit(includingbothtangibleandintangible),suchasimpactonVeterans,workforcequalityoflife,andbottom-linedollars.Theactionplanownermayneedtonegotiateforresourcesand/ortimingbasedonresourceavailability;resourcesincludeconsiderationofbudget,personneltime,availablegrantfunding,etc.Oncetheactionplanorbusinessplanissignedbytheactionplanowner,AGErepresentative,DataFACTSteammember,andSLTchampion,itbecomesacovenanttoprovideresourcesandaccomplishtheplan.

6.2b C4V manages the supply chainusingsupplier-input-process-output-customer(SIPOC)mapping.SuppliersareselectedthroughtheformalizedgovernmentcontractingsystemundertheFAR.Thecontractingsystemfostersefficientandeconomicprocurementofallproductsthroughstandardizationofproductsandutilizationofnationalorotherconsolidatedcontracts.Userpreferenceisbalancedwithstandardizationforeconomiesofscale,withjustificationrequiredtopermitdevia-tionfromthestandardtoprovidethebestvalue.C4VprovidesclearcommunicationtotheCOorCORaboutrequirementsandexpectationsbasedontheidentifiedrequirementsandexpecta-tionsofC4Vcustomers.

Whenselectingsuppliers,theCORensures that the suppli-ers are qualifiedandwillenhanceperformanceandVeteransatisfactionbyreviewingrequestsfornewordifferentproducts,conductingtrialsrelatedtotheitem,andanalyzinguserfeedback.Priortoselectingasupplierformedicines,theCommitteefortheAcquisitionofMaterials(CAM)gathersopinionsandpreferencesfromkeystakeholdersanddefinesthecriteriafortheselectionprocesstoincludecompliancewithfederalandVAacquisitionregulations(FARandVAAR)andFoodandDrugAdministra-tion(FDA)approval,asappropriate.Abackgroundcheckofthesupplierensuresitshouldnotbeexcludedfromparticipation.Stakeholdersincludeamixofclinicaland/orothersupplyusers,aswellasSMEs.Akeycriterioninselectingtherightsupplieristhevalueequationdescribedpreviously.TheCAMevaluatestotalcost,customerserviceprovided,on-timedelivery,reliabilityandresponsiveness,andbothhardandsoftresourcesavings.Frequently,anewitemmaybecomethenewstandard,promotingorganizationalagilityandaddingvalueforC4V,Veterans,andothercustomers.Cost-benefitanalyses,validatedbyDataFACTS,andstandardizationopportunitiesareconsideredbeforeselection.

C4V usesauniquedeviceidentifiertrackertomaintainadatabaseforspecificbiologicalsandimplants,suchaspacemakers,insulinpumps,andorthopedichardware.Mostdevices,includingpacemakers,implants,andprosthetics,arealsotrackedbyserialandmodelnumbers.ThisinformationisintegratedwiththeRecallManagementSystemtoensureappropriateresponseandtonotifythepatientandproviderwithinthespecifiedtimeframeforanypatientsafetyalerts,advisories,orrecalls.

Anenhancementinsupply-chainmanagementatC4VwastheimplementationofVendorTrack,aservicetoverifythecredentials

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ofallvendorsandtoprovidesecurity,safety,andregulatoryinstructionbeforeengagementwithC4V.WhenVendorTrackrequirementsarecomplete,thesupplierisissuedabadge.Vendorsfoundonpremiseswithoutabadgeandanysterilesupplyitemsbroughtintoaworkareawithoutasign-insheetaresenttoLogisticsforproperauthorization.VendorslogintoVendorTrackuponentryintoaC4Vsite,whichhelpstoensureproperreceiptofitems.SterilesuppliesarecheckedbytheSterileProcess-ingServicetoverifytheirsterilitybycheckingforteststrips,packageintegrity,andoutdateditems.Inaddition,assupplyitemsarechecked,thevendorisgivenasheetverifyingtheiruse.ThisprocessalsosafeguardstheenvironmentforVeteransandtheworkforce.

TheCAMconductsanauditandassessmentprogramforsup-pliers,trackingbothpositiveperformanceandadversetrends.Suppliersarecategorizedintothreetiersbasedonthelevelofimportanceandriskofwhattheysupply.Whileauditfrequencyandimpactoffindingsdependonthetierofthesupplier,allsuppliersaretrackedforprice,timelinessofdelivery,accuracyoforderfulfillment,fillrates,backorders,andtimelinessofrecallnotification.

Supplierperformanceevaluationsarepatternedafterworkforceperformanceevaluationsandincludeaself-assessmentandadevelopmentplan,whichmayidentifyperformancegaps,enhancesupplierengagementininnovationatC4V,orhelpthesupplierunderstandtheimpactofitsperformanceontheVeteransservedby C4V.Tier1suppliers,thehigh-importanceorhighest-risksuppliers,areevaluatedquarterly;tier2suppliersareevaluatedtwiceperyear;andtier3suppliersareevaluatedannually.TheevaluationprocesshelpspositionthesuppliertoenhanceC4V’sperformanceandcustomers’satisfaction,completingtheSIPOCintegration.Suppliersareprovidedwithwritten feedback reports tohelpthemimprove.High-performingsuppliersandthosewithinnovativeimprovementideasareeligibleforaResourcefulnessAward.Ifasupplierhasapatternofpoor performance, awrittenperformanceimprovementplanmayberequiredorC4Vmayterminateacontract.

6.2c(1) C4Vprovidesasafe operating environmentfollowingtheIDEALSmodel,asillustratedinFigure6.2-1.TheSafetySystemaddressesaccident preventionprimarilyinSteps1and2,identifyingrisksanddesigningallprocessestoconsidersafety.Audits,inspections,andobservationsareintegratedintotheexecutionphasetoensurethatprocessesareexecutedaccordingtoplan.Intheeventofanincident,RCAisconducted,withafocusonrecovery,error-proofing,andpreventionofsimilarevents.

6.2c(2) C4V ensures preparedness for disastersoremergenciesusingthefinalsystemoftheILMS,theDisasterandEmergencyPreparednessSystem(DEPS),showninFigure6.2-2.DEPSconsiders prevention, continuity of operations, and recovery structuredintheIDEALSformat.Theprocessbeginswitharisk

analysisfordisastersthatareman-made,natural,ortechnology-related.Afteridentification,anevaluationandanalysisofthepotentialbusinessimpactisconducted,withtheassistanceandsupportofDataFACTS.Risksaremitigated,asappropriate,throughthephysicalandITsecuritymeasuresdescribedprevi-ously;structuraldesignofbuildingsandtransportationsystems;andITbackupsystemsandredundancies.Theroleofsuppliers and partners iscrucialinC4V’sislandenvironment,andDEPSconsiderationsareincludedincontracts.FEMAprovidesaddi-tionalredundancyasabackupsupplier,intheeventofadisaster.

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Category 7 Results

7.1 Product and Process ResultsBeneficialtrenddirectionisindicatedbyagreenarrow.

7.1a TheultimateindicatorofsuccessforC4Visthehealthandwell-beingoftheVeteransserved.WhilethefactthatC4Visacomplexity2facilitymeansthathighest-acuityVeteransaremorelikelytobeservedelsewhere,therisk-adjusted(standardized)mortalityratio(SMR)duringanacutecareevent,andwithinthefollowing30days,isevidenceofsuccessfulservicesandprocesses.ThegoalforSMRistobe1orunder,meaning“lessthanexpected.”

Foroutpatients(ambulatorycare),qualityistrackedprimarilybysuccessinpreventinghospitalizationfordesignatedconditions,suchasdiabetes,pulmonarydisease,heartfailure,anddehydra-tion.InadditiontothePACTsegmentationshowninFigure7.1-3,segmentanalysisisalsodonebydiseaseconditionandbylivingconditions.

OutpatienthealthpromotionistrackedthroughaHEDIScomposite—17indicatorsshowtheeffectivenessofthehealthcareteaminpreventingillness.TheHPEXcompositeisasimilarsetof“coremeasures”fortheinpatientsetting.HEDISandHPEXdetails,includingcondition,PACT,provider,etc.,areavailableon-site(AOS).

HAIsarepreventedthroughdiligentcareandshorterhospitalstays.Infectionscommoninacutecareincludemethicillin-resistantstaphaureus(MRSA)andcatheter-associatedurinarytractinfections(CAUTI),showninFigure7.1-5.MRSAratesaregraphedusingaten-foldscaleinordertoshowC4Vsuccess.

Infectionsassociatedwithcriticalcareareasarecentralline-associatedblood-streaminfection(CLABSI)andventilator-associatedpneumonia(VAP),showninFigure7.1-6.C4VhadnoinstancesofVAPin2014andexpectsnoMRSAorVAPin2015.

HAIratesareper1,000beddaysofcareforMRSAandper1,000linedaysforCAUTI.

VHAalsotracksapatientsafetyindicator(PSI)composite,showninFigure7.1-7.Thiscompositescorecomparesactualpatientsafetyexperiencewithpredictedsafety.APSI<1indicatesasaferenvironmentthanwaspredicted.

7.1b(1) Theseverity-adjustedlengthofstay(LOS)showsC4V’sefficiencyandeffectivenessintreatingVeteransandcorrelatestolowercomplications.Lowerisbetter,aslongasthereadmission

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rates(seeFigure7.1-24)donotindicatethatpeoplearedischargedtooquickly.

Thewell-beingderivedfromfunctionalindependenceisofgreatvaluetoVeterans.Figure7.1-9showsthefunctionalindependencemeasure(FIM)scoreforeachoftheC4Vrehabilitationservices.Comparisons(*)areobtainedfromnationaldataservices.

C4V’ssizehelpsittoensurepromptandpersonalizedattention,withLOSintheEmergencyDepartmentbetterthanthenationalstandardoftwohoursforthosetreatedanddischarged,orfourhoursforthosewhoneedtobeadmitted.

Electronicfillingofclaimshashelpedgainefficiencyinbenefitsmanagement.Thebreakthroughimprovementin2013wasaresultofVINFpartnershipwiththeVIlibraries.Additionally,claimsaccuracy(Figure7.1-12)isimportanttoensurethatVeteransarepaidpromptlyandcorrectly.

VIVCisdesignedtobeaplaceofpeaceandrestforthelivingandthefinalrestingplaceforVeterans.NCAShrineDesignationisaBaldrige-basedorganizationalassessmentandimprovementprogramwithoperationalstandardsandmeasurespopulatingabalancedscorecard.SomemeasuresfromthescorecardareshowninFigure7.1-13,withtheremainderofthescorecardAOS.

Someproductivitymeasuresarealsoreportedin7.5;thosereportedhereareprimarilycustomerfocused.IntegrationofbenefitspersonnelwiththePACTsandtutelagefromVINFhavehelpedincreasetheproportionoffullydevelopedclaims(FDC):thosethathaveallrequiredinformationincludedwiththeclaim.Thishelpsreduceprocessingtime.

Althoughgroundsmaintenancemayseemeasyinatropicalparadise,rapidgrowthandmajorstormsrequireongoingandtimelymaintenanceintervention.TherehaveneverbeenanymajordeficienciescitedatVIVC.

Inordertoaddressaccessconcerns,C4Vbeganofferingcancella-tionslotstowaitingVeterans,anapproachmodeledafterstandbypassengersintheairlineindustry.Cancellationslotsaremore

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difficulttofillonSt.John,duetothesmallerpopulationandtravellimitationsamongislands.

ArecentmajorinitiativethroughoutVBAandVHAwasto“fixthephones,”eliminatingasourceoffrustrationforVeterans.CallerstoC4Vexperienceafastanswerandnomorethanasinglevoicepromptbeforetalkingwitharealperson,whoisanxioustoshowI-CARE.

WaitingtimeforappointmentswasanissuethroughouttheVAin2014.Figure7.1-23showsthepercentageofpatientswithawaittimeoflessthantwoweeksfortheirappointments,segmentedbyserviceandwhetherthepatientwasneworestablishedwiththePACT,andcomparedagainsttheVAaverageandVA90thpercen-tile.Figure7.1-24showsrisk-standardizedreadmissionratesasevidenceofeffectivenessofcare.ThismeasureisthecheckandbalancetothereductionsinLOSshowninFigure7.1-10.

Asanewerfacilitywithnewequipment,C4VenjoysveryhighITsystemuptime.Similarly,otherequipment,primarilyrelatedtomemorialsandhealthservices,mustbeavailablewhenneeded,andcollaborationbetweenVIVCandmaintenancestaffyieldsa98%equipmentoperationalreadinessrate.

VHAmeasuresefficiencythroughtheStochasticFrontierCostEfficiencyModel.C4Vlagsslightlyonthismeasureduetoitssizeandthenecessitiesofminimumstaffingrequirementsinordertoprovidesafepatientcare.

Efficiencyininternalprocessesleadstoenhancedoverallperfor-mance.Forexample,afrequentdelayintreatmentiswaitingfor

testresults.TheC4Vlaboratoryhasmadediligenteffortstoreportcriticalresultsinatimelymanner,asshowninFigure7.1-27.

OthersupportstaffmembersintheC4Vworksystemsalsounderstandtherequirementsfortimelinessandaccuracy,asevidencedbythehiringcycletimeresultsattainedbyhumanresources,showninFigure7.1-28.Theadministrativesegment

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oftheworkforceisnotshown,asnonehavebeenhiredsincetheC4Vinception.VIcompetitorsdeclinedtoprovidecomparisoninformation,andtheislandlocationmakesthevalidityofothercomparisonssomewhatquestionable.

7.1b(2) ThebestmeasureofC4Veffectivenessinpreparednessforadisasteroremergencyistheresponsetoactualeventsand/ordrills.Figure7.1-30showstheappropriatenessandtimelinessofresponseseachyear,segmentedbytypeofemergency.ThedetailedresponsetimespereventandperareaofC4VimpactedareAOS.

EmergencyresponsivenessiswhatitisbecauseoftheC4V dedicationanddiligenceinensuringthattrainingisofferedand

understandingisevaluatedbeforeputtingskillsintopractice.Figure7.1-31showsthetrainingcomplianceforallstaff,andFigure7.1-32showsthetrainingandcertificationofincidentcom-mandersatC4VthroughDepartmentofHomelandSecurity(DHS)multilevelhospitalincidentcommand(HIC)progressivetraining.

7.1c Suppliersareheldaccountableforkeepingnecessaryitemsinstockandready,asshowninFigure7.1-33.Accountabilityistrackedthroughorderfulfillmentrates(desiredquantitiesdeliv-eredwhenordered)andauthorized,periodic,automaticreplenish-mentlevelsmaintainedonhand.Thesemeasuresprimarilypertaintohealthservices.

Suppliersarealsoheldaccountableforthebudget,asistheC4V leadership.C4Valsotrackstimelypaymentstosuppliers,inaccordancewithFARandtoavoidpenaltiesandsurchargesforlatepaymentspercontract.

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7.2 Customer-Focused Results7.2a(1) Figures7.2-1through7.2-16showvariousaspectsofC4V customersatisfaction,progressingfromgeneraltopicstomorespecificareasaddressed.EachAdministrationisalsoscoredusingavendor-providedsatisfactionindex,enablingcomparisonwithnon-VAprovidersofsimilarservices,showninFigure7.2-2.Ingeneral,satisfactionissurveyedregardingtimelyaccesswiththespecificquestionsontheSHEPandHCAHPSsurveys.ResultsareshowninFigures7.2-3through7.2-8.AdditionalsegmentationisAOS.

AmajorbenefittoVAcareistheabilitytocoordinatecarethroughoutthecountry.ThisenablesvisitingVeteranstoreceivecare“justlikeathome.”InterregionalcoordinationishelpfulwithinallthreeadministrativefunctionsofC4V .

NCAratingsforsatisfactionthroughACSIareamongthebestofanyindustryinthecountry,andVIVCisamongthebestwithinNCA.Tobettergaugerelativeperformance,VIVCalsoasksthenextofkintocompareC4Vserviceswithothersimilarexperiences.

AppearanceisonefactorthatsetsNCAfacilitiesapartfromallothersandbuildsthereputationandbrandoftheAdministration.

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ItisthereforeparticularlyimportantthattheVeterans,nextofkin,andcommunityaresatisfiedwiththeVIVCappearance(Figure7.2-11).

Funeraldirectorsplayamajorroleinthenextofkinandfamilyexperienceatthetimeofloss.FuneraldirectorsalsoserveasoutreachtothecommunityabouttheavailabilityoftheseservicesfromtheVA.

OverallsatisfactionwithbenefitsenrollmentisshowninFigure7.2-13.TheinnovativeinclusionofbenefitspersonnelduringTAPoutreachandwiththePACTsledtobreakthroughimprovement.TherearenoknowncomparativedataoutsidetheVBAforenroll-mentprocesssatisfaction.

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Forhealthservices,leavingtheEmergencyDepartment(Figure7.2-16)priortobeingseenbyaphysicianorotherindependentpractitionerisusuallyduetodissatisfactionwiththewaittime.LeavingalsoplacesVeteransatriskofnotreceivingappropriatecareandisverycarefullymonitored.

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7.2a(2) Engagementismeasuredprimarilythroughthewilling-nessoftheVeterantorecommendC4Vservicestootherswhomaybeeligibletoreceivecare.Thisquestionisaskedonavarietyofsurveytools.

EngagementisalsoindicatedbyVeterans’willingnesstopar-ticipateintheirowncareandtheefficiencyandeffectivenessofservices.EngagementcanbediscernedbythenumberofVeteransparticipatingwithelectroniccommunicationsandregisteringfore-benefitsandMHV.Theseportalsenablesecurecommunicationswithbenefitsandhealthrepresentatives.

Beingvestedintheirowncarepromoteswellnessandwell-beingforVeterans.A“vestingvisit”isrequiredeverytwoyears,whentheVeteranmustmeetwithhis/herpractitionerandhavecertainscreeningsconducted.VestingresultsinhigherpaymentratestoC4VfromtheVA—creatingawin-winsituation.VaccinationratesarealsotrackedasanindicatorofVeteranwillingnesstoengageinhis/herownhealthandwellness.

EngagementisalsoindicatedbythenumberofVeteransenrolledforcareatC4Vwhoalsoserveasvolunteers.

Unlikeanon-VAcemetery,servicesareheldatacommittalshelter,whichmaynotbeavailableattherequesteddateortime.Duetoitslowervolume,VIVChasnothadthisissue.Nextofkinfrequentlyalsorequestanhonorguardfortheservices.Honorguarddutiesareperformedbyvolunteers,andmanynon-VAcemeterieshavedifficultyfillingallrequests.

7.3 Workforce-Focused Results 7.3a(1) C4Vexpandsworkforcecapabilityandcapacitybyattractingthebrightestandbestfromthestudentpopulationtojointheworkforce.Figure7.3-1showstheproportionofselectednursingschoolgraduateswhoacceptedC4Vpositions.

Oncehired,theentireC4Vworkforceisexpectedtocontinuetogrowinknowledge,skills,andcapabilitythroughtheextensive

trainingprogramsofferedandrequired.Nurses,inparticular,areencouragedtoreturntoschoolforbaccalaureateandadvanceddegrees.

Capability,orlackofcapability,isindicatedwhentheVAmustpurchaseservicesfromotherproviderstomeetVeteranneeds,referredtoas“fee-basis”care.Figure7.3-4showsC4Vresults,whichincreasedin2014withnewlegislationtoprovideVeteran’schoicecardsinresponsetothetimelinessofaccessissueselsewhereinthecountry.

Workforcecapacityismeasuredbyensuringthatadequatestaffingisavailableandmatchedtotheworkloadthroughpredefinedparameters,referredtoas“inquality.”Thismodelcorrectsforbothunderstaffingaswellasoverstaffing.Vacanciesarealso

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monitored,althougheachpositionisre-evaluatedforneedpriorto equipment.TheSLTattributesthis,atleastinpart,torequiringfillingwhenamemberoftheworkforceleaves.Vacancycompari- extensivesafetytrainingandensuringthateveryoneistrainedsoninformationisonlyavailablefromthehealthsector. andknowledgeable.Additionally,theworkforceissatisfied

withsafety.7.3a(2) TheworkforceclimateisevaluatedprimarilythroughthesurveytoolsofferedbytheVA,suchastheAES.Thistoolis Insomespecialtyareas,particularprecautionsaretakentoensureusedthroughoutthefederalgovernmentandalsoprovidesnon-VA safetyandregulatorycompliance;precautionsincludemonitoringcomparisoninformation.Figures7.3-7and7.3-8showsatisfaction radiationexposureinspecificjobcategories.withpsychologicalsafetyanddiversity. Training,accountability,physicalcontrolsforsafety,andtheC4Visdeeplycommittedtoworkforcehealthandsafety.An focusofseniorleadersonsafetyhaveallcombinedtoresultinnoextensivewellnessprogramisoffered,andtheinnovationof securityincidentsofanytype(Figure7.3-14).invitingthespouseofanyworkforcemembertoparticipateledto TheC4Vworkforceisalsohighlysatisfiedwiththesupportivebreakthroughimprovementinparticipation. environmentandwithwork-lifebalance.SafetyismeasuredaccordingtoOSHAstandards,asshown 7.3a(3) OverallsatisfactionismeasuredthroughaspecificinFigure7.3-10.Itisnoteworthythattherehavebeenno questionontheAES(Figure7.3-18),aswellastheBestPlacestoDARTincidentsinmemorialservices,despitetheuseofheavy Work(BPTW)survey(Figure7.3-19).

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EngagementisindicatedbythefactthattheworkforcestaysatC4Vwhenotheroptionsareavailabletothem.Retentionratesaretrackedspecificallyfordifficult-to-fillpositions,asshowninFigure7.3-20.Engagementisalsoindicatedbyworkforceparticipationinsuggestions,innovation,wellnessactivities,etc.

Thenumberofactiveadultvolunteersalsodemonstrateshighlevelsofengagement.Over60%ofC4Vvolunteershaverecruitedatleastonevolunteer—clearevidenceof“willingnesstorecommend.”

C4Valsoparticipatesinthecalculationofanengagementindexscore,withcomparisonsthroughoutthegovernmentandtheVA.Thisprocessincludesvolunteers.Studentengagementisindicated

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bythenumberwhoacceptpositionsatC4Voncetheirtraining createtheconditionsforworkforcememberstobesatisfiedwithiscomplete. theirdevelopmentopportunities,asshowninFigure7.3-27.

7.3a(4) Perhapsthebestindicatorofdevelopmentalopportunities 7.4 Leadership and Governance Results atC4Vistheperceptionoftheworkforcethattheorganiza-7.4a(1) ThebestindicatorofhoweffectivelytheSLTcom-tionhasthetalentnecessarytoachieveitsgoals,asshowninmunicatesthegoalsandprioritiesoftheorganizationistosimplyFigure7.3-23.Allsegmentsaresatisfiedwiththeirpromotionasktheworkforce.ThisisaquestionontheAES,andtheresultsopportunities(Figure7.3-24),particularlywhenconsideringtheareshowninFigure7.4-1.Thesurveyalsoincludesquestionstosmallsizeoftheorganization.evaluateperceptionsaboutfeelingencouragedandempoweredto

Leaderstakeanactiveroleinthedevelopmentoftheworkforce, comeupwithnewandbetterwaysofdoingthings,leadersgen-fromidentifyingopportunities,toplanningacourseofaction,to eratingahighlevelofmotivationandcommitment,andthelevelcoachingandmentoring,asshowninthecompletionofmid-year ofrespectfortheorganization’sseniorleaders,showninFiguresreviews(Figure7.3-25)andtheformalizedVAcoachingand 7.4-2through7.4-4.Resultsaresegmentedbyservice.Segmentedmentoringprogram(Figure7.3-26).Alloftheseopportunities analysisisalsodonebygender,shift,specificworkarea,Veteran

status,etc.ThetraditionalsurveytoolisaboutperceptionsofSLT

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engagementinthemissionthroughVeteransupport,asshowninFigure7.4-6.

Toevaluateseniorleadercommunicationandengagementwiththeworkforce,C4Vperiodicallyaskstheworkforceaboutthemostrecentopportunitytocommunicatewithaseniorleader,withmorerecentlybeingpreferred.Becausecomparisondataarenotdirectlyavailable,workforcemembersareaskedtocomparetheirC4Vexperiencewithpreviousplacestheyhaveworked.BecauseC4Visaneworganization,mostemployeeshaveworkedelsewhererelativelyrecently.

Figure7.4-7indicatesappropriategovernancebySLTmem-bersspendingtheappropriateproportionoftheirtimeinthe

“managementzone”commensuratewiththeirposition,asdescribedinFigure1.1-5,inordertobalancetheshort-andlonger-termperspectivesforC4V.Calendarnotationsregardingthezoneforeachtaskareaggregatedmonthly,inordertoprovidefeedbackandimprovegovernance.Earlyon,C4Vrequiredmore“hands-on”andshorterperspectives,butastheorganizationmatures,leadershipcantakealonger-termview.“Good”perfor-manceiswhenseniorleadersspend70–90%oftheirtimeinthestrategicmanagementzone.

7.4a(2) C4Vdoesnothaveatraditionalgovernanceboardbutreportstohigherheadquarters,asnotedontheorganizationchart.Accountabilityisestablishedthroughthechainofcommand,congressionaloversight,theVAOIG,andotherauditingandregulatoryauthorities.KeymeasuresofinternalandexternalfiscalaccountabilityareshowninFigures7.4-8through7.4-10.Therobustinternalauditprogram,coupledwithworkforceeducationaboutproperprocedures,helpskeepexternalauditsclean.Medi-calrecordscodingdoesnotdrivepaymentintheVAasmuchasinnon-VAfacilitiesbutremainsvitallyimportantforpurposessuchasforriskadjustmentandforenablingproperdisabilityratings.

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7.4a(3) AllaccreditationrequirementsnotedinFigureP.1-4havebeenmaintainedsinceC4V’sinceptionin2010.ManyoftheoversightorganizationswithinVAandthefederalgovernmentalsohaveregulatoryauthorityoverC4V.Figures7.4-11and7.4-12showsregulatorycompliance.

7.4a(4) Figure7.4-13showstheC4Vcommitmenttoethics,asevidencedbyalackofissuesorfindings.Figures7.4-14through7.4-16showtheworkforceperceptionoforganizationalethicsandtrustandconfidenceinleadership.

7.4a(5) C4VfulfillssocietalresponsibilitiesbycaringforVeteranswhohavesacrificedmuchforthecountry.C4VsupportstheVAinitiativetoeliminateVeteranhomelessnessthroughtheVASup-portiveHousing(VASH)initiative,incollaborationwithHUD,bydistributingvoucherstoVeteransinneed.C4Vdoesnotsupplythefundingforthevouchers.

Figure7.4-18showsenvironmentalsocialresponsibilitythroughuseoftheGreenMachinetoeliminatewasteandhelpreplenishtheearth’sozonelayer,andFigure7.4-19showssupportthroughvolunteering.

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7.4b Manyresultsarelinkedtostrategyimplementation,asnotedinFigure2.1-5;twospecificimplementationmeasuresimpacthomelessnessandtheVeteranstatusoftheworkforce.ThehomelessVeteranpopulationremainshigherintheVIthanintheUnitedStates,inpartduetothemoderateclimateandbecausetheVIeconomicrecoveryissomewhatlaggingfromthemainlandduetoitsheavyrelianceonthetourismindustryandcruiseships.

TheinnovativeVETBase,describedin3.2a(2),alsosupportsthecommunityandpromotesgoodstewardshipofresourcesbymakingservicesmoreavailableandknowntoVeterans,whileavoidingduplicationofefforts.

7.5 Financial and Market Results7.5a(1) Asagovernment/nonprofitorganization,C4V’sfinancialandmarketresultsaredifferentthantypicalbusinesses.C4Visnotprofitdrivenormotivated.Allocationsareprovidedbasedonthefundingmodelsdescribedpreviously,andfinancialperformanceisevaluatedbasedonactualexpensescomparedwithbudget,asshowninFigure7.5-1.Thereisnorevenuegenerated.

Asalabor-intenseproviderofservices,C4ValsotracksFTEEsandcomparesactualworkforcetothebudgetallocation.Atstart-up,someaspectsofC4Vwereoverbudgetduetotrainingandonboarding,whileotherswerelowerthanbudgeteduntilservices

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wereavailable.Aftertwoyearsof“gettinggoing,”thebudgetsofdollarsandFTEEsaremorestableandnear100%,asexpected. VHAisauthorizedtoseekreimbursementfromthird-party

healthinsurers(Figure7.5-6)forthecostofmedicalcareVAalsomanagesbyaunitcostreport(UCR),withmeasuresfurnishedtoinsuredVeteransandtobillcopaymentsforofefficiency(UCR-1)andproductivity(UCR-5).Theseratiosnon-service-connectedcare.measureefficiencyforoverall,administrativeandoverhead,

andsalarycostsbasedonfacilitywork(FacWork).Theseratios BenefitsandhealthservicesreachedouttouniqueVeteranswhopermitcomparisonsacrossvariouscomplexityratings.WhenC4V maybeeligibleforservicesasajointeffort.Figure7.5-7showsopened,thesemeasureswereskewed,duetoboththetraining/ thepercentageofeligibleVeteranswhoareenrolled.learningcurveandthelowerinitialworkatthefacility.The

4 VeteranscanlosevestedstatusbynotbeingevaluatedwithinaratiosarelikelytoremainlowerthanaverageforC Vproductiv- two-yeartimeperiod.C4VconductedafocusgroupofVeteransityandefficiencyduetolowervolumesandminimumstaffing whohadloststatusatthebeginningofFY2014toidentifyrootrequirements. causesandopportunitiesforimprovement.Atoneofthosegroups,7.5a(2) Marketsharemeasuresarealsoatypicalforagovern- aprojectwasstartedtopersonallycalleachVeteranwhowasmentorganization.TheC4Vmarketandserviceofferingsare abouttolosehis/herstatusandencouragehim/hertoscheduleandeterminedbyhigherheadquartersandCongress,ratherthan appointmentsoon.Alargepercentage(20%)ofthoseVeteranslocally.TheaimofC4Vleadershipistoprovidecare,services, madeanappointmentandreengagedagainwiththeirPACTintheandbenefitstoVeteranstothegreatestextentpermissiblebylaw. firstquarter.Therearenoresultsformarketpositionornewmarketsentered.