Facilitating a Culture of Employee Engagement and Innovation in VHA Mental Health: Improving Access and Beyond

Bruce F. Nelson, PhDVISN 2 Mental Health Lead

& Todd Burnett, PsyD

VISN 20 Mental Health Lead

Objectives• To appreciate the complexity of trying to get a healthcare system just

right. It is not simply a matter of creating a system of levers to be pushed.

• To provide examples of how employees have improved access into the storyline.

• To review some of the policies and programs in place to engage all employees in process improvement, particularly our front-line providers/employees.

• To become acquainted with some of the findings from I/O psychology that can inform our improvement efforts.

• organizational factors contributing to a vibrant, disciplined, and entrepreneurial workforce which, in turn, can impact access.

• leadership’s role in fostering a culture of creativity and innovation, bringing the strengths of the workforce into finding solutions.

• employee engagement so that they can be enlisted to improve care and access.• individual differences in employee creativity and innovation. Can we be more strategic

in who does what?• small groups can advance creative solutions to an organization’s problems.

Senate and House Veterans Affairs Hearings (May 12 & 13)

Staffing

Space

Expanded Service Hours

Staff Productivity

Community Partnerships

Expanding Access to Care• Nationally, VA completed more than 46 million

appointments between May 1, 2014, and February 28, 2015. This represents an increase of 2 million more completed appointments than during the same time period in 2013-2014.

• In February 2015, VA completed 97 percent of appointments within 30 days of the Veteran’s preferred date.

• VA has completed 12 million same-day appointments, which is 20 percent of VA’s total appointments per year.

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Providing More Care in the Community • VA completed over 1 million appointments per month

through doctors and clinics in the community, which represents nearly 20 percent of total appointments.

• VA made over 2.6 million authorizations for Veterans to receive care in the private sector from May 1, 2014 through March 31, 2015. This represents a 44 percent increase in authorizations when compared to the same period in the previous year.

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Real-world challenges to accessing MH services

• Challenges• Coordinated patient flow processes• Demand volume in PC and MH• Staffing Ratios / MH & PC Vacancy rates• Workload Capture, coding, mapping discrepancies• Standard of care practice (inappropriate episode of care lengths)• Facility location

“More Veterans are enrolling… more are using VHA services… and more

are increasing their utilization by requesting

more VA services.”

How fast is the conveyor belt moving: Growth at VHA Facilities

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How fast is the conveyor belt moving?Year VHA

Uniques*Percent Growth

of Uniques VHA Enrollment MH Uniques MH Encounters

FY02 4,544,353 6,788,781 718,995 9,146,799

FY03 4,805,421 6% 7,120,347 765,227 9,240,978

FY04 4,977,772 4% 7,331,138 823,349 9,397,592

FY05 5,094,425 2% 7,655,563 891,945 9,660,288

FY06 5,188,825 2% 7,872,439 919,665 9,814,993

FY07 5,230,112 1% 7,833,446 993,937 10,484,214

FY08 5,299,645 1% 7,834,764 1,082,282 11,528,361

FY09 5,448,058 3% 8,061,251 1,175,500 12,925,771

FY10 5,638,263 3% 8,342,674 1,280,290 14,339,115

FY11 5,795,165 3% 8,574,198 1,364,196 14,591,963

FY12 5,911,682 2% 8,763,174 1,420,837 14,887,263

FY13 6,017,636 2% 8,926,610 1,493,022 15,614,293

FY14 6,186,007 3% 9,093,511 1,559,345 16,736,66336% 34%

54% 45%

Thesis• The reality is that we are in one of the most complex sectors of the

economy (healthcare) and we are a government entity (political).

• Despite the associated challenges to the above, we as leaders can create a more formal and strategic process of engaging the strengths found in our workforce. We can achieve a better balance between a top-down and a bottom-up driven process. Think Gallup’s Strength-based Leadership.

• For those of us trained in the clinical/counseling specialties within psychology who now find ourselves in leadership roles, we should be paying attention to the findings and lessons learned from our friends in the I/O psychology specialty. Just how competent are we at systems thinking? System’s interventions?

• The whole of Access is not the sum of the defined metrics currently being tracked. Other examples exist that can help advance the cause. We will provide an example of a highly innovative program that have increased access.

Logical Follow Up Questions:Questions related to outstanding organizational performance, one component of which is access:

• What proportion of the variance is attributable to organizational culture? • The degree to which a culture of creativity and innovation has been achieved? • The degree to which employees feel empowered to solve local problems?• The degree to which an optimal balance between a top-down and a bottom-up

driven approach has been achieved? • The presence of strong strategies that promote Workforce Development?

• What proportion of the variance is attributable to leadership?

• What proportion of the variance is attributable to small groups?

• What proportion of the variance is attributable to individual differences?• Employee engagement? • Perceived Care felt?

Macro Perspective

Macro Perspective: HealthcareLipsitz (2012) provides us with a sobering reality in his publication, Healthcare: A Highly Challenging Sector of our Economy

• “Healthcare systems are enormously complex, both in terms of their complicated design and in scientific terms by its nonlinear, dynamic and unpredictable nature. The traditional mechanical approaches, such as regulations that are enforced through surveys, certifications, payments, and penalties will fall short. To help guide future policies and avoid the unanticipated consequences of regulation, we need to apply the principles of complexity science.”

Macro Perspective: Lipsitz continued• “Nonlinear Interactions: Output is greater than the sum of its parts.

Healthcare systems have developed silos of care with relatively little attention to the patient transitions and communication between channels. The current fee-for service system discourages sharing responsibility for patient care between venues by limiting payment to only one service at a time.”

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3511782/

• Think about the VA’s overarching goals of aligning services, care coordination, and achieving patient centered care.

• It is very hard to get it right.

Macro Perspective: Government EntityFrom Secretary McDonald’s presentation to the Senate Appropriations Committee.

• “We know that it is difficult for Members of Congress to contemplate the closing of a facility in their own District, even when that facility is underutilized and wasteful. Yet, given the current and future demands on the VA system, we cannot afford to waste scarce resources on an inefficient system. We would like to work with Members of Congress to do the harder right, rather than the easier wrong. We ask for your help to realign our Medical facilities to best serve our Veterans and shed facilities that are not economically viable and no longer provide value.”

• Yet another level of complexity and accountability.

SVAC 2012: Impact of Care Coordination

0%1%2%3%4%5%6%7%8%9%

0%10%20%30%40%50%60%70%80%90%

100%

FY12 FY13 FY14 FYTD15New Access (<14) PCMHI

Some Recent Communications from VA Top Leadership Specific to Innovation

“Mental health care professionals can play a proactive role at VA by improving mental health services for Veterans and their families and ensuring better outcomes for all concerned.”

- R. McDonald, Secretary VA

“We need our leaders in the organization to commit to fostering an environment of open communication that welcomes input from employees. After all, employees who are closest to the problems often have the best ideas for improvement.”

- C. Clancy, Interim Undersecretary

Who would disagree? The question is how do we formalize?

Some Recent Communications from VA Top Leadership Specific to Innovation

Before she assumed her new job as assistant secretary for policy and planning for the U.S. Department of Veterans Affairs, former state Department of Veterans Affairs Commissioner Linda Schwartz expressed frustration at being an outside observer of the VA. On the inside for about five months now, Schwartz said, "There's a lot of opportunity for change and innovation.”

“We need to be putting innovation in the field and moving away from a 3000 foot screwdriver approach.” H. Kudler, Chief Consultant, VACO MHS.

• VA Idea House as a recent example of trying to stimulate frontline employees to innovation.

Some Definitions from I/O Psychology

“Creativity focuses on the generation of novel ideas, innovation in work organizations is concerned with the generation of possible alternatives, selections, from among those alternatives, and implementation of the chosen alternative(s).” (Hammond, et al., 2011).

“Creativity is typically defined as the first stage of the problem-solving process, such as identifying the problem and generating ideas. Innovation is focused on the implementation of that idea and its acceptance by various stakeholders in the organization.” (Reirter-Palmon, 2011).

Organizational Culture

Organizational Culture: Effective OrganizationsMott (1972) presented evidence that effective organizations display two characteristics:

• “The efficient organization follows well structured, stable routines to deliver its products and services in high quantities with high quality at low cost.”

• “While efficiency implies mastering routine, adaptability means mastering the process of deliberately changing routine. It is a proactive process: it allows the organization to deliberately and continually change and create.” (Basadur & Basadur, 2011).

“Many organizations are not as effective as others because they value short-term results above all and reward successful implementers of routine disproportionately.” (Basadur & Basadur, 2011).

Patient safety is of the highest priority yet how do we introduce the optimal degree of adaptability?

Organizational Culture: Some General Findings from the Field of IO Psychology and Considerations for VA

“Research on organizational or team climate found that a climate that promotes openness, provides support and psychological safety, and encouragement is related to creativity” (Amabile & Gryskiewicz, 1988; Anderson & West, 1998; Hunter, et al., 2007).

The research findings conclude that creativity is essential to fostering innovation in organizations, achieving scientific breakthroughs, and developing high quality educational systems (e.g. Amibile 1996; Craft et. al 2001).

Creative SolutionsExpanding Telehealth and Non Face-to-Face Visits

• Telehealth services are now mission critical to VA providing care in more than 45 clinical areas.

• At the end of Fiscal Year 2014 12.7% of all Veterans enrolled for VA care received Telehealth based care. This includes over 2 million telehealth visits, touching 700,000 Veterans.

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Non‐tradition MH deliveryVA TMH Services FY 2003‐2014

5/23/2015

Fiscal Year

Patients

Visits

2003 8,000 14,0002004 8,981 17,6862005 13,358 27,1732006 19,758 41,2352007 24,499 48,8752008 28,893 63,5982009 39,790 90,2452010 50,000 112,0002011 55,308 140,2782012 76,000 212,0002013 85,000 280,0002014 108,000 335,0002003 ‐ 2014 1,250% 2,293%2010 ‐ 2014 116% 199%

0

50000

100000

150000

200000

250000

300000

350000

400000

Patients Visits

TMH Impact

237 7211119

16791254

2752

4472

6708

75%

80%

85%

90%

95%

100%

0

1000

2000

3000

4000

5000

6000

7000

8000

FY12 FY13 FY14 FYTD15

Tele-mental Health

Uniques Encounters New 14-day Access New 30-day Access

Outpatient Extended Hours Completed EncountersSource: Outpatient Visits data CDW Uses Wait Time Primary Stop  CodesExtended Hour Encounters are completed encounters that occur before0800 and after 1629 Mon – Fri or any time on Saturday or Sunday

Mental Health Outpatient Extended Hour Encounters FY Monthly Comparison

201320142015

19,000

18,000

17,000

16,000

20,000

21,000

26,000

25,000

24,000

23,000

22,000

OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP

4

5/23/2015

Female Veterans and Access: Extended Hours

5/23/2015 26

• Female Veterans under the age of 44 account for nearly 25% of primary care extended hour encounters.

• <25: Female Veterans account for 23% of all extended hour encounters

• 25-34: Female Veterans account for 19% of all extended hour encounters

• 35-44: Female Veterans account for 22% of all extended hour encounters

Organizational culture: what distinguishes great organizations from the merely good ones? Collins

HighCulture of Discipline

LowLow High

Ethic of Entrepreneurship (creativity)

Where does your facility stand?

Hierarchicalorganizations

Great organizations

Bureaucratic organizations Start-up organizations

Organizational culture: Google's serendipitous interaction

http://www.npr.org/blogs/alltechconsidered/2013/03/13/174195695/serendipitous-interaction-key-to-tech-firms-workplace-design

Three key components to the intervention that fosters innovation:• Rapid Learning• Collaboration• Fun

Exercise #1: Find a total stranger and spend five minutes sharing how you intend to improve access at your site.

Exercise #2: During this week’s conference, make it a goal to introduce yourself to 2 new individuals at some point. You must talk for at least 5 minutes.

Organizational culture: 3M example

3M corporation: People are encouraged to spend at least 15% of their time working outside the assigned project areas.

Leaders establish the vision for the future and set the strategy for getting there; they cause change. They motivate and inspire others to go in the right direction and they, along with everyone else, sacrificeto get there.

~ John Kotter

Leadership: Some General Findings from the Field of IO Psychology and Considerations for VA

“One of the most important factors that contribute to successful implementation of creative endeavors is effective management” (Mumford, et al. 2002).

“Leadership was correlated 0.47 with creative performance in research organizations.” (Stenmark, et al., 2011).

“Certain types of organizational structures tend to inhibit creativity and innovation. Specifically, vertical organizational structures, as opposed to horizontal structures, tend to minimize creativity,” (Hunter, et al. 2005).

Are there ways to flatten the organization? How do we engage leadership to make a concerted effort to foster innovation?

Leadership: From the Leadership Competency Model

Champions Innovation. Looks beyond current reality and the “status quo.” Challenges assumptions. Creates a work environment and culture that values, fosters, and rewards creativity and innovation. Positions the organization for success by identifying, developing, and implementing new or cutting-edge programs, processes, or strategies. Anticipates the potential impact of decisions on existing delivery systems.

Leading Change. Positions the organization for future success by identifying new opportunities, implementing new strategies, and developing and improving products and services. Creates a culture that fosters creativity and applies innovative solutions to drive organizational change. Communicates the mission and values and provides milestones for decision-making and action.

Operational Impact

66.41%

54.63%

48.42%

91.86%

FY12 FY13 FY14 FYTD15

New MH Access (<14 days)

Employee Engagement and Caring

Employee Engagement• Some Definitions:

• Kahn’s (1990) definition of engagement includes a harnessing of organization members to work roles. Engagement during work performance is simultaneously cognitive (consistent with identity), emotional (positive affect), physical (motivating effort), and existential (offering meaning).

• Disengagement refers to work role uncoupling, characterized by withdrawal and defensiveness either physically, cognitively, or emotionally (Kahn, 1990).

Caring: Some General Findings from the Field of IO Psychology and Considerations for VA

“The results of structural equation modeling indicate that caring between colleagues is positively associated with the positive psychological conditions of psychological safety, psychological meaningfulness, and psychological availability, which in turn results in employee motivation to engage in innovative behaviors.” (Vinarski-Peretz & Carmeli, 2011).

• Where does your facility score on these variables based on the AES?

AES Feedback“Nothing we do is more important than hiring and developing people. At the end of the day you bet on people, not on strategies.”

~ Lawrence Bossidy

4.1 3.993.7 3.6 3.59

2.73

Veteran Sat.(Appt.

Access)

Veteran Sat.(MH Care)

MH Prov. -Quality of MH

MH Prov. -Job

Satisfaction

MH Prov. -Collaboration

MH Prov. -MH Access

National (FY15Q1)

MH Veteran & Staff Survey Feedback…

Employee Engagement: Some General Findings from the Field of IO Psychology and Considerations for VA

Managers have the greatest impact on employee engagement, which makes this finding very worrisome:

• A strikingly low percentage -- just 35% -- of U.S. managers are themselves engaged, while 51% are not engaged and 14% are actively disengaged.” (Adkins, 2015)

• By Gallup's estimates, • the "not engaged" group costs the U.S. $77 billion to $96 billion annually

through their impact on those they manage. And when we factor in the impact of the "actively disengaged" group, those figures jump to $319 billion to $398 billion annually.”

Employee Engagement Our employees are not unaware or immune from our organizations attempt to deploy mechanical approaches:

From Garcia’s, 2015, research on PTSD provider burnout, “the most robust predictor of burnout was their perceptions of organizational politics and bureaucracy, as well as their overall workload.”

He found that 30 percent of the providers he surveyed said they were either very likely or somewhat likely to leave their position within two years.

"Unfortunately," says Garcia, "certain mandates tend to make employees feel over-controlled. In many cases, rules and administrative procedures need to be in place. However, employees also need to feel that they have some control over how they conduct their work. It's a difficult issue, and more research is needed into what specific aspects of 'organizational bureaucracy and politics' most impact burnout.”

Just for fun.

Exercise #3: In recent years, would you say the organization trended toward a more top-down driven process or a bottom-up driven process to address access?

From your perspective, are sufficient processes and systems in place achieve a highly creative and innovative environment to address access?

Can you cite some recent examples of creative ideas developed by frontline staff that were implemented to address access?

Take a moment to reflect on your current work environment and rate on a 1 to 10 scale how close it comes to having these goals met:

• Full support of leadership in fostering a culture of front-line creativity and innovation?

• A high degree of caring exists between employees?• Between supervisors and employees?

Individual Differences:

Individual Differences: Some General Findings from the Field of IO Psychology and Considerations for VA

“Hiring practices should incorporate identification of individual problem-solving styles to ensure good decisions are made with respect to cognitive fit with the job or department under consideration.” Basadur & Basadur, 2011.

Individual Differences: Some General Findings from the Field of IO Psychology and Considerations for VA

From Hammond, et al. Meta-Analytic Study regarding Predictors of Individual-level Innovation at Work:

• “Of all the predictor categories, job characteristics held the most consistent and strongest positive relationships with creativity and innovation.”

• “Jobs can be redesigned to facilitate creativity and innovation at work by increasing complexity and autonomy, as well as by clearly requiring (and encouraging) creativity and innovation on the job.”

Individual Differences: Some General Findings from the Field of IO Psychology and Considerations for VA

From Basadur & Basadur (2011):• “Every implemented solution (action) results in the opportunity

to discover (generate) new problems and opportunities to trigger the process anew.”

• “This recognizes that, as new problems are generated, conceptualized, and solved, and the new solutions are implemented, new problems and opportunities can be discovered.”

• “This circular process, which emphasizes continuous creativity beginning with problem generation, also serves as a model for organizational adaptability.”

Individual Differences: Basadur & Basadur continued

Creativity as a Cognitive Process with Four Distinct Stages (individuals have unique preferences).• Stage 1: Generators, 20.1%: “enjoy continually…scanning the

environment, picking up information, ….and sensing opportunities.”

• Stage 2: Conceptualizers, 26.2%: “transform idea fragments from generators into well-defined problems worth pursuing.”

• Stage 3: Optimizers, 21.7%: “critiquing the conceptualizations to identify real world constraints and practical difficulties.”

• Stage 4: Implementers, 32%: “Carrying forward the solutions and plans and adapting them to real-life situations.”

Group-based Creativity and Innovation

Group-based Creativity and Innovation• “The use of work groups as a form of work organization is

both ubiquitous and increasing” (Guzzo & Shea, 1992; Pfeffer, 1998; West, 2002). • “Sometimes groups are invoked to perform highly standardized

tasks in which applying well-rehearsed routines suffices to achieve high performance.”

• “Quite often, however, the group tasks are ill defined and require some creativity to achieve high-quality decisions, or to adequately adapt to environmental change.”

Group-based Creativity and InnovationFrom De Dreu, et al. (2011)

• “Groups tend to be more creative when they are under mild rather than severe time pressure, when there is prior preference diversity rather than preference homogeneity, when groups are populated by members low rather than high in need for closure, or by members high rather than low in openness to experience.”

• “When leadership styles are transformational rather than transactional, when group decision making is participative, and when there is shared social identity.”

• “Above are subsumed under one header – epistemic motivation.”

An Example within V02The Behavioral Telehealth Center. A centrally located, VISN-wide resource for patients in Primary Care.

• Provide MH Screenings and Care Management protocols; TeleMOVE! Care Program, and RAPID

• Newly diagnosed cases of depression and start of an antidepressant medication.

• Women’s health screening for peri- and post-natal depression.

RAPIDRecognizing and Assessing Progressive cognitive Impairment and Dementia • Recognize undiagnosed dementia• Provide access to comprehensive assessment for

cognitive impairment• Offer education and support to caregivers• Link Veterans to dementia care management• Algorithm =

RAPIDDementia is under-diagnosed in primary care. • Only 25-40% moderate to severe get diagnosed

(Plassman et al., 2007 Prevalence of dementia in the United States).

• In VISN 2:• VACO Estimated Prevalence = 13.9%• Diagnosed = 7.3%

Patients with dementia are high utilizers (RAPID positive patients)• In VISN 2 compared to age/illness matched comparison

patients used: • 2X as many outpatient appointments• 2X the number of hospitalizations• 2X length of stay

(Wray et al., 2013).

RAPIDIncreases detection of dementia• 7X more likely to get a diagnosis in month after screen

(Wray, et al 2013). Increases coordination across Carelines• Primary Care• Behavioral Health (BTC)• Geriatrics (Dementia Care and GEMs)Provides opportunity to support families

TeleMOVE! Care Program- HistoryVISN 2 is a leader and innovator in virtual MOVE!

• FY08- Centralized behavioral health technicians provide monthly f/u support via telephone to CBOC participants

• FY09- VISN 2 site for national pilot: MOVE! Telephone Lifestyle Coaching QI project– Centralized, telephone-based, comprehensive weight management support– Most successful outcomes associated with a national MOVE! pilot

• FY10- OTS RFPs to launch Home Telehealth- Weight Management– T-21 funding– Vision: use funds to establish a VISN-level program offering an array of virtual

weight management services• FY11- TeleMOVE! Care Program clinical services launched

– Home Telehealth-Weight Management: in-home messaging devices.– MOVE! Telephone Lifestyle Coaching via telephone.– MOVE! Support Calls: via telephone.– MOVE! Coach with Care (FY15): a mobile app component.

TeleMOVE! Care Program (cont.)• Effective

• 2 out of 3 Veterans lose weight• ~32% achieve clinically significant weight loss • 54% increase in clinically significant weight loss • 61% increase in treatment intensity

• Patient-centered• Veterans, particularly special populations, desire virtual options

• 1 out of 2 Veterans choose TeleMOVE!• % rural• % female• % OEF/OIF/OND

• Cost saving• Efficient utilization of FTEE

• 3 FTEE (2 RN, 1 RD) centrally located with VISN reach• 100% MOVE! program implementation (up from 49%)

• Reduction in beneficiary travel costs

Citations & ResourcesDivision 10: The Society for the Psychology of Aesthetics, Creativity, and the Arts. Special issue on The Psychology of Creativity and Innovation in the Workplace, February, 2011. Ten articles in total. (Link)

Good to Great, James Collins.

Gallup’s monthly e-publications

Use of Technology to Improve Access to Mental Care

When:

• September 1 – 2, 2015

• Where:• Dallas, TX

• Conference focusing on the use of technology to address access issues and barriers to the efficient delivery of mental health care

MH Business Operations: Understanding the Building BlocksWhen:

July 29 – 30, 2015

Where:Minneapolis, M

Other Info:Formal announcement went out May 11th

Nominations due to your VISN this week

Conference focusing on the business operations of MH in VHA:

• Proper workload documentation and procedural coding

• Clinic set-up and management

• Monitoring provider productivity and patient flow processes

Mental Health Leadership Mentoring Program

• Announcements expected in May / June

• Nominations July, 2015

• Contact your VISN MH Lead for more information (as needed)

MENTAL HEALTH ACCESSChallenges, practical realities, and striking a balance

Productivity has limits• Increasing staffing• Extended hours• Increasing staff productivity (up 9%)

• Increasing the use of care in the community

• Leaders clarify direction, align resources, and confront barriers to obtain results• Make needed decisions without delay / amid

uncertainty• Distinguish cause from effect and maintain focus

on drivers of outcomes

• Leadership requires intention and engagement• Know your leadership strengths and growing edges• Engage people and take time to observe needs /

realities from their perspectives• Culture trumps initiative: invest in ongoing learning

• People first• Learn and own your limitations• Facilitate the success of others• Refine conversation on common goals, shared priorities,

and overarching mission• Keep knowledge current and relevant• Discern meaningful results from related activities

Adaptive Management

Articulate a vision that inspires

Form action teams that innovate

Promote Reverse-Mentoring

Streamline Decision-making

Invest in people (not strategies)

Reward Contribution

Foster Collaboration

Manage Accountability

Differentiate results from

related activities