The Department of Veterans Affairs recently addressed a national crisis of prolonged wait times by successfully executing a nationwide, single-day “Stand Down” event to ensure that veterans who were at greatest risk were seen first. As a result of this effort, almost all of the 56,000-plus urgent-care consults that were originally identified have now been reviewed and successfully resolved.
When access to care becomes a systemic problem, it is critical to identify and address the highest-priority needs of patients first.
Communicating expectations and objectives to leadership and staff is essential to success, and every staff member must understand his or her role in achieving it.
Systemic problems require the development and implementation of new processes that will sustain success and prevent problems from recurring in the future.
Stand Downs, which address significant organizational needs, followed by system improvements, should be considered as tools to address both short-term and long-term objectives.
The U.S. Department of Veterans Affairs (VA) operates the largest integrated health care system in the country, with over 1,700 sites of care that serve almost 9 million veterans. Systemic challenges resulting from veterans’ demand for services that exceeded the capacity of the VA to deliver timely care led to a national crisis in 2014. Media reports on the VA’s access crisis suggested that hundreds of thousands of veterans may have been in immediate jeopardy due to long wait times for clinical services.
In addition, because of the way that the data on wait times had been maintained, it was not clear how many veterans were truly at risk for harm due to a delay in accessing care. This lack of data prevented us from effectively determining which action steps were most important in order to effectively address the access crisis. The VA had not previously analyzed its wait-time data on the basis of clinical urgency because of a number of data-limiting factors (for example, the electronic medical record allowed clinicians to order consults with 31 different prioritization categories).
To accelerate efforts to improve these access issues, we planned and successfully executed a one-day “Stand Down” event simultaneously in all 168 VA medical centers throughout the country. The goal of our Stand Down event was to meet the urgent-care needs of our patients and to ensure that veterans who were at greatest risk were seen first.
In military terms, stand down means to take a break from combat duties. The VA has previously utilized Stand Down events in our efforts to address veteran homelessness. These efforts bring together the VA and community-based resources during a single event to provide a comprehensive set of services to assist those who are in significant need. Our Stand Down event called on staff to take a break from regular duties and come to work on a Saturday to address the urgent-care needs of veterans.
Identifying Patients at Greatest Risk
We sought to focus our attention first on veterans who had been waiting the longest to be seen for primary care or other clinical services and were at the greatest risk for potential harm. The VA keeps data on wait times in a number of formats, but the measure that we found to be most reflective of the veteran experience was the number of veterans who had been waiting for care for more than 30 days beyond their preferred date for a consult or their clinically indicated date, as determined by a VA health care professional.
Since not all consults have the same urgency, we needed to identify veterans with the highest-priority needs first. We started by reclassifying our data on requests for consults into Urgent and Routine consults. We then sorted our data by the type of clinical service for which the veteran was waiting. A group of VA clinical leaders categorized all clinical services into clinical tiers. Tier 1 consults included all services for conditions that could have potentially serious medical consequences if there was a delay in care. For example, a consult for cardiology would be categorized as Tier 1, while a consult for audiology or a dietician would be categorized as a lower tier. Services that were determined to be Tier 1 and those that were classified as Urgent (as determined by the clinician who ordered the consult) were specifically targeted for the Stand Down.
A Coordinated System-Wide Approach
Once we had narrowed the scope of our challenge to the population of veterans whose urgent-care needs had either not been addressed at all or had not been addressed to their satisfaction, we set out to resolve these consults. Instead of having each of our 168 medical centers address their urgent consults in a different way and time frame, we decided to take a coordinated system-wide approach.
First, we organized a team of VA clinicians, administrators, practice management staff, and data analysts to plan the events across the country. The planning team was given two weeks to organize the national Stand Down. The team developed and distributed guidance for each VA site on how to conduct and locally staff its Stand Down.
Next, all 168 sites were provided with data on the wait time for each veteran with an urgent-care need. Many VA centers began contacting veterans the week before the Stand Down to offer appointments on the day of the event. These sites reached out to assess the clinical needs of the veterans who had been waiting longest for care. If veterans remained in need of care, they were offered the option of being seen by staff on the day of the Stand Down event. If veterans were not able to be seen that day or chose to wait, they were offered appointments at earlier dates whenever possible to decrease their wait.
Once the list showing the names and locations of veterans who had been waiting the longest for urgent care became available to the VA, there was a real sense of urgency to take action. As planned, the Stand Down occurred within two weeks after we obtained the data on urgent-care needs.
The National Stand Down Event
The national Stand Down took place on November 14, 2015. Each site contacted the targeted veterans on the wait lists, performed a clinical assessment of their current needs, and resolved the status of their consult with an updated plan of action. This plan of action could include asking a patient to come immediately to the VA medical center or a closer medical facility, scheduling a more timely appointment by creating additional time slots for seeing patients, or documenting that the veteran had already been seen or no longer required the consultation.
To assist the thousands of VA clinicians and many other staff and volunteers who participated in the Stand Down, we invited many of the VA’s partners to the Stand Down for on-site support during the event. These groups included third-party administrators, veterans service organizations, labor unions, volunteer organizations, academic partners, and the U.S. Department of Defense. We also sent executives from Washington, D.C., to sites across the country to augment our field staff. A command center at VA headquarters monitored the event as it unfolded at all of the sites that day.
We originally identified 56,527 urgent-care consults as needing to be reviewed. On November 16, 2015, we determined that 55,794 of the consults had been reviewed for clinical urgency and, of those, 46,046 patients had had their consult appropriately dispositioned (i.e., the veteran’s consult was closed, the veteran was seen but the clinical reports were not complete so the consult could not be closed at that time, or the veteran was scheduled for an upcoming appointment).
The remaining veterans — in the range of 10,000 or so — were unable to be contacted on the day of the Stand Down due to our inability to reach them (for example, because of a wrong phone number). Following the Stand Down, we continued our efforts to contact these veterans, and currently all but a few hundred have been reached and their urgent-care needs resolved.
After Action Review
Following the Stand Down, we requested that all 168 sites participate in an “After Action” review of the event and respond to questions about what went well, what could be improved, and what the VA can do to sustain the timeliness of care and prevent future delays.
The Stand Down taught us that, during a crisis, it is important to first ask the right question in order to prioritize efforts. In addressing the access crisis at the VA, this question was: Which veterans are at greatest risk from a delay in care? Once we were able to identify the highest-priority veterans, it was important to use those data to achieve and track measurable results.
As a result of data analytics developed for the Stand Down, all VA medical centers now have a real-time dashboard that shows all urgent consults and their wait times on a real-time basis.
In addition, we recognize that every patient’s sense of what constitutes an urgent-care need and what constitutes successful resolution may be different. VA clinicians now have only two levels of urgency to choose from when ordering consults (down from 31), and, as we redesign our systems for access, we recognize the need to educate veterans in how to work together to match their needs and VA resources.
Following the Stand Down, the VA committed to implementing same-day access for primary care and “First Contact Resolution” for mental health by the end of 2016. This goal is part of the overall transformation plan that seeks to bring human-centered redesign principles to the VA.
Our goal is to sustain the success of our first Stand Down and to not allow the backlog of urgent consults to rebuild. We are now implementing systemic approaches for improving access and sharing best practices across the system. Following the success of the first event, a second national Stand Down event was held on February 27, 2016. The use of Stand Downs, followed by systems redesign, is a new way of thinking that will help us in our quest to meet the health needs of veterans who require our help the most.