Since publication of the Institute of Medicine 

(IOM) report titled Crossing the Quality Chasm, 

much attention has focused on change within the 

culture of health care delivery systems. Within 

VHA, the culture shifts may be characterized as 

transformational. The shifts influence not only 

the larger VHA health care delivery system but 

also the changes required by individual providers 

in the delivery of health care, and in our medical 

education and research priorities. Importantly, 

our culture must also address the changes occurring to our Veterans themselves, both as individuals and as a population.

Transformational Systems Change

During the latter part of the 20th century, organizational change emerged as a science unto 

itself. Much has been written about the need to 

manage and lead change; this work has made 

clear the role of leaders in championing change 

and the need for proven methodologies in instituting change. During the same time, system 

management and change emerged as a core 

component of graduate medical education. 

In 2007, VanDeusen Lukas et al published findings critical for success in health care system 

change within VHA.1

 Their work demonstrated 

not only consistency between change in VHA 

and other health care delivery change models 

but also highlighted the required components of 

effective organizational transformation. These 

components include communicating the need 

for change, aligning and integrating change activities across all levels of a health care organization, 

and pairing leadership engagement with process 

improvement activities. 

The changes in the health care delivery system 

motivated by the Affordable Health Care Act, 

combined with the continued evolution of 

health care technologies such as e-connected 

medicine and the growth in patient engagement 

and expectations, have all contributed to a rapidly changing environment. In recent years, numerous initiatives have led to improvement and 

cultural change throughout VHA. As a result, 

VHA, in partnership with Veterans’ families, 

our students, and our trainees, is now engaged 

in building a culture of data-based continuous 

improvement to meet the ever-evolving needs 

of our Veteran patients.

Transforming the Individual 

Practice of Medicine

Of equal importance to the system-wide 

and cultural changes occurring within VHA, 

changes are taking place in the individual- and 

population-based care of our Veteran patients. 

Dougherty and Conway outlined the 3Ts 

of transformative change, providing insight 

into the characteristics of such change.2 The 

practice of medicine continues to move toward biomedical research strongly linked to 

clinical efficacy research (T1), thereby better 

defining the knowledge used in individual 

care decisions. T1 is balanced by improved 

population health achieved through outcomes, 

comparative effectiveness, and health services 

research—and translation of research into 

evidence-based tools for both clinicians and 

patients (T2). These practices, accompanied 

by effective measurement systems based in the 

domains of health care value (technical quality, 

access, satisfaction, and efficiency), comprise 

FORUM

Translating research into quality health care for Veterans

Commentary

Practicing, Teaching, and Researching in an 

Era of Transformational Change

Jeff Murawsky, M.D., Veterans Integrated Service Network 12, Westchester, Illinois

 October 2013

Contents

Director’s Letter 2

The Individual, Research, and 

Transformational Change 3

The Critical Role of Leadership 

in Creating a Culture of 

Improvement 4

Patient Engagement and Diabetes 

Self Management 5

Progress Toward Recovery 

Transformation in Mental Health 6 

Dialogue: A Conversation 

with Linda W. Belton of the

VHA National Center for 

Organization Development 7

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

for Information Dissemination and Education Resources, 

in conjunction with AcademyHealth. This and past issues 

of FORUM are available on the web at www.hsrd.research.

va.gov/publications/forum.
the third component (T3) of a culture that is 

able to adapt to and satisfy the requirement 

for continuous improvement. 

By applying the 3Ts across VHA practices, 

we can improve the care of our patients while 

aligning our research and educational missions. 

In fact, the 3Ts are reflected in our transformational initiatives around the Patient Aligned 

Care Team, Mental Health Integration, and EHealth initiatives—and through new sources of 

feedback, such as Patient Almanacs, Inpatient 

Evaluation Center, and Corporate Data Warehouse reports. Creating a culture of patient care 

decisions at the individual level, or an N of one 

patient, supported by population analytics or 

an N of 1,000, defines the proactive, patientcentered culture envisioned by large integrated 

health care delivery systems.

Supporting an Engaged, PatientCentered Culture

Change throughout the broader health care 

delivery system and research-driven individual 

patient care plans are necessary components 

of a successful organizational culture. Changes 

in our Veteran patients’ attitudes and expectations will more clearly refine both present 

and future culture changes. Enhanced engagement of patients in their care planning and 

self-management decisions will be central to 

reaching VA’s goal of improved Veteran wellbeing and improved population health. 

New educational methods and research efforts, 

such as those described by Dr. Weiner, are 

needed to understand this new dynamic and are 

important to effective organizational change. 

System and individual changes associated with 

an increased awareness of health care equity 

and literacy are key to achieving the desired 

care outcomes. Furthermore, these changes 

are necessary if VHA is to continue providing 

the high-quality medical education needed to 

develop the workforce to sustain a new culture. 

Through improved analytics, individualized care 

plans will change how we measure and achieve 

enhanced patient wellness, shifting from an 

absolute process-based outcome to an individually tailored outcome. “Patient centeredness” 

will redefine the journey of improvement from 

one that not only focuses on the application of 

evidence-based information but one that also 

addresses how such information is delivered and 

aligned with individual goals. 

Culture change is complex, continuous, multivariate, and essential to the effective delivery 

of health care services within VHA. The continued evolution of culture and practice is the 

only component of our system and practice 

that will not change. New models, methods, 

measures, technologies, and expectations are 

constantly emerging. VHA welcomes innovations in a culture that values safety, understands 

risk, redesigns systems, improves care based on 

data, and engages patients while honoring their 

preferences. At the same time, VHA will integrate leading-edge research and effective medical education to ensure that future generations 

effectively serve those who have served.

References

1. VanDeusen Lukas, C. et al. “Transformational Change 

in Healthcare Systems: An Organizational Model,” 

Health Care Management Review 2007; 32(4):309-20.

2. Dougherty, D. and P. Conway. “The ‘3T’s’ Road Map 

to Transform U.S. Health Care. The How of HighQuality Care,” Journal of the American Medical Association 

2008; 299(19):2319-21.

FORUM — Translating research into quality health care for Veterans 2

Director’s Letter 

The late Senator (and former sociologist) Daniel Patrick Moynihan famously said, “The central conservative truth is that it is 

culture, not politics, that determines the success of a society. 

The central liberal truth is that politics can change a culture....” 

Health care systems and researchers are increasingly paying attention to organizational culture in health care settings and how 

to improve it. Patient safety events often reveal local breakdowns 

in communication, teamwork, and leadership that enable problematic practices to 

develop; positive culture as assessed by VA’s All Employee Survey and other markers is correlated with better health care outcomes. 

The role of health care culture is central to at least three important clinical initiatives in VA. First, team training developed by the SimLearn Center is targeting 

the critical role of team communication in reducing surgical errors. Second, the 

Patient Aligned Care Team (PACT) rollout is illustrating the importance and challenge of building functioning, collaborative teams that include physicians, nurses, 

and support staff. Finally, the Office of Patient Centered Care and Cultural Transformation is piloting programs to transform VA culture into one where patients, 

rather than providers, are at the center of care. 

A 2003 review in the International Journal for Quality in Health Care identified key 

factors that impede culture change, including inadequate leadership; constraints 

imposed by external stakeholders and professional allegiances; perceived lack of 

ownership; and competing cultures within health care systems.1 

Health services research has contributed in various ways to our understanding of 

health care culture and culture change. Both HSR&D and QUERI benefit from the 

presence of anthropologists on various research teams. Research has contributed 

practical tools to measure culture and can illuminate those aspects of culture that 

may serve to either facilitate or impede efforts to improve care. A big challenge for 

research and health care systems is to develop and test effective programs that 

can either promote a healthy culture or improve a dysfunctional one. 

 

David Atkins, M.D., M.P.H. 

Director, HSR&D

1. Scott, T. et al. “Implementing Culture Change in Health Care: Theory and Practice,” International Journal for 

Quality in Health Care 2003; 15(2):111-8.

VA Office of Research & Development, Health Services Research & Development Service October 2013
VA Office of Research & Development, Health Services Research & Development Service October 2013

When I was a first-year medical student in the 

late 1980s, I was assigned to shadow a family physician in a rural New Hampshire town 

where many patients were uninsured. The 

physician’s receptionist knew everyone and 

made decisions about how much of patients’ 

fees would be waived or whether patients 

would be turned away. The doctor said that 

he did not concern himself with financial 

matters and was there to care for the patients. 

Years later, I had an opportunity to explore 

the role of front desk clerks in rationing access to care across large health care systems. 

Most striking was the minimal guidance given 

to frontline bureaucrats in how to manage 

patients who could not afford prepayments 

and how—in the absence of guidance—they 

made ad hoc decisions based on their personal 

values. The strongest predictor of whether an 

indigent patient received care was which clerk 

signed him or her into the office. 

Perhaps the most important message is that 

everyone in a health care organization is powerful and that, without a process for communicating its mission and obtaining everyone’s 

buy-in, the results are potentially capricious 

and chaotic. This lesson is particularly applicable to periods of organizational change. 

Dr. Murawsky emphasizes the importance of 

“communicating the need for change, aligning 

and integrating change activities across all levels of a health care organization, and pairing 

leadership engagement with process improvement activities” as essential ingredients for 

creating an effective environment for change. 

In essence, any effort designed to ensure that 

systems function properly is about getting everyone on the same page. First and foremost, 

the effort requires an acknowledgment of the 

interdependence and equal importance of all 

individuals in contributing to the desired outcome; other key elements include clear messaging, incentives, team building, leading by 

example, and an environment in which every 

individual is viewed—and views him- or herself—as a potential problem solver. 

How does the researcher’s perspective contribute to the organizational change process? 

From the researcher’s perspective, the patient, 

physician, and, indeed, all health system employees are potential research subjects. Health 

services researchers examine the interactions 

of myriad variables at the level of the organization, provider, and patient as they facilitate 

or impede the search for solutions to patients’ 

problems. Close partnership between research 

and operations assures that the right questions are being asked and that lessons learned 

inform decision making.

The changes occurring in VHA pose a specific 

challenge for systems leaders and researchers. Dr. Murawsky refers to this challenge as 

creating a “culture of patient care decisions 

at the individual level, or an N of one patient, 

supported by population analytics or an N of 

1,000. . . .” For health care organizations to 

advance in both arenas, we need valid metrics 

for both adherence to evidence-based practices 

and adaptation to patient context. Tools for 

measuring the former are far more developed 

and widely used than those for measuring the 

latter. 

Even as algorithms evolve toward sophisticated patient care management systems that 

permit us to tailor decisions based on risk levels, capture clinical actions, and incorporate 

patient preferences and goals, we still face the 

challenge of assessing whether care plans are 

adapted to patients’ life circumstances and 

needs, or context. For instance, if a particular 

patient’s blood pressure is poorly controlled 

because his medication delivery packages are 

routinely stolen from his entryway, will the 

provider elicit such information and propose 

that the patient pick up his medication at the 

clinic pharmacy? Adapting care to patient 

context must be a part of the culture of patient care decisions at the N of one patient. 

Challenges are opportunities to innovate. For 

instance, to assess clinician performance in 

contextualizing care, we both employ unannounced standardized patients and recruit real 

patients to audio-record their encounters. Our 

performance measure, Content Coding for 

Contextualization of Care, or 4C, is designed 

to answer four questions for each encounter. 

Were there clues—such as loss of control of a 

chronic condition—that a patient’s life situation is interfering with the patient’s care? If so, 

has the provider noticed and looked into the 

situation? If so, has the provider uncovered 

contextual factors—such as a Veteran’s loss of 

social support—that can be addressed? And, 

finally, is the provider or Patient Aligned Care 

Team taking the steps needed to adapt the care 

to the patient’s context? When care is adapted 

to the patient’s context, evidence is that patients experience better health care outcomes. 

No doubt, we have scratched only the surface 

with our focus on clinicians, given the key roles 

that even clerks may play when, for instance, 

patients show up late because of contextual 

factors that may be central to their care. 

This is, indeed, an exciting time as HSR&D 

researchers, focusing on evidence-based and 

patient-centered strategies, contribute innovative tools and new knowledge to support 

VHA’s commitment to transformative change 

that advances the care and health of Veterans. 

References

Kerr, E.A. and R.A. Hayward. “Moving toward a PatientCentered Performance Management System,” FORUM

October 2012.

Weiner, S.J. et al. “Patient-Centered Decision Making and 

Health Care Outcomes: An Observational Study,” Annals 

of Internal Medicine 2013; 158:573-9.

Weiner, S.J. et al. “Rationing Access to Care to the Medically Uninsured: The Role of Bureaucratic Front Line 

Discretion at Large Healthcare Institutions,” Medical Care

2004; 42(4):298-304.

Response to Commentary

The Individual, Research, and 

Transformational Change

Saul J. Weiner, M.D., Jesse Brown VA Medical Center, Chicago, Illinois

FORUM — Translating research into quality health care for Veterans 3
As VHA strives toward higher levels of Veteran-centered, data-driven, and team-based 

care, VA medical centers need to engage in 

continuous change and improvement. Recognizing that most medical centers have not 

yet fully developed a culture of improvement, 

the Office of Systems Redesign (OSR) initiated a program of Improvement Capability 

Grants (ICG) in 2009. OSR awarded grants 

to support local approaches to building improvement capability in five VISNs and 25 

VA medical centers in FY2009 and FY2010. 

OSR commissioned the Center for Organization, Leadership, and Management Research 

(COLMR) to evaluate the experiences of the 

grantees over the course of the program. 

One of the key findings that emerged from the 

evaluation is that strong senior executive support 

and engagement play critical roles in building 

a culture of improvement, consistent with the 

literature on the importance of senior leadership 

in organizational change (e.g., Beer, Eisenstat, 

& Spector, 1990; Lukas et al., 2007). While 

leadership at all levels is important, the drive for 

a sustained improvement culture must come 

from the top—in VA medical centers, leadership 

begins with the medical center director and the 

other members of the quadrad or pentad. 

The experiences of the ICG sites offer lessons in four areas to build strong improvement capability, lessons that can help senior 

executives foster needed change.

Vision and alignment. Senior executives develop, communicate, and translate a vision for continuous improvement that supports the medical center’s 

strategic and operational priorities. Senior executives create a motivating vision for improving 

the organization by focusing on the organization’s long-term goals. They see a clear 

direction for the organization’s future and 

have identified the path that will enable them 

to fulfill their vision. Senior executives align 

and integrate their vision with organizational 

priorities, structures, processes, and local context. In addition, they clearly communicate 

their vision for performance improvement 

to middle managers and staff. Leaders also 

acknowledge and reinforce positive behaviors 

that support their goals and encourage staff 

to take initiative in improving their work.

Personal expertise. Senior executives have deep 

knowledge about performance improvement principles and 

incorporate them in their management behavior. Senior 

executives are well-trained in advanced improvement methods so they can lead in a strong 

improvement culture and guide other staff in improvement management approaches. They serve 

as executive sponsors or coaches of improvement initiatives, and facilitate change by addressing barriers encountered in the improvement 

process. Senior executives actively participate in 

setting the performance improvement agenda by 

contributing to the identification, prioritization, 

adoption, implementation, and monitoring of 

improvement initiatives. They ensure that these 

initiatives support the facility’s overall strategic 

and operational priorities. Importantly, senior 

executives apply systems redesign tools and 

principles to respond to crises rather than using 

them only when time allows.

Infrastructure. Senior executives understand what 

is required in order for performance improvement 

projects and training to succeed, and they develop 

systems, processes, and structures to support success.

To develop a sustained culture of improvement, medical centers need both key staff 

with improvement expertise (i.e., system 

redesign coordinators and quality managers) 

and a larger group of trained staff versed in 

supporting improvement teams and helping 

spread improvement efforts on a daily basis 

across the medical center. Senior executives provide staff with the time and other 

resources required to engage in performance 

improvement and succeed in their work. 

They also hold staff accountable for applying their training, hold managers accountable 

for facilitating improvement, and implement 

reward systems to spur change efforts. Senior 

executives play a key role in supporting the 

development of data systems that track measures and monitor improvement progress. 

Finally, they develop structures and processes 

to elicit information about successful projects 

in order to acknowledge and promote accomplishments—and share lessons about factors 

that contributed to success; they also elicit 

information to learn from projects that failed. 

Staff engagement. Senior executives foster active 

collaboration and engagement in performance improvement efforts by establishing a psychologically safe environment. Senior executives show respect for 

their staff and recognize their considerable 

technical skills, tacit knowledge, and practical 

experience. They teach, coach, and monitor 

improvement work on the frontlines of care 

delivery. They manage by asking questions 

that stimulate staff to develop their own solutions. They encourage innovation by fostering 

an environment in which staff feel secure in 

taking risks and by accepting that failures may 

occur. Senior executives are also careful to 

demonstrate their support for improvement 

without dominating, thereby encouraging 

others to lead improvement efforts.

Active engagement of senior executives is critical to implementing strategies that build solid 

knowledge, skills, and commitment to systems 

redesign among senior leaders and middle managers; establish an infrastructure of improvement 

expertise; align improvement efforts with organizational priorities; and engage staff across the 

organization in routinely improving their work. 

Leadership at all levels of the organization is 

important, but the drive for a sustained improvement culture must come from the top. 

References

Beer, M., Eisenstat, R. A., and Spector, B. “Why Change 

Programs Don’t Produce Change,” Harvard Business 

Review 1990; 68(6):158-66.

Lukas, C.V. et al. “Transformational Change in Health 

Care Systems: An Organizational Model,” Health Care 

Management Review 2007; 32(4):309-20.

FORUM — Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service October 2013

Research Highlight

The Critical Role of Leadership in Creating 

a Culture of Improvement

Carol VanDeusen Lukas, Ed.D., Lauren Babich, Ph.D., Martin P. Charns, D.B.A., 

Center for Healthcare Organization and Implementation Research, VA Boston 

Healthcare System, Boston, Massachusetts
VA Office of Research & Development, Health Services Research & Development Service October 2013

FORUM — Translating research into quality health care for Veterans 5

At any given time, over 1 million Veterans 

receive health care services for diabetes, 

and many suffer adverse vascular outcomes, 

such as myocardial infarction, blindness, 

and peripheral artery disease. Glycemic control, as measured by hemoglobin (Hb) A1c, 

is associated with lower morbidity and mortality. Given that diabetes is a self-managed 

condition, achieving diabetes control requires patient involvement in most aspects 

of treatment planning and management.

Personalized Diabetes Care Using 

Patient-Reported Measures

Patient-reported measures, such as functional health literacy (FHL) and patient 

activation, play critical roles in achieving 

diabetes control through enhanced diabetes 

self-management.1, 2 Thus, identifying these 

characteristics and incorporating information on these characteristics into routine 

self-management and collaborative goal 

setting may lead to better patient outcomes. 

The ability to integrate information about 

FHL and patient activation into the context 

of traditional primary care encounters is, 

however, limited. Nonetheless, VA’s transition to Patient Aligned Care Teams (PACT) 

provides an opportunity for developing and 

implementing patient-centered, personalized 

approaches to diabetes care that are aligned 

with patient preferences.

While the independent effects of FHL and 

patient activation on diabetes control are well 

documented, their combined effect is less clear. 

Using brief, validated screening measures, we 

explored the relationship between/among 

FHL, patient activation, and glycemic control 

in a cohort of multimorbid, diabetic Veterans 

receiving care within VA PACTs.

Brief Measures of Functional Health 

Literacy and Patient Activation 

Using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD9-CM) diagnoses codes and relevant ICD-9-CM 

and Current Procedural Terminology procedure 

codes, we identified Veterans who had coexisting hypertension, diabetes, and ischemic heart 

disease and were receiving primary care between 

November and December 2010. We excluded 

patients with limited life expectancy and those 

who died during the study period. We mailed 

to eligible participants a self-administered 

questionnaire with brief measures of FHL and 

patient activation and then collected laboratory, 

demographic, and clinical data from the medical 

records of the patients who returned surveys. 

Using validated scoring for the Single Item Literacy Screener and the Patient Activation Measure, we classified patients based on their level 

of health literacy and patient activation into four 

categories.3 We based these categories on combined high versus low levels of FHL and patient activation, e.g. high FHL/high activation. 

Subsequently, we examined the relationship 

between/among patients’ self-reported FHL, 

patient activation, and mean HbA1c levels. 

We received surveys from 195 individuals (50 

percent response rate). Of those, we studied 

183 individuals (94 percent) with complete data 

for all variables in the analyses. The mean age of 

the study cohort was 68 years. We found a normal distribution for FHL and patient activation, 

with approximately 50 percent of participants 

reporting high FHL and 45 percent reporting 

high patient activation. Patients identified with 

both high FHL and patient activation (i.e., high 

FHL/high activation) had significantly lower 

HbA1c levels compared to those with low levels 

of both FHL and patient activation. 

Bringing Personalized Diabetes 

Care to the Clinical Encounter 

Providing high-quality care to patients with 

diabetes can pose significant challenges. 

However, VA’s transformation to the PACT 

model of care offers the ideal setting in 

which to meet these challenges. One approach to providing more personalized care 

is to incorporate into routine PACT care 

patient self-reported measures (e.g., FHL 

and patient activation) that have been shown 

to influence diabetes outcomes. We demonstrated that brief, validated measures of FHL 

and patient activation may be feasibly obtained among multimorbid Veterans within 

the context of primary care encounters. 

Further, we found that the combined effects 

of FHL and patient activation are associated 

with better glycemic levels. Thus, understanding patients’ FHL and activation levels 

may result in more personalized care and a 

greater likelihood of diabetes control. 

Future research is needed to inform how 

measures of FHL and patient activation can 

be efficiently integrated into routine discussions between patients and their clinicians. 

Interventions that incorporate information 

about patients’ FHL and activation levels 

hold promise for providing collaborative care 

that is personalized to patients’ desired level 

of engagement and understanding of diabetes 

self-management.

References

1. Schillinger, D. et al. “Association of Health Literacy 

with Diabetes Outcomes,” The Journal of the American 

Medical Association 2002; 288:475-82.

2. Remmers, C. et al. “Is Patient Activation Associated 

with Future Health Outcomes and Healthcare Utilization among Patients with Diabetes?” The Journal of 

Ambulatory Care Management 2009; 32:320-7.

3. Morris, N.S. et al. “The Single Item Literacy Screener: 

Evaluation of a Brief Instrument to Identify Limited 

Reading Ability,” BMC Family Practice 2006; 7:21.

Research Highlight

Patient Engagement and Diabetes 

Self-Management 

LeChauncy D. Woodard, M.D., M.P.H., and Aanand D. Naik, M.D.,

Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, 

Houston, Texas
FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service October 2013

A decade ago, the President’s New Freedom 

Commission outlined a vision of recoveryoriented mental health services. As part of 

the “recovery transformation,” the commission foresaw a future in which “everyone of 

all ages with a mental illness would have access to effective treatments and supports—

the essentials for living, working, learning 

and participating fully in the community.”1

Although VA is a national leader for many 

indicators of care quality, improving mental health care has proven challenging. To 

determine whether patients are receiving appropriate mental health treatment, it is often 

necessary to know patients’ preferences, 

outcomes, and history of psychosocial services. Given that such information is often 

not documented in medical records, policymakers have struggled to identify gaps in 

mental health service provision and to tailor 

the delivery of needed services. One approach to implementing recovery-oriented 

care calls for informing patients of potentially beneficial services, educating clinicians 

about new evidence-based practices, and 

monitoring implementation to ensure the 

delivery of services that improve outcomes.

Implementing Recovery

Recovery transformation includes returning 

Veterans to mainstream jobs, also known 

as “competitive employment.” VA has a 

national program of individual placement 

and support, an evidence-based approach to 

supported employment (SE) for individuals 

with serious mental illness. This SE model 

has the singular goal of competitive employment and is characterized by rapid job 

search, an alliance between an SE specialist and the Veteran’s treatment team, and 

ongoing support of the individual during 

employment. Eligibility for SE is based only 

on an individual’s expressed interest in returning to work; there are no requirements 

regarding the presence of symptoms, for example. Evidence shows that SE helps about 

60 percent of enrollees secure competitive 

employment while traditional rehabilitation 

programs help approximately 10 to 20 percent of enrollees find employment. In fact, 

receipt of SE is the single best predictor of 

employment among individuals with serious 

mental illness. Employment can improve 

symptoms and social skills, increase selfefficacy, and reduce costs. 

Despite evidence of its effectiveness, SE 

has been vastly underused. A 2009 SAMHSA survey indicated that only 2 percent of 

individuals with serious mental illness nationally receive SE services. Several factors 

may contribute to underuse of SE services, 

including: (1) in usual mental health care 

settings, individuals are not routinely asked 

if they would like to return to work; (2) 

many individuals with serious mental illness 

are not strong advocates for themselves; 

(3) many clinicians are not knowledgeable 

about the eligibility requirements for SE; 

and (4) caseloads for SE specialists are typically full, with a waiting list for enrollment. 

Transforming Care Practices

The overarching aim of the VA HSR&D 

QUERI project, “Enhancing Quality of Care in Psychosis (EQUIP),” was 

to improve the use of evidence-based 

recovery-oriented services by Veterans with 

schizophrenia. This 15-month, clinic-level, 

controlled trial engaged four VISNs and 

enrolled 801 adults with schizophrenia and 

171 clinicians across eight specialty mental 

health clinics. Each VISN selected two services to be targeted, and each VISN selected 

SE as one of the services. 

Each site used evidence-based quality improvement tools to determine why eligible 

Veterans were not using SE. Researchers 

partnered with leaders at each site to identify gaps in care processes and to address 

deficiencies in knowledge. Sites installed 

patient-facing kiosks that permitted patients to self-report their clinical status, 

preferences, and treatment use. The kiosks 

queried patients about their interest in returning to work, whether they had received 

a referral to SE, and, if yes, how many SE 

appointments they had attended in the 

previous month. The kiosk printed reports 

for patients on the spot. If appropriate, the 

patient-level report provided either “talking 

points” that patients could use with their clinicians to discuss an SE referral or written 

encouragement for beginning or sustaining 

the use of SE services. The study also generated reports for clinicians with names and 

dates of their patients who reported interest 

in returning to work or who were previously 

referred, along with their attendance rate.

Study results indicated that Veterans at intervention sites were twice as likely to use SE 

services during the study compared to Veterans at control sites. A formative evaluation 

indicated an increase in SE capacity at intervention sites, including the addition of an SE 

worker, SE training for additional clinicians, 

and adjustments to SE caseloads to allow 

for new patients. Employment differences, 

a more distal outcome, were evident when 

examining site-level differences; an intervention site with good fidelity to the SE model 

showed significant increases in employment. 

References

1. President’s New Freedom Commission on Mental 

Health (2004). Achieving the Promise: Transforming Mental Health Care in America. Final Report. 

2. Drake, R.E., Bond, G.R., Becker, D.R. et al. (2012). 

Individual Placement and Support: An Evidence-Based 

Approach to Supported Employment. New York: Oxford 

University Press. 

3. Hamilton, A.B. et al. “Implementation of EvidenceBased Employment Services in Specialty Mental 

Health: Mixed Methods Research,” Health Services 

Research. In press.

Research Highlight

Progress Toward Recovery 

Transformation in Mental Health 

Alexander S. Young, M.D., M.S.H.S., and Amy N. Cohen, Ph.D., VA HSR&D Center for 

the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles VA 

Healthcare Center, Los Angeles, California
VA Office of Research & Development, Health Services Research & Development Service October 2013

FORUM — Translating research into quality health care for Veterans 7

FORUM recently sat down with Linda 

Belton, Director, Organizational Health, 

VHA National Center for Organization 

Development, to discuss her views 

on culture change and organizational 

transformation in VHA.

Would you briefly describe the mission of 

VHA’s National Center for Organization 

Development (NCOD) with respect to 

VHA’s organizational culture?

NCOD is an internal consulting service to 

VA leaders and staff in support of workforce 

engagement and satisfaction to enhance Veteran outcomes. Practitioners in organizational 

development integrate service, training, and 

research in ways that positively affect culture. 

The mission of Organizational Health is to 

help create an environment where employees 

want to work and Veterans want to receive care. 

If we had a motto it would be “All Things 

Connected.” Acting as conveners, we bring 

together diverse programmatic efforts within 

VA under the organizational health umbrella.

What strategies does the NCOD 

use to address organizational culture 

and change in VHA—across the 

patient, organization/system, and 

provider levels?

A primary strategy is data-driven assessment 

through on-site consultation or online tools, 

including the All Employee Survey (AES), 

360/180 degree, change management, and 

team and Servant Leadership assessments. 

With that information in hand, NCOD staff 

help individuals and work groups fashion 

practical plans. We then support those plans 

through executive coaching, leadership development, team building, facilitation, transition 

briefings, change management, enhancement 

of psychological safety, and AES action 

planning. (Psychological safety is the ability 

to give input, feedback, disagree, etc., without 

fear of reprisal.) 

Can you provide an example or two of 

recent successes with regard to organizational culture and change?

NCOD’s Civility, Respect and Engagement 

in the Workplace (CREW) program offers an 

excellent example of the significant impact 

that culture change can have in VHA. As we 

know, patient-centered care is best delivered 

by an engaged, empowered workforce. With 

that in mind, NCOD launched CREW in 

2005 to address AES findings of low civility, 

which appeared to affect outcomes adversely. 

NCOD’s data provide a business case for 

civility: less sick leave, fewer Equal Employment Opportunity complaints and grievances; 

lower ICU mortality rates and lengths of stay;

higher patient and employee satisfaction; enhanced psychological safety; and reductions 

in work-related injuries.1 CREW is rooted in 

relationship and team building via regular, 

facilitated work group meetings. Post-CREW 

data demonstrate statistically significant improvement in civility scores. More than 1,200 

work groups have now participated in CREW. 

In 2011, The Joint Commission recognized 

CREW as a best practice.

Another excellent example is Organizational 

Health’s endorsement of “Servant Leadership” as a framework for achieving transformational change. Leadership is critical 

to shaping and sustaining culture. In fact, 

NCOD data illustrate a spillover effect from 

leaders’ behaviors to employees’ perceptions 

of their workplace and Veterans’ perceptions 

of their care.2

 

Servant Leadership is a philosophy that distinguishes “serving to lead” from “leading to 

serve.” It values characteristics such as putting 

people first, integrity, humility, building teams 

and communities, leading change effectively, 

exercising stewardship, sharing power, and 

establishing a culture of accountability. 

To help VA leaders grow as Servant Leaders, 

NCOD designed a 360-degree assessment to 

gauge Servant Leader skills. The VA Servant 

Leader 360 is behaviorally based, developmental, and action-oriented. Participants 

receive an electronic report and a consultation 

session with NCOD. Interested readers may 

contact Jaimee.Robinson@va.gov.

What do you see as the biggest challenges in the next one to three years in 

terms of culture and change in VHA? Any 

words of wisdom or opportunities you 

see for our readers regarding organizational culture and change?

Over the next several years, we can expect a 

“permanent whitewater” of change, reflecting 

shifts in legislative direction, Veteran demand, 

and culture. NCOD will continue to support 

change efforts in VA. Perhaps the biggest 

challenge is not any one event or issue 

but rather the way in which we approach 

change itself. Culture change doesn’t happen 

by caveat, policy, or training; it happens in 

the “interstitial spaces.” I believe the 

real challenge of managing culture change 

(and where NCOD can be most helpful) lies 

in the following:

• Patience. Culture change won’t be accomplished by next quarter or next year. It takes 

time to assimilate change into all levels of 

the organization. True culture change is 

woven into the fabric of the organization.

• Persistence and focus. Avoid the “flavor 

of the month” phenomenon. Juggling too 

many culture change efforts risks diluting 

the change that’s really important. Set the 

direction and maintain “true north.”

Dialogue

A Conversation with VHA National 

Center for Organization Development’s 

Linda Belton

Continued on page 8
Peter L. Almenoff, M.D., FCCP, 

Director of Operational

Analytics and Reporting, Office 

of Informatics and Analytics, 

Washington, D.C.

David Atkins, M.D., M.P.H.,

Director, HSR&D

VA Central Office,

Washington, D.C.

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse

Executive, VA New York

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A.,

Director, VA HSR&D Center

of Innovation, Boston, MA

Seth A. Eisen, M.D., M.Sc.,

Past Director, HSR&D

VA Central Office,

Washington, D.C.

Joseph Francis, M.D., M.P.H.,

Director of Clinical Analytics 

and Reporting, Office of

Informatics and Analytics, 

Washington, D.C.

Skye McDougall, Ph.D.,

Chief Medical Officer

VAMC Long Beach,

Long Beach, CA

Richard Owen, M.D., Director, 

VA HSR&D Center of

Innovation, Little Rock, AR

DeAnne M. Seekins, MBA, VA 

Medical Center Director,

Durham, NC

Frances Weaver, Ph.D.,

Director, VA HSR&D Center 

of Innovation, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

• Draw the connections. We sometimes 

see conflicting priorities that, if understood in the larger systems context, may 

not be conflicting at all. Helping employees connect the dots between programs 

and initiatives, between culture change 

and VA’s mission, brings us back to the 

common denominator: the Veteran.

• Leadership. Culture change cannot be 

delegated; it must be led. Alignment, consistent messaging, and authentic modeling 

are all key components of culture change. 

• Make it real. How can change be made 

meaningful to every employee? Does 

every employee know what he or she will 

do differently to support the change? 

If we help employees find their own 

answers to these questions, we create 

a personal connection to change and 

the organization’s mission. That’s when 

change becomes transformation and 

transformation becomes culture.

References

1. VHA Office of Public Health, Occupational Health 

Division (2012).

2. National Center for Organization Development: 

Executive Teams Assessments and AES, 2011; AES 

and SHEP 2008–2012.

Continued from page 7

FORUM

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