Federal Register / Vol. 79, No. 228 / Wednesday, November 26, 2014 / Notices 70617 

1Public Law 113–146. Signed into law by 

President Obama on August 7, 2014; the statute’s 

full title is, ‘‘To improve the access of Veterans to 

medical services from the Department of Veterans 

Affairs, and for other purposes.’’ Besides Section 

203, another key provision of this law (Section 101) 

is relevant to portions of this report because it 

requires hospital care and medical services to be 

furnished to Veterans through agreements with 

specified non-VA facilities if Veterans: (a) Have 

been unable to schedule an appointment at a VA 

medical facility within the Veterans Health 

Administration’s (VHA’s) wait-time goals for 

hospital care or medical services and such Veterans 

opt for non-VA care or services; (b) reside more 

than 40 miles from a VA medical facility; (c) reside 

in a state without a VA medical facility that 

provides hospital care, emergency medical services, 

and surgical care and such Veterans reside more 

than 20 miles from such a facility; or (d) reside 

within 40 miles of a VA medical facility but are 

required to travel by air, boat, or ferry to reach such 

facility or such Veterans face an unusual or 

excessive geographical burden in accessing the 

facility. Section 101 also provides for such care 

through agreements with any healthcare provider 

participating in the Medicare program, any 

federally-qualified health center, the Department of 

Defense (DoD), and the Indian Health Service (IHS). 

2 In June 2014, Senator Mark Warner sent a letter 

to President Obama offering pro bono private sector 

assistance to address the VA’s exam scheduling and 

workflow challenges. (The pro bono offer to help 

VA leveraged a template established in 2010–11, 

when NVTC, at the request of Senator Warner, 

partnered with the U.S. Army to help address the 

serious technology and business process challenges 

being encountered at Arlington National Cemetery.) 

Health and Human Services (HHS), VA 

medical treatment facilities are required 

to query the NPDB at the time of initial 

appointment for all licensed, registered, 

and certified health care professionals 

which is followed with the enrollment 

in the NPDB Continuous Query (CQ) 

process with annual renewal of all 

licensed independent practitioners 

appointed to a VA medical treatment 

facility. In accordance with 38 CFR, 

Chapter 1, Part 46, information is 

collected so that VA can consider if 

malpractice payments were made 

related to substandard care, professional 

incompetence, or professional 

misconduct on the part of a licensed 

health care practitioner or if any 

adjudicated adverse action was taken 

against the licensure or clinical 

privileges of a these health care 

practitioner. 

Additionally, complete and thorough 

credentialing is required to assure that 

only qualified healthcare professionals 

provide care to our Nation’s veterans. 

The term credentialing refers to the 

systematic process of screening and 

evaluating qualifications and other 

credentials, including licensure, 

required education, relevant training 

and experience, current competence and 

health status. 

Affected Public: Individuals or 

Households. 

Estimated Annual Burden: 2,500 

burden hours. 

Estimated Average Burden per 

Respondent: 5 minutes. 

Frequency of Response: Annually. 

Estimated Number of Respondents: 

s500. 

Dated: November 21, 2014. 

By direction of the Secretary. 

Crystal Rennie, 

Department Clearance Officer, Department of 

Veterans Affairs. 

[FR Doc. 2014–27849 Filed 11–25–14; 8:45 am] 

BILLING CODE 8320–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

Publication of Technology Task Force 

Review of Scheduling System and 

Software of the Department of 

Veterans Affairs 

AGENCY: Department of Veterans Affairs. 

ACTION: Notice. 

SUMMARY: The Veterans Access, Choice, 

and Accountability Act of 2014 directs 

the Department of Veterans Affairs (VA) 

to publish a report of the Northern 

Virginia Technology Council’s review of 

VA’s health care scheduling system and 

software. This Federal Register Notice 

announces VA’s publication of the 

Council’s report. 

ADDRESSES: The Council’s entire report 

on VA’s health care scheduling system 

and software is available at http://

www.va.gov/opa/choiceact/. 

FOR FURTHER INFORMATION CONTACT: 

James A. Tuchschmidt, MD, Acting 

Principal Deputy Under Secretary for 

Health (10A), 810 Vermont Avenue 

NW., Washington, DC 20420, 

Telephone: 202–461–7008 (this is not a 

toll-free number). 

SUPPLEMENTARY INFORMATION: Section 

203 of the Veterans Access, Choice, and 

Accountability Act of 2014 (Pub. L. 

113–146, ‘‘the Act’’) directs the 

Department of Veterans Affairs (VA), 

through the use of a technology task 

force, to conduct a review of VA’s needs 

with respect to its scheduling system 

and scheduling software used to 

schedule appointments for veterans for 

hospital care, medical services, and 

other health care. The Act requires that 

the task force provide VA and Congress 

with a report on its review within 45 

days of enactment, and that the report 

include: 

• Proposals for specific actions to be 

taken by VA to improve its health care 

scheduling system and scheduling 

software; and 

• A determination as to whether one 

or more existing off-the-shelf systems 

would meet VA’s needs to schedule 

health care appointments for veterans 

and improve the access of veterans to 

such care. 

On September 11, 2014, VA signed a 

Memorandum of Agreement with the 

Northern Virginia Technology Council 

to conduct the review. On October 29, 

2014, the Council completed its review 

and provided VA with a report titled, 

‘‘Opportunities to Improve the 

Scheduling of Medical Exams for 

America’s Veterans: A Report Based on 

a Review of VA’s Scheduling Practices 

by the Northern Virginia Technology 

Council (NVTC).’’ 

This Federal Register Notice 

announces the Council’s report on its 

review of VA’s scheduling system and 

software. The Executive Summary of the 

report is as follows: 

Executive Summary 

This section provides a brief summary 

of this Report by answering three 

fundamental questions: 

• Why was this review performed for 

the VA? 

• What were the findings that 

informed the NVTC’s recommendations 

to VA? 

• What recommendations were 

rendered by NVTC? 

Why NVTC Conducted This Review 

The impetus for NVTC’s review is 

found in Section 203 of the [Veterans 

Access, Choice, and Accountability Act 

of 2014] 1. Section 203 called for a 

Technology Task Force to perform a 

review of VA’s scheduling system and 

software. 

Following the law’s enactment, 

NVTC 2 began working with VA to 

develop a plan for a team of NVTC 

member companies to evaluate VA’s 

scheduling processes and systems, for 

the purpose of recommending 

scheduling improvements. In a 

Memorandum of Agreement (MoA) 

signed by both parties on September 11, 

2014, VA accepted NVTC as the 

Technology Task Force required by 

Section 203 of the [Act]. In a Scope of 

Work statement, attached to the MoA, 

the agreed latitude of NVTC’s Review 

was outlined—i.e., for NVTC to examine 

and propose improvements to: 

• The scheduling of a new patient for 

his or her first visit. This would start 

with VA’s attempt to arrange exam 

appointments, and include the activities 

required to schedule, communicate, and 

confirm each appointment with the 

Veteran, concluding with the exam itself 

and the delivery of requested exam 

results. 

• The scheduling of a specialty 

consult visit from initial request from a 

primary care physician through the 

appointment being scheduled, 

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70618 Federal Register / Vol. 79, No. 228 / Wednesday, November 26, 2014 / Notices 

3NVTC selected Booz Allen Hamilton (BAH), HP, 

IBM, MITRE, and SAIC to serve as the core team 

for coordinating with other member companies 

(MAXIMUS, Qlarion, and Providge Consulting) to 

conduct this Review. 

4The two site visits by the NVTC Team were 

graciously hosted by the VAMC Directors at the 

VA’s Medical Centers in Richmond and Hampton, 

Virginia. 

5From the ‘‘vendor library,’’ available on the 

Federal Business Opportunities (FedBizOps, to 

support VA’s solicitation to procure a new medical 

appointment scheduling solution: https://

www.fbo.gov/index?s=opportunity

&mode=form&id=6672c05c6f046cf98d178d89

81884d94&tab=core&tabmode=list&. 

6Final Report on the Patient Scheduling and 

Waiting Times Measurement Improvement Study, 

Booz Allen Hamilton, July 11, 2008 (hereinafter 

referred to as the 2008 Booz Allen Hamilton Wait 

times report). 

7Business Blueprint for VHA Medical 

Appointment Scheduling Solution, Department of 

Veterans Affairs, May 2014. 

communicated, and confirmed with the 

veteran (also concluding with the exam 

and effective delivery of its results). 

In examining these two foundational 

processes, NVTC agreed to an approach 

that is segmented into an analysis of 

four domains: People, process, 

technology, and performance 

measurement. The purpose of NVTC’s 

review was to identify improvement 

opportunities and recommend actions 

that will enable VA leaders to restore 

America’s confidence in the enduring 

integrity of VA while servicing the 

health care needs of those who have 

selflessly served our country. The NVTC 

Team’s approach to this assignment has 

been to discover root causes of VA’s 

scheduling challenges in an effort to 

identify ways to help VA overcome 

them. The NVTC Team 3 conducted a 

six-week effort (September 15 to 

October 29, 2014) to review VA’s 

current scheduling ‘‘systems,’’ which 

include people, processes, technologies, 

and performance measures. The 

findings and recommendations 

identified in this report were greatly 

informed by on-site observations at two 

VA medical centers.4 During these 

visits, the NVTC Team met with VA 

staff to not just solicit information from 

them about the issues and challenges 

they encounter on the job, but also to 

listen to their ideas on how veterans 

might be better served by making 

changes to current scheduling 

processes, procedures, and practices. 

During the two site visits the NVTC 

Team was able to make, it met with 

many dedicated leaders, health care 

providers, schedulers and other 

specialists, all of whom were 

remarkably cooperative, clearly 

dedicated to providing high-quality 

services to veterans, and quite generous 

in terms of the amount of time and 

information they readily shared with 

NVTC Team members. The NVTC team 

also observed a number of practices that 

had been put in place in the last six 

months to improve the timeliness of 

patient appointments. Additional 

opportunities for improvement still 

exist, however. In addition to the two 

day-long site visits, NVTC team 

members also examined a library of 

scheduling related information 5— 

provided by VA—to gather additional 

insight on the challenges and issues 

addressed in this report. 

While this report is based on site 

visits and data from only two VA 

medical centers, we are reasonably 

confident that the findings are 

generalizable to many other VA medical 

facilities. We make this assertion 

because the findings of this Report are 

very similar to the findings of an older 

but more comprehensive Wait Times 

study done by Booz Allen Hamilton in 

2008. That study was much larger and 

included longer site visits to 25 VA 

medical centers and many of their 

community-based outpatient clinics. 

The recommendations of this Report 

echo those of the earlier Wait Times 

report and suggest that the issues 

identified are representative and 

enduring. We feel that this significantly 

enhances the power of the NVTC Report 

and the recommendations that have 

been made.6

It is the consensus of the NVTC Team 

that the recommendations in this report 

will take a significant amount of time to 

be fully implemented, assuming they 

are accepted. Indeed, incremental but 

sustained improvements, based on a 

comprehensive plan of action will be 

needed—subject to persistent 

monitoring and periodic assessments— 

to ensure that initial gains in 

accountability and performance quality 

actually lead to results that consistently 

satisfy the health care access and 

delivery needs of America’s veterans. 

NVTC is pleased to present this 

document with its findings and 

recommendations for improving the 

scheduling of medical exams for 

America’s veterans. 

What NVTC Found 

Through its on-site observations and 

analyses of current business processes, 

available technologies, and a review of 

industry and government best practices, 

the NVTC Team identified a number of 

findings and recommendations designed 

to help VA leaders address their most 

critical challenges. During that review 

period, a common theme emerged from 

the Team’s analyses that can be 

summarized as follows: VA’s examscheduling processes are insufficiently 

enabled by state of-the-art technologies 

or (consistently applied) standard 

operating procedures. This situation has 

resulted in a counterproductive and 

error-prone working environment that 

has frustrated staff members for years, 

thus fueling a persistent staff-retention 

problem, the net effect of which has 

contributed in no small part, it appears, 

to the gradual erosion of public 

confidence in the Department’s ability 

to provide veterans with timely access 

to needed health care services. 

NVTC’s Team confirmed what VA 

already acknowledges—that the current 

scheduling processes do not adequately 

meet the needs of veterans, health care 

providers, or scheduling staff members.7

Clinic grids are inflexible, productivity 

cannot be accurately measured, not 

enough scheduling resources (staff, 

rooms, equipment, etc.) are available, 

and linkages among scheduled 

appointments and ancillary 

appointments (e.g., lab and radiology) 

are not established. In the latter 

instance, the absence of such links 

results in appointment cancellations 

and rebookings, additional travel costs, 

and higher levels of veterans’ 

dissatisfaction. 

Though the findings of the NVTC 

Team may not be all that different from 

those already documented in VA, it is 

hoped that, with the recommendations 

that follow, VA leaders will better 

understand how issues in one 

deficiency area (e.g., staff retention) 

actually cause (or exacerbate) persistent 

issues in other areas (e.g., the nonstandard usage of scheduling processes 

and procedures). Other examples of this 

cause-and-effect relationship is the 

impact of inflexible clinic grids on the 

tendency to over-book scheduled 

appointments, or the impact of a 

scheduler’s inability to simultaneously 

view the schedules of multiple 

providers (a technical resource issue) on 

the ability of a scheduler to 

appropriately sequence ancillary 

appointments (often perceived as a 

human performance issue). Yet another 

is the impact of placing too much 

managerial emphasis on metrics that do 

not have the effect of driving desired 

scheduling behaviors. 

NVTC Team members also hope that 

the insights derived from their analyses 

of VA’s longstanding scheduling issues 

will shed a different light on the relative 

weight of individual issues, in terms of 

their respective impacts on scheduling 

activities, end-to-end. Also, some of 

NVTC’s key recommendations may 

prove to be somewhat more innovative 

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Federal Register / Vol. 79, No. 228 / Wednesday, November 26, 2014 / Notices 70619 

8Consistent with findings and Recommendations 

of 2008 Booz Allen Hamilton Wait times report. 

than others received by VA leaders in 

the past. 

At a minimum, the NVTC 

recommendations should provide a 

useful framework for tackling near term 

challenges and issues, while at the same 

time motivating VA leaders to work 

with maximum urgency, to significantly 

enhance the experiences of veterans 

served by the Department, which will 

lead to a steady rebuilding of public 

trust in both the timeliness and quality 

of healthcare being provided to 

America’s most deserving heroes. 

What NVTC Recommends 8

As a result of its analysis of VA’s 

scheduling processes, technologies, 

people, performance measures, and 

industry best practices, the NVTC team 

derived a total of 39 recommendations 

from its multi-dimensional review of 

VA’s current medical exam scheduling 

operations. These 39 key 

recommendations—each of which is 

identified in the body of this Report— 

are associated with the following 13 

groups of identified, key issues: 

• Appointment Scheduling (Process) 

• Appointment Metrics (Process) 

• Patient Capacity (Process) 

• Communications (Process) 

• System Usability (Technology) 

• Systems/Data Integration 

(Technology) 

• IT Infrastructure Support 

(Technology) 

• Recruitment/Hiring (People) 

• Training/Development (People) 

• Staff Retention (People) 

• Staff Management (People) 

• Patient Wait Times (Performance) 

• Management Data Usage 

(Performance) 

More than half (i.e., 20) of the Team’s 

39 recommendations were derived from 

the four People-related groups of key 

issues: Recruitment/Hiring, Training/

Development, Staff Retention, and Staff 

Management. 

The other 19 recommendations were 

fairly evenly distributed among the 

Process, Technology, and Performance 

dimensions of NVTC’s Review. The fact 

that 51.3 percent of the Team’s 

recommendations align with ‘‘people’’ 

issues should not be misinterpreted by 

readers of this Report. More to the point, 

it must not be seen as an adverse 

reflection on the schedulers, health care 

providers, and other VA staff members 

currently engaged in scheduling 

activities at VA’s medical facilities, who 

work quite hard—indeed, much harder 

than should ever be necessary—in their 

creative efforts to compensate for all the 

issues driving the 19 other process-, 

technology-, and performance-related 

recommendations made by the NVTC 

Team. 

Furthermore, when it comes to crosscutting issues discovered as a result of 

this Review, the evidence suggests that 

virtually all of the 19 issues driving the 

process-, technology-, or performancerelated recommendations (in Section 4 

of this Report) demonstrably impact, 

either directly or indirectly, at least one 

of the people-related issues/

recommendations. 

Consider, for just one example, the 

issue identified as ‘‘Additional Exam 

Rooms’’ under the Patient Capacity 

group (in subsection 4.1 of the full 

Report): 

• The NVTC Team found that at least 

two exam rooms per provider are 

needed to allow rooming a patient while 

providing other team members (or 

providers) co-visiting opportunities. 

And, larger rooms would more readily 

permit efficient engagement of multiple 

team members in real time. Yet, it 

appears that only one exam room is 

provided in many situations observed at 

the medical centers visited by the NVTC 

Team during the course of this Review. 

This process-related issue, which 

resulted in a recommendation that 

additional exam rooms be provided, has 

a direct impact on one of the Peoplerelated issues identified (in subsection 

4.3 of the full Report), having to do with 

schedulers and providers working 

together as a team (for the benefit of 

Veterans). It also impacts the 

productivity of health care providers at 

most VA medical facilities. More 

significantly, a search of related VA 

documents provided to the NVTC Team 

revealed that a short supply of exam 

space is a critical infrastructure 

challenge for many facilities. Many sites 

indicate that primary care and specialty 

providers almost never have two exam 

rooms during clinic sessions, and site 

leadership commonly noted that one of 

the most significant interventions they 

can make to improve the timeliness of 

care is to increase available exam space. 

Following a thorough analysis of all 

39 of its key recommendations, to 

discover the cross-dimensional (or 

cross-cutting) implications of each of 

them, NVTC rendered the following set 

of 11 synthesized recommendations to 

VA: 

Recommendation #1—VA should 

aggressively redesign the human 

resources and recruitment process. 

From General Schedule (GS)-5 clerks to 

senior clinicians, the hiring of needed 

staff proceeds too slowly. The causes are 

complex, but much of the delay can be 

traced to redundant, inconsistent, and 

inefficient hiring processes. There 

should be a system-wide focus on 

improving these processes as soon as 

possible. Measures that capture 

performance from the customer 

perspective should be carefully 

monitored. Such measures may include 

the time from a request for a position to 

be filled to the time the hired candidate 

actually begins work. 

Recommendation #2—VA should 

prioritize efforts to recruit, retain, and 

train clerical and support staff. In many 

cases, clerical and support staff should 

be hired in anticipation of need rather 

than after vacancies are realized. Job 

stress, which contributes to turnover, 

should be reduced through careful study 

of workflow processes; for example, 

separating the call function from the 

frontline clerk function appears to be a 

prudent strategy. In many instances, 

‘‘role creep’’ results in clerks performing 

functions that may be beyond their job 

descriptions and GS levels. An 

inventory of functions should be 

carefully mapped to appropriate GS 

levels so that individuals are properly 

positioned—and compensated. Better 

retention will improve the impact of 

training, which should be another area 

of focus. Training should be based on a 

more standardized and frequently 

updated curriculum, and placed within 

a more clearly defined management 

infrastructure to support professional 

growth. A multi-modality approach to 

training should include case-based 

distance learning that leverages a 

learning management system and 

permits monitoring both at the facility 

and individual level. Overall, these 

measures will help to ensure that each 

physician has adequate support from 

clerical staff, which will help to 

maximize provider productivity. 

Recommendation #3—VA should 

develop a comprehensive human capital 

strategy that, based on projected needs, 

addresses impending health care 

provider shortages. In addition to the 

current shortage of nurses, shortages of 

nurse practitioners, primary care 

providers, and specialty physicians are 

projected or already realized. VA needs 

to undertake an aggressive strategy that 

includes increasing provider efficiency 

(e.g., more support staff and exam 

rooms), using alternate types of 

providers (e.g., family practitioners, 

doctors of nursing practice, care 

coordinators, coaches), and developing 

its own aggressive recruitment pipeline 

(e.g., starting the recruitment process in 

high school, providing aggressive 

tuition forgiveness). Mid-level 

practitioners, especially nurse 

practitioners, have proven particularly 

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70620 Federal Register / Vol. 79, No. 228 / Wednesday, November 26, 2014 / Notices 

9There are a number of COTS scheduling 

packages on the marketplace that might help meet 

VA’s scheduling needs either by themselves or in 

concert (see, e.g., http://www.capterra.com/

medical-scheduling-software/); VA would need to 

evaluate them to determine whether they satisfy the 

intent of NVTC’s Recommendation #5. 

valuable in providing or augmenting 

scarce specialty resources. There should 

be an immediate focus on recruiting, 

training, and retaining mid-level 

practitioners. Finally, there should be a 

deliberative effort within this human 

capital strategy to support team 

medicine, further enabling nonphysicians to partner with physicians to 

directly accommodate patient needs. 

Recommendation #4—VA should 

create a stronger financial incentive 

structure. This is especially critical for 

a location like Hampton, VA, where VA 

must compete head-on with the 

Department of Defense (DoD) in the 

health care provider marketplace. VA 

should explore the use of more 

aggressive incentive structures in 

compensation packages, especially for 

providers. VA should develop supply 

and demand projection models so that 

future staff needs—particularly for 

specialty physicians—can be 

anticipated. Recruitment cycles for 

physicians are often very long. Waiting 

until demand has exceeded supply will 

inevitably lead to chronic delays in care. 

Staffing needs, especially for specialty 

physicians, should be anticipated based 

on an understanding of how much 

supply is required to meet changing 

patient demand, and appropriate supply 

models should be created and used 

across the enterprise. 

Recommendation #5—VA should 

accelerate steps to improve the agility, 

usability, and flexibility of schedulingenabling technologies that also facilitate 

performance measurement and 

reporting functions.9 Another example 

of the cross-cutting effect of 

multidimensional issues is provided by 

IT, which—when optimally designed 

and deployed—is a critical enabler of 

human processes. However, IT that is 

not well-aligned to scheduling processes 

(as suggested by the System Usability 

group of key issues detailed in the body 

of this Report) causes costly, stressful 

human workarounds, and undermines 

system efficiency. The current 

scheduling software, which was first 

created in the time of paper records, has 

a non-intuitive ‘‘roll and scroll’’ 

interface that can be described as 

cumbersome, at best, to use. From a 

scheduling perspective, it is outdated; 

from a measurement perspective, it is 

inadequate—it was never intended to 

perform measurement functions. 

Nonetheless, VA currently must rely on 

this tool to schedule tens of millions of 

veterans’ appointments each year. 

Recommendation #6—VA should take 

aggressive steps to use fixed 

infrastructure more efficiently. Facilities 

should use projection models to 

anticipate needs for increased exam 

space and plan more strategically 

regarding building and/or leasing 

additional space. Facilities should use 

demand projection models to anticipate 

changing outpatient demand and should 

plan to increase space as necessary. 

Failure to use such approaches results 

in chronic undersupplies of space and 

human resources. 

Recommendation #7—VA should 

evaluate the efficiency and patient 

support gained by centralizing the 

phone calling functions in facility-based 

call centers with extended hours of 

operation. While it is recognized that 

the best place for a patient to make a 

follow-on appointment is when leaving 

a clinic, a majority of the appointments 

made in VA are by patients calling for 

an appointment or receiving a call from 

VA to schedule an appointment. 

Because the location of in- and outbound patient scheduling calls differs 

among VAMCs, this evaluation would 

determine the most beneficial 

placement of the call center function 

and allow for sharing of lessons learned 

from individual VA medical centers VAwide. Removing the in- and out-bound 

call requirement from the clinic 

scheduler’s responsibility, if appropriate 

for the individual clinic’s needs, will 

increase efficiency of communication 

with veterans and reduce stress on 

frontline clerks in clinics. 

Recommendation #8—VA should 

invest in more current and usable 

telephone systems and provide adequate 

space for call center functions. Although 

most facilities have call systems that can 

track hold times, call abandonment, and 

other key measures, a number of 

questions were raised about these 

systems. Given the importance of 

efficient phone communications, a 

standard for functionality should be 

established and all facilities should be 

required to meet that standard. 

Centralized call centers improve the 

efficiency of communications 

significantly. In addition to enhanced 

technology, call centers should be 

provided adequate space and resources. 

Robust multi-modal communications 

infrastructures are important to support 

the frequency of contact essential to the 

Patient Aligned Care Team (PACT) 

concept of continuous healing 

relationships. 

Recommendation #9—VA should take 

aggressive measures to alleviate parking 

congestion because it appears to have 

some impact on the timeliness of care. 

While less important than exam space, 

parking space was found to be in short 

supply at many VA facilities. Obstacles 

to parking may discourage veterans from 

keeping their appointments and cause 

veterans to be late for their 

appointments. Late arrivals can disrupt 

clinic flow for the rest of the session. 

Recommendation #10—VA should 

engage frontline staff in the process of 

change. Successful process redesign 

requires behavior change. To sustain 

such change, those who do the work 

must be engaged in redesigning the 

processes that influence their work and 

behaviors. This is the critical, and often 

weakest, link between people and 

processes, and if it is not made, process 

improvement will not be optimized or 

sustained. A culture of innovation must 

be created in which everyone sees 

improving his or her job, and the 

processes associated with it, as part of 

his or her job. Success requires a critical 

nexus between leadership, culture, 

process redesign techniques, and 

employee engagement. 

Recommendation #11—VA must 

embrace a system-wide approach to 

process redesign because this is the 

means by which many other 

recommendations may be successfully 

executed. Processes, the intermediate 

steps by which goals are achieved, often 

determine whether goals are achieved 

efficiently, or at all. To be successful in 

improving the many complex and 

interrelated processes that influence the 

timeliness of care, sound systematic 

approaches must be used. An integral 

dimension of success will be to engage 

Veterans in process redesign. Even 

when conducted in a rigorous fashion, 

process redesign is not always 

successful. The most common sources 

of failure are related to poor staff 

acceptance, failure to actually change 

behaviors, and inadequate leadership. 

VA faces unique challenges in scaling 

change across an enterprise of its size, 

which stands alone in U.S. health care. 

As mentioned earlier, one of the key 

elements of success will be engaging 

frontline staff in the redesign and 

change process, which will increase the 

probability that processes will be 

properly redesigned and the likelihood 

that frontline staff will modify their 

behaviors. 

Conclusion 

Improving the timeliness of veterans’ 

care depends upon the readiness, 

willingness, and organizational and 

personal commitments to improve 

multiple dimensions of a complex, 

system-of-systems challenge. All aspects 

of the VA enterprise must be 

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considered, and proven approaches to 

‘‘systems’’ engineering and redesign 

must be implemented and scaled across 

the entire Department. This will require 

strong leadership and engagement of 

staff who have been empowered to 

affect real and lasting change. 

However, improving the timeliness of 

care may be viewed in a broader context 

that extends beyond examination of 

VA’s scheduling operations. Indeed, it 

goes to the intent of the Department’s 

attempts to institutionalize, since 2010, 

a different relationship with the 

patient–with the launching of an 

initiative to transform the primary care 

system into a team-based care model 

(PACT). The PACT system of care shares 

many features with patient-centered 

medical homes (PCMH). In addition to 

improving chronic disease management, 

the VA initiative aims to increase 

veterans’ accessibility to their primary 

care providers, improve continuity with 

the primary care team, intensify 

preventive health services, integrate 

mental and behavioral health into 

primary care, and enhance coordination 

of care as veterans transition between 

primary and specialty care providers, 

hospital and ambulatory settings, and 

VA and private health care systems. The 

PACT model is meant to be proactive, 

personalized, and veteran-driven, 

focusing not just on the management of 

disease but also more holistically on the 

veteran’s physical, psychological, social, 

and spiritual well-being. The model 

requires effective communication and 

coordination among team members for 

acute, preventive, chronic, and end-oflife care to achieve improved continuity 

and efficiency—an aspirational goal in 

itself that remains unfilled across parts 

of the enterprise. 

Such intensely veteran-focused care 

would be delivered in many forms—not 

just through face-to-face visits. In this 

paradigm, the health care system would 

be responsive 24 hours per day, every 

day, whether by phone, email, 

e-consults, telemedicine, expanded use 

of personal health records, or other 

means. This vision is expected to 

include individual and group visits, as 

well as an expanded role for team 

medicine that includes the coordinated 

efforts of physicians, mid-level 

practitioners, care coordinators, and 

care coaches. Assessments of access in 

this paradigm would not be limited to 

traditional VA measures of wait times 

and drive times. 

While this model is still somewhat 

aspirational, it is an aspiration that VA 

is uniquely positioned to achieve. Yet, 

full accomplishment of this objective is 

what will be needed, at a minimum, to 

restore America’s trust in VA’s ability to 

serve the health care needs of its 

veterans. 

NVTC is reminded that VA has a 

strong history and longstanding 

tradition of innovation—its enterprisewide electronic health record; mailorder pharmacy system; clinical quality 

measurement and improvement 

programs; barcode drug dispensing 

system; telemedicine efforts; homebased care programs; and a broad array 

of clinical care innovations for special 

populations such as blind rehabilitation, 

posttraumatic stress disorder (PTSD) 

care, spinal cord injury care, and 

prosthetic expertise are but a few 

examples. 

In the past, however, emphasis on 

innovation has, understandably, been 

more typically geared toward clinical 

processes. That emphasis must be 

sustained. At the same time, a similar 

focus must be also be placed on 

innovations that support customercentric process redesign. This will 

require excellence in executive 

leadership distributed broadly and 

deeply across the enterprise; 

correspondingly, this will require 

appropriate levels of empowerment 

conferred from the top-down. 

Only by persistently staying the 

course will VA be positioned again, to 

blaze new trails for other health care 

systems to follow. 

Signing Authority 

The Secretary of Veterans Affairs, or 

designee, approved this document and 

authorized the undersigned to sign and 

submit the document to the Office of the 

Federal Register for publication 

electronically as an official document of 

the Department of Veterans Affairs. Jose 

D. Riojas, Chief of Staff, approved this 

document on November 21, 2014, for 

publication. 

Dated: November 21, 2014. 

Jeffrey M. Martin, 

Program Manager, Office of Regulation Policy 

& Management, Office of the General Counsel, 

Department of Veterans Affairs. 

[FR Doc. 2014–28055 Filed 11–25–14; 8:45 am] 

BILLING CODE 8320–01–P 

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