Organizational Factors Affecting Communication Flow at VHA Call Centers and Patient Perceptions of Access: A Qualitative Study
Authors: Medich M. , McGowan M. , Rose D. , Stockdale S. 
Published: August 2020

Research ObjectiveFor most Veterans, telephoning a VA administrative call center is their first step in engaging the Veterans Healthcare System. Recent studies have found that Veterans experience lingering dissatisfaction communicating with their primary care (PC) teams and that telephone access, specifically the average speed of answer, has important consequences for patient satisfaction. This study explores the organizational and work experience factors that may impact communication between Veterans, call centers, and their PC teams.Study DesignCross‐sectional, observational.Population StudiedMedical Support Assistants (MSAs) working in call centers and PC clinics, Administrative Staff Chiefs and MSA Supervisors in one regional network.We conducted site observations at call centers (n = 9) and PC clinics (n = 11) and semi‐structured interviews with call center (n = 16) and PC clinics (n = 13) MSAs. Site visits included informal discussions (n = 20) with Administrative Staff Chiefs and MSA Supervisors. We also observed MSA work environments. Our interviews with MSAs focused on communication flows, training, and work experiences. We mapped out communication flows to illustrate where communication breakdown, choke points, and loops occur.Principal FindingsMost communication breakdowns occur due to a combination of technology issues, software issues, and protocols that are barriers to regular, open communication between call centers, PC clinics, and other service lines. Organizational factors impacting call center functioning include physical location of call centers (co‐located at a medical center v. offsite), infrastructure (information technology support, facility management support), (high) MSA turnover, lack of standardized training, and communication challenges.MSAs report working at VA for an average of 5 years; as an MSA for 3 years. Almost all reported that they would like to leave their current position within the next year. Most MSAs stated that they are “good at their job” because they “break the rules to help the Veteran.” Contributing factors from work experiences to communication include working as an MSA to “get their foot in the door” to other positions at VA, challenges with call centers being short staffed, high turnover, low pay, limited opportunities for career growth, navigating multiple software programs simultaneously, balancing multiple tasks, and dealing with “angry Vets.”Promising practices used by several call center administrators include offering hands‐on experience/simulations of real‐time work in addition to standard training, mechanisms to destress MSAs after handling difficult calls. One call center created Preceptor positions for experienced MSAs for new MSAs to shadow, allowing personalized mentoring, team building, and task variation. Other notable practices include an open‐door policy with MSA Supervisors, group Skypes, and the use of floor walkers for monitoring any difficulties or queries. Two call centers have negotiated with human resources to streamline the hiring process and fill open positions as soon as possible.ConclusionsFrom our interview with MSAs, we identified several communication choke points: technology, software/scheduling processes, administrative protocols, and MSA work experiences.Implications for Policy or PracticeOur findings demonstrate the task complexity of scheduling and customer service provided in primary care. It also illustrates the complexity of communication flows between Veterans, call centers, and their primary care teams.Primary Funding SourceDepartment of Veterans Affairs.