The Veterans Health Administration (VHA) and the Institute for Healthcare Communication (formerly the Bayer Institute) began working together in 1991 to teach communication skills to clinicians at VHA centers. As of September 1999, more than 7,714 physicians have participated in workshops and 125 VHA staff have been trained to lead workshops nationwide. The growth and success of the partnership is a direct result of the dedication of the Office of Employment Education and its development of the VHA Health Care Communications (HCC) Program. The HCC Program has been recognized and promoted by both the former Under Secretary for Health, Department of Veterans Affairs, Kenneth W. Kizer, MD, MPH, and newly appointed Under Secretary for Health, Thomas Garthwaite, MD, MPH, as one of the strategies to meet the goals of the VHA’s corporate vision.
The Beginning: A Time for Change
In 1991, the Office of Employee Education granted permission for two patient education coordinators, Pam Hebert, DrPH, and Barbara Snyder, MPH, to attend one of the newly developed Institute faculty development workshops. Excited by the information presented at the session, the coordinators shared their experiences and enthusiasm with Robert Frymier, MD, then the director of the Regional Medical Education Center (RMEC) based in Cleveland, Ohio with the responsibility for the training of VHA employees in eight states. Dr. Frymier’s interest in physician-patient communication and the positive feedback from the VHA education coordinators attracted him to the Institute workshops. The VHA Office of Employee Education liked the Institute’s programs for numerous reasons:
- Programs were research driven, not just anecdotal
- Programs were interactive and experimental, not just “talking heads”
- Programs were superbly designed, fast-paced and made use of actual clinician-patient interactions
- Programs were continuously updated and improved
- Programs were consistently ranked as “outstanding” by VHA learners
- Faculty were carefully selected, thoroughly trained, evaluated and certified
- Convenience—workshops were brought into the VHA’s medical centers, reducing travel costs and participant time away from the job
- The Institute is a non-profit organization that rigorously avoids product promotion
Within six months, Dr. Frymier, Dr. Heber, and Barbara Snyder had begun workshops for VHA clinicians in the Great Lakes and Southeast regions of the United States. Despite the benefits that could be gained through the skills taught in the workshops, Dr. Frymier was unsuccessful in convincing other regional centers to implement the Institute training. After a year of trying to convince the regional centers to implement the programs using traditional means such as sharing materials and discussing its value, Dr. Frymier decided on a different route.
Dr. Frymier knew that the designs and content of the workshop would enhance the communication skills of VHA clinicians and that the workshops would sell themselves if only he could get the decision-makers to experience them. With that in mind, a group of 26 Chiefs-of-Staff, Chiefs-of-Medicine and Associate Chiefs-of-Staff for Education were invited to visit the Regional Medical Education Center in Cleveland where they were introduced to the Institute workshops. After participating in the workshop, 24 of the 26 facilities in the Great Lakes Region understood the value of the program and were willing to introduce the program in their own institutions.
The Momentum Continues
During this time period, it is important to note that several developments in the nation’s health care industry were in their infancy—all of which supported the need for a communications program. These developments included the consumer movement, the emergence of competition and a renewed focus on patient satisfaction.
At the same time, the VHA was working to create a new image. The “old VHA” was perceived as bureaucratic, impersonal, and insensitive to patient’s needs for courtesy, respect, privacy, and a partnership role in clinical decision-making. Some of the VHA’s medical centers lagged behind the private sector in customer service and customer satisfaction measures, and the VHA’s quality-of-care was incorrectly perceived as inferior. The Institute programs offered a way to improve the quality-of-care provided by the VHA.
When Dr. Kizer was appointed as Under Secretary of Health for the VHA in 1993, he realized the importance of designing a decentralized health care system with patient care at the center, rather than the bureaucracy. Dr. Kizer, along with Dr. Garthwaite, coined the efforts to transform the VHA’s structure and values at “The Vision for Change.”
As part of the VHA transformation, its educational division was also being reinvented. The eight autonomous Regional Medical Education Centers were abolished in favor of an emerging virtual learning organization, called Employee Education System (EES). And the VA Health Care Communications Program was established through EES to assist the VHA in improving its quality-of-care and raising the bar on customer service standards.
This new virtual learning system, EES, led by Dr. Robert Means, recognized that the Institute programs could help meet the corporate goals. The Institute programs addressed the goals in several important ways. The Institute programs:
- Explicitly defined the core goals of the physician-patient relationship
- Linked communication to the latest research
- Offered clinicians the opportunity to practice and master a variety of new skills and techniques that would enable them to improve the accuracy of their diagnoses, enhance patient adherence to their treatment regimens, and improve their patient satisfaction measures
Taken together, these factors resulted in enhanced patient care.
Despite the success of the Bayer Institute programs in the Great Lakes and the Birmingham regions of the VHA, the program had not been implemented on a national level. Under the auspices of the EES, Dr. Frymier convened a meeting of Network Directors, Quality Managers and Clinical Managers who were highly influential at the national level, in hopes of expanding the outreach of the workshops. J. Gregory Carroll, PhD, Director of the Institute, was invited to introduce excerpts from several workshops to the group. After experiencing portions of the workshops, this group saw
the value and benefits of the information and material presented. This meeting was pivotal in disseminating the program nationally.
The national implementation gained further momentum after Dr. Kizer sent a letter to Dr. Frymier praising the efforts of the EES and asking Dr. Frymier to double the faculty certified by the Institute. Dr. Frymier had written Dr. Kizer to tell him about the Institute programs and how the programs reflected the VHA’s Vision for Change. These actions fueled the growth and success of the Institute workshops throughout the 200 VHA clinics and outpatient centers.
The VHA/ Institute Today
As of September 1999, the VHA had more than 125 certified Institute Faculty who facilitate the ongoing Institute workshops nationwide. The HCC Program offers four Institute workshops for clinicians. The workshops include:
- Clinician-Patient Communication to Enhance Health Outcomes
- “Difficult” Clinician-Patient Relationships
- Choices and Changes: Clinician Influence and Patient Action
- Communication: A Risk Management Tool
All clinical staff members are encouraged to attend the workshops, which in most centers are promoted by the Chief-of-Staff, the Associate Chief-of-Staff for Education or the Office of Quality Management; there are a small number of VHA centers that mandate the programs or have included it in their strategic plan. There was an initial fear that mandating the programs would backfire, however that has proven to be untrue. Mandated participants rate the programs as high as voluntary participants.
In addition to offering Institute workshops, the EES recently used information learned through Institute workshops to develop guidelines on shared decision making that were distributed to all VHA employees.
Furthermore, the HCC Program worked with the Institute to develop a workshop, Treating Veterans with CARE, which was specifically created for VHA non-clinical staff who have direct contact with patients.
All of the workshops and the CARE workshops contribute toward meeting performance standards for staff education and training, including training requirements for performance improvement and customer service.
The Office of Employee Education
Today the Office of Employee Education is a virtual learning and performance consulting organization consisting of approximately 300 VHA employees scattered across the nation. Its mission is to provide employee-focused educational learning and performance services which are accessible, timely, and cost effective and that are driven by organizational objectives and strategic initiatives.