Outpatient Health Care Services for Veterans Back to Customer Experience Profiles Veterans Health Administration, Department of Veterans Affairs Executive Summary Data Highlights Customer Experience Insights Delivering Services Equitably Leading Customer Experience Practices The Veterans Health Administration, in partnership with the VA’s centralized Veterans Experience Office, continues to pave the way as a leader in the federal government in using customer research and human-centered design to improve services. The investment in customer experience helps the agency meet the health care needs of veterans, adapt to new health care delivery models in response to the pandemic, and to raise trust in the VA overall. Using in-depth customer research, customer journey mapping and other tools and methods, the agency continues to root out challenges veterans experience when receiving health care. For example, the agency is making it easier for veterans to refill prescriptions and improving the discharge experience for veterans who receive services at a VHA hospital. Service Overview The VHA provides numerous medical and mental health services to veterans at more than 1,200 facilities across the country and served more than 7 million veterans in 2020. Primary Customers Veterans and their families, caregivers and surviving spouses. Key Services Assistance with applying for VHA health care. Assistance with scheduling and viewing health care appointments. Health care and telehealth services ranging from surgery and physical therapy to dental care, mental health and vision care. Online systems to communicate securely with VHA health care professionals. Assistance with refilling and tracking prescriptions and viewing lab and tests results. Service Snapshot (all data for fiscal year 2020) 45.8 million calls to outpatient services contact centers. Average wait time for calls: 72 seconds. 122.6 million visits to VA.gov. 119 million outpatient visits to VA Health facilities. 1.1 million veterans received video telehealth visits to their homes in fiscal 2020, a 1,037% increase from fiscal 2019.1 Data Highlights increase in trust in the VA among veterans between 2016 and 2020. of veterans said they got their appointment on a date and time that worked for them in the first half of fiscal year 2021. Customer Experience Insights Improvement from last year Room for improvement Veterans have good relationships with their health care providers, contributing to rising trust in the VA overall. Veterans gave high marks to all aspects of their outpatient health care experience. They were particularly pleased with their interactions with VA health care providers, whom they felt listened carefully and explained things in ways they could understand. Trust in the VA and VHA outpatient services has been rising since 2016 and continued to rise in 2020. Men reported slightly higher trust scores with outpatient services (89.4%) than women (85.7%) in fiscal year 2020. Increasing trust has been a key focus of the VHA’s customer experience efforts, as the agency recognizes that higher levels of trust will lead more veterans to access health care services, potentially improving health care outcomes. The VHA is focusing on how to maintain trusted relationships with veterans in a virtual environment, anticipating that telehealth will continue as an option for care for the rest of 2021 and beyond. For example, the agency adapted its “Own the Moment” customer experience principles for telehealth and created a training session for clinical contact center staff that focuses on building trust with veterans during telehealth phone calls. This program has been piloted in two of the agency’s regional health care systems, known as Veterans Integrated Service Networks, and the VHA is planning to expand the training to all its clinical contact centers. The VA greatly expanded telehealth options to keep veterans and staff safe during the pandemic and seeks to improve access to and the convenience of telehealth in the future. With the onset of COVID-19 in early 2020, most outpatient appointments for veterans shifted from in-person to telephone or video call, resulting in a more than 1,000% increase in telehealth visits over the previous year.4 This increase helped veterans to safely access care during the pandemic, with many appreciating the convenience of attending appointments from home. While the shift to telehealth appointments allowed many veterans to access care from the safety of their own homes, in some instances it also made it more difficult to access care. For example, some of the previously scheduled in-person appointments that were cancelled at the beginning of the pandemic were never rescheduled or rescheduled much later, leading to delays in veterans seeing health care providers.5 Telehealth has been a component of VHA outpatient services for several years, and the pandemic further demonstrated both the possibilities of expanding telehealth and the issues that prevent some veterans from accessing these services. For example, more than 40% of rural veterans enrolled in the VA health care system lack a sufficiently strong internet connection to access telehealth.6 Anticipating sustained demand for telehealth services, the VA is tackling this issue through partnerships with the private sector to bring internet access to rural veterans and by establishing remote clinics where veterans can access telehealth services closer to their homes. Making appointments on VA Video Connect, the VA’s primary video telehealth platform, also requires the coordination of two different scheduling systems—a complicated process that limited some veterans’ ability to make or reschedule appointments.7 VHA is improving information about the process and timing for receiving prescriptions. Not knowing when to expect their prescriptions has been a common concern for veterans, especially because there are different processes and timelines for filling prescriptions, depending on medication type and whether the VHA or a private pharmacy is involved. To address this concern, the VHA created an online tool that allows veterans to track their prescriptions, rather than requiring them to contact the agency for updates. With this improvement the percentage of customers surveyed who cited this as a challenge dropped to 9% in the first half of 2021 from 21% in 2019. The VHA is continuing to develop tools to streamline the process of receiving and refilling prescriptions. For example, in May 2021 VHA launched a new prescription-ordering capability within the MyHealtheVet app. VA prescription labels included a code that veterans can scan with their phone to quickly renew prescriptions within the app. VHA also began sending automatic alerts via the app to remind veterans when to refill prescriptions or visit a provider to have a new prescription written. The discharge process at VA hospitals can create confusion. When discharged from a VA hospital, veterans receive information and equipment to help them continue their care at home but can sometimes feel overwhelmed trying to absorb everything they are told they need to do. Getting the discharge experience right is essential to ensuring that veterans stay healthy and to minimize the risk that they will need to quickly return to the hospital. The VA conducted in-depth customer research to understand the hospital discharge experience and created a journey map that outlines the process, bright spots, problem areas and most impactful parts of the discharge experience. They learned veterans can feel overwhelmed by the amount of information relayed during discharge and worried they will be unable to remember everything. The timing of the process can also be confusing—leaving veterans wondering exactly when they will be going home or worried about arranging transportation.8 To address these issues, the VHA is developing a discharge checklist—a document that will lay out all the steps involved in discharge, which veterans and VA staff members can go through together. The VHA is also working to develop a booklet on the discharge process that veterans can use to write down and organize important information to remember at home. These resources will be designed around the needs of veterans and caregivers to ensure that information is available and easy to understand at discharge and beyond.9 Delivering Veterans’ Health Care Services Equitably The Veterans Health Administration serves a diverse array of veterans across racial and ethnic lines, education levels, economic statuses and ages, ranging from WWII veterans to recent veterans who served in Iraq and Afghanistan. To be more equitable, some services could address different groups’ needs more effectively. For example, female veterans often report being sexually harassed and having their military service questioned when seeking health care.10 VHA’s investment in improving the customer experience and using human-centered design is helping the agency understand and meet the unique needs of veterans from different backgrounds. The agency is restructuring customer surveys to collect more demographic information, so it can evaluate the experience underserved populations have when they receive services. The agency is also examining areas where language may be a barrier to receiving services. One result is that the agency has made more information available online in Spanish and Tagalog, since the VA operates facilities in the Philippines and Puerto Rico. And to help improve the experiences of female veterans, the VA is beginning to implement the Deborah Sampson Act, which creates a dedicated Office of Women’s Health at VA, requires every VA health facility be staffed with a dedicated women’s health primary care provider, and requires VA facilities to be retrofitted to enhance privacy and improve care for women. Leading Customer Experience Practices The Partnership and Accenture developed the following list of practices to understand how agencies prioritize the customer experience, and steps they can take to improve. The list is based on research about effective customer experience practices in both government and the private sector, and aligns with practices in a customer experience maturity self-assessment for agencies developed by the Office of Management and Budget. Organizational Commitment Organizational Commitment A strong commitment and plan from agency leaders to prioritize customer experience is essential for sustained progress. The agency: 1. Includes high-quality customer experience in its strategic goals. Yes Customer service is one of the priorities listed in the agency’s strategic plan and is included in several of its strategic goals. 2. Specifies customer feedback as a key measure of the organization’s performance. Yes The percent of veterans who agree with the statement, “I trust VA to fulfill our country’s commitment to Veterans,” is a key performance measure. 3. Has a senior executive with the responsibility and authority to lead efforts to improve the customer experience across the organization. Yes The VA has a chief veterans’ experience officer who leads the agency’s customer experience efforts and strategy. Ease of Customer Interactions Ease of Customer Interactions Interactions with the federal government should be easy, transparent and designed around user needs. For the most common services provided, customers can: 1. Complete common transactions using the service delivery channel of their choice. Yes Veterans can apply for care, schedule appointments and manage prescriptions online or over the phone. Both in-person and telehealth options are available for outpatient care. 2. Obtain status updates through online self-service. Yes For example, veterans can track the status of health care claims or prescription medication shipments online. 3. Receive a response to feedback or answers to questions over social media. Partially The Veterans Health Administration responds to some of the feedback on Facebook, but regularly receives questions that are not addressed. VHA does not respond to customer feedback on Twitter. 4. Access online information and support in languages other than English. Yes In addition to English, some website content is available in Spanish and Tagalog. Interpretation services are available over the phone and at VA health facilities. Listening to Customers and Acting on Feedback Listening to Customers and Acting on Feedback To understand and prioritize customer needs, agencies should collect, publish, analyze and act on feedback. The agency: 1. Collects meaningful customer experience data across interactions and service delivery channels and shares it with the public. Yes The Veterans Health Administration collects and publicly shares customer experience data for its outpatient services in line with OMB guidance. 2. Collects and analyzes customer feedback to understand customers’ experiences based on their own words. Yes 3. Aggregates and analyzes customer feedback across channels and programs, and shares feedback with relevant staff members so they can act on it. Yes Back to Customer Experience Profiles Footnotes and Methodology Footnotes VA FY2022/FY2020 Annual Performance Plan and Report, pg. 26. Retrieved from https://bit.ly/3utYh9T. Data is from Q1 and Q2 fiscal 2021 follow-up surveys emailed to customers after they received outpatient services. Survey scale: 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” Each category aggregates responses to multiple survey questions and represents the number of respondents who chose “agree” and “strongly agree” for those questions. Ibid.; https://blogs.va.gov/VAntage/wp-content/uploads/2021/05/va-trust-report-fy21q2.pdf https://www.va.gov/health/docs/VA_COVID_Response.pdf VA Office of Inspector General, “Appointment Management During the COVID-19 Pandemic,” September 1, 2020. Retrieved from https://bit.ly/39Xmwnq. https://blogs.va.gov/VAntage/61913/multiple-vha-partnerships-work-bring-veterans-online/ VA Office of Inspector General, “Review of Veterans Health Administration’s COVID-19 Response and Continued Pandemic Readiness,” July 16, 2020. Retrieved from https://bit.ly/3zR43DO. https://www.performance.gov/cx/dashboard/actionplans/2020/2020-hisp-action-plan-va-vha.pdf Ibid. Stars and Stripes, “’We’re not aliens, we’re women:’ New task force to target gender inequality at the VA,” May 2, 2019. Retrieved from https://bit.ly/3urkXHW. Customer experience indicators methodology The Partnership and Accenture developed the following list of practices to understand how agencies prioritize the customer experience, and steps they can take to improve. The list is based on research about effective customer experience practices in government and the private sector, and aligns with practices in a customer experience maturity self-assessment for agencies developed by the Office of Management and Budget. Organizational Commitment A strong commitment and plan from agency leaders to prioritize customer experience is essential for sustained progress. The agency: Includes high-quality customer experience in its strategic goals. Criteria: a) customer experience with the agency’s services is listed in the strategic plan as one of the organization’s top priorities, or a supporting goal of one of the priorities b) the strategic plan provides specific actions the agency will take to improve customer experience Specifies customer feedback as a key measure of the organization’s performance. Criteria: There is a performance measure included in the agency’s strategic plan, annual performance report or agency priority goals that is based on feedback directly from customers. Has a senior executive with the responsibility and authority to lead efforts to improve the customer experience across the organization. Criteria: Based on a review of the agency’s organizational chart and online descriptions of leadership positions, the agency has an executive who meets the following criteria: a) customer experience is that executive’s primary responsibility b) the executive reports to the head of the organization or a deputy c) the executive’s work spans all major service delivery channels (e.g., online services, contact centers, face-to-face services). Ease of Customer Interactions Interactions with the federal government should be easy, transparent and designed around user needs. For the most common services provided, customers can: Complete common transactions using the service delivery channel of their choice. Criteria: Based on a review of the agency’s website, customers have multiple options to complete common transactions including going online, calling, using webchat and visiting field offices or other physical locations. Obtain status updates through online self-service. Criteria: customers can get real-time updates through an online self-service channel that provides estimated timelines. Receive a response to feedback or answers to questions over social media. Criteria: Does the agency respond to questions through the direct message feature on Facebook and Twitter, or in the comment section of posts? To assess this, we examined social media posts on the service’s primary account across a three-month period. “No” indicates the agency never or rarely responds to comments; “partially” indicates the agency responds sometimes, but not consistently; and “yes” indicates the agency responds to comments on a frequent and consistent basis. Access online information and support in languages other than English. Criteria: “No” indicates content is available only in English and translation features are not available on the website; “partially” indicates that some content or services are available in English and Spanish; “yes” indicates that content or services are available in English and Spanish and additional languages. Listening to Customers and Acting on Feedback To understand and prioritize customer needs, agencies should collect, publish, analyze and act on feedback. The agency: Collects meaningful customer experience data across interactions and service delivery channels and shares it with the public. Criteria: In alignment with the Office of Management and Budget’s guidance on customer experience measurement, the agency shares customer feedback with the public and that: a) represents multiple service delivery channels b) provides details into different aspects of the experience (i.e., beyond overall customer satisfaction) Collects and analyzes first-hand customer feedback to understand customers’ experiences, based on their own words. Criteria: In alignment with Office of Management and Budget’s guidance on customer experience measurement, in customer or user research such as interviews, focus groups, surveys and other feedback mechanisms, customers can describe their experiences in their own words, and the agency has automated analytic capabilities to identify and act on insights that emerge from customer feedback data. Aggregates and analyzes customer feedback across channels and programs, and shares feedback with relevant staff members so they can act on it. Criteria: Agency has an automated system to collect feedback across multiple channels and programs into a centralized location, analyze it for insights, and share those insights with relevant agency business owners or other appropriate colleagues responsible for taking action. The agency also tracks the impact of actions taken in response to customer feedback. This customer experience profile was produced in collaboration with Accenture Federal Services.