Article

The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.¹ According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.² A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.³ The ED is a critical and high-yield space for antimicrobial stewardship efforts.⁴

Urinary tract infections (UTIs) are one of the most common reasons for ED visits.⁴ In 2018, there were about 3 million UTI discharge diagnoses reported in the US.⁵ Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.⁶ Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.⁶

Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.⁶ The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.^7-13

Program Description

In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).

Methods

This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.

The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.

A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.

The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).

Discussion

Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.⁶ The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.

Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.

Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.

While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.

Limitations

Inconsistent and incomplete documentation of clinical data in the electronic health record made the characterization of patient encounters challenging. Furthermore, ED HCPs varying clinical practices may have impacted the heterogeneity of UTI diagnosis and management at VAGLAHS.

Conclusions

Implementation of an ED pharmacist-driven UTI aftercare program at VAGLAHS reduced unnecessary antimicrobial exposure, improved antibiotic management, and ensured continuity of care postdischarge. Findings from our project implicate possible future pharmacist involvement predischarge, such as targeting inappropriate asymptomatic bacteriuria treatment.^14-16 This pilot program suggested the feasibility of integrating antimicrobial stewardship practices within the ED setting in an ongoing effort to improve the quality of care for veterans.

The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.¹ According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.² A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.³ The ED is a critical and high-yield space for antimicrobial stewardship efforts.⁴

Urinary tract infections (UTIs) are one of the most common reasons for ED visits.⁴ In 2018, there were about 3 million UTI discharge diagnoses reported in the US.⁵ Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.⁶ Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.⁶

Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.⁶ The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.^7-13

Program Description

In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).

Methods

This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.

The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.

A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.

The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).

Discussion

Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.⁶ The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.

Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.

Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.

While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.

Limitations

Inconsistent and incomplete documentation of clinical data in the electronic health record made the characterization of patient encounters challenging. Furthermore, ED HCPs varying clinical practices may have impacted the heterogeneity of UTI diagnosis and management at VAGLAHS.

Conclusions

Implementation of an ED pharmacist-driven UTI aftercare program at VAGLAHS reduced unnecessary antimicrobial exposure, improved antibiotic management, and ensured continuity of care postdischarge. Findings from our project implicate possible future pharmacist involvement predischarge, such as targeting inappropriate asymptomatic bacteriuria treatment.^14-16 This pilot program suggested the feasibility of integrating antimicrobial stewardship practices within the ED setting in an ongoing effort to improve the quality of care for veterans.

The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.¹ According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.² A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.³ The ED is a critical and high-yield space for antimicrobial stewardship efforts.⁴

Urinary tract infections (UTIs) are one of the most common reasons for ED visits.⁴ In 2018, there were about 3 million UTI discharge diagnoses reported in the US.⁵ Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.⁶ Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.⁶

Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.⁶ The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.^7-13

Program Description

In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).

Methods

This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.

The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.

A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.

The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).

Discussion

Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.⁶ The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.

Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.

Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.

While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.

Limitations

Inconsistent and incomplete documentation of clinical data in the electronic health record made the characterization of patient encounters challenging. Furthermore, ED HCPs varying clinical practices may have impacted the heterogeneity of UTI diagnosis and management at VAGLAHS.

Conclusions

Implementation of an ED pharmacist-driven UTI aftercare program at VAGLAHS reduced unnecessary antimicrobial exposure, improved antibiotic management, and ensured continuity of care postdischarge. Findings from our project implicate possible future pharmacist involvement predischarge, such as targeting inappropriate asymptomatic bacteriuria treatment.^14-16 This pilot program suggested the feasibility of integrating antimicrobial stewardship practices within the ED setting in an ongoing effort to improve the quality of care for veterans.

Veterans have a high burden of digestive diseases, and gastroenterologists are needed for the diagnosis and management of these conditions.^1-4 According to the Veterans Health Administration (VHA) Workforce Management and Consulting (WMC) office, the physician specialties with the greatest shortages are psychiatry, primary care, and gastroenterology.⁵ The VHA estimates it must hire 70 new gastroenterologists annually between fiscal years 2023 and 2027 to provide timely digestive care.⁵

Filling these positions will be increasingly difficult as competition for gastroenterologists is fierce. A recent Merritt Hawkins review states, “Gastroenterologists were the most in-demand type of provider during the 2022 review period.”⁶ In 2022, the median annual salary for US gastroenterologists was reported to be $561,375.⁷ Currently, the US Department of Veterans Affairs (VA) has an aggregate annual pay limit of $400,000 for all federal employees and cannot compete based on salary alone.

Retention of existing VA gastroenterologists also is challenging. The WMC has reported that 21.6% of VA gastroenterologists are eligible to retire, and in 2021, 8.2% left the VA to retire or seek non-VA positions.⁵ While not specific to the VA, a survey of practicing gastroenterologists conducted by the American College of Gastroenterology found a 49% burnout rate among respondents.⁸ Factors contributing to burnout at all career stages included administrative nonclinical work and a lack of clinical support staff.⁸ Burnout is also linked with higher rates of medical errors, interpersonal conflicts, and patient dissatisfaction. Burnout is more common among those with an innate strong sense of purpose and responsibility for their patients, characteristics we have observed in our VA colleagues.⁹

As members of the Section Chief Subcommittee of the VA Gastroenterology Field Advisory Board (GI FAB), we are passionate about providing outstanding gastroenterology care to US veterans, and we are alarmed at the struggles we are observing with recruiting and retaining a qualified national gastroenterology physician workforce. As such, we set out to survey the VA gastroenterology section chief community to gain insights into recruitment and retention challenges they have faced and identify potential solutions to these problems.

Methods

The GI FAB Section Chief Subcommittee developed a survey on gastroenterologist recruitment and retention using Microsoft Forms (Appendix). A link to the survey, which included 11 questions about facility location, current vacancies, and free text responses on barriers to recruitment and retention and potential solutions, was sent via email to all gastroenterology section chiefs on the National Gastroenterology and Hepatology Program Office’s email list of section chiefs on January 31, 2023. A reminder to complete the survey was sent to all section chiefs on February 8, 2023. Survey responses were aggregated and analyzed by the authors using descriptive statistics.

The VA gastroenterologist recruitment and retention survey was emailed to 131 gastroenterology section chiefs and completed by 55 respondents (42%) (Figure). Of the responding section chiefs, 36 (65%) reported gastroenterologist vacancies at their facilities. Seventeen respondents (47%) reported a single vacancy, 12 (33%) reported 2 vacancies, 4 (11%) reported 3 vacancies, and 3 (8%) reported 4 vacancies. Of the sites with reported vacancies, 32 (89%) reported a need for a general gastroenterologist, 12 (33%) reported a need for a hepatologist, 11 (31%) reported a need for an advanced endoscopist, 9 (25%) reported a need for a gastroenterologist with specialized expertise in inflammatory bowel diseases, and 1 (3%) reported a need for a gastrointestinal motility specialist.

Numerous barriers to the recruitment and retention of gastroenterologists were reported. Given the large number of respondents that reported a unique barrier (ie, being the only respondents to report the barrier), a decision was made to include only barriers to recruitment and retention that were reported by at least 2 sites (Table). While there were some common themes, the reported barriers to retention differed from those to recruitment. The most reported barriers to recruitment were 46 respondents who noted salary, 23 reported human resources-related challenges, and 12 reported location. Respondents also noted various retention barriers, including 32 respondents who reported salary barriers; 13 reported administrative burden barriers, 6 reported medical center leadership, and 4 reported burnout.

Survey respondents provided multiple recommendations on how the VA can best support the recruitment and retention of gastroenterologists. The most frequent recommendations were to increase financial compensation by increasing the current aggregate salary cap to > $400,000, increasing the use of recruitment and retention incentives, and ensuring that gastroenterology is on the national Educational Debt Reduction Program (EDRP) list, which facilitates student loan repayment. It was recommended that a third-party company assist with hiring to overcome perceived issues with human resources. Additionally, there were multiple recommendations for improving administrative and clinical support. These included mandating how many support staff should be assigned to each gastroenterologist and providing best practice recommendations for support staff so that gastroenterologists can focus on physician-level work. Recommendations also included having a dedicated gastroenterology practice manager, nurse care coordinators, a colorectal cancer screening/surveillance coordinator, sufficient medical support assistants, and quality improvement personnel tracking ongoing professional practice evaluation data. Survey respondents also highlighted specific suggestions for recruiting recent graduates. These included offering a 4-day work week, as recent graduates place a premium on work-life balance, and ensuring gastroenterologists have individual offices. One respondent commented that gastroenterology fellows seeing VA gastroenterology attendings in cramped, shared offices, contrasted with private practice gastroenterologists in large private offices, may contribute to choosing private practice over joining the VA.

Discussion

Gastroenterology is currently listed by VHA WMC as 1 of the top 3 medical specialties in the VA with the most physician shortages.⁵ Working as a physician in the VA has long been recognized to have many benefits. First and foremost, many physicians are motivated by the VA mission to serve veterans, as this offers personal fulfillment and other intangible benefits. In addition, the VA can provide work-life balance, which is often not possible in fee-for-service settings, with patient panels and call volumes typically lower than in comparable private hospital settings. Moreover, VA physicians have outstanding teaching opportunities, as the VA is the largest supporter of medical education, with postgraduate trainees rotating through > 150 VA medical centers. Likewise, the VA offers a variety of student loan repayment programs (eg, the Specialty Education Loan Repayment Program and the EDRP). The VA offers research funding such as the Cooperative Studies Programs or program project funding, and rewards in parallel with the National Institute of Health (eg, career development awards, or merit review awards) and other grants. VA researchers have conducted many landmark studies that continue to shape the practice of gastroenterology and hepatology. From the earliest studies to demonstrate the effectiveness of screening colonoscopy, to the largest ongoing clinical trial in US history to assess the effectiveness of fecal immunochemical testing (FIT) vs screening colonoscopy.^10-12 The VA has also led the field in the study of gastroesophageal reflux disease, hepatitis C treatment, and liver cancer screening.^13-15 VA physicians also benefit from participation in the Federal Employee Retirement System, including its pension system.

These benefits apply to all medical specialties, making the VA a potentially appealing workplace for gastroenterologists. However, recent trends indicate that recruitment and retention of gastroenterologists is increasingly challenging, as the VA gastroenterology workforce grew by 5.0% in fiscal year (FY) 2020 and 1.8% in FY 2021. However, it was on track to end FY 2022 with a loss (-1.1%).⁵ It must be noted that this trend is not limited to the VA, and the National Center for Health Workforce Analysis predicts that gastroenterology will remain among the highest projected specialty shortages. Driven by increased demand for digestive health care services, more physicians nearing traditional retirement age, and substantially higher rates of burnout after the COVID-19 pandemic.¹⁶ All these factors are likely to result in an increasingly competitive market for gastroenterology, highlight the growing differences between VA and non-VA positions, and may augment the impact of differences for the individual gastroenterologist weighing employment options within and outside the VA.

Suboptimal human resources were the second most commonly cited impediment to recruiting gastroenterologists. Many section chiefs expressed frustration with the inefficient and slow administrative process of onboarding new gastroenterologists, which may take many months and not infrequently results in losing candidates to competing entities. While this issue is specific to recruitment, recurring and long-standing vacancies can increase work burdens, complicate logistics for remaining faculty, and may also negatively impact retention. One potential opportunity to improve VHA competitiveness is to streamline the administrative component of recruitment and optimize human resources support. The use of a third-party hiring company also should be considered.

Survey responses also indicated that administrative burden and insufficient support staff were significant retention challenges. Several respondents described a lack of efficient endoscopy workflow and delegation of simple administrative tasks to gastroenterologists as more likely in units without proper task distribution. Importantly, these shortcomings occur at the expense of workload-generating activities and career-enhancing opportunities.

While burnout rates among VA gastroenterologists have not been documented systematically, they likely correlate with workplace frustration and jeopardizegastroenterologist retention. Successful retention of gastroenterologists as highly trained medical professionals is more likely in workplaces that are vertically organized, efficient, and use physicians at the top of their skill level.

Conclusions

The VA offers the opportunity for a rewarding lifelong career in gastroenterology. The fulfillment of serving veterans, teaching future health care leaders, performing impactful research, and having job security is invaluable. Despite the tremendous benefits, this survey supports improving VA recruitment and retention strategies for the high-demand gastroenterology specialty. Improved salary parity is needed for workforce maintenance and recruitment, as is improved administrative and clinical support to maintain the high level of care our veterans deserve.

Veterans have a high burden of digestive diseases, and gastroenterologists are needed for the diagnosis and management of these conditions.^1-4 According to the Veterans Health Administration (VHA) Workforce Management and Consulting (WMC) office, the physician specialties with the greatest shortages are psychiatry, primary care, and gastroenterology.⁵ The VHA estimates it must hire 70 new gastroenterologists annually between fiscal years 2023 and 2027 to provide timely digestive care.⁵

Filling these positions will be increasingly difficult as competition for gastroenterologists is fierce. A recent Merritt Hawkins review states, “Gastroenterologists were the most in-demand type of provider during the 2022 review period.”⁶ In 2022, the median annual salary for US gastroenterologists was reported to be $561,375.⁷ Currently, the US Department of Veterans Affairs (VA) has an aggregate annual pay limit of $400,000 for all federal employees and cannot compete based on salary alone.

Retention of existing VA gastroenterologists also is challenging. The WMC has reported that 21.6% of VA gastroenterologists are eligible to retire, and in 2021, 8.2% left the VA to retire or seek non-VA positions.⁵ While not specific to the VA, a survey of practicing gastroenterologists conducted by the American College of Gastroenterology found a 49% burnout rate among respondents.⁸ Factors contributing to burnout at all career stages included administrative nonclinical work and a lack of clinical support staff.⁸ Burnout is also linked with higher rates of medical errors, interpersonal conflicts, and patient dissatisfaction. Burnout is more common among those with an innate strong sense of purpose and responsibility for their patients, characteristics we have observed in our VA colleagues.⁹

As members of the Section Chief Subcommittee of the VA Gastroenterology Field Advisory Board (GI FAB), we are passionate about providing outstanding gastroenterology care to US veterans, and we are alarmed at the struggles we are observing with recruiting and retaining a qualified national gastroenterology physician workforce. As such, we set out to survey the VA gastroenterology section chief community to gain insights into recruitment and retention challenges they have faced and identify potential solutions to these problems.

Methods

The GI FAB Section Chief Subcommittee developed a survey on gastroenterologist recruitment and retention using Microsoft Forms (Appendix). A link to the survey, which included 11 questions about facility location, current vacancies, and free text responses on barriers to recruitment and retention and potential solutions, was sent via email to all gastroenterology section chiefs on the National Gastroenterology and Hepatology Program Office’s email list of section chiefs on January 31, 2023. A reminder to complete the survey was sent to all section chiefs on February 8, 2023. Survey responses were aggregated and analyzed by the authors using descriptive statistics.

The VA gastroenterologist recruitment and retention survey was emailed to 131 gastroenterology section chiefs and completed by 55 respondents (42%) (Figure). Of the responding section chiefs, 36 (65%) reported gastroenterologist vacancies at their facilities. Seventeen respondents (47%) reported a single vacancy, 12 (33%) reported 2 vacancies, 4 (11%) reported 3 vacancies, and 3 (8%) reported 4 vacancies. Of the sites with reported vacancies, 32 (89%) reported a need for a general gastroenterologist, 12 (33%) reported a need for a hepatologist, 11 (31%) reported a need for an advanced endoscopist, 9 (25%) reported a need for a gastroenterologist with specialized expertise in inflammatory bowel diseases, and 1 (3%) reported a need for a gastrointestinal motility specialist.

Numerous barriers to the recruitment and retention of gastroenterologists were reported. Given the large number of respondents that reported a unique barrier (ie, being the only respondents to report the barrier), a decision was made to include only barriers to recruitment and retention that were reported by at least 2 sites (Table). While there were some common themes, the reported barriers to retention differed from those to recruitment. The most reported barriers to recruitment were 46 respondents who noted salary, 23 reported human resources-related challenges, and 12 reported location. Respondents also noted various retention barriers, including 32 respondents who reported salary barriers; 13 reported administrative burden barriers, 6 reported medical center leadership, and 4 reported burnout.

Survey respondents provided multiple recommendations on how the VA can best support the recruitment and retention of gastroenterologists. The most frequent recommendations were to increase financial compensation by increasing the current aggregate salary cap to > $400,000, increasing the use of recruitment and retention incentives, and ensuring that gastroenterology is on the national Educational Debt Reduction Program (EDRP) list, which facilitates student loan repayment. It was recommended that a third-party company assist with hiring to overcome perceived issues with human resources. Additionally, there were multiple recommendations for improving administrative and clinical support. These included mandating how many support staff should be assigned to each gastroenterologist and providing best practice recommendations for support staff so that gastroenterologists can focus on physician-level work. Recommendations also included having a dedicated gastroenterology practice manager, nurse care coordinators, a colorectal cancer screening/surveillance coordinator, sufficient medical support assistants, and quality improvement personnel tracking ongoing professional practice evaluation data. Survey respondents also highlighted specific suggestions for recruiting recent graduates. These included offering a 4-day work week, as recent graduates place a premium on work-life balance, and ensuring gastroenterologists have individual offices. One respondent commented that gastroenterology fellows seeing VA gastroenterology attendings in cramped, shared offices, contrasted with private practice gastroenterologists in large private offices, may contribute to choosing private practice over joining the VA.

Discussion

Gastroenterology is currently listed by VHA WMC as 1 of the top 3 medical specialties in the VA with the most physician shortages.⁵ Working as a physician in the VA has long been recognized to have many benefits. First and foremost, many physicians are motivated by the VA mission to serve veterans, as this offers personal fulfillment and other intangible benefits. In addition, the VA can provide work-life balance, which is often not possible in fee-for-service settings, with patient panels and call volumes typically lower than in comparable private hospital settings. Moreover, VA physicians have outstanding teaching opportunities, as the VA is the largest supporter of medical education, with postgraduate trainees rotating through > 150 VA medical centers. Likewise, the VA offers a variety of student loan repayment programs (eg, the Specialty Education Loan Repayment Program and the EDRP). The VA offers research funding such as the Cooperative Studies Programs or program project funding, and rewards in parallel with the National Institute of Health (eg, career development awards, or merit review awards) and other grants. VA researchers have conducted many landmark studies that continue to shape the practice of gastroenterology and hepatology. From the earliest studies to demonstrate the effectiveness of screening colonoscopy, to the largest ongoing clinical trial in US history to assess the effectiveness of fecal immunochemical testing (FIT) vs screening colonoscopy.^10-12 The VA has also led the field in the study of gastroesophageal reflux disease, hepatitis C treatment, and liver cancer screening.^13-15 VA physicians also benefit from participation in the Federal Employee Retirement System, including its pension system.

These benefits apply to all medical specialties, making the VA a potentially appealing workplace for gastroenterologists. However, recent trends indicate that recruitment and retention of gastroenterologists is increasingly challenging, as the VA gastroenterology workforce grew by 5.0% in fiscal year (FY) 2020 and 1.8% in FY 2021. However, it was on track to end FY 2022 with a loss (-1.1%).⁵ It must be noted that this trend is not limited to the VA, and the National Center for Health Workforce Analysis predicts that gastroenterology will remain among the highest projected specialty shortages. Driven by increased demand for digestive health care services, more physicians nearing traditional retirement age, and substantially higher rates of burnout after the COVID-19 pandemic.¹⁶ All these factors are likely to result in an increasingly competitive market for gastroenterology, highlight the growing differences between VA and non-VA positions, and may augment the impact of differences for the individual gastroenterologist weighing employment options within and outside the VA.

Suboptimal human resources were the second most commonly cited impediment to recruiting gastroenterologists. Many section chiefs expressed frustration with the inefficient and slow administrative process of onboarding new gastroenterologists, which may take many months and not infrequently results in losing candidates to competing entities. While this issue is specific to recruitment, recurring and long-standing vacancies can increase work burdens, complicate logistics for remaining faculty, and may also negatively impact retention. One potential opportunity to improve VHA competitiveness is to streamline the administrative component of recruitment and optimize human resources support. The use of a third-party hiring company also should be considered.

Survey responses also indicated that administrative burden and insufficient support staff were significant retention challenges. Several respondents described a lack of efficient endoscopy workflow and delegation of simple administrative tasks to gastroenterologists as more likely in units without proper task distribution. Importantly, these shortcomings occur at the expense of workload-generating activities and career-enhancing opportunities.

While burnout rates among VA gastroenterologists have not been documented systematically, they likely correlate with workplace frustration and jeopardizegastroenterologist retention. Successful retention of gastroenterologists as highly trained medical professionals is more likely in workplaces that are vertically organized, efficient, and use physicians at the top of their skill level.

Conclusions

The VA offers the opportunity for a rewarding lifelong career in gastroenterology. The fulfillment of serving veterans, teaching future health care leaders, performing impactful research, and having job security is invaluable. Despite the tremendous benefits, this survey supports improving VA recruitment and retention strategies for the high-demand gastroenterology specialty. Improved salary parity is needed for workforce maintenance and recruitment, as is improved administrative and clinical support to maintain the high level of care our veterans deserve.

Veterans have a high burden of digestive diseases, and gastroenterologists are needed for the diagnosis and management of these conditions.^1-4 According to the Veterans Health Administration (VHA) Workforce Management and Consulting (WMC) office, the physician specialties with the greatest shortages are psychiatry, primary care, and gastroenterology.⁵ The VHA estimates it must hire 70 new gastroenterologists annually between fiscal years 2023 and 2027 to provide timely digestive care.⁵

Filling these positions will be increasingly difficult as competition for gastroenterologists is fierce. A recent Merritt Hawkins review states, “Gastroenterologists were the most in-demand type of provider during the 2022 review period.”⁶ In 2022, the median annual salary for US gastroenterologists was reported to be $561,375.⁷ Currently, the US Department of Veterans Affairs (VA) has an aggregate annual pay limit of $400,000 for all federal employees and cannot compete based on salary alone.

Retention of existing VA gastroenterologists also is challenging. The WMC has reported that 21.6% of VA gastroenterologists are eligible to retire, and in 2021, 8.2% left the VA to retire or seek non-VA positions.⁵ While not specific to the VA, a survey of practicing gastroenterologists conducted by the American College of Gastroenterology found a 49% burnout rate among respondents.⁸ Factors contributing to burnout at all career stages included administrative nonclinical work and a lack of clinical support staff.⁸ Burnout is also linked with higher rates of medical errors, interpersonal conflicts, and patient dissatisfaction. Burnout is more common among those with an innate strong sense of purpose and responsibility for their patients, characteristics we have observed in our VA colleagues.⁹

As members of the Section Chief Subcommittee of the VA Gastroenterology Field Advisory Board (GI FAB), we are passionate about providing outstanding gastroenterology care to US veterans, and we are alarmed at the struggles we are observing with recruiting and retaining a qualified national gastroenterology physician workforce. As such, we set out to survey the VA gastroenterology section chief community to gain insights into recruitment and retention challenges they have faced and identify potential solutions to these problems.

Methods

The GI FAB Section Chief Subcommittee developed a survey on gastroenterologist recruitment and retention using Microsoft Forms (Appendix). A link to the survey, which included 11 questions about facility location, current vacancies, and free text responses on barriers to recruitment and retention and potential solutions, was sent via email to all gastroenterology section chiefs on the National Gastroenterology and Hepatology Program Office’s email list of section chiefs on January 31, 2023. A reminder to complete the survey was sent to all section chiefs on February 8, 2023. Survey responses were aggregated and analyzed by the authors using descriptive statistics.

The VA gastroenterologist recruitment and retention survey was emailed to 131 gastroenterology section chiefs and completed by 55 respondents (42%) (Figure). Of the responding section chiefs, 36 (65%) reported gastroenterologist vacancies at their facilities. Seventeen respondents (47%) reported a single vacancy, 12 (33%) reported 2 vacancies, 4 (11%) reported 3 vacancies, and 3 (8%) reported 4 vacancies. Of the sites with reported vacancies, 32 (89%) reported a need for a general gastroenterologist, 12 (33%) reported a need for a hepatologist, 11 (31%) reported a need for an advanced endoscopist, 9 (25%) reported a need for a gastroenterologist with specialized expertise in inflammatory bowel diseases, and 1 (3%) reported a need for a gastrointestinal motility specialist.

Numerous barriers to the recruitment and retention of gastroenterologists were reported. Given the large number of respondents that reported a unique barrier (ie, being the only respondents to report the barrier), a decision was made to include only barriers to recruitment and retention that were reported by at least 2 sites (Table). While there were some common themes, the reported barriers to retention differed from those to recruitment. The most reported barriers to recruitment were 46 respondents who noted salary, 23 reported human resources-related challenges, and 12 reported location. Respondents also noted various retention barriers, including 32 respondents who reported salary barriers; 13 reported administrative burden barriers, 6 reported medical center leadership, and 4 reported burnout.

Survey respondents provided multiple recommendations on how the VA can best support the recruitment and retention of gastroenterologists. The most frequent recommendations were to increase financial compensation by increasing the current aggregate salary cap to > $400,000, increasing the use of recruitment and retention incentives, and ensuring that gastroenterology is on the national Educational Debt Reduction Program (EDRP) list, which facilitates student loan repayment. It was recommended that a third-party company assist with hiring to overcome perceived issues with human resources. Additionally, there were multiple recommendations for improving administrative and clinical support. These included mandating how many support staff should be assigned to each gastroenterologist and providing best practice recommendations for support staff so that gastroenterologists can focus on physician-level work. Recommendations also included having a dedicated gastroenterology practice manager, nurse care coordinators, a colorectal cancer screening/surveillance coordinator, sufficient medical support assistants, and quality improvement personnel tracking ongoing professional practice evaluation data. Survey respondents also highlighted specific suggestions for recruiting recent graduates. These included offering a 4-day work week, as recent graduates place a premium on work-life balance, and ensuring gastroenterologists have individual offices. One respondent commented that gastroenterology fellows seeing VA gastroenterology attendings in cramped, shared offices, contrasted with private practice gastroenterologists in large private offices, may contribute to choosing private practice over joining the VA.

Discussion

Gastroenterology is currently listed by VHA WMC as 1 of the top 3 medical specialties in the VA with the most physician shortages.⁵ Working as a physician in the VA has long been recognized to have many benefits. First and foremost, many physicians are motivated by the VA mission to serve veterans, as this offers personal fulfillment and other intangible benefits. In addition, the VA can provide work-life balance, which is often not possible in fee-for-service settings, with patient panels and call volumes typically lower than in comparable private hospital settings. Moreover, VA physicians have outstanding teaching opportunities, as the VA is the largest supporter of medical education, with postgraduate trainees rotating through > 150 VA medical centers. Likewise, the VA offers a variety of student loan repayment programs (eg, the Specialty Education Loan Repayment Program and the EDRP). The VA offers research funding such as the Cooperative Studies Programs or program project funding, and rewards in parallel with the National Institute of Health (eg, career development awards, or merit review awards) and other grants. VA researchers have conducted many landmark studies that continue to shape the practice of gastroenterology and hepatology. From the earliest studies to demonstrate the effectiveness of screening colonoscopy, to the largest ongoing clinical trial in US history to assess the effectiveness of fecal immunochemical testing (FIT) vs screening colonoscopy.^10-12 The VA has also led the field in the study of gastroesophageal reflux disease, hepatitis C treatment, and liver cancer screening.^13-15 VA physicians also benefit from participation in the Federal Employee Retirement System, including its pension system.

These benefits apply to all medical specialties, making the VA a potentially appealing workplace for gastroenterologists. However, recent trends indicate that recruitment and retention of gastroenterologists is increasingly challenging, as the VA gastroenterology workforce grew by 5.0% in fiscal year (FY) 2020 and 1.8% in FY 2021. However, it was on track to end FY 2022 with a loss (-1.1%).⁵ It must be noted that this trend is not limited to the VA, and the National Center for Health Workforce Analysis predicts that gastroenterology will remain among the highest projected specialty shortages. Driven by increased demand for digestive health care services, more physicians nearing traditional retirement age, and substantially higher rates of burnout after the COVID-19 pandemic.¹⁶ All these factors are likely to result in an increasingly competitive market for gastroenterology, highlight the growing differences between VA and non-VA positions, and may augment the impact of differences for the individual gastroenterologist weighing employment options within and outside the VA.

Suboptimal human resources were the second most commonly cited impediment to recruiting gastroenterologists. Many section chiefs expressed frustration with the inefficient and slow administrative process of onboarding new gastroenterologists, which may take many months and not infrequently results in losing candidates to competing entities. While this issue is specific to recruitment, recurring and long-standing vacancies can increase work burdens, complicate logistics for remaining faculty, and may also negatively impact retention. One potential opportunity to improve VHA competitiveness is to streamline the administrative component of recruitment and optimize human resources support. The use of a third-party hiring company also should be considered.

Survey responses also indicated that administrative burden and insufficient support staff were significant retention challenges. Several respondents described a lack of efficient endoscopy workflow and delegation of simple administrative tasks to gastroenterologists as more likely in units without proper task distribution. Importantly, these shortcomings occur at the expense of workload-generating activities and career-enhancing opportunities.

While burnout rates among VA gastroenterologists have not been documented systematically, they likely correlate with workplace frustration and jeopardizegastroenterologist retention. Successful retention of gastroenterologists as highly trained medical professionals is more likely in workplaces that are vertically organized, efficient, and use physicians at the top of their skill level.

Conclusions

The VA offers the opportunity for a rewarding lifelong career in gastroenterology. The fulfillment of serving veterans, teaching future health care leaders, performing impactful research, and having job security is invaluable. Despite the tremendous benefits, this survey supports improving VA recruitment and retention strategies for the high-demand gastroenterology specialty. Improved salary parity is needed for workforce maintenance and recruitment, as is improved administrative and clinical support to maintain the high level of care our veterans deserve.

Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.¹ There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.² Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.³

The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.^4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.^6,7

Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.^1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.¹ Frequently, a VMB is incorporated into the structure and flow of the huddle.

In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.¹ VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.¹ In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.^6,8-12

This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.

Implementation

The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.

The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.

Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.

The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.¹³

Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.¹⁴ Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.¹⁴ Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.

After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.

Program Impact

A total of 55 improvement opportunity tickets were submitted by staff members during the initial 23 months after the implementation of the outpatient cardiology clinic VMB. Most were submitted by nurse practitioners, although there were contributions from all faculty and staff. The high percentage of ticket submissions by nurse practitioners may be related to their full-time daily presence in the clinic, whereas some other staff members are part-time (most physicians are present 1 day each week). Improvement opportunities were noted within a variety of areas, including clinic facilities (eg, clinic equipment), communication between the clinic and patients (eg, telephone calls from patients or appointment letters), and patient care (eg, medication reconciliation and laboratory requisition).

In an improvement opportunity ticket, a staff member identified that the low seating in the patient waiting area was a fall risk and not diversified for varying body types. They posted a ticket, and the issue was discussed as a group. This staff member assumed ownership of the problem and placed an interior design request for taller chairs and bariatric options. The ticket was resolved when the waiting area was upgraded to include safer and more inclusive seating options for patients. Of 55 tickets submitted by staff as of June 2024, 45 have identified solutions, 4 are in process, and 6 have been placed in the parking lot. On average, the morning huddle spends about 5 to 10 minutes addressing tickets, but on occasion, more complex topics require additional time. The kudos board receives feedback from patients who express their gratitude, and serves as a space to celebrate awards received by staff members.

Implementing a VMB into daily huddles within the cardiology clinic led to increased staff engagement and ownership of challenges, as well as improved communication between frontline workers and leadership. VMBs have proven to be useful for annual staff performance evaluations because staff members who engaged in the board and volunteered to take accountability for ticket resolution could use those accomplishments in their assessments. Finally, VMBs made quality improvement and safety work accessible by normalizing frequent conversations. This empowered staff to engage in improvement projects and even led some members to enroll in formal Lean training.

The outpatient cardiology clinic VMB at the VAAAHS was identified as a best practice during a site visit by the Promising Practice Team in the Veterans Health Administration Office of Integrated Veteran Care. The outpatient cardiology clinic leadership team, including the authors of this article, was invited to present our visual management work as a main topic at the January 2024 Office of Integrated Veteran Care collaborative meeting.

Further Implementation

The SR program has collaborated with additional VAAAHS teams to implement VMBs. Forty-four physical VMBs and 20 virtual VMBs are currently in use throughout the VAAAHS. Virtual VMB content is similar to a physical board and can be modified by each team to meet its particular needs. Several virtual VMBs have been implemented at the VAAAHS and can achieve the same goals of staff teamwork, empowerment, and engagement. Each team can choose the format of the VMB that best fits their needs, which may be partially influenced by the team’s overall interaction style (on-site teams may function better with a physical VMB, and off-site teams may find a virtual VMB works best). VMBs have been implemented in various work areas, including laboratories, inpatient wards, subspecialty outpatient clinics, procedural areas, and the engineering department. In fiscal year 2024, 180 tickets were electronically submitted by teams across the VAAAHS, of which 170 identified solutions and were marked completed. Ticket counts may be underestimated since not all physical board tickets are reported in the electronic system. The SR program periodically attends morning huddles of various teams and obtains feedback on their VMBs, a practice that highlights its contribution to staff engagement, transparency, teamwork, and continuous improvement (Table). A goal of the SR program is to identify areas of the VAAAHS in which VMBs would add value to the team and implement them as necessary.

Discussion

VMBs are common in health care and are implemented to promote the core principlesof Lean thinking and HROs, including visual management and daily accountability. The goals of a visual management tool are to make problems visible and document their management. A VMB can serve as a focal point for team discussion and a physical space to track each problem through its initial identification, understanding of root causes, consideration of potential solutions, and recording of intervention results.

A VMB can foster a culture of safety, leadership commitment, and continuous process improvement when designed and implemented to reflect team needs. VMBs can empower staff members to share work concerns and openly promote engagement. As a central place for discussion between staff and leaders, VMBs can also foster teamwork and communication. The daily huddle provides a safe, productive working environment by ensuring that lines of communication are open among all team members, regardless of role or leadership designation.

Limitations

This article focused on the implementation of 1 type of visual management tool. It provides an in-depth discussion of the development, implementation, and experience with a VMB at multiple clinics of a single section in 1 health care system. These reported experiences may not represent other VA facilities. Perceptions of the impact and usefulness of the VMB were mostly anecdotal. Further evaluation of the VMB implementation experience and utility at other VA health care systems would provide additional insight into the optimal implementation of VMBs.

Conclusions

Through increased transparency, empowerment, and communication, VMBs are an important tool in the visual management tool belt for organizations committed to HROs and Lean management. Given the successful institution of VMBs at the VAAAHS, the description of our experience may aid other VA systems for the incorporation of visual management into the daily culture of their respective health care teams.

Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.¹ There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.² Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.³

The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.^4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.^6,7

Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.^1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.¹ Frequently, a VMB is incorporated into the structure and flow of the huddle.

In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.¹ VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.¹ In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.^6,8-12

This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.

Implementation

The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.

The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.

Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.

The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.¹³

Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.¹⁴ Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.¹⁴ Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.

After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.

Program Impact

A total of 55 improvement opportunity tickets were submitted by staff members during the initial 23 months after the implementation of the outpatient cardiology clinic VMB. Most were submitted by nurse practitioners, although there were contributions from all faculty and staff. The high percentage of ticket submissions by nurse practitioners may be related to their full-time daily presence in the clinic, whereas some other staff members are part-time (most physicians are present 1 day each week). Improvement opportunities were noted within a variety of areas, including clinic facilities (eg, clinic equipment), communication between the clinic and patients (eg, telephone calls from patients or appointment letters), and patient care (eg, medication reconciliation and laboratory requisition).

In an improvement opportunity ticket, a staff member identified that the low seating in the patient waiting area was a fall risk and not diversified for varying body types. They posted a ticket, and the issue was discussed as a group. This staff member assumed ownership of the problem and placed an interior design request for taller chairs and bariatric options. The ticket was resolved when the waiting area was upgraded to include safer and more inclusive seating options for patients. Of 55 tickets submitted by staff as of June 2024, 45 have identified solutions, 4 are in process, and 6 have been placed in the parking lot. On average, the morning huddle spends about 5 to 10 minutes addressing tickets, but on occasion, more complex topics require additional time. The kudos board receives feedback from patients who express their gratitude, and serves as a space to celebrate awards received by staff members.

Implementing a VMB into daily huddles within the cardiology clinic led to increased staff engagement and ownership of challenges, as well as improved communication between frontline workers and leadership. VMBs have proven to be useful for annual staff performance evaluations because staff members who engaged in the board and volunteered to take accountability for ticket resolution could use those accomplishments in their assessments. Finally, VMBs made quality improvement and safety work accessible by normalizing frequent conversations. This empowered staff to engage in improvement projects and even led some members to enroll in formal Lean training.

The outpatient cardiology clinic VMB at the VAAAHS was identified as a best practice during a site visit by the Promising Practice Team in the Veterans Health Administration Office of Integrated Veteran Care. The outpatient cardiology clinic leadership team, including the authors of this article, was invited to present our visual management work as a main topic at the January 2024 Office of Integrated Veteran Care collaborative meeting.

Further Implementation

The SR program has collaborated with additional VAAAHS teams to implement VMBs. Forty-four physical VMBs and 20 virtual VMBs are currently in use throughout the VAAAHS. Virtual VMB content is similar to a physical board and can be modified by each team to meet its particular needs. Several virtual VMBs have been implemented at the VAAAHS and can achieve the same goals of staff teamwork, empowerment, and engagement. Each team can choose the format of the VMB that best fits their needs, which may be partially influenced by the team’s overall interaction style (on-site teams may function better with a physical VMB, and off-site teams may find a virtual VMB works best). VMBs have been implemented in various work areas, including laboratories, inpatient wards, subspecialty outpatient clinics, procedural areas, and the engineering department. In fiscal year 2024, 180 tickets were electronically submitted by teams across the VAAAHS, of which 170 identified solutions and were marked completed. Ticket counts may be underestimated since not all physical board tickets are reported in the electronic system. The SR program periodically attends morning huddles of various teams and obtains feedback on their VMBs, a practice that highlights its contribution to staff engagement, transparency, teamwork, and continuous improvement (Table). A goal of the SR program is to identify areas of the VAAAHS in which VMBs would add value to the team and implement them as necessary.

Discussion

VMBs are common in health care and are implemented to promote the core principlesof Lean thinking and HROs, including visual management and daily accountability. The goals of a visual management tool are to make problems visible and document their management. A VMB can serve as a focal point for team discussion and a physical space to track each problem through its initial identification, understanding of root causes, consideration of potential solutions, and recording of intervention results.

A VMB can foster a culture of safety, leadership commitment, and continuous process improvement when designed and implemented to reflect team needs. VMBs can empower staff members to share work concerns and openly promote engagement. As a central place for discussion between staff and leaders, VMBs can also foster teamwork and communication. The daily huddle provides a safe, productive working environment by ensuring that lines of communication are open among all team members, regardless of role or leadership designation.

Limitations

This article focused on the implementation of 1 type of visual management tool. It provides an in-depth discussion of the development, implementation, and experience with a VMB at multiple clinics of a single section in 1 health care system. These reported experiences may not represent other VA facilities. Perceptions of the impact and usefulness of the VMB were mostly anecdotal. Further evaluation of the VMB implementation experience and utility at other VA health care systems would provide additional insight into the optimal implementation of VMBs.

Conclusions

Through increased transparency, empowerment, and communication, VMBs are an important tool in the visual management tool belt for organizations committed to HROs and Lean management. Given the successful institution of VMBs at the VAAAHS, the description of our experience may aid other VA systems for the incorporation of visual management into the daily culture of their respective health care teams.

Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.¹ There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.² Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.³

The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.^4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.^6,7

Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.^1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.¹ Frequently, a VMB is incorporated into the structure and flow of the huddle.

In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.¹ VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.¹ In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.^6,8-12

This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.

Implementation

The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.

The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.

Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.

The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.¹³

Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.¹⁴ Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.¹⁴ Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.

After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.

Program Impact

A total of 55 improvement opportunity tickets were submitted by staff members during the initial 23 months after the implementation of the outpatient cardiology clinic VMB. Most were submitted by nurse practitioners, although there were contributions from all faculty and staff. The high percentage of ticket submissions by nurse practitioners may be related to their full-time daily presence in the clinic, whereas some other staff members are part-time (most physicians are present 1 day each week). Improvement opportunities were noted within a variety of areas, including clinic facilities (eg, clinic equipment), communication between the clinic and patients (eg, telephone calls from patients or appointment letters), and patient care (eg, medication reconciliation and laboratory requisition).

In an improvement opportunity ticket, a staff member identified that the low seating in the patient waiting area was a fall risk and not diversified for varying body types. They posted a ticket, and the issue was discussed as a group. This staff member assumed ownership of the problem and placed an interior design request for taller chairs and bariatric options. The ticket was resolved when the waiting area was upgraded to include safer and more inclusive seating options for patients. Of 55 tickets submitted by staff as of June 2024, 45 have identified solutions, 4 are in process, and 6 have been placed in the parking lot. On average, the morning huddle spends about 5 to 10 minutes addressing tickets, but on occasion, more complex topics require additional time. The kudos board receives feedback from patients who express their gratitude, and serves as a space to celebrate awards received by staff members.

Implementing a VMB into daily huddles within the cardiology clinic led to increased staff engagement and ownership of challenges, as well as improved communication between frontline workers and leadership. VMBs have proven to be useful for annual staff performance evaluations because staff members who engaged in the board and volunteered to take accountability for ticket resolution could use those accomplishments in their assessments. Finally, VMBs made quality improvement and safety work accessible by normalizing frequent conversations. This empowered staff to engage in improvement projects and even led some members to enroll in formal Lean training.

The outpatient cardiology clinic VMB at the VAAAHS was identified as a best practice during a site visit by the Promising Practice Team in the Veterans Health Administration Office of Integrated Veteran Care. The outpatient cardiology clinic leadership team, including the authors of this article, was invited to present our visual management work as a main topic at the January 2024 Office of Integrated Veteran Care collaborative meeting.

Further Implementation

The SR program has collaborated with additional VAAAHS teams to implement VMBs. Forty-four physical VMBs and 20 virtual VMBs are currently in use throughout the VAAAHS. Virtual VMB content is similar to a physical board and can be modified by each team to meet its particular needs. Several virtual VMBs have been implemented at the VAAAHS and can achieve the same goals of staff teamwork, empowerment, and engagement. Each team can choose the format of the VMB that best fits their needs, which may be partially influenced by the team’s overall interaction style (on-site teams may function better with a physical VMB, and off-site teams may find a virtual VMB works best). VMBs have been implemented in various work areas, including laboratories, inpatient wards, subspecialty outpatient clinics, procedural areas, and the engineering department. In fiscal year 2024, 180 tickets were electronically submitted by teams across the VAAAHS, of which 170 identified solutions and were marked completed. Ticket counts may be underestimated since not all physical board tickets are reported in the electronic system. The SR program periodically attends morning huddles of various teams and obtains feedback on their VMBs, a practice that highlights its contribution to staff engagement, transparency, teamwork, and continuous improvement (Table). A goal of the SR program is to identify areas of the VAAAHS in which VMBs would add value to the team and implement them as necessary.

Discussion

VMBs are common in health care and are implemented to promote the core principlesof Lean thinking and HROs, including visual management and daily accountability. The goals of a visual management tool are to make problems visible and document their management. A VMB can serve as a focal point for team discussion and a physical space to track each problem through its initial identification, understanding of root causes, consideration of potential solutions, and recording of intervention results.

A VMB can foster a culture of safety, leadership commitment, and continuous process improvement when designed and implemented to reflect team needs. VMBs can empower staff members to share work concerns and openly promote engagement. As a central place for discussion between staff and leaders, VMBs can also foster teamwork and communication. The daily huddle provides a safe, productive working environment by ensuring that lines of communication are open among all team members, regardless of role or leadership designation.

Limitations

This article focused on the implementation of 1 type of visual management tool. It provides an in-depth discussion of the development, implementation, and experience with a VMB at multiple clinics of a single section in 1 health care system. These reported experiences may not represent other VA facilities. Perceptions of the impact and usefulness of the VMB were mostly anecdotal. Further evaluation of the VMB implementation experience and utility at other VA health care systems would provide additional insight into the optimal implementation of VMBs.

Conclusions

Through increased transparency, empowerment, and communication, VMBs are an important tool in the visual management tool belt for organizations committed to HROs and Lean management. Given the successful institution of VMBs at the VAAAHS, the description of our experience may aid other VA systems for the incorporation of visual management into the daily culture of their respective health care teams.

Enhancing the quality of care for the evolving American veteran population is critical: many are vulnerable as a result of unique psychological and physical exposures, and many are increasingly coming from populations the federal government considers “potentially vulnerable.”¹ To ensure that the needs of veterans enrolled in the Veterans Health Administration (VHA) are met, the US Department of Veterans Affairs (VA) workforce must be aware of shifts in the demographics of those who served.

The I*DEA (inclusion, diversity, equity, and access) Council is a new VHA equity team that aims to eliminate gaps in health care and benefits to ensure that historically underserved veteran communities receive the treatment they need. The Council is the oversight body for veteran and employee-facing I*DEA programs, policies, and initiatives.² One strategy to achieve better health outcomes for enrolled veterans is to prioritize the VA health care workforce. In this capacity, the I*DEA Council examines obstacles to hiring, promoting, and retaining employees from underserved communities.

This article discusses how diversity encompasses more than gender and ethnicity and proposes applying the following I*DEA strategies to leadership positions within the VA health care workforce: inclusion of diverse perspectives and ideas, equity of opportunities, and accessibility to leadership roles within VHA facilities. Implementing these actions may help attract and retain qualified clinicians as health care leaders and enable the VHA to better serve the diverse veteran population.

Veteran Demographics

Characteristics of the current population of veterans differ significantly from those of individuals who served in previous eras. Since 2016, Gulf War era veterans have comprised the largest share of the veteran population, even larger than the share of Vietnam War era veterans.³ Among Gulf War veterans, 47% of women and 39% of men are aged < 35 years.⁴ Another notable change is the increase in the number of female veterans. In 1992, only 4% of veterans were female.⁵ Now, about 11% of veterans are female, a number projected to grow to 18% by 2046 (Table 1).³

With respect to race and ethnicity, about 74% of the current veteran population identifies as White, 13% as Black, 8% as Hispanic or Latino, and 2% as Asian.^3,6 In addition, about 30% of veterans have ≥ 1 disability.⁷ About 1 million current veterans (3%) identify as lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+).⁸ Almost 1 in 4 veterans—about 4.4 million—reside in rural communities, and 55% of these rural veterans are aged > 65 years.⁹ Of the 4.4 million veterans who live in rural areas, 61% are enrolled in VA health care, and among those individuals 8% are women and 10% are minorities.⁹

Studies have found that age, sex, race and ethnicity, disability status, and LGBTQ+ identification all significantly affect health care access and outcomes in the general population.^10-16 Female patients are more likely to have their symptoms downplayed or dismissed, and are often less likely to receive aggressive treatments when compared with male patients. They are also frequently underrepresented or even excluded from clinical trials.¹¹ Female veterans have unique health care needs and report preferences for being treated by female clinicians.^17,18

Higher rates of chronic health conditions and reduced access to mental health services are found among Black Americans compared to White Americans.¹³ Black veterans are also denied VHA benefits more often than White veterans.¹⁹ Patients with disabilities have barriers to accessing care, including difficulty with transportation and a lack of knowledge among clinicians regarding the best course of care.¹⁴ Additionally, veterans who identify as LGBTQ+ are less likely than veterans who are cisgender and heterosexual to access Veterans Health Administration (VHA) care.²⁰ Veterans in rural communities experience more challenges to accessing health care; up to one-third of veterans in this population are unable to access the internet at home.⁹

To optimize care for the evolving veteran population, VHA clinicians and leaders need to be aware of the changing demographic characteristics and unique health care needs of the veteran population. Increased inclusion, diversity, and equity within the health care workforce is associated with improved quality of care, improved clinical outcomes, and have had positive financial effects on health care institutions.^21-25

VA Workforce Demographics

According to the VA Office of Resolution Management, Diversity, and Inclusion, at the end of fiscal year 2020 57% of VA employees identified as White, 25% as Black, 8% as Asian, 7% as Hispanic or Latino, 2% as American Indian or Alaskan Native, and 1% belonged to ≥ 2 races.²⁶ Women comprise about 60% of the permanent VA workforce.²⁷ About 12% of VA employees report having a disability, which is similar to the rate of disability among noninstitutionalized civilians in the US (12.7%).²⁸ Five percent of VA employees identified as LGBTQ+.²⁹

Although the general workforce is relatively diverse, there is not as much diversity within VA leadership, and little data exist about the demographic characteristics of VHA physicians. As of September 2020, there were 494 senior executive service and Title 38 (health care workers) senior executive service equivalent leaders in the VHA.²⁶ Almost 78% of these leadership positions belonged to white men and women: about 50% to white men and 28% to white women. In contrast, 8% of these positions were occupied by Black men, 7% by Black women, 3% by Asian men, 2% by Asian women, and 2% by Hispanic or Latino men.²⁶

I*DEA in the VA

The I*DEA Council seeks to eliminate gaps in VHA care and benefits to ensure that historically underserved veteran communities receive fair treatment.³⁰ In addition to continued attention to racial disparities, the new initiative will also examine challenges experienced by other groups, including women, individuals who identify as LGBTQ+, tribal communities, and veterans who live in rural areas, aiming to eliminate disparities that exist within the VHA.

Published in 2021, the I*DEA Action Plan discusses recommendations to enhance inclusion, diversity, equity, and accessibility within the VHA. Its mission statement states that the Council aims to “advance an inclusive environment that values and supports the diverse communities we serve” and “cultivates equitable access to care, benefits and services for all” from 2021 to 2025.³¹ To achieve better health outcomes for veterans, the I*DEA Council plans to focus on the VHA workforce and examine and address obstacles to hiring, promoting, and retaining employees.³¹

There are several potential benefits of increased I*DEA integration into the health care workforce.^21-25 The inclusion of ideas and perspectives from diverse backgrounds, establishing equity of opportunities for all who are appropriately qualified, and accessibility to leadership roles that enable decision making by fostering culture change are direct components of I*DEA that may be beneficial. Diversity encompasses more than race, ethnicity, and gender, and creating a more diverse workforce involves recruiting qualified clinicians with diverse backgrounds and perspectives. Doing so would better reflect the diversity of veteran patients and could enhance the ability of clinicians to learn from each other and be inclusive, while understanding veterans’ unique barriers to accessing health care.

I*DEA integration may reduce the incidence of microaggressions and help transform workplace culture.³² This would be particularly beneficial for patients, as microaggressions can decrease patient satisfaction and may potentially negatively affect health outcomes.^33,34 In addition, health care professionals (HCPs) would benefit from fewer microaggressions in the workplace and this would foster a more positive, supportive work environment and improve morale.

Current VHA workforce data reflect changes in the veteran population. The workforce is relatively diverse regarding race and ethnicity, gender, disability, and LGBTQ+ status. However, room for improvement remains with respect to greater inclusion, diversity of perspectives, equity, and accessibility to leadership positions and decision making roles. This would ultimately benefit and improve care for veterans. Prioritizing this within the VHA, as reflected in one of the I*DEA Task Force recommendations, is of great significance.³¹

It can be difficult to accurately assess the progress made in implementing I*DEA strategies at individual institutions within the VHA. While demographic diversity can be gauged using employee statistics, assessing perceptions of inclusion, incorporation of diverse perspectives, equity, and accessibility is more challenging. We recommend continuing to administer questions focusing specifically on these perceptions to current HCPs via the VHA annual All Employee Survey.³⁵

Implementation

The VA has begun initiating I*DEA concepts in its workforce, starting with the establishment and usage of Special Emphasis Programs.³⁶ The goal of these programs is to increase the employment of historically marginalized groups, including women, people belonging to racial and ethnic minorities, people with disabilities,and individuals identifying as LGBTQ+.^28,37-42 For example, each federal agency has a designated Federal Women’s Program whose responsibilities include helping with the recruitment and advancement of female employees.³⁷

The VHA also has an affirmative action plan with goals for recruiting and retaining individuals with disabilities.²⁸ To strengthen equity and inclusion, the VHA offers multiple educational courses (some mandatory), both virtual and in-person, on topics such as understanding microaggressions, managing implicit bias, and understanding the importance of gender and generational diversity.⁴³ Creating awareness and addressing misconceptions about veteran demographics at VA medical centers is important, as is enhancing awareness among the physician workforce about VA strategies and action plans to increase I*DEA. The VHA has hired officers specifically tasked with focusing on these initiatives.

Workforce Strategies

It is important to recognize overlaps between organizational ethics, quality improvement, and I*DEA initiatives. Establishing an I*DEA Council to ensure the delivery of quality care to veterans is commendable. At the facility level, individual I*DEA officers can make observations and recommendations but are not empowered to effect change. Without participation and buy-in from individuals in leadership positions, the efficacy of I*DEA initiatives is limited.

We propose implementing simple strategies to enhance the inclusion of diverse ideas and perspectives, equity of opportunities, and accessibility to clinical leadership roles within the VHA (Table 2). A competitive selection process with specific, objective criteria to enable the selection of qualified clinical leaders is vital. Specific achievements in or contributions to quality improvement, education, research, professional publications, or diversity enhancing efforts should be required qualifications for clinical leadership roles.⁴⁴

Establishing term limits for clinical leadership positions—something already being implemented at the National Institutes of Health—would be of tremendous value in the VHA.^45-47 Term limits would facilitate I*DEA initiatives and accessibility of leadership roles to qualified clinicians fromvarious demographics. Improving diversity of thought among clinical leaders is especially important, given how buy-in from leadership is critical in transforming the culture of an organization. Term limits would enable access to leadership roles for forward thinking, qualified clinical leaders who could institute and support changes that would promote continuous process improvement initiatives. Leaders could have the option to reapply following the completion of a term, with the ability to demonstrate specific achievements.

Another strategy for increasing equity is to ensure transparency of committee structures, with the rotation of committee members and term limits set for committee chairs whenever possible. This provides access to leadership roles, which enables participation in decision making processes. Residents and fellows who work and train at VA hospitals should have awareness of the facility’s organizational structure and the ability to participate in certain committees. The VHA workforce should be regularly informed about educational opportunities, leadership openings, and I*DEA initiatives to increase their access and use.

Exit interviews for clinicians leaving the VA would enable feedback, provide focused reviews of any problematic issues that need to be addressed, and serve as assessments of organizational ethics.⁴⁸ Transparency and truth telling could be encouraged by having these exit interviews conducted by staff in the human resources department or others outside the home department of the departing clinician.

Mentorship has played a significant role in exposing individuals from historically underrepresented groups to careers in health care, while also advancing and enhancing their careers after they become health care professionals.^49-51 Implementing and publicizing VA and veteran health care-focused mentorship and volunteer programs targeted at local communities, rural areas, schools, undergraduate programs, and medical students could increase the likelihood that students and trainees from these groups are exposed to the VHA which may lead them to join the workforce.

Conclusions

Veterans receiving care from the VHA are becoming increasingly diverse. I*DEA strategies could optimize the VHA workforce and enhance the provision of quality care for veterans. The inclusion of diverse perspectives and backgrounds, equity of opportunities, and accessibility to leadership positions is important. Careful selection of qualified clinical leaders within the VHA—with established term limits for leadership positions, rotation of committee chairs and members, and exit interviews to obtain insights from clinicians who leave the VHA—all align with these strategies. This will foster energy and culture change, create an environment conducive to collaboration, learning, and professional growth and will enable continuous process improvement within individual VA medical centers.

Enhancing the quality of care for the evolving American veteran population is critical: many are vulnerable as a result of unique psychological and physical exposures, and many are increasingly coming from populations the federal government considers “potentially vulnerable.”¹ To ensure that the needs of veterans enrolled in the Veterans Health Administration (VHA) are met, the US Department of Veterans Affairs (VA) workforce must be aware of shifts in the demographics of those who served.

The I*DEA (inclusion, diversity, equity, and access) Council is a new VHA equity team that aims to eliminate gaps in health care and benefits to ensure that historically underserved veteran communities receive the treatment they need. The Council is the oversight body for veteran and employee-facing I*DEA programs, policies, and initiatives.² One strategy to achieve better health outcomes for enrolled veterans is to prioritize the VA health care workforce. In this capacity, the I*DEA Council examines obstacles to hiring, promoting, and retaining employees from underserved communities.

This article discusses how diversity encompasses more than gender and ethnicity and proposes applying the following I*DEA strategies to leadership positions within the VA health care workforce: inclusion of diverse perspectives and ideas, equity of opportunities, and accessibility to leadership roles within VHA facilities. Implementing these actions may help attract and retain qualified clinicians as health care leaders and enable the VHA to better serve the diverse veteran population.

Veteran Demographics

Characteristics of the current population of veterans differ significantly from those of individuals who served in previous eras. Since 2016, Gulf War era veterans have comprised the largest share of the veteran population, even larger than the share of Vietnam War era veterans.³ Among Gulf War veterans, 47% of women and 39% of men are aged < 35 years.⁴ Another notable change is the increase in the number of female veterans. In 1992, only 4% of veterans were female.⁵ Now, about 11% of veterans are female, a number projected to grow to 18% by 2046 (Table 1).³

With respect to race and ethnicity, about 74% of the current veteran population identifies as White, 13% as Black, 8% as Hispanic or Latino, and 2% as Asian.^3,6 In addition, about 30% of veterans have ≥ 1 disability.⁷ About 1 million current veterans (3%) identify as lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+).⁸ Almost 1 in 4 veterans—about 4.4 million—reside in rural communities, and 55% of these rural veterans are aged > 65 years.⁹ Of the 4.4 million veterans who live in rural areas, 61% are enrolled in VA health care, and among those individuals 8% are women and 10% are minorities.⁹

Studies have found that age, sex, race and ethnicity, disability status, and LGBTQ+ identification all significantly affect health care access and outcomes in the general population.^10-16 Female patients are more likely to have their symptoms downplayed or dismissed, and are often less likely to receive aggressive treatments when compared with male patients. They are also frequently underrepresented or even excluded from clinical trials.¹¹ Female veterans have unique health care needs and report preferences for being treated by female clinicians.^17,18

Higher rates of chronic health conditions and reduced access to mental health services are found among Black Americans compared to White Americans.¹³ Black veterans are also denied VHA benefits more often than White veterans.¹⁹ Patients with disabilities have barriers to accessing care, including difficulty with transportation and a lack of knowledge among clinicians regarding the best course of care.¹⁴ Additionally, veterans who identify as LGBTQ+ are less likely than veterans who are cisgender and heterosexual to access Veterans Health Administration (VHA) care.²⁰ Veterans in rural communities experience more challenges to accessing health care; up to one-third of veterans in this population are unable to access the internet at home.⁹

To optimize care for the evolving veteran population, VHA clinicians and leaders need to be aware of the changing demographic characteristics and unique health care needs of the veteran population. Increased inclusion, diversity, and equity within the health care workforce is associated with improved quality of care, improved clinical outcomes, and have had positive financial effects on health care institutions.^21-25

VA Workforce Demographics

According to the VA Office of Resolution Management, Diversity, and Inclusion, at the end of fiscal year 2020 57% of VA employees identified as White, 25% as Black, 8% as Asian, 7% as Hispanic or Latino, 2% as American Indian or Alaskan Native, and 1% belonged to ≥ 2 races.²⁶ Women comprise about 60% of the permanent VA workforce.²⁷ About 12% of VA employees report having a disability, which is similar to the rate of disability among noninstitutionalized civilians in the US (12.7%).²⁸ Five percent of VA employees identified as LGBTQ+.²⁹

Although the general workforce is relatively diverse, there is not as much diversity within VA leadership, and little data exist about the demographic characteristics of VHA physicians. As of September 2020, there were 494 senior executive service and Title 38 (health care workers) senior executive service equivalent leaders in the VHA.²⁶ Almost 78% of these leadership positions belonged to white men and women: about 50% to white men and 28% to white women. In contrast, 8% of these positions were occupied by Black men, 7% by Black women, 3% by Asian men, 2% by Asian women, and 2% by Hispanic or Latino men.²⁶

I*DEA in the VA

The I*DEA Council seeks to eliminate gaps in VHA care and benefits to ensure that historically underserved veteran communities receive fair treatment.³⁰ In addition to continued attention to racial disparities, the new initiative will also examine challenges experienced by other groups, including women, individuals who identify as LGBTQ+, tribal communities, and veterans who live in rural areas, aiming to eliminate disparities that exist within the VHA.

Published in 2021, the I*DEA Action Plan discusses recommendations to enhance inclusion, diversity, equity, and accessibility within the VHA. Its mission statement states that the Council aims to “advance an inclusive environment that values and supports the diverse communities we serve” and “cultivates equitable access to care, benefits and services for all” from 2021 to 2025.³¹ To achieve better health outcomes for veterans, the I*DEA Council plans to focus on the VHA workforce and examine and address obstacles to hiring, promoting, and retaining employees.³¹

There are several potential benefits of increased I*DEA integration into the health care workforce.^21-25 The inclusion of ideas and perspectives from diverse backgrounds, establishing equity of opportunities for all who are appropriately qualified, and accessibility to leadership roles that enable decision making by fostering culture change are direct components of I*DEA that may be beneficial. Diversity encompasses more than race, ethnicity, and gender, and creating a more diverse workforce involves recruiting qualified clinicians with diverse backgrounds and perspectives. Doing so would better reflect the diversity of veteran patients and could enhance the ability of clinicians to learn from each other and be inclusive, while understanding veterans’ unique barriers to accessing health care.

I*DEA integration may reduce the incidence of microaggressions and help transform workplace culture.³² This would be particularly beneficial for patients, as microaggressions can decrease patient satisfaction and may potentially negatively affect health outcomes.^33,34 In addition, health care professionals (HCPs) would benefit from fewer microaggressions in the workplace and this would foster a more positive, supportive work environment and improve morale.

Current VHA workforce data reflect changes in the veteran population. The workforce is relatively diverse regarding race and ethnicity, gender, disability, and LGBTQ+ status. However, room for improvement remains with respect to greater inclusion, diversity of perspectives, equity, and accessibility to leadership positions and decision making roles. This would ultimately benefit and improve care for veterans. Prioritizing this within the VHA, as reflected in one of the I*DEA Task Force recommendations, is of great significance.³¹

It can be difficult to accurately assess the progress made in implementing I*DEA strategies at individual institutions within the VHA. While demographic diversity can be gauged using employee statistics, assessing perceptions of inclusion, incorporation of diverse perspectives, equity, and accessibility is more challenging. We recommend continuing to administer questions focusing specifically on these perceptions to current HCPs via the VHA annual All Employee Survey.³⁵

Implementation

The VA has begun initiating I*DEA concepts in its workforce, starting with the establishment and usage of Special Emphasis Programs.³⁶ The goal of these programs is to increase the employment of historically marginalized groups, including women, people belonging to racial and ethnic minorities, people with disabilities,and individuals identifying as LGBTQ+.^28,37-42 For example, each federal agency has a designated Federal Women’s Program whose responsibilities include helping with the recruitment and advancement of female employees.³⁷

The VHA also has an affirmative action plan with goals for recruiting and retaining individuals with disabilities.²⁸ To strengthen equity and inclusion, the VHA offers multiple educational courses (some mandatory), both virtual and in-person, on topics such as understanding microaggressions, managing implicit bias, and understanding the importance of gender and generational diversity.⁴³ Creating awareness and addressing misconceptions about veteran demographics at VA medical centers is important, as is enhancing awareness among the physician workforce about VA strategies and action plans to increase I*DEA. The VHA has hired officers specifically tasked with focusing on these initiatives.

Workforce Strategies

It is important to recognize overlaps between organizational ethics, quality improvement, and I*DEA initiatives. Establishing an I*DEA Council to ensure the delivery of quality care to veterans is commendable. At the facility level, individual I*DEA officers can make observations and recommendations but are not empowered to effect change. Without participation and buy-in from individuals in leadership positions, the efficacy of I*DEA initiatives is limited.

We propose implementing simple strategies to enhance the inclusion of diverse ideas and perspectives, equity of opportunities, and accessibility to clinical leadership roles within the VHA (Table 2). A competitive selection process with specific, objective criteria to enable the selection of qualified clinical leaders is vital. Specific achievements in or contributions to quality improvement, education, research, professional publications, or diversity enhancing efforts should be required qualifications for clinical leadership roles.⁴⁴

Establishing term limits for clinical leadership positions—something already being implemented at the National Institutes of Health—would be of tremendous value in the VHA.^45-47 Term limits would facilitate I*DEA initiatives and accessibility of leadership roles to qualified clinicians fromvarious demographics. Improving diversity of thought among clinical leaders is especially important, given how buy-in from leadership is critical in transforming the culture of an organization. Term limits would enable access to leadership roles for forward thinking, qualified clinical leaders who could institute and support changes that would promote continuous process improvement initiatives. Leaders could have the option to reapply following the completion of a term, with the ability to demonstrate specific achievements.

Another strategy for increasing equity is to ensure transparency of committee structures, with the rotation of committee members and term limits set for committee chairs whenever possible. This provides access to leadership roles, which enables participation in decision making processes. Residents and fellows who work and train at VA hospitals should have awareness of the facility’s organizational structure and the ability to participate in certain committees. The VHA workforce should be regularly informed about educational opportunities, leadership openings, and I*DEA initiatives to increase their access and use.

Exit interviews for clinicians leaving the VA would enable feedback, provide focused reviews of any problematic issues that need to be addressed, and serve as assessments of organizational ethics.⁴⁸ Transparency and truth telling could be encouraged by having these exit interviews conducted by staff in the human resources department or others outside the home department of the departing clinician.

Mentorship has played a significant role in exposing individuals from historically underrepresented groups to careers in health care, while also advancing and enhancing their careers after they become health care professionals.^49-51 Implementing and publicizing VA and veteran health care-focused mentorship and volunteer programs targeted at local communities, rural areas, schools, undergraduate programs, and medical students could increase the likelihood that students and trainees from these groups are exposed to the VHA which may lead them to join the workforce.

Conclusions

Veterans receiving care from the VHA are becoming increasingly diverse. I*DEA strategies could optimize the VHA workforce and enhance the provision of quality care for veterans. The inclusion of diverse perspectives and backgrounds, equity of opportunities, and accessibility to leadership positions is important. Careful selection of qualified clinical leaders within the VHA—with established term limits for leadership positions, rotation of committee chairs and members, and exit interviews to obtain insights from clinicians who leave the VHA—all align with these strategies. This will foster energy and culture change, create an environment conducive to collaboration, learning, and professional growth and will enable continuous process improvement within individual VA medical centers.

Enhancing the quality of care for the evolving American veteran population is critical: many are vulnerable as a result of unique psychological and physical exposures, and many are increasingly coming from populations the federal government considers “potentially vulnerable.”¹ To ensure that the needs of veterans enrolled in the Veterans Health Administration (VHA) are met, the US Department of Veterans Affairs (VA) workforce must be aware of shifts in the demographics of those who served.

The I*DEA (inclusion, diversity, equity, and access) Council is a new VHA equity team that aims to eliminate gaps in health care and benefits to ensure that historically underserved veteran communities receive the treatment they need. The Council is the oversight body for veteran and employee-facing I*DEA programs, policies, and initiatives.² One strategy to achieve better health outcomes for enrolled veterans is to prioritize the VA health care workforce. In this capacity, the I*DEA Council examines obstacles to hiring, promoting, and retaining employees from underserved communities.

This article discusses how diversity encompasses more than gender and ethnicity and proposes applying the following I*DEA strategies to leadership positions within the VA health care workforce: inclusion of diverse perspectives and ideas, equity of opportunities, and accessibility to leadership roles within VHA facilities. Implementing these actions may help attract and retain qualified clinicians as health care leaders and enable the VHA to better serve the diverse veteran population.

Veteran Demographics

Characteristics of the current population of veterans differ significantly from those of individuals who served in previous eras. Since 2016, Gulf War era veterans have comprised the largest share of the veteran population, even larger than the share of Vietnam War era veterans.³ Among Gulf War veterans, 47% of women and 39% of men are aged < 35 years.⁴ Another notable change is the increase in the number of female veterans. In 1992, only 4% of veterans were female.⁵ Now, about 11% of veterans are female, a number projected to grow to 18% by 2046 (Table 1).³

With respect to race and ethnicity, about 74% of the current veteran population identifies as White, 13% as Black, 8% as Hispanic or Latino, and 2% as Asian.^3,6 In addition, about 30% of veterans have ≥ 1 disability.⁷ About 1 million current veterans (3%) identify as lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+).⁸ Almost 1 in 4 veterans—about 4.4 million—reside in rural communities, and 55% of these rural veterans are aged > 65 years.⁹ Of the 4.4 million veterans who live in rural areas, 61% are enrolled in VA health care, and among those individuals 8% are women and 10% are minorities.⁹

Studies have found that age, sex, race and ethnicity, disability status, and LGBTQ+ identification all significantly affect health care access and outcomes in the general population.^10-16 Female patients are more likely to have their symptoms downplayed or dismissed, and are often less likely to receive aggressive treatments when compared with male patients. They are also frequently underrepresented or even excluded from clinical trials.¹¹ Female veterans have unique health care needs and report preferences for being treated by female clinicians.^17,18

Higher rates of chronic health conditions and reduced access to mental health services are found among Black Americans compared to White Americans.¹³ Black veterans are also denied VHA benefits more often than White veterans.¹⁹ Patients with disabilities have barriers to accessing care, including difficulty with transportation and a lack of knowledge among clinicians regarding the best course of care.¹⁴ Additionally, veterans who identify as LGBTQ+ are less likely than veterans who are cisgender and heterosexual to access Veterans Health Administration (VHA) care.²⁰ Veterans in rural communities experience more challenges to accessing health care; up to one-third of veterans in this population are unable to access the internet at home.⁹

To optimize care for the evolving veteran population, VHA clinicians and leaders need to be aware of the changing demographic characteristics and unique health care needs of the veteran population. Increased inclusion, diversity, and equity within the health care workforce is associated with improved quality of care, improved clinical outcomes, and have had positive financial effects on health care institutions.^21-25

VA Workforce Demographics

According to the VA Office of Resolution Management, Diversity, and Inclusion, at the end of fiscal year 2020 57% of VA employees identified as White, 25% as Black, 8% as Asian, 7% as Hispanic or Latino, 2% as American Indian or Alaskan Native, and 1% belonged to ≥ 2 races.²⁶ Women comprise about 60% of the permanent VA workforce.²⁷ About 12% of VA employees report having a disability, which is similar to the rate of disability among noninstitutionalized civilians in the US (12.7%).²⁸ Five percent of VA employees identified as LGBTQ+.²⁹

Although the general workforce is relatively diverse, there is not as much diversity within VA leadership, and little data exist about the demographic characteristics of VHA physicians. As of September 2020, there were 494 senior executive service and Title 38 (health care workers) senior executive service equivalent leaders in the VHA.²⁶ Almost 78% of these leadership positions belonged to white men and women: about 50% to white men and 28% to white women. In contrast, 8% of these positions were occupied by Black men, 7% by Black women, 3% by Asian men, 2% by Asian women, and 2% by Hispanic or Latino men.²⁶

I*DEA in the VA

The I*DEA Council seeks to eliminate gaps in VHA care and benefits to ensure that historically underserved veteran communities receive fair treatment.³⁰ In addition to continued attention to racial disparities, the new initiative will also examine challenges experienced by other groups, including women, individuals who identify as LGBTQ+, tribal communities, and veterans who live in rural areas, aiming to eliminate disparities that exist within the VHA.

Published in 2021, the I*DEA Action Plan discusses recommendations to enhance inclusion, diversity, equity, and accessibility within the VHA. Its mission statement states that the Council aims to “advance an inclusive environment that values and supports the diverse communities we serve” and “cultivates equitable access to care, benefits and services for all” from 2021 to 2025.³¹ To achieve better health outcomes for veterans, the I*DEA Council plans to focus on the VHA workforce and examine and address obstacles to hiring, promoting, and retaining employees.³¹

There are several potential benefits of increased I*DEA integration into the health care workforce.^21-25 The inclusion of ideas and perspectives from diverse backgrounds, establishing equity of opportunities for all who are appropriately qualified, and accessibility to leadership roles that enable decision making by fostering culture change are direct components of I*DEA that may be beneficial. Diversity encompasses more than race, ethnicity, and gender, and creating a more diverse workforce involves recruiting qualified clinicians with diverse backgrounds and perspectives. Doing so would better reflect the diversity of veteran patients and could enhance the ability of clinicians to learn from each other and be inclusive, while understanding veterans’ unique barriers to accessing health care.

I*DEA integration may reduce the incidence of microaggressions and help transform workplace culture.³² This would be particularly beneficial for patients, as microaggressions can decrease patient satisfaction and may potentially negatively affect health outcomes.^33,34 In addition, health care professionals (HCPs) would benefit from fewer microaggressions in the workplace and this would foster a more positive, supportive work environment and improve morale.

Current VHA workforce data reflect changes in the veteran population. The workforce is relatively diverse regarding race and ethnicity, gender, disability, and LGBTQ+ status. However, room for improvement remains with respect to greater inclusion, diversity of perspectives, equity, and accessibility to leadership positions and decision making roles. This would ultimately benefit and improve care for veterans. Prioritizing this within the VHA, as reflected in one of the I*DEA Task Force recommendations, is of great significance.³¹

It can be difficult to accurately assess the progress made in implementing I*DEA strategies at individual institutions within the VHA. While demographic diversity can be gauged using employee statistics, assessing perceptions of inclusion, incorporation of diverse perspectives, equity, and accessibility is more challenging. We recommend continuing to administer questions focusing specifically on these perceptions to current HCPs via the VHA annual All Employee Survey.³⁵

Implementation

The VA has begun initiating I*DEA concepts in its workforce, starting with the establishment and usage of Special Emphasis Programs.³⁶ The goal of these programs is to increase the employment of historically marginalized groups, including women, people belonging to racial and ethnic minorities, people with disabilities,and individuals identifying as LGBTQ+.^28,37-42 For example, each federal agency has a designated Federal Women’s Program whose responsibilities include helping with the recruitment and advancement of female employees.³⁷

The VHA also has an affirmative action plan with goals for recruiting and retaining individuals with disabilities.²⁸ To strengthen equity and inclusion, the VHA offers multiple educational courses (some mandatory), both virtual and in-person, on topics such as understanding microaggressions, managing implicit bias, and understanding the importance of gender and generational diversity.⁴³ Creating awareness and addressing misconceptions about veteran demographics at VA medical centers is important, as is enhancing awareness among the physician workforce about VA strategies and action plans to increase I*DEA. The VHA has hired officers specifically tasked with focusing on these initiatives.

Workforce Strategies

It is important to recognize overlaps between organizational ethics, quality improvement, and I*DEA initiatives. Establishing an I*DEA Council to ensure the delivery of quality care to veterans is commendable. At the facility level, individual I*DEA officers can make observations and recommendations but are not empowered to effect change. Without participation and buy-in from individuals in leadership positions, the efficacy of I*DEA initiatives is limited.

We propose implementing simple strategies to enhance the inclusion of diverse ideas and perspectives, equity of opportunities, and accessibility to clinical leadership roles within the VHA (Table 2). A competitive selection process with specific, objective criteria to enable the selection of qualified clinical leaders is vital. Specific achievements in or contributions to quality improvement, education, research, professional publications, or diversity enhancing efforts should be required qualifications for clinical leadership roles.⁴⁴

Establishing term limits for clinical leadership positions—something already being implemented at the National Institutes of Health—would be of tremendous value in the VHA.^45-47 Term limits would facilitate I*DEA initiatives and accessibility of leadership roles to qualified clinicians fromvarious demographics. Improving diversity of thought among clinical leaders is especially important, given how buy-in from leadership is critical in transforming the culture of an organization. Term limits would enable access to leadership roles for forward thinking, qualified clinical leaders who could institute and support changes that would promote continuous process improvement initiatives. Leaders could have the option to reapply following the completion of a term, with the ability to demonstrate specific achievements.

Another strategy for increasing equity is to ensure transparency of committee structures, with the rotation of committee members and term limits set for committee chairs whenever possible. This provides access to leadership roles, which enables participation in decision making processes. Residents and fellows who work and train at VA hospitals should have awareness of the facility’s organizational structure and the ability to participate in certain committees. The VHA workforce should be regularly informed about educational opportunities, leadership openings, and I*DEA initiatives to increase their access and use.

Exit interviews for clinicians leaving the VA would enable feedback, provide focused reviews of any problematic issues that need to be addressed, and serve as assessments of organizational ethics.⁴⁸ Transparency and truth telling could be encouraged by having these exit interviews conducted by staff in the human resources department or others outside the home department of the departing clinician.

Mentorship has played a significant role in exposing individuals from historically underrepresented groups to careers in health care, while also advancing and enhancing their careers after they become health care professionals.^49-51 Implementing and publicizing VA and veteran health care-focused mentorship and volunteer programs targeted at local communities, rural areas, schools, undergraduate programs, and medical students could increase the likelihood that students and trainees from these groups are exposed to the VHA which may lead them to join the workforce.

Conclusions

Veterans receiving care from the VHA are becoming increasingly diverse. I*DEA strategies could optimize the VHA workforce and enhance the provision of quality care for veterans. The inclusion of diverse perspectives and backgrounds, equity of opportunities, and accessibility to leadership positions is important. Careful selection of qualified clinical leaders within the VHA—with established term limits for leadership positions, rotation of committee chairs and members, and exit interviews to obtain insights from clinicians who leave the VHA—all align with these strategies. This will foster energy and culture change, create an environment conducive to collaboration, learning, and professional growth and will enable continuous process improvement within individual VA medical centers.

Trust is built step by step, commitment by commitment, on every level.

Robert C. Solomon¹

The US Department of Veterans Affairs (VA) was created in response to criticism of its predecessors. Since its establishment in 1930, the VA has never been short of critics who denounced its corruption, called for its dismantling in favor of privatization, and derided its incompetence.² Despite multiple scandals that have handed more ammunition to those who object to its continued existence, the VA has not only survived, but thrived. This editorial is written in the form of a debate between exemplar opponents and defenders of the VA on whether it is currently fulfilling its commitment to veterans.

In May 2024, the Veterans Signals survey found that 80.4% of respondents reported trust in the VA, the highest level ever recorded.³ At its 2016 launch, the survey found that only 55% of veterans expressed trust in the VA. The survey was conducted 2 years after the scandal over access to care for veterans in Phoenix. Scores would surely have been even lower than 55% during that period when the critique of the VA—even from those who believe in its mission—was most trenchant.⁴ Administered quarterly, the survey samples > 38,000 of the 9 million enrolled veterans. Veterans surveyed were using services from all 3 branches of the VA: Veterans Health Administration, Veterans Benefits Administration, and National Cemetery Administration. Participants are asked whether they trust the VA to fulfill the country’s commitment to veterans and specifically how they rate the VA in 3 specific criteria: effectiveness, emotional resonance, and overall ease. In the latest survey, 80.5% of veterans rated the VA positively for effectiveness, 78.4% for emotional resonance, and 75.9% for overall ease. Even more impressive is the 91.8% of participants who reported they trust the VA for outpatient health care, capping a 7-year upward trend.³

The paradigmatic VA antagonist will rightly point out the well-known methodological limitations of this type of survey, including self-selection, sampling bias, and especially low response rates. However, VA researchers will counter that the 18% response rate for the latest Veterans Signals survey is higher than the industry average.⁵

VA critics might say that it would not matter if the response rate were 4 times higher; what matters is not what veterans say on a survey but what decisions they make about their care. The VA defender would be constrained to concede that even the most statistically sophisticated survey remains an indirect measure of veteran trust. They could, though, marshal far stronger evidence. Two direct demonstrations published in the literature suggest that veterans do as they say and are acting on their trust in the agency. First, the VA delivered more services, health care, and benefits to veterans during the 2023 fiscal year than ever before. Importantly for Federal Practitioner readers, the 16 million documented health care visits were 3 million more than previous records.⁶ Second, and in some ways even more encouraging for the future of the VA as a health care system, is that due in large part to the passage of the PACT Act, there has been a surge in VA enrollment by veterans. The VA recently announced that in the last year, > 400,000 veterans signed up for its health care and services. Enrollments are 30% more than the previous year and represented the highest figure in the past 5 years, a remarkable 50% increase over 2020 pandemic levels.⁷

VA critics could legitimately rebut this data by asking, “So more veterans are signing up for VA, and you are delivering more care, but what about the quality of that care? Has it improved?” The VA proponent’s rejoinder from multiple converging empirical studies would be a resounding yes. We have space to cite only a few examples of that rigorous recent research. What stands out ethically about these studies is that the VA has a broad program of research into the quality of the care it delivers and then transparently publishes those findings. The VA quality improvement research mission is truly unique and provides a shared open set of data for both critics and defenders to objectively examine VA successes and failures.

Among the most persuasive analysis was a systematic review of 37 studies contrasting VA with non-VA care from 2015 to 2023. The authors examined clinical quality, safety, patient access, experience, cost-efficiency, and equity of outcome. “VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety,” the systematic review authors stated while qualifying that “Access, cost/efficiency, and patient experience between the 2 systems are not well studied.”⁸

A second systematic review looked specifically at similar key areas of quality, safety, access, patient experience, and comparative cost-efficiency for surgical treatment delivered in the VA and the community from 2015 to 2021. Only 18 studies met the inclusion criteria, but as the authors argued:

Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.⁹

At this juncture, the faultfinder may become frustrated and resort to a new tactic, challenging the very assumption that is the subject of the debate and demanding proof that there is any connection between veterans’ trust in the VA and their health and well-being. “Fair enough,” the VA side would reply, “here is some research that bolsters that connection.” Kopacz and colleagues examined the relationship between trust and healing at 6 sites and included 427 veterans and active-duty service members with combat posttraumatic stress disorder (PTSD) symptoms. The researchers found that trust and lack thereof are related to several significant mental, social, and physical health outcomes. The authors indicate the need for more research to better understand the importance and impact of trust and healing, but they show it is significant.¹⁰ Finally, veterans recognize the crucial link between trust in the unique expertise of VA practitioners in the treatment of PTSD. In a 2019 study, a majority expressed a preference to receive their PTSD treatment at the VA compared to a smaller group choosing care in the community.¹¹

You be the judge of who won the debate, but knowing the dedication of my fellow federal practitioners, many of you will endorse my sentiment that we all need to stop talking and get back to doing our best to enhance veteran trust and healing; doing our essential part to keep fulfilling our commitment.

Trust is built step by step, commitment by commitment, on every level.

Robert C. Solomon¹

The US Department of Veterans Affairs (VA) was created in response to criticism of its predecessors. Since its establishment in 1930, the VA has never been short of critics who denounced its corruption, called for its dismantling in favor of privatization, and derided its incompetence.² Despite multiple scandals that have handed more ammunition to those who object to its continued existence, the VA has not only survived, but thrived. This editorial is written in the form of a debate between exemplar opponents and defenders of the VA on whether it is currently fulfilling its commitment to veterans.

In May 2024, the Veterans Signals survey found that 80.4% of respondents reported trust in the VA, the highest level ever recorded.³ At its 2016 launch, the survey found that only 55% of veterans expressed trust in the VA. The survey was conducted 2 years after the scandal over access to care for veterans in Phoenix. Scores would surely have been even lower than 55% during that period when the critique of the VA—even from those who believe in its mission—was most trenchant.⁴ Administered quarterly, the survey samples > 38,000 of the 9 million enrolled veterans. Veterans surveyed were using services from all 3 branches of the VA: Veterans Health Administration, Veterans Benefits Administration, and National Cemetery Administration. Participants are asked whether they trust the VA to fulfill the country’s commitment to veterans and specifically how they rate the VA in 3 specific criteria: effectiveness, emotional resonance, and overall ease. In the latest survey, 80.5% of veterans rated the VA positively for effectiveness, 78.4% for emotional resonance, and 75.9% for overall ease. Even more impressive is the 91.8% of participants who reported they trust the VA for outpatient health care, capping a 7-year upward trend.³

The paradigmatic VA antagonist will rightly point out the well-known methodological limitations of this type of survey, including self-selection, sampling bias, and especially low response rates. However, VA researchers will counter that the 18% response rate for the latest Veterans Signals survey is higher than the industry average.⁵

VA critics might say that it would not matter if the response rate were 4 times higher; what matters is not what veterans say on a survey but what decisions they make about their care. The VA defender would be constrained to concede that even the most statistically sophisticated survey remains an indirect measure of veteran trust. They could, though, marshal far stronger evidence. Two direct demonstrations published in the literature suggest that veterans do as they say and are acting on their trust in the agency. First, the VA delivered more services, health care, and benefits to veterans during the 2023 fiscal year than ever before. Importantly for Federal Practitioner readers, the 16 million documented health care visits were 3 million more than previous records.⁶ Second, and in some ways even more encouraging for the future of the VA as a health care system, is that due in large part to the passage of the PACT Act, there has been a surge in VA enrollment by veterans. The VA recently announced that in the last year, > 400,000 veterans signed up for its health care and services. Enrollments are 30% more than the previous year and represented the highest figure in the past 5 years, a remarkable 50% increase over 2020 pandemic levels.⁷

VA critics could legitimately rebut this data by asking, “So more veterans are signing up for VA, and you are delivering more care, but what about the quality of that care? Has it improved?” The VA proponent’s rejoinder from multiple converging empirical studies would be a resounding yes. We have space to cite only a few examples of that rigorous recent research. What stands out ethically about these studies is that the VA has a broad program of research into the quality of the care it delivers and then transparently publishes those findings. The VA quality improvement research mission is truly unique and provides a shared open set of data for both critics and defenders to objectively examine VA successes and failures.

Among the most persuasive analysis was a systematic review of 37 studies contrasting VA with non-VA care from 2015 to 2023. The authors examined clinical quality, safety, patient access, experience, cost-efficiency, and equity of outcome. “VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety,” the systematic review authors stated while qualifying that “Access, cost/efficiency, and patient experience between the 2 systems are not well studied.”⁸

A second systematic review looked specifically at similar key areas of quality, safety, access, patient experience, and comparative cost-efficiency for surgical treatment delivered in the VA and the community from 2015 to 2021. Only 18 studies met the inclusion criteria, but as the authors argued:

Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.⁹

At this juncture, the faultfinder may become frustrated and resort to a new tactic, challenging the very assumption that is the subject of the debate and demanding proof that there is any connection between veterans’ trust in the VA and their health and well-being. “Fair enough,” the VA side would reply, “here is some research that bolsters that connection.” Kopacz and colleagues examined the relationship between trust and healing at 6 sites and included 427 veterans and active-duty service members with combat posttraumatic stress disorder (PTSD) symptoms. The researchers found that trust and lack thereof are related to several significant mental, social, and physical health outcomes. The authors indicate the need for more research to better understand the importance and impact of trust and healing, but they show it is significant.¹⁰ Finally, veterans recognize the crucial link between trust in the unique expertise of VA practitioners in the treatment of PTSD. In a 2019 study, a majority expressed a preference to receive their PTSD treatment at the VA compared to a smaller group choosing care in the community.¹¹

You be the judge of who won the debate, but knowing the dedication of my fellow federal practitioners, many of you will endorse my sentiment that we all need to stop talking and get back to doing our best to enhance veteran trust and healing; doing our essential part to keep fulfilling our commitment.

Trust is built step by step, commitment by commitment, on every level.

Robert C. Solomon¹

The US Department of Veterans Affairs (VA) was created in response to criticism of its predecessors. Since its establishment in 1930, the VA has never been short of critics who denounced its corruption, called for its dismantling in favor of privatization, and derided its incompetence.² Despite multiple scandals that have handed more ammunition to those who object to its continued existence, the VA has not only survived, but thrived. This editorial is written in the form of a debate between exemplar opponents and defenders of the VA on whether it is currently fulfilling its commitment to veterans.

In May 2024, the Veterans Signals survey found that 80.4% of respondents reported trust in the VA, the highest level ever recorded.³ At its 2016 launch, the survey found that only 55% of veterans expressed trust in the VA. The survey was conducted 2 years after the scandal over access to care for veterans in Phoenix. Scores would surely have been even lower than 55% during that period when the critique of the VA—even from those who believe in its mission—was most trenchant.⁴ Administered quarterly, the survey samples > 38,000 of the 9 million enrolled veterans. Veterans surveyed were using services from all 3 branches of the VA: Veterans Health Administration, Veterans Benefits Administration, and National Cemetery Administration. Participants are asked whether they trust the VA to fulfill the country’s commitment to veterans and specifically how they rate the VA in 3 specific criteria: effectiveness, emotional resonance, and overall ease. In the latest survey, 80.5% of veterans rated the VA positively for effectiveness, 78.4% for emotional resonance, and 75.9% for overall ease. Even more impressive is the 91.8% of participants who reported they trust the VA for outpatient health care, capping a 7-year upward trend.³

The paradigmatic VA antagonist will rightly point out the well-known methodological limitations of this type of survey, including self-selection, sampling bias, and especially low response rates. However, VA researchers will counter that the 18% response rate for the latest Veterans Signals survey is higher than the industry average.⁵

VA critics might say that it would not matter if the response rate were 4 times higher; what matters is not what veterans say on a survey but what decisions they make about their care. The VA defender would be constrained to concede that even the most statistically sophisticated survey remains an indirect measure of veteran trust. They could, though, marshal far stronger evidence. Two direct demonstrations published in the literature suggest that veterans do as they say and are acting on their trust in the agency. First, the VA delivered more services, health care, and benefits to veterans during the 2023 fiscal year than ever before. Importantly for Federal Practitioner readers, the 16 million documented health care visits were 3 million more than previous records.⁶ Second, and in some ways even more encouraging for the future of the VA as a health care system, is that due in large part to the passage of the PACT Act, there has been a surge in VA enrollment by veterans. The VA recently announced that in the last year, > 400,000 veterans signed up for its health care and services. Enrollments are 30% more than the previous year and represented the highest figure in the past 5 years, a remarkable 50% increase over 2020 pandemic levels.⁷

VA critics could legitimately rebut this data by asking, “So more veterans are signing up for VA, and you are delivering more care, but what about the quality of that care? Has it improved?” The VA proponent’s rejoinder from multiple converging empirical studies would be a resounding yes. We have space to cite only a few examples of that rigorous recent research. What stands out ethically about these studies is that the VA has a broad program of research into the quality of the care it delivers and then transparently publishes those findings. The VA quality improvement research mission is truly unique and provides a shared open set of data for both critics and defenders to objectively examine VA successes and failures.

Among the most persuasive analysis was a systematic review of 37 studies contrasting VA with non-VA care from 2015 to 2023. The authors examined clinical quality, safety, patient access, experience, cost-efficiency, and equity of outcome. “VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety,” the systematic review authors stated while qualifying that “Access, cost/efficiency, and patient experience between the 2 systems are not well studied.”⁸

A second systematic review looked specifically at similar key areas of quality, safety, access, patient experience, and comparative cost-efficiency for surgical treatment delivered in the VA and the community from 2015 to 2021. Only 18 studies met the inclusion criteria, but as the authors argued:

Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.⁹

At this juncture, the faultfinder may become frustrated and resort to a new tactic, challenging the very assumption that is the subject of the debate and demanding proof that there is any connection between veterans’ trust in the VA and their health and well-being. “Fair enough,” the VA side would reply, “here is some research that bolsters that connection.” Kopacz and colleagues examined the relationship between trust and healing at 6 sites and included 427 veterans and active-duty service members with combat posttraumatic stress disorder (PTSD) symptoms. The researchers found that trust and lack thereof are related to several significant mental, social, and physical health outcomes. The authors indicate the need for more research to better understand the importance and impact of trust and healing, but they show it is significant.¹⁰ Finally, veterans recognize the crucial link between trust in the unique expertise of VA practitioners in the treatment of PTSD. In a 2019 study, a majority expressed a preference to receive their PTSD treatment at the VA compared to a smaller group choosing care in the community.¹¹

You be the judge of who won the debate, but knowing the dedication of my fellow federal practitioners, many of you will endorse my sentiment that we all need to stop talking and get back to doing our best to enhance veteran trust and healing; doing our essential part to keep fulfilling our commitment.