Organizational Assessment as a Driver of Change at VA Vet Centers

Introduction and Organizational Context

Every type of organization has — or should have — as a major goal the need to optimize the productivity of its human resources (Farr, Schuler & Smith, 1993). One organization that has recently assumed critical importance in the United States is the Department of Veterans Affairs (VA). Today, the VA is responsible for administering an enormous healthcare and benefits network for its active duty and retired service members and their families at U.S. taxpayer expense.

Among the most prominent of such government-administered programs is the healthcare system comprised of VA medical centers (VAMCs), outpatient clinics (VAOPCs), community and outreach clinics, and numerous Vet Centers. Taken together, almost one-third of the American population — around 70 million persons who are veterans, dependents, and survivors of deceased veterans — are eligible for VA benefits and services. The VA reports that its original 54 hospitals established in 1930 have grown to a nationwide healthcare system that includes 173 medical centers (with at least one located in each of the 48 contiguous states, Puerto Rico, and the District of Columbia); almost 400 outpatient clinics, community and outreach clinics; 131 nursing home care units; and 39 domiciliaries (VA Fact Sheet, 2004).

The Vet Center in question is comprised of one counseling psychologist (who also serves as the Center director), one nurse practitioner, a medical records specialist, a receptionist, and two volunteers who work three days a week for four hours per day. These volunteers are retired and 100% service-connected veterans. The staff members are all federal Civil Service employees; the volunteers are unpaid but receive free meals and access to the Center's computers, which one of them uses for college research.

Because all organizations are, by definition, comprised of people, making the most of this resource is simply good business practice. In order to identify problem areas and opportunities for improvement, a snapshot of how the people in an organization feel about it assumes increasing importance and relevance. This is the fundamental purpose behind any organizational assessment. "Improvement in the quality of work was the original goal of organizational assessment" (Alioth et al., 1993, p. 221). While the need for high-performance teams is generally associated with traditional business corporations, such teams have long been a mainstay in the healthcare industry (Farr et al., 1993). In recent years, the emphasis on teams and teamwork in healthcare organizations in particular has increased.

Purpose and Justification for Organizational Assessment

Farr and his colleagues cite several reasons for this increased focus on developing effective healthcare teams. First, as the healthcare industry in the United States has become more specialized, sophisticated, complex, and technical, the various disciplines involved in the delivery of healthcare have also become increasingly interdependent: "The very nature of health care is bringing providers from numerous disciplines together to address healthcare problems" (Farr et al., 1993, p. 5). Second, team-based healthcare organizations are widely regarded as being more effective, efficient, and adaptive than bureaucratic, hierarchically structured ones. Manion et al. (1996) observed that "Teams are a way... to release potential for improved productivity, better decisions, and process innovation" (p. 4). Similarly, teams are viewed as being "critical to sustainability in healthcare" organizations and "the basic unit of work" (Porter-O'Grady & Wilson, 1998, p. vii). Third, healthcare organizations today demand a team-based approach for philosophical reasons (Coopman, 2001).

There are a variety of organizational assessment tools that can be used, depending on the type of organization and the level of assessment involved (Dallimore & Souza, 2002). Ford (1999) suggests that the application of any instruments and procedures tends "to have a common goal of diagnosing an organization's communication strengths and weaknesses by offering a triangulated approach to examining communication practices" (p. 2). Given these general principles, virtually any organization can benefit from a well-conducted assessment.

According to Guion, "Any need analysis is useful when it helps people in organizations overcome force of habit in studying organizational problems" (1998, p. 52). Farr, Schuler, and Smith (1993) further point out that there should also be possibilities to reach the goal of behaving cooperatively, at least partly, in essential components of organizational assessment and selection. "Crucial for this is a better knowledge of participants' perceptions of and reactions to selection and assessment situations and of the relationships between individual and organizational perspectives" (p. 4). Developing a clear understanding of such perceptions requires the selection of an appropriate instrument.

Survey methods are frequently used for organizational assessment purposes because they are standardized and provide a significant return on investment (Guion, 1998). Surveys can be developed in-house or selected from an appropriate existing model; the former approach allows for increased flexibility and individualization, but raises issues of verifiability and replicability (Leedy, 1992). As Guion notes, "Questionnaires can be developed after interviews and conferences to be sure that major questions are asked. They do not, of course, shout out the optimal corrective actions; appropriate action is inferred by people making informed judgments" (p. 52). In order to obtain timely and accurate informed judgments, this study surveys all employees of a Vet Center located in the author's city of residence.

Because Vet Centers are among the smallest VA healthcare facilities, applying the results of an employee survey will be relatively straightforward compared to other components of the VA healthcare system. The VA clinic director can use the results immediately to identify problem areas and potential opportunities for improving the delivery of healthcare services to veteran patients, as well as improving the administration of the human resources function. Supplemental results from future surveys can then be used to determine the effectiveness of any remedial actions taken and to identify any further problem areas that may have developed in the interim.

The interunit level of organizational assessment is appropriate for the purposes of this research project. According to Freeman (2001), a number of organizational assessment approaches are research-based and yield useful comparison data across groups of programs: "The methods have been used to assess single programs as well" (p. 121). However, in order to justify the time and resources required to develop, administer, analyze, interpret, and implement changes pursuant to an organizational assessment, there must be solid goals focused not on collecting vague complaints but on identifying specific information that will be helpful in developing measures for improved decision-making and implementation by the Vet Center director (Alioth et al., 1993).

Necessity for Assessment and the VA's Growing Challenges

According to the leadership of three major veteran service organizations, the VA estimated that there were 4.9 million unique veteran patients in Fiscal Year 2003 — a 31.5% increase from the 3.7 million projected in 2002. "Today, over 300,000 American veterans are waiting for appointments in VA facilities. For approximately half of those men and women, the waiting period will surpass six months. VA must be adequately funded to meet this growth and end these intolerable waiting periods" (Sisk, Conley & Heath, 2002, p. 3). Furthermore, the challenges facing this organization are going to worsen before they improve for two fundamental reasons: the veteran population continues to age, driving increased demand for healthcare services associated with the aging process; and America continues to prosecute a costly war on terrorism in Afghanistan and Iraq that is resulting in large numbers of combat casualties and acute psychological trauma. Vet Centers have experienced only moderate success in treating such psychological trauma cases in the past (Sommer & Williams, 1994).

Treating returning veterans appropriately and effectively has long been a national priority, even when funding from Congress has not been forthcoming to support such initiatives. According to Gerber (2003), ever since the 19th century, the government has undertaken to provide all veterans — and particularly disabled veterans — with generous pensions and a vast array of medical, rehabilitation, and reintegration services. The government has assumed these responsibilities based on Abraham Lincoln's commitment to provide for "those who have borne the battle, his widows and his orphans" (Second Inaugural Address).

As a result, this national commitment has come to rest on an understanding that profoundly valorizes the disabled veteran's status: "For these benefits came to be conceived as a right, not a privilege, or charity, or 'welfare,' as that word is used pejoratively in the contemporary U.S. to reference public assistance grudgingly provided those considered the unworthy poor" (Gerber, 2003, p. 899). Vet Centers in particular stand on the front lines of providing healthcare services to that segment of the population perhaps most in need of specialized medical care.

Furthermore, while the Vet Center approach has experienced mixed results in treating post-traumatic stress disorder cases, many veterans are more willing to participate actively in medical care at Vet Centers by virtue of their "laid-back" atmosphere and less intimidating facilities compared to mainstream VA counterparts (Hansen, Madden & Owen, 1992). According to one veteran, "A lot of us don't trust, and I'm one of them. But I trust these guys here at the Vet Center more than I trust anyone in Washington State. They're dumb enough to tell me the truth" (Hansen et al., 1992, p. 166). Similarly, veterans who may feel marginalized in the mainstream VA healthcare system — including Black veterans and women veterans — may be drawn to Vet Centers by virtue of the camaraderie such settings provide:

"What happens here at the Vet Center is exactly like that Brotherhood in Vietnam. When our group meets here at the Vet Center, that is the Brotherhood...same damned thing. We all got involved because we got in similar situations. Now we're here, and that Brotherhood is just as strong. Non-racist, too — it doesn't exist. Everybody belongs in this place...those in the rear — women. If you're a Vietnam vet, and stuff is kicking you around, we know what made you wrong. If you need some help, get in here." (Hansen et al., 1992, p. 167)

Clearly, the nation's veterans healthcare system is tasked with a vitally important role, and Vet Centers are in a better position than many facilities to provide traumatized veterans with the healthcare interventions they will require in the future. Making the most of existing resources within such an organization requires a realistic acknowledgment of what may reasonably be expected from surveying a single Vet Center, although a best practices model could be developed based on an aggregate of such efforts conducted across the country.

According to Hendrix (1984), effectiveness should be of interest to everyone in an organization. However, "Empirically assessing organizational effectiveness has been wrought with difficulty in that no one ultimate criterion exists. A contingency approach to organizational effectiveness considers effectiveness to be a function of the manager, the situational environment, and the criterion of success" (p. 95). Within this framework, no single criterion of effectiveness serves as a universal indicator; a wide number of criteria may be appropriate depending on other components of the setting, such as the unique business situation and the manager involved. "Many organizations have various and often contradictory goals. Effectiveness criteria at one organizational level may differ from those at other levels, and criteria appropriate at one point in time may change and be less appropriate at later times" (Hendrix, 1984, p. 95). Because the Vet Center director is also a healthcare provider, there will be some inherent conflicts of interest in how the survey results may be perceived from these two different perspectives by the same decision-maker.

For example, in his or her capacity as a clinician, the consulting psychologist would want to provide each veteran patient with the maximum amount of personalized healthcare services possible. However, in his or her capacity as a Vet Center administrator tasked with maintaining a budget and ensuring access to as many veterans who need services as possible, there would be a concomitant requirement to balance these clinical goals against the reality of scarce resources.