New performance model helps transform Veterans Health agency

Delivery of health care and management structure change radically

Any change model that can transform a government agency successfully must be powerful stuff indeed, and it seems that the High Performance Development Model (HPDM) at the Department of Veterans Affairs/Veterans Health Administration (VHA), in Washington, DC, has done just that.

It all began in the mid-90s, recalls Larry Bifareti, executive work force planning and development officer for the VHA.

"Prior to that, we were a caricature of government, and of medicine in general. We were inpatient-based, very centralized, with a confusing chain of command and most decisions made in Washington. Staff offices had line authority but no accountability. One center would compete against another, sometimes trying to steal prestigious programs. But two dynamic leaders [Jesse Brown and Ken Kaiser] transformed the VHA into what we truly feel is a world leader in health care delivery," he says.

The HPDM must be seen in a whole context, Bifareti adds. "Yes, we emphasize primary care, appropriate medical care, and quality," he says. "But there has been an equally dramatic transformation on the management side. Decision making has been decentralized; we have gone from 100 independent centers to major geographic regions — 22 area networks." These 22 networks are referred to as Veterans Integrated Service Networks (VISNs).

VHA leadership recognized that the culture of the organization didn’t fit what needed to be done, Bifareti explains. "That’s why we moved from a handful of decision makers to a more broad-based approach," he says. To bring about the change, a select group met on a monthly basis, to serve as a guiding force.

"Leadership saw succession as a key issue — to change the way leaders thought, and to transform them into team players, network builders," he notes. 

In order to determine how best to proceed, the group benchmarked a number of high-performing organizations in the private sector. "We saw that we had to address the entire organization," Bifareti says. "We came back with a number of concepts that became the framework for the HPDM." The report for the model and all its elements was presented toward the end of 1996.

The benchmarking process had revealed one common theme: Actions consistently based on core competencies lead to success.

Accordingly, the model included the following core competencies:

  • organizational stewardship;
  • systems thinking;
  • creative thinking;
  • flexibility/adaptability;
  • customer service;
  • interpersonal effectiveness;
  • personal mastery;
  • technical skills.

For each core competency, there is a general description, behavior examples for four different levels, an extensive list of learning opportunities (books, videos, CD-ROMs, and so on). The four levels are:

  • Level I — frontline staff, those without supervisory responsibility;
  • Level II — first-line supervisors and team leaders;
  • Level III — division or product-line leaders and other middle managers;
  • Level IV — senior executive leaders.

"Clearly, these represent the level of supervisory or managerial responsibility for a given individual," explains Sarah Gurwitz, MA, human resources consultant with the VHA Human Resource Management Group. "You can look at the behaviors for the various core competencies and see the skills you need to develop to prepare yourself for the next level up."

There is a progressive nature to the competencies, adds Mary "Bunny" Huller, MA, HPDM coordinator for Employee Education Systems. "When we depicted them in a triangle of core competencies, we found that those competencies that were more focused on self — personal mastery and technical skills, for example — build to those broader in scope at the top of the triangle. From a leadership perspective, if you look at oneself first, you are better able to look at other core competencies."

In order to trace individual core competency progress across the four levels, the VHA uses a 360-degree assessment/feedback model.

"The 360 degrees really refers to the face of a clock," explains Sue Dyrenforth, PhD, director of the VHA National Center for Organizational Development.

"In order to really progress along the levels, one of the most important foundations is to have accurate feedback that you can use: feedback on your performance as perceived by your boss or bosses, your peers, and those who report to you." The person who is to receive the feedback originates a list of those from whom they wish to receive that feedback. "These people are then notified and can go on the intranet site to respond," Dyrenforth says. Responses are given in each core competency, and for each individual item.

"They indicate where they see the person currently performing, where they would prefer to see them performing, and what changes are required to get to that next level," she notes.

When it came time to introduce the HPDM, instead of dictating the new model from "on high," it was unveiled at a huge summit meeting, to which each network sent six representatives. "This helped make implementation a huge success," Bifareti says.

The representatives were encouraged to identify two implementation initiatives that would be most appropriate for their organization — either as a network or as a facility. "What happened was that implementation was unconstrained," he notes. "This resulted in a number of innovative programs that met local culture. If the change had come from Washington, DC, they would have drawn boundaries; this approach was really enriched."

Incentives also helped spur innovative plans. "We gave out grants of $25,000 to networks that came up with plans," Gurwitz notes. "You had to have measurable results; in other words, did you do what you said you would do?" These programs were shared with the other networks through the VHA web site. They included awareness programs, leadership development, and various assessment tools.

As the incentive program evolved, three prizes of $75,000 and a grand prize of $150,000 were awarded for outstanding initiatives. "You could receive an award based on one component of the model or on the broadest use of it," Gurwitz explains.

"The incentive strategy, the prizes in and of themselves, have stimulated a lot of innovation," Dyrenforth adds. "We received an award for continuous assessment the first year, and we used it to fund postdoctoral fellowships in organizational development. That program has now gone national."

"Network directors are a very competitive group; they want to be successful," Gurwitz says. "In the first year, we received submissions from 11 VISNs. The second year, we got 19.

"I’ve gotten e-mails from people telling me how excited they are about the program, expressing the feeling that maybe they are finally doing the right things," she continues. "One VISN put their money into an award program for facilities, to spur individual employees to compete at the grass-roots level."

The impact of the HPDM is widening as the program evolves. "We did a pilot study last spring [April to June 2002] with more than 500 participants and 5,000 respondents," Dyrenforth explains. "As a result, we now have VHA norms, and can not only look across the whole country and systemwide, but over specific occupations and levels of organization."

Aggregate data can be used for strategic planning, she notes. "This can help us figure out what direction we need to go in for all our developmental programs; it really helps in the planning process," she says.

The 360-degree assessment "is an operationally excellent example of tracking continuous assessment," Dyrenforth continues. "When we have the 180-degree assessment [so that even frontline employees who do not have supervisory responsibility can get feedback], all VHA employees will be able to get this kind of feedback on demand." Currently, assessments are conducted every 18 months, she notes.

The HPDM has provided a framework for further organizational change, Bifareti notes. "The next step in trying to move organizational culture was in-depth work force analysis and succession planning to address the aging work force," he says. "We created a model in 1999, and in 2000, came out with a whole series of recommendations, one of which was to establish at all levels of the organization consistent leadership development programs. It has been rolled out all around the HPDM. The main concept is that every employee should be a leader."

"The VHA saw HPDM becoming a long-term strategy," says Nancy Sadel, VHA HPDM coordinator. She heads a national program office for HPDM to coordinate activities and share data on work force development. Her office also supports the web-based development for the program.

"We plan to do a national web-based personal development plan for each individual in a national leadership program," she explains.

"Together, these individuals with their mentors and supervisors will plan and develop individual development strategy through self-assessments and assessments from others." This program will be launched this month, Sadel says.

The HPDM has widespread support among those instrumental in implementing the program. "It is owned throughout the organization," Bifareti adds.

"The model is a tool for what we hope will continue to transform the organization," Dyrenforth says. "One of the things I look forward to is to follow outcome measures as well as activity. My personal evaluation is I have the best job in the universe; this is the most exciting organizational undertaking I’ve ever been involved with."

"This has been such a rewarding initiative," Gurwitz adds. "I see the VA moving toward meeting employees’ needs as well as veterans’ needs and putting them together. This was just the initiation of the health care phase; now, it’s being taken on by the rest of the organization."

VHA: Past and Present

This is a comparison of the pre- and post-High Performance Development Model implementation:

Status quo managers Leaders who can who supervised people facilitate change
Were expected to know all the answers Are externally customer-focused
Had an internal focus Can create learning organizations
Managed schedules and work Who coach and mentor 
Narrowly structured career tracks Promotion based on performance
Service silos development Broad career
Limited development opportunities  Alignment around core competencies
Expectation of lifelong employment Expectation of  lifelong employability

Source: Department of Veterans Affairs/Veterans Health Administration, Washington, DC.

Need More Information?

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