As the patient-centered care director at the VA San Diego Healthcare System, Dirk Evans has worked diligently to implement patient-centered care principles throughout the system’s facilities. Dirk has reached out to the international healthcare community, providing insights to the changes happening to care delivery in the U.S. and how medical groups around the world can implement patient-centered care principles.
HMC Healthcare News recently sat down with Dirk to discuss his thoughts on patient-centered care principles and how they are being implemented at VA facilities in San Diego County.
HMC: The VA health system is known for safe, efficient, and digitally driven care with the veteran at the center. Can you discuss where the healing environment plays a role?
Evans: The environment is essentially “the stage” that all healthcare interactions take place on. It literally is where the patient experience is played out so to speak. We tend to typically think of it in terms of colors, floor covering, window treatments, ceilings, and artwork – the right brain part of the healing environment. Those are the aesthetic qualities and are beyond doubt crucial pieces in creating a healing environment.
Equally important, and the part we need to start with in creating the healing environment, is considering what needs to happen in that space – the left brain part of the healing environment. Similar to a kitchen work triangle, this is where the importance of working with the users of the space can’t be understated. This is where we need to ask questions like:
• Does the space support or hinder the flow of work that needs to occur in it?
• Does the design take into consideration step-by-step processes?
• If we work with the customer to create a spaghetti diagram of work to occur in the space, would it demonstrate efficiency or extra steps and re-work?
When these questions are appropriately addressed, the safety, efficiency, and support of digital technology can be realized to their ideal or target state in space designs. The reason we want to achieve that state is to minimize frustration and have “the system” make sense to the veteran patient, as well as healthcare providers. This is how we keep veterans in the center of the work we do. Our veteran patients are the reason we are here. If the environment isn’t designed to maximize productivity, the resulting frustration and energy spent developing work-around solutions by users can supersede where our primary focus should be—on the patient experience.
Theoretically this has been the goal with our facility. Over time, demand for the care we provide has shifted in both model of delivery and volume. As we respond to that demand we have partnered with Planetree, the internationally recognized leader in patient-centered care, to really maximize our responses to be as patient-centered and efficient as possible.
HMC: As health technology advances, are you making necessary improvements in your facilities to accommodate those technologies? Are you providing “best in class” technology for veterans in order to keep up with the private sector?
Evans: Today’s VA always strives to provide “best in class” technology for veterans, and yes, we do keep up with the private sector. Sometimes we lead those advances and sometimes we recognize them and adapt to them as rapidly as possible. Two examples of this are the electronic medical record and robotic surgery. The VA has the best electronic medical record available. A veteran can show up at any VA facility and their records at previous facilities are instantly accessible to facilitate the best possible continuity of care providing as much patient safety as possible in the process. This digital record was developed in house.
Additionally, San Diego is a national pilot site for an electronic medical record exchange for veterans whose care is co-managed by private sector providers. This allows accessibility for providers outside the VA to see select medical information of patients who opt to turn this feature on in their electronic record. Lastly, San Diego has also been selected as a developer for the next generation of electronic record called VLER—Virtual Lifetime Electronic Record. Current design work involves making sure veterans and their families have space to access their medical record as they choose.
When robotic surgery for certain procedures proved safer and more effective, VA San Diego leadership surveyed providers who recommended we purchase a surgical robot and implement its use in those procedures. Leadership then approved the purchase of robotic surgery technology and implemented it into indicated surgical routines. The VA continues to either lead the way or rapidly adopt new technologies. We work with designers to accommodate those improvements we adopt, as well as pre-plan with a vision for technologies we know are on the way.
HMC: How do you provide space for veteran’s young families in your facility? What about activities for young children as they wait for their parent during treatment?
Evans: Younger families are somewhat of a newer phenomenon with today’s veteran patients and we are adapting to accommodate them. Our facilities currently have patient lounge spaces, some of which accommodate children well. Other areas are being remodeled with younger families in mind. Our Voluntary Services Department has done a good job of providing books, crayons, children’s furniture, and toys, and we are in the process of doing more. One way to accommodate families is make sure our design teams include patient users as part of the team. This is a newer process for us but our teams are adapting. Including patient input in design is crucial to succeeding in meeting their needs. It’s too easy to assume we know what patients want and get it wrong.
This approach also envisions empowering staff to communicate recognized needs and facilitate the process of change. One example of this is in our Spinal Cord Injury unit where staff recognized an increase in patients with younger families that needed changing tables for infants. Staff identified a need and quickly set about the process of identifying the space and facilitating its modifications to meet patient and family needs.
HMC: Is there a stigma of the “VA” for younger vets? How do you address that from an organizational standpoint? How does the image of your facility appeal to younger vets?
Evans: There may be a stigma of the “VA” for younger vets entering our healthcare system for several reasons, which include unfamiliarity with a new healthcare system and it’s processes and providers, historical perspectives, and confusion from misunderstandings presented by the press. For example, veterans spend anywhere from a few to 20 years or more receiving healthcare in the DOD system. Transitioning to a new system can be confusing with many unknowns. Additionally, the VA healthcare system has been lumped together with the DOD system, which has had some challenges, as witnessed by recent press from Walter Reed Army Hospital. In reality the systems are two separate organizations—DOD and Veterans Healthcare Administration (VHA).
To address this from an organizational standpoint we have implemented a number of approaches. We have veterans’ transition advocates with offices on bases to facilitate smooth transitions. We intentionally facilitate “Muster” events on base and at the hospital to assist transitioning veterans in becoming familiar with our process, facilitate “One Stop” appointment strategies, and connect them with advocates that can help them navigate a new healthcare organization. We also conduct Focus Groups to hear what our patients want. Responding to Focus Group information, we have implemented a Facebook page and Twitter account, and have begun developing strategies to utilize them as means of communicating with a multi-generational patient demographic. Additionally, we have recently implemented secure text messaging between patients and providers.
In regards to overall image and appeal to younger vets, as facilities remodel we are doing so with input from veterans related to design and what they would like in their hospital and healthcare settings. We are being as efficient as possible in all aspects of how we design our facilities and processes to best meet patient needs.
HMC: How does the VA San Diego address veteran’s spiritual needs in the healing environment? Are there quiet meditation areas?
Evans: VA San Diego has a robust Chaplain program to meet veteran needs. This program includes a dedicated multi-faith chapel, as well as the availability of clergy to offer support for a multitude of beliefs. As we continue to remodel and build new facilities, a provision for quiet meditation areas is one of our criteria in developing new spaces.
Approximately a year ago we worked with Planetree’s in-house architect to develop a tool to apply in developing new projects. The tool encompasses all of Planetree’s Patient-Centered Care Principles. Planetree’s architect facilitated the process to prioritize which components most emphasized VA San Diego’s organizational character. As a group we determined the aspects of care delivery that were most important to us, then determined how much each component played a role in that aspect. When we develop new projects we refer to the tool to guide us in meeting our design goals that reinforce our organizational characteristics. Addressing spirituality and spiritual needs is an area that we determined was important to us. The process is newer to us and we are working at hardwiring it into our design and project development procedures. This is becoming the way we do things from here forward.
HMC Architects is currently working with the VA San Diego on Halls and Walls, Second floor Psychiatric Expansion, and Fifth floor Master Plan Study. HMC is one of only five firms in the world to be a founding member of the Planetree Visionary Design Network and remains committed to the principles of patient-centered care in all of its healthcare projects.
