Envisioning Transformation in VA Mental Health Services Through Collaborative Site Visits

In 2008, the VHA published the Uniform Mental Health Services Handbook (UMHSH) (1), which provides a groundbreaking policy that outlines minimum mental health services requirements across the VHA. However, a 2011 facility self-report survey measuring the presence of mental health services (2) found that only 69% of VHA medical centers had implemented at least 95% of the required elements. Policy mandates had not resulted in desired systemwide change. Development of national standards of care and training initiatives were insufficient in ensuring local implementation of change management processes.

The challenge was clear—providing the range and quality of mental health services envisioned by the VHA required that OMHO engage the field in continuous dialogue and solicit its participation in the change process. It was critical to emphasize engagement by all stakeholders in all phases of implementation (3). Thus OMHO created site visits to enhance policy implementation and promote improved QI processes. The visits provided an opportunity to assess each site and obtain important data about facilitators of and barriers to the delivery of high-quality services, while informing leadership about needed support and modeling a collaborative, consultative QI approach.

Collaboration across all levels of a health care system is needed to improve service delivery (4). The site visit process was designed around a foundation of partnership, including partnerships within the newly formed OMHO (3). [A table listing partners’ tasks is available as an online supplement to this article.] To be successful, the team guiding large, systemwide change must include individuals with credibility, content expertise, and the ability to work with and motivate others (3). Within OMHO, the clinical and administrative experience of the TA team was brought together with the program evaluation and survey development skills of the Program Evaluation Center team. A site visit protocol was developed via interteam meetings to allow for cross-fertilization of ideas. Together these teams created a standardized protocol that included administrative data for each facility as a tool to highlight areas requiring more in-depth individualized analysis by site (5). This process became the prototype for informing upper management at the national and facility level of concerns identified through administrative data and from discussions with key stakeholders across the system.

The OMHO guiding leadership team identified the need to actively engage stakeholders in the change process (3). It obtained input from national policy partners, researchers, regional and facility mental health leadership, mental health experts in the field, and veterans and their family members. Ultimately, this improved the site visit process and its implementation success (6). Leaders of the OMHO team proactively communicated the urgent need for change, reflecting upon the gap between the current and desired implementation of mental health services. Partnerships with these stakeholders merged into a vested interest in the shared vision of site visit QI (7). Partners helped to improve the standardized site visit protocol, providing suggestions for additional content. Field and regional stakeholders were particularly central to ensuring that all processes would be viewed as logical and reasonable to the facility-level staff responsible for local change.

In order to maximize diversity in profession, expertise, and organizational position, site visit teams consisted of facility, regional, and national stakeholders. Thus facilities were visited by a team of peers, increasing credibility and acceptance of site visit findings. Furthermore, the site visitor teams themselves developed strong relationships around a shared purpose of providing consultation and enhancing services. Many former site visitors continue to serve as consultants for VHA, for example, serving on temporary leadership assignments to other sites and providing consultation.

Finally, stakeholders across system levels were actively involved in evaluating the site visit process. Multiple opportunities were available to provide constructive feedback, which was used to refine the site visit process. By actively seeking feedback from multiple stakeholders, the OMHO leadership team engaged the entire mental health care system in the effort, creating a platform for empowerment in the change process and for ongoing dialogue about QI (3).

Prior to the initiation of the site visits, national leadership often heard complaints from local and regional leaders that national leaders did not understand the complexity of implementing policy. As is common in organizational hierarchies (6), there was distrust of national leaders and their vision for mental health services, with frequent misunderstandings of national mental health policies. By visiting facilities in person, OMHO leaders made themselves accessible to providers in the field and observed firsthand the policy implementation challenges that confronted VHA facilities. National and regional leaders strengthened their relationships by working together to address facility challenges. Relationships forged in these processes have developed into ongoing dialogue about methods to overcome system challenges and improve problem areas identified by sites.

OMHO site visit teams systematically identified strengths at each facility and frequently identified strong practices, recognizing that even sites with many challenges may have areas of strength. These were highlighted in site visit reports and in exit briefings with senior facility and Veterans Integrated Service Network leaders. This effort helped to build mutual respect and trust.

OMHO developed a range of quantitative metrics from administrative data to monitor mental health policy implementation. Although administrative information provided a range of data to assess policy implementation, local interpretation of coding guidance and data entry procedures affected data quality, potentially diminishing their reliability (5,8). Another lesson learned was that administrative data without context about care processes could be misleading. Data outliers may signal services of truly poor quality but also may result from data entry error or idiosyncratic processes. Single data points cannot adequately describe how well sites implement policy (8). Administrative data are also limited by existing measurement systems. The site visits reinforced that not everything of interest can be measured. Although rare, safety issues requiring immediate attention were identified on site visits, as were concerns about work climate and morale that required intervention. Through collaborative site visits, metrics were placed in context and were used to understand the challenges facing VHA facilities as well as to identify strong practices.

The site visit process aimed to assess and enhance implementation of mental health policy, identify areas for QI, empower local QI processes, obtain background information, identify strong practices to share nationally, and provide a cadre of trained reviewers to support national efforts to achieve the larger goal of improving mental health care. These goals were accomplished by using implementation science strategies and focusing on partnerships. Through the site visit process, 69 strong practices were identified and highlighted in a national repository as a resource for dissemination. These strong practices served as a resource for sites working on QI in a stated area. The percentage of facilities that had implemented the UMHSH rose from 69% in fiscal year 2011 (prior to site visits) to 91% in fiscal year 2015 (following site visits). A September 2015 analysis found that sites had completed 72% of initial site visit recommendations.

One notable example of process improvement was in the implementation of primary care–mental health integration (PCMHI). Integration of mental health services in primary care has been critical in reducing stigma in accessing services, decreasing wait time for services, and increasing treatment engagement for veterans reporting mental or behavioral health concerns for the first time. VA policy requires both colocated collaborative care and care management services at all medical centers and larger outpatient clinics (1). However, despite additions in PCMHI staffing, in 2011 only 37% of sites provided both required services and 18% of sites provided no PCMHI services.

The site visits provided critical information on the local challenges of implementation and an opportunity to connect local facilities with national resources and consultation support. With ongoing monitoring of local progress and connection to technical assistance, great strides were made. By 2015, 70% of sites had fully implemented PCMHI, nearly doubling the implementation, and only 8% of sites reported having no PCMHI services. These improvements laid the foundation for same-day access to mental health services in primary care and improved treatment engagement.