NAVAPD recently repeated the Patient Care survey of its membership first done in 2008. The results reveal that physicians’ believe the quality of care provided in VA facilities has declined in the past 3 years. Positive responses suffered an overall decline while overall negative responses rose. Positive responses dropped 34%. Negative responses increased by 31%.

2011-1 2011-2 2011-3 2011-4 2011-5 2011-6 2011-7 2011-8 2011-9 2011-10 2011-11 2011-12 2011-13 2011-14 2011-15 2011-16 2011-17 2011-18 2011-19 2011-20 2011-21 2011-a 2011-b 2011-c 2011-d 2011-e 2011-f 2011-g 2011-l1 2011-l2 2011-l3 2011-l4

When asked how likely they were to recommend their facil-ity to a colleague, 54% replied Not at All or only Slightly. This is an 83% increase in negative responses over the 2008 survey results.

The largest increase in negative responses (105%) was to the question: “how satisfied are you with your medical center?”

The biggest decline in positive responses (-56%) was re-lated to the availability of equipment and supplies (Question #18).

The topics with the highest negative absolute responses were communication between administration and medical staff (Question #1) and the opportunity to participate in hospital-related discussions (Question #4). It is worth not-ing that these questions were already rated quite nega-tively in the 2008 survey. The highest percentage of posi-tive responses relate to the clinical information system (Question #17) and the quality and timeliness of laboratory services (Question #10) and radiology services (Question #11).

There was a 30% decline in the number of respondents who say they are proud to be associated with their facility (Question a).

The total number of respondents in 2008 was 247; the total for the 2011 Survey is 242. The percentage of re-spondents with 6-10 years and 20 or more years of service increased over the 2008 Survey. All other groups declined.

The 2011 survey was purposely an exact duplication of the 2008 survey to provide direct comparison and trending data. It has served that purpose well. It is clear that the trend of physician attitudes about the quality of care is to-ward the negative.

It should be noted that neither survey provides a valid as-sessment of the absolute division of positive versus nega-tive opinion of the care provided in the VA.. This is because the possible responses were inadvertently biased toward the positive. That is, three of the four available responses for most questions are positive in nature—unless “Satisfactory” is deemed a negative response.

For a valid assessment of the relative positive and negative attitude there should be an equal number of positive and negative choices. Correcting this in future surveys will make trend comparison to past surveys more difficult.

The information about all questions follow in graphic form and focuses on changes from the 2008 survey. Also included are comments from the survey.

 

Administration/COS have to be more clinically oriented, efficient and understanding of the demands that are placed on the providers.

Need to focus on recruitment and retention of physician in primary care and psychiatrists and the underlying reasons no one wants to work/stay here (huge worklord).

This hospital needs total turnover of hospital administration from the top. It is too "top heavy." We have a Director, Associate Director and now just created a "Deputy Director," while they freeze clinical positions.

I have never seen such a poorly managed organization in my entire 59 years of life! The management has no clue on how to manage. We haven't had a [specialty] staff meeting in over 15 months. My annual review was on paper – no verbal discussion, yet I was asked to sign that the review was discussed! [Physician] turnover is at record highs. I am considering leaving as well.

APNs are not the answer.

The "hiring freeze" has left many positions unfilled, resulting in cancelled cases, uncertainty in knowing what workload can be scheduled and general dissatisfaction of many excellent employees. Huge inefficiencies when one person calls in sick and much of the day is cancelled!!

Some senior members in leadership positions with a "can't do" attitude need to be replaced.

I would suggest to publish the result of this survey and provide a breakdown to each individual hospital in the future. This would be critically important for comparison purposes.

More nursing staff and support staff.

Computer information technology needs serious upgrading not patches to work with CPRS or VISTA.

Physician morale worst in a decade here a overwhelmed by administrative trivia which would be better bundled biweekly to save time & use it more efficiently for clinical duties. Nursing service becoming too assertive for their own and not for patient or facility benefits.

Administrators have become authoritarian and disrespectful. There is (sic) rarely funds for upgrading important equipment. Physicians are being fired "without cause" and those who are retiring are not being replaced. I am just about ready to throw in the towel!

The way the VA gives out money to the medical centers drives me crazy! They should let us use the funds for things (or people) we really need, not for things (or people) they think we should have.

[Need] A process for rapid & full implementation of evidence-based care as it becomes available.

The system is NOT transparent.

"Physician – supervisors" are given unchecked authority by the administration in:
a. applying federal regulations regarding Religious compensatory time.
b. use of remote access by physicians.
c. limiting of hospital privileges without due process.

The "chain of command" nature of the organization interferes with the integrity of the hospital.

Physicians interested in clinical research are hindered on multiple levels.

Doctors are intimidated and afraid to speak up for fear of harassment or loss of their jobs.

Quality of care would improve if doctors were treated with respect and involved in the process of change.

Need more effective Medical Staff.

Nursing Service runs the hospital and Med. Staff is bullied by them.

No follow-thru on processes for staff or equipment.

There is need for empowerment of the professional staff (an elected representative for the clinical executive board).

There is need for a feedback line to central office branches to combat an atmosphere of intimidation.

Need to control workload. 60-65 hours per week not conducive to good function.

There is NO clinical accountability. Service chiefs are free to do absolutely nothing. I know having worked for the same two-faced con artist for almost 30 years. And administration knows all about the situation and does nothing.

Need more communication between administration & staff.

Need input from staff into decisions made at higher levels.

The pharmacy is increasingly obstructionist in not approving medications for our patients – requiring more & more & more unpaid time from doctors for justification – I believe this lowers quality of care & satisfaction.

More involvement of primary care physicians who have more experience with inpt/outpt transfer not just a check box (to meet administrative uses) but REAL INPUT/RESPECT FOR EXPERIENCE/EXPERTISE.

I only have a 1/8th assignment (in occupational health). I only do outpatient work, so have little information with personnel and process dealt with in this survey.

In every year since I began VA work in 2009, I have worked more hours than my 1/8th contract. Recently, I received a paycheck that was about $1000 in excess of the usual amount. This was the first excess payment I have received since beginning VA work. I was not provided with any justification for the excess so that I could know if it was the total amount owed me, or if it was just payment for some of the excess hours I have worked. The excess payment I recently received is the ONLY communication directly to me about why I was not being paid for excess hours, or what was being done to address the apparent delay. It's like the whole issue was in a black hole! THIS IS ONE AREA WHERE VA ADMINISTRATION COULD COMMUNICATE MORE WITH ITS PROFESSIONALS.

Increase staffing to handle patient load.

Chief of Staff is a problem, very judgemental, very rigid. Chief of Nursing (Nurse Executive) is same way. It leads to a very dysfunctional Quad.

There is a strong disconnect between Washington planning, VISN planning, hospital planning, & medical leadership which leads to inefficiencies, very slow reaction to change, poor planning.

Increasingly nonfunctional CPRS with no improvements in site.

Increasingly poor administrative leadership and staff inefficiencies and sloth.

Pharmacy and RX system a burden to providers and obstacle to good care.

We need to limit special interest influence in medicine. As a primary care provider, I have a new requirement to add to my limited clinical visit almost on a monthly basis. Some requirements expect me to practice outside the scope of my practice (e.g. providing transplant medications) all of which force me to provide substandard care. On top of this there are rumors of increasing penal capacity further compromising care.

Front Office needs to walk in the steps of the doctors one day. We are too understaffed & over-burdened by regulations, paperwork, and lack of leadership.

[Need]Better oversight of upper/middle management/not allowing upper management to become entrenched in a particular facility and form a clique which operates to serve themselves by being punitive and micromanaging in order to look good on the books!

I am a psychiatrist at the XXXXXX outpatient clinic. We are mandated to see people within 24 hours & get them into treatment within 14 days. We can usually get them in, i.e., they get an intake & maybe a medical eval. However there are not enough staff to provide adequate, let alone, excellent treatment. Only a few are getting the evidence-based psychotherapies for PTSD. We are constantly denied getting more staff.

Administration is clueless. They talk about quality of care but it's only talk. There's little support for us in primary care. Support services are terrible, physician orientation was horrible – totally lacking, and administration is walking around saying what a great job the VA does!

For staffing, it would help to have faster credentialing.

If work outside regular tour of duty, have way to pay for time or comp time for full time physicians.

Replace VISN Director for the good of all.

Nursing Floors install rubber floors to reduce hip fractures from falls.

Scale back unfunded mandates and programs such as rural health and homelessness that are expensive and detract from the front line mission of caring for patients and stabilizing staff. Focus on med-surg and supporting it.

Criteria for performance pay are unfair in that some criteria are based on the entire medical center's performance which I have no control over (and which is often below expectations) rather than solely on my performance which I can control. Also upper management is overstaffed while front line workers are understaffed.

Nursing care is excellent but we don't have enough nurses or other ancillary staff to handle some of our patients who are not sick enough to be in intensive care but are too sick for a regular floor.

Need to resolve issue of consultant's codes expiring & not being able to write a note if on call.

I am working during offered meetings [and cannot attend].  I "keep up" by working overtime every day. The most difficult/stressful challenge is managing patient expectations, followed by leadership expectations.

Personal intervention by Congress-people will prevent any chance we have of matching quality and efficiency of non-governmental health systems.  The VA must stop being such an incredibly top-down organization.

Ranges from excellent/very good to poor on weekends/holidays.

Improved transparency and communication is needed.  Value of the physician providers and medical staff is needed.  More input from clinicians – Most decisions affecting patient care made by NON clinical staff.

Recent center Director -> incompetent. Just departed Chief of Staff -> evil. Good top leadership is what we are most in need of.

The trend in recent years has been toward excessive centralization of processes such as IT and contracting to Central Office in Wash DC – this is unfortunate.

I work at a CBOC ~ 85 min away from primary VA med Center. We are forgotten yet have > 35K mailings for monthly activity reminders. No clerks; an RN works as a clerk; another a LPN with 3 PCPs & 2 BA (or BH) providers. 6 support staff. No calls thru to clinic. It is terrible & worse hospital PCC – No voice & all inpt. interests. We are trying (preventibly) to keep them out of hospital. Help!

The ability of the administration to respond to last minute changes in a provider's schedule limits the ability to care for patients. More services need to scheduled on one day to limit patient travel.

No input from staff in reference to hospital changes.

Our Urology department is understaffed for the volume we see. Difficult to recruit new physicians because of low pay compared to private sector.

We are walking a thin line – dedication to giving the best care for veterans is always at risk for being compromised by number crunchers and "treat by the book" types. Too much concern for "efficiency" can hurt physicians' morale & limit the chance to THINK about our patients.

Far too many RNs as "administrators" and only the less competent RNs left to do actual nursing.

Stop spending so much money on business that "police" VHA providers. Instead, spend that money on more "worker bees" so that current doctors and nurses do not get so burned out & dissatisfied with their jobs.

Administration that looks to true quality of care and not just the numbers (e.g. 30 day mandates). Administration that is proactive and not just reactive to change/improve. Ancillary staff and nursing that is not protected by union but evaluated by true job performance or lack thereof.

More involvement of Medical Staff in clinical issues and patient care issues.

More communication between administrative staff and clinical staff.  More respect for clinical staff.

Administrative assistants can produce barriers to good morale and efficiency for the sake of bureaucracy.

There is a dishonest relationship between adm & workers!

Pharmacy is bad (old meds stopped do not list), often broken.  Get new staff in.

Re-empower the doctors, they make NO decisions currently.  Compare directly with the real flagships, like MINN/WestLA/Palo Alto/Gainesville/Houston.  DC needs help.  Yikes.  Get back the space and equipment committees!

More input from clinicians in executive management decisions.

Respect of nursing staff towards doctors is problematic.  I work with MANY very empowered & obstructionary nurses at this hospital.

Chief of staff ineffective partner of clinicians.  VA employees physicians too long and have NO accountability of performance.

Frail elderly patient with multiple complex medical and psychosocial problems need case managers. Palliative Care treatment team should assume primary care duties in appropriate patients.

VA needs better public relations visibility to clearly trumpet and display its dedicated stable noble mission, and great outcomes & service instead of only focusing on rarer negatives. Also remove political influence.

To (sic) top heavy administration more interested in getting numbers correct than the patients.

As the administration has made efforts to reduce overtime & comp time by other disciplines, physicians are increasingly assigned menial tasks and expectations rise without compensation, recognition, or appreciation.

Increasingly other disciplines are respected more, put in charge of key decisions marginalizing, not offering or allowing input and degrading & disrespecting roles of physicians.

Many decisions are made outside the physicians/nurses control; the administration needs to sit down & discuss & be open to CLINICIANS sayso in anything which involves patient care.

Pharmacy/pharmacists need to have a little more respect or regard for physicians.

Primary care staff is not treated with the same level of respect as subspecialist.

We do not have enough nurses to take care of the complex sick patients that we have (need more nurses per patient).  We need orderlies or non-nurse workers to take patients to xrays, appts, tests so the nurses can do patient care.  We need better trained doctors to work in TCU/Rehab unit (current one is not trained for sick patients).  Administration needs to stop pressuring doctors to discharge patients before they are ready.  We need better triage in ER so inappropriate patients are not admitted to us (we have limited specialist availability.  We need at least 2 doctors on weekend staff to take care of inpatients.

VA 605 they favour and keep SDA only at the administration level.  They follow only religious guidelines (not medical).  They get rid of non-SDAs (NOT contributing 10%).

Senior leadership at our hospital is absolutely out of touch with patient care.  Numbers are more important but the numbers don't reflect the quality of care, access, or need of the hospital staff.  As a result we have suffered high turnover of staff.

The scheduling package in Vista is atrocious!  Extremely poor, hard to work with & coordinate between clinics in the same service.

I am proud to be associated with the best medical system in the country.  We need higher pay.

Our hospital serves too many veterans and appointments and studies are too far.  Dental services are very limited for a vast majority of veterans.

Specialty clinics are not well run.  Communications between clinic & patient is poor.  Communication between specialist and primary care is poor.  Long delays in receiving appropriate specialty care.

I recommend that certain equipment be considered critical to the function of a clinic and automatically replaced when needed, rather than begging for funds and hoping to get it bought eventually, and meanwhile trying to figure out how to get the care for the patients.

I am in Imaging/Radiology.  Communications excellent with specialists; moderate with primary care.

Imaging Dept would function so much more efficiently if the schedulers were part of/hired by/trained by Imaging.  We do not function like a primary clinic & scheduling is complex, needs more oversight by Imaging to decrease wait times, improve thru-put.

Move more quickly on construction projects.

There is very little rank & file physician input even in clinical matters.  They keep doing employee surveys but they don't change & they don't share the results with us.  Nursing leadership is dysfunctional and even antagonistic to physicians.  Physician leadership is WEAK & don't (sic) advocate for us.

Doctors currently have no financial incentive to see patients. In private practice they make more money. At VA, they make the same when they don't. They try to not see patients.

Our psychiatric physicians, just like other medical specialty physicians, would be MORE EFFICIENT, and deliver better QUALITY AND QUANTITY of care, IF we had an LPN Nurse – Secretary or Medical assistant.  We have neither, and so we all return phone calls, faxes, copying, BPs, weights, etc. – OURSELVES…

Greater involvement of ACOSs in policy and other key decisions.

We should return to Dr. Ken Kizer's plan of a MAXIMUM of 10 FTEE staff in each VISN office.  We waste enormous sums on EXCESSIVE VISN STAFF and EXCESSIVE VACO STAFF and EXCESSIVE VACO PROGRAMS and EXCESSIVE TRAVEL TO VACO MEETINGS.  The hospitals would use these funds much more wisely and much more effectively.

Generally, specialty physicians & nurses provide excellent care.  The administration is awful – worst I've seen in nearly 50 yrs. in medicine.

Things would be fine except being imposed on by C&P exams.

(I won't even go into the failed pay for performance statute)  Medical staff needs a voice in decision making at the Administrative leadership level.  Practicing physicians should have a strong voice in patient care issues and planning.  Programs (current) need to have a strong foundation & RESOURCES before new directives & expansion of services is dictated by Central Office & Congress.  (We can't keep up with the work we have now)

Need a competent Director.  Give dept. chairmen autonomy over their dept., including techs and ancillary staff.  Benchmark like-size VAMCs against each other.  Dedicated specialty leaders for each medical/surgical specialty.

Please realize you're asking very general questions; the staff I work with (nurses & technologists) are overall very good & dedicated.  The ward nurses may be better than I know.  The administration is concerned ONLY with the APPEARANCE of quality, based on unrealistic criteria, & security.

Enough staffing to be able to deliver the best care.  Feels like more work is required to be done & not enough time & staffing.

Part of the problem is we have NO hospital now, just outpatient clinics and outsourced care.

I work in an outpatient clinic.  HAS, who provides clerical & scheduling services, obstructs Veterans access to care.  Administration has failed to address this serious and expensive problem.

I work at a VA/Air Force Joint Venture.  The Air Force is responsible for processing RME and providing supplies.  This has been unsatisfactory.

Lack of appropriate staff.  Clinic is dirty.

Supervision to residents – constantly.  Nurses with better initiative.

More staff.

Nursing leadership is not employee focused so morale is poor which affects relationships with docs & care of veterans.

I love veterans & I'm very concerned that quality of Jackson VA Medical center care has deteriorated.  There are not enough physicians.  The ER is understaffed to a frightening degree.  Nurses do whatever they want.  We've had some bad patient outcomes hospital-wide.  Several physicians have had heart attacks within the past 3 years – including the Assistant Chief of Staff.  My health is deteriorating.  C and P is placed as more important than actual patient care.

There is NO EFFECTIVE communication regarding important matters between the RANK & FILE physicians and the hospital administration.  In fact, the overall organization of the VA system, pits the rank & file physicians and the administration as ADVERSARIES.  Until Dr. Kaiser's systemic renovation there was SOME but NOT LOCAL support & communication between us.  IDEA – A modest improvement might result if there was a physician who worked as a clinician half time and as an assistant hospital Director with veto power over the hospital Director for decisions affecting clinical care.

Need pain specialists.  Need staff assigned to specifically coordinate discharges and transfers.

We need more staff! – PSAs, social workers, psychologists, office managers.  Need to be able to hire the positions we have earned.  Hiring process needs to be more efficient.

Need improved efficiency of processes – treatment planning, c&p exams, initial intakes, etc.

The VHA is underfunded.  Our facility is underfunded, year after year.  The VERA model doesn't work for our smaller facility.  10% greater funding would allow us to hire needed staff and purchase needed equipment, and improve pt care & staff satisfaction.

HR department needs to improve.  Suggest new people, additional training, performance improvement plans.

We need to bring some common sense to the VA policy that all re-useable medical equipment must be sterilized or disinfected according to the manufacturer's recommendations.  This has significantly impeded our ability to render care.

VA leadership is weak at the top & at facility levels.  CO is making ridiculous politically driven demands that have nothing to do with quality medical care.  The demands on primary care are excessive.

The second decade of the third millennium will be one of change and stress in VHA.  The progress VHA made under Ken Kizer is being eroded by reversion to central decision-making, mandates, and unyielding fiscal constraints.  VHA is in great danger in losing its preeminence in many areas it once dominated.  It needs a consistently realized vision.

Care is better on some units than others. Less house staff hours impact.  Nurses not at same level of competency.

Quit abusing physicians and staff.  Quit cutting FTEs.

We have far too few beds – Hines VA.

Discharge rates by physicians are not updated or clear.  Sometimes there is a considerable time gap between patient discharge and discharge plan or note and causes lot of confusion in after-care.

Used to! (feel proud to be a physician or dentist at this hospital)

I am currently at a facility with only nursing home and reah beds – no inpt acute care, surgery, etc.  No emergency room.  I have been here after 20 years at a tertiary care facility where excellent care was delivered in spite of the administration.  My answers about the previous facility would have been very different.

Resources should be appropriately allocated to support mandated services.