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Case: Cincinnati Veterans Administration Medical Center
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The Cincinnati VA Medical Center (CVAMC) provides health care to eligible veterans in
Ohio, southeast Indiana, and northern Kentucky. The CVAMC is an acute care,
university affiliated 220-bed facility. It is a part of the Veterans Healthcare
Administration of the Department of Veterans Affairs. It comprises one of five medical
centers within the Veterans Integrated Services Network 10 (VISN 10). The CVAMC
works to provide a variety of services as needed across the continuum of care for veteran
patients, as well as trainee education and the pursuit of new knowledge through research.
The mission arises from Federal mandates to support health care, education and research.
CVAMC’s vision is to “… shape our future by breaking the traditional VA mold,
building on our strengths, and emerging as the health care center of choice for all
Veterans. As pioneers of change we will:
1. Establish the patient at the core of all processes with the focus on continuity of care
leading to optimal patient outcomes.
5. Be recognized as an innovative, vital health care leader and educational resource in
our VA system and the Greater Cincinnati community.”
The CVAMC is able to offer a variety of inpatient and outpatient healthcare services.
The Medical Service staff offers services in primary care, general internal medicine, and
in multiple medical subspecialties such as cardiology, nephrology, pulmonary, and
gastroenterology. The Surgery Service offers general surgical care and specialty care in
offers support for patients with acute and chronic debilitating conditions. It offers
programs in occupational, physical, and speech therapy as well as chronic pain
management and prostheses.
The CVAMC also provides specialty services in support of other medical centers
within the VISN. This includes surgical, psychiatric, neurological, and medical specialty
The primary customer is the veteran patient. Highest priority is given to veterans
with medical conditions or injuries related to their service in the military, and to those
veterans with limited resources who otherwise would have difficulty obtaining the care
they need. CVAMC offers a broad range of services to other eligible veterans as well.
Other customers include the families of veteran patients, the veterans support
organizations (VSO), the trainees including residents and medical students, and the staff
at the other VISN facilities. There is a special relationship with the University of
The 1,100 employees of the CVAMC include physicians, nurses, psychologists,
dieticians, social workers, therapists and other health care professionals. This number
also includes those members of the services that support the delivery of care including
environmental management, security, medical administration, finance, and acquisition
Veteran patients require accessibility to care. This includes the need to be seen at
a location convenient to them, as much as possible. Additionally, they must be able to
get an appointment with their clinicians within a reasonable period of time. A thirty-day
limit for specialty clinic consultation has been targeted as a key customer service
standard. Patients do not want to have to wait for long periods on the day of their
appointments. They need access to the latest technology and specialty skills as
to support the patient when treatment decisions are being made. They want convenient
access to care for the veteran patients, as they are often responsible for getting the patient
to the appointments.
The veterans services organizations play a key role in supporting veteran patients.
They demand that the veteran’s needs be met. To this end, they require access to top
management of the CVAMC in order to discuss their concerns.
The trainees demand access to teaching facilities. They want to be able to assist
in the care of patients with a variety of health conditions. They want to be able to discuss
issues with experienced staff. They demand access to the latest technology and
The CVAMC holds a special place in the competitive healthcare market in the
region. It is the only hospital in its service area dedicated to veterans. While this limits
the number of potential customers, it can use this in its pursuit of its targeted customers.
It is relatively small compared to the area’s major medical centers, but it can take
advantage of its membership in the very large chain of medical centers in the VHA when
role of supporting veterans with limited resources, it has been viewed at times as a
provider of last resort. Federal regulations restrict the ability to advertise, limiting the
ability to market its services. The CVAMC also faces a declining population of veterans
in its service area.
The CVAMC has a number of competitors in the region. These include all of the
major medical facilities which provide inpatient or outpatient care. These compete with
the CVAMC mostly for patients with insurance or Medicare coverage. Veteran patients
with limited resources may also go to places other than the CVAMC, since some support
There are several factors of importance when competing in this health care
market. The reputation for quality may be a critical factor for some patients. Cost is a
major factor for many veteran patients, since they have little or no out-of-pocket expenses
for care provided at the CVAMC. Accessibility is critical, since patients are often
unwilling to tolerate long waits for appointments or long delays on the day of their visits.
Many patients show strong preferences for local access to care, the ability to avoid bridge
or downtown traffic, and ease of parking. Continuity of care is important to many
patients. Many patients want their providers to be able to coordinate their visits and tests,
with good communication of results among their providers. Staff courtesy, empathy and
efforts to educate the patients may also be factors of importance to health care customers.
Change continues to affect the health care market. Recent changes in federal
reimbursement of medical facilities under the Balanced Budget Act have caused financial
CVAMC must attend to these changes if it is to prosper in this changing health care
environment.
The major new initiative for the CVAMC is to improve access to care by the
placement of outpatient facilities at sites more convenient to veteran patients. This
process started with the planning for and implementation of the community based
outpatient clinic (CBOC) in Bellevue, KY. Analysis of zip code information for eligible
veterans in the region showed that there is a high concentration of patients in the three
counties of northern Kentucky. Focus groups were held with patients from this area that
The CVAMC has taken part in a new VISN case management program. This
involves assigning a nurse to patients in certain high-risk categories. The categories of
risk were determined by review of resource utilization including days of hospitalization.
The case manager is trained to improve coordination of care and assure appropriate
preventative measures are taken to improve the health state of the patient, limiting the use
of scarce resources.
Major research programs are helping the CVAMC achieve its missions. The
medical center is one of three sites funded nationally as a Patient Safety Center of Inquiry
staff positions while improving the quality of care that we are able to offer to veteran
patients.
The computerized system for automated production of prostheses represents a
new service that is not available elsewhere in the VISN. Additionally, it is far superior in
cycle time to any system available anywhere else in the region. This system allows the
CVAMC to offer its patients with amputations unparalleled service. The shorter cycle
The major unique factor at the CVAMC is the strategic planning process. This
occurs at the Quorum, a quarterly meeting of managers from all services as well as
representatives of major customer groups. Results of prior initiatives are reviewed. The
group decides whether the resources should continue to be assigned to those projects.
New initiatives are considered in view of changes in the environment and customer
needs. The large size of the group improves organizational buy-in for initiatives. The
Discussion Questions
1. Based on this background information about the CVAMC, propose a set of
approaches that the medical center might pursue to help achieve its vision and truly
be customer-focused. Focus on the types of customers the CVAMC has identified,
their needs, and the organization’s role in the community and with respect to its
competition.
2. The Appendix to this case shows a patient satisfaction survey used at the CVAMC.
Appendix: VA Survey
