4.3 Service Delivery Framework
4.3.1 Training
NVC training was delivered nationally in 2006 and was designed to provide direct client service staff with an enhanced understanding of the NVC programs. Training was developed by the NVC learning team with the objective of providing staff with as much information as was available at that time; as such, training material and information was a ‘point in time’ view of NVC. Staff indicated that much of the training was knowledge-based lecture style on policy and systems and since that time, they have not received any follow-up training coordinated by Head Office.
The lack of follow-up training has resulted in experienced staff not evolving with policy and process intent and, new staff feeling that they do not have a good understanding of the programs, services and benefits. This has made it necessary for field offices to develop their own training. The development and delivery of such training by district office staff directly impacts their ability to deliver client service. The regional offices were also identifying training needs and developing ad hoc training plans. The lack of nationally coordinated training and the reliance of localized developed training have created inconsistencies among districts in the amount and types of training provided to staff, which has ultimately resulted in an inefficient use of the limited training dollars and field resources.
In August 2009, a National SDC learning plan proposal was developed but, has never been implemented; therefore, a current national training plan does not exist, which could potentially identify and address training gaps. In the absence of a national training plan regions and district offices have developed their own training and planning initiatives such as mentoring and peer-to-peer support, while other offices are using local service providers, OSI clinics or Ste. Anne’s Hospital for informal but effective training. Front-line staff identified the need for ongoing skills-based training in the areas of case planning, disengagement and motivational interviewing in order to successfully case manage NVC clients.
Conclusion
Initial training at implementation provided a “point-in-time” view of the NVC but there has not been any coordinated follow-up training on a national level to ensure staff are evolving with policy and process intent and that new staff have a good understanding of the programs, services and benefits. Most training provided has been lecture style or relying on peer-to-peer support and staff have identified a need for more skills based training.
The absence of nationally coordinated training has resulted in inconsistencies among districts in the amount and types of training provided to staff. It is also unknown if existing or new staff are developing the skills required to deliver quality service consistently across the country. Ultimately this results in an inefficient use of training dollars and field resources.
Recommendation 6 (Essential)
It is recommended that the Director General, Service Delivery Management Division in consultation with the Program Management Division, develop, resource and sustain a National Learning Program for the New Veterans Charter.
Management Response:
Management agrees with this recommendation however management views this as a strategic priority and not a program. Service Delivery Management Division is committed to provide a national training plan to provide support to delivery of programs and services to clients and also to establish standards for training and determine needs.
| Corrective Action(s) to be taken | OPI (Office of Primary Interest) | Target Date |
|---|---|---|
| 6.1 Develop a National Learning Strategy to identify the resources required to develop and sustain this program. | Service Delivery Management Division | November 2010 |
| 6.2 Conduct a learning needs assessment. | Service Delivery Management Division | February 2011 |
| 6.3 Implement a National Learning Strategy. | Service Delivery Management Division | April 2011 |
4.3.2 Tools
Client demographics at VAC have changed dramatically in recent years such that the number of VAC’s traditional war service clients is tapering off and the number of modern day CF Veterans is increasing. As of March 2010, the total estimated Canadian Forces Veteran population was 593,700 with 155,700 war service Veterans.
These modern day Veterans have different requirements, challenges and expectations compared to the traditional clientele. This change in client base has resulted in the need for case managers to juggle a variety of client needs and expectations. To support this change there are a variety of tools at the disposal of front- line staff to assist in the delivery of services. These tools encompass numerous systems, policies, and business processes.
Field staff reported the greatest frustration and hindrance to service delivery was the difficulty they experience trying to access VAC policies, business processes and directives. It was identified that while staff were generally aware of relevant policies, business processes, and directives, because of frequent changes they often were not sure if they had the most current version. Staff felt changes to policies, business processes and directives were not being communicated in a coordinated manner. For example, staff indicated that a new or revised policy would be sent via e-mail but the applicable business processes would not be included. This causes confusion for staff, particularly since some front-line staff indicated that they follow the business processes to the letter. Staff suggested that VAC needed a more coordinated approach for communicating changes to policy and business processes.
The Veterans Services Support Network (VSSN) Intranet site was developed to provide consistent and timely policy and operational guidance for staff. The VSSN was to link front-line staff working in district offices, regional management centres and centres of expertise with established points of contact from the two Management Centres in Charlottetown — Program and Service Policy Division and National Operations Division. Under the 2009 organizational realignment, Service Delivery Management emerged as the single point of contact at Head Office for regional, district and operational staff. This single point of contact was to replace VSSN and allow for more efficient and effective advice and direction to the field. However, even though VSSN was no longer being updated it was still available online and many staff were still relying upon VSSN for guidance. This creates situations where staff are using information which is no longer up-to-date nor accurate.
The VAC Intranet site is the main source of information for field staff seeking information on programs, policies, or business processes. Given the volume of this information it can be difficult to find the information required which is why a search engine was created. However, staff raised concern with the effectiveness of this search engine as it does not clearly display the required information. For example, information provided via the search engine was not presented in order of relevance such as legislation, policy, business process or with any revisions highlighted. Staff expressed a lack of confidence in the information provided via the search engine as they often encounter outdated or incomplete information. This was causing them to spend excessive amount of time searching for the information they require to conduct their work.
Due to the time required to locate required documents, staff are creating their own reference material and sharing this information with others. This reference material, which may not be accurate nor approved, is being used to support service delivery decisions. This reference material reduces the consistency of client service and could result in the wrong decisions being made.
Conclusion
VAC’s programs and services are delivered by front-line staff in district offices across the country. Field staff reported that they are spending excessive amounts of time searching for information they require to conduct their work. This additional searching causes an administrative burden and negatively impacts direct client service. In the absence of easily accessible tools such as policy and operational guidance, staff are creating and sharing their own reference material which may not be accurate. The current system which provides staff with policies, directives and guidance in support of program and service delivery is inefficient. The changes to policies, business processes and directives are not communicated in a coordinated manner and staff are feeling challenged to meet the emerging needs of our clientele with the tools and resources presently available to them.
Recommendation 7 (Essential)
It is recommended that the Director General, Service Delivery Management Division develop and implement a process to streamline access to current policies, business processes and directives and more effectively identify and communicate changes.
Management Response:
Management agrees with this recommendation and the process to streamline access to policies, business processes and directives will be part of the Departmental transformation agenda. Service Delivery Management is the single point of contact for the dissemination of policies, businesses processes and directives to staff.
| Corrective Action(s) to be taken | OPI (Office of Primary Interest) | Target Date |
|---|---|---|
| 7.1 The new process for the Single Point of Contact is being further developed to ensure effective communication and dissemination of access to policies, business process and directives. | Service Delivery Management Division | September 2010 |
| 7.2 A review of VSSN will be conducted to determined its functionality and potential improvements or removal. | Service Delivery Management Division | December 2010 |
| 7.3 Place all policies, business processes and directives on-line through the Departmental WIKI when available. | Service Delivery Management Division | March 2011 |
4.3.3 Functional Direction
Functional direction provides operational staff with guidance on policy and process to support decision making. This functional direction comes in various forms from the district, regional and Head Office levels of the department. Head Office personnel, comprising of both health professionals and functional specialists, support the development of program policies and processes as well as set precedents on non-routine cases. Regional and district personnel, also comprising of both health professionals and functional specialists, provide input into policies and processes and assist operational staff on complex cases.
Prior to NVC, Health Care Team (HCT) rendered certain decisions regarding treatment and services for clients. HCT is comprised of case management, nursing, medical representatives and the manager of client services as part of an overall client-centred service approach to service delivery.
With the implementation of the NVC, two new positions, a rehabilitation officer and a mental health officer, were created and staffed at both the regional and national levels. The purpose of these positions was to provide functional direction to front-line staff and to play a key role in the delivery of intense and complex case management services to clients and families through an Interdisciplinary Team (IDT) composed of health professionals and case managers. The terms of reference for the IDT have not been clearly articulated in policy nor business process. Therefore, the composition and use of IDTs were not consistent across the country. In some areas, the IDTs were meeting twice a week and some were meeting every two weeks. Some client service teams were adding IDT to the end of their HCT, while other client service teams were doing IDT via email.
The standard of practice for rehabilitation case management includes extensive use of an IDT to ensure a collaborative approach to a well developed rehabilitation plan, resulting in better client outcomes. The lack of consistent use of the IDT and lack of individual consultation with health professionals among case managers in VAC offices leads to wide variations in quality, timeliness and effectiveness of services to clients, ultimately impacting client outcomes.
Within IDTs and HCTs there are numerous functional specialists and health professionals: District Nursing Officers (DNOs), District Medical Officers (DMOs), contract Occupational Therapists (OTs), Regional Rehabilitation Officers (RROs), Regional Mental Health Officers (RMHOs) and Standards Training and Evaluation Officers (STEOs). In some client service teams, these positions were being used collaboratively to ensure quality of service, desired client outcomes and improved case management. However, the collaboration and consultation was not consistent across client service teams. There was also confusion and a lack of guidance regarding who was a functional specialist and when these professionals should be consulted in relation to NVC clients.
Front-line staff spoke positively of the guidance and direction provided by the RRO and RMHO; however, in some areas staff commented timely access was an issue. Individuals in these positions were providing guidance to an entire region, therefore, the response time might not be as immediate as required. Also in some regions these positions had a high turnover in staff, resulting in less continuity of service and direction provided to front-line staff.
Staff were not clear of the role of the DNO and DMO and contract OTs in relation to NVC. Staff stated that their preferred option was to use local resources first, then consult with the regional functional specialist as necessary; however, business processes were inconsistent on this approach. Staff suggested that greater utilization of the DNO, DMO and contract OT could provide them with more local resources and reduce the burden of the RRO and RMHO.
Staff identified that there is lack of clarity with the role of various Head Office personnel and difficulties getting the information that they needed in a timely manner. However, it should be noted that at the time of fieldwork Head Office had recently realigned and responsibilities were still in the process of being determined and communicated.
While there was guidance regarding when various functional specialists and health professionals should be engaged, indicators for referral were not easily accessible on the internal website and many staff were not using them, and others were not even aware of such indicators for referral. There was also some role confusion among the health professionals and functional specialists. There were some who wanted to be consulted and were not; while there were others who were being consulted and do not see case planning of NVC clients as being their role.
Conclusion
Collaboration allows for individuals working together and examining new perspectives. Collaboration also invites input from varying perspectives, thus, improving the quality of service and outcomes leading to improved case management. Staff were not clear on processes and guidelines with respect to consultation with functional specialists and health professionals. There was even confusion in which positions are functional specialists for the NVC. Business processes and policy were not clear on the definition, purpose, composition and usage of the IDT. Clarification of the IDT and clearly articulated roles and responsibilities of health professionals and functional specialists would stimulate collaboration and improve the quality of service and outcomes for a client.
Functional direction comes in different forms from the district, region and Head Office levels of the department. Front-line staff report they do not have sufficient access to functional direction to get the guidance and direction they require on a timely basis. Greater utilization of the DNO, DMO and contract OT could provide staff with more local resources to provide more timely support and help reduce the burden of the RRO and RMHO.
Recommendation 8 (Essential)
It is recommended that the Director General, Service Delivery Management Division clarify and communicate the purpose and composition for the interdisciplinary team.
Management Response:
Management agrees with this recommendation and is linked to Recommendation #9.
| Corrective Action(s) to be taken | OPI (Office of Primary Interest) | Target Date |
|---|---|---|
| 8.1 Communicate the present purpose and composition of the IDT. | Service Delivery Management Division | September 2010 |
| 8.2 Clarify and communicate the role of the IDT in relation to the future role of Health Professionals and Functional Specialists following the decision taken of the Health Professional Review. | Service Delivery Management Division | March 2011 |
Recommendation 9 (Essential)
It is recommended that the Director General, Service Delivery Management Division, clarify the role of health professionals and functional specialists in relation to the NVC programs and to each other and more effectively communicate when to consult with these positions.
Management Response:
Management agrees with this recommendation.
| Corrective Action(s) to be taken | OPI (Office of Primary Interest) | Target Date |
|---|---|---|
| 9.1 A review of the Role of the Health Professionals commenced in June 2010. | Service Delivery Management Division | August 2010 |
| 9.2 The key findings and recommendations will be presented to Director General Policy and Program Review Committee and then to Senior Management Committee for approval and decisions. | Service Delivery Management Division | October 2010 |
| 9.3 Implementation and times lines will be determined for the approved recommendations. | Service Delivery Management Divisi | December 2010 |
4.3.4 Delegated Authority
The authority to approve eligibility, to establish entitlement and to approve payments is exercised in accordance with the delegation from the Minister by means of an Instrument of Delegation, and the Delegation of Financial Signing Authorities Chart for VAC, to positions at the appropriate organizational levels where these responsibilities can be most efficiently and effectively exercised and where accountability for results can best be established. For most NVC programs, the delegated authority rests with Head Office (e.g., Disability Award Program or Financial Benefits Program). For the Rehabilitation program, the majority of approval authority rests with field staff.
For medical and/or psychosocial rehabilitative services, case managers have the authority to approve any services defined on VAC’s benefit grid. This benefit grid defines the types of services, frequency and dollar limit which field staff can approve. Any rehabilitative services not on the grid or which exceed the 20% dollar threshold must be approved by Head Office. In these situations the case manager, in consultation with the IDT prepares a strong rationale and/or compelling evidence/information to support why a particular medical and/or psychosocial rehabilitation service or benefit is required in this unique situation to meet the client’s needs. The case is then forwarded to the RRO with the supporting documentation. Following the RRO review, the case is then submitted to Head Office for approval. The result is a cumbersome and involved decision making process causing delays for the client.
One issue identified by staff was that the guidelines within the Benefit Grid were not reflective of the needs of rehabilitating clients. It was described that clients with rehabilitation needs are working towards restoring function which in many cases requires services not currently identified on the benefit grid (e.g. life skills) or services that continually exceed the limits contained on the benefit grid. Therefore, there are numerous requests being forwarded to Head Office for approval. Before these requests are sent to Head Office they have already been reviewed and recommended by both the IDT and the RRO and in many cases similar requests, are routinely being approved. As a result, field staff felt that too many routine decisions were being routed to Head Office for approval which causes unnecessary delays without adding value to the decision making process.
This observation is supported in the Programs of Choice Analysis Audit dated June 2009. According to that audit, from May to December 2008 there were 745 decisions relating to the treatment benefits program rendered by Head Office with 96% approved. The audit identified the need for the development of new policy guidelines for dealing with requests for benefits and services which are not contained on the Benefit Grids, or exceed the benefit grid, which would allow for greater empowerment of front-line staff and would improve client service. The audit recommended that VAC determine how changes to business processes could be implemented to reduce the volume of cases adjudicated by Head Office and to assign resources to conduct regular reviews and edits to the Benefit Grids. Currently there is work being undertaken but at this point in time, the recommendation remains outstanding.
In an effort to address this issue, VAC management is working to phase in the transfer of a significant level of delegated authority and decision making for the rehabilitation program to the district office level. During fieldwork, these revisions were being tested in one of VAC’s district offices. Field staff interviewed from the test site felt positive about the delegation changes as they empowered staff and allowed for faster decisions resulting in improved service to clients. However, there was not a strong quality assurance process in place nor was a formal evaluation planned to determine if the revised authorities were actually working better or simply allowing for faster decisions.
In anticipation of changes to the delegated authorities, it is imperative that a proper quality assurance function be established. Over the past decade VAC has been making significant changes to its client service delivery model and enhancing its programs in order to better respond to the diverse range of disability and health needs which are experienced by VAC clients. The cumulative effect of the foregoing service enhancements, and legislative and program changes results in increased demands for field staff. A formal quality assurance process would ensure that the decision making process is evidence based, applied consistently across the country, and is reflective of client service objectives.
In the area of vocational services, the delegated authority has been defined in the Canadian Forces Members and Veterans Re-establishment and Compensation Regulations. Specifically, Section 15.1 of the regulations prescribes in detail the services and costs which field staff have the authority to approve. Any expenses that are not detailed within Section 15.1, or exceed the rates as prescribed follow a similar path as described above to be approved. The issue identified with vocational services is that the rates have not been updated since the NVC was introduced in 2006 and cover very specific costs. For example, supplies and internet fees are included as part of section 15.1 but the purchase of a computer is not specifically spelled out. The lack of interpretation of acceptable costs in Section 15.1 results in a significant number of vocational services decisions being directed to Head Office approval. However, it should be noted that because these expenses are defined in legislation, unlike the medical and/or psychosocial service in the benefit grid, any potential updates or changes would require a Treasury Board submission.
Conclusion
Appropriate delegation of authority empowers field staff to effectively case manage clients. However, the current process for approving services is not efficient as it is taking too long for routine decisions, impacting on the client and the relationship the case manager has with the client.
VAC is currently revising the delegated authorities to allow for more timely decision making. To successfully implement any revised authority case managers need to be supported with training, have access to up-to-date policies and business processes, and receive sufficient support from functional specialists. However, as described in Sections 4.3.1 to 4.3.3 these areas require improvement. In addition, developing a strong quality assurance process is necessary to ensure that any future revisions to improve efficiency does not come at the cost of reducing the quality and consistency of decision making.
Another issue identified, is that the guidelines within the Benefit Grid were not reflective of the needs of rehabilitating clients. The Programs of Choice Analysis Audit identified the need for the development of new policy guidelines for dealing with requests for benefits and services which are not contained on the Benefit Grids, or exceed the benefit grid, which would allow for greater empowerment of front-line staff and would improve client service. Currently there is work being undertaken to address the recommendations from the Programs of Choice Audit.
Recommendation 10 (Essential)
It is recommended that the Director General, Program Management Division in consultation with Service Delivery Management Division, Policy Division and Finance Division complete the modifications to the delegation of authority for the New Veterans Charter and implement the revised authority with a supportive framework which includes a comprehensive quality assurance component.
Management Response:
Management agrees with this recommendation. The Director General, Program Management Division in consultation with Service Delivery Management Division, Policy Division and Finance Division have completed the modifications to the delegation of authority for the New Veterans Charter, and an accompanying supportive framework, which includes a comprehensive quality assurance component. Implementation is targetted for October 2010.
This is similar to the “Rehab 2" recommendation of the Audited Financial Statements. This is being actioned, as per the enclosed Management Action Plan.
| Corrective Action(s) to be taken | OPI (Office of Primary Interest) | Target Date |
|---|---|---|
| 10.1 Guidelines/Directives development (Sect. 15(1) and 15(3) of NVC Regulations) | Program Management Division | Completed |
| 10.2 Robust Quality Assurance and Performance Monitoring Process | Program Management Division | October 2010 |
| 10.3 Promulgation of Policy | NVC Policy Directorate | Completed |
| 10.4 Obtain Minister Delegation required for Sect. 15(3) | Finance Division | Completed |
| 10.5 Implementation | Service Delivery Management Division | October 2010 |
| 10.6 Monitoring | Service Delivery Management Division / Program Management Division | On-going |
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