TEAM:     Report  on  RCS  Clinical  Capacity   For  Counselors  and  Team  Leaders     February  16,  2015       Fourteen  members,  one  Team  Leader  and  Counselor  from  each  of  the   7  regions.     TASK:   Define  the  working  clinical  capacity  for  Counselors  and  Team  Leaders     POLICY  REV:  The  current  RCS  Policy  manual  was  reviewed  to  find  any  existing   references  to  “Capacity”  and  the  only  reference  found  is  stated  here:     “(1)  Veteran  Centric  Care  -­‐  Extend  Vet  Center  capacity  to  provide   quality  readjustment  counseling  services  to  eligible  Veterans  and   their  families  in  or  near  their  respective  communities.”       DRIVING     PRINCIPLES:   VA  CORE  VALUES:     Integrity:  “Act  with  high  moral  principle.  Adhere  to  the  highest   professional  standards.  Maintain  the  trust  and  confidence  of  all  with   whom  I  engage”.    We  have  strived  to  provide  accurate  data  and  to   identify  areas  where  the  program  can  enhance  data  integrity  as  well   as  other  areas  of  improvement.   Commitment:  “Work  diligently  to  serve  Veterans  and  other   beneficiaries.  Be  driven  by  an  earnest  belief  in  VA’s  mission.  Fulfill   my  individual  responsibilities  and  organizational  responsibilities.”     As  a  team,  we  have  done  everything  possible  to  promote  VA’s   mission  in  this  endeavor.    We  agreed  to  identify  issues  that  may  be   considered  “unpopular,  tacit  and  perhaps  un-­‐solicited”  but  as  a  team,   we  believe  they  are  paramount  to  success  of  this  task.   Advocacy:  “Be  truly  Veteran-­‐centric  by  identifying,  fully  considering,   and  appropriately  advancing  the  interests  of  Veterans  and  other   beneficiaries.”    Many  of  the  team’s  discoveries  reveal  unintended   consequences  that  burden  our  veterans  and  employees,  and  are   directly  tied  to  the  capacity  issue  at  hand.    Most  significant,  is  the   compensation  time  for  counselors.    Across  industry  and  government,   compensation  time  was  created  to  reduce  and  or  share  the  burden  of   overtime  expense.    The  use  of  comp-­‐time  with  FLSA  exempt   employees  creates  a  burden  on  the  clinicians  and  ultimately  our   veterans.    The  team  consensus,  recommends  this  shift  be  reversed,  to   avoid  future  burnout  of  clinicians  and  reduced  services  (capacity)  to   veterans,  thereby  appropriately  returning  this  burden  back  to  the   Agency.   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   1   Respect:  “Treat  all  those  I  serve  and  with  whom  I  work  with  dignity   and  respect.  Show  respect  to  earn  it”.    This  team  consisted  of  a   cohesive  group  that  stayed  on  task  and  dedicated  their  time  to  this   objective.    We  faced  our  differences  and  put  aside  our  fears  to  present   a  cohesive  presentation  of  facts  in  a  respectful  professional  manor.   Excellence:  “Strive  for  the  highest  quality  and  continuous   improvement.  Be  thoughtful  and  decisive  in  leadership,  accountable   for  my  actions,  willing  to  admit  mistakes,  and  rigorous  in  correcting   them.”    The  team  would  like  to  humbly  admit  that  our  short  time   together,  we  have  assuredly  made  some  mistakes  in  this  endeavor  and   therefore,  recommend  hiring  a  professional  consulting  team   consisting  of  methods  specialists,  statisticians  and  engineers  to   perform  time  studies  to  eliminate  any  appearance  of  bias  found   within  this  report.   Plain  Writing  Act:  Public  Law  111–274  111th  Congress     METHODS:     Policy  Review,  data  collection,  research  and  consultation  across  team   members  covering  all  Regions  within  RCS.    The  data,  when  viewed   across  different  Vet  Centers  clearly  revealed  an  unacceptable  or   inconsistent  range  of  data  to  incorporate  into  a  quantifiable  and   defensible  data  set,  if  we  included  data  from  multiple  Vet  Centers.   .       FOCUS:   Our  focus  was  narrowed  to  one  Vet  Center  in  Midland,  Texas  RCS-­‐3B   #0716.       The  decision  was  arrived  at  for  purposes  of  accuracy  and  validation  of   data  collection.    Counselor  capacity  is  assumed  to  be  static  across  RCS   however;  Vet  Center  over-­‐all  capacity  and  to  an  equal  degree,  Team   Leader  capacity  varies  to  such  a  high  degree  that  it  prohibited  a  cross   section  presentation  of  clinical  data.         DISCOVERY:       RCS  currently  has  a  serious  data  integrity  issue  across  the  program.    The  following   illustrate  these  anomalies:   • A  systemic  lack  of  data  verification  protocol  and  monthly  reconciliation   at  the  Vet  Center  level.   • A  systemic  failure  to  capture  real  or  accurate  data  Nation  Wide.     RCS-­‐NET  data  is  not  precise  and  does  not  provide  decision  makers  with  consistently   valid  information.    These  identified  inconsistencies  result  in  a  distorted  perception   of  clinical  capacity.    This  is  likely  a  result  of  depending  on  an  outdated  but  accurate   standard,  combined  with  efforts  to  meet  or  exceed  50%  total  activity  time  or  twenty   hours  of  forty.    We  discovered  that  work  hours  have  been  manipulated  or  under   reported  in  Vet  Centers  across  most  Regions.    Many  counselors  log  8  hours  worked   even  when  actual  hours  worked  exceed  8  hours  in  one  day.    Furthermore,  in  some   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   2   Regions,  the  Team  Leader  has  been  coerced  to  under  report  clinical  visits  on  a  given   day  in  order  to  avoid  showing  that  output  exceeds  100%.    It  is  understood  that   output  cannot  exceed  capacity  or  100%  however;  data  manipulation  has  become  the   norm  in  most  locations.  When  employees  work  10  hours  in  a  day  and  actually   produced  10  hours  service  time;  those  10  hours  would  be  logged  as  8  hours  worked   and  reducing  the  true  output  (omitting  2  hours)  to  reflect  a  distorted  125%  activity   time…  to  correlate  with  the  8  hours  logged  as  worked.    The  importance  of  lost   activity  time  and  hours  worked  cannot  be  over-­‐emphasized  in  this  endeavor.     Additional  discoveries  include:   • Inconsistency  across  VISN’s  related  to  VA  training  requirements  in   (TMS).    Mandatory  training  fluctuates  across  Regions.    Additionally,  a   minority  of  Team  Leaders  has  obtained  TMS  administrative  rights  to   remove  trainings  that  are  not  required  by  RCS;  like  “hand  hygiene  and   infection  control”  just  two  of  many  examples.    This  inconsistency  will   result  in  a  small  variance  across  Regions  but  presents  a  negative  impact   on  clinical  capacity.   • Interpretation  of  RCS  Policy  has  resulted  in  a  large  variance  across  RCS.     Multiple  policies  have  clearly  been  lost-­‐in-­‐translation;  across  all   Regions  and  this  has  a  very  significant  influence  on  clinical  capacity.     For  example,  some  Team  Leaders  provide  (1  hour)  supervision  to   counselors  on  a  weekly  basis  while  other  Team  Leaders  provide  the   required  supervision  on  a  monthly  basis.    The  policy  could  for  purposes   of  argument,  result  in  a  Team  Leader  providing  supervision  every  six   months.    The  policy  is  written  as  follows:  “…Team  Leader  is  responsible   for  providing  individual  counseling  supervision  to  Vet  Center   counselors  on  an  ongoing  and  regularly  recurring  basis.”    While  the   intent  is  to  provide  flexibility  for  newer  employees,  this  has  produced   drastic  differences  across  RCS.    This  issue  is  further  exacerbated  by  the   size  of  the  Vet  Center  clinical  staff,  when  a  Team  Leader  spends  six  or   seven  hours  per  week  providing  supervision  to  all  clinical  staff.       ANALYSIS:     We  began  from  the  historic  standard  of  50%  activity  time  which  basically  consisted   of  capturing  all  productive  hours  worked  both  clinical  and  non-­‐clinical  to  include   Counseling,  Education,  Consultation,  Supervision,  Travel,  Outreach  and  COTR  duties.     The  50%  standard  originally  encompassed  both  Clinical  (Direct)  and  Non-­‐Clinical   (Indirect)  service  time.    This  standard  was  the  established  norm  until  around  2012   when  the  norm  of  50%  Total  Activity  Time  was  verbally  modified  to  be  50%  Direct   (Clinical)  Service  Time.    This  was  not  updated  in  the  policy  manual  1500.02.    In   2014  some  performance  plans  required  60%  Direct  Service  time.    It  is  unknown  by   this  team  what  effect  that  may  have  had  on  the  over-­‐all  output,  if  any.    It  appears,  to   have  been  motivated  solely  by  a  desire  to  increase  output.    It  is  doubtful  this   informal  modification  to  the  Standard  had  any  real  measurable  effect  on  output.     National  Working  Group:  Clinical  Capacity  Assessment  February  2015   3   The  task  of  this  team  was  to  identify  the  real  clinical  capacity  of  a  licensed  counselor   working  for  RCS.    The  objective  was  to  identify  all  non-­‐clinical,  internal  and  external   demands,  from  OPM,  VISN’s,  Regional  Managers  and  Central  Office,  that  take  priority   over  clinical  work.    In  addition  to  identifying  these  internal  draws  from  capacity,  it   was  agreed  that  we  must  then  identify  all  other  non-­‐clinical  demands  such  as  (1)   Professional  demands  and  licensure  requirements,  literature  review  demands  etc.     (2)  Internal  and  External  Customer  Service  Demands  such  as  other  stake-­‐holders,   co-­‐workers  and  other  internal  departments  like  fiscal,  contracting,  mental  health,   logistics,  IT  etc.  and  ultimately,  we  had  to  identify  all  other  demands  that  would  be   categorized  as  (3)  Universal  demands  such  as  reading/writing  emails,  phone  calls   etc.    All  of  these  resources  in  one  way  or  another  influence  or  reduce  our  real   capacity,  which  is  limited  by  time  constraints  of  2080  hours  per  year.     We  defined  our  time  constraints  on  the  following:    365.25  days  per  fiscal/calendar   year  or  12  months  or  52  weeks  and  reduced  that  to  our  available  working  capacity   which  is  52  weeks  or  260  work  days  or  2080  available  work  hours  across  one  year.     We  began  by  deducting  all  internal  capacity  draws  or  employee  benefits  such  as:     Federal  Holidays  (OPM  Fixed)                80  hours  per  year     Annual  Leave  (OPM  Variable)         156  hours  per  year     Sick  Leave  (OPM  Variable)           104  hours  per  year     Required  Work  Breaks  (OPM  Fixed)       130  hours  per  year   Office  of  Personnel  Management  (OPM)  demands  total     470  hours  per  year     These  fixed  and  variable  OPM  demands  totaling  470  hours  per  year  is  deducted   from  the  fixed  available  work  hours  of  2080  per  year  and  reduces  our  clinical   capacity  by  22.6%  of  total  work  hours.    Note:  the  Annual  leave  ranges  from  104  to   208  hours  per  year  depending  on  clinician’s  length  of  service  with  VA  and  we  used   the  mid-­‐point.    The  sick  leave  ranges  from  104  to  408  hours  per  year  and  the   number  we  used;  104  hours  does  not  include  bereavement,  FLMA  or  disabled   veteran’s  allotment  of  104  hours  of  up-­‐front  sick  leave  provided  on  day  one  of   employment.    OPM  draws  alone,  leave  us  with  77.4%  available  capacity  across  any   time  period  from  one  day,  week,  month,  pay-­‐period  or  year.    While  use  of  various   types  of  leave  occur  sporadically  across  the  year,  the  total  must  be  leveled  across  all   available  work  days.     Next  we  identified  all  VISN  demands  that  vary  across  different  VISN’s  (See   Spreadsheet  Tab  labeled  “Variances  Across  Regions.”    VISN  18  is  used  in  the  Tab  1   for  Midland,  Texas  only.    VISN  demands  are  as  follows:       TMS  online  trainings  (VISN  18)       19.25  hours  per  year     Annual  Flu  Shot  (Travel  Time  Included)          1.75  hours  per  year     Annual  TB  Test  (Travel  Time  Included)          1.75  hours  per  year     PIV  Badge  Renewal  every  two  years  (2  Trips)        1.75  hours  per  year     Vista  Data  Entry  for  annual  or  sick  leave          1.10  hours  per  year   VISN  Demands           Total        25.6  hours  per  year   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   4     This  VISN  demand  of  25.6  hours  per  year  takes  another  1.2%  away  from  the   maximum  available  2080  hours  per  year  so  now  we  have  arrived  at  a  total   deduction  for  both  OPM  and  VISN  demands  of  23.82%  of  the  2080  and  now  we  are   left  with  76.18%  of  available  capacity  or  1,584.4  hours  for  potential  clinical  output.     Next,  we  identified  all  Central  Office  and  Regional  Demands  that  also  vary  across   Regions  due  to  policy  interpretation,  communication  breakdown  and  variable   demands,  Regional  preferences  etc.    We  identified  the  following  as  C.O.  and  R.O.   demands:       Int/Ext  Case  Staffing  Demand  (Non-­‐Clinical  Producing)   48  hours  per  year     Staff  Meeting  Attendance  (Varies  Across  Program)   12  hours  per  year     Monthly  Supervision  with  Team  Leader  (Variable)   12  hours  per  year     Administrative  Site  Visit  (Meet  with  RO  Staff)     1.1  hours  per  year     Clinical  Site  Visit  (Meet  with  RO  Staff)       1.1  hours  per  year     STEPs  Updated  for  annual  site  visits       1.2  hours  per  year     RCS-­‐Net  Data  Entry  (Non-­‐Clinic)  Hrs.,  Edu,  Conslt  Time      19.5  hours  per  year     RCS-­‐Net  Downtime  -­‐  Updates  during  work  hours.     1.5  hours  per  year     Central  Office  and  Regional  Office  demands  Total                           96.4  hrs  per  year     This  Central  Office  or  Regional  Office  demand  total  of  96.4  hours  per  year   represents  another  4.63%  of  reduced  clinical  capacity.    When  included  with  other   non-­‐clinical  demands;  OPM  480  hours,  VISN  25.6  hours  and  Central  Office/Regional   demand  of  96.4  hours  per  year  for  a  total  of  602  hours  reduction  from  max  available   working  hours  of  2080;  leaves  only  1,488  hours  per  year  or  71.54%  remaining   clinical  capacity.     Finally,  we  identified  professional  or  State  demands  for  licensure  requirements.     This  will  vary  across  States,  license  held  and  when  multiple  licenses  are  held,  this   will  variable  will  increase  somewhat.    Referring  to  Tab  1  on  the  spreadsheet  or  the   actual  capacity  calculations  in  Midland,  all  counselors  are  LCSW’s  and  require  30   CEU  hours  every  two  years  or  15  per  year.    Most  conferences  that  offer  CEU’s  offer  a   maximum  of  7  hours  in  a  full-­‐day  presentation.    As  a  result,  we  calculated  a   counselor  would  take  2.5  days  off  each  year  to  satisfy  this  State  Requirement  for   licensure:     State  or  Licensure  Demands   Total           20  hours  per   year     Subtracting  these  20  hours  from  the  above  remaining  hours  of  1488,  we  get  1468   available  hours  or  70.57%  remaining  clinical  capacity.     We  then  combined  all  other  demands  for  counselors  ranging  from  Team  Leader   Demand  to  Universal  Demands  such  as  email  reading/writing/response/saving/   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   5   and  included  duplicating  daily  output  onto  (an  electronic  SARS  spreadsheet  for   comparison  with  RCS-­‐Net  data  to  assure  data  integrity).  We  identified  the  following:       National  PTSD  Conference  Calls  (TL  Demand)     12  hours  per  year     Email  writing/response/saving  (Universal  Demand)   42  hours  per  year     Scheduling  Appointments  (outlook  or  other)     19  hours  per  year     Not  included  are  MST,  LMFT  Conf  Calls       0  hours  per  year     Literature  Review  (Professional  Demand)       3.5  hours  per  year     Time  duplicating  electronic  SARS  (TL  Data  Integrity)   10.5  hours  per  year     NOT  INCLUDED:  Annual  Counselor  Training                                (40)  hrs  per  year     Team  Leader  &  Universal  Demands  Total       87  hours  per  year   The  total  Team  Leader  and  Universal  Demands  represent  87  hours  per  year.    This   sub-­‐set  represents  another  4.18%  draw  from  maximum  working  capacity  of  2080.     We  subtract  these  87  hours  from  the  above  total  of  1468  and  we  arrive  at  1381   available  hours  in  the  year  to  provide  clinical  services.    This  represents  our  best   estimate  for  a  Counselor’s  Clinical  Capacity.    1381  hours  remain  from  a  total  of  2080   max  capacity  hours  in  a  given  work  year  or  across  260  workdays.    This  leaves  us  at   66.3%  clinical  capacity  from  2080  per  year.    This  leaves  only  one  remaining  variable   to  calculate.       Compensation  Time  and  Over  Time:       Hours  authorized  when  demand  exceeds  capacity  in  an  8-­‐hour  day  or  over  40   hours  in  a  week.     Using  real  data  from  approved  compensation  request  records,  we  see  that  another   105.75  hours  were  allotted  to  a  Midland  clinician  for  hours  worked  in  excess  of  8   per  day.    This  counselor  worked  approximately  120  miles  away  from  the  Vet  Center   in  San  Angelo  Texas.    He  stayed  over-­‐night  two  nights  each  week  and  worked  three   full  days  on  Tuesday,  Wednesday  and  Thursday  and  returning  to  Midland  late   Thursday  evening.      The  clinician  without  requesting  comp  time  or  overtime   donated  these  8.5  hours.    In  February  2014,  a  new  mandate  from  RCS-­‐3B  RMO;  he   was  then  required  to  request  and  take  all  comp  time  earned  within  the  next  three   pay  periods.    This  policy  resulted  in  his  working  only  4  days  each  week  and  lowered   his  (un-­‐captured)  individual  clinical  capacity  from  260  max  days  in  a  work  year  to   208  thereby  reducing  his  capacity  by  20%.    These  additional  hours  must  be   acknowledged  for  capacity  calculation  as  it  represents  both  reality  and  the  historic   inappropriate  distribution  of  the  burden  onto  RCS  clinical  staff.    In  this  example,  the   capacity  burden,  carried  by  the  staff  member,  was  then  shifted  onto  the  veteran  or   customer.  The  employee  is  compensated  (time  for  time)  and  all  is  equal  between  the   Agency  and  the  clinician.  The  burden  shifts  to  the  veterans  because  the  counselor   was  not  available  on  day  five  of  the  workweek.    This  intangible  loss  is  frequently   over-­‐looked  because  the  veteran  or  customer  does  not  complain.    Therefore,  the  end   result  for  determining  clinical  capacity  is  as  follows:   Total  remaining  time  from  above  deductions  is  1381  remaining  hours  to  provide   clinical  services,  minus  the  105.75  Comp  time  hours  (that  were  productive)  leaving   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   6   a  grand  total  of  1,275.25  hours  across  a  year  to  allocate  for  clinical  capacity.    We   have  now  calculated  and  lost  38.69%  of  our  maximum  2080  available  work  hours  to   internal/  external  and  customer  demands.    This  leaves  only  61.31%  clinical  capacity   from  the  maximum  2080  hours  in  a  year.    In  hours  per  year  we  are  left  with   1,275.25  and  in  a  month  we  are  left  with  only  106.27,  while  weekly  we  have  24.52   hours  for  Counselors  to  provide  clinical  services.  (See  spreadsheet  Cell  I36).    When   viewed  across  a  workday,  the  counselor  is  left  with  only  4.90  hours  (Clinical   Capacity)  per  workday  to  provide  clinical  services.    (See  Cell  K36)    Note:  to  meet  the   historic  50%  Standard,  the  clinician  must  capture  4.0  hours  of  the  remaining  4.9   hours  available  in  a  work  day.     RCS  Counselor  Capacity   COUNSELOR   CLINICAL   CAPACITY     1275.25  Hours/ Year     24.52  Hours/ Workweek     4.90  Hours/ Workday     OPM   470  hours   22.6%  Draw   Comp  Time   105.75  Hours   5.08%  Draw   CO  &  RMO   96.4  hours   4.6%  Draw   TL  &  Universal   87hours   4.18%  Draw   States   VISN   20  hours   .96%  Draw   25.6  hours   1.23%  Draw       The  second  task  is  to  identify  Team  Leader  Capacity  (internal  and  external   demands)  in  addition  to,  the  clinical  demands  measured  above.    Since  the  Team   Leader  is  or  perhaps  should  be  a  clinician,  the  starting  place  for  Team  Leaders  is  the   same  capacity  of  24.52  hours  per  week  for  counselor  clinical  capacity.    In  2014,  the   standard  or  expectation  for  Team  Leaders  was  reduced  from  50%  to  25%  Direct   Service  Time  or  10  hours  per  workweek.    So  a  Team  Leader  is  starting  with  24.52   hours  per  week  and  additional  demands  cannot  fall  below  10  hours  or  capacity  will   be  exceeded.    This  leaves  14.52  hours  per  week  for  Team  Leader  to  navigate  all   other  internal  and  external  customer  demands.    In  the  interest  of  brevity,  this  report   will  summarize  the  identified  Team  Leader  draws  from  identified  capacity  of  24.52   National  Working  Group:  Clinical  Capacity  Assessment  February  2015     7   hours  per  week.    We  will  identify  both  the  range  of  draws  and  discuss  the  largest   impact  draws.    Our  presentation  will  not  be  as  detailed  as  above  but  all  data   collected  can  be  quickly  referenced  in  the  spreadsheet  (and  verified  upon  request)   for  a  more  detailed  critique.    Verification  would  involve  printing  or  providing  copies   of  thousands  of  emails  processed  in  2014  among  other  things.     To  begin,  the  range  from  low  to  high  percentage  draws  is  from  0.0096%  to  “Monitor   Staff  Licensure  for  Timely  Renewal”  (TL  Demand)  to  a  high  of  3.8798%  to  account   for  “Email  Writing  and  Response/Staff/RO/CO  and  Support  Facility”  (Universal   Demand).    The  data  to  support  this  significant  draw  was  captured  from  FY  2014   email  traffic.    With  such  a  large  range  of  draws,  we  have  chosen  to  display  in  this   report,  only  those  draws  in  excess  of  0.5%.    In  an  effort  to  fine-­‐tune  the  draws,  we   look  at  daily  draws,  not  weekly.     For  a  quick  review  of  the  chosen  range  to  include  in  descending  order,  we  found  the   following  for  Midland  0716:     • All  Other  Draws     5.4014%     25.93  minutes  “(Cell  L60)   • Emails         3.8798%       16.62  minutes  per  day   • Comp  Time       2.9760%     14.28  minutes  “   • Phone  Calls/Response   2.6442%     12.69  minutes  “   • Trouble  Shooting     1.9712%        9.46  minutes  “   • Planning  Outreach     1.7312%        8.31  minutes”   • Directors/Staff  Meetings   1.4423%        6.92  minutes  “   • Veterans  Council  Meetings   1.4423%        6.92  minutes  “   • RO  Conference  Calls     1.2500%        6.00  minutes  “   • Supervise  Clinical  Staff   1.1541%        5.54  minutes  “     • Homeless  Stand  Downs   0.7692%        3.69  minutes  “   • Monitor  RCS-­‐Net  Reports   0.7596%        3.65  minutes  “   • Walk-­‐Ins  to  Center     0.6731%        3.23  minutes  “   • Lease  Status  Calls       0.5769%        2.77  minutes  “   • Running  Balance/SOA   0.5769%        2.77  minutes  “   • COTR  Conf  Calls     0.5769%        2.77  minutes  “     Total  TL  Draws  from  available  Capacity  in  a  Work  Day  is  131.55  minutes  per   workday     Conclusions  from  the  above  calculations  illustrate  the  Team  Leaders  clinical   capacity  across  one  workday.    Evenly  spread  across  the  260  workdays  per  year  and   40  hours  per  week  with  8  hours  per  day,  our  research  reveals  the  following:     Remember,  the  smaller  draws  are  not  included  in  the  chart  below;  therefore,  the   numbers  will  not  match  exactly  with  the  calculations  on  the  spreadsheet.         National  Working  Group:  Clinical  Capacity  Assessment  February  2015   8   Team  Leader  Daily  Capacity   2.77  Lease  Status   2.77  Fiscal/Running   3.65  Monitor   Calls   Bal  and  SOA   RCS  Net  Reports   2.77  COTR  Conf  Calls   3.23  Walk  Ins   3.69  Homeless  Std   Downs   5.54  Supv     Clinical   Staff   6    RO  Conf  Calls     TL  CAPACITY   2.81  Hours/   Workday     6.92  Vet  Council  Mtg   42.69  Minutes  per   Workday  Float  Time   6.92  Directors  Staff     Mtgs   25.93  Min  All  Other   Draws  (See   Spreadsheet)   8.31  Planning   Outreach   9.46  Trouble   Shooting   12.69  Phone  Calls   14.28  Comp   Time   16.62  Min   Emails     Referring  back  to  spreadsheet,  Hours  available  per  workweek  for  Team  Leaders  to   provide  Clinical  Services  is  14.07  hours  See  Cell  (I-­‐116)     Hours  available  per  workday  for  Team  Leaders  to  provide  Clinical  Services  is  2.81   hours  see  Cell  (K-­‐116)     Almost  complete,  but  one  critical  element  must  be  addressed.    The  fact  of  Clinical   Staff  and  Team  Leaders  donating  their  undocumented  and  untraceable  personal   time  to  the  program  and  veterans  that  creates  a    “False  Capacity.”    In  other  words,   the  Capacity  Constraints  are  clearly  defined  by  time  and  are  indeed  FIXED.    (365.25   days,  12  Months,  52  Weeks,  260  Work  Days  and  2080  Work  Hours)    We  have   previously  discussed  the  lack  of  data  integrity  and  the  negative  impact  of   authorizing  “Compensation  Time.”    A  quick  review  reminds  us  that  compensation   time  ultimately  places  the  burden  onto  the  veteran  or  customer.      Now,  we  must   look  at  the  effects  of  this  “False  Capacity”  (resulting  from  donated  time)  as  it  can  and   does  have  a  vast  impact  upon  Capacity.  This  issue  of  donated  time  cannot  easily  be   tracked  across  our  existing  RCS-­‐NET  database.    It  has  been  either  inaccurately   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   9     reported  or  completely  unreported  by  both  Counselors  and  Team  Leaders  and  on   occasion,  guided  by  the  Regional  Management.     To  illustrate  the  effects  of  this  phenomenon,  the  Midland  Vet  Center  tracked  these   hours  and  our  spreadsheet  allows  for  this  on  TAB  1  “Capacity  Breakdown”  Line  107.     An  explanation  can  be  found  in  Cell  D107.    When  we  include  these  seemingly   insignificant  35  hours  of  donated  time  over  a  brief  4-­‐month  period,  the  effects  are   surprising.    This  donation  over  4  months  would  equal  105  hours  over  one  year.    The   instructions  provided  on  the  spreadsheet,  requests  that  we  enter  these  as  a   NEGATIVE  number  because  the  formulae  are  designed  to  subtract.    Simply  entering   as  a  negative  35  hours  will  illustrate  the  cause  and  effect  of  ADDING  FALSE   CAPACITY.    This  field  can  be  loaded  with  projected  data  (negative)  to  illustrate  the   significance  of  DONATED  TIME.    We  urge  the  reader  to  fill  this  cell  with  105  to   illustrate  the  effects  spread  over  one  year.    In  our  analysis  we  used  “Real  Data”  and   therefore  included  the  negative  35  hours  to  measure  the  affect  on  “real”  capacity  for   Team  Leaders,  which  was  identified  earlier  as  being:     14.07  Hours  Per  Work  Week  Capacity    (Cell  I  116)   2.81  Hours  Per  Work  Day  Capacity  (Cell  K  116)     Now  if  we  remove  those  -­‐35  hours  in  Cell  D-­‐107  our  available  capacity  is  reduced  to:     13.39  Hours  Per  Work  Week  Capacity   2.68  Hours  Per  Work  Day  Capacity     Removal  of  this  negative  35  hours  results  in  a  capacity  decrease,  because  it  was   added  value  (capacity)  that  frequently  never  gets  captured  or  measured.  At  first   glance,  these  numbers  may  seem  insignificant  but  with  further  scrutiny  reveals  this   .68  (From  above  2.68  and  using  only  the  difference  from  2.82  and  2.68)  hours  or   40.8  minutes  per  workweek  becomes  significant.    When  viewed  across  a  workday   we  see  the  decrease  went  from  2.81  hours  down  to  2.68  hours  for  a  difference  of  .13   hours  or  7.8  minutes  across  every  single  workday  in  the  year.    Recall  if  you  will;   these  35  documented  hours  were  donated  by  one  staff  member  from  Oct  13  thru  Jan   14…  only  four  months,  and  yet  it  clearly  demonstrates  a  significant  impact  on  Actual   Capacity.    The  impact  of  this  is  certainly  positive  for  the  Agency  but  eventually  has   catastrophic  effects  on  the  staff  member.    It  creates  the  illusion  of  capacity  that   never  existed,  but  surfaced  from  employee  donations.    When  or  if,  you  multiple  this   35  donated  hours  over  4  months  by  3  to  get  an  annual  view,  you  would  end  up  with   105  hours  of  false  capacity  and  hours  worked  but  not  logged  or  counted,  and   thereby  distorting  our  real  capacity.    Calculated  out  this  represents  23.4  minutes   per  day  across  an  entire  year…given  to  the  program.    This  value  exceeds  all  other   significant  draws  in  this  report  with  the  single  exception  of  the  sum  of  “All  Other   Draws”  of  25.93  minutes  (See  Chart  Above).       This  data  and  charts  will  hopefully  demonstrate  that  many  of  our  Vet  Centers  have   exceeded  their  real  capacity  and  have  survived  only  due  to  the  significant   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   10   contributions  of  the  Clinical  Staff.    We  pray,  this  is  presented  without  bias  and  can   be  further  challenged  by  professional  capacity  planners/consultants.  We   recommend  this  practice  of  allowing  employees  to  donate  personal  time  to  create   unavailable  capacity  for  the  Agency,  be  stopped.    This  most  assuredly  leads  to   burnout  and  turnover  rates,  which  is  very  costly  to  the  Agency.     CONSIDERATIONS  AND  RECCOMENDATIONS  OF  THIS  WORKING  GROUP     The  working  group  would  like  to  acknowledge  many  years  of  success  with  the  “Top-­‐ Down”  approach  that  resulted  in  the  long  standing  50%  activity  time  standard.    Our   research  confirms  both  the  efficacy  and  accuracy  of  that  standard.    It  worked  when   the  program  was  young  and  has  continued  to  work  as  we  have  grown.    We  are  now   at  a  turning  point  due  to  growth  and  demands  for  both  clinical  and  non-­‐clinical  time.     We  are  grateful  for  the  growth  in  the  program  as  well  as  the  opportunity  to  present   our  working  group  findings  to  Central  Office.       Moving  forward,  we  recommend  a  “Bottom-­‐Up”  approach  for  identifying  actual  or   real  capacity  in  order  to  meet  current  and  future  demands.  The  historical  Top-­‐Down   (Central  Office  to  RO  to  Vet  Center)  will  no  longer  provide  adequate  outcomes  due   to  the  many  variances  and  programmatic  problems  discovered  by  this  group.    We   consider  any  attempt  to  accurately  identify  capacity  from  the  top  would  be  futile   and  ultimately  destructive  to  the  program.    Furthermore,  the  lack  of  existing  valid   data  can  be  better  managed  at  the  Central  Office  level,  yet  the  capacity  planning  can   be  better  managed  with  a  “Bottom-­‐Up”  approach  based  on  our  findings.    A  Vet   Center  Team  Leader  can  use  the  “rough”  methods  contained  in  our  spreadsheet   however;  we  believe  a  professional  tool  would  be  most  helpful  as  some  Team   Leaders  are  not  spreadsheet  friendly.    With  our  current  National  budget,  we  would   request  hiring  a  consulting  firm  to  verify,  formalize  and  enhance  our  findings.    Team   Leaders  can  use  their  own  data  to  identify  their  Vet  Center  Capacity  and  seek   approval  and  over-­‐site  from  the  Regional  Office.    Once  approved  at  the  Regional   level,  a  tertiary  review  can  be  done  in  Washington.    It  is  abundantly  clear  and   supported  by  the  team  conclusions,  that  a  “Bottom-­‐Up”  approach  is  needed  to  move   RCS  forward  now  and  in  the  21st  Century.     CLINICAL  STAFF  SUPERVISION:    We  recommend  a  clarification  to  the  existing  RCS   Policy  Manual  1500.02  to  quantify  and  clarify  expectations  for  supervision.    The   ambiguity  must  be  eliminated  to  resolve  this  significant  capacity  draw.    Improved   communications  alone,  could  resolve  this  issue  without  the  need  to  modify  existing   policy.     DATA  INTEGRITY:    We  propose  or  recommend  Central  Office  standardize  across  all   regions,  a  data  integrity  policy.    Consider  creating  a  full  time  position,  to  improve   communication  and  ensure,  consistent  data  entry  and  data  integrity.    This  data  must   be  accurate  for  harvest  at  the  local,  regional  and  national  levels.    The  importance  of   this  single  issue  is  further  illustrated  below.     National  Working  Group:  Clinical  Capacity  Assessment  February  2015   11   COMPENSATION  TIME,  DONATED  TIME  AND  OVERTIME:    For  Readjustment   Counseling  Service,  we  recommend  the  burden  resulting  from  these  variable  costs   be  appropriately  returned  to  the  agency.    The  future  use  of  overtime  is  both   authorized  and  necessary,  while  eliminating  the  negative  impact  of  compensation   time  on  both,  our  clinical  capacity  and  ultimately,  our  combat  veterans.    Once  any   requested  and  pre-­‐approved  overtime  is  captured  and  analyzed,  it  can  be  used  for   critical  management  decisions  such  as  spotting  increased  demands,  indicating  a   need  for  more  FTE’s  at  specific  locations.    Any  signs  of  developing  overtime  patterns   could  be  addressed  quickly  by  Central  or  Regional  Offices  to  determine  if  alternative   methods  exist,  for  meeting  local  client  demand.    Ultimately,  the  Team  Leader  will   know  of  any  patterns  as  they  develop.    It  is  fundamentally  clear  that  such  a   recommendation  might  create  fear  of  abuse,  as  is  often  the  case  with  overtime.    In   defense  of  that  unrealistic  fear,  is  the  demonstrated  commitment  by  longer-­‐term   RCS  counselors  and  Team  Leaders.    Their  proven  commitment  alone  should  serve  to   soften  those  fears  for  overtime  abuse.    We  remain  committed  to  our  mission  but  can   no-­‐longer  shoulder  these  burdens  alone.    We  suggest  a  review  of  the  employee   satisfaction  survey  to  see  if  RCS  employees  are  satisfied  with  their  pay.    We  believe   such  a  review  would  reveal  the  fact  that  employee  income;  is  not  the  real  issue,  but   is  growing  in  strength.    We  hope  the  reader  will  recognize  that  clinicians  stay  with   RCS  because  they  believe  in  the  mission.    A  few  clinicians  leave  RCS  for  the  larger   VA,  and  are  immediately  promoted  to  the  GS-­‐12  level  without  being  a  supervisor.       Comparatively,  RCS  pay  is  capped  at  the  GS-­‐11  grade  for  equally  credentialed   counselors.    Those  clinicians  who  leave  are  less  committed  to  the  mission  and  more   focused  on  personal  income  growth.    The  professional  staff  across  RCS  has  proven   their  dedication  to  serving  our  combat  veterans  and  has  borne  the  burden  for  many   years.    We  believe,  we  have  reached  a  critical-­‐mass,  whereby  counselors  and  Team   Leaders  are  being  stretched  too  far.    Once  this  tipping  point  is  reached,  it  will  have   catastrophic  effects  on  RCS  as  a  whole  and  most  importantly  on  our  combat   veterans.    No  one  wants  this  to  come  to  fruition  and  thus  far,  the  professional   employees  of  RCS  have  single  handedly  avoided  this  outcome  for  the  veteran,  on   behalf  of  the  Agency.    We  pray  the  reader  recognize  these  facts  and  implement  a   solution,  before  we  reach  the  cliff.           POLICY  EFFECTS  ON  CAPACITY:    We  recommend  that  RCS  continue  as  it  has   historically  and  until  recently,  to  adhere  to  the  RCS  Policy  Manual  1500.2.    We  have   recognized  a  pattern  that  has  a  direct  or  indirect  impact  on  Capacity.    Non-­‐ adherence  to  existing  RCS  Policy  on  the  part  of  leadership  creates  fear  and   uncertainty  among  the  frontline  staff.    We  submit  two  policy  examples  that  affect   capacity  in  support  of  this  recommendation:   1. Annual  Training  for  Staff:    Policy  indicates  that  RCS  “must”  provide  staff  with   annual  training…    This  affects  capacity  planning  and  has  been  omitted  in  our   conclusions  and  calculations  herein.    Much  like  OPM  policies  must  be   included,  we  believe  RCS  policy  should  also  be  included.    Since  the  team  has   no  knowledge  and  little  hope  that  annual  training  will  be  returned;  we  chose   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   12   to  omit  it  in  our  analysis.    We  have  included  2.5  days  per  year  for  clinicians  to   take  off,  to  obtain  required  CEU’s.    These  2.5  days  is  50%  of  the  five-­‐day   annual  training  draw  that  is  NOT  included  in  this  report  but  clearly  would   provide  great  benefit  to  staff  and  ultimately  our  combat  veterans.   2. Vet  Center  HOURS  of  Operation:    Current  policy  indicates    (7)  “Upon  request   from  Veterans,  Vet  Centers  will  maintain  non-­‐traditional  appointment   schedules,  after  normal  business  hours  during  the  week  and  on  weekends,  to   accommodate  working  Veterans  and  family  members.”    We  ask  as  a  group;   “When  did  this  change”?    Vet  Centers  are  in  process  of  being  expected  to   work  specific  hours  after  the  normal  TOD  and  on  Saturdays.    This  “Top-­‐ Down”  approach  creates  further  fear  and  confusion  as  it  not  only  contradicts   existing  policy,  but  also  serves  to  tacitly  refer  to  the  presumed  incompetence   of  Team  Leaders.    We  have  always  accommodated  client  demands  for  both,   after  hours  and  weekends.    If  a  few  Team  Leaders  have  failed  in  this   objective,  please  consider  removing  them  from  their  position.    This  decision   appears  on  the  surface  to  be  based  on  a  need  to  have  “talking  points”  rather   than  on  actual  veteran  needs.    Furthermore,  we  believe  our  recommendation   to  shift  to  a  “Bottom-­‐Up”  Capacity  planning  approach  would  also  result  in   better  staff  utilization  across  the  program.    We  as  a  working  group  have  no   idea  where  or  who  has  determined  that  our  capacity  can  be  so  easily   stretched  with  no  concerns  for  the  affects  on  RCS  staff.    We  want  to   emphasize  that  our  objective  is  not  one  of  complaint  or  resistance  but  one  of   rational  acknowledgment  of  a  fluctuating  demand  that  can  best  be  identified   at  ground  zero.    There  was  great  debate  whether  this  should  be  included   herein  and  it  was  decided  we  should  include  it  simply,  because  it  impacts   capacity  and  therefore  falls  within  our  assigned  purview.       SUMMARY:  A  NEW  SET  OF  LENSES     We  believe  the  efforts  of  this  working  group  can  be  considered  a  success  IF,  the   reader  is  able  to  walk  away  with  a  “New  Set  of  Lenses”  from  which  to  view  the   output  of  our  Vet  Center  teams.    If  no  single  recommendation  we  have  proposed  is   accepted  and  absolutely  nothing  changes  moving  forward;  the  front  line  workers   will  collectively  know,  that  we  gave  our  best.    Our  present  staff  and  those  who   served  before  us  have  sacrificed  for  the  survival  and  success  of  RCS.    To  illustrate   this  new  insight  or  perspective  let  us  look  at  the  output  measurements  anew  and  as   follows:     COUNSELORS:  (Current  Standard)  50%  Direct  Service  Time   50%  Direct  Service  Time  requires  20  clinical  hours  to  include  travel,   individual  and  groups  per  week.    20  hours  of  clinical  output  across  40   available  hours  per  week.    Now  we  know  from  the  results  of  this  working   group  that  one  counselor  has  only  24.52  hours  of  real  capacity  across  the   week.    Therefore,  if  the  counselor’s  clinical  output  is  equal  to  20  hours  per   week,  this  would  meet  the  historic  expectation  of  50%  Direct  Service  Time.     National  Working  Group:  Clinical  Capacity  Assessment  February  2015   13   This  translates  to  a  production  output  efficiency  rating  of  81.56%    (20  of   24.52).    This  has  always  been  the  minimum  acceptable  output  rate  when   compared  to  the  historic  50%  standard  of  measurement.    Now  let  us  look   with  renewed  clarity,  at  the  recent  expectation  to  obtain  a  60%  direct  service   time.       60%  Direct  Service  Time  requires  24  clinical  hours  to  include  travel,   individual  and  groups  per  week.    24  hours  of  clinical  output  across  40   available  hours  per  week.    Now  we  know  from  the  results  of  this  working   group  that  one  counselor  has  only  24.52  hours  of  real  capacity  across  the   week.    Therefore,  if  the  counselor’s  clinical  output  equals  24  hours  per  week,   this  would  meet  the  2012  adjusted  expectation  of  60%  Direct  Service  Time   however;    this  translates  to  a  production  output  efficiency  rating  of   97.87%  (24  of  24.52).    This  is  unsustainable  over  time  and  will  lead  to   burnout.           TEAM  LEADERS:  (Current  Standard)  25%  Direct  Service  Time   50%  Direct  Service  Time  (Historically)  required  20  clinical  hours/travel,   individual  or  groups  per  week  in  addition  to  meeting  other  Team  Leader   duties.    20  hours  of  clinical  output  across  40  available  hours  per  week.    Now   we  know  from  the  results  of  this  working  group  that  one  Team  Leader  has   only  14.7  hours  of  real  capacity  across  the  week.    This  clearly  shows  the   Team  Leader  capacity  was  exceeded  when  50%  was  the  norm.    This  now   translates  to  a  production  output  efficiency  rating  of  136.05%  because   the  maximum  capacity  is  only  14.7  hours.  Fortunately,  this  was  recognized  in   or  around  2012  and  the  expectation  for  Team  Leaders  was  informally   reduced  to  25%  Direct  Service  time.    Using  this  2012  expectation  we  can   draw  the  following  conclusion.    When  the  Team  Leader  produces  10  hours  of   clinical  output  (10  of  40  =  25%)  across  a  workweek  the  minimum  goal  has   been  met.    This  results  in  an  efficiency  rating  of  68.02%  or  (10  of  14.7)   Caution  is  called  for  here,  as  the  reader’s  first  impression  when  reading   68.02%  efficiency  could  easily  lead  to  a  first  impression;  this  is  under-­‐ performance.    To  clarify  the  small  range  involved  in  this  Team  Leader   capacity  (10  of  14.7)  let  us  note  that  only  4.7  hours  per  week  or  56  minutes   per  day,  remains  available  to  the  Team  Leader.    To  illustrate:               1  more  hour  of  clinical  work  in  a  workweek  =      74.82%  Efficiency   2  more  hours  of  clinical  work  in  a  workweek  =  81.63%  Efficiency   3  more  hours  of  clinical  work  in  a  workweek  =  88.43%  Efficiency   4  more  hours  of  clinical  work  in  a  workweek  =  95.24%  Efficiency   5  more  hours  exceeds  capacity  in  a  workweek=102%  Efficiency     NEW  PERSPECTIVE:  New  Standard  Recommendations  from  this  working  group     Team  Leader  weekly  capacity  is  14.7  hours  or  rounded  up  to  15  hours   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   14   Counselor  weekly  capacity  is  24.52  hours  or  rounded  up  to  25  hours         Lowest  Common  Denominator  is  75   Team  Leader  equals  10/15  or  50/75  for  an  efficiency  rating  of  66.66%  that   aligns  with  existing  expectation  of  25%  of  40  hour  workweek.    (Existing   Standard)  66.66%  Efficient   Counselor  equals  20/25  or  60/75  for  an  efficiency  rating  of  80%  that  aligns   with  existing  expectation  of  50%  of  40-­‐hour  workweek.  (Existing  Current   Standard)  80%  Efficient     To  balance  the  demand  for  Counselors  and  Team  Leaders,  we  recommend   reducing  Counselor  current  expectations  by  two  visits  from  20  to  18  clinical   hours  per  workweek.    This  would  result  in  18/25  or  54/75  for  a  balanced   efficiency  rating  of  72%  minimum  efficiency.  (More  realistic  than  current   80%  expectation)    Additionally  adding  one  visit  hour  to  Team  Leader  output   from  10  to  11  would  result  in  11/15  or  55/75  for  a  balanced  efficiency  rating   of  73.33%.  (Balanced  across  positions)    This  difference  between  the  two   can  be  accounted  for  by  the  rounding  up  from  14.7  to  15  for  Team  Leader   Capacity  as  well  as  the  rounding  up  from  24.52  to  25  for  Counselors.     Outcome:     Team  Leader  Standards  should  change  to  an  expected  clinical  output  of  11   visits  (clinical  hours)  per  workweek  and  Counselors  Standards  should  be   decreased  to  18  visits  (clinical  hours)  per  workweek  based  on  current   data  and  capacity  calculations.     Note:    When  looking  at  maximum  capacity  for  both  positions,  ONLY  3.7  hours   (float)    (14.7  minus  11)  of  remaining  capacity  exists  for  a  TL  across  any   workweek  and  ONLY  6.62  hours  (float)  (24.52  minus  18)  of  remaining   capacity  exists  for  Counselors  across  any  given  workweek.    Additional  output   from  these  capacities  would  look  like  this:     Team  Leaders:               (FLOAT)     12/15  or  60/75  would  result  in  an  efficiency  rating  of    80.0%   13/15  or  65/75  would  result  in  an  efficiency  rating  of  86.7%     14/15  or  70/75  would  result  in  an  efficiency  rating  of  93.3%     15/15  or  75/75  would  result  in  an  efficiency  rating  of  100%     3  Hours   2  Hours   1  Hours   Max  Cap   Counselors:                 19/25  or  57/75  would  result  in  an  efficiency  rating  of  79.2%   20/25  or  60/75  would  result  in  an  efficiency  rating  of  83.3%   21/25  or  63/75  would  result  in  an  efficiency  rating  of  87.5%   22/25  or  66/75  would  result  in  an  efficiency  rating  of  91.6%   23/25  or  69/75  would  result  in  an  efficiency  rating  of  95.8%   6  Hours   5  Hours   4  Hours   3  Hours   2  Hours   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   15   24/25  or  72/75  would  result  in  an  efficiency  rating  of  96.0%   25/25  or  75/75  would  result  in  an  efficiency  rating  of  100%   1  Hour   Max  Cap       The  above  referenced  “Float”  in  hours  per  week  is  the  bucket  we  must  pull   from  to  accommodate  all  other  non-­‐clinical  demands  not  accounted  for  in   this  report  such  as  Outreach  Events  (not  planning  them),  PDHRA  events,   Yellow  Ribbon  Events,  National  VA2VETS  events,  disaster  response  etc.     Across  any  given  work  week  these  additional  demands  must  come  from  the   6.62  hour/week  bucket  for  Counselors  and  3.7  hour/week  bucket  Team   Leaders.    As  evidenced  by  our  findings,  our  remaining  (float)  capacity  for  all   of  these  demands  remain  extremely  limited.      When  viewed  by  workday,   counselors  have  79.4  minutes  daily  float  and  Team  Leaders  have  44.4   minutes  float  time  per  workday.     KNOWN  PROBLEMS  AND  AREAS  FOR  IMPROVEMENT:     This  data  represents  a  single  Vet  Center  due  to  the  drastic  range  of  variables   across  RCS  Vet  Centers  and  time  constraints  of  this  working  group.    This  does   not  represent  a  sufficient  sample  size;  therefore,  it  is  suggested  that  a  larger   sample  of  Vet  Centers  be  encouraged  to  submit  their  own  unique  data  to   Central  Office  for  a  better  reflection  of  the  uniqueness  of  each  and  every  Vet   Center.    The  spreadsheet  used  in  this  report  is  readily  available  for  such   purpose.       All  variables  are  not  captured  in  this  report,  such  as  time  spent  dealing  with   staff  problems  and  HR,  MST  counselors  and  LMFT  counselors  who  must   attend  weekly  or  monthly  conference  calls.    Several  such  omitted  draws  can   be  identified  by  a  larger  cross-­‐section  of  Vet  Centers.       EXECUTIVE  SUMMARY:       This  working  group  held  the  first  conference  call  on  January  6,  2015  to  define   the  objectives  and  tasks  for  the  group.      We  held  five  weekly  conference  calls   lasting  one  hour  each  thereafter,  beginning  January  16th  and  ending  February   13,  2015.    Additional  information  exchange  via  phone,  email  and  fax  were   frequently  shared.    In  hindsight,  we  should  have  utilized  our  Tandberg   system  for  those  five  conferences,  as  most  members  have  never  met  in   person.    We  want  to  emphasis,  the  majority  of  work  was  completed  after   work  hours  and  primarily  on  weekends.    We  volunteered  to  participate  and   therefore  eagerly  donated  our  personal  time  to  this  endeavor.     We  began  with  a  policy  review  of  RCS  1500.02,  which  revealed  only  one   reference  to  Capacity  and  that  reference  emphasized  our  historical   adherence  to  “Veteran  Centric  Care.”    We  then  agreed  to  be  guided  in  our   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   16   efforts  by  the  VA-­‐RCS  Core  Values  and  Principles  of  Integrity,  Commitment,   Advocacy,  Respect  and  Excellence!    We  further  agreed  to  submit  a  report   designed  to  communicate  rather  than  impress;  so  we  adopted  the  “Plain   Writing  Act:  Public  Law  111-­‐274  from  the  111th  Congress.     Our  findings  revealed  many  systemic  failures  across  the  program  and  at  all   levels  from  Central  Office,  Regional  Offices  and  Vet  Centers.    Each  of  these   misfortunes  has  tremendous  impact  on  clinical  capacity.    Of  these,  we   identified  the  key  problems:  (1)  Policy  and  it’s  wide-­‐ranging  Interpretation;   (2)  Ineffective  and  conflicting  Communication  across  Regions;  and  a  most   significant  failure  was  found  across  our  (3)  data  entry,  collection  and   validation  process  or  lack  thereof.    A  systemic  failure  to  monitor  data  entry,   data  verification  and  data  analysis  was  discovered  to  be  paramount.    This  is  a   systemic  failure  and  not  isolated  to  RCS-­‐Net  design,  but  shared  more  by   Central  Office,  Regional  Offices  and  Vet  Centers  specifically.     Our  analysis  of  all  components  that  influence  capacity  within  RCS  began  with   our  long-­‐standing  goal  for  clinicians  and  Team  Leaders  to  maintain  50%  total   activity  time.    Our  detailed  analysis  validated  the  efficacy  and  accuracy  of  this   standard.    We  were  able  to  fine-­‐tune  the  existing  standard  to  a  more  precise   level.    As  our  program  has  grown  over  the  years,  so  too  have  our   shortcomings.    These  historic  and  new  influences  are  now  having  significant   negative  impacts  across  the  program.     The  group  identified  both  internal  and  external  sources  that  pull  from  our   maximum  clinical  capacity  and  we  refer  to  that  as  “draw.”    We  agreed  to  first   focus  on  one  clinician  or  licensed  counselor.    We  then  agreed  that  the   identified  counselor  capacity  would  be  the  “starting”  place  for  calculating   team  leader  capacity.    The  rationale  is  that  most  if  not  all,  team  leaders  are   also  licensed  counselors  and  therefore  are  subject  to  the  same  internal  and   external  draws  as  all  counselors.         Throughout  this  report,  we  frequently  reference  the  long-­‐standing  50%  total   activity  time  that  included  outreach,  education,  consultation,  and  COTR.   (Managing  clinical  contractors)    We  also  occasionally  reference  how  that   standard  has  evolved  over  the  past  few  years.    First,  it  was  modified  from   50%  TOTAL  to  50%  DIRECT  meaning  time  spent  in  outreach,  education  and   consultation  were  removed.    It  is  assumed,  the  standard  evolved  from  “total   to  direct”  because  of  a  misconception  on  some  level,  that  the  remaining  50%   or  twenty  hours  per  week,  was  untapped.    This  report  demonstrates  this  was   never  the  case.     A  major  discovery  is  the  significant  impact  on  capacity  that  “Compensation   Time”  has  had.    While  it  appears  to  be  a  flexible  means  of  addressing  demand,   the  use  of  such,  reduces  real  capacity  over  time.    An  equally  important  issue   is  the  apparent  desire  of  RCS  management  to  avoid  the  use  of  overtime  to   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   17   meet  temporary  excess  demands.    Our  research  reveals  that  overtime  would   not  only  improve  data  integrity,  but  also  our  ability  to  capture  real  program   costs  for  budget  planning.    The  use  of  overtime  would  also  prevent  employee   burnout.     Our  review  at  the  ground  level  of  RCS  (Vet  Centers)  exposed  a  major   unintended  consequence  of  the  long-­‐standing  measurement  of  50%  activity   time.    This  unintended  consequence  has  resulted  in  devoted  clinical  staff   donating  their  personal  time  toward  our  Veteran  Centric  Mission.    Some   forms  of  these  donated  hours  have  been  captured  by  RCS-­‐Net  however;  most   have  not.    The  reasons  for  not  capturing  these  hours  are  many;  such  as  (1)   hours  never  reported  by  staff,    (2)  efforts  to  manipulate  activity  time  by  staff,   (3)  motives  to  distort  and  improve  reported  activity  time  by  Regional  Offices,   (4)  the  systemic  failure  to  measure  the  use  and  impact  of  compensation  time,   and  finally;  what  the  working  group  identified  as  the  single  most  important   and  intended  consequence  demonstrated  daily  by  RCS  staff  as  follows:   (5)  Integrity  “…highest  professional  standards…”  of  RCS  staff;  Commitment   “…diligently  serving  veterans…an  earnest  belief  in  VA’s  mission  and   fulfillment  of  my  individual  responsibilities  and  organizational   responsibilities”  by  RCS  staff;  Advocacy  “…being  truly  Veteran  Centric  and   advancing  the  interest  of  Veterans…”    by  RCS  staff;  Respect    “What  other   explanation  exists  for  RCS  client  satisfaction”  than  Vet  Center  staff;  and   finally,  Excellence  “striving  for  the  highest  quality  and  continuous   improvement…being  thoughtful  and  decisive  in  leadership,  accountable  for   my  actions,  willing  to  admit  mistakes  and  rigorous  in  correcting  them.”               ADDENDUM:     We  requested  by  did  not  receive,  data  on  the  number  of  requested  and  or   approved  hours  for  compensation  time  Nationwide.    We  did  however;   receive  last  minute  delivery  of  data  requested  from  RCS-­‐Net;  we  add  the   following  brief  analysis  of  Region  3B  data  in  support  of  our  summary.    The   data  received,  was  precisely  as  requested.    Several  hours  of  data  correction   and  analysis  was  needed  to  eliminate  incongruities.    The  data  set  covered   Region  3B  for  FY  2014.    Hours  captured  for  Outreach,  Outreach  Workers,   MVC  drivers,  temporary  staff,  office  managers  etc.  were  removed.    The  focus   of  the  data  was  limited  to  (1)  Readjustment  Counselors  (2)  Team  Leaders  (3)   MST  Counselors  and  (4)  LMFT  Counselors…all  clinical  staff  ONLY.    The  data   included  all  working  activity  performed  daily  and  entered  into  RCS  Net  for   every  day  in  FY  2014.    It  consisted  of  over  34,000  rows  of  data.    It  was  broken   down  by  Vet  Center,  Position,  Staff  Name,  Hours  Logged  as  Worked,  Hours   for  Individual  sessions,  Hours  for  Group  sessions,  Hours  for  family  sessions   and  the  sum  of  those  last  three  for  a  field  called  Total  Hours  worked.         National  Working  Group:  Clinical  Capacity  Assessment  February  2015   18                 In  support  of  the  group’s  conclusions  that  we  have  a  systemic  data  integrity   problem,  the  following  was  revealed  in  the  eleventh  hour  data  set.   • From  34,000  plus  daily  entries  of  Hours  worked,  over  1700  were   blank  even  though  work  time  had  been  allocated  for  those  days.   • Outreach  was  originally  included  and  only  distorted  the  real  focus.   • Specific  Vet  Centers  are  donating  more  hours  and  some  Vet  Centers   donate  zero  hours.    Donated  hours  are  revealed  when  the  sum  of  total   output  across  a  day  is  greater  than  the  hours  entered  as  worked.   • Specific  staff  members  are  clearly  giving  of  themselves  to  the  point   they  will  burnout.   • Vet  Centers  that  were  added  to  RCS  from  a  previous  realignment   never  donated  time  in  FY  14.    The  unique  number  of  Vet  Centers  in  3B   that  are  outside  of  the  normal  0700  series  identified  this.     • 55  Clinical  staff  donated  one  hour  or  less  over  FY  14   • 24  Clinical  staff  donated  over  one  week  in  FY  14   • 7  Clinical  staff  donated  over  two  weeks  or  80  hours  in  FY  14   • 2  Clinical  staff  donated  over  three  weeks  or  120  hours  in  FY  14   • 10  Vet  Centers  donated  over  100  hours  in  FY  14   • 3  Vet  Centers  donated  over  200  hours  with  the  highest  being  290.8   hours   • 9  Vet  Centers  in  Region  3B  made  zero  donations  in  FY  14     The  quick  review  of  the  corrected  RCS  Region  3B  data  for  FY  14  revealed  the   following  facts:         3052   Extra  work  hours  were  donated     381.5      Extra  workdays     76.3   Extra  workweeks     6.36   Extra  months   1.47   Extra  work  years  for  one  person       It  would  require  1.47  Full  Time  employees  working  2080  hours  at   100%  Efficiency  without  missing  days  to  replace  donated  time.     $117,318.88  is  the  added  value  of  these  donations  to  Region  3B.    If   paid  at  the  minimum  overtime  rate  of  GS-­‐10  Step  1  at  1.5  or  $25.62   times  1.5  would  equal  an  overtime  rate  of  $38.44  per  hour  which  is   usually  less  than  the  regular  hourly  rate  of  clinicians  in  RCS.     Clinicians  get  the  higher  of  the  two  rates.   Now,  let’s  look  on  the  National  level  by  simply  multiplying  the  numbers   above  by  7.       21,364    Extra  work  hours  are  projected  to  have  been  donated          2,670  Extra  workdays   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   19           534    Extra  workweeks   44.5    Extra  months   10.27    Extra  Work  Years  for  one  person   It  would  require  10.27  Full  Time  employees  working  2080  hours  at   100%  Efficiency  without  missing  days  to  replace  donated  time.     $821,232.16  is  the  added  value  of  these  donations  on  a  National  level  and  if   paid  at  the  minimum  overtime  rate  of  GS-­‐10  Step  1  multiplied  by  1.5  or   $25.62  times  1.5  or  $38.44  per  hour  which  is  usually  less  than  the  regular   hourly  rate  of  clinicians  in  RCS.    Clinicians  get  the  higher  of  the  two  rates.       We  would  like  to  thank  Michael  Fisher  from  Central  Office,  Don  Smith,  Acting  Chief   RCS  and  each  and  every  Regional  Manager  for  allowing  us  the  opportunity  to   participate  on  this  working  group.    In  addition,  special  thanks  to  the  RCS-­‐NET  team   who  provided  us  with  much  needed  data.           Respectfully  Submitted,     /S/    Stan  Gajda       Team  Leader     Springfield,  MA     Region  1A     /S/    Joanne  Boyle     Counselor   Baltimore,  MD     Region  1A     /S/    Samantha  Blevins   Team  Leader   Morgantown,  WV   Region  1B     /S/    Jerome  Tomlain   Counselor   Lexington,  KY     Region  1B     /S/    Paul  Greene     Team  Leader   Evansville,  IN     Region  2     /S/    Tamara  Brown   Counselor   Fort  Wayne,  IN   Region  2     /S/    Patrick  Murphy   Team  Leader   Miami,  FL     Region  3A     /S/    Rita  (Diane)  Lee   Counselor   Fayetteville,  NC   Region  3A     /S/    Kent  Knight     Team  Leader   Midland,  TX     Region  3B     /S/    Van  Hall       Counselor   Little  Rock,  AR     Region  3B     /S/    Rodney  Haug     Team  Leader   Fort  Collins,  CO   Region  4A     /S/    Meaghan  Lee     Counselor   Missoula,  MT     Region  4A     /S/    Ken  Dube     Team  Leader   Eugen,  OR     Region  4B     /S/    Austin  Wampler   Counselor   San  Bernardino,  CA   Region  4B                   National  Working  Group:  Clinical  Capacity  Assessment  February  2015   20                             National  Working  Group:  Clinical  Capacity  Assessment  February  2015   21