Monetizing Civility in the
U.S. Department of Veterans Affairs
Presented by: Cynthia Cominsky, MEd MBA2
Kelley A. Carameli, DrPH1, Andrew B. Brown2, Stacie Furst-Holloway, PhD MBA2,
Cynthia Cominsky, MEd MBA2, Scott C. Moore, PhD1, Adam C. Carle, PhD3,
Steven R. Howe, PhD2, Katerine Osatuke, PhD1, & Sue R. Dyrenforth, PhD1
1 Veterans Health Administration (VHA), National Center for Organization Development (NCOD)
2 University of Cincinnati, McMicken College of Arts & Sciences, Department of Psychology
3 University of Cincinnati, School of Medicine and Cincinnati Children's Hospital Medical Center
Background
Workplace Civility
 Civility: A workplace issue characterized by coworkers’ personal interest
in and respect for each other, their cooperation and teamwork, fair
resolution of disputes and complaints, and valuing individual difference.
 Civility in the healthcare environment predicts organizational
performance and positively influences patient satisfaction and
employee job satisfaction, and reduces employee burnout.
Osatuke et al., 2009
 Managers, supervisors, and senior leadership are key assets in shaping
workplace culture and employee attitudes, particularly on issues of
workplace wellness, diversity, and civility.
Powell & Yalcin, 2010; Moore, 2010
 Still, to motivate healthcare leaders to invest in organizational civility
initiatives, financial and strategic business case models are needed.
2
Study Purpose
To explore the impact of workplace civility on the healthcare
environment, and monetize this impact as a business case model.
 Civil work environments are associated with improved clinical
teamwork, greater patient safety practices, and reduced staff
burnout.
Simons, 2008
 Workplace human capital initiatives can facilitate these outcomes
through skill-building, educational training, and systems support
designed to improve workplace civility.
3
Method
Study Design
 Cross-section research design using archival, survey data
 VA All Employee Survey
 VA datasets tracking employee sick leave usage, EEO complaint activity,
patient care experiences, and compensation and pension claims
processing
Population Studied
 U.S. Department of Veterans Affairs (VA) staff, facilities, and clients.
 Data years: 2010
 VA employee perceptions: Job satisfaction, Civility (annual N ≈ 200,000 VA
4
employees, 68% response rate)
 VA performance outcomes: Sick leave usage, EEO complaints, Claims
processing time (annual N ≈ 300,000 VA employees)
 Veteran client perceptions: Healthcare satisfaction, Patient loyalty (annual N
≈ 140,000 Veteran inpatients, 53% response rate)
Method
Key Measures
 VA All Employee Survey
Cooperation: (a) People treat each other with respect in my work group. (b) A spirit of
cooperation and teamwork exists in my work group.
Civility
Measured as a composite
factor from 8 items
Employee Job
Satisfaction
Satisfaction with
Direct Supervisors
and Senior Managers
Turnover Intentions
Conflict Resolution: Disputes or conflicts are resolved fairly in my work group
Coworker Support: (a) The people I work with take a personal interest in me. (b) The
people I work with can be relied on when I need help.
Diversity Acceptance: (a) This organization does not tolerate discrimination. (b)
Differences among individuals are respected and valued in my work group. (c)
Managers work well with employees of different backgrounds in my work group.
• Compared with what you think it should be, what is your current overall level of
satisfaction with your job?
• Compared with what you think it should be, how satisfied are you with the quality of
direction supervision you receive?
• Compared with what you think it should be, how satisfied are you with the quality of
senior managers at your facility?
• If I were able, I would leave my current job because I am dissatisfied.
Scale: 1 Strongly Disagree/Not At All Satisfied to 5 Strongly Agree/Very Satisfied
5
Method
Key Measures
 VA Datasets
EEO Complaints
Number of formal and informal Equal Employment Opportunity (EEO) complaints.
Sick Leave Usage
Average number of sick leave hours per 1,000 employees.
Claims Processing
Time
Total processing time in days once a claim enters the system (Day 1) to the time of its
closing day or resolution (Day XX).
 VHA Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Inpatient Care
Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best
hospital possible, what number would you use to rate this hospital during your stay?
(Percent of respondents answering 9 or 10 Best Hospital Possible)
Inpatient Loyalty
Would you recommend this hospital to your fiends and family?
(Percent of respondents answering 3 Probably yes or 4 Definitely yes)
Analytic Techniques
 Civility mean scores (facility-level, N = 57 to 152) were segmented into
low-moderate-high quartiles, then matched to secondary VA datasets.
 Analyses included bivariate correlations.
6
Results
Impact of Civility on Workplace Culture
 In VA, greater civility is linked to positive organizational changes:
 Civility perceptions have remained stable across the organization, where, on
average, employees report moderate workplace civility .
 Greater employee job satisfaction, satisfaction with supervisors/leaders,
patient satisfaction with quality of care, and faster claims processing times.
 Lower sick leave usage, turnover intentions, and EEO complaints.
Table 1: Civility and Key Outcomes
Outcome Metric
Average workgroup civility (VA employees)
Average EEO complaints (formal, informal) at the VHA level
(per 1,000 employees) (128 facilities)
Average per capita sick leave hours used by VHA employees
(128 facilities)
Average number of processing days for VBA claims
Average employee overall job satisfaction
Average employee satisfaction with direct supervisors
Average employee satisfaction with senior managers
Average employee intent to stay with VA
7 Percent favorable inpatient satisfaction score
Percent of inpatients who recommend VHA services
Outcome Average
2010 CIVILITY (Quartile)
Low High
2011 Low
High
Moderate
3.72 < 3.11 3.12 3.87 >4.50
2009
2010
3.74
3.71
13.1
10.1
6.4
10.7
9.9
7.8
6.7
80.8
80.3
69.3
83.4
82.2
77.8
77.0
167
3.89
3.83
3.41
3.54
63%
66%
164
3.82
3.78
3.33
3.47
64%
68%
153
3.80
3.79
3.34
3.43
64%
68%
200
2.86
2.56
2.22
2.55
61%
65%
161
3.66
3.57
3.07
3.24
63%
67%
151
4.12
4.18
3.70
3.72
66%
70%
137
4.54
4.67
4.22
4.24
68%
73%
Results
Impact of Civility on Workplace Culture – EEO Complaint Cost Savings
 In VA, civility exerts a stronger influence on reducing formal EEO
complaints (r = -.34 to -.45) compared to informal ones (r = -.21 to -.27).
 Reducing EEO complaints incurs substantial cost savings ($17K per complaint).
 Investment: Human capital initiatives addressing Alternative Dispute
Resolution (ADR), conflict management, and diversity and inclusion
training/support for management, employees, and union leaders.
 In financial terms…
2010
Quartile Average of Informal
EEO Complaints per capita
If VA facilities shifted
their informal EEO
complaint activity to the
next lower quartile, the
potential annual cost
savings would be
$17.8 M (FY10).
Informal EEO Complaints per capita Grouped by
Lowest to Highest Complaint Facilities (N = 232)
30
22.7
25
17.7
20
15
10
6.1
5
0
Lowest
8
24.1
Low-Moderate High-Moderate
Highest
Informal EEO Complaints per capita (Quartiles)
Results
Impact of Civility on Workplace Culture – Turnover Cost Savings
 Veterans Health Administration (VHA) facilities with greater civility also
had lower turnover intentions among physicians and nurses (r = .46).
 Employee replacement costs (i.e., recruitment, hiring, training) are estimated
at 93% to 200% of an employee’s annual salary.
 Investment: Human capital initiatives addressing conflict management and
diversity and inclusion training/support, VA’s CREW Initiative (Civility, Respect,
and Engagement in the Workplace – a Joint Commission “Best Practice”).
 In financial terms…
9
Quartile Average of
Quit Rate Percentage
If VHA facilities shifted
their quit rate average
(all staff) to the next
lower quartile, the
potential annual cost
savings would be
$572.6 M (FY10).
VA Quit Rate Percentages Grouped by
Lowest to Highest Loss Facilities (N = 265)
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
2010
7.7%
4.8%
3.6%
1.7%
Lowest
Low-Moderate High-Moderate
Quit Rate Percentage (Quartiles)
Highest
Results
Impact of Civility on Workplace Culture – Claims Processing Savings
 Veterans Benefits Administration (VBA) facilities with greater employee
satisfaction and workplace attitudes (e.g., civility) experience improved
claims processing accuracy (r = .30 to .51) and reduced claims processing
time (r = -.34 to -.61).
 Investment: Human capital initiatives addressing conflict management and
Quartile Average of C&P
Claims Processing Days
diversity and inclusion training/support, VA’s CREW Initiative (Civility, Respect,
and Engagement in the Workplace – a Joint Commission “Best Practice”).
 In financial terms…
Claims Processing Time Grouped by
Lowest to Highest Efficiency Facilities (N = 57)
If VBA facilities in the highest
2010
2015 Goal (125 days)
claims processing quartiles
250
214.4
achieved VA’s FY15 claims
200
176.5
153.1
processing benchmark (125
114.0
150
days) today, Veterans at
100
these facilities could receive
50
their claim 58.1 days sooner
0
Lowest
Low-Moderate High-Moderate
Highest
(FY10).
10
Processing Time (Quartiles)
Conclusions
Workplace Civility and the Workplace Environment
 In VA, civility is tracked as a key performance indicator of organizational
excellence.
 Our VA research found that greater workplace civility is linked to improved
employee, patient, and organizational outcomes that when monetized can
incur substantial cost savings.
 These findings suggest that the cost of workplace incivility is high.
 For example, VA facilities in the lowest civility quartile were observed as
spending $4.1 to $14.7 million more on formal EEO complaints and $20.3
million more in sick leave usage compared to VA facilities in the highest
civility quartile (FY10).
 These findings also provide an initial “business case” model for investing in
human capital initiatives that foster civil work environments.
11
Implications for Policy,
Delivery or Practice
 Policy: Workplace civility is dependent upon leadership endorsement of
a civil work environment. Across VA, “civility” is recognized in facilityand organization-level strategic goals, mission, and core values.
 NOTE: Civility is more than “being nice” in the workplace, it is a workplace
culture shift toward a climate that is positive, healthy, and high-performing.
 Delivery: Human capital initiatives designed to improve workplace
civility may be strategically targeted to specific audiences (i.e., facilities,
workgroups, occupational groups) experiencing lower civility.
 This strategic delivery may minimize the costs incurred by training all
employees regardless of need to improve workplace civility.
 Practice: Workplace environment → Employees → Clients
12
In VHA medical centers, Veteran inpatients report more civil treatment from
their care providers when physicians and nurses at those facilities also report
greater workplace civility.
For more information, please contact VHA
National Center for Organization Development (NCOD)
Telephone:
Email:
Website:
(513) 247-4680
VHANCOD@va.gov
http://www.va.gov/NCOD