When we think of design we think of Apple, Gucci, or Nike, but we don’t think of government. Traditionally, the United States Department of Veterans Affairs (VA) has had no designers or design as we know it. But the VA, like everything human-made, is designed. It was designed to provide a range of services to United States Veterans — people willing to die for the ideals of their country. It’s a 100-year-old organization that has grown over time to employ 400,000 people with a budget of ~377 billion dollars that had undergone numerous scandals over its existence.
Of the 630,000 homeless in the US, 67,000 are Veterans. In 2020, there were 6,146 Veteran suicides. Something is very wrong, and the VA was poorly Designed.
The VA’s most recent troubles were in 2014 when it was found that the administration was hiding how backed up it was in Phoenix at a VA medical center. People were waiting months (115-day average) for appointments. The scandal came to light because of people like Paula Pedene who became a whistleblower exposing the facts. The scandal sparked an effort to reform the VA to regain Veteran trust through an improved user experience. It brought in leaders from the private sector, like the former CEO of Procter and Gamble, who was appointed as the new VA Secretary at the time. He, and the staff he came with, cleared the way for design work to begin. As many of us working in the UX field are aware, design began proliferating in corporations over the last 15 years. Now it was coming to the government. I first heard about this work from two women who, for four years, partnered with numerous people to introduce human-centered design (HCD) into the VA as part of a larger transformation.
Eulani Labay and Roseann Stempinski worked with the VA and other governmental agencies starting in 2016. They helped the VA take new approaches and provide services that put Veterans at the center. Although it took time and patience, the VA is now regarded as a center of customer experience (CX) excellence among governmental agencies.
It has appointed a Chief Design Officer, Erin Siminerio, which points to its commitment to HCD, and it is being redesigned to provide real support and care for a long-neglected group of people. Dr. Teresa Boyd of the Veterans Health Administration (VHA) said, “wait times are down nationwide, in many cases better than times in private practice.” She goes on to say, “VHA has undergone tremendous transformation since 2014, and the agency is operating with a renewed focus, unprecedented transparency, and increased accountability.” You can read the full article here.
FOREFRONT OF TRANSFORMATION
When asked about their time working with the VA, Labay and Stempinski recognized that they were at the forefront of changes there, and this was exciting for both. They had to introduce solid user research to understand needs without general organizational acceptance. They needed to gain the trust of their partners at the VA. There was no codified HCD approach to work with; they had to build it as they went and introduce best practices for efforts involving tools from service design, communication design, and experience design, among others.
Crucially, they describe much of this work as designing the conditions within which to do the work needed. It’s one thing to design a website or a logo, what I call the artifacts and objects of design; it’s quite another to shift mindsets and improve process or organizational objectives at a strategic level.
As with many organizations where design is nascent, there is a great deal of need, few practitioners, and education that must accompany the work. Labay and Stempinski knew that, at the strategic level, the problem was one of building the capacity for the organization to work in a new way. The specific problem where a Veteran had an appointment wait time of 115 days was just one of the obvious, visible problems, but the underlying issues were deep.
TIP OF THE ICEBERG
In a talk they gave in 2021, Labay and Stempinski used the metaphor of an iceberg to convey the mental model for the work they did.
When most people think of design, they think about how something appears. People often conflate art and design for this reason. They think that a designer’s job is to make things pretty, and the people at the VA were no different. I’d seen an iceberg model used to describe service design work and systems design so the model made sense in this context.
Having worked as service and experience designers, as well as design strategists, Labay and Stempinski drew from their experience. They had been trained to think deeply about the problem-solving required to affect organizational change, and they knew to apply those principles to address the work in front of them. People working within established organizations often work according to the confines of the system that has developed around them, which can result in entrenched thinking and resistance to change. Multiple design decisions are made over a long period of time, by numerous people reacting to externalities, often lacking high-level direction and oversight. As many organizations don’t think past the given sprint, quarter, year, or election cycle, it’s no wonder that things eroded and were breaking. The people that Labay and Stempinski met at the VA were hard-working, deeply committed individuals within a broken system, so it’s reductive to assign blame to people within such a system. The 2014 scandal may well have been the fault of specific individuals, but their inability to schedule the sheer number of Veterans coming home from Iraq and Afghanistan is a situation where events conspired against them.
One approach many designers find helpful in building trust is inviting stakeholders into the process and working transparently. The pair implemented this in one of their first efforts.
They interviewed nearly 100 Veterans at medical centers nationwide and brought VA execs and other stakeholders along. This research was to understand a Veteran’s experience obtaining primary care at VA Medical Centers (VAMCs) nationwide to improve the experience. The fieldwork involved a very complex site selection. They were after the broadest set of interviews from a wide variety of facilities and individuals. They looked at the size, location, and performance of facilities, in addition to the characteristics of the Veterans. Those from the Vietnam War needed care that more recent Veterans from Afghanistan did not. There were Veterans with private healthcare who could take or leave the VA, and there were Veterans completely dependent on the VA services. They heard stories of differences between Veterans of different genders — some women didn’t have gynecological services at a given location for instance.
As designers and user researchers, we know that these interviews and visits provide much-needed insight, contextual awareness, and increased empathy for those interviewed. But while out doing the research, Labay and Stempinski were also conducting synthesis sessions, analyzing the information they were hearing. VA stakeholders could work directly with them as a team to understand the patterns they observed. This transparency into the tactical efforts of interviews and synthesis served another very important purpose — the VA workers they brought with them heard the Veterans’ stories directly, which gave them a much better understanding of their needs, but the process was also being modeled. In this way, Labay and Stempinski were helping to educate their partners.
During one of the sessions, the team was working throughout the afternoon to find themes and insights. One of the VA executives was struck and said, “This is where the magic happens.” Following this, she became an advocate for both the research and the process, often using sticky notes to map out her thinking. For an executive to engage outside of Excel or Powerpoint and revise the way she internalized information was a win.
“Having the VA staff and executives on the road with us be part of that process and understand what it takes to bring the voice of the Veteran into the room when you’re making decisions about experiences that affect them, I think was huge.” Eulani Labay
Erin Siminerio, the person who would become the VA’s first Chief Design Officer, was struck by what one Veteran said during an interview — “I watch while I wait.” The interviewee meant that as they waited for their primary care appointment, they were aware and taking note of how the VAMC staff were interacting with others, and what they were doing (or not doing). Erin would repeat this many times over the years, ostensibly as a way to remind both herself and others of the need to advocate for Veterans.
BREADTH AND DEPTH OF RESEARCH
Stempinski walked me through a scenario. A Veteran may get a card in the mail for a radiology appointment, and they’re told to go to room XB-4321 on the LA Medical Center’s campus. They show up, find a directory, and the building or room names don’t align with the information on the card. Veterans might drive over an hour for an appointment, get lost on campus, miss their time, and the appointment is canceled — all because no one took the time to understand the full experience and address this as a problem.
She mentioned how powerful this and other stories were to tell. Their fieldwork was among the first of its kind at the VA. Before this, some of the staff’s attitude had been… “Well, I’m a Veteran, so I know what it’s like…” and while they know what the experience is like for themselves, they were enlightened by the experiences of others — some of whom were very much different than themselves. Even in the synthesis sessions, there was some staff who held tightly onto this bias. Some naysayers, concerned with cherry-picking the data, accused the design team of not picking the “right Veterans” to speak with. If you’ve done user research, you’ve likely experienced this. For the VA, getting the experience right was sometimes a matter of life or death, so the stakes were high. But often these same naysayers, recognizing their sisters and brothers in arms as experiencing these pain points, were willing to change their minds.
Labay noted that the VA staff were motivated to override their administrative roles and “really get these metrics right” to solve the pain points the Veterans were experiencing. Labay and Stempinski formalized their work into understanding models such as journey maps, personas, etc., to convey the problems they were seeing. Journey maps were foreign to the VA staff but embodied clarity, and they were unused to creating such artifacts themselves. VA teams absorbed the information in the maps, really appreciating the quality of the information. The designers ended up calling this “Journey Map Happy.”
The maps were more than pretty because the visualizations helped solidify what had previously been hand waving. The maps illuminated Veterans’ stories and got teams in the VA asking a lot of questions. If the Veteran was experiencing X, Y, or Z, why is that? How do we focus on this? What did we learn? These first efforts fed years of project work to dig deep and answer these questions and many others. When presented to executive sponsors, they were able to point to the maps and say, “Oh. Well, right here is where we need to…” — so the maps (and other artifacts of HCD) communicated as intended.
Artifacts of the process unlock thinking and mindsets. Having never seen the problems expressed this way (PowerPoint, Excel, and Word had been their primary tools), the VA staff were able to gain a new perspective.
Labay points out that they could have made Excel versions of the same information, but that they often took a chance with the form because the form itself (the maps) had an appeal and was ultimately more shareable and effective. They not only convey information but highlighted the process in a way that struck a chord with the VA staff and helped further HCD through that novelty.
DIVING BELOW THE SURFACE
After the early work, Labay and Stempinski moved on to capacity-building. They worked together with their design colleagues to create a curriculum, teach, and coach VA employees on HCD. This empowered the VA and shifted its culture from a reliance on outside sources to one that could do the work itself. Traditional consultancies are often brought in to solve problems, and for various reasons, those consultants simply engage in the task at hand. As part of their role as designers, Labay and Stempinski were tasked with enabling VA team members to be able to practice HCD.
This is reflected in what became the following model:
Their efforts were multi-pronged. In addition to engaging in projects, they enabled the practice of HCD and altered the mindsets required for that work to continue. In their project work, the foundation of their previous work gave them a little more leeway to take risks to achieve results. This was one way to navigate the circumstances within the greater transformation they were trying to achieve. “Transformational design has a long tail,” Labay says, and you have to “trust in the process.” She says, “You have to know that over time, you’ll have some failures but also a success, and you will have achieved a kind of proof of concept.” The work they did wasn’t always successful, and in such a hierarchical organization they had their share of criticism. But this is inherent in the process of design and, in the case of the VA, was a function of the institution itself. HCD contains trial and error.
Ultimately, the model for capacity-building stood to embody the work they did. In the work they do today, they very much believe that without helping to create the conditions within which design work can get done, the practice of design is less successful.
In addition to the small changes to specific experiences based on their work, they measure the success of this design transformation through several lenses.
HCD AWARENESS & CAPACITY BUILT: Many of the people they worked with became aware, supporters, and practitioners of human-centered design…some even became teachers of the method. They’d practiced, evangelized, and inspired design within the VA and among their colleagues, and helped instill the ideas among the staff.
DESIGN LEADERSHIP: Erin Siminerio was a Program Lead. Labay and Stempinski helped teach her HCD. She went on to become the VA’s first Chief Design Officer. As a witness to what the designers were doing, she grew to embrace the practice and became a huge advocate of design, but more importantly, for the Veterans themselves. Whenever you’ve laid the groundwork for design, you’ve achieved a level of organizational success.
DESIGN UNDERLYING A CENTER OF EXCELLENCE: Even more successful was that the VA became a center of excellence, serving as a model for other government organizations as they aspired to develop their customer experience practice. When Labay and Stempinski first arrived, there was a bit of a culture clash. It takes time to influence mindsets, align on a common language, and get past initial misunderstandings. One of the concepts I talked about with them was their idea of “organizational readiness,” or how ready the VA was to accept the shifts they were bringing. “Good ideas die on the vine if there aren’t the right conditions,” Labay said, and to get past the “hamster wheel of journey map creation,” to affect real change, they had to change the conditions within which HCD could be leveraged. They implemented a formal HCD capacity-building program. Over time, and through the hard work it took to build trust and create those conditions, they were able to shift the organizational focus.
Thank you to Eulani and Roseann for sharing this story with me, and more importantly, for taking the time to collaborate, edit, and improve it.
Eulani Labay is a transdisciplinary designer who facilitates collaboration on complex social and environmental issues. She draws from rigorous research, a participatory process, and a rich background in storytelling and the arts to design strategies for intentional and transformative experiences. She is experienced with influencing systems at scale, from individual to international, toward measurable positive impacts.
Eulani believes creative acts can bring us closer to equity, well-being, and connectedness; she frequently mentors media makers in change-making through their art, and she advocates for responsible practices in developing AI and emerging technologies. She is a mindfulness and meditation teacher-in-training and is currently working to improve access to mental health services at the largest managed care organization in the US.
Learn more and connect with Eulani here.
Roseann Stempinski: Understanding and enabling systemic transformation has been at the heart of Roseann Stempinski’s 20+ year career in innovation. Her work has shaped brand communications, e-commerce systems, healthcare, and sustainability experiences as well as organizational change while working within IDEO, BCG Brighthouse, eBay, Adobe, startups, and the U.S. Federal Government. She has degrees in Graphic Design and Industrial Design, as well as a deep expertise in Human-centered Design (HCD).
Today, Roseann helps purpose-driven humans navigate systemic challenges to realize climate-beneficial futures. Blending her expertise of how humans approach change with insights from living systems and regenerative and circular economics, she translates complexity into approachability and creates conditions that push boundaries so possibility can emerge.
Learn more and connect with Roseann here.
USA Spending — https://www.usaspending.gov/agency/department-of-veterans-affairs?fy=2023
CNN story on the numerous VA Scandals — https://www.cnn.com/2014/05/23/politics/va-scandals-timeline/index.html
Arizona PBS story on Paula Pedene — https://azpbs.org/horizon/2021/11/phoenix-whistleblower-shares-experience-exposing-va-scandal/
ALNAP — 2014 Report on human-centered work at the VA — https://www.alnap.org/system/files/content/resource/files/main/Toward_A_Veteran_Centered_VA.pdf
VA News on the use of Journey Maps — https://news.va.gov/72161/journey-maps-plotting-moments-matter-veterans-families/
Cronkite News on the transformation success — https://cronkitenews.azpbs.org/2019/07/24/va-touts-transformation-five-years-after-phoenix-hospital-scandal/
Whitehouse.gov — executive order on governmental focus on customer experience — https://www.whitehouse.gov/briefing-room/presidential-actions/2021/12/13/executive-order-on-transforming-federal-customer-experience-and-service-delivery-to-rebuild-trust-in-government/
Performance.gov official US Government site on government impact- https://www.performance.gov/cx/projects/
United States Census — https://data.census.gov/