VA Secretary McDonald Outlines Steps For VA Transformation at Institute of Medicine Annual Meeting

VA Secretary Robert A. McDonaldRemarks by Secretary Robert A. McDonald Institute of Medicine Annual Meeting October 20, 2014

Thank you, Victor. And thank you for the opportunity to address today’s annual meeting. Victor and I have known each other since he was the Chancellor of the Duke Medical System and I was the Chair of the Duke Business School Board of Advisors—so it’s great to be able to renew our partnership—this time in the interests of the Institute of Medicine, VA, and the Americans we serve.

Distinguished members of the Institute of Medicine, ladies and gentlemen:

Good afternoon. It’s a privilege to join you.

As the Nation’s foremost advisory body in medicine and healthcare, you know that the Department of Veterans Affairs is in the midst of overcoming problems involving access to healthcare. We own them, and we’re fixing them.

But I know you also know that VA has a legacy of excellence, innovation, cutting-edge research, and achievements in healthcare delivery that is as broad and historically significant as it is profound—and often unrecognized.

There’s something else. Right now, VA has before it perhaps its greatest opportunity to enhance care for Veterans in its history.

Others know that truth, as well. Last July, Sloan Gibson—VA’s deputy secretary, my West Point classmate, and a friend for almost 40 years now—met with Harvey Fineberg, distinguished clinician, healthcare leader, and your former president. When Sloan commented that VA could accomplish more in the next two-to-three years than we could have in two-to-three decades, Dr. Fineberg immediately corrected him—“No!,” he said, “VA can accomplish things now it never could have accomplished!”

He’s right: We’re in an extraordinary position. We have an opportunity to not only right wrongs, but to reframe perceptions about VA by lengthening our lead in areas where we’ve always excelled, taking the lead in service delivery areas that are lagging, and charting new ground in emerging or evolving areas of healthcare.

The problems we face are serious. The President, Congress, Veterans service organizations, taxpayers, and VA’s rank and file all understand the need for immediate reforms to achieve three non-negotiable goals—goals we set for ourselves more than two months ago on our “Road to Veterans Day.” This initiative outlines what we intend to accomplish by Veterans Day 2014. It begins with our mission and immediate objective: To better serve and care for those who have “borne the battle” and for their families and survivors. From there, we developed a series of goals and actions that enable the Department to move quickly and decisively to:

•     Rebuild trust with Veterans and stakeholders.
•     Improve service delivery, focusing on Veteran outcomes.
•     And set a course for long-term excellence and reform.

Toward that end, I’ve been on the road traveling to 35 VA facilities in 18 cities, meeting with hundreds, if not thousands of Veterans, VA employees, VSOs, and other stakeholders, and discussing the issues with Members of Congress, VSOs, unions, and myriad other partners.

Based on what we’ve heard—and the lessons I’ve learned about mission-driven corporations, strong institutional values, and good management practices during my 33-years at Procter & Gamble—we’ve wasted no time in developing a healthcare “Blueprint for Excellence.”

This blueprint is critical to achieving part three of our Road to Veterans Day initiative—setting a course for long-term excellence and reform. It is VA’s template to re-establish the Department’s preeminence and leadership in American healthcare. It could not have been produced by better, more knowledgeable people, including VA’s former Under Secretary for Health, Jonathan Perlin, who has completed a short-term assignment at VA—and Interim Under Secretary, Carolyn Clancy, whom most of you know. Their input to this blueprint, and their professional advice on the optimal ways to accomplish this goal, have been invaluable since I became VA Secretary.

The Blueprint lays out four broad themes and supporting strategies for transformation.

First, we must improve the performance of healthcare now. There’s a lot at stake: We deliver 240,000 episodes of care each day—more than 90 million scheduled appointments in 2013 alone. And do 400,000 surgical procedures annually—nearly 1,100 per day.

Second, it’s imperative that we re-set VA’s culture to put a high premium on job performance and the strong VA institutional values that support it—Integrity, Commitment, Advocacy, Respect, and Excellence. These attributes go to the heart of our mission and dictate how employees act, relate to Veterans and each other, and treat the almost 6.5 million patients we see each year. By “living” VA’s core values, we can go a long way toward overcoming the challenges before us.

Third, VA must transition from “sick care” to “healthcare” in the broadest sense. And fourth, we must develop efficient, transparent, accountable, agile business and management processes to support the span of care, services, and programs we deliver. Above all, it’s imperative that VA regain and retain a laser focus on its customer base—that means everyone from the 90-year-old Veteran who crossed Omaha Beach, to the 19-year-old who battled insurgents in Afghanistan’s Korengal “Valley of Death.”

That said, VA’s vision for change is not only Veteran-centric, but Veteran-driven—putting our customers in control of their VA experience. The healthcare industry, itself, is moving toward a more customized, consumer-centric version of primary care access.

We call our patient experience solution, MyVA. It, too, is part of our overarching Road to Veterans Day strategy. It’s called MyVA because that’s how Veterans should view us—as an organization that belongs to them and provides quality care in the ways they need and want to be served.

Let me give you an example of what I mean. Recently, at a national press conference, I gave out my personal cell phone number. The reason? Because Veterans struggle to connect with VA. Then, when they finally get connected, they discover they’re connected with only one of nine VA lines of business. Procter & Gamble was the first company to put 1-800 numbers on the back of its packages. We did so because we sought feedback—and we want to establish a similar customer service relationship at VA.

First and foremost, it means delivering quality medical care and providing Veterans the very best medical outcomes possible. But it also means:

• Shaping VA through a better understanding of Veterans’ needs and preferences.
• Providing a single-entry, user-friendly access so they can effortlessly navigate VA care and services.
• Removing cumbersome processes and procedural obstacles that frustrate users.
• Providing the full spectrum of resources—financial, human, and otherwise—to serve them efficiently and effectively.
• And, last, empowering employees at the lowest level possible to respond and react quickly and knowledgably to Veterans at each point of interaction.

To do this, we’re looking at ways to restructure and reorganize, combine functions, simplify operations, make process improvements, leverage technology, and enhance efficiency and productivity. It’s a 360-degree effort designed to present Veterans with a seamless, integrated, and responsive VA—no matter whether they come to us digitally, by phone, or in person.

Our goal is simple: Provide quality medicine and first-rate healthcare delivered with the same proactive, real-time, courteous, coordinated service as the top-ranked customer service companies in the country.

The fact is, VA already has that type of service excellence in many areas. For the past decade, the American Customer Satisfaction Index, the ACSI, has ranked VA’s National Cemetery Administration as the top customer-service organization in the Nation—public or private. Better than Google, Lexus, and all the rest.

And since 2004, the ACSI has consistently shown that Veterans receiving both VA inpatient and outpatient care give VA higher satisfaction ratings than patients at private hospitals. With the right strategies and action plans in place, there’s no reason why we can’t scale that performance excellence VA-wide.

Right now, one of the biggest challenges we face is the shortage of clinicians and other healthcare professionals. It was an underlying reason for the problems that occurred in Phoenix and elsewhere.

And that’s why, as part of a national recruitment effort, I’ve been going to the Nation’s medical and nursing schools—Duke, UC Davis, San Francisco, Dartmouth, University of Vermont, and Johns Hopkins last week, Howard University later this week, and many others in the coming months—to personally tell students about VA’s great mission and encourage them to join a revitalized Team VA in caring for those who defend us. Audiences everywhere have been welcoming and interest is high.

Here’s what I tell them: At VA, we have the most inspiring mission in government and the best clients in the field of healthcare—great reasons to work at VA.

Beyond our noble and respected mission, and the exceptional people we serve, VA offers practical reasons to work for Veterans.

• The recently-enacted Veterans Access, Choice, and Accountability Act (VACAA) of 2014 doubled the amount of our education debt reduction payment—from $60,000 to $120,000!
• We offer student loan repayments of up to $10,000 annually, with a lifetime cap of $60,000, as well as scholarships and recruitment, relocation, and retention incentives.
• And, as part of the drive to recruit the best and brightest, we’ve eased the pay disparity with the private sector—always an issue—through salary increases for VA’s physicians and dentists.

The demand for VA care will not decrease any time soon. The Nation’s been at war for over a decade, and we’ll continue to be caring for many of our severely wounded and ill Veterans for decades to come, if not a lifetime.

In a still recovering economy, the number of Veterans seeking our services continues to grow steadily, and we continue to serve a population that is older, with more chronic conditions, and less able to afford care in the private sector.

The issue of non-VA care has garnered a lot of attention over the past months. Yet, for all its potential in solving our current access problems, purchased care is not a replacement for a strong and vital Veterans’ healthcare system. Veterans need VA, and Americans everywhere—indeed the global community—benefit from VA.

• In VA research leading to major breakthroughs and advances in medical science and care—PTSD and Traumatic Brain Injury, TBI, being only two of many.
• In training 70 percent of America’s physicians—62,000 medical students and residents, 23,000 nurses, and 33,000 other health professionals—each year.
• And VA has the highly-specialized knowledge and know-how to deliver clinical and rehabilitative care to those who have “borne the battle.”

The fact is, whether in prosthetics, geriatrics, PTSD and TBI treatment, or polytrauma care—to say nothing of disability and education benefits, home loans or homeless rescues, and final honors in our national cemeteries—there’s no other one institution like VA positioned to deliver a broad spectrum of Veteran-specific care and services to the 1 percent of our population that currently serve in uniform.

The Veterans Access, Choice, and Accountability Act, or “Choice Act,” goes a long way toward enabling VA to meet the current demand for care. It provides authorities, funding, and other tools to better serve Veterans in the short term, and support the large-scale reforms we’re making for long-term excellence.

The law provides $5 billion to hire physicians and other medical staff, and $10 billion to fund additional purchased care while VA builds the internal capability to meet current demand.

But as most of you know, VA has always sponsored non-VA care where its been needed to respond to extraordinary circumstances: Like geography, where rural Veterans can’t easily get to a VA facility; technology, where it makes sense to refer Veterans to great providers for certain, highly-specialized procedures; and, in times like now, when we face a shortfall in clinicians, patient support staff, space, information and technology resources.

What’s changing with the Choice Act is the volume of that care. Since last May, VA has authorized almost 1.2 million referrals for Veterans to receive care in the private sector—369,000 more Veterans than in the same period in 2013. This growth in purchased care sets the stage for re-envisioning new relationships and reenergizing existing partnerships between VA and the private sector—as well as other parts of the public sector—for better care, better health, and better value. Providing seamless Veterans’s care is a “team sport,” and we need your help.

Purchased care addresses some of VA’s current problems but, as important, it opens the doors to other transformative aspects of patient care. In care coordination and interoperability, for example—challenges common to both public and private sector healthcare providers.

If VA and private providers are caring for the same Veteran-patient, we’re in a position to collaborate, to share information and knowledge. There’s a potential to leverage improvements in electronic health records by developing a public-private infrastructure and platform to generate new ways of using patient information and data, new ideas, new approaches, and new solutions for better patient care.

Increased purchased care also has the potential for increasing high-value care—particularly in reducing medical waste and redundancies. Here again, because we’re working in tandem, there’s practical, real-time opportunity to ask ourselves, “How do we prevent costly redundancies in x-rays, MRIs, blood tests, and countless other tests?” More than that, asking, “How do we reduce unnecessary testing, period?” It gives us the opportunity to tackle these types of issues and develop answers and solutions that have import across the medical community.

It all comes down to what Dr. Fineberg said—we have an unique opportunity before us at VA to “accomplish things now [we] never could have accomplished.” In addition to non-VA care, the Choice Act covers a lot of ground—everything from expanding survivor benefits, to improving the delivery of care for Veterans struggling with TBI and the effects of military sexual trauma, to increasing by up to 1,500 the number of residents working in VA hospitals, to executive accountability, and more.

Employees across the Department have rolled up their sleeves, and work is underway to make the changes to VA systems, procedures, and culture that the law requires. We’ve done a lot, but there’s a lot left to do if we’re to right the wrongs, institute reforms and employee accountability, modernize, and recruit the numbers of healthcare professionals we need.

We are committed to doing the right thing—delivering the right programs, in the right way, at the right time, for those special Americans we serve.

As we go forward, one thing’s clear. VA cannot do what needs to be done and accomplish its goals without a full complement of partners—public, private, and volunteer. We don’t have all the answers. We can’t operate in a vacuum—no 21st century organization can. That’s why we’re aggressively leveraging our existing relationships and affiliations and forging new ones. Here are a few examples:

• VA’s partnering with the Institute of Medicine in a study of access standards and wait time metrics.
• We’ve entered into a first-of-its-kind partnership with Walgreens to provide vaccinations to Veterans—Walgreens will share its immunization records with VA to ensure we have complete patient medical records.
• We’re collaborating on a new nursing academic partnership focused on psychiatric and mental healthcare—a key area of care for the Department and for DoD.
• We’re partnering with DoD Health Affairs to improve recruitment of recently or soon-to-be discharged military healthcare professionals.
• Expanding a pilot program to bring combat medics and corpsmen into VA facilities as clinicians.
• Partnering with the Northern Virginia Technology Council to establish a pro-bono technology task force to review VA’s scheduling system and make recommendations for improvement.
• Setting up a consulting Board of Physicians—comprising the foremost medical minds in the Nation—to advise me on industry best practices.

And there is another critically important reason partnerships are important—much in the news lately—the emerging situation with Ebola. As part of our healthcare mandate, VA ensures the care of victims of emergencies or national disasters that would otherwise overwhelm local healthcare systems and responders. In point, we’ve responded to every presidentially-declared disaster since 1992, including the 9/11 attack in New York, the H1N1 influenza pandemic, Haiti earthquake relief, and recently, Hurricane Katrina.

Just last week, I attended an emergency Cabinet meeting before I left Washington on Wednesday afternoon, and an Ebola drill at VA’s West Roxbury facility in Boston on Friday afternoon. Circumstances demonstrate the power, value, and need for an integrated, prepared system when anyone with a possible diagnosis arrives at a medical facility. Equally important, as the Ebola situation has borne out, is the responsibility to protect our healthcare workers across the Nation. Partnerships are important to making sure this happens.

In my less than three months at VA, one thing stands out as I’ve traveled around the country—the goodwill and support shown by the medical community to VA, its mission, and its achievements. Ken Kizer, Jim Madara, Harvey Fineberg, the Surgeon General of the Navy, Matt Nathan, Jonathan Perlin, and so many others from both the public and private sectors, have all expressed their willingness to publicly speak out and “right the record” in telling the VA story.

We’re taking advantage of their offer. Right now, VA’s in the process of creating a VA Alumni Group—a “Friends of VA” committee of sorts. Our thought is to gather interested leaders in medicine and the healthcare industry, brief them regularly on VA operations, initiatives, and performance, and solicit their input and assistance.

One of our objectives is to insert a degree of balance and truth to the one-sided conversation about VA care and services. And so, I’d like to invite members of the Institute of Medicine to consider becoming a part of this initiative. We want and need your authoritative advice. We seek your input as we move forward in implementing the Veterans Access, Choice, and Accountability Act. We welcome your participation and collaboration across the spectrum of care, and I personally look forward to collaborating with you.

In closing, I’d like to thank you, Victor, for giving me this important opportunity to speak with you and your distinguished colleagues this afternoon. I want to thank the Institute for its record of work in improving the health of Americans, and people around the world. And I look to your recommendations and influence in improving VA healthcare for Veterans.

Thank you, ladies and gentlemen.