Leaders Speak: Dr. David Shulkin on Reforming the Delivery of Veterans Healthcare

The mission of the U.S. Department of Veterans Affairs was borne from the immortal words of Abraham Lincoln's second inaugural address: to care for him who shall have borne the battle, and for his widow and his orphan.

The Veterans Health Administration embodies that promise of a grateful nation -- providing quality health care that Veterans have earned through their service and sacrifices. Although the covenant with Veterans is immutable, healthcare evolves and so must VHA.

In the late 1990's VHA evolved from a hospital-centric model to become a delivery system, offering exemplary measured performance in a range of care settings. Today, the "triple aim" of better health, better care, and better value represents the aspiration of all health systems, especially VHA! Dr. David Shulkin, Under Secretary for Health at VA joined me on The Business of Government Hour this week to discuss VA’s healthcare mission, strategic priorities, challenges faced, innovations pursued, and efforts to promote a positive culture of service. Here is a snapshot of our discussion.

On the Mission of the Veterans Health Administration. Our commitment is to take care of those that have served our country by providing exceptional health care that improves their health and well-being. VHA continues to work at being the benchmark of excellence and value in healthcare and benefits by providing exemplary services that are both patient-centered and evidence-based. This care is to be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement. We emphasize prevention and population health and contribute to the nation’s well-being through education, research and service in national emergencies.

I’m not sure everybody realizes VA is the largest integrated healthcare delivery system in the country providing care at 1,233 health care facilities, including 168 VA Medical Centers and 1,053 outpatient sites of care of varying complexity (VHA outpatient clinics), serving more than 8.9 million Veterans each year. As Under Secretary of Health within VA, I am the Chief Executive of the VHA. I direct a healthcare system with an annual budget of approximately $65 billion, overseeing the delivery of care to more than 9 million enrolled Veterans. VA, the nation's largest health care system, employs more than 305,000 health care professionals and support staff at more than 1,000 sites of care, including hospitals; community based outpatient clinics; nursing homes; domiciliaries; and 300 Vet Centers. The department is the second largest government organization second to U.S. the Department of Defense in terms of size and scope.

On the Increasing Complexity of Caring for America’s Veterans. Today, VA faces unprecedented demands for services and benefits.  The service offerings themselves have multiplied over the years through expanded eligibility for existing benefits and new benefits programs.  Both the number and types of benefits and services have expanded dramatically, and many Veterans have increasingly complex needs, expectations, and requirements of VA.  Part of this is driven by Veteran demographics.  In 1975, there were two million Veterans over the age of 65.  By 2017 that number is expected to be near 10 million, the majority of whom served in the Vietnam era.  As Veterans age, service-­‐connected issues become more chronic and more acute.  Additionally, service-­‐connected issues for those returning from the wars in Iraq and Afghanistan are more complex than in prior eras.  Demands for mental health care and suicide prevention are rising dramatically.  The standards for care are changing, challenging our ability to meet expectations.  Overall, this has increased the complexity in caring for America’s Veterans. This challenging environment required VA to re-­‐examine its operating norms and institute new programs to meet these challenges. 

On Reforming How VA Delivers. VA, as a whole, is working to rebuild trust with Veterans and the American people, improve service delivery, and set the course for long-term VA excellence and reform. This initiative is called “MyVA.”  It is what we are calling our transformation from VA’s current way of doing business to one that puts the Veterans in control of how, when, and where they wish to be served.  It is a catalyst to make VA a world-­‐class service provider.  It will modernize VA’s culture, processes, and capabilities to put the needs, expectations, and interests of Veterans and their families first. MyVA represents an opportunity to affect fundamental changes in VA’s systems and structures to align with our mission and values.  The MyVA vision is to provide a seamless, unified Veteran Experience across the entire organization and throughout the country. All of us in the VA healthcare system are focused on the “MyVA” initiative as well as VHA’s Blueprint for Excellence. The Blueprint is aligned with the department’s Strategic Plan and supports the “MyVA” initiative. The Blueprint lays out themes and supporting strategies for transformation to improve the performance of VA health care now— making it not only more Veteran-centric, but also Veteran-driven by putting our customers in control of their VA experience.

This transformation will take time.  If done properly, it will build a high-­‐performing organization that continually changes and improves.  The benefits of this will be profound and evident in every task an employee undertakes.  But the reason for all of it circles back to one clear and simple mission: serving Veterans.

On Key Priorities. It took about a year to vet my nomination to become VA’s Under Secretary for Health. As a result, I had some time to really think about what VHA needed to do to transform. When I came board I identified five key priorities:

"ACCESS” - My first priority is to fix access issues plaguing our system ensuring that veterans were able to access the care and services they needed and were entitled to because of their service to the nation.

“EMPLOYEES” - My second priority was to focus on the employee. I wanted to make sure they were passionate about their work, but most of all that they had the tools that they needed to do their jobs and meet the mission of the VHA. 

“BEST PRACTICES” -- My third priority involved transforming the system into a truly integrated enterprise across the country where we take best practices from one VA medical center and make sure that those practices are spread throughout the country. This goal seeks to ensure consistency of best practices and resource prioritization by focusing on what's working well, ensuring that effective systems are supported appropriately, and ineffective systems are promptly addressed.

“HIGH-PERFORMING HEALTHCARE NETWORK” - My fourth priority was to work with our community providers. In today’s complex and rapidly changing health care environment where VA is experiencing a steep increase in demand for care, it is essential for VA to work with providers in communities across the country to meet Veterans’ needs.  To be effective, these relationships must be principle-based, streamlined, and easy to navigate for Veterans, community providers, and VA employees. This priority goal focuses on creating a culture of high-performance, based on implementation of best practices—from leadership to clinical to operational to support settings.

 “TRUST” - My fifth priority was to restore pride, public trust, and confidence in VA.

 On Improving Access to Care. VA has taken multiple steps to expand capacity at our facilities by focusing on staffing, space, productivity, and VA Community Care. In the latest budget request provides $65 billion for VA medical care, a 6.3-percent increase above the 2016 enacted level.

Building on momentum generated by the various Stand Downs, VA is continuing efforts to improve access to care, improve the Veteran experience, and improve the VA employee experience by maximizing accessibility to outpatient services. We are re-focusing people, tools, and systems as we embark on a continuous improvement journey towards same day access for primary care and urgent specialty care.

We are empowering each VA facility to focus on the needs of its specific population Clinical operations will meet customer demand through resource-neutral, continuous improvements at the facility level and scaling-up excellence across the enterprise. VA has placed special emphasis on increasing access for Veterans in rural and remote locations. Telehealth services are mission-critical to the future of VA care to Veterans. Telehealth uses information and telecommunication technologies to provide health care services when the patient and practitioner are separated by geographical distance. The number of Veterans receiving care via VHA’s telehealth services grew approximately 5 percent in FY 2015, and is anticipated to grow by approximately 6 percent.

On Expanding Mental Health Care to Veteran. Long deployments and intense combat conditions require comprehensive support for the emotional and mental health needs of Veterans and their families. Accordingly, VA continues to develop and expand its mental health system. VA has integrated mental health services into primary care in the Patient Aligned Care Team model. Providing mental health care within the primary care clinic minimizes barriers that may discourage Veterans from seeking mental health care. This integrated healthcare is not seen in other health care systems nationally.

VA has many entry points for mental health care, including 167 medical centers, 1,035 Community-Based Outpatient Clinics and Outpatient Services sites, 300 Vet Centers providing readjustment counseling, 80 Mobile Vet Centers, a national Veterans

Crisis Line, and a variety of other outreach efforts. VA’s Primary Care-Mental Health Integration (PC-MHI) program, which provides mental health care as a routine component of primary care, is now established in 98.8 percent of VHA divisions, 98.5 percent of the very large and 81.2 percent of large community based outpatient clinics. VHA provided over 1 million PC-MHI encounters in 2015, an increase of 8 percent from 2014 and an increase of 28 percent from 2013.

We will continue to focus on expanding and transforming mental health services for Veterans to ensure that accessible and patient-centered care, including treatment for posttraumatic stress disorder (PTSD).

On Promoting a Positive Culture of Service. Recent shortcomings of VHA performance highlight the importance of reconnecting leadership and staff to both the VA mission and the expressed values of the organization, as a basis for cultural transformation.

VA's culture has been described as too closed and inflexible. Although the majority of VHA employees are committed to serving America's Veterans, there are times when our behavior falls short of our values and expectations, and the culture we have is not the culture we want. We have significant leadership and management challenges that we must fix. Thus, we are committed to a culture that honors our mission, our values, and most importantly, the Veterans that we are privileged to serve. In short, Veterans' needs must always come first.

Given the wisdom of the adage that "culture eats strategy for lunch," to transform the agency, it will be critical to address VA culture in the coming months and years. No matter how wellconceived the strategy, how competent the employees, or how efficient the business processes, if culture is compromised, the organization's mission suffers.

Individual performance in such an environment is not characterized by minimal expectations,but is inspired to the highest possible levels of performance and conduct. In addition to creating a positive and “Veterans-first” culture of service in VA, this theme seeks to improve Veteran services by building an environment of continuous learning, facilitated by responsible risk-taking and balanced by personal integrity and constructive, sustainable accountability.

A healthy culture derives from the behaviors of its leaders. Leaders must model selfless service toward Veterans and staff, embracing the concept of servant leadership. VA leaders must demonstrate open communication, respect for employee input, and sustainable accountability. Successful ethical leadership requires specifically demonstrating and supporting the effective integration of strong ethics practices into personal behaviors and organizational culture. This can be demonstrated by communicating expectations for ethical practice, ethical decision-making, and supporting local ethics programs.

Employee engagement and satisfaction are best predicted by three foundational factors: Leadership, policies, and culture. Leadership, leadership development, and culture must be addressed to ensure the foundation for necessary improvements to be made and sustained.

On Leadership. Leadership is multi-faceted. I have had the great fortune of being able to work under many great leaders. The essence of leadership is being able to set priorities, a clear vision, and most of all communicate them clearly. A strong leader needs to be a good communicator. It of course assumes that you have good judgment, that you have the ability to see the implication of both near term and long term decisions and to set short-term direction and a long-term strategic vision. But once you do that, I think what really differentiates leaders is their ability to prioritize and communicate.

I invite you to download and listen to this leadership conversation in its entirety:  Dr. David Shulkin, Under Secretary for Health at VA on The Business of Government Hour