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1 Commission on Care Final Report June 30, 2016

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3 Final Report of the Commission on Care June 30, 2016 Commission on Care 1575 I Street, NW Washington, DC 20005 commissiononcare.sites.usa.gov

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5 1575 I Street, NW Washington, DC 20005 ▪ June 30, 2016 We are honored to submit to the President, through the Secretary of Veterans Affairs, in accordance with the Veterans Access, Choice , and Accountability Ac t of 2014 (VACAA), veterans’ health care. We believe these the enclosed recommendations for transforming our nation’s veterans receive the health recommendations are essential to ensure that care they need and deserve, both now and in the future. We worked with an absolute commitment to putting veterans at the heart of our deliberations, and believe our recommendatio ns will create an integrated, community- based health care system for veterans that will be sustainable for the long term. During the term of the Commission on Care, we evaluated the 4,000-page Independent Assessment Report ; held public meetings; listened to a broad range of stakeholders, including veterans and leaders of veterans service organizations; made site visits to Veterans Health Administration (VHA) facilitie s; and exchanged ideas with individual and health care providers, members of veterans, VA and VHA leaders, VHA employees Congress, economists, and health care experts. Overall, the Commissioners agree with the findings of the , Independent Assessment Report consistent with the expansive body of other evidence the Commissioners have which are reviewed. This evidence shows that although care delivered by VA is in many ways comparable or better in clinical quality to that generally available in the private sector, it is inconsistent from facility to facility, and can be substantially compromised by problems with access, service, and poor ly functioning ope rational systems and processes. The Commissioners also agree th at America’s veterans deserve much better, that many profound deficiencies in VHA op erations require urgent reform, and that America’s veterans deserve a better organize d, high-performing health care system.

6 The most public and glaring deficiency was access problems. Congress attempted to solve this problem through a provision in VACAA that directed VHA to implement a oice. The Commission finds, however, that temporary program allowing for greater ch are flawed. In its place, we offer specific the design and execution of the Choice Program grated veteran-centric, community-based recommendations for standing up inte delivery networks that will optimize the balance of access, quality, and cost- effectiveness. The Commission also finds th at the long-term viability of VHA care is threatened by ilities, capital needs, inform problems with staffing, fac ation systems, health care disparities and procurement. Fixing these pr rate, concurrent, and oblems requires delibe requires fundamental changes in governance and leadership sequential actions. It also the next two decades through the rapid of VHA to guide the organization during changes coming in demographics, technolo gy, and in the structure of the overall U.S. health care system. VHA has many excellent clinical program s, as well as research and educational programs, that provide a firm foundation on which to build. As the transformation process takes place, VHA must ensure that the current quality of care is not compromised, and that all care is on a trajectory of improvement. VHA has begun to needed changes outlined in the Independent Assessment make some of the most urgently and we support this important work. Report, report will greatly enhance VHA’s ongoing Implementing the recommendations in this reform efforts by providing both a systems-oriented f ramework and vitally needed changes in organizational structure. Founda tional among these changes is forming a governing board to set long-term strategy and oversee the implementation of the transformation process, and building a stro ng, competency-based leadership system. The remaining recommendations work in h armony to ensure veterans receive timely access to care, have options for where and ho w they receive care, are cared for in an environment that embraces diversity and inclusion, and are supported in making informed decisions about their own health and well-being. These recommendations are

7 not small -scale fixes to finite problems. Instead, they constitute a bold transformation of a complex system that will take years to fully realize, but that our country must undertake to provide our veterans with the high serve. -quality health care they richly de Respectfully Submitted, Nanc y M. Schlichting Delos M. Cosgrove, MD Vice Chairperson Chairperson David P. Blom David W. Gorman Commissioner Commissioner The Hon. Thomas E. Harvey, Esq. Rear Adm. Joyce M. Johnson, DO, USPHS (ret.) Commiss ioner Commissioner The Hon. Ikram U. Khan, MD Phillip J. Longman Commissioner Commissioner Col. Lucretia M. McClenney , USA (ret.) Lt. Gen. Martin R. Steele , USMC (ret.) Commissioner Commissioner Charlene M. Taylor Marshall W. Webster, MD Commis sioner Commissioner

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9 TABLE OF CONTENTS TABLE OF CONTENTS ... VII LIST OF FIGURES ... X LIST OF TABLES ... XI EXECUTIVE SUMMARY ... 1 INTRODUCTION ... 21 COMMISSION RECOMME NDATIONS ... 23 Redesigning the Veterans’ Health Care Delivery System ... 23 The VHA Care System ... 23 Recommendation #1: Across the United States, with local input and knowledge, integrated community-based health VHA should establish high-performing, care networks, to be known as the VH A Care System, from which veterans will access high-quality he alth care serv ices. ... 23 Clinical Operations ... ... 37 Recommendation #2: Enhance clinical operations through more effective use of providers and other health professionals, and improved data collection and management. ... 37 Recommendation #3: Develop a process f or appealing clinical decisions that comparable to those afforded patients provides veterans protections at least under other federally-supported programs. ... 40 Recommendation #4: Adopt a continuous improvement methodology to support VHA transformation, and consolidate best practices and continuous erans Engineering Resource Center. ... 43 improvement efforts under the Vet ... 47 Health Care Equity ... Recommendation #5: Eliminate health c are disparities among veterans treated in the VHA Care System by committing adequate personnel and monetary resources to address the causes of the pr oblem and ensuring the VHA Health Equity Action Plan is fully implemented. ... 47 Facility and Capital Assets ... 55 Recommendation #6: Develop and implement a robust strategy for meeting and managing VHA’s facility and capital-asset needs. ... 55 Information Technology ... 66 Recommendation #7: Modernize VA’s IT systems and infrastructure to improve veterans’ health and well-being and provide the foundation needed to transform VHA’s clinical an d business processes. ... 66 vii

10 C C F INAL R EPORT OMMISSION ON ARE Supply Chain ... ... 81 Recommendation #8: Transform the manage ment of the supply chain in VHA. ... 81 Governance, Leadership, and Workforce ... 94 ... 94 Board of Directors ... directors to provide overall VHA Care Recommendation #9: Establish a board of System governance, set long-term strategy, and direct and oversee the transformation process. ... 94 Leadership ... ... 101 Recommendation #10: Require leaders at all levels of the organization to champion a focused, clear, benchmarked strategy to transform VHA culture and sustain staff engagement. ... 101 Recommendation #11: Rebuild a system for leadership succession based on a benchmarked health care competency mode l that is consistently applied to recruitment, development, and advancemen t within the leadership pipeline. ... 107 Recommendation #12: Transform organizational structures and management tional VHA standards, while also processes to ensure adherence to na promoting decision making at the lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the spread of best practices. ... 120 Recommendation #13: Streamline and focus organizational performance measurement in VHA using core metrics that are identical to those used in the private sector, and establish a personnel performance management system for health care leaders in VHA that is distinct from performance measurement, is based on the lead ership competency model, assesses leadership ability, and measures the achi evement of important organizational strategies. ... 128 Diversity and Cultural Competence ... 135 Recommendation #14: Foster cultural and military competence among all VHA Care System leadership, providers, and staff to embrace diversity, promote e veteran health outcomes. ... 135 cultural sensitivity, and improv Workforce ... ... 139 Recommendation #15: Create a simple-to-administer alternative personnel system, in law and regulation, which governs all VHA employees, applies best practices from the private sector to human capital management, and supports pay and benefits that are competitive with the private sector. ... 139 Recommendation #16: Require VA and VHA executives to lead the transformation of HR, commit funds, and assign expert resources to achieve an effective human capita l management system. ... 149 Eligibility ... ... 155 Recommendation #17: Provide a streamlined path to eligibility for health care for those with an other-than-honorable disc harge who have substantial honorable 155 service. ... viii

11 T ABLE OF ONTENTS AND C L ISTS OF IGURES AND T ABLES F Recommendation #18: Establish an exp ert body to develop recommendations for benefit design. ... 161 VA care eligibility and E VISION AN D MODEL ... 171 APPENDIX A: FINANCING TH APPENDIX B: LEADERSHIP IMPLEMENTA TION ... 191 APPENDIX C: PILOT PROJECTS FOR EVALUATING EXPANDED CARE ... 201 APPENDIX D: HISTORY AS A CONTEXT FOR SYSTEMIC TRANSFORMATION . 207 APPENDIX E: THE EVOLVING HEALTH CARE INDUSTRY ... 217 APPENDIX F: THE COMM ISSION’S PR OCESS ... 225 APPENDIX G: VETE RAN FEEDBACK ... 243 APPENDIX H: ADDITI ONAL RESOURCES ... 253 APPENDIX I: ENABLI NG LEGISLATION ... 261 APPENDIX J: COMPOSITIO N OF THE COMMISSION ... 275 APPENDIX K: CO MMISSION STAFF ... 287 APPENDIX L: ACRONYM LIST ... 289 ix

12 OMMISSION ON C F INAL R EPORT ARE C LIST OF FIGURES Figure 1. Projected Costs of Recommended Option ... 33 Figure 2. Disparities Among Veterans in the Incidence of Hepatitis C Virus ... 52 Figure 3. The Complicated Process of M eeting and Managing VHA’s Capital-Needs ... 64 Figure 4. VA IT Spending ... ... 69 Figure 5. Organizations Compri sing VA’s Supply Chain ... 85 Figure 6. Diversity of Seni or-Level Hires in VHA... 1 11 Figure 7. Minority Women are Under Repres ented in Higher-Level Positions in VHA ... 112 Figure 8. At Each Leadership Level, Master y of Leadership Competencies Increases ... 115 6 Organizational Chart ... 12 Figure 9. Proposed VHA 26 Organizational Chart ... 1 Figure 10. Current VHA Figure A-1. Changes in Number of Veter ans, Enrollees over a 20-year Period ... 172 Figure A-2. Projected Costs of Recommended Option ... 178 Figure A-3. Projected Cost s of CDS Alternative 1 ... 181 Figure A-4. Projected Cost s of CDS Alternative 2 ... 182 Figure A-5. Projected Cost 183 s of CDS Alternative 3 ... Selected Services Scenario ... 184 Figure A-6. Projected Costs of Keep Figure A-7. Projected Costs of Premium Support Scenario ... 186 Figure A-8. Projected Costs of Eligibility Expansion Scenario ... 187 Figure A-9. Cost of Hiring A dditional RN Care Managers ... 188 Figure A-10. Projected Costs of Temporarily Covering Veterans with OTH Discharges ... 189 x

13 T C ABLE OF ONTENTS AND L F T ABLES ISTS OF IGURES AND LIST OF TABLES ... 5 Table 1. VHA Care System Operations ... Table 2. VHA Care System Operations ... ... 29 Table 3. Major Health Conditions in Racial/Ethnic Minority Groups ... 51 Table 4. Comparison of Health Outcomes by Race ... 52 Table 5. Overview of VHA Care System Governing Board ... 98 Table 6. Cultural Transformatio n Efforts in VA and VHA ... 103 Table 7. White Males are Over Represented in VHA SES Development Program, HCLDP ... 113 Table 8. Priority Groups ... ... 164 Table B-1. Organizational Health and Cultural Transformation ... 191 Table B-2. Recruitment, Retention, Development, and Advancement ... 193 Table B-3. Organizational St ructure and Function ... 1 96 trics and Management ... 199 Table B-4. Performance Me Table B-5. Leadership Implementation: Human Capital Management ... 200 ructure and Topics ... Table F-1. Workgroup St . 231 Table F-2. Alignment Wo rkgroup Activities ... . 232 Table F-3. Health Care Operat ions Workgroup Activities ... 234 Table F-4. Data, Tools & Infrastr Activities ... 235 ucture Workgroup Table F-5. Leadership Workgroup Activities ... . 237 Table F-6. VA Facility Site Visit Locations ... ... 240 Table F-7. SWOT Analysis of Commi ssioner Site Visit Observations ... 242 Table G-1. Veteran Profiles Developed by the VA Center for Innovation ... 246 xi

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15 EXECUTIVE SUMMARY pulation of data systems to cover up long Two years ago, a scandal over VHA employees’ mani and left the veterans’ health care system appointment scheduling delays made headlines reeling. The White House and Congress investigated the situation and identified chronic troubled organizational culture. The White management and system failures, along with a cretary of veterans affairs (SECVA) and the House appointed new leadership, including the se undersecretary of health (USH), and Congress e nacted substantial legislation that established a temporary program, the Choice Program, to fund expanded community care to alleviate wait times; directed a comprehensive independent assessment of VHA care delivery and management systems; and established this commission to review that assessment, examine how veterans’ care should be organized and access to care, and look more expansively at delivered during the next 2 decades. The independent assessment included an examination of the hospital care, medical services, 1 and other health care provid ed in VA medical facilities. The legislation identified 12 specific areas for in-depth evaluation:  Demographics Staffing/Productivity  Health Care Capabilities Health Information Technology   Business Processes   Care Authorities Supplies   Access Standards Facilities   Scheduling – Workflow  Leadership  Workflow–Clinical The Independent Assessment Report provided a detailed analysis of the assessment and associated Independent findings. The Commission work during the past 10 months was informed by the Assessment Report gs (held in 12 sessions) with testimony , as well as by 26 days of public meetin by a broad range of experts and stakeholders, intensive deliberations, site visits to VHA facilities, and very importantly by the wide-r anging experience and expertise of commission members appointed by congressional leaders and the President. In an effort to focus the Commission’s recommendations and set the tone for subsequent a vision, a mission, and a set of values to drive reform as change, the Commissioners developed shown below. The vision provides the conceptual framework for the model of veterans’ health care put forth in this report, and the mi ssion and values shape the content of the recommendations. Vision e quality, access, choice, and well-being. Transforming veterans’ health care to enhanc  Quality: Provide community-based, innovati ve care that drives improved outcomes.  Access: Ensure timely access to the best prov iders for meeting veterans’ health care needs. 1 No. 113–146, § 201(a)(1). Veterans Access, Choice, and Accountability Act of 2014, Pub. L. 1

16 C F INAL R EPORT OMMISSION ON C ARE  Choice: Integrate health care within communi ties to foster convenience and efficiency.  Well-Being: Support veterans in achieving optimal physical and mental health. Mission Provide eligible veterans prompt access to quality health care. Values  Provide veteran-centric care.  Involve all stakeholders, and especially vete rans and their families, in designing the evolving future health care for veterans.  Assimilate veterans into the greater community.  Create community-based integrated networks to improve health care access and choice for veterans. The recommendations in this report acknowledge that although VHA provides health care that is in many ways comparable or better in clinical quality to that generally available in the private cility, and can be substantially compromised by sector, it is inconsistent from facility to fa tioning operational systems and processes. problems with access, service, and poorly func Some of these challenges are not exclusive to VHA, and reflect large-scale problems in the U.S. health system in general, such as acute shor tages of primary care doctors and lack of health care capacity in poor and rural areas. Other chal lenges reflect deficiencies within VHA itself, in areas such as staffing, facilities, capital needs, information systems, healthcare disparities and procurement. It is important to understand VA’s long histor y as a health care provider, which has included previous cycles of crisis and renewal that offer lessons for the present. It is also important to consider how VHA can implement major reform in a manner that is sustainable. This report addresses both of these issues. The Commission’s focus on access to care clearly highlighted the need for a long-range strategic ccess problems were the primary catalyst for the evaluation of the veterans’ health system. A law establishing this body, and an examination of access has necessarily been central to the commission’s work; however, Congress wisely directed the Commission to undertake a strategic examination as well. The report begins with an Introduction that addresses the controversy over veterans’ health care and gives a brief description of the Commission’s vision for improving it . There are three main recommendation sections: Redesigning the Veterans’ Health Care Delivery System ; Governance, Leadership, and Workforce ; and Eligibility . Each section includes detailed discussions of the high- level areas in which change must occur in the respective areas to facilitate bold reform. The fication of the problem, the Commission’s format for each discussion includes identi recommendations for addressing the problem, background information, analysis, and implementation steps for Congress, VA, and othe r agencies. This executive summary provides a brief overview of each of the recommendations. 2

17 E S XECUTIVE UMMARY n all additional content. Of particular interest For the ease of our readers, the appendices contai Financing the Vision and Model , Leadership Implementation, History as a Context are appendices on for Systemic Transformation, Veteran Feedback Additional Resources. These and other , and appendices provide policymakers and those char ged with implementing the plan with a clear picture of the rationale for the recommendations and the context that frames them. Recommendations ndations to be piecemeal fixes to everyday The Commission does not intend for these recomme problems. Instead, they are presented as th e foundation for far-reaching organizational transformation that adheres to a systems approach. The Commission’s recommendations comprise the essential elements for such transformation. Redesigning the Veterans’ Health Care Delivery System The VHA Care System Recommendation #1: Across the United States , with local input and knowledge, VHA should establish high-performing , integrated community health care networks, to be known as the VHA Care System, from which veterans wi ll access high-quality health care services. Due to changing veteran demographics, increasi ng demand for VHA care in some markets and terans being adjudicated as having service- declining demand in other markets, more ve connected conditions, aging facilities, provider shortages and vacancies, and other factors, VHA faces a misalignment of capacity and demand that threatens to become worse over time. Some facilities and services have low volumes of care concerns, and in high that can create quality demand areas, VHA often lacks the capacity to avoid lengthy wait times and other access issues. ce, and Accountability Act of 2014 (VACAA), With passage of the Veterans Access, Choi Choice Program . It was designed to alleviate Congress tasked VHA with creating the temporary access issues by allowing for greater use of co mmunity care for enrolled veterans who meet the law’s wait-time or distance-to- a-VHA-facility requirements. Both the design and implementation of the law have proven to be flawed. VHA must instead establish high-performing, integrated, community-b ased health care networks, to be known as the VHA Care System. The Commission Recommends That . . .  VHA Care System governing board (see reco mmendation on p. 94) develop a national delivery system strategy, including criteria and standards for creating the VHA Care System, comprising high-performing, in tegrated, community-based health care networks, including VHA providers and fac ilities, Department of Defense and other federally-funded providers and facilities, and VHA-credentialed community providers and facilities. 3

18 C C F INAL R EPORT OMMISSION ON ARE Integrated community-based health care networks be developed with local VHA  r composition is reflective of local needs leadership input and knowledge to ensure thei and veterans’ preferences.  Integrated, community-based health care ne tworks must include existing VHA special- emphasis resources (e.g., spinal cord injury (SCI), blind rehabilitation, mental health, prosthetics, etc.). In areas for which VHA has special expertise, VHA should also play the role of enhancing care in the local co mmunities by collaborating with community care providers to implement services that may not exist, focused on the needs of veterans (e.g., expansion of integrated primary care/mental health care).  Networks be built out in a well-planned, phased approach, overseen by the new governing board, which determines the crit eria for the phases to ensure effective execution of the strategy.  VHA credential community providers. To qualify for participation in community ed with appropriate education, training, networks, providers must be fully credential meets VHA standards, demonstrate high- and experience, provide veteran access that quality clinical and utilization outcomes, de monstrate military cultural competency, and have capability for interoperable data exchange.  Providers in the networks should be pa id using the most contemporary payment approaches available to incentivize quality and appropriate utilization of health care services (i.e., using Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) physician payment methodology being proposed by CMS).  The highest priority access to the VHA Care System be provided to service-connected also be of high priority. veterans, and low-income veterans The current time and distance criteria for co mmunity care access (30 days and 40 miles)  be eliminated.  Veterans choose a primary care provider from all credentialed primary care providers in the VHA Care System. All primary care providers in the VHA Care  System coordinate care for veterans.  VHA Care System provide overall health ca re coordination and navigation support for veterans.  Veterans choose their specialty care provid ers from all credentialed specialty care providers in the VHA Care System with a referral from their primary care provider. The recommendations above work together to su pport the VHA Care System, as outlined in Table 1 below. 4

19 E XECUTIVE UMMARY S Table 1. VHA Care System Operations Key Component Expectations care  Veterans can choose a primary provider from all credentialed primary care providers in the VHA Care System. Choice can receive their care at  Veterans VHA Care System location across the any country with coordination their by primary care provider. All primary care providers in the  VHA Care System must coordinate care for exclusively veterans. Specialty care is from accessed through referrals care providers. primary their  Veterans can choose specialty care providers from all credentialed their from specialty care providers in the VHA Care System with a referral primary care provider. Coordination Care as primary care is traditionally defined internal medicine or family  Although VHA may designate other specialty providers as primary practice, care coordinators based on veterans’ specific health needs (e.g., endocrinologists patients patients, neurologists for diabetic with Parkinson’s disease, for OB/GYN for female patients). of have overall responsibility will ensuring care coordination for  VHA veterans, complex care navigation. including Clinical Operations Recommendation #2: Enhance clinical operations through more effective use of providers oved data collection and management. and other health professionals, and impr A shortage of providers and clinical managers, combined with inadequate support staff and ency of all health professionals, detract from policies that fail to optimize the talents and effici the effectiveness of VHA health care. The problem starts with inadeq uate numbers of providers. Ni nety-four percent of VHA sites with clinically meaningful access delays indica ted that increasing the number of licensed 2 independent practitioners wa s critical or very important to increasing access. At the same time, ineffective use of providers and other health professionals contributes to suboptimal productivity. Highly tr ained clinical personnel are often unable to perform at the top of their license, meaning they spend much of their time performing tasks that should be 3 For example, doctors and nurses often escort patients; clean examination done by support staff. care; and place the orders for consultations, rooms; take vital signs; schedule; document prescriptions, or other necessary care that could be done more cost effectively by support staff. Twenty-three percent of VHA providers identified “not working to top of provider licensure” 4 as a barrier in health care provision. 2 RAND Corporation, Systems and Management Processes of the Department of Independent Assessment of the Health Care Delivery , 95, accessed June 3, 2016, Veterans Affairs, Assessment B (Health Care Capabilities) ceact/documents/assessme nts/assessment_b_health_c are_capabilities.pdf. http://www.va.gov/opa/choi 3 Grant Thornton, Independent Assessment of the Health Care Delivery Sy stems and Management Processes of the Department of Veterans Affairs, Assessment G (Sta ffing/Productivity/Time Allocation) , ix, accessed June 3, 2016, http://www.va.gov/opa/choi ceact/documents/assessme nts/Assessment_G_Staffing _Productivity.pdf. 4 Ibid., 95. 5

20 C C F INAL R EPORT OMMISSION ON ARE advanced practice regist VHA is also currently failing to optimize use of ered nurses (APRNs). provide primary, acute, and specialty health APRNs are clinicians with advanced degrees who care services. The Commission Recommends That. . .  VHA increase the efficiency and effect iveness of providers and other health professionals and support staff by adopting po licies to allow them to make full use of their skills. g requirements under the Millennium Act.  Congress relieve VHA of bed closure reportin  VHA continue to hire clinical managers and mo ve forward on initiatives to increase the supply of medical support assistants. Recommendation #3: Develop a process for a ppealing clinical decisi ons that provides veterans protections at least comparable to those afforded patients under other federally supported programs. All federal providers and most health insurers have processes to ensure that beneficiaries have enforceable protections that allow them to obtain medically necessary care within their health 5 Such processes are imperative, partic ularly for care plans using capitated benefits package. conserve resources. Most veterans, and even payment models for which there are incentives to for resolving clinical disputes. This may be their advocates, are unsure of VHA’s process because there is not one policy in place for VHA, but 18 (one for each Veteran Integrated Service 6 Network [VISN]). As part of the MyVA initiative, the Secretary of Veterans Affairs has set a goal of world-class service for veterans, including a proactive patient advocacy team that is integrated into patient- 7 centered care and cultural transformation plans. The processes in place for patient grievances and central protections to ensure access to medi cally necessary care rema in poorly understood despite these efforts. Also, they may be less comprehensive and fair than appeals processes 8 private health insurers and other fede ral payers are required to provide. The Commission Recommends That . . . VHA convene an interdisciplinary panel to a ssist in developing a revised clinical-  appeals process. 5 MaryBeth Musumeci, A Guide to the Medicaid Appeals Process, accessed June 3, 2016, https://kaiserfamilyfo undation.files.wordpres s.com/2013/01/8287.pdf. 6 VHA Clinical Appeals, VHA Directive 2006-057 (2006). 7 “About the VHA Patient Advocate and Veteran Experience Program (VHA PA & VEP),” accessed from VA Intranet, May 31, 2016, http://vaww.infoshare.va.gov/s ites/OPCC/VEP/ SitePages/vep- about.aspx. 8 MaryBeth Musumeci, A Guide to the Medicaid Appeals Process, accessed June 3, 2016, Appeals, VHA Directive 2006- com/2013/01/8287.pdf. VHA Clinical https://kaiserfamilyfounda tion.files.wordpress. 057 (2006). 6

21 E XECUTIVE UMMARY S provement methodology to support VHA Recommendation #4: Adopt a continuous im transformation, and consolidate best practice s and continuous improvement efforts under the Veterans Engineering Resource Center. identify problems and make changes to improve VHA has not effectively empowered its staff to the overall quality of care. Best practices exist in pockets of VHA; however, communication and support for implementation appear to be challenges. Various facilities indicate best practices are in place Facilities often struggle to implement best but seem isolated rather than widely adopted. 9 practices, and information sharing is limited and ad hoc. rans Engineering Resource Center (VERC)— VHA has a program of system engineering—Vete t it is not well known throughout VHA and until that can assist with transformation efforts, bu recently has been underutilized. The Commission Recommends That . . . The Veterans Engineering Resource Center (VER C) be tasked to assist in transformation  in areas that affect systemwide activities efforts, particularly in areas such as access and human resources management, contracting, and require substantial change, such as purchasing, and information technology.  The many idea and innovation portals wi thin VHA be consolidated under VERC. improvement of workflow processes be  A culture to inspire and support continuous developed and fully funded.  VHA’s reengineering centers be enabled to id entify proactively prob lem areas within the system and offer assistance. Health Care Equity arities among veterans treated in the VHA Recommendation #5: Eliminate health care disp nel and monetary resources to address the Care System by committing adequate person A Health Equity Action Plan is fully causes of the problem and ensuring the VH implemented. The Office of Health Equity (OHE), tasked wi th eliminating health disparities by building cultural and military competence within VHA, has not been given the resources or level of authority needed to be successful. Until VHA lead ership establishes the elimination of health care disparities as a critical strategic priority and commits the resources required to address this problem, health care disparities will cont inue to persist among veteran patients. 9 The MITRE Corporation, Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs , Assessment F (Workflow—Clinical), 14 and A-2, accessed January 1, 2016, http://www.va.gov/opa/c hoiceact/documents/assessments/Asse ssment_F_Workflow_Clinical.pdf. 7

22 C C F INAL R EPORT OMMISSION ON ARE A systematic review of VHA in 2007 identified the existence of racial and ethnic health inequalities. Health care disparities exist amon g veterans and especially among minority and 10 vulnerable veterans. care to enhance quality, access, VHA cannot transform veterans’ health disparities are addressed and eliminated. VHA choice, and well-being unless these health care has a plan for addressing these issues—the Heal th Equity Action Plan (HEAP)—but it has not been fully implemented. The Commission Recommends That . . .  tablishing health care equity as a strategic VHA work to eliminate health disparities by es priority.  VHA provide the Office of Health Equity ad equate resources and level of authority to successfully build cultural and military competence among all VHA Care System providers and employees.  VHA ensure that the Health Equity Action Plan is fully implemented with adequate staffing, resources, and support.  VHA increase the availability, quality, and use of race, ethnicity, and language data to improve the health of minority veterans an d other vulnerable veteran populations with strong surveillance systems that monitor trends in health status, patient satisfaction, and 11 quality measures. Facility and Capital Assets Recommendation #6: Develop and implement a ro bust strategy for meeting and managing VHA’s facility and capital-asset needs. needs should expect that its facilities have been Veterans who turn to VHA to meet health care designed and equipped to provide state-of-the-art care. As health care continues to move to A not only lacks modern health care facilities ever greater use of ambulatory care delivery, VH in many areas, but generally lacks the means to readily finance and acquire space, to realign its sily of unneeded buildings. Many of those barriers facilities as needed, or even to divest itself ea ternal processes compound its capital asset are statutory in nature, although VA’s own in challenges. Establishing integrated care netw orks holds the promise of markedly improving veterans’ access to care. That promise cannot be realized without transformative changes to VHA’s capital structure. Political resistance do omed previous attempts to better align VHA’s capital assets and veterans’ needs. It is critic al that an objective process be established to streamline and modernize VHA faci lities in the context of building out the VHA Care System’s integrated networks to ensure the ideal balance of facilities within each network. VHA needs as 10 Somnath Saha et al., Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review, U.S. Department of Veterans Affairs, Health Services Research & Development Service, June 2007, access ed June 22, 2016, http://www.hsrd.research.va .gov/publications/esp/RacialDisparities-2007.pdf. 11 Kathleen G. Sebelius, Secretary, Department of Health and Human Services, HHS Action Plan to Reduce Racial and Disparities in Health and Health Care Ethnic Health Disparities: A Nation Free of , accessed March 30, 2016, http://www.minorityhealth.hhs.gov/npa/f iles/Plans/HHS/HHS_Plan_complete.pdf. 8

23 E S XECUTIVE UMMARY sure that all facility plans are fully integrated much control as possible to drive the process to en with the strategic vision for the VHA Care System. The Commission Recommends That . . . VA leaders streamline and strengthen the facility and capital asset program  management and operations.  The VHA Care System governing board be responsible for oversight of facility and capital asset management.  Congress provide VHA greater budgetary flexib ility to meets its facility and capital asset needs and greater statutory authority to divest itself of unneeded buildings.  Congress enact legislation to establish a VHA facility and capital asset realignment process based on the DoD Base Realignmen t and Closure Commission (BRAC) process to be implemented as soon as practicabl e. The Commission recommends the VHA Care System governing board subsequently make fa cility decisions in alignment with system needs.  New capital be focused on ambulatory care development to reflect health care trends. ing or selling facilities that have already  VHA move forward immediately with repurpos been identified as being in need of closing. Information Technology s and infrastructure to improve veterans’ Recommendation #7: Modernize VA’s IT system health and well-being and provide the foundatio n needed to transform VHA’s clinical and business processes. , VA requires a comprehensive electronic To operate a high-performing VHA Care System health care information platform that is intero perable with other systems; enables scheduling, s that empower veterans to better manage their billing, claims, and payment, and provides tool platform will promote care continuity, cost health. Creating a single, uniform, integrated IT 12 savings, and consistent care delivery and business processes. VA’s antiquated, disjointed clinical and administrative systems cannot su pport these essential clinical and business processes and consequently are unable to suppo rt the Commission’s transformation vision for VHA. In addition, VHA lacks an experienced seni or health care IT leader focusing on the strategic health care IT needs of veterans. The Commission Recommends That . . .  VHA establish a Senior Executive Service (SES )-level position of VHA Care System chief information officer (CIO), selected by and reporting to the chief of VHA Care System (CVCS) with a dotted line to the VA CIO. The VHA CIO is responsible for developing 12 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 43-44, accessed February 25, 2016, integrated_report.pdf. http://www.va.gov/opa/choice act/documents/assessments/ 9

24 C F INAL R EPORT C OMMISSION ON ARE and implementing a comprehensive health IT strategy and developing and managing the health IT budget.  VHA procure and implement a comprehens ive, commercial off-the-shelf (COTS) information technology solution to include clinical, operational and financial systems that can support the transformation of VHA as described in this report. Supply Chain ment of the supply chain in VHA. Recommendation #8: Transform the manage chain has become a competitive differentiator Effective management of all aspects of the supply for health care delivery systems. Modernization and automation of the supply chain in health care have the potential to save hundreds of millions of dollars, if done well. VHA cannot modernize its supply chain management and create cost efficiencies because it is encumbered expert leadership, antiquated IT systems that with confusing organizational structures, no inhibit automation, bureaucratic purchasing requirements and procedures, and an ineffective approach to talent management. The problems are systemic. The organizational stru cture is chaotic, contracting operations are not aligned to business functions, and processes are poorly constructed, lacking standardization across the organization. Information technology infrastructure is inadequate, and it lacks A is unable to produce appropriate interoperability among IT systems. VH high-quality data on y manage the process using the insights such supply chain utilization and does not effectivel 13 data could provide. The Commission Recommends That . . .  VHA establish an executive position fo r supply chain management, the VHA chief supply chain officer (CSCO), to drive su pply chain transformation in VHA. This individual should be compensated relative to market factors.  VA and VHA reorganize all procurement an d logistics operations for VHA under the CSCO to achieve a vertically integrated busi ness unit extending from the front line to central office. This business unit would be responsible for all functions in a fully integrated procure-to-pay cycle managemen t that includes policy and procedures, contract development and solicitation, or dering, payment, logistics and inventory management, vendor relations and integr ation, data analytics and supply chain visibility, IT alignment, clinician en gagement and value analysis, and talent management across all these supply chain functions.  VA and VHA establish an integrated IT sy stem to support business functions and supply chain management; approp riately train contracting and administrative staff in supply chain management; and update supply chain management policy and procedures to be consistent with best practice standards in health care. 13 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies), vi, accessed April 29, 2016, t/documents/assessments/Asse http://www.va.gov/opa/choiceac ssment_J_Supplies.pdf. 10

25 E S XECUTIVE UMMARY VHA support the Veterans Engineering Re source Center (VERC) Supply Chain  tent support from leadership, continued Modernization Initiative including consis funding and personnel, and the alignment of plans and funding within OIT to accomplish the modernization goals. Governance, Leadership, and Workforce Board of Directors ors to provide overall VHA Care System Recommendation #9: Establish a board of direct and oversee the tran sformation process. governance, set long-term strategy, and direct long delays in care at the Phoenix VA The existence—and concealment—of unacceptably other VA medical centers, had both direct and Medical Center, and similar problems at multiple 14 As the indirect causes. Weak governance was foun d to be among those indirect causes. authors of a root-cause analysis of the Phoe nix scandal highlighted, “a governance gap in leadership continuity and strategic oversight fr om one executive leadership team to another” 15 contributed to the wait-time problems. The report authors observed, “Unlike other health care 16 vernance mechanism to fill the role systems, VHA does not have a go of a board of directors.” The governance limitations made evident in th e Phoenix scandal have profound implications for the long term. As discussed in this repo rt, the Commission believes VHA must institute a far-reaching transformation of both its care delivery system and the management processes supporting it. Changes of the magnitude facing VHA would be difficult for any health care system to achieve. A transformation will take ye ars to accomplish and must be sustained over ppointees, each administration’s expectations for time. Yet the short tenure of senior political a 17 short-term results, and VHA’s operating in a “dynamic environment [in which it is] answering 18 to a large number of stakeholders, sometimes with competing demands” offer little reason for optimism that real transformation could take hold without fundamental changes in governance. The Commission Recommends That . . . Congress provide for the establishment of an 11-member board of directors accountable  ll VHA Care System governance, and with to the President, responsible for overa transformation process and set long-term decision-making authority to direct the strategy. The Commission also recommends the governing board not be subject to the Federal Advisory Committee Act (FACA) and be structured based on the key elements included in Table 5. 14 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, xvi, accessed June 15, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 15 Booz Allen Hamilton, Veterans Health Administration (VHA) National Cent er for Patient Safety (NCPS) Systems Review: Final Report, September 22, 2015, 3. 16 Ibid. 17 Ibid. 18 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, xiv, accessed June 15, 2016, integrated_report.pdf. http://www.va.gov/opa/choice act/documents/assessments/ 11

26 C F INAL R EPORT OMMISSION ON C ARE  The Board recommend a chief of VHA Care System (CVCS) to be approved by the President for an initial 5-year appointmen t. Additionally, the Commission recommends the governing board be empowered to reappo int this individual for a second 5-year term, to allow for continuity and to protect the CVCS from political transitions. If necessary, the CVCS can be removed by mu tual agreement of the President and the governing board. Leadership levels of the organization to champion a Recommendation #10: Require leaders at all focused, clear, benchmarked strategy to transform VHA culture and sustain staff engagement. High-performing organizations have healthy cultur es in which diverse staff feel respected and engaged at work. These workers, in turn, are be tter able to demonstrate compassion and caring toward customers in their delivery of high-q uality services. Leaders at all levels of the organization are responsible for promoting a po sitive organizational environment and culture through how they treat staff and the systematic approach they take to decision making and management. VHA has among the lowest scores in organizational health in government. For hasized the importance of leadership attention the past decade, VHA’s executives have not emp to cultural health, and it has not been well inte grated in training, assessments, and performance accountability systems. The Commission Recommends That . . .  VHA create an integrated and sustainable cultural transformation by aligning all programs and activities around a single, benchmarked concept.  VHA align leaders at all levels of the organization in support of the cultural transformation strategy and hold them accountable for this change.  VHA establish a transformation office to drive progress of this transformation and VHA Care System board of directors (see report on it to the CVCS and the new governance discussion in the previous section). leadership succession based on a Recommendation #11: Rebuild a system for benchmarked health care competency model th at is consistently applied to recruitment, development, and advancement wi thin the leadership pipeline. cellent leaders to succeed. Succession planning VHA, like any large organization, requires ex and robust structured programs to recruit, retain , develop, and advance high potential staff are essential to maintaining a pipeline of new leaders. In health care, leadership programs must prepare candidates with the specialized know ledge and skills required of health care executives, while also helping to mature their leadership traits. VHA does not use a single leadership competency model, and what it do es use is not specific to health care or es not use competency models as a tool to benchmarked to the private sector. VHA also do establish standards for hiring, assessment, and promotion. As a result, executive leaders and 12

27 E XECUTIVE UMMARY S need to guide career transitions and ensure promising staff members do not have the tools they VHA has the leaders it needs for the future. The Commission Recommends That . . . for VHA, the goal of implementing an VA establish, as an OMB management priority  effective leadership management system in the agency. VHA executives prioritize th e leadership system for funding, strategic planning, and  investment of their own time and attention. VHA adopt and implement a comprehensive system for leadership development and  iority of diversity and inclusion. management that includes a strategic pr Congress create more opportunities to attract outside leaders and experts to serve in  temporary rotations and direct hiring of VHA through new and expanded authority for senior military treatment facility leaders, health care management training graduates, alth care leaders and technical experts. and private not-for-profit and for-profit he structures and management processes to Recommendation #12: Transform organizational while also promoting decision making at the ensure adherence to national VHA standards, lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the spread of best practices. organized to promote agile, clear decision Leadership structures and processes should be making, the free flow of ideas, and identification of organizational priorities, as well as make tability within the organization. VHA currently clear reporting relationships and lines of accoun anizational structure, and clear role definitions lacks effective national policies, a rational org that would support effective leadership of the or ganization. The responsibilities of VHA Central Office (VHACO) program offices are unclear, and the functions overlap or are duplicated. The role of the VISN is not clear, and the delegated responsibilities of the medical center director are not defined. The Commission Recommends That . . .  VHA redesign VHACO to create high-perfo rming support functions that serve VISNs and facilities in their delivery of veteran-centric care.  VHA clarify and define the roles and resp onsibilities of the VISNs, facilities, and reorganized VHA program offices in relati on to one another, and within national standards, push decision making down to the lowest executive level with policies, budget, and tools that support this change.  VHA establish leadership communication mechanisms within VHACO and between VHACO and the field to promote transpa rency, dialogue, and collaboration.  VHA establish a transformation office, repo rting to the CVCS with broad authority and a supporting budget to accomplish the transformation of VHA and manage the large-scale changes outlined throughout this report. 13

28 C OMMISSION ON ARE F INAL R EPORT C nizational performance measurement in Recommendation #13: Streamline and focus orga ose used in the privat e sector, and establish VHA using core metrics that are identical to th a personnel performance management system for health care leaders in VHA that is distinct from performance me asurement, is based on the le adership competency model, d measures the achievement of important organizational assesses leadership ability, an strategies. To achieve the Commission’s vision of quality, access, and choice for veterans, VHA must ers accountable for improvement. VHA can effectively measure outcomes and hold lead t veterans deserve care that uniformly meets or measure itself against internal best practices, bu concise, balanced measure set—identical to exceeds private-sector quality standards. A clear, ff, and administrators focus and direction for private-sector standards—will give leadership, sta ring these quality outcomes to veterans. They their work. VHA leaders are responsible for delive in their management and direction to staff. Short- do so by exercising leadership skills and traits term gains can be realized at the expense of staff morale and well-being, but the long-term health of the organization cannot. Therefore, or ganizations must be sure to assess leaders’ they achieve it. how performance not just on what they achieve but The Commission Recommends That . . . Organizational Performance Measurement  VHA streamline organizational performance measures, emphasize strategic alignment and meaningful effect, and use benchmarked meas ures that allow a direct comparison to the private sector.  The new Office for Organizational Excellence work with experts to reorganize its internal structure to align business functi ons with field needs and consolidate and eliminate redundant or lo w-priority activities. Personnel Performance Management System  VHA create a new performance management system appropriate for health care executives, tied to health ca benchmarked to the private re executive competencies, and sector. The CVCS and all secondary raters hold primary raters accountable for creating  meaningful distinctions in performance among leaders.  VHA recognize meaningful distinctions in performance with meaningful awards. Diversity and Cultural Competence Recommendation #14: Foster cultural and mi litary competence among all VHA Care System leadership, providers, and staff to embr ace diversity, promote cultural sensitivity, and improve veteran health outcomes. approach to developing the cultural and The VHA Care System must implement a systemic d providers, as well as measure the effects of military competence of its leadership, staff, an 14

29 E S XECUTIVE UMMARY r vulnerable veterans. these efforts on improving health outcomes fo Although VHA has made some strides in specific program areas, cultural competency is an essential part of providing ique needs military service, and especially effective care to veterans because of the un participation in combat operations, may cause. The Commission Recommends That . . .  VHA implement a systemic approach to esta blishing cultural and military competence across VHA and its community providers, and provide the resources required to fully integrate the related strategy in to veterans’ care delivery.  Cultural and military competency training be required on a regular basis for VHA Care System leadership, staff, and providers.  Cultural and military competency be criter ia for allowing community providers to participate in the VHA Care System. Workforce Recommendation #15: Create a simple-to-administ er alternative personnel system, in law and regulation, which governs all VHA employees , applies best practices from the private sector to human capital management, and suppo rts pay and benefits that are competitive with the private sector. VHA has staffing shortages and vacancies at every level of the organization and across adership, clinical staff, supply chain personnel, numerous critical positions, including facility le and customer service staff. VHA lacks competitiv e pay, must use inflexible hiring processes, and continues to use a talent management approach from the last century. A confusing mix of ke staffing and management a struggle for both personnel authorities and position standards ma 5 was not created with a modern health care supervisors and human resources personnel. Title delivery system in mind and falls short of offeri ng what is needed to create a high-performing health care system. The Commission Recommends That . . . Congress create a new alternative personnel system that applies to all VHA employees  and falls under Title 38 authority. The syst em must simplify human capital management in VHA; increase fairness for employees; an d improve flexibility to respond to market conditions relating to compensation, benefits, and recruitment.  VHA write and implement regulations for th e new alternative personnel system, in collaboration with union partners, employ ees, and managers, that does all of the following: - Meets benchmark standards for human capital management in the health care sector and is easy for HR professio nals and managers to administer. Promotes veteran preferences and hiring. - 15

30 C F INAL R EPORT OMMISSION ON C ARE - Embodies merit system principles (merit-b ased, nonpartisan, nondiscrimination, due process) through simplified, sensible processes that work for managers and employees. - Creates one human capital management proc ess for all employees in VHA for time performance evaluati on, and disciplinary and leave, compensation, advancement, standards/processes. - Provides due process and appeals stand ards to adverse personnel actions. Allows for pay advancement based on pr - ofessional expertise, training, and demonstrated performance (not time-in-grade). - Promotes flexibility in organizational struct ure to allow position s and staff to grow as the needs of the organization change and the success of each individual merits. Establishes simplified job documentation that is consistent across job categories and - development and career trajectories for describes a clear path for staff professional advancement. - Eliminates most distinctions (except for benefits) between part-time and full-time employees. - Grandfathers current employees with respect to pay and benefits.  VHA ensure all positions, to include human resources management staff, are adequately trained to fulfill duties. Recommendation #16: Require top executives to lead the transformation of HR, commit funds, and assign expert resources to achi eve an effective human capital management system. Effective planning for and management of human capital are core enabling requirements for e employees fails, then the organization fails. any business: If the system that supports th Executive leaders must ensure the success of hu man capital management; however, for too long top priority for leadership time, attention, in VA, human capital management has not been a and funding support. Human capital management personnel must be equal members of the leadership team, contributing fully to strategi c decisions and planning for future initiatives. The Commission Recommends That . . . sponsibility for the operation’s entire HR  VHA hire a chief talent leader who holds re enterprise, is invested with the authorit y and budget to accomplish the envisioned transformation, and reports directly to the chief of VHA Care System.  VA and VHA prioritize the transformation of human capital management with adequate attention, funding, and continuity of vision from executive leaders. VA align HR functions and processes to be co nsistent with best practice standards of  high-performing health care systems. 16

31 E S XECUTIVE UMMARY and the Office of Information and  VA Human Resources and Administration Technology should create an HR informatio n technology plan to support modernization l data for tracking, quality improvement, of the HR processes and to provide meaningfu and accountability. Eligibility Recommendation #17: Provide a streamlined path to eligibility for health care for those with an other-than- honorable discharge who have substantial honorable service. Addressing access issues is at the core of th e Commission’s charge. Veterans face a range of barriers to care, from geographic barriers to faci lity-specific problems, such as long wait times for an appointment or lack of evening or week end hours. These barriers, which affect even those with service-incurred health conditions, can be overcome. Some fo rmer service members, however, have encountered a more fundamental ba rrier when applying for care. Because of the character of their discharge, they are not consider ed veterans, and thus are not eligible for VA care. In some cases, individuals have been dismisse d from military services with an other-than- honorable (OTH) discharge because of actions that resulted from health conditions (such as traumatic brain injury [TBI], po sttraumatic stress disorder [PTSD] , or substance use) caused by, duals do not meet the or exacerbated by, their service. Under VA re gulations, these indivi definition of a veteran, and are therefore ineligib le for VHA medical care. This situation leaves a ers who have service-incurred he alth issues (namely mental group of former service memb health issues) unable to receive the specialized care VHA provides. The Commission Recommends That . . . VA revise its regulations to provide tentative eligibility to receive health care to former  scharge who are likely to be deemed eligible because of service members with an OTH di their substantial favorable service or extenu ating circumstances that mitigate a finding of disqualifying conduct. Recommendation #18: Establish an expert body to develop recommendations for VA care eligibility and be nefit design. Although VHA continues to offer the promise of heal th care to all eligible veterans, its capacity 19 to meet that promise is constrained by appropriated funding. The Commission Recommends That . . .  The President or Congress task another body to examine the need for changes in eligibility for VA care and/or benefits design, which would include simplifying eligibility criteria, and may include pilots fo r expanded eligibility for nonveterans to use 19 The MITRE Corporation, Independent Assessment of the Health care Delivery Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 24, accessed April 11, 2016, integrated_report.pdf. http://www.va.gov/opa/choice act/documents/assessments/ 17

32 C C F INAL R EPORT OMMISSION ON ARE s, providing payment through private underutilized VHA providers and facilitie insurance. The SECVA revise VA regulations to provide  that service-connected-disabled veterans be afforded priority access to care, subject only to a higher priority dictated by clinical care needs. Conclusion The next 20 years will see continued dynamic change in health care, well beyond the Commission’s capacity to forecast the future. What is clear, though, is that the concept of access to care is itself undergoing marked change. Th e potentially explosive growth of telemedicine, increasing emphasis on preventive care, and lik ely proliferation of technologies that permit routine home-based health monitoring and ca re of patients with chronic illnesses will dramatically affect access needs. We are also witnessing profound changes in the nature of patient–provider engagement and in where and how care is delivered. VHA must keep pace with, and even be a leader in, these changes. Patient-access is a sharp lens through which to gauge how well a health system is functioning, particularly if we understand access to reflect not only timeliness, but care quality, and patient expectations. Providing veterans timely care remains a challenge today, notwithstanding establishment of the and VHA leadership’s focus on improving access. Access is Choice Program not a problem for VHA alone: Delivering timely care is challenging for many providers and health systems, in part due to the unavailability of providers in some communities and national shortages of some categories of health professionals. For VHA, an important conclusion is that providin g timely access to care is not simply a matter of increasing staffing, modernizing IT systems, installing new leadership, or any other single effort, although all of these changes are needed. As the Independent Assessment Report emphasized, multiple systemic problems have co ntributed to VHA’s access problems, and an integrated systems approach is essential to addr ess the myriad issues affecting access to care and the service veterans receive. The Commission’s report underscores the importanc e of transforming VA health care delivery and the systems that underlie it. In employing the term transformation, the Commission means fundamental, dramatic change—change that requires new direction, new investment, and profound reengineering. Some will question that view, and perhaps challenge the notion that the nation should invest further in the VA heal th care system. None, however, should question the nation’s obligation to those who sustained in jury or illness in service, or who are at increased health risk as a result of deployme nts to combat zones or other service-related experiences. In this report, the Commission fully acknowledges the deep problems the Independent Assessment Report described. Importantly, though, the Co mmission recognizes the VA health some unique and exceptional clinical programs care system has valuable strengths, including of veterans who turn to VA for care. For and services tailored to the needs of the millions 18

33 E UMMARY XECUTIVE S example, VHA’s behavioral health programs, part icularly with their integration of behavioral health and primary care, are largely unrivalled, and profoundly important to many who have suffered from the effects of battle and for whom VHA is a safety net. Even considering these strengths, some may question how a system beleaguered with the problems VHA faces can achieve lofty transformation goals. This is not th e first time VHA has faced challenges; however, and history has demonstrated that with appr opriate structure and strategies in place, transformation can be achieved and sustained. ill require careful stewardship, sustainable Transformation is a difficult process that w leadership, and unwavering focus and commitmen t to the long-term vision and strategy. The Commission’s recommendations in some area s acknowledge VHA’s efforts to begin the transformation process and suggest that wher e these efforts align with the Commission’s recommendations, they should be sustained. Re aping the fruits of transformation will take more than a single Congress or a single 4-year administration. For this reason, the Commission strongly recommends a new governance model and an extended term for the leader of the VHA Care System to sustain a continuing transfo rmation. Even should VHA implement all the Commission’s recommendations, it will not succeed in transforming on its own; it will require the full support from both the White House and Congress. Our nation’s veterans deserve no less. 19

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35 INTRODUCTION anipulating data systems to cover up long Two years ago, a scandal over VHA employees m alth care system reeling. The White House and delays in scheduling care left the veterans’ he Congress investigated the situation and identified chronic management and system failures, along with a troubled organizat ional culture. In response, the White House appointed new leadership, including the secretary of veterans affairs (SECVA) and undersecretary of health (USH), and Congress enacted substantial legislat ion that established a temporary program, the Choice Program, to fund expanded community care to alleviate wait times; directed a comprehensive independent assessment of VHA care delivery and management systems; and established this commission to review that assessment, examine access to care, and look more expansively at how veterans’ care should be orga nized and delivered during the next 2 decades. The Commission on Care’s work during the past 10 months was informed by the Independent Assessment Report , as well as by 26 days of public meetin gs (held in 12 sessions) with testimony by a broad range of experts and stakeholders, intensive deliberations, site visits to VHA facilities, and very importantly by the wide-r anging experience and expertise of commission members appointed by congressional leaders and the President. The charge given this Commission, with its emphas is on access to care, reflects the need for a long-range strategic evaluation of the veter ans’ health system. Access problems were the primary catalyst for the law establishing this body, and an examination of access has necessarily been central to the Commission’s work; however, Congress wisely directed the Commission to undertake a strategic examination as well. The next 20 years will see continued dynamic change in health care, well beyond the Commission’s capacity to forecast the future. What is clear, however, is that the concept of change. The potentially explosive growth of access to care is itself undergoing marked telemedicine, increasing emphasis on preventive care, and likely proliferation of technologies that permit routine home-based health monitori ng and care of patients with chronic illnesses witnessing profound changes in the nature of will dramatically affect access needs. We are also how care is delivered. VHA must keep pace patient–provider engagement, and in where and with, and even be a leader, in these changes. Patient-access is a sharp lens through which to gauge how well a health system is functioning, access to reflect not only timeliness, but care quality and patient particularly if we understand expectations. Providing veterans timely care remains a challenge today, notwithstanding establishment of the Choice Program and VHA leadership’s focus on improving access. Access is not a problem for VHA alone; Delivering timely care is challenging for many providers and health systems, in part due to the unavailability of providers in some communities and national shortages of some categories of health professionals. For VHA, an important conclusion is that providin g timely access to care is not simply a matter of increasing staffing, modernizing IT systems, installing new leadership, or any other single effort, although all of these changes are needed. As the Independent Assessment Report 21

36 C C F INAL R EPORT OMMISSION ON ARE ntributed to VHA’s access problems, and an emphasized, multiple systemic problems have co integrated systems approach is essential to addr ess the myriad issues affecting access to care and the service veterans receive. The commission’s report underscores the importanc e of transforming VA health care delivery transformation and the systems that underlie it. In employing the term , the commission means fundamental, dramatic change—change that requires new direction, new investment, and view, and perhaps challenge the notion that profound reengineering. Some will question that the nation should invest further in the VA heal th care system. None, however, should question the obligation owed those who sustained injury or illness in service, or who are at increased health risk as a result of deployments to comb at zones or other service-related experiences. In this report, the Commission acknowledges the deep problems the Independent Assessment Report described. Importantly, though, the commissi on recognizes the VA health care system has valuable strengths, including some unique and exceptional clinical programs and services who turn to VA for care. For example, VHA’s tailored to the needs of the millions of veterans their integration of behavioral health and behavioral health programs, particularly with primary care, are largely unrivalled, and prof oundly important to many who have suffered from the effects of battle and for whom VHA is a safety net. Others may question how a system with the range of problems VHA faces can meaningfully improve, let alone realize a tran sformation. Mindful of its 20-ye ar charge, the Commission notes that VA health care faced similar challeng es 20 years ago and underwent a historic transformation. The long history of the VA heal th care system has seen highs and lows. Among the lessons in that history is that the mission —to care for those who have borne the battle—is not only powerful, but enduring. History has demonstrated that transformation can be es for sustainability must be built into the achieved, but also that structures and strategi framework. is difficult. It is a process that will require As the commission report emphasizes, transformation careful stewardship, sustainable leadership, and unwavering focus and commitment to the long-term vision and strategy. VHA has begun some of this work; our recommendations in est that where they are aligned with the some areas acknowledge VHA’s efforts and sugg Commission’s recommendations, they should be su stained. The fruits of the transformation, though, will not be realized over the course of a single Congress or a single 4-year administration. For this reason, the Commission, strongly recommends a new form of governance and an extended term for the leader of the VHA Care System to sustain a continuing transformation. Even should VHA implement all the Commission recommends, it will not succeed in transforming on its own; it wi ll require the full support from both the White House and Congress. Our nation’s veterans deserve no less. 22

37 COMMISSION RECOMMENDATIONS Redesigning the Veterans’ Health Care Delivery System The VHA Care System local input and Recommendation #1: Across the Unit ed States, with knowledge, VHA should establish high -performing, integrated community- known as the VHA Care System, from based health care networks, to be -quality health care services. which veterans will access high Problem The Commission Recommends That . . . Due to changing veteran VHA  System governing board (see Recommendation #9) Care demographics, increasing demand for criteria develop a national system strategy, including delivery VHA care in some markets, and and standards for creating the VHA Care System, comprising declining demand in other markets, ‐ ‐ performing, integrated, community high based health care more veterans being adjudicated as facilities, and Department networks, including VHA providers having service-connected conditions, ‐ of Defense and other federally and funded providers facilities, and VHA facilities. ‐ credentialed community providers and aging facilities, provider shortages and based be health  Integrated, community ‐ care networks vacancies, and other factors, VHA leadership developed with local VHA to input and knowledge faces a misalignment of capacity and ensure their composition is reflective of local needs and demand that threatens to become veterans’ preferences. worse over time. Some facilities and based ‐ Integrated,  community must networks care health services have low volumes of care that emphasis include existing VHA special ‐ resources (e.g., spinal can create quality concerns, and in cord injury (SCI), blind rehabilitation, mental health, etc.). which prosthetics, special In areas for VHA has high demand areas, VHA often lacks the expertise, VHA should also play role of enhancing care in the capacity to avoid lengthy wait care the local communities by collaborating with community times and other access issues. services focused exist, not may that providers to implement veterans expansion the needs of on (e.g., of integrated With the passage of the Veterans primary care/mental health care). Access, Choice, and Accountability Act ‐ approach, phased  Networks be built out in a planned, well of 2014 (VACAA), Congress tasked the overseen by the new governing board, which determines criteria for the phases to the ensure effective execution of VHA with creating the temporary strategy. Choice Program . It was intended to alleviate access issues by allowing for => page. Recommendations continue on next greater use of community care for enrolled veterans who meet the law’s wait-time or distance-to-a-VHA-facility requirements. 23

38 EPORT C F INAL R ARE C OMMISSION ON Both the design and implementation of The Commission Recommends That . . . the law have proven to be flawed. VHA must instead establish high- page. previous from Recommendations <= continued performing, integrated, community- based health care networks, to be  providers. community credential VHA To qualify for networks, participation in community providers fully be must known as the VHA Care System. appropriate with credentialed and training, education, meets experience, provide veteran access VHA that Background quality standards, demonstrate high ‐ clinical and utilization VHA has long had authority to outcomes, military and competency, cultural demonstrate purchase hospital care and medical capability have for interoperable data exchange. services based on geographic the  Providers in the most networks be paid using inaccessibility or VHA’s lack of a approaches incentivize contemporary payment available to 20 required service. In 2013, VA moved care services quality and appropriate utilization of health beyond the use of individual using (i.e., of Act Reauthorization CHIP and Access Medicare physician methodology payment [MACRA] 2015 being purchased-care authorizations to by proposed CMS). regional contracting under the Patient-  The highest priority access be System Care VHA the to Centered Community Care (PC3) and to service ‐ connected veterans, income ‐ low provided 21 Program. In all cases, purchased care priority. veterans also of high be was a secondary means of providing current The  care community for criteria distance and time care, to be used “when VA health care be access (30 days and 40 miles) eliminated. 22 facilities are not feasibly available.” from primary provider choose Veterans  all care a Choice Even before the creation of the primary care credentialed providers the VHA Care in System. Program in 2014, some 10 percent of  primary care providers in the VHA Care System coordinate All VHA medical spending went for care veterans. for purchased-care services. Care System overall health care VHA The  provide veterans. navigation coordination and support for When Congress enabled what became providers  Veterans choose care specialty all from their , it tasked Choice Program known as the in providers care specialty credentialed System Care VHA the VHA with implementing a from with a referral care provider. their primary fundamentally new mechanism for Choice -care authority (which still exists), the purchasing care. Unlike traditional purchased Program promises veterans who meet specific geograph ic or wait-time-related criteria that they 23 can elect to receive treatment from with in a network of a community providers. Under the current Choice Program , however, most VHA patients ar e promised little or no actual choice of providers outside VHA. To be eligible for the program, VHA patients must meet the 24 following criteria: 20 C. § 1703(a). Contracts for Hospital Care and Medical Services in Non-Department Fac ilities, 38 U.S. 21 RAND Corporation, Systems and Management Processes of the Department of Independent Assessment of the Health Care Delivery Veterans Affairs, Assessme 37, accessed February 16, 2016, nt C (Care Authorities), http://www.va.gov/opa/c hoiceact/documents/assessments/Asse ssment_C_Care_Au thorities.pdf. 22 Non-VA Medical Care Program, VHA Directive 1601, (2013). 23 Veterans Access, Choice, and Accountability Ac t of 2014, Pub. L. 113-146, 128 Stat. 1754, (2014). 24 Veterans Access, Choice, and Accountability Act of 2014, Pub. L. 113-146, 128 Stat. 1754, (2014), as amended by Construction Authorization and Choice Improvement Act, Pub. L. No. 114-19, 129 Stat. 215, (2015). The Independent Assessment proposed that VA should “Develop and implement more sensitive standards of geographic access to care. s that are more sensitive to stance to alternative standard VA should compare the ‘one-size-fits-all’ approach of driving di differences between Veteran subgroups, clinical populations, geographic regions , and individual facilities. This 24

39 C R OMMISSION ECOMMENDATIONS VHA facility with a full-time primary care  Live more than 40 miles from the closest provider  Cannot be seen within 30 days of the date veterans’ providers indicate they need to be seen. Cannot be seen within 30 days of veterans’ preferred appointment date if providers have  not provided a specific appointment date. 25 This standard is difficult to reconcile with other statutory priorities for VA care. For example, under the , a veteran with severe service-incurred health conditions may have no Choice Program access to providers outside VHA, yet a veteran with no service-related disabilities does have 26 Implementing the has posed challenges, including difficulties Choice Program such a choice. arising from overlapping, but fundamentally diffe rent, care-purchasing authorities. Veterans, 27 VHA staff, and community providers have been confused because of conflicting requirements and processes in eligibility rules, referrals and authorizations, provider credentialing and 28 network development, care coordination, and claims management. Adding to the confusion is the fact that VHA, facing a 90-day deadline for implementing the program, outsourced the creation and managemen t of its provider networks to two private contractors, thus blurring lines of responsi bility and leaving both patients and providers confused about who exactly holds responsibilit y for what. In execution, the program has aggravated wait times and frustrated veter ans, private-sector health care providers 29 participating in networks, and VHA alike. In October 2015, VA submitted a report to Congre ss that proposed legislation to harmonize the 30 VA’s report also set out a plan for different purchased-care authorit ies into a single approach. port acknowledged that “[n]o organization can establishing high-performing networks. The re excel at every capability,” and that “[s]ervi ce delivery systems designed around core 31 potential value to their customers.” competencies . . . provide the highest As further articulated by Dr. David Shulkin, USH: assessment highlighted the importance of time spent driving, mo and availability of needed de of transportation, traffic, services as key considerations in as sessing geographic access to care.” 25 Enrollment System, 38 U.S.C. § 1705. Management of Health Care: Patient 26 Ibid. 27 RAND Corporation, Systems and Management Processes of the Department of Independent Assessment of the Health Care Delivery nt C (Care Authorities), 43, accessed June 2, 2016, Veterans Affairs, Assessme t/documents/assessments/Asse ssment_C_Care_Aut horities.pdf. Pete Henry, retired http://www.va.gov/opa/choiceac VA medical center director, response to questions about the challeng es facing field officials, email to Commission on Care staff, January 18, 2016. 28 Plan to Consolidate Programs of Department of Veterans Affairs to Improve Access to Care, 30, Department of Veterans Affairs, accessed January 13, 2016, http:// ons/VA_Community_Care_R eport_11_03_2015.pdf. www.va.gov/opa/publicati 29 “Despite $10B ‘Fix,’ Veterans are Waiting Even Longer to See Doctors,” Quil Lawrence, Eric Whitney, and Michael Tomsic, accessed May 16, 2016, http ://www.npr.org/sections/health-s hots/2016/05/16/477814218/attempted-fix-for- va-health-delays-creat es-new-bureaucracy. 30 Department of Veterans Affairs, Plan to Consolidate Programs of Department of Veterans Affairs to Improve Access to Care, 30, accessed January 13, 2016, http:// www.va.gov/opa/publicati ons/VA_Community_Care_R eport_11_03_2015.pdf. 31 Ibid., 18. 25

40 ARE C INAL R EPORT F OMMISSION ON C It’s become apparent that the VA alone ca nnot meet all the health care needs of U.S. veterans. The VA’s mission and scope are not comparable to those of other ll patients in areas where they have no U.S. health systems. Few other systems enro facilities for delivering care. Fewer still p rovide comprehensive medical, behavioral, and social services to a defined population of pati ents, establishing lifelong relationships with them. These realities, combined with the wai t-time crisis, have led the VA to reexamine its approach to care delivery . . . .[A]ddressing veterans’ needs requires a new model of care: rather than remaining primarily a direct care provider, the VA should become an integrated payer and provider. This new visi on would compel the VA to strengthen its to meet veterans’ needs, while working current components that are uniquely positioned 32 with the private sector to address critical access issues. Analysis VHA needs systemic transformation, and merely clarifying and simplifying the rules for purchased care, as proposed in the Independent Assessment Report , is not sufficient to achieve that goal. VHA must replace the arbitrary eligibilit y requirements and unworkable clinical and administrative restrictions of current purc hased programs with the new VHA Care System, available to all enrolled veterans. The VHA Care System is defined as VHA employ ed providers and facilities; Department of Defense (DoD) and other federally-funded prov iders and facilities; and community-based, VHA-credentialed community providers and facilit ies, forming integrated networks to deliver high-quality and high-access care to enrolled veterans across the United States. VHA may establish the networks with the use of national contractors or with internal resources, but networks should be developed with local VHA le adership input and knowledge to ensure their composition is reflective of loca l needs and veterans’ preferences. al VHA programs and competencies that are This new delivery model must preserve critic greater scope than is available in the private unique to VHA or that are of higher quality or 33 sector, either locally or nationally They include specialized behav ioral health care programs, (in patient-aligned care teams), specialized integrated behavioral health and primary care 34 These nters, and services for homeless veterans. rehabilitation services, spinal cord injury ce and similar programs and services are core compet encies and special capabilities that serve the needs of combat veterans, veterans with condit ions incurred or aggravated in service, and 35 veterans reliant on safety-net services and supports. Because of its unique capabilities and competencies, VHA should play an important role in expanding and enhancing the care of veterans across the United States by collaborati ng with local network providers to improve the 32 David J. Shulkin, “Beyond the VA Crisis — Becoming a High-Performance Network,” New England Journal of Medicine, 374, (2016): 1003-1005, ac cessed June 15, 2016, http ://doi.org/10. 1056/NEJMp1600307. 33 RAND Corporation, Systems and Management Processes of the Department of Independent Assessment of the Health Care Delivery ssment A (Demographics) , accessed June 2, 2016, Veterans Affairs, Asse t/documents/assessments/Asse ssment_A_Demographics.pdf. http://www.va.gov/opa/choiceac 34 Special capabilities like spinal cord injury care, which draw from specialty care available in the full-service hospitals in which they are currently provided, merit continued support stances where VHA might no and investment. Thus, in in longer operate a full-service hospital th at had once housed a spinal cord injury center, it would need to establish community partnerships to assure veterans would continue to rece ive the same high quality care. 35 David J. Shulkin, “Why VA Health Care Is Different,” Federal Practitioner , 33, no. 5 (2016): 9-11, /article/why-va-health-care-is-differe http://www.fedprac.com/home nt/c8da5ba1261bdbe726bddcbceea81f27.html. 26

41 C OMMISSION ECOMMENDATIONS R lly needed by veterans, such as mental health availability and quality of care in areas especia and rehabilitation. Management and Oversight a well-planned, phased approach overseen by VHA Care System networks will be built out in e criteria and sequencing for the phases, to the new governing board, which will determine th ensure effective execution of the strategy. The timing and phasing criteria may include veteran service needs, access issues, quality issues , facility issues, and IT capabilities. ill require ongoing management and evaluation The networks within the VHA Care System w of their performance. This process will be th e responsibility of VHA management and board, with board oversight of network performance. the VHA Care System. Local leadership will The governing board will oversee the budget for provide input on funding, and the local netw orks will determine their funding needs and f of VHA Care System (CVCS), formerly the submit their respective requests to the chie verning board will recommend to Congress the undersecretary of health for VHA. The go budget required to implement the VHA Care Syst em, with multiyear appropriations. The local network leaders will have the flexibility to m anage their respective network budgets based stem will be combining a national strategy and upon local needs. A key element of the new sy llow for effective decision making to ensure local flexibility for managing the budget to a veterans’ needs are met. Provider Payment Providers in the networks should be paid us ing the most contemporary payment approaches available to incentivize quality and appropriate utilization of health care services (i.e., using n Act of 2015 [MACRA] physician payment Medicare Access and CHIP Reauthorizatio methodology being proposed by CMS). MACRA is intended to move the health care industry 36 away from a fee-for-service model to value-based payments. Such a system is expected to 37 drive improved quality and lower costs. Care Administration From a strategic perspective, service-connected disabled veterans should receive the highest priority access to the VHA Care System. This principle should guide access to all types and points of care. Veterans with limited financial me ans should also have high priority. If needed, cost sharing (applicable only to those who are non-service-connected disabled and not financially needy) can provide a means for offe ring broader choice. The current time and distance criteria for community care access (30 da ys and 40 miles) should be eliminated. VISN geography should also be eliminated as a factor terans can access care. in determining where ve Eligible veterans should be permitted to receive care at any facility and by any provider in the VHA Care System, whether in a veteran’s home VISN or not. Choice and Care Coordination The topic of choice was the most contentiou s issue considered by the Commission. Some Commissioners advocated complete choice of prov iders for veterans, with no requirement for 36 “The Medicare Access CH IP Reauthorization Act (MACRA)” Nationa l Partnership for Families and Women, accessed June 6, 2016, http ://www.nationalpartnership.org /issues/health/macra.html. 37 Ibid. 27

42 OMMISSION ON C INAL R EPORT F C ARE care coordination by primary care physicians . Others advocated for a tightly managed model with VHA controlling access to community provider s, as is done today. After considering the costs of various design options, the importance of care coordination, and the need for greater veteran access to both primary care and specialt y care services, the Commission agreed to the following design principles:  VHA will establish and credential community networks with a focus on quality of providers, access to comprehensive serv ices, and utilization of VHA resources.  Veterans will have complete choice of prim ary care providers within the VHA Care System.  System (including VHA providers, DoD All primary care providers in the VHA Care community providers) will coordinate and other federally funded providers, and veterans’ care.  Specialty care will require a referra l from a primary care provider.  VHA will assume overall responsibility for care coordination and navigation for all enrolled veterans. twork design and consistently monitored with Quality of care must be a core element of ne metrics that are routinely used by the private sector. Accordingly, VHA must adopt standards that both ensure networks are composed of high-quality providers and set appropriate expectations of those providers. Critically, all providers in the networks must have fully interoperable IT platforms to allow for complete data exchange. Providers must work together to maximize patients’ well-being using evidence-based protocols of care. r quality and patient-safety issue throughout Lack of coordination among providers is a majo the U.S. health care system. It is important for VH A to coordinate the care it provides because it serves an especially vulnerable population that has more chronic medical conditions, behavioral health conditions, and individuals of lower socioeconomic status than the general medical 38 population. Veterans who receive health care excl usively through VHA generally receive well- agmented among those combining VHA care with coordinated care, yet care is often highly fr care secured through private health plans, Medi care, and TRICARE. This fragmentation often 39 t safety, and shifts cost among payers. results in lower quality, threatens patien 38 Journal of the American Medical Association , 307, no. 8, (2012): Kenneth Kizer, “Veterans and the Affordable Care Act,” tp://doi.org/10. 1001/jama.2012.196. 789-790, accessed June 20, 2016, ht 39 enberg et al., ible Population,” Patricia Vand Department “The Impact of the Affordable Care Act on VA’s Dual Elig of Veterans Affairs, access rd.research.va.gov/publicati ons/forum/apr13/ apr13-1.cfm. ed June 2, 2016, http://www.hs Kenneth Kizer, “Veterans and the Affordable Care Act,” Journal of the American Medical Association , 307, no. 8, (2012): 789-790, accessed June 20, 2016, http ://doi.org/10.1001/jama. 2012.196. Brigham R. Fran dsen et al., “Care Fragmentation, Quality, and Costs American Journal of Managed Care , 21, no. 5, (2015): Among Chronically Ill Patients,” 355-362, accessed June 20, 2016, http ://www.ajmc.com/journals/issue/ 2015/2015-vol21-n5/care-fragmentation- quality-costs-among-chronically-ill-patients. Chuan-Fen Liu et al., “Use of Outpatient Care in Veterans Health Administration and Medicare among Vete rans Receiving Primary Care in Community-Based and Hospital Outpatient , 45, no. 5 part 1, (2010): 1268- Clinics,” Health Services Research 1286, accessed June 20, 2016, http://doi.org/10.1111/ j.1475-6773.2010.01123.x. 28

43 C R OMMISSION ECOMMENDATIONS VHA Care System will operate as outlined in Table 2 below. Table 2. VHA Care System Operations Component Expectations Key provider Veterans can choose a care from all credentialed primary  primary System. care providers in the VHA Care Choice can receive their care at  any Veterans VHA Care System location across the country with coordination by their primary care provider. VHA All primary care providers in the Care System must coordinate care  for veterans. Specialty care is exclusively accessed through referrals from primary care providers. credentialed  Veterans can choose their specialty care providers from all their specialty care providers in the VHA Care System with a referral from primary care provider. Care Coordination as primary care is traditionally defined internal medicine or family  Although VHA may designate other specialty providers as primary practice, care coordinators based on veterans’ specific health needs (e.g., endocrinologists patients patients, neurologists for diabetic with Parkinson’s disease, for OB/GYN for female patients). of have overall responsibility will ensuring care coordination for VHA  including complex care navigation. veterans, Scope of Provider Networks System, VHA must make critical tradeoffs In setting up networks within the VHA Care establishing broad networks would expand regarding their size and scope. For example, veterans’ choice, yet would also consume far mo re financial resources (i.e., taxpayer dollars) . Currently, money VHA spends on expanding due to increased utilization or cost shifting 40 choice is not available to spend on other programs and services vital to its mission. e of networks as a cost-management tool, Health plans commonly limit the size and scop orks (managed care plans) or more open offering insurance products with narrow netw networks (preferred provider plans). Well-manag ed, narrow networks can maximize clinical 41 quality by requiring participating clinicians to adhere to evidence-based protocols of care. Achieving high quality and cost effectivene ss may constrain consumer choice. A patient’s be part of that smaller network or the narrow preferred doctor, clinic, or hospital may not 42 network may not offer sufficient geographic access for some patients. VHA must balance these competing considerations. In doing so, it faces a variety of options. In addition to the scope of networks, for example, is the question of whether and how VHA will iders within the networks. This is another area play a role in steering patients to different prov considerations. Private-sector health plans involving tradeoffs among competing values and 40 The MITRE Corporation , Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 23 accessed June 2, 2016 , http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 41 u,” Ken Terry, accessed June 2, 2016, “What Tier Networks Will Mean to Yo http://medicaleconomics.mod ernmedicine.com/medical-ec onomics/content/what-tiere d-networks-will-mean-you. 42 mmittee on Ways and Means, Subcommittee on Health, Hearing on Ibid. U.S. Congress, House of Representatives, Co th st “Health Care Consolidation , 112 Congress, 1 Session, (2011), (Statement of Paul B. Ginsburg, President, Center for Studying Health System Change , Research Director, National Institute for Health Care Re form), accessed June 2, 2016, timony_9-9-11_Final.pdf. http://waysandmeans.house.gov /UploadedFiles/Ginsburg_Tes 29

44 C C F INAL R EPORT OMMISSION ON ARE oved through a referral from a primary care often require all specialty care to be preappr ospective and concurrent utilization review and physician. Managed care plans may also use pr ive reviews, patients must receive approval care management for hospitalization. For prospect from their health plan before being admitted to the hospital to ensure the admission is clinically appropriate. Plans may also use concurrent utilizat ion or case management for inpatient care to 43 ensure the care and tests ordered and the length of stay in the hospital are appropriate. The Commission carefully weighed these issues in recommending an approach. The Commission considered the effect of cost usin g various configurations of VHA services and community delivered services (CDS). Option s considered by the commission include the following:  Recommended Option: This option provides an integrated network of VHA, DoD and ty providers, credentialed by VHA. It other federally funded providers, and communi requires veterans to attain a referral from th eir primary care provider to access specialty care.  CDS Alternative 1: The main difference between this option and the Recommended Option is primary care, inpatient medical and su rgical care, and some standard specialty care would not be eligible for CDS networ ks and would be accessed within VHA unless the Choice Program distance exception applies. VHA providers and CDS network The division of care between CDS Alternative 2:  providers would be the same as for ; however, veterans would only CDS Alternative 1 need to consult their primary care provider before seeking specialt y care, rather than obtaining a referral.  CDS Alternative 3: This option would combine the broad network in the Recommended Option, but would have no referral or consultati on requirement; thus, it would be an extremely generous benefits package.  Premium Support: Under this scenario, enrollees who are younger than 65 would choose a subsidized insurance premium with cost sharing. Access to VA services, including special services, would be eliminated. Eligibility Expansion : Under this scenario the VA health care system would expand to  allow all veterans, regardless of priority group. Other-Than-Honorable Discharges : A policy change for which individuals with other-  than-honorable (OTH) discharge is outlined in Recommendation #17. This option would allow temporary eligibility for VA health care to those with an OTH discharge until the adjudication process to determine long-term eligibility took place. 43 Paul B. Ginsburg, “Achieving Health Care Cost Cont ainment Through Provider Payment Reform that Engages Patients and Providers ,” Health Affairs , 32, no. 5, (2013): 929-934, accessed June 20, 2016, http://doi.org/10.1377/hlthaff.2012. 1007. While these approaches can help k eep costs down, patients, doctors and hospitals can experience the process as bureaucratic interference in clinical care. To implement utilization management, s and patients can access to question the linical appeals process that both doctor health plans usually include a strong c decisions made by administrators. 30

45 C R OMMISSION ECOMMENDATIONS Recommended Option Below is a more detailed summary of the Commission’s . Additional information, including cost projections for all of the options above, can be found in Appendix A. Cost Model for Commission Recommended Option t initially, all care currently provided by VA This option would expand community care. At leas addition, expanded community care, also called would continue to be available through VA. In network consisting of providers (medical CDS, would be provided by an integrated ans, midlevel practiti practitioners including physici oners and therapists, and hospitals and clinics) vetted by VHA. The CDS network woul d include all primary and standard specialty care; it would not include special-emphasis care (care that is provided in a substantially 44 In 2014, 68 percent of care would have been eligible for CDS different way than by VHA). a primary care provider would be required to networks at current VHA prices. A referral from receive specialty care. This refe rral could come from a provider either at VHA or from the community network (i.e., from any provider in the VHA Care System). In this scenario, we assumed all other characteristics of the VHA Ca re System would remain the same as under current policy. We assume that the Choice Program ends and that those formerly in the Choice Program care offered in the CDS networks. will take advantage of the community Both CDS networks and traditional Care in th e Community (CITC) are priced at Medicare 45 dule data to VA Health Service Categories. allowable rates by matching Medicare fee sche A few benefits that are not covered by Medicare, such as dental, are priced at historic CITC unit be the same as that for care in VA facilities. costs. Cost sharing for CDS networks is assumed to For care shifting into the CDS networks, we assu me VA is able to adjust resources such that of unit costs remain in VA facilities. Note only the equipment and national overhead portions ding or nonrecurring that unit costs do not include costs associated with the physical buil maintenance; those costs are not modeled. ary and standard specialty care in the community We expect that allowing enrollees to get prim e community because many veterans would have a will increase reliance for care provided in th choice among a larger number of providers and would be more likely to have the option to receive care at a more convenient location. We also expect enrollment to increase because some eligible veterans would be induced to enroll by the prospect of having VA pay for them to see a ent of eligible care sh ifts from VA facilities provider in the community. We assume that 60 perc to CDS networks. Currently reliance is 34 percent. Under this scenario, we model reliance levels of 40, 50, and 60 percent, which correspond to reliance rates increases of approximately 18, 47, and 76 percent, respectively. These reliance incr eases apply only to CDS care, not CDS-eligible care that is provided in VA fa cilities. Although the choice of providers is expanded and wait times are potentially reduced in VA, there contin ues to be a requirement for a referral to access specialty care, as there is in the current system . We modeled enrollment increases of 5, 15, and 44 Special-emphasis care includes: prosth etics and orthotics, recreational therap y, rehabilitative ca re, pharmacy, home- based primary care, spinal cord injury an d disorders, some categories of long-t erm services and supports, mental health, and homeless care. We count all mental he health categories cannot easily be alth as special-emphasis because mental differentiated by care that is VA sp ecial-emphasis and care that is not. 45 Medicare Allowable rates were provided by Milliman at the request of VA. They were produced using repricing performed at the area-specific level for i npatient, outpatient, and pr ofessional care. For services that were not repriced within an HSC, Medicare amounts were estimated. 31

46 C C F INAL R EPORT OMMISSION ON ARE s, which assume integrated, narrow, and well- 20 percent for the low, middle and high estimate managed networks that are designed and managed with cost as one of the major considerations. We also modeled an enrollment increase of 50 percent, more consistent with a less-managed, relatively broad network for which cost is a le ss important consideration. Finally, we assume that newly entering veterans who receive trea tment in CDS networks because of this policy and in CDS networks. Much of this care was have a 20 percent utilization increase for new dem formerly subject to sizable cost sharing with private insurance or Medicare and now would be subject to little, if any, cost sharin g associated with VA-financed care. There are a number of caveats a ssociated with our estimates. These caveats are important, and to the extent that these assump tions do not hold, the estimates will be inaccurate. The estimates do not include savings and costs of reducing or repurposing infrastructure, or effects on VA’s teaching, research, and emergency preparedne ss missions. Medicare allowable rates are assumed adequate to provide all veterans with robust CDS networks in their local areas. For erage rates are assumed to represent future rates. care priced at historic CITC rates, national av Shifting care into CDS networks does not affect the unit cost of care that remains in VA facilities. Reductions in the volume of care with in VA facilities, and potentially adverse effects on quality, are not addressed. Other than equipm ent and national overhead, the costs of care shifting out of VA facilities are phased out concu rrently with other effects in the model. Finally, estimates do not include administrative costs as sociated with CDS networks; these costs could be substantial. Figure 1 displays estimates for the Recommended Option . Estimates for well-managed, narrow networks range from $65 billion to $85 billion in 2019 , with a middle estimate of $76 billion. The middle estimate is moderately above the baselin e projection of $71 billion. Although reliance and enrollment increases push VA budgetary costs up, the switch from VA unit costs to the less costly Medicare allowable rates for CDS netw orks and CITC mitigate the increases. The estimate for the less-managed, broader network sc enario is $106 billion in 2019, illustrating that costs could increase markedly if governance of th e network places less importance on cost or if VA were unsuccessful in ti ghtly managing the network. This model is described more fully in Appendix A, along with models for a range of other options, some of which are prev iously described in this section. Consult Appendix A for more details on the technical assumptions necessary to understand the results presented here. The ay a critical role in our estimates, and any assumptions and caveats detailed in Appendix A pl substantially affect the estimates. deviation from these assumptions could 32

47 C R OMMISSION ECOMMENDATIONS Figure 1. Projected Costs of Recommended Option Mitigating Risks drive times to see a doctor may lead to longer wait times, Choice involves tradeoffs. Reducing 46 VHA reliance on for example, if it induces substantially more veterans to seek more care. contracting could also have unintended conseq uences for already underserved communities. Providers in such communities who join the local VHA network may decide to limit the number of Medicare and Medicaid patients they accept into their practices. In other, highly concentrated health care markets, which ar e increasingly common throughout the United 47 re in the community except at higher prices. States, VHA may not be able to contract for ca Such circumstances underscore the importance of VHA retaining the option of building its own capacity. Policymakers must also carefully weigh concer ns that leaders of seven major veterans in which they warned “choice should never be organizations expressed in a recent joint letter 48 the ultimate goal of a health care system de signed to meet the unique needs of veterans.” These organizations do not support providing unfettered choice, and the VSO leaders stated that “any health care reform proposal that elev ates the principle of ‘c hoice’ above all other uences for veterans who rely on VA, resulting clinical considerations would have severe conseq 46 Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of RAND Corporation, Veterans Affairs, Assessment B (Health Care Capabilities), 284, accessed May 2, 2016, http://www.va.gov/opa/choi ceact/documents/assessme nts/assessment_b_health_c are_capabilities.pdf. 47 David M. Cutler and Fiona Scott Morton, “H ospitals, Market Share, and Consolidation,” Journal of the American Medical Association , 310, no. 18, (2013): 1964-1970, accessed June 20, 2016, http://doi.org/10.1001/jama.2013.281675. 48 er sent to Commission on Care, April 29, 2016. Garry J. Augustin e, Disabled American Veterans et al., lett 33

48 C F INAL R EPORT OMMISSION ON C ARE in less ‘choice’ rather than the intended desire for more health care options for many disabled 49 veterans.” The Commission has addressed this concern in several ways, including the following:  recommendations to substantially improve VHA operations, thereby enhancing the attractiveness of using VHA providers and facilities by enrolled veterans  VHA control of network design  VHA Care System governing board oversight of network execution and phasing  high standards for community provider partic ipation, including credentialing, military competence, and quality and utilization performance  VHA oversight of care coordination and navigation  requirement of primary care referral for specialty care provider can result in higher utilization of The Commission recognizes that greater choice of health care services, which increases costs. This risk can be mitigated by recommendations in incentivize cost mitigation, all cost savings this report that will produce cost savings. To associated with improved efficiency and operat ions should be reinvested into the VHA Care System. Examples of cost mitigation strategies include the following: owed to VHA more effectively recovering third-party payments   maintaining VHA as a secondary payer when veterans have other health insurance and treatment is for non-service-connected care ibility and/or benefit design could also  increasing cost-sharing or changes in elig substantially contain the projected co sts of increasing provider-choice reducing fixed costs of underutilized facilities and services   managing the supply chain to produce cost savings  improving facilities to increase provider prod uctivity (e.g., increase in outpatient exam rooms)  adopting information technology that improv es the quality and efficiency of care Effectively implementing and managing integrat ed networks will require extensive changes in as flexible and smart procurement policies and the governance and leadership of VHA, as well 49 Ibid. 34

49 C OMMISSION ECOMMENDATIONS R this report. The highest priority for standing contracting authorities, as discussed elsewhere in 50 up networks should be locations where VHA quality of care is deficient or capacity is strained. , first priority for care should go to those Where capacity constraints exist within networks by service-connected disabled veterans and veterans with greatest medical need, followed 51 VHA should develop processes and proc edures for insuring that veterans indigent veterans. have the knowledge and assistance they need to make informed health care decision and to navigate effectively through the expanding heal th care networks. By employing strategies find administrative means to guard against proven by other managed care plans, VHA will eful spending, and fraud. inappropriate treatment, wast previously required inpatient hospital stays As many surgical and medical procedures that ere continues to be a substantial shift from have routinely become outpatient procedures, th 52 inpatient to outpatient care. Consequently, to ensure improved access to care for veterans, the VHA Care System and long-term plans for fac ilities should focus on creating a robust ambulatory network and reshaping inpatient resources to match expected demand. ’ and providers’ decisions and Additionally, to inform veterans create increased accountability for performance, all VHA and community netw ork providers and facilities must provide transparent information on inpatient and outpatie nt quality, service, and access using the same performance metrics, including those used by Medicare. Implementation Legislative Changes Enact legislation amending 38 U.S. Code, Chapter 17 to consolidate existing purchased-  care authorities and authorize the SECVA to furnish enrolled veterans needed hospital ts with providers the SECVA deems meet care and medical services through agreemen quality standards the SECVA will establish. Veterans would be eligible for community care on the same basis as for VHA-furnished care, and current wait time and geographic distance criteria should no longer be applicable. VA Administrative Changes Develop national policy to govern local esta blishment of networks, and in doing so,  eating a robust ambulatory capability and focus its design and long-term planning on cr reshaping inpatient resources to match expected demand.  Establish standards that community providers must meet to qualify for participation in community networks, to include becoming fully credentialed, meeting patient-access criteria, demonstrating high-quality clinical outcomes and appropriate use decisions, demonstrating military cultural competency , and having capability for interoperable data exchange. 50 Information on what medical centers are deficient in th eir care is available, for example, from the VHA’s own Strategic Analytics for Improvem ent and Learning (SAIL) data. 51 It would seem prudent to begin such phased development by piloting that effort, and limi ting the scope of unfettered choice to service-connected veterans. 52 Mehul V. Raval et al., “The Importance of Assessing Both Inpatient and Outpatient Surgical Quality,” Annals of http://www.ncbi.nlm.nih.gov/pubmed/21183845. Surgery , 253, 3, (2011): 611-618, accessed June 20, 2016, 35

50 C ARE F INAL R EPORT OMMISSION ON C care providers in the VHA Care System can  Establish systems to ensure that all primary effectively coordinate veterans’ care.  Provide veterans navigation services for complex care needs, including information formed decision making about treatments needed by patients and their families for in and providers. Navigation services should assist veterans and their families with eligibility, cost-sharing, and other administrative issues.  Establish policies and procedures to ensure that VHA provider as well as community providers within each network, provide transparent information (using the same metrics) on care-quality, service, and access. Eliminate the practice of cross-country refe  rrals if quality care is available locally.  Employ the most current payment approaches that incentivize quality and appropriate use of health care services. Other Department and Agency Administrative Changes None required.  36

51 C OMMISSION R ECOMMENDATIONS Clinical Operations erations through more effective use Recommendation #2: Enhance clinical op th professionals, and impr oved data collection and of providers and other heal management. Problem The Commission Recommends That . . . A shortage of providers and clinical managers, of effectiveness and efficiency the increase VHA  combined with inadequate support staff and health other and providers and professionals policies that fail to optimize the talents and them support staff by adopting policies to to allow efficiency of all health professionals, detract of full use make their skills. from the effectiveness of VHA health care.  relieve Congress VHA of bed reporting closure requirements under the Millennium Act. The problem starts with inadequate numbers and  VHA continue to hire clinical managers move of providers. Ninety-four percent of VHA sites forward on initiatives of increase the supply to with clinically meaningful access delays assistants. support medical indicated that increasing the number of 53 or very important to increasing access. licensed independent practitioners was critical At the same time, ineffective use of providers and other health professionals contributes to suboptimal productivity. Highly tr ained clinical personnel are often unable to perform at the top of their license, meaning they spend much of their time performing tasks that should be 54 done by support staff. For example, doctors and nurses often escort patients; clean examination rooms; take vital signs; schedu le; document care; and place the orders for consultations, prescriptions, or other necessary ca re that could be done more cost effectively by oviders identified “not working to top of support staff. Twenty-three percent of VHA pr 55 er in health care provision. provider licensure” as a barri advanced practice regist ered nurses (APRNs). VHA is also currently failing to optimize use of APRNs are clinicians with advanced degrees who provide primary, acute, and specialty health care services. Background A large part of the VHA’s problem with inadeq uate clinical support staff derives from its difficulties in hiring, retaining, and traini ng medical support assistants (MSAs). These ty, among other duties. fy health care eligibili individuals answer phones, schedule care, and veri 53 Independent Assessment of the Health Care Delivery RAND Corporation, Systems and Management Processes of the Department of , 95, accessed June 3, 2016, Veterans Affairs, Assessment B (Health Care Capabilities) http://www.va.gov/opa/choi ceact/documents/assessme nts/assessment_b_health_c are_capabilities.pdf. 54 Grant Thornton, Independent Assessment of the Health Care Delivery Sy stems and Management Processes of the Department of , ix, accessed June 3, 2016, ffing/Productivity/Time Allocation) Veterans Affairs, Assessment G (Sta http://www.va.gov/opa/choi ceact/documents/assessme nts/Assessment_G_Staffing _Productivity.pdf. 55 Ibid., 95. 37

52 OMMISSION ON C INAL R EPORT F C ARE 56 Congress has recently given VHA the flexibilit y to offer MSAs market-based pay rates. VHA is 57 changing cumbersome rules that have made hi ring new MSAs exceptionally time-consuming. VHA is working to resolve its problems with reso urce allocation in clinics. For example, the agency has committed to increasing use of clin ical managers to help medical centers better match resources to patient demand. Widely used by other health care systems, clinic managers enhance operations by ensuring that telephone pr otocols, scheduling, and clinic workflow are that staff members are assigned appropriate operating at peak efficiency. They also ensure caseloads and are meeting productivity standards and wait time targets and that administrative duling, coding, and/or documentation. staff has appropriate training in sche Many states have already taken the steps to ensu re APRNs have full practice authority. VHA is working to do the same, which will allow a vast increase in the number of VHA clinicians 58 available to treat patients independently. To effectively manage clinician supply for the inpa tient setting, administrators require accurate bed count data. Currently in VHA, data inte grity of bed counts is compromised as a ss. VHA is required by statute to complete a consequence of disclosure requirements of Congre 59 complicated reporting, approval, and notificati on process when it closes hospital beds. To avoid the reporting requirements some VA medical centers count beds as unavailable indefinitely. This action can skew occupanc y rates and thwart planning activities. VHA 60 and other requirements that developed its guidance in part to satisfy the Millennium Act 61 essentially froze beds at FY 1998 levels. Analysis VHA has taken a number of measures to address data integrity issues. VHA has started hiring ces for effective performance. VHA has made clinical managers to assist in managing resour training of MSAs. Additionally, VHA has efforts to address problems affecting supply and e full practice for APRNs working within the recently proposed a rule that would authoriz 62 agency. These measures by themselves, however, will no t be sufficient to solve the current problems. VHA must ensure all facilities have enough suppo rt positions—both clerical and clinical—to 56 Sloan D. Gibson, Deputy S ecretary, Department of Vete rans Affairs, pres entation to Commission on Care, April 18, 2016. 57 38 U.S.C. § 7401(3)(A)(iii). 58 Establishing Medication Prescribin g Authority for Advanced Practice Nurses, VHA Directive 2008-049, (2008). 59 Inpatient Bed Change Program and Procedures, VHA Handbook 1000.01, (2010). 60 The Veterans Millennium Health b. L. No. 106-117, 113 Stat. 1545, Sec. 301. Title III of the Care and Benefits Act, Pu Millennium Act prohibits the secretary from closing in any rcent of the beds within a fiscal year more than 50 pe department medical center unless the secretary first submits to the veterans’ committees a ju stification for such closure and waits to take action on a closure until 21 days after the submission of the report. It al so requires the secretary to report annually to the veterans committees on be d closures during the preceding fiscal year. 61 Extended Care Services, 38 U.S.C. § 1710B(b) requires staffing for exte nded care to remain at FY 1998 levels. 62 “VA Proposes to Grant Full Practice Authority to Advanced Practice Registered Nurses ,” Department of Veterans l/pressrelease.cfm?id=2793. http://www.va.gov/opa/pressre Affairs, accessed June 3, 2016, 38

53 C R OMMISSION ECOMMENDATIONS eir licenses and to avoid problems with turnover, enable all clinicians to work at the top of th 63 unexpected staff absences, and surges in patient demand. VHA must have authority to pay competitive rates for the personnel it needs. This goal would ation #15 of this report for creating a new be accomplished in part by adopting Recommend employees. Currently, for example, clinical personnel system under Title 38 for all VHA 64 managers and practitioners earn fa r more in the private sector. As VHA develops improved clinic managemen t tools such as the Health Operations Dashboard, these tools draw from clinical da ta, patient data, and other sources to allow 65 To be effective tools, the data fed into them managers to make decisions using real-time data. must be accurate. Relieving VHA from some of the reporting requirements of the Millennium Act will help accomplish effective use of the dashboard for inpatient management. Implementation Legislative Changes  Create a new alternative personnel system under Title 38 authority as mentioned in Recommendation #15.  Eliminate bed reporting requirements unde r the Millennium Bill, and require VHA to report new beds as closed, authorized, operatin g, staffed, or temporarily inactive within 90 days of enactment. VA Administrative Changes  Develop policy to allow full practice authority for APRNs.  Develop leadership tracks, including clin ical and group practice managers, for ambulatory settings. Develop training programs for medi  cal support assistants (MSAs).  Modify policy in VHA Handbook 1000.01, Inpatient Bed Change Program and Procedures, as appropriate. Administrative Changes Other Department and Agency None required.  63 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment E (Workflow—Scheduling), 17-18, accessed June 3 2016, http://www.va.gov/opa/choi ceact/documents/assessme nts/Assessment_E_Workf low_Scheduling.pdf. 64 an salary for Clinic Manager III (a manager of a clinic with more than For example, Salaries.com listed a medi 64 50 physicians) in Dallas, TX, as $94,000. The pay grade assigned fo r this position is GS-13, which pays about $73,800 in the first step and incr eases up to $96,000. Office of Personnel Management, Schedule 1 General Schedule , accessed March 31, 2016, https://www.opm.gov/po licy-data-oversight/pay-leave/salar ies-wages/pay-executive-order-2016- adjustments-of-certain -rates-of-pay.pdf. 65 Commission on Care, April 18, 2016. Sloan D. Gibson, Deputy Secretary for Veterans Affairs, presentation to 39

54 C OMMISSION ON ARE F INAL R EPORT C Recommendation #3: Develop a process fo r appealing clinical decisions that provides veterans protections at least comparable to those afforded patients under other federally-supported programs. Problem The Commission Recommends That . . . All federal providers and most health insurers in assist to panel interdisciplinary an convene VHA  have processes to ensure that beneficiaries a developing appeals ‐ clinical revised national have enforceable protections that allow them process. to obtain medically necessary care within their 66 health benefits package. rticularly for care plans using Such processes are imperative, pa capitated payment models for which there are ince ntives to conserve resources. Most veterans, and even their advocates, are unsure of VHA’s pr ocess for resolving clinical disputes. This may VHA, but 18 (one for each Veteran Integrated be because there is not one policy in place for 67 Service Network [VISN]). As part of the MyVA initiative, the SECVA has set a goal of world-class service for veterans, including a proactive patient advocacy team that is integrated into patient-centered care and 68 The processes in place for patient grievances and central cultural transformation plans. protections to ensure access to medically necessary care remain poorly understood despite these efforts. Also, they may be less comprehensive and fair than appeals processes private health 69 rs are required to provide. insurers and other federal paye Background VHA policy has long required medical centers to operate a patient advocate program to address 70 patient complaints. In 1996, Congress enacted an eligibility reform statute that, for the first 71 time, gave enrolled veterans acce ss to a uniform benefits package. In implementing that law, ical disputes were handled and consequently VHA conducted a systemwide review of how clin instituted an external appeal system in FY 2000. The policy, as outlined in a subsequent directive, allowed VISNs to request external prof essional boards to conduct impartial reviews of 72 ss for internal clinical appeals. It That directive also addressed a proce clinical determinations. stated as policy that patients or their repr esentatives who have disputes regarding clinical determinations or services pertaining to provision or denial of care that are not resolved at the facility level must have access to a fair and impart ial review of those disputes that could result in a different and/or improved clinical outcome. That policy requires VISN directors to have internal appeals are to be handled. Under this written policy and procedures in place for how policy, VISNs still have authority to request an exte rnal review at any time during the clinical 66 A Guide to the Medicaid Appeals Process, accessed June 3, 2016, MaryBeth Musumeci, undation.files.wordpres s.com/2013/01/8287.pdf. https://kaiserfamilyfo 67 VHA Clinical Appeals, VHA Directive 2006-057, (2006). 68 “About the VHA Patient Advocate and Veteran Experience Program (VHA PA & VEP),” accessed from VA Intranet, May 31, 2016, http://va ww.infoshare.va.gov/sites/OPCC/ VEP/SitePages/ve p-about.aspx. 69 MaryBeth Musumeci, accessed June 3, 2016, A Guide to the Medicaid Appeals Process, Appeals, VHA Directive 2006- tion.files.wordpress. com/2013/01/8287.pdf. VHA Clinical https://kaiserfamilyfounda 057 (2006). 70 VHA Clinical Appeals, VHA Directive 2006-057 (2006). 71 Veterans’ Health Care Eligib ility Reform Act of 1996, Pub. L. No. 104-262, 110 Stat. 3177 (1996). 72 VHA Clinical Appeals, VHA Directive 2006-057 (2006). 40

55 C R OMMISSION ECOMMENDATIONS 73 appeals process. 2011, it continues to serve as guidance Although the directive itself expired in because it has not been renewed or replaced. to manage and attempt to VHA policy directs that all facilit ies have a patient advocate office serve as the liaison between patients and clinicians, resolve complaints. That office, which can 74 are dissatisfied with a clinical decision. If a clinical generally the first stop for veterans who is issue is not resolved at the point of the service, it generally goes to the facility director, who is to provide veterans written notification of the fa cility’s decision and inform veterans about the VISN’s appeals process. Under the same policy directive, veterans may appeal the facility decision to the VISN director. That official, or a clinical review p anel that he or she establishes, is to render a decision within 30 days (or 45 days if the director requests an external clinical 75 cility, he or she must notify the veteran Should the VISN director agree with the fa review). r to a VACO office to arrange for an external that the decision is final or may refer the matte 76 review. The VHA process does not appear fully comparable to procedures required under other federal and federally-supported health care programs. For example, under the Affordable Care Act, health care plans are required to provide exte rnal reviews to beneficiaries whose internal 77 appeals have been denied. Unlike those and other appeals processes, veterans have no right to external review; such review is at the discretion of the VISN di rector. Medicare has an extensive review process for clinical disputes between it s managed care organizations and beneficiaries. Beneficiaries have the right to an internal a ppeal with an option for an expedited review, an internal reconsideration of the initial revi ew, an independent review, a hearing with an dicare Appeals Council and, finally, a federal administrative law judge, a review by the Me 78 district court review. lities to review appeals from its Medicaid has requirements for loca beneficiaries and for states to offer timely acce ss to fair hearings to determine whether managed 79 Although VHA’s care organizations have denied or terminated medically necessary care. timeframe for decision making seems reasonable , the national policy makes no provision for an organizations and plans providing health expedited review, unlike Medicare managed care benefits to federal employees. VHA’s policy is also silent on meeting with veterans to hear their of the appeal. Unlike Medicaid, VHA also lacks cases much less hold hearings during any point the matter is being appealed. The Commission any provision for service-continuity while al-appeals process that provides veterans recommends that VHA develop a revised clinic protections at least comparable to those afford ed patients under othe r federal and federally- right to an external review at the veteran’s supported programs, including, at a minimum, a discretion. 73 Ibid. 74 VHA Patient Advocacy Progra m, VHA Handbook 1003.4, (2005). 75 VHA Clinical Appeals, VHA Directive 2006-057, (2006). 76 Ibid. 77 “Appealing Health Plan Decisions,” Department of Health & Human Services , accessed June 1, 2016, http://www.hhs.gov/healthcare/about-the- law/cancellations-and-app eals/appealing-health-pla n-decisions/index.html. 78 Managed Care Appe als Flowchart CY2016 , accessed May 26, 2016, Centers for Medicare & Medicaid Services, https://www.cms.gov/Medicare /Appeals-and-Grievances/MMCAG/Downloa ds/Managed-Care-Appeals-Flow-Chart- .pdf. 79 MaryBeth Musumeci, A Guide to the Medicaid Appeals Process, accessed June 3, 2016, m/2013/01/8287.pdf. https://kaiserfamilyfoundation.f iles.wordpress.co 41

56 C OMMISSION ON ARE F INAL R EPORT C Implementation Legislative Changes None required.  VA Administrative Changes  Convene an interdisciplinary panel to assist in developing a revised clinical-appeals provided within the VHA Care System, to process and policy that includes all care Services, MyVA’s Patient Advocates and include representation from Patient Care Equity, the National Center for Ethics in Veterans Experience Program, the Office of Clinical Administration. VHA should have Health Care, and the Office of Access and that panel examine and offer recommendations regarding the following: Each level of review in the clinical-a ppeals process—from the facility’s initial - e VISN director to assess the fairness and reconsideration to a final decision by th impartiality in those processes compared to Medicare Managed Care and Medicaid appeals processes and private-sector manag ed care providers’ best practices. Whether VHA should establish a unifor - m national clinical appeals process. The advisability of requiring review pane ls consisting of individuals such as - attorneys, clinicians, case managers, patien t advocates, and administrators to review clinical appeals. - Whether hearings or judicial reviews are appropriate at any level of the appeals process. are equitable for all types of veterans - Whether resolutions of clinical appeals (service-connected or non-service-connected, by racial or ethnic group, by age, or gender). - Options for increasing veterans’ awaren ess of the clinical-appeals process.  Publish the new clinical appeals policy and process for comment and input by veterans, VHA business partners, and other stakeholders.  Once the new policy is finalized, VHA must train staff on the new process. Other Department and Agency Administrative Changes None required.  42

57 C OMMISSION R ECOMMENDATIONS us improvement methodology to Recommendation #4: Adopt a continuo support VHA transformation , and consolidate best practices and continuous improvement efforts under the Vetera ns Engineering Resource Center. Problem The Commission Recommends That . . . VHA has not effectively empowered its staff to Resource (VERC) Center  Engineering Veterans The identify problems and make changes to be transformation in assist to tasked efforts, improve the overall quality of care. access as such areas in particularly that areas in and and affect substantial require activities systemwide Best practices exist in pockets of VHA; change, such management, as human resources however, communication and support for contracting, information and purchasing, implementation appear to be challenges. technology. Various facilities indicate best practices are in The many idea and be  innovation portals within VHA place but seem isolated rather than widely consolidated under VERC. adopted. Facilities often struggle to implement and inspire A  culture to continuous support best practices, and information sharing is be improvement of workflow processes developed 80 and fully funded. limited and ad hoc.  VHA’s reengineering centers be enabled to VHA has a program of systems engineering— identify problem proactively within the system areas assistance. offer and the Veterans Engineering Resource Center (VERC)—that can assist with transformation A and until recently has been underutilized. efforts, but it is not well known throughout VH Background To become a truly veteran-centric care prov ider, VHA is working to become a learning 81 organization. Learning organizations focus on work er competency rather than on rules compliance. Instead of using results to identify high- and low-performers, VHA will use this information to identify opportunities to interven e with training or other resources to improve employees’ performance universally. Employees and patients should benefi t from this approach because it values listening and encourages risk taking and innovation. x Sigma as a systemic change approach to VA and VHA have adopted the tenets of LEAN Si move the system forward. This methodology employs a rigorous define, measure, analyze, improve, and control approach to systemic chan ge. LEAN, initially used by manufacturers, has 82 been used successfully by many health care organizations. The goal of implementing LEAN practices is to eliminate waste, ensuring that any work done adds value. The MyVA plan calls for MyVA districts and the Office of Policy and Planning to ensure the transmission of best practices and the adopting of LEAN throug hout the enterprise to provide a more comprehensive view of quality that balances a results-oriented approach with more process- 80 Independent Assessment of the Health Care Deli The MITRE Corporation, very Systems and Management Processes of the Department of Veterans Affairs , Assessment F (Workflow—Clinical), 14 and A-2 accesse d January 1, 2016, http://www.va.gov/opa/c hoiceact/documents/assessments/Asse ssment_F_Workflow_Clinical.pdf. 81 etary for Veterans Affairs, Department of Sloan D. Gibson, Deputy Secr Veterans Affairs, Build ing on Excellence, 67, presentation to Commission on Care, April 18, 2016. 82 MyVA Integrated Plan, Department of Veterans Affairs, July 30, 2015, 12, accessed June 30, 2016, http://www.va.gov/opa yva_integrated_plan.pdf /myva/docs/m 43

58 C INAL R EPORT F OMMISSION ON C ARE 83 oriented practice. So far these efforts have been guided by trial and error, rather than 84 directives and adopting a LEAN, process-driven model. VHA must sustain its commitment to LEAN Six Sigma as a continuous improvement methodology. VHA will have to use VERC staff and other traine d staff members to ensure that principles of LEAN Six Sigma are applied at every level of th e system. VERC has the mission to propose, develop, and facilitate innovative solutions to challenges within VHA health care delivery through the integration of systems engineering principles. to care, health policy, population health, With VERC’s reach already extending into access LEAN management, business systems, clinical sy stems, safety systems, and innovation, all other programs and initiatives become redundant or ancillary. VHA must assess its new system for best practice diffusion to ensure that select ed practices are being appropriately scaled. This goal can best be achieved by colla psing all related efforts into VERC. There are a number of emerging be st practices within the health care sector that apply to all aspects of VHA—health care capabilities, staffi ng, access, supplies, and facilities—and involve the testing, dissemination, and application of pr ocedures or systems that have been shown to 85 improve approaches, processes, or systems. VHA needs to have the opportunity to fully leverage and build on institutional streng ths by implementing best practices. VHA has recently developed the Diffusion of Excelle nce Initiative, which is designed to serve as combination of targeted national guidance and the mechanism for improving practice through a 86 nationally-supported local best pr actice sharing and innovation. Its organizational structure includes a governance board chaired by the US H, a Diffusion Council, and action teams responsible for implementi ng promising practices. VHA also has many business lines charged with disseminating best practices information, including VERC, Systems Redesign SharePoi nt—Center for Improvement Education, VA Center for Innovation, MyVA—Best Practice s in LEAN, MyVA Blog, MyVA Performance Improvement Hub, Knowledge Management System –Improvement in Action (I-ACT), VA Idea House, VA Pulse: Promising Practices Consorti um, Evidence-based Synthesis Program (ESP), Quality Enhancement Research Initiative (QUERI), the Annual Conference on the Science of Dissemination and Implementation, and th e Diffusion of Excellence Initiative. Analysis LEAN Six Sigma offers VHA a methodology to effect change and VERC offers VHA the agents to lead its implementation. VHA must consolidate its transformational tools, including its best 83 2015, 21, accessed June 30, 2016, MyVA Integrated Plan, Department of Veterans Affairs, July 30, /myva/docs/m yva_integrated_plan.pdf http://www.va.gov/opa 84 The MITRE Corporation, Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Vete rans Affairs , Assessment F (Workflow— Clinical), viii acces sed January 1, 2016, hoiceact/documents/assessments/Asse http://www.va.gov/opa/c ssment_F_Workflow_Clinical.pdf. 85 Transforming Health Care Schedu ling and Access: Getting to Now, 41, Institute of Medicine of the National Academies, accessed January 1, 2016, http://www.va.gov/opa/c hoiceact/documents/assessments/A ssessment_D_Access_Standards.pdf. 86 ing on Excellence, 67, Veterans Affairs, Build Sloan D. Gibson, Deputy Secr etary for Veterans Affairs, Department of presentation to Commission on Care, April 18, 2016. 44

59 C R OMMISSION ECOMMENDATIONS uses a systemic change process to streamline practice repositories within VERC. The VERC redundancy to ensure t hat every step in the workflow and procedures by eliminating waste and process adds value. The VERC offers services to VHA health care facilities upon request, but VHA would substantially benefit if the service wa s authorized to perform outreach to ensure 87 awareness across the VHA Care System. iative, VHA lacked a uniform way to scale and Until developing the Diffusion of Excellence Init . Although the Diffusion Initiative is initially optimize best practices throughout the enterprise be successful, a long-term plan should also allow targeting best practices from within VHA, to for the adoption of best practices from the priv ate sector and other government sectors (e.g., the Medicare program related to pricing, contract ing, privatization, value-based purchasing, management, and oversight). Plans should also a llow for adaptation at the local and regional levels to reflect respective differences in pr ovider supply, veteran needs, and marketplace 88 characteristics. VHA has multiple offices and sites invested in system reengineering, continuous process . Repositories of best practices do not get improvement, and best practices implementation hat could benefit from the information and are information to the intended person or group t 89 dependent upon VHA employees knowing they exist. VHA’s National Leadership Council has proposed consolidating these best practice repositories under the VERC, which now serves within the Office of Organizational Excellence. Until 90 recently, VERC has been underutilized because it is not known throughout the enterprise. QUERI is a system that identifies evidence-b ased care practices that may be scaled for systemwide implementation. QUERI was integra lly involved in the transformation of VHA 91 and is now integral to from a largely hospital-based system to one centered on primary care to a learning organization. QUERI recently the collaborative endeavor to transform VHA in released a policy brief that indicated veterans ’ reliance on VHA was strongly correlated to 92 d availability of other health care coverage. economic factors such as unemployment rates an VA should use a systematic, continuous perf ormance improvement proc ess to improve access Although many VA facilities achieve very high-performance ratings on key access and to care. to improve performance. These efforts need to quality measures, a systematic effort is needed 87 Heather Woodward-Hagg, PhD, Acti mmission on Care, February 8, 2016. ng Director, VERC, briefing to Co 88 Grant Thornton, Independent Assessment of the Health Care Delivery Sy stems and Management Processes of the Department of 28, accessed January 1, 2016, Veterans Affairs, Assessment I (Business Processes), ssment_I_Busines hoiceact/documents/assessments/Asse s_Processes.pdf http://www.va.gov/opa/c 89 ng Director, VERC, briefing to Co mmission on Care, February 8, 2016. Heather Woodward-Hagg, PhD, Acti 90 Transforming Health Care Schedu ling and Access: Getting to Now, 27, Institute of Medicine of the National Academies, accessed January 1, 2016, http://www.va.gov/opa/c hoiceact/documents/assessments/A ssessment_D_Access_Standards.pdf. 91 d Thriving,” Amy Kilbourne, QUERI Program Director, “HSR&D Perspectives Blog, QUERI Corner: Surviving an January 20, 2015, accessed from VA In tranet, April 4, 2016, http://vaww.blog .va.gov/hsrd/categor y/queri-corner/. 92 Christine Yee, Austin Frakt, and Steven Pizer, U.S. Department of Veterans Affairs, “Economic and Policy Effects on Demand for VA Care,” Partnered Evidence-based Policy Reso urce Center, Policy Brief, March 2016, accessed June 21, raktPizer.pdf. 2016, http://www.queri.research.va.gov/part nered_evaluation/YeeF 45

60 C F INAL R EPORT OMMISSION ON C ARE be embedded into routine use across the VA syst em. The best solutions should be adjusted to 93 reflect local needs and designed to respond to veterans’ preferences, needs, and values. A systems approach to health care is “one that applies scientific insights to understand the elements that influence health outcomes, models the relationships between those elements, and alters design, processes, or policies based on th e resultant knowledge in order to produce better 94 health at lower cost” and would benefit VA greatly, espe cially with resources like VERC to serve as a guide. Emerging best practices have im proved health care access and scheduling in various locations 95 A variety of and serve as promising bases for rese arch, validation, and implementation. in establishing and ma quality improvement organizations are involved intaining standards in health care as well as developing measures for the monitoring and assessment of these standards, including The Centers for Medicare & Medicaid Services, the Joint Commission, the 96 National Committee for Quality Assuranc e, and the National Quality Forum. The tools of operations management, industri al engineering, and systems approaches are ar, a wide range of industries successful in increasing process ga ins and efficiencies. In particul oaches to address scheduling issues, among have employed systems-based engineering appr 97 other logistical challenges. Implementation Legislative Changes  None required. VA Administrative Changes  Consolidate all best practices and contin uous improvement portals under VERC to provide a more accessible and comprehensive approach to best practice sharing and adoption. Other Department and Agency Administrative Changes  None required. 93 Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of RAND Corporation, Veterans Affairs, Assessment B (Health Care Capabilities), 110 and 297 accessed January 1, 2016, http://www.va.gov/opa/choi ceact/documents/assessme nts/assessment_b_health_c are_capabilities.pdf. 94 Institute of Medicine of the National Academies, 27 Transforming Health Care Schedu ling and Access: Getting to Now, accessed January 1, 2016, http://www.va.gov/opa/c hoiceact/documents/assessments/Asse ssment_D_Access_S tandards.pdf. 95 Ibid., 15. 96 Ibid., 60. 97 Ibid., 27-28. 46

61 C OMMISSION R ECOMMENDATIONS Health Care Equity care disparities among veterans Recommendation #5: Eliminate health treated in the VHA Care System by committing adequate personnel and monetary resources to address the caus es of the problem and ensuring the VHA Health Equity Action Pl an is fully implemented. Problem The Commission Recommends That . . . establishing  VHA work to eliminate health disparities by The Office of Health Equity (OHE), a care equity as health strategic priority. tasked with eliminating health the provide VHA  resources adequate Equity Health of Office disparities by building cultural and and and cultural build successfully to authority of level military competence within VHA, has providers among military competence all VHA Care System not been given the resources or level employees. and of authority needed to be successful. VHA Health ensure that the  fully is Plan Action Equity Until VHA leadership establishes the implemented support. and resources, staffing, adequate with elimination of health care disparities increase VHA  of race, use and quality, availability, the as a critical strategic priority and health ethnicity, of minority data language and the improve to commits the resources required to veterans and with other populations veteran vulnerable address this problem, health care surveillance monitor strong health in trends that systems 98 satisfaction, patient status, measures. quality and disparities will continue to persist among veteran patients. A systematic review of VHA in 2015 identified the existence of racial and ethnic health inequalities. Health care disparities exist amon g veterans and especially among minority and 99 vulnerable veterans. care to enhance quality, access, VHA cannot transform veterans’ health disparities are addressed and eliminated. VHA choice, and well-being unless these health care has a plan for addressing these issues—the Heal th Equity Action Plan (HEAP)—but it has not been fully implemented. Background It is time to refocus, reinforce, and repeat the message that health 100 disparities exist and that heal th equity benefits everyone. Across the nation, health care systems are ra ising awareness about health care equity, 101 The growing incidence of health ca re disparities and inequities is inequality, and disparities. said to be ascribed to individual and collective cultural indifference on th e part of health care 98 Kathleen G. Sebelius, Secretary, Department of Health and Human Services, HHS Action Plan to Reduce Racial and Disparities in Health and Health Care, accessed March 30, 2016, Ethnic Health Disparities: A Nation Free of http://www.minorityhealth.hhs.gov/npa/f iles/Plans/HHS/HHS_Plan_complete.pdf. 99 Department of Veterans Affairs, Evidence Brief: Update on Prevalen ce of and Interventions to Redu ce Racial and Ethnic Disparities within the VA, accessed May 19, 2016, http:// www.hsrd.research.va.gov/publicati ons/esp/HealthDisparities.pdf. 100 HHS Action Plan to Reduce Racial and Kathleen G. Sebelius, Secretary, Department of Health and Human Services, Ethnic Health Disparities: A Nation Free of Disparities in Health and Health Care, accessed March 30, 2016, http://www.minorityhealth.hhs.gov/npa/f iles/Plans/HHS/HHS_Plan_complete.pdf. 101 Centers for Disease Control and Prevention, CDC Health Disparities and Inequalities Report – United States, 2013 , accessed April 5, 2016, http://www. cdc.gov/mmwr/pdf/ other/su6203.pdf. 47

62 C C INAL R EPORT OMMISSION ON F ARE 102 providers and the health care system as a whole. A health disparity is a particular type of health difference that is closely linked with soci al or economic disadvant age. Health disparities stematically experienced greater social and/or adversely affect groups of people who have sy ethnic group, gender, age, sexual orientation, economic obstacles to health based on racial or on, socioeconomic status, mental health, military era, geographic location, religi cognitive/sensory/physical disability, and ot her characteristics historically linked to 103 discrimination or exclusion. The United States is becoming increasingly divers e, with racial and ethnic minorities making up 104 Indicators of overall health, such as life expectancy more than 36 percent of the population. and infant mortality, have improved for most Americans; however, some minorities still face 105 entable disease, death, and disability. comparatively greater likelihood of prev ojected to decline from 22 million to 14.5 million Although the country’s veteran population is pr by 2040, the percentage of minority veterans will increase from 20 percent to 34 percent during 106 Currently, African Americans make up 11 percent of the veteran population, the same period. 107 and Hispanics, 6 percent. Survey data show that minority veterans use VA health care more than White veterans, as 108 shown below:  African American: 38 percent Hispanic: 34 percent   American Indian/Alaska Native: 38 percent White: 32 percent  102 G.L.A. Harris, “Reducing Health care Disparities in the Military Through Cultural Competence,” JHHSA (2011), 146. 103 “Office of Health Equity,” U. fairs, accessed June 12, 2016, S. Department of Veterans Af http://www.va.gov/HEALT HEQUITY/index.asp. 104 “Minority Health and Health Equity – CDC,” Center s for Disease Control and Prevention (CDC), accessed March 28, 2016, http://www.cdc.go v/minorityhealth/index.html. 105 Ibid. 106 National Center of Veterans Analysis and Statistics, Minority Veterans 2011 Report, May 2013, accessed April 6, 2016, http://www.va.gov/vetdata/docs/Special Reports/Minority_Ve terans_2011.pdf. 107 U.S. Census Bureau, American Community Survey, Public 2011. Department of Defense, Use Microdata Sample (PUMS), Population Representation in the Mili tary Services Fiscal Year 2011 Report, accessed April 5, 2016, http://www.va.gov/vetdata/docs/Speci alReports/Minority_ Veterans_2011.pdf 108 Reliance projections here are based on ambulatory care ut ilization. Westat, 2015 Survey of Veteran En rollees’ He alth and Use of Health Care , 82, accessed May 19, 2016, YPLANNING/SoE2015/2015_ VHA_SoE_Full_Findin gs_Report.pdf. http://www.va.gov/HEALTHPOLIC 48

63 C R OMMISSION ECOMMENDATIONS rans’ use of VHA health care offer revealing Survey data on racial and ethnic minority vete 109 insights on current equity issues: Fifty-seven percent of African Americans indi cated they are more likely to use VA as  110 their primary source of health care as compared to 45 percent of Whites. The percentage of African Americans who report  ed they use VA for all or most of their 111 care needs is 18 percent higher than the percentage of Whites who do so.  A higher percentage of Whites assessed thei r health to be good or excellent than did 112 African Americans. Analysis VHA Office of Health Equity care inequities, understand the cause of them, VA created the OHE in 2012 to identify health tended to reduce disparity drivers within VA. and bring to clinical practice interventions in ral government offices, and nongovernment OHE partners with other VA offices, fede 113 institutions with missions aimed at promoting health equity. OHE has substantial stakeholder involvement from minority veterans groups, including the Advisory Committee on Minority Veterans (ACMV), rural veterans groups, wome n veterans, and the Office of Diversity and 114 A staunch internal partner and stakeholder of OHE, ODI’s mission is to Inclusion (ODI). foster a diverse workforce and an inclusive work environment. The OHE and ODI missions intersect with ODI’s special emphasis programs, intended to engage affinity groups and agencies to raise the awareness of the im portance of diversity and demonstrate VA’s 115 commitment to a diversity model. atic reviews and data analyses that not only OHE’s foundational work included updated system on health care inequities, but also identified more areas of revalidated VA’s previous findings ance, hepatitis C virus (HCV) was noted to have health care disparity among veterans. For inst terans and Vietnam-era veterans. Additionally, disparate effect on racial/ethnic minority ve OHE convened stakeholders and worked with the Health Equity Coalition to develop the VHA Health Equity Action Plan (HEAP), which alig ns with the VHA Strategic Plan Objective 1e: Quality & Equity, which states, “Veterans will rece ive timely, high quality, personalized, safe effective and equitable health care irrespective of geography, gender, race, age, culture or sexual 109 Department of Veterans Affairs, 2011 Survey of Veteran Enrollees’ Health and Reliance Upon VA , accessed April 2, 2016, http://www.va.gov/HEALTHPOLICYP LANNING/SOE2011/SoE 2011_Report.pdf. 110 2011 Survey of Veteran Enrollees’ Department of Veterans Affairs, April 2, Health and Reliance Upon VA , 85, accessed 2016, http://www.va.gov/H EALTHPOLICYPLANNING/SO E2011/SoE2011_Report.pdf. 111 Ibid. 112 Ibid. 113 Department of Veterans Affairs, Office of Health Equity, US Department of Veterans Affairs Office of Health Equity Mission and Accomplishments, accessed March 30, 2016, http://www.va.gov/HEALTHEQUIT Y/docs/OHE_Mission_a nd_Accomplishments_November_2015.pdf. 114 “Office of Diversity and Inclusion (ODI),” Depart ment of Veterans Affair s, accessed May 13, 2016, http://www.diversity.va.gov/. 115 “Office of Diversity and Inclusion (ODI), Special Emphasi s Programs,” Department of Veterans Affairs, accessed va.gov/programs/default.aspx. May 17, 2016, http://www.diversity. 49

64 C C F INAL R EPORT OMMISSION ON ARE 116 orientation.” s: awareness, leadership, health system HEAP aims to address five strategic area and life experience, cultural and linguistic compet ency, and data that are vital for effectively strategies are conceptually modeled after the implementing its mission. HEAP implementation for Action to End Health Disparities’ National goals and strategies of the National Partnership Health Equity sponsored by the U.S. Department of Health Stakeholder Strategy for Achieving 117 and Human Services. implemented because VHA leadership failed to Despite OHE’s best efforts, HEAP was not fully establish it as a strategic priority with adequate staffing, resources, and support, and the departure of the then USH, a champion for health equity. These factors led to the reduction of OHE staffing from 8 to 2 FTEs in FY 2013 and a realignment of OHE to several layers down in the organization. As a result of an FY 2015 budget reduction, OHE continues to operate with a 118 two-person staff. The reduced staffing level is inadeq uate to meet the requirements and mission of the office. arly given the number of minority veterans OHE has a broad and challenging mission, particul who rely on VA health care, the health risks in those populations, and the health care disparities 119 those populations experience. OHE faces serious challenges in its efforts to carry out its action challenges intensified by its limited staffing plan and to realize its broad and critical mission, and the downgrade of this office within VH A’s organization structure. These include the 120 following:  lack of quality data on vulnerable po pulations and disparate health outcomes layed or halted due to staff and resource health equity projects that have been de  limitations lack of data on the overall impact of exis ting health equity initiatives at facilities  lack of common definitions on vulnerable populations and health equity concepts  E has compiled a substantial record of Notwithstanding its limited staffing, OH accomplishments. Among its initiatives, OHE embarked in 2015 on a strategy of working collaboratively with the Quality Enhancement Rese arch Initiative (QUERI) to advance health equity. The two collaborative efforts focus on us ing a population health approach to examine the distribution of diagnosed health conditions, mortality, and health care quality across the VA health care system. A fully staffed OHE would have the capability of creating additional 116 accessed May 17, 2016, Department of Veterans Affairs, VHA Strategic Plan: FY 2013–2018, _STRATEGIC_PLAN_ FY2013-2018.pdf. http://www.va.gov/health/docs/VHA 117 akeholder Strategy for Achieving Health Equity, “National Partnership For Action (NPA), National St “U.S. Department of Health & Hu man Services, acce ssed May 16, 2016, http://minorityhealth.hhs.gov/npa/templ ates/content.aspx?lvl=1&lvlid=33&ID=286 118 Uche S. Uchendu, Executive Director, OHE, briefing to Commission on Care, December 14, 2015. 119 “Management Brief no. 99,” Department of Veterans Affairs, accessed May 19, 2016, ov/publications/management_ briefs/default.cfm?Managem entBriefsMenu=eBrief-no99. http://www.hsrd.research.va.g Somnath Saha et al., “Racial and Et hnic Disparities in the VA Health Ca re System: A Systematic Review,” Journal of , 23, no. 5, (2008): 654-671. General Internal Medicine 120 Uche S. Uchendu, Executive Director, Office of Health Equity, briefing to Commission on Care, December 14, 2015. 50

65 C OMMISSION ECOMMENDATIONS R equity program and provide needed services to analytical tools to manage the daily health care 121 advance health equity. Among Minority Veterans Health Care Disparities jor, life-threatening health conditions, as Minority groups are at increased risk of ma 122 123 documented in a substantial body of research and illustrated in the table below: Table 3. Major Health Conditions in Racial/Ethnic Minority Groups Health Conditions Major and Examined in Racial/Ethnic Minority Groups Identified Americans Hispanics American Indian African or Alaska Natives  Colon Cancer  Hepatitis C  Major Non ‐ cardiac Surgery  HIV  Cancer  Pregnant Women with PTSD Kidney  Chronic disease Disease  Heart  Diabetes Stroke  Venous Thromboembolism  (VTE) Cancer  Heart Disease  HCV is more prominent among some racial and ethnic minority veterans and they are less likely to receive treatment for HCV. In VHA, so me racial and ethnic minorities diagnosed with HCV are disproportionately more at risk for havin g associated liver disease (ALD). Disparities among veterans in the incidence of HCV, illustr ated in the graphs below, show the important 124 policy and resource implications for VA. 121 Ibid. 122 Andy I. Choi et al., “White/Black Racial Differ ences in Risk of End-Stage Renal Disease and Death,” The American , acial Differences in End- Stage Renal Di sease Rates 122, no. 7, (2009): 672-678. Andy I. Choi et al., “R Journal of Medicine Journal of the American , 18, no. 11 (2007): 2968-2974. Hashem B. in HIV Infection with Diabetes,” Society of Nephrology Cirrhosis and Hepatocellular El-Serag et al., “Racial Differences in the Progression to Carcinoma in HCV-Infected Veterans,” The American Journal of Gastroenterology , 109, no. 9, (2014): 1427-1435. Cleo A. Sa muel et al., “Racial Disparities in Cancer Care in the Veterans Affairs Health Care System and the Role of Site of Care,” American Journal of Public Health , 104, Supplement 4, (2014): S562-571. 123 Department of Veterans Affairs, Evidence Brief: Update on Prevalence of an d Interventions to Reduce Racial and Ethnic Disparities within the VA , accessed May 19, 2016, http://www.hsrd.research. va.gov/publications/esp/H ealthDisparities.pdf. 124 Department of Veterans Affairs, Office of Health Equity, Hepatitis C Factsheet, Hepatitis C, Advanced Liver Disease & Health Care Disparities, accessed May 25, 2016, https://github.c om/department-of-veterans-affairs/VHA- %20FINAL%2010162015.pdf. Asset/raw/master/Hep %20C%20FACT%20SHEET 51

66 C OMMISSION ON ARE F INAL R EPORT C the Incidence of Hepatitis C Virus Figure 2. Disparities Among Veterans in ethnic differences in outcomes for VA patients A recent review of evidence related to racial and ggestive of gaps in morbidity and mortality showed moderate- and low-strength evidence su s with major health conditions. These data, outcomes among vulnerable veteran population 125 light targets for further research. presented in the table below, high Table 4. Comparison of Health Outcomes by Race Health Outcomes Worse Racial Minority Group Relative For Comparison Reference to Population (usually White) ‐ Evidence Moderate Strength the on VA from early 2000s) (based data patients disease kidney chronic Increased end ‐ stage renal disease among end ‐ stage renal disease Increased HIV patients (with or without among v. American African White diabetes) colon cancer survival 3 years after diagnosis Decreased among White Increased Hispanic cirrhosis and hepatocellular carcinoma v. hepatitis C patients Low ‐ Strength Evidence (each finding supported by only a limitations) single retrospective study with important methodological Increased mortality among diabetes patients Increased risk of preterm birth among PTSD patients White African v. American mortality at 2 years post ‐ hospitalization among stroke Increased patients Decreased survival 3 years after diagnosis of rectal cancer surgery noncardiac major Increased risk of 30 ‐ day post ‐ op mortality after or Indian American v. White Alaskan Native among Increased of preterm birth PTSD patients risk other racial/ethnic Combined Increased injury ‐ related death among alcohol use disorder patients minority v. African American groups 125 “Management Brief no. 99,” Department of Veterans Affairs, accessed May 19, 2016, tBriefsMenu=eBrief-no99. ov/publications/management_br iefs/default.cfm?Managemen http://www.hsrd.research.va.g 52

67 C R OMMISSION ECOMMENDATIONS namely, the , OHE’s focus, health equity, is intended to combat health care disparities nostic, or treatment services o ffered to veterans with similar differences in the preventive, diag health conditions. Health care disparities stem from a combination of complex factors occurring 126 system, provider, and patient. at the level of the health Health care disparities can result from 127 ll as from social disparities, biological differences among vari ous racial/ethnic groups as we also termed social determinants, which stem from such factors as socioeconomic status, discrimination, education levels, housing, tr ansportation, and crime and violence, and are 128 For example, poor-quality housing poses a risk of causally linked to subsequent adult disease. exposure to many conditions that can contribute to p oor health, such as indoor allergens that 129 exposure to lead and other toxic substances. can lead to and exacerbate asthma, injuries, and Social determinants that driv rican Americans, Hispanics, e health disparities among Af /ethnicity; gender; age; geographic location American Indians, and Alaska Natives include race religion; socio-economic status; sexual orientation; military era; disabilities, including cognitive, haracteristics historically linked to discrimination or exclusion. sensory, or physical; and other c Positioned in a department that also provides be nefits that fall within the social determinants of health, OHE is in a unique position to improve veterans’ health. The Henry Ford Health System (HFHS) is an exam ple of a health system that is committed to health equity and one VHA can emulate as it works to improve health equity. HFHS is a nonprofit, vertically integrated health care or ganization that serves the primary and specialty health care needs of residents in southeastern Michigan, including Detroit and its surrounding 130 metropolitan area. HFHS’s comprehensive health equity staff has a health care equity campaign with a goal of increasing knowledge, awareness, and opportunities to ensure health care equity is understood and practiced by HFHS providers and other staff, the research 131 The campaign is also intended to make health care community, and the community-at-large. 132 equity a key, measurable aspect of clinical quality. A similar effort by VHA would create a system for tracking improvement of health eq uity over time and holding the organization accountable for ongoing efforts in this regard. veterans will receive timely, high quality, The VHA strategic plan for FY 2013–2018 states that equitable health care, irrespective of geography, gender, race, personalized, safe, effective, and 133 age, culture, or sexual orientation. Although that statement signals a sensitivity to health equity, the level of funding support for the VHA o ffice with the lead role in promoting health equity and reducing disparity calls into se rious question the leadership priority and commitment to that strategic goal. VHA leadership must make health care equity a strategic 126 Henry Ford Health System, Healthcare Equity Cam paign 2009-2011 Final Report , accessed April 1, 2016, http://www.henryford.com/docume nts/Diversity/Health care%20Equity%20Campa ign%20Report.pdf. 127 Kinney, and Robert E. Braun, James H. Price, Molly A. Mc Ethnic Health Disparities in Social Determinants of Racial/ Children and Adolescents, /Webinars/20120416151902.pdf ww.sophe.org/Sophe/PDF accessed April 1, 2016, http://w 128 Ibid. 129 on, Commission to Build a Heal thier America, accessed “What Drives Health,” Robert Wood Johnson Foundati th.org/WhatDrivesHealth.aspx. April 1, 2016, http://www.commissiononheal 130 Healthcare Equity Cam paign 2009-2011 Final Report Henry Ford Health System, , accessed April 1, 2016, http://www.henryford.com/docume care%20Equity%20Campa ign%20Report.pdf. nts/Diversity/Health 131 Ibid. 132 Ibid. 133 Department of Veterans Affairs, VHA Strategic Plan: FY 2013–2018, accessed May 17, 2016, N_FY2013-2018.pdf. http://www.va.gov/health/docs/V HA_STRATEGIC_PLA 53

68 OMMISSION ON C F INAL R EPORT ARE C priority by directing and funding the im plementation of VHA HEAP nationwide and designating a leader and clinical champions within each VISN and VAMC, as a designated full- time equivalent (FTE), providing OHE budgetary support in FY 2017 and beyond to fully staff e its mission and goals, to include providing the office so that it can successfully achiev entation of the VHA HEAP; and ensuring OHE additional needed funding to support implem reports to the chief of VHA Care System (CVCS). Implementation Legislative Changes  None required. VA Administrative Changes  Make health equity a strategic priority by directing the implementation of the VHA health equity clinical champion within HEAP nationwide and designating a leader and eir respective FTE position descriptions each VISN and VAMC for whom part of th includes focusing on health equity issues.  Reestablish OHE staffing based on the 20 11 VHA Health Care Equality Workgroup recommendations to enable OHE to fulfi ll VHA’s vision to provide appropriate individualized health care to each veteran in a method that eliminates disparate health outcomes and assures health equity. Action required includes, but is not limited to, funding FTE staffing levels commensurate with the scope and size of other federal offices of health equity.  Reinstate OHE within the office of the CVCS to underscore health equity as a priority and to position the office to champion succe ssfully the advancement of health equity for 134 all veterans.  Monitor and evaluate the department’s success in implementing HEAP. Other Department and Agency Administrative Changes  None required. 134 r VHA Commitment, February 2016. Principal Department of Veteran Affa irs, Health Equity Coalition Request fo , Health Equity Coalition, March 21, 2013. Deputy Under Secretary of Health Memorandum 54

69 C ECOMMENDATIONS R OMMISSION Facility and Capital Assets ent a robust strategy for meeting Recommendation #6: Develop and implem and managing VHA’s facility and capital-asset needs. Problem The Commission Recommends That . . . Veterans who turn to VHA to meet their streamline leaders VA  strengthen the facility and and health care needs should expect that its and management operations. program asset capital facilities have been designed and equipped VHA Care System governing board be responsible The  to provide state-of-the-art care. As health oversight for management. asset capital facility of and care continues to move to ever greater use of  VHA greater budgetary flexibility to Congress provide ambulatory care delivery, VHA not only meets facility and capital asset needs and greater its lacks modern ambulatory health care unneeded of itself divest to authority statutory buildings. facilities in many areas, but generally lacks the means to readily finance and acquire enact Congress establish legislation to facility VHA a  asset capital based and the on process realignment space, to realign its facilities as needed, or Commission Base DoD and Closure Realignment even to divest itself easily of unneeded as soon as implemented be to process practicable. buildings. Many of these barriers are The VHA the that recommends Commission Care statutory in nature, although VA’s own System governing make subsequently facility board internal processes compound its capital asset alignment in decisions needs. system with challenges. Establishing integrated care on capital New be focused ambulatory care  networks, as proposed in trends. reflect development health care to Recommendation #1 holds the promise of  VHA or forward repurposing with immediately move markedly improving veterans’ access to care. facilities selling as identified been already have that closing. of being in need That promise cannot be realized without transformative changes to VHA’s capital structure. Political resistance doomed previous a ttempts to better align VHA’s capital assets and veterans’ needs. It is critical that an obje ctive process be established to streamline and modernize VHA facilities in the context of the bu ild out of the VHA Care System’s integrated networks to ensure the ideal balance of facilit ies within each network. VHA needs as much control as possible to drive the process so that all facility plans are fully integrated with the strategic vision for the VHA Care System. Background Most VHA health care centers were designed when care was focused on inpatient hospital treatment. VA acquired some of these facilitie s nearly a century ago from the Public Health 135 Service; many others were transferred from the War Department shortly after World War II. The average VHA building is 50 years old—five times older than the average building age of 136 not-for-profit hospital systems in the United States. Most of its facilities were designed to meet markedly different needs than today’s heal th care facilities. So me were tuberculosis 135 st th , report prepared by Robinson Adkins, 90 Cong., 1 Veterans Administration, sess., 1967, Medical Care of Veterans House Committee Print 4, 62. 136 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment K (Facilities) , vi, accessed April 11, 2016, ssment_K__Fac t/documents/assessments/Asse http://www.va.gov/opa/choiceac ilities.pdf. 55

70 C C INAL R EPORT OMMISSION ON F ARE 137 sanatoriums, others for years primarily housed patients with mental health conditions . Although many have been extensively renova ted, the renovations themselves are now outdated, and the condition of buildings shows this strain. Independent assessments of 138 meaning C minus score, ed that VHA facilities average a infrastructure and facilities show much of the total facilities portfolio is nearing th e end of its useful life, and 70 percent of facility 139 correction repairs are being made on Grade D facilities. ys of care have declined nearly 10 percent as During the past 8 years, veteran inpatient bed da 140 Current facilities, whether outpatient clinic workload has increased more than 40 percent. they have been maintained adequately or not, often do not support contemporary ambulatory care needs, with outpatient care often housed in converted inpatient spaces. Through its capital planning methodology, VA has identified more than $51 billion in total 141 capital needs during the next 10 years. Capital funding during the past 4 years has averaged 142 If funding levels remain consistent during the next 10 years, just $2 billion annually. anticipated funding would be $25 billion to $35 billion less than the $51 billion capital 143 requirement. VA planning must also take account of demographic changes and population migration that have led to underutilized medical centers in some areas of the country, and a 144 need for new capacity in others. Analysis New Planning Paradigm 145 As the department acknowledged, “VA’s health care delivery model must . . . change.” n can excel at every capability,” and stated Importantly, it recognizes that “No organizatio “[s]ervice delivery systems designed around core competencies . . . provide the highest 146 The acknowledgement that VHA can best serve veterans potential value to their customers.” ue capabilities, while relying more heavily on by focusing on its core competencies and uniq purchased care holds important implications for VHA’s capital needs and capital asset management. Rather than assessing VHA’s capital needs by reference to an expectation that each VA medical center, or constellation of medi cal centers, must provide virtually all needed hospital and medical services, capital needs mu st be redefined within the framework of the VHA Care System’s high-performing integrated community health care networks. VHA must determine what services it will continue to prov ide directly in a given community before it can determine its respective infrastructure needs. In identifying its core competencies, unique 137 th st , report prepared by Robinson Adkins, 90 sess., 1967, Cong., 1 Medical Care of Veterans Veterans Administration, House Committee Print 4, 62. 138 The MITRE Corporation, very Systems and Management Processes of the Independent Assessment of the Health Care Deli , 27, accessed April 11, 2016, Department of Veterans Affairs, Assessment K (Facilities) http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_K__Fac ilities.pdf. 139 Ibid. 140 Ibid., 46. 141 Ibid., 17. 142 Ibid., 18. 143 Ibid., 18. 144 Ibid., 59-61. 145 Department of Veterans Affairs, Plan to Consolidate Programs of Department of Veterans Affairs to Improve Access to Care, 18, 015.pdf. ons/VA_Community_Care_R accessed January 13, 2016, http:// www.va.gov/opa/publicati eport_11_03_2 146 Ibid. 56

71 C OMMISSION ECOMMENDATIONS R would be setting at least a general framework capabilities, and needed ancillary services, VHA through which network and local planners could assess where and how needed services would be delivered, including which would be prov ided directly by VHA and which through purchased care. Such a mapping exercise would be a first step in developing the integrated community health care networks. ke different forms in each service-area, and The shape of an integrated delivery network will ta planning and developing those local networks will necessarily require assessing VHA’s physical plant and capacity in a new light. Th at reassessment process would inform capital planning, and must take account of at least three distinct needs: capital needs associated with and the disposal of placement space needs; buildings VA would retain; meeting new or re unused, unneeded property. Property Divestiture VHA’s principal mission is to provide health care to veterans, yet over time it has acquired an of vacant buildings. As recently as October ancillary mission: caretaker of an extensive portfolio 2015, VA reported that its inventory includes 336 buildings that are vacant or less than patient-care funds to maintain more than 50 percent occupied, requiring it to expend 147 10,500,000 square feet of unneeded space. The SECVA recently testified that it costs VA an 148 operate vacant and un estimated $26 million annually to maintain and derutilized buildings. 149 -management is circumscribed in law, VA’s authority to carry out property and the nges in either attempting to repurpose or department at times faces insurmountable challe 150 In contrast to more rigid property- divest itself of underutilized or vacant property. divestiture provisions, VA has had success in usin g a flexible authority to enter into long-term 151 leases of VA property for enhanced use. lease underutilized capital This authority allows VA to 147 Ibid., 92. 148 “Witness Testimony of Honorable Robert A. McDonald, Secr etary, U.S. Department of Veterans Affairs, Hearing on Veterans’ 2/10/2016: U.S. Department of Veterans Affairs Budget Request for Fisc al Year 2017,” House Co mmittee on Affairs, accessed June 20, 2016, http s://veterans.house.gov/w le-robert-a-mcdonald-2. itness-testimony/the-honorab 149 Authority for Transfer of Real Property; Department of Veterans Affairs Capita l Asset Fund, 38 U.S.C. § 8118 rvices, 38 U.S.C § 8122. For example, operty and to Negotiate for Common Se Authority to Procure and Dispose of Pr t full market value in transferring prop erty, unless the proper ty is transferred under section 8118, VA must receive at leas to homeless vetera ns, and any proposed transfer is subject to the requirement in to an entity that provides services , notify Congress in advance, and no section 8122 that VA first hold hearings t proceed for a specified period. VA rmined to be “excess,” though y not make such a declaration property can be dete under 38 U.S.C. § 8122(d)(1), VA ma r use for provision of services to home unless the property is not suitable fo less veterans and reviewed for possible disposal under the Property Act Disposal, administered by the General Services Administration (GSA) (40 U.S.C., subchapter III). GSA employs a rigorous, multistep process to assure that the asset is not needed by any other Federal agency. Under the Act, the agency dis posing of the asset is responsible fo r funding disposal costs, including environmental remediation. GAO has testif ied that properties remain in an agency ’s possession for years and continue to accumulate maintenance and operations costs because of the legal requirements agencies must meet and the length of the process. (U.S. Governme Federal Real Property: Progress Made on Planning and Data, but Unneeded nt Accountability Office, GAO-11-520T (Washington, DC, 2011), 5, http://www.gao.gov/products/GAO-11- Owned and Leased Facilities Remain, 520T). 150 With many properties under the protection of the Nationa l Historic Preservation Act ( 16 U.S.C. § 470h-3), VA faces obstacles and delays in efforts to dive st itself of these propert ies; VACO staff report that stakeholder concerns have been obstacles. 151 Enhanced-Use Leases of Real Prope rty, 38 U.S.C. §§ 8161-8169, as amended by Veterans Millenni um Health Care and Benefits Act, Section 208, Pub. L. No. 106-117, 113 Stat. 1545 (1999), as in effect when GAO testified on this VA Real Property: VA Emphasizes Enhanced-Use Leases to successful program (U.S. Government Accountability Office, 57

72 C C INAL R EPORT OMMISSION ON ARE F years to develop housing for homeless and at-risk assets to private-sector entities for up to 75 veterans and their families. Most recently, however, Congress imposed severe limits on that 152 leasing authority. Ongoing Capital Needs delivery model that relies more on purchased Establishing a transformative new health care care will not eliminate the need for new clinics, facility renovations, and remedying VHA space deficiencies. The scope of thos e needs must still be determined in light of a proposed new Independent Assessment Report catalogued the delivery system, but they cannot be ignored. The challenges of managing and operating VA’s capital program and the need to deploy best practices to improve total performance, and cl early address the importance of more modern 153 facilities for delivering high quality care. Of particular concern is an apparent breakdown in the process of bringing new clinics online and renewing the leases of existing clinics. Wi th current law requiring congressional approval 154 more than $1 million, of any lease with an av erage annual rental of a Congressional Budget 155 156 has upended the approval process and halted the leasing program. Office (CBO) ruling Indicative of the scope of the problem, VHA’s then USH testified in 2013 that VA, since 2008, 157 which required authorization as major leases. had opened 180 leased medical facilities, 50 of 158 Currently, 24 major VA leases are in limbo. GAO-09-776T (Washington, DC, 2009), http ://www.gao.gov/asse ts/130/122697.pdf). Manage its Real Property Portfolio, For example, VA has authority to outlease its facilities for up to 3 years, but may not retain the proceeds of any such leasing (Authority to Procure and Dispose of Property and to Negotiate for Common Serv ices, 38 U.S.C. § 8122(a)(1)). U.S. Government Ac Federal Real Property: Progr ess Made on Planning and Da ta, but Unneeded Owned and countability Office, Leased Facilities Remain, GAO-11-520T (Washington, DC, 2011), 5, http://www.gao.gov/pr oducts/GAO-11-520T. 152 Before the sunset of that authority in 2011, VA could ente r into such a long-term lease if (1) at least part of the property’s use would contribute to VA’s mission, (2) the lease woul d not be inconsistent with that mission; and (3) the ress reauthorized § 8162(a)(2)). Cong operty (Enhanced-Use Leases, 38 U.S.C. lease would enhance the use of the pr enhanced-use leasing, but limited it to a single use: the development of su r veterans who are pportive-housing fo Veterans and Caring for Camp homeless or at risk of homelessness (Honoring America’s Lejeune Families Act of 2012, Sec. 211, Pub. L. No. 112-154, 126 Stat. 1165 (2012).) 153 Independent Assessment of the Health Care Deli very Systems and Management Processes of the The MITRE Corporation, , accessed June 2, 2016, Department of Veterans Affairs, Assessment K (Facilities) http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_K__Fac ilities.pdf. 154 Congressional Approval of Certain Medi cal Facility Acquisiti ons, 38 U.S.C. § 8104. 155 th Hearing on Assessing VA’s Capital Inventory Opti ons to Provide Veterans’ Care Before the Committee on Veterans Affairs, 113 Cong., 42 (June 27, 2013) (State ment of Robert A. Sunshine, Deputy Dire ctor, Congressional Budg et Office), accessed June 20, 2016, https://www.gpo. gov/fdsys/pkg/CHRG-113hhrg 82242/html/CHRG-113hhrg82242.htm. 156 Ibid CBO maintains that the structure of . VHA’s lease transactions—the lease of a facility, designed by and built for VHA, and for which payments retire most or all of the debt over the life of the lease—is in the nature of a governmental acquiring the facility should be budgeted up front, rath er than spread over the purchase, and, as such, the full cost of Congress offset that aggregat e cost, CBO’s position has had duration of the lease. As budget rules generally require that the effect of blocking what had previous ly been a manageable funding process. 157 th Hearing on ons to Provide Veterans’ Care Before the Committee on Veterans Affairs, 113 Assessing VA’s Capital Inventory Opti Cong., 44 (June 27, 2013) (Sta tement of Robert A. Petzel, M.D., Unde r Secretary for Health , Veterans Health Administration, U.S. Department of Veterans Affairs), June 20, 2016, https://www.gpo.gov/ fdsys/pkg/CHRG- 113hhrg82242/html/CHRG-113hhrg82242.htm. 158 “Witness Testimony of Honorable Robert A. McDonald, Secr etary, U.S. Department of Veterans Affairs, Hearing on 2/10/2016: U.S. Department of Veterans Affairs Budget Request for Fisc al Year 2017,” House Co mmittee on Veterans’ s://veterans.house.gov/w itness-testimony/the-honorab le-robert-a-mcdonald-2. Affairs, accessed June 20, 2016, http 58

73 C R OMMISSION ECOMMENDATIONS 159 that it can provide flexibility and speed. One of the primary benefits of leasing is But the time VHA has required to execute a lease, from pl anning through to activation, has taken almost 160 9 years in the case of a major lease, expectations of build-to-suit in contrast with private-sector 161 leases that often take fewer than 3 years. In acknowledging the magnitude of the challeng es associated with VA’s capital program and Independent Assessment Report includes the budget constraints within which VA is operating, the idered, to include alternative vehicles for a suggestion that transformative options be cons 162 blic–private partnerships. capital delivery such as pu Capital Asset Management eengineering. Facilities-related functions are Capital asset management itself requires r dispersed through VA, resulting in a lack of accountability for outcomes, a mismatch between paration of project execution and facilities planning efforts and funding decisions, and se 163 164 management, suggesting a need for transformative changes in operations. In its work to foster transformation, departme nt officials have recognized many organizational and process challenges that require priority attention, including the need to realign its infrastructure, identify new (private) sources of financing, streamline investment decision 165 making and contracting, and improve the management of capital projects. Organizational change aimed at streamlining and better aligning co re processes is vital to effective operation of VA’s facilities programs. Capital-Asset Imperatives The planning and development of a new delivery model centered on establishing integrated identifying, planning for, and realizing VHA’s networks of care has major implications for inherent in that model, establishes a new set capital needs. Greater reliance on community care, of imperatives, specifically, a need for  facility realignment more effective means of repurposing or ot her divestiture of unneeded buildings and  land  new, more effective tools to meet VHA’s need for new clinic capacity and major construction  more effective management of VHA’s capital needs 159 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment K (Facilities) , 159, accessed June 2, 2016, t/documents/assessments/Asse ssment_K__Fac ilities.pdf. http://www.va.gov/opa/choiceac 160 Ibid., 159-160. 161 Ibid., 160. 162 Ibid., vii-ix, 34. 163 Ibid., vi, 20. 164 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, K-5, accessed June 2, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 165 Interviews of VA staff by Commission on Care staff, April 2016. 59

74 C C INAL R EPORT OMMISSION ON F ARE Facility Realignment VA planning must closely examine the role of, and fu ture for, individual facilities, in light of a transformative new delivery model. For more t han a quarter century, VHA leaders have cited the need for medical center mission changes, rea lignments, disposal of unneeded buildings, and 166 where indicated, hospital closures. The critical importance of transforming VA health care delivery gives new urgency to pr oviding tools to realign VHA’s care-delivery infrastructure. The Commission recognizes that the SECVA does have authority to “consolidate, eliminate, abolish, or redistribute the functions of . . . [V A] facilities, and to carry out an administrative 167 reorganization” of a field facility. But that authority may generally not be unilaterally 168 In addition, despite VA’s having estab lished two previous commissions to address exercised. e had only limited success in achieving that the need for facility realignment, leaders hav objective. The exercise of SECVA’s broad au thority to reorganize is tempered by the prerogatives and fiscal authority held by Co ngress. Congress has rejected legislation that 169 future of individual VA facilities, proposed a process to reassess the reflecting concerns over veterans losing access to care and the potent ial of constituents losing employment. Such concerns can be addressed. To be successful, a capital asset realignment process must be amework that provides for sound planning; the conducted on a systemwide basis within a fr exercise of objective, independent expertis e; and a reliable mechanism for implementation. 170 Congress can look to and adapt a proven model —the military base realignment and closure (BRAC) process—to meet those objectives and ac hieve marked improvements in access to care. Congress should enact legislation, based on Do D’s BRAC model, to establish a VHA capital asset realignment process to more effectively a lign VHA facilities and improve veteran’s access to care. Creating a robust capital asset realig nment process is vital because previous capital 171 This process should offer a level of rigor far beyond what divestiture efforts have failed. tal assets. It should require VHA to employ currently exists for repurposing and selling capi ing board (see Recommendation #9) to conduct criteria set by the VHA Care System govern locally-based analyses of capital assets, based on national process criteria. Information generated would be used to assist an in dependent commission, established under the 166 Philly.com, accessed December 31, 2015, “VA Chief Seeks Panel to Revamp System,” Christopher Scanlan, news/26134051_1_va-hospitals-d http://articles.philly.com/1989-07-18/ erwinski-veterans-hospital. “Distinguished Group Selected for CARES Commission,” Department of Vete rans Affairs, Office of Public and Intergovernmental Affairs, March 3, 2003, accessed December 31, 2015, h ttp://www.va.gov/opa/pressre l/pressrelease.cfm?id=578. 167 Authority to Reorganize Offices, 38 U.S.C. § 510. 168 Authority to Reorganize Offices, 38 U.S.C. § 510(c). In instances where a re organization would re duce employment by 15 percent or more at a facility, VA must provide Cong ress a detailed plan and justification, and must defer implementation for at least 45 days. 169 th Veterans Millennium Health Care and Benefits Act, H.R. 2116, 106 Cong. (1999). Section 107 of House-passed providing hospital care at H.R. 2116 would have established a mechanism for VA to cease medical centers which were no longer providing high quality, effici ent hospital care because of physical plant, functional factors such as aging redirect funds instead towa obsolescence, and low utilization, and to rd establishment of enhanced-service programs. In opt that provision, and it was not incl uded in the Veterans Millennium Health taking up H.R. 2116, the Senate did not ad Care and Benefits Act, Pub. L. No. 106-117, ssed January 12, 2016, 113 Stat. 1545 (1999), acce https://www.gpo.gov/fdsy s/pkg/PLAW-106publ117/ht ml/PLAW-106publ117.htm 170 Defense Base Closure and Realignment Commission, d Realignment Act of 1990 (as amended through Defense Base Closure an FY 05 Authorization Act), accessed June 23, 2016, http://www .brac.gov/docs/BRAC 05Legislation.pdf. 171 “VA Chief Seeks Panel to Revamp System,” Christopher Scanlan, Philly.com, accessed December 31, 2015, http://articles.philly.com/1989-07-18/ news/26134051_1_va-hospitals-d erwinski-veterans-hospital. “Distinguished Group Selected for CARES Commission,” Department of Vete rans Affairs, Office of Public and Intergovernmental l/pressrelease.cfm?id=578. ttp://www.va.gov/opa/pressre Affairs, March 3, 2003, accessed December 31, 2015, h 60

75 C R OMMISSION ECOMMENDATIONS 172 garding realignment and capital asset needs. legislation, in making recommendations re The one-time process, to include making site independent commission would conduct a thorough, visits and holding hearings to inform recomme ndations that would constitute a proposed national realignment plan. The VHA Care System governing board would review, and adopt or make recommendations to revise, the independent commission’s recommended realignment e VHA Care System governing board to plan. The commission would then empower th a specified timeframe, Congress disapproves implement the recommendations unless, within mmission on Care envisions that after the the entire plan on an up or down vote. The Co completion of a realignment carried out under such proposed legislation and in the course of ongoing VHA transformation, the VHA Care System governing board would make all additional facility alignment deci sions, to meet veterans’ needs and to fully integrate with the strategic vision for the VHA Care System. Repurposing and Divestiture of Unneeded Buildings and Land Maintaining health care facilities to provide state-of-the-a rt care requires ongoing financial ining outdated, vacant, and unused buildings support. Bearing the additional cost of mainta diminishes operating funds needed for patient care , and yields no benefit. Even taking unused mothball status , requires tens of millio ns of dollars in basic buildings offline and placing them in 173 building maintenance. If VA could sell, repurpose, or ot herwise divest itself of unused or underutilized buildings in a timely, cost-effectiv e manner, it would free funds for the purposes 174 for which they are appropriated. Enhanced-use leasing authority has in the past pr ovided VHA a viable tool that prevents the need for such unnecessary spending, while permi tting development of vacant property for uses 175 compatible with VHA’s mission, and effective use of the proceeds, whether in cash or in kind. ly effective use in leveraging an asset that This leasing mechanism has been put to particular VHA can no longer use, but which has development potential, as consideration for an asset it may need, such as clinic space. But limiting enhanc ed-use leasing to a single use that may not be feasible in many locations precludes effectiv e use of a valuable capital-alignment tool. In many instances, however, the condition or re mote location of VHA buildings does not lend itself to enhanced-use leasing. Given the need to dispose of a large inventory of vacant 172 th needs assessments (CHNA) that not-for-profit hospitals The process should take into account the community heal are required to carry out under current la w, (Patient Protection an d Affordable Care Act of 2010, Pub. L. No. 111-148, unities to engage community provider s in collaborative partnerships. This 124 Stat.119, sec. 9007(a) (2010)) and opport create a hospital community health ne eds assessment every three years. This provision requires tax-exempt hospitals to hospital CHNA is developed alongside co mmunity stakeholders. The community health needs assessment requirements y the hospital serves; a community health needs assessment include: demographic assessment identifying the communit actual health care issues; appraisal of current efforts to survey of perceived healthcare issues; quantitative analysis of address the healthcare issues; and formulation of a 3-year plan under which the community comes together to address those remaining issues collectively. 173 very Systems and Management Processes of the Independent Assessment of the Health Care Deli The MITRE Corporation, Department of Veterans Affairs, Assessment K (Facilities), 49, accessed June 3, 2016, t/documents/assessments/A ssessment_K_Fac ilities.pdf. http://www.va.gov/opa/choiceac 174 Ibid., B-13. 175 th Hearing on Assessing VA’s Capital Inventory Opti ons to Provide Veterans’ Care Before the Committee on Veterans Affairs, 113 Cong., (June 27, 2013) (Statement of Robert A. Petzel, M.D., Under Secr etary for Health, Veterans Health Administration, U.S. Depart ment of Veterans Affairs) , accessed June 20, 2016, ml/CHRG-113hhrg82242.htm. https://www.gpo.gov/fdsy s/pkg/CHRG-113hhrg82242/ht 61

76 C C INAL R EPORT OMMISSION ON F ARE buildings for which there is no realistic pros pect of their being repurposed, a streamlined divestiture process is needed. Meeting Clinic Capacity and Ot her Infrastructure Needs Developing a new delivery model and establishing a thorough realignment process may shrink VHA’s future capital needs but will not elimi nate them. As congressional budget rules have frustrated VHA efforts to lease needed clinic sp ace, it is critical that VHA and Congress find models or remedies to establish new ambulatory ca re space and renew leases of existing clinics. Congress and VHA should work together to find the means to meet VHA’s need for new clinic capacity. Given an impasse in congressional author ization of VA clinic leasing based on build- to-lease contracts, VA should explore the feasibility of restru cturing those arrangements. VA ncern that it is entering into capital leases. should explore an arrangement that remedies the co Such an approach, for which VA provides the bu ilder with space needs rather than a complete benefit of bringing projects on line much sooner. Absent an design, would have the additional effective solution to meeting VA’s ongoing need fo r clinic space, Congress must be willing, as it 176 was in passing VACAA, to take extraordinary steps to overcome a funding challenge, and, in t 5 years, the operation of current congressional this instance to waive, or suspend for at leas authorization and scorekeeping requirem ents governing major medical leases. statutory spending limits make it difficult for In addition to severe leasing challenges, current 177 VHA to modernize and renovate its aging facilities. Notably, minor construction funds, 178 any VA facility, are limited ring, extending, and improving” available for “constructing, alte 179 to $10 million, yet such projects may require substantially more given the age and condition of many VA buildings. Congress last lifted the threshold of what constitutes a major medical facility project—the amount above which a projec t requires specific authorization—more than a 180 The Commission believes that with the tight controls a governing board would decade ago. antially, providing needed flexibility to carry out exercise, that threshold should be lifted subst minor construction projects. providers and particip As VHA works more closely with community ates in discussions regarding community health needs, it should be open to opportunities to discuss and 181 potentially work toward joint effort s at meeting infrastructure needs. 176 Veterans Access, Choice, and Acco untability Act of 2014, Pub. L. No. 113-146, 128 stat. 1754, sec. 803 (2014). 177 Veterans Health Administration: Review of Minor Construction Prog ram, 8, accessed VA Office of Inspector General, June 3, 2016, http://www.va.gov/ oig/pubs/VAOIG-12-03346-69.pdf. 178 Consolidated Appropriations Act, 2016, Pub. L. No. 114-113, 129 Stat. 2242 Di v. J., Title II, Department of Veterans Affairs (2015). 179 A major medical facility project is one involving a tota l expenditure of more than $10 million. Congressional Approval of Certain Medical Facility Acquisitions, 38 U.S.C. § 8104(a)(3)(A). 180 Sec. 812 of the Veterans Benefits, Health Care, and 2006, Pub. L. No. 109-461, 120 Information Technology Act of to what constitutes a major medical fac ility project from more than $7 million Stat. 3403 (2006), raised the threshold as to more than $10 million. 181 One such public–private model, such as under discussion in Omaha, NE, where talks have centered on private donors’ partially fundin g construction of a replacement medical center , necessarily poses ch allenges, but merits exploration and support. (“VA Exploring Public-Private Plan for New Facility,” Lincoln Journal Star, accessed June 3, 2016, http://journalstar.com/news/st ate-and-regional/nebraska/va-explor ing-public-private-plan-for-new- facility/article_6a90778e-6962-545f-a86a-3f27930b d84e.html.) Although Congress must ultimately provide apt facilities ons, for purposes of facility CVA to accept gifts or donati for VA care-delivery, the law has long authorized the SE 62

77 C R OMMISSION ECOMMENDATIONS Capital Asset Management to do on its own to more effectively meet The Commission fully recognizes that VHA has much its capital asset needs. At the core, leaders mu st strengthen and streamline the capital asset programs’ management and operation, to include better aligning the component elements; streamlining the leasing program, contractin g, and investment decisions; managing and streamlining project delivery for construction and renovation; and adopting a facility (or building) life-cycle-model planning tool. These ar e all important elements of needed system transformation. As depicted in Figure 3, meeting and managing VHA’s capital-asset needs require an integrated approach that requires congressional support to tackle the multiple capital-asset challenges facing VHA. The Commission’s recommendations for meeting and managing those interrelated section following Figure 3. capital-asset needs are set forth in the Implementation construction. (Congressional Approval of Certain Medical Facility Acquisitions, 38 U.S.C. § 8104(e)) Nevertheless, new legislative authority would almost assure dly be needed to permit development of public–private partnerships that acement medical fac construction of new or repl ilities. For example, H.R. 5099 would provide new platforms for the establish a pilot program permitting VA to enter into pu blic-private partnership agreements to plan, design, and construct new VA facilities us ing private donations. To Establish a Pilo t Program on Partners hip Agreements to th Cong. (2016), Construct New Facilities for the Departme nt of Veterans Affairs, H.R. 5099, 114 se-bill/5099. https://www.congress.gov/bill/ 114th-congress/hou 63

78 R C ARE F INAL C EPORT OMMISSION ON Figure 3. The Complicated Process of Meeting and Managing VHA’s Capital-Needs Implementation Legislative Changes  Provide VA new, more flexible authorities to realign facilities, meet capital-asset needs, and divest itself of unneeded buildings.  Establishing a VHA capital asset realignmen t process that provides (notwithstanding any other law) for more effectively aligni ng VHA facilities with the objective of improving the access, quality, and cost-effe ctiveness of VA care, and provides for: 64

79 C OMMISSION ECOMMENDATIONS R Establishing an independent commission (emp - owered to hold public hearings, make yses and data) charged with developing site visits, and have full access to VHA anal a national capital asset realignment plan that would include recommendations to the VHA Care System governing board (see Recommendation #9) for systemwide in facility mission, facility downsizing, facility realignment (to include changes integration of facilities, and closures), with the rationale for each recommended change. The proposed plan would identify (a) the cr iteria used in developing realignment - recommendations, (b) proposals for reinvestment and savings/cost avoidance resulting from the realignment, (c) the projected care improvements that would e adverse effects on displaced employees, result, and (d) mechanisms to minimize th asible, VA retrains and reemploys displaced to include assuring that, to the extent fe employees. - The VHA Care System governing board would be empowered to adopt or alter the proposed realignment plan, and to implement the final plan unless, within a specified timeframe, Congress disapproves the plan as a whole on an up-or-down vote. n and scorekeeping  Waive or suspend for at least 5 years current authorizatio requirements governing major medical fa cility leases under 38 U.S.C. § 8104. Amend 38 U.S.C. § 8104 to lift the threshold of what constitutes a major medical facility  project from $10 million to $50 million. Amend pertinent provisions of 38 U.S.C. § 8161, and what follows, to reinstate and  extend for 10 years the authority in prior law (as in effect on December 30, 2011) for VHA to enter into enhanced-use leases for any use that is not incompatible with VA’s mission. Provide the VHA Care System governing bo ard authority to promulgate regulations  that for a period of not more than 5 years, and notwithstanding any other law, would buildings, to include (a) shifting to a third ease the divestiture of unneeded vacant VHA party the cost of meeting environmental requ irements, (b) allowing VHA to retain the proceeds of any property sale, and (c) creating a streamlined process to address historic preservation considerations. VA Administrative Changes  None required. Other Department and Agency Administrative Changes None required.  65

80 C OMMISSION ON F INAL R EPORT C ARE Information Technology systems and infrastructure to Recommendation #7: Modernize VA’s IT improve veterans’ health and well-being and provide the foundation needed to transform VHA’s clinical and business processes. Problem The Commission Recommends That . . . To operate a high-performing VHA Care level ‐ (SES) Service Executive Senior a establish VHA  System, VA requires a comprehensive information chief System Care VHA of position officer electronic health care information platform by selected (CIO), VHA of chief the to reporting and that is interoperable with other systems and Care System (CVCS) with a dotted line CIO. VA to the other health care providers; enables VHA CIO is The responsible for developing and and strategy implementing IT health comprehensive a scheduling, billing, claims, and payment; managing developing budget. IT health the and and provides tools that empower veterans to VHA  and a comprehensive, procure implement better manage their health. Creating a single, ‐ ‐ off (COTS) information shelf commercial the uniform, integrated IT platform will promote clinical, operational and include solution technology to care continuity, cost savings, and consistent financial support the transformation systems that can 182 care delivery and business processes. this in described as VHA of report. VA’s antiquated, disjointed clinical and ssential clinical and business processes and administrative systems cannot support these e consequently are unable to support the Commi ssion’s transformation vision for VHA. In addition, currently within VHA, there is no experi enced senior health care IT leader focusing on the strategic health care IT needs of veterans and VHA staff. Background A fully functional electronic he alth record (EHR) can improve the quality of patient care, help 183 avert medical errors, and improve communica tion among providers and with patients. Starting in the 1970s, VHA became a leader in the development of EHR technology with VistA 184 and a computerized patient record system (CPRS). Full implementation of the EHR, together 185 with other reforms, helped impr ove the quality of care at VHA. During the last decade, VHA 186 has not been able to maintain an IT advantage. Although in the past most VHA clinicians 182 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 43-44, accessed February 25, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 183 care?” Robert Wood Johnson cessed May 20, “Does health information technology improve quality of Foundation, ac issue_briefs/2011/rwjf71333. ontent/dam/farm/reports/ 2016, http://www.rwjf.org/c 184 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment H (Health Information Technology), 29-30, accessed April 4, 2016, http://www.va.gov/opa/choice act/documents/assessments/ Assessment_H_Health_Inform ation_Technology.pdf. 185 Phillip Longman, Best Care Anywhere: Why VA Care Is Better Than Yours (3rd ed., Berrett-Koehler Publishers, Inc., 2012). Jonathan B. Perlin, Robert M. Kolo dner, and Robert H. Roswe ll, “The Veterans Health Administration: Quality, tient-Centered Care,” orming Strategies for Pa Value, Accountability, and Information as Transf The American Journal of Managed Care ccessed June 3, 2016, (November 2004), 828-836, a http://citeseerx.ist.psu.edu /viewdoc/download?doi=10.1.1. 476.450&rep=rep1&type=pdf. 186 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment H (Health Information Technology), vi, accessed April 5, 2016, http://www.va.gov/opa/choice act/documents/assessments/ Assessment_H_Health_Info rmation_Technology.pdf. 66

81 C R OMMISSION ECOMMENDATIONS ions and databases enabled by VistA and CPRS, have had a high opinion of the clinical applicat 187 Many large U.S. health a lack of upgrades has put VHA’s EHR at risk of becoming obsolete. care systems that were early adopters of home grown EHR systems found themselves in similar circumstances and have since pu rchased and migrated to commercial off-the-shelf (COTS) 188 189 products. DoD recently made the same choice. re system that delivers quality, access, choice, To achieve the Commission’s vision of a health ca and veteran well-being, VHA requires effectiv e, robust, and modern information technology systems. A robust EHR system would allow veter ans and clinical provid ers to send, receive, find, and use electronic health information in a manner that is appropriate, secure, timely, and reliable. It would be seamlessly interoperable wi th other systems including DoD, private-sector providers, and with other VA enterprise syst ems such as those in the Veterans Benefits inical workflow, evidence-based practice, and Administration (VBA). It would support VHA cl patient safety. It would provide clinicians, patien ts, and administrators the data, analytic power, and user interfaces required to monitor the effe ctiveness of care and improve it over time. A robust IT system for VHA should include more t han just the EHR, however, extending to all the systems and tools required to facilitate and au tomate business processes that support access and veterans’ care. These capa bilities include an effective scheduling system, telephone systems, mobile applications, telehealth, financial management systems, human resources systems, and other systems that enable community care. To realize such a transformation of IT in a sy stem as complex as VHA requires exceptional leadership and staff, sufficient budget, a robust change management plan, effective systems for 190 Presently, VHA accountability and quality control, and efficient and agile contracting. 191 appears to lack a majority of these factors required for success. Analysis Leadership and Staff Prior to 2006, VHA had a chief health informatic s officer responsible for the VHA electronic record system and for coordinating with VA on IT systems. The programmers in VHA worked 192 VHA was closely with the clinicians who used the tool to create a system that met their needs. able to prioritize clinical needs and patient sa fety requirements within its overall budget and ific budget line item for the electronic health plan for IT spending; however, there was no spec 187 Ibid., 29-30. 188 : Size Still Matters,” Frank Konk el, accessed February 4, 2016, “$5 Billion Leidos-Lockheed Deal 2016/02/5b-leidos-lockheed-deal-s ize-still-matters-federal-it- http://www.nextgov.com/defense/ contracting/125617/?oref=nextgov_today_nl. 189 , Accenture EHR Cont accessed May 12, 2016, ract,” Tom Sullivan, “DoD Awards Cerner, Leidos http://www.healthcareitne ehr-contract-winner. ws.com/news/dod-names- 190 LaVerne H. Council, Assistant Secretary for Information & Technology, Chief Informati on Officer, Department of Veterans Affairs, briefing to Commi ssion on Care staff, April 27, 2016. 191 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 41, accessed February 16, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 192 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment H (Health Information Technology), v, accessed March 31, 2016, ation_Technology.pdf. http://www.va.gov/opa/choice act/documents/assessments/ Assessment_H_Health_Inform 67

82 C F INAL R EPORT OMMISSION ON C ARE record system or related technology, and there was limited central oversight or accountability for information technology infrastructure. VA’s IT budget was centralized in 2006, and the Office of Information and Technology (OIT) was assigned to deliver, operate, and manage IT and its budget, across the department. With this change, VHA’s needs became only one of the priorities that OIT has had to accommodate 193 and VHA’s priorities hav e not always prevailed. To ensure that clinical needs and patient safety are a priority, many large health care systems, and Kaiser Permanente, have a medical CIO such as DoD, Cleveland Clinic, Geisinger, (i.e., CMIO) who manages and advocates for the clinical IT needs of the organization. A CMIO ensures that clinicians are involved in the select ion of any IT systems they use to perform their job functions and provide patient care, including EHRs. Clinicians involved in the selection and eel ownership of it and fully adopt its use. The deployment of an IT system are more likely to f CMIO usually reports to the health system’s CE O or CMO, and working in concert with these individuals and the organization’s CIO, make s sure that health information needs are 194 prioritized and funded. VA does not have staff with the necessary expertis e to execute large-scale IT projects. Previous system implementations have failed because VA did not have individuals with adequate em development and deployment. If VA had an experience to effectively plan and manage syst adequate system and skilled staff to monitor and identify program and contracting problems affecting the progress of prior IT implementati ons, effective and timely decisions could have been made to either redirect or terminate VA IT projects that ultimately failed. To avoid repeating these previous IT implementation failu res, VA needs to develop effective oversight systems and develop in-house staff with the expertise to oversee, fully support, manage, and 195 execute complex integrated IT programs. Given all of these critical needs, the Commission believes that it is essential for VHA to have a CIO with health care expertise and substantial experience, reporting to the chief of VHA Care System. The VHA CIO will be resp onsible for managing the comple x implementation of a state- of-the-art comprehensive information system plat form to support the new integrated VHA Care System, with the functionality, interoperabilit y, and data management capabilities to support the delivery and coordination of high-quality heal th care for veterans. The CIO will need to work closely with clinical and operational leader s on the effective execution of the new system, and will also need to collaborate with the VA CI O to ensure the integration and coordination of the health care information system and the Veterans Benefit Administration system. 193 Ibid., 10. 194 “CMIOs Help Hospitals Make Tech Transition s,” Naseem S. Miller, accessed May 13, 2016, https://www.acep.org/content.aspx?id=79744. 195 Department of Veterans Affairs Office of the Inspector General, Review of the Awards and Administration of Task Orders Issues by the Department of Veterans Affairs for the Replacement Scheduling Appl ication Development Program , accessed May 25, -09-01926-207.pdf. reports/2009/VAOIG 2016, http://www.va.gov/oig/52/ 68

83 C OMMISSION ECOMMENDATIONS R Budget The 1-year budget appropriations cycle makes it difficult to secure multiyear funding for long- 196 term development and important IT projects. The budget process is disconnected from total 198 197 lifecycle IT costs. under which That disconnect has grown wider with a change in law appropriations—in effect a 2-year budget— Congress provides VHA advanced medical care 199 As the Congressional Research Service (CRS) while health IT funding remains 1-year money. testified, providing an advance appropriation for some VHA accounts and funding IT accounts e a situation whereby, for example, VHA under a regular appropriation act could creat it has procured medical equipment that could not purchase computer software although example would be the difficulty of needs software. Another procuring IT infrastructure to 200 support opening of a new community-based outpatient clinic (CBOC). Spending on new systems and upgrades to g 4. VA IT Spendin e Figur existing systems now represents only 15 percent of VA’s total IT budget (see 201 meaning that essential Figure 4), upgrades like a new scheduling package and EHR modernization have not had the funding or focus required to succeed. Clinical users have become increasingly frustrated by the lack of any clear advances with VistA during the past decade. Numerous VHA clinicians have experience with commercial EHR systems and want the same level of features, modern clinical capabilities, integration, and mobility they see emerging in the commercial 202 marketplace. contract to overhaul the Pentagon’s electronic In July 2015, DoD awarded a $4.3 billion, 10-year y members and retirees. O fficials estimate that health records for millions of active-duty militar 196 accessed January 12, 2016, “Coming in 2016: Cloud Legislation,” Aisha Chowdh ry and Adam Mazmanian, https://fcw.com/articles/201 5/12/22/cloud-bill-2016.aspx. 197 on Officer, Department of Technology, Chief Informati LaVerne Council, Assistant Secretary for Information & mmission on Care, December 15, 2015. Veterans Affairs, briefing to Co 198 Pub. L. No. 111-81, 123 Stat. 2137 (2009). Veterans Health Care Budget Re form and Transparency Act of 2009, 199 d Further Continuing Appropriations Act, 2015, Pub. L. No. 113-235 (December 16, 2014), With the Consolidated an Congress expanded advanced appropriations to additional VA program accounts. 200 Representatives, Committ Funding the U.S. Department of Veterans U.S. Congress, House of ee on Veterans Affairs, on Veterans Affairs U.S. House of Representatives, 111th Congress, 1st Sess., Affairs of the Future: Hearing before the Committee g49914/pdf/CHRG- April 29, 2009, 60, accessed June 3, 2016, https://www.gpo.gov/fdsy s/pkg/CHRG-111hhr 111hhrg49914.pdf. 201 Department of Veterans Affairs, Information Technology Agency Summary , accessed May 25, 2016, https://itdashboard.gov/drupal/summary/029. 202 very Systems and Management Processes of the The MITRE Corporation, Independent Assessment of the Health Care Deli Department of Veterans Affairs, Assessment H (Health Information Technology), v, accessed March 31, 2016, Assessment_H_Health_Inform act/documents/assessments/ http://www.va.gov/opa/choice ation_Technology.pdf. 69

84 C C INAL R EPORT OMMISSION ON F ARE 203 during its potential 18-year life, the contract could be worth just less than $9 billion. The recent Senate appropriations bill for VA OI T allots $63 million toward development and 204 modernization of VA’s existing EHR (i.e., VistA Evolution). Assuming that VA’s similar in size and scope to DoD’s EHR implementation of a new COTS EHR would be implementation, VA would be short $3.67 billio n in funding for a new COTS EHR, given the current funding amount of $63 million per year . VA will require a substantial increase in IT funding to support the successful implemen tation of a new comprehensive COTS EHR. Robust Change Plan Because VistA has been customized at each medical center, there are few standard data complex, heterogeneous mix of hardware and elements. The varied algorithms lead to a software that impedes system changes and new capabilities and raises operations and 205 Due to excessive project management overhead, a complex legacy maintenance costs. IT infrastructure that is difficult to moderniz e, and more than 130 variations of the primary facilities, the implementation of improved software system deployed across VHA medical 206 VA is currently weighing ars has been extremely limited. IT capabilities in the last 10 ye whether to continue to modernize VistA or purchase a COTS health information technology platform. The Commission recommends moving to a COTS program. Whether VHA moves forward with the purchase of a COTS product, as recommended by the Commission, or continues attempting to modern ize VistA, VHA must effectively manage the change process. At present, a lack of standard clinical documentation has made it harder to develop effective clinical de cision-support systems and hi nders EHR information exchange among VA Medical Centers (VAMC), between VA and non-VA facilities (including those of DoD), and between VA and individual veterans. Shared data must be well labeled in a way that gest such data. An electronic medical record the receiving system can identify and properly in elds. The lack of data standards presents can contain as many as 100,000 different data fi challenges to using comparable data for analys is and disparities among the 130 tailored local 207 ing information sharing, data aggregation, and analytics. instances of VistA, complicat VHA has not established comprehensive semantic defi nitions for data elements through the use of standard nomenclatures, terminologies, and code sets. Doing so is required to ensure stems, leverage follow-on IT products, and consistency and integration across multiple sy 208 facilitate analytics for clinical decision making. The Office of the National Coordinator (ONC) for Health IT, under HHS, is responsible for advancing national connectivity and interopera bility of health information technology. The 203 “Cerner wins $4.3 billion DoD co ntract to overhaul electronic health records,” Amy Brittain, The Washington Post, ner-wins-dod-contract-to- accessed May 25, 2016, http s://www.washingtonpost.com/na tional/health-science/cer overhaul-electronic-health-reco rds/2015/07/29/7fbfccfa 0fb28_story.html. -35f5-11e5-b673-1df005a 204 , Veterans Affairs, and Related Agencies Appropr iation Bill, 2017, accessed S. Rept. 114-237 – Military Construction May 25, 2016, https://www.congress.gov/congressiona l-report/114th-congress /senate-report/237/1. 205 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the 44, accessed February 25, 2016, Department of Veterans Affairs, Volume 1: Integrated Report, http://www.va.gov/opa/choice integrated_report.pdf. act/documents/assessments/ 206 Ibid., 41. 207 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment H (Health Information Technology), vi, accessed March 31, 2016, act/documents/assessments/ ation_Technology.pdf. http://www.va.gov/opa/choice Assessment_H_Health_Inform 208 Ibid., viii. 70

85 C R OMMISSION ECOMMENDATIONS admap with the goal of being able to use ONC developed the National Interoperability Ro rmation can follow a patient where and when it electronic health information exchange, so info is needed, across organizational, health IT deve loper, and geographic boundaries. The roadmap lays out a clear path to catalyze the collaborati on of stakeholders who are going to build and 209 VA’s intent to expand veteran care to more community use the health IT infrastructure. providers through the creation of locally-integra ted health care networks will mean that it is important for VHA to follow the ONC roadmap and standards. Following this roadmap includes using the continuity of care docume nt to exchange data, which was established by ONC and is followed by community health care providers. VA OIT is currently collaborating with the ONC on VA’s plans for interoperabi lity and has committed VA to following the 210 roadmap. VHA does not yet have a robust, detailed strate gy and roadmap for IT initiatives across VHA 211 National that integrates veteran access to schedulin g via phone, telehealth, and mobile apps. t and the veteran mobile scheduling Veteran deployment of the VistA Scheduling Enhancemen prepare for the implementation of new COTS Appointment Request app, are initial steps to electronic medical system with a scheduling package. To resolve the underlying systemic issues with VistA scheduling, VA awarded a contract for the 212 appointment scheduling system in August 2015. implementation of VA’s new COTS medical This system is a COTS scheduling solution that , when implemented, is expected to move VHA from primarily a face-to-face appointment mode l to a coherent, resource-based system with 213 Deployment is awaiting the broad opportunities for improved services for VA stakeholders. final decision on whether VHA will continue with VistA or purchase a full COTS product. COTS Solution The current VistA/computerized patient records systems are based on a tightly integrated, rous and diverse functional components and monolithic architecture and design with nume associated interdependencies. These characte ristics impose barriers to modernizing the st of infrastructure operation and maintenance respective systems. In addition, the high co 214 (85 percent of the total IT budget) reduces funding available for new development efforts. Maintenance and data sharing are further complicated because most VAMCs have customized their local versions of VistA, leading to approx imately 130 different versions of VistA across the 215 country. 209 bility Roadmap Version 1.0,” Health “A Shared Nationwide Interopera IT.gov, accessed March 29, 2016, licy-researchers-implementers/interoperability. https://www.healthit.gov/po 210 LaVerne Council, Assistant Secretary for Information & on Officer, Department of Technology, Chief Informati Veterans Affairs, briefing to Commi ssion on Care staff, April 27, 2016. 211 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment H (Health Information Technology), 44, accessed April 4, 2016, act/documents/assessments/ ation_Technology.pdf. http://www.va.gov/opa/choice Assessment_H_Health_Inform 212 “$623M Medical Appointment Schedu G2Xchange, accessed May 3, 2016, ling System (MASS) Contract,” https://www.g2xchange.com/static s/623m-medical-appointment-schedu ling-system-mass-contract. 213 The MITRE Corporation very Systems and Management Processes of the , Independent Assessment of the Health Care Deli Department of Veterans Affairs, Assessment H (Health Information Technology), 40, accessed May 3, 2016, http://www.va.gov/opa/choice act/documents/assessments/ Assessment_H_Health_Inform ation_Technology.pdf. 214 Ibid., vi. 215 Ibid., vi. 71

86 C C F INAL R EPORT OMMISSION ON ARE VHA relies on a VistA scheduling package to prov ide veterans with access to health care. The system is antiquated, highly inefficient, does not optimally support processes or allow for efficient scheduling of appointments. A report on scheduling published by the Northern Virginia Technology Council (NVTC) in Octo ber 2014, showed that VA’s exam-scheduling processes are not enabled by state-of-the-art technologies or consistently applied standard 216 operating procedures. To improve this situation, VHA has developed, and is in the process of a national roll out of, VistA scheduling enh ancements, which provides an improved user interface (i.e., graphic user interface or GUI). Although the new GUI will help veterans gain access to care by implementing better scheduling procedures, it does not address the need that 217 accurate and timely data on clinic use. managers, planners, and administrators have for For instance, VHA’s new health care operations dashboard shows that more than 55 percent of 218 clinic slots in VHA go unused each day. However when questioned about this data, VHA 219 The underlying VistA scheduling so ftware does not allow accurate notes that it is not correct. representation of clinician time toward each clinic stop. As a result, whether data is presented in derlying data cannot be captured accurately, a dashboard or a new GUI tool, as long as the un s to effectively manage the supply of clinic then VHA will not have the information it need 220 slots. VA’s financial management information technology system is woefully outdated and VA has previously wasted approximately $500 million in tw o failed attempts to replace it. Given VA’s lack of an integrated finance and logistics IT system, VA has no method to perform commitment 221 accounting. VA’s current financial management system does not support streamlining and 222 automation of VA’s revenue cycle. Community care processes currently include eligibility determinations, referrals and 223 authorizations, care coordination, network management, claims, and customer service. VA’s information technology systems limitations often demand manual processes to support community care that can reduce the timeliness an d accuracy of data and obscure the true state s slows collections and payment activities and of VHA’s activities. Relying on manual processe 224 Barriers to automation are multifactorial, introduces errors and waste into the process. 216 Ibid., 39-40. 217 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment E (Workflow—Scheduling), 26, accessed May, 13, 2016, http://www.va.gov/opa/choi ceact/documents/assess ments/Assessment_E_Wor kflow_Scheduling.pdf. 218 Crystal Wilson, Office of Analytics and Business Intelligence, Veterans Health Administration, email to Commission on Care staff, May 3, 2016. 219 Joe Francis, Director of Clinical Analytics and Reporting , Veterans Health Administra tion, email to Commission on Care staff, May 3, 2016. 220 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment E (Workflow—Scheduling), 26, accessed May, 13, 2016, http://www.va.gov/opa/choi ceact/documents/assessme low_Scheduling.pdf. nts/Assessment_E_Workf 221 Jan R. Frye, Letter to Secretary Mc Donald, March 19, 2015, accessed May 17, 2016, http://extras.mnginteractive.c om/live/media/site36/ 2015/0522/20150522_025126_Whistleb lowerMemo.pdf. 222 Grant Thornton, Independent Assessment of the Health Care Delivery Sy stems and Management Processes of the Department of Veterans Affairs, Assessment I (Business Processes), 24, accessed May 24, 2016, http://www.va.gov/opa/choi ceact/documents/assess ments/Assessment_I_Bus iness_Processes.pdf. 223 Baligh Yehia, MD, ADUSH Community Care, briefi ng to Commission on Care, April 18 and 19, 2016. 224 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 42, accessed March 28, 2016, act/documents/assessments/ http://www.va.gov/opa/choice integrated_report.pdf. 72

87 C OMMISSION ECOMMENDATIONS R les governing which veterans may receive care outside VHA including confusing eligibility ru which services may be billed to third-party and for what conditions, in what circumstances, and 225 insurers. In addition, there are mult ing community care—all with iple authorities for purchas 226 and reimbursement rates, as well as antiquated financial management different business rules information systems that are not standardized to private-sector processes. All of these impediments are exacerbated by workers thro ughout the revenue cycle who are poorly high turnover, and work in environments compensated and marginally trained, experience 227 with a continuous 20 percent vacancy rate; thus, they cannot effectively manage certain business practices such as insur ance verification and ensuring clinicians complete necessary 228 coding documentation. Many large U.S. health care systems that or iginally developed in-house EHRs have since 229 purchased and migrated to COTS EHRs. DoD recently made the same choice, deciding to replace its homegrown EHR with a COTS prod uct to take advantage of private-sector innovation and have an EHR that communicates wi th private-sector systems. For a system in 230 this was an which 60 to 70 percent of military heal th care takes place outside the DoD, important business consideration that is also consistent with VHA’s long term direction. Very d labor-driven business models are shifting large IT programs with purpose-built systems an stems. Large propriet rapidly toward more open source, COTS sy ary IT solutions are , and open-source solutions or IT as-a-service increasingly being replaced by less risky, agile 231 models, and getting away from client-server models. Interoperability VHA’s EHR issues stymie interoperability amon g VHA facilities as well as between VHA and DoD and other non-VHA providers. Multiple a ssessments noted the lack of interoperability ntially substantial implic resulted in incomplete patient records with pote ations for veterans and VHA. Incomplete records introduce unnecessary clinical risk, complicate the transition from 225 very Systems and Management Processes of the The MITRE Corporation, Independent Assessment of the Health Care Deli Appendix I (Business Processes), Department of Veterans Affairs, Volume 1: Integrated Report, 19-20, accessed April 26, 2015. http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 226 ng to Commission on Care, April 18 and 19, 2016. Baligh Yehia, MD, ADUSH Community Care, briefi 227 Healthcare Talent Manage ail to Commission on Care, April 11, 2016. ment, Veterans Health Administration, em Opportunities to Improve the Scheduling of Medical Exams for Northern Virginia Technology Council, America’s Veterans, accessed April 25, 2016, ht tp://www.va.gov/opa/choiceact/document s/NVTCFinalReporttoVA-revised3.pdf. 228 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Inte grated Report, Appendix I, Business Processes. I3-I4, accessed November 24, 2015, act/documents/assessments/ http://www.va.gov/opa/choice integrated_report.pdf. 229 : Size Still Matters,” Frank Konk “$5 Billion Leidos-Lockheed Deal el, accessed February 4, 2016, http://www.nextgov.com/defense/ 2016/02/5b-leidos-lockheed-deal-s ize-still-matters-federal-it- contracting/125617/?oref=nextgov_today_nl. 230 “DoD Awards Cerner, Leidos ract,” Tom Sullivan, accessed May 12, 2016, , Accenture EHR Cont http://www.healthcareitne ws.com/news/dod- names-ehr-contract-winner. 231 “$5 Billion Leidos-Lockheed Deal : Size Still Matters,” Frank Konk el, accessed February 4, 2016, http://www.nextgov.com/defense/ 2016/02/5b-leidos-lockheed-deal-s ize-still-matters-federal-it- contracting/125617/?oref=nextgov_today_nl. 73

88 OMMISSION ON C INAL R EPORT F C ARE DoD to VHA care, and inhibit VHA’s ability to bill and collect revenue in an accurate and 232 timely manner. As GAO reported in August 2015, VA and DoD have taken initial steps to increase 233 They have deployed interoperability between their existing electronic health record systems. the Joint Legacy Viewer (JLV), which provides a pa tient-centric, integrated view of a patient’s health data from VA, DoD, and community health partners on one screen. It has been available 234 at all VA medical centers since October 2014 and currently has more than 70,000 users. The JLV is a positive step in supporting coordi nation of care among VA, DoD, and community view veterans’/service members’ medical records partners, but it only allows for providers to 235 and does not yet allow for the other agencies’ medical records to be updated by providers. D and community partners is the deployment of VA’s next evolution in interoperability with Do their Enterprise Health Management Platform (eHMP). eHMP is intended to provide VA from VA, DoD, and community health partners streamlined access to complete patient history in a single, reliable, customizable, and secure inte rface that is easy to use. It is reported to deliver a modern, web-based user interface and supporting infrastructure and is intended to replace the Computerized Patient Record Syst em (CPRS) as VA’s primary point-of-care 236 application. The national rollout of eHMP is expected to be completed by December 2017. VHA does not have everything that is needed in an IT system to manage the business and clinical aspects of care in the community and support the overall veteran experience in an expanded community network. To address these gaps and provide health care well into the future, VA intends to develop in house a co mprehensive and interoperable digital health platform (DHP). The DHP is intended to seam lessly integrate all of VHA’s core processes, billing, and claims. Through consolidation of including scheduling, supply chain management, more than 40 contact center systems and more than 130 versions of the VistA EHR and clinical procurement/inventory systems, the DHP is design ed to enable VHA’s operation as a holistic, 237 platform business and greatly reduce the cost of system maintenance across the IT enterprise. Because there is no unique patient identifier, problems exist with “1) accessing and integrating information from different providers and prov ider computer systems, 2) aggregating and providing a lifelong view of a patient’s info rmation, and 3) supporting population-based 238 research and development.” To accurately match veteran pa tient data that is exchanged between VA and non-VA providers, both organi zations need to use the same unique patient 232 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 44, accessed February 16, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 233 “Electronic Health Records: VA and DOD Need to Establish Goals and Metric s for Their Interoperability Efforts,” U.S. Government Accounta bility Office, accessed April 1, 2016, http://www.gao.gov/products/GAO-16-184T. 234 Veterans Affairs et al., briefing to Commission on Care, April 18, 2016. Sloan Gibson, Deputy Secretary of 235 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment H (Health Information Technology), A-35, accessed March 31, 2016, http://www.va.gov/opa/choice act/documents/assessments/ Assessment_H_Health_Inform ation_Technology.pdf. 236 Veterans Affairs et al., briefing to Commission on Care, April 18, 2016. Sloan Gibson, Deputy Secretary of 237 LaVerne H. Council, Assistant Secretary for Information & Technology, Chief Informati on Officer, Department of Veterans Affairs, briefing to Commi ssion on Care staff, April 27, 2016. 238 “Analysis of Unique Patient Identifier Options,” So lomon I. Appavu, The Department of Health and Human tp://www.ncvhs.hhs.gov/wp-conten PPAVU-508.pdf. t/uploads/2014/08/A Services, accessed May 20, 2016, ht 74

89 C R OMMISSION ECOMMENDATIONS 239 identifier. This practice is currently not used. Each health care system uses a unique patient 240 identifier number, but it is specific to that system. VA uses patients’ social security numbers as unique identifiers; whereas, due to stricter security stand ards required by HIPPA privacy laws that community providers must adhere to , many non-VA providers use other personally identifiable information (e.g., first name, last na me, date of birth, and phone number) to match ies have shown that patient identification error patient identities between record systems. Stud 241 rates range from 7-20 percent. patients and their records, a For VA to accurately identify unique national patient identifier is essential. The security of electronic records is an ongoin g concern. One in three Americans had health 242 care records breached in 2015. Recent hacks of U.S. hospital health care systems through the use of ransomware, viruses that hold systems hostage until victims pay for a key to regain 243 access, further highlight the need for enhanced VA cybersecurity. VA’s OIG has repeatedly identified the same weaknesses and deficiencies in VA’s information security program in its 244 annual FISMA audit reports. Although VA has recently made some progress in developing rity gaps, OIG’s FY 2015 audit concluded that policies and procedures to address current secu material weakness for VA and that VA must take comprehensive information security is still a 245 measures to mitigate security vulnerabilit ies affecting VA’s mission-critical systems. For sharing of veteran data to be secure, only th e designated correct parties can have access to 247 246 patients’ data. Interoperability increases the ri Cybersecurity sk to veterans’ health records. guidelines and best practices are being develope d by HHS in response to the requirements in 248 the recently enacted Cybersecurity Information Sharing Act; however, security protocols also cannot impede health information exchange with VA community providers and health systems. VA OIT needs to be involved in the health information exchange planni ng discussions, which 239 “Interoperability 2015: Curr ent State and Next St eps”, Kent Gale, KLAS Resear ch, accessed March 9, 2016, ility-industry- http://www.klasresearch.com /docs/default-source/ default-document-library/2pg-e mr-interoperab specific.pdf?sfvrsn=0. 240 lomon I. Appavu, The Department of Health and Human “Analysis of Unique Patient Identifier Options,” So t/uploads/2014/08/APPAVU-508.pdf. Services, accessed May 20, 2016, ht tp://www.ncvhs.hhs.gov/wp-conten 241 “The Right Fit: How We Solve the Puzzle of Interoperabilit et: Future of Health Care, y,” Russell Branzell, Media Plan the-right-fit-how-we-solve-the-puzzle- accessed May 25, 2016, http://www.futu reofhealthcarenews.com/telemedicine/ of-interoperability. 242 “Public Health Enemies: Protecting Your Medical Records,” Russell Branzell, Media Planet: Future of Health Care, accessed May 25, 2016, http: om/digital-health/public-hea lth-enemies-protecting-your- //www.futureofhealthcarenews.c medical-records. 243 “Virus Infects Medstar Health Syst Shutdown,” John Woodrow Cox, Karen em’s Computers, Forcing an Online cessed March 28, 2016, http s://www.washingtonpost.com/lo cal/virus-infects-medstar- Turner and Matt Zapotosky, ac cials-say/2016/03/28/480f7d66-f515-11e5-a3ce- health-systems-computers-hospital-offi f06b5ba21f33_story.html?hpid=hp_loca l-news_medstar-health-virus-345pm pe rcent3Ahomepage pe rcent2Fstory. 244 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the A-24, accessed May 25, 2016, Department of Veterans Affairs, Assessment H (Health Information Technology), act/documents/assessments/ Assessment_H_Health_Info rmation_Technology.pdf. http://www.va.gov/opa/choice 245 Federal Information Security Modernization Act Audit for Department of Veterans Affairs, Office of the Inspector General, Fiscal Year 2015 , accessed May 25, 2016, http://www. va.gov/oig/pubs/VAOIG-15-01957-100.pdf. 246 “Interoperability 2015: Curren t State and Next Step s; Market Immaturity Highlights Opportunity,” Ke nt Gale, KLAS Research, accessed esearch.com/docs/defau lt-source/default-do cument-library/2pg- March 9, 2016, http://www.klasr emr-interoperability-indust ry-specific.pdf?sfvrsn=0. 247 Jon White, M.D., The Office of the National Coordina tor for Health Information Technology, briefing to Commission on Care, December 15, 2015. 248 “Public Health Enemies: Protecting Your Medical Records,” Russell Branzell, Media Planet: Future of Health Care, accessed May 17, 2016, http: //www.futureofhealthcarenews.c om/digital-health/public-hea lth-enemies-protecting-your- medical-records. 75

90 C C F INAL R EPORT OMMISSION ON ARE VA OIT can assist in removing impediments are currently handled solely within VHA, so that 249 to health information exchange. (i.e., provide consent) to allow VA to share their health Veterans currently have to opt in ers. Although the technology is in place for information with non-VHA/community care provid th more than 100 health information exchange VA to exchange patient health information wi ed in these networks because, due to lack of partners, only a fraction of data can be exchang of veterans have opted in to allow VA to share their health awareness, only 3 percent 250 information. The standard industry policy is to have patients opt out of having their health data shared with their other health care provider s. VA is prohibited from taking this approach 32 prohibits VA from disclosing information because statutory language in 38 U.S.C. § 73 alcohol abuse, infection with the human relating to drug abuse, alcoholism or le cell anemia, except when re immunodeficiency virus, or sick quired in emergencies, without 251 written authorized cons ent from the patient. In response to this limitation, VA approved and submitted Legislativ e Proposal VHA-10 (10P- 07), Authority for the Department of Veterans A ffairs (VA) to Release Patient Information under 38 U.S.C. § 7332 to Health Care Providers for Treatment of Shared Patients in 2013. The proposal allows veterans to opt out of sharing their data with VA community providers instead of having to opt in. The proposal was approved by OMB and was included in the president’s 2015 Budget. VHA provided a briefing to a Sena te Veterans Affairs Committee staff in April 2015 on this legislative proposal. A House Bill wa s introduced, but it limited the opt-out option gislative Affairs responded back to . VA’s Office of Congressional and Le Choice Program to the Congress that the bill should be expanded to include all external purchased care options 252 (i.e., community providers) thus directly supporting more veterans. Collaboration between VA OIT and VHA is pa ramount to transforming VHA’s health IT infrastructure. Such collaboration would be most effectively achieved by establishing an IT leader for VHA who is focused on ensuring that the strategic and operational IT needs of VHA clinicians, staff, and veterans are met. Current OIT leadership is in the process of modernizing VA’s IT management processes, to include putti ng in place IT account managers (ITAMs) for 253 An account manager is neither senior partments, including VHA. each of the agency’s de enough, nor has the level of expertise and experi ence, to manage the complexity of the VHA IT system. VHA’s extensive IT needs require a VHA CIO with authority over the health IT budget VA needs a robust process for IT investment and the execution of the health IT strategy. decisions, especially those relating to VHA’s health strategy. The VHA CIO would work with the CVCS and the VA CIO to define the health IT strategy and key IT acquisitions/projects and ensure that health IT funding is aligned and committed to the execution of VHA’s health IT 249 Jamie Bennett, VLER He alth Program Manager, phone call with Co mmission on Care Staff, March 2, 2016. 250 Elaine Hunolt, email on February 1, 2016 in response to fo llow-up questions from her briefing to the Commission on Care, December 15, 2015 251 Protection of Patient Rights Sec. 7332 - Conf identiality of certai n medical records. 38 U.S.C. § 7332 Subchapter III - 252 Elaine Hunolt, email on February 1, 2016 in response to fo llow-up questions from her briefing to the Commission on Care, December 15, 2015. 253 “OI&T Enterprise Strategy: Putting Veterans First,” LaVerne Council, Assistant Secretary for Information & r, Department of Veterans Affair s, briefing to Commission on Care, Technology, Chief Information Office December 15, 2015. 76

91 C OMMISSION ECOMMENDATIONS R le years, and VA must commit to funding strategy. Rolling out a new system takes multip system deployments to completion. se in and reallocation The modernization of VHA’s IT infrastructure requ ires a substantial increa ess for VA health care IT funding should be of VA’s IT budget to implement it. The budget proc the same as the process for VHA medical care funding. That shift can be accomplished by IT within VA’s IT appropriation, and providing for establishing a separate line item for health ddition, there is also a potential supplementary advanced appropriations for that account. In a role for government-wide IT legislation. For example, H.R. 4897, the Information Technology Modernization Act of April 2016, would create a $3.1 billion revolving fund for upgrading 254 outdated federal IT systems. purchase a comprehensive COTS health IT The Commission strongly recommends that VA with minimal customization. VHA leadership platform, and implement all information systems the best solution to support veterans’ future is in the process of assessing whether VistA is as a COTS product or open-source EHR, should health care needs or whether a new EHR, such 255 be used. The decision to choose a COTS product would be consistent the approach adopted by DoD and by other large health systems that have moved away from homegrown solutions to commercial and open-source products. It would a llow VHA to focus energy on excellent patient care as a core competency and shift the IT development and maintenance risk of software 256 products to external vendors with more expertise in this area. It is also likely to accelerate interoperability as vendors continue to offer IT solutions that meet meaningful use standards and the roadmap published by ONC. y functionalities required by VHA. These A COTS product must be able to execute ke requirements include one st andard version of an EHR across all VHA sites of care; as with Veterans Benefit Administration (VBA), and between interoperability within VA, such VHA and DoD, and community providers; robust security; and the ability to accommodate a national unique patient identifier. This system mu st also be a robust clinical management tool omizable interface for clinical users, allows that supports VHA clinical workflow and has a cust for evidence-based clinical order sets and pati ent safety features like automated medication th clinical and administ rative functions, and reconciliation, has robust analytic capability for bo enables automated abstraction and reporting of performance measures. The system must also seamlessly support admi nistrative functions like scheduling, patient intake, eligibility determination, referrals, and pa tient out-of-pocket expense determination. The system must enable effective business oper ations in billing coding, automated claims processing, and all aspects of supply chain mana gement. This COTS purchase should include a scheduling package. Improvements in schedulin g should dramatically increase access and satisfaction, as well as data quality, produc tivity, and operational reporting capabilities. 254 “Two IT Modernization Bills Could See Movement in Congress,” Aisha Chowdhry , accessed April 28, 2016, https://washingtontechnology.com/arti cles/2016/04/22/it-bills -congress.aspx. 73 Sloan Gibson, Deputy Secretary of Veterans Affairs et al., briefing to Commission on Care, April 18, 2016. 256 “DoD awards Cerner, Leidos, Accenture EHR Contract,” Tom Sullivan , accessed May 12, 2016, ehr-contract-winner. http://www.healthcareitne ws.com/news/dod-names- 77

92 C F INAL R EPORT OMMISSION ON C ARE Broadening and improving scheduling capabilities will provide more opportunities for veterans 257 to become active partners in their own care. For VHA to transition to a COTS product, the new VHA CIO must develop and implement a strategy that will allow the current nonstandard data to effectively roll into a new system, engage clinical-end users and internal experts in the procurement and transition process, ensure e current systems to fund only critical changes effective cybersecurity, and limit spending on th plan should be coordinated with ONC and DoD. required for continued operations. Finally, this Implementation Legislative Changes  Provide a specific appropriation to fully fund the complete development and deployment of the comprehensive COTS electr onic health platform, recognizing this will require significant resources above the cu rrent annual appropriation and funding to support VHA’s IT transformation; including fu nds that ensure appropriate training of all staff, recognize loss of staff productivity during implementation, and provide proper maintenance and upgrades of VA IT infrastr ucture in preparation for new and successor technologies. ation a line item for health IT, and provide  Establish within the Department’s IT appropri unt, consistent with the overall VHA IT for advanced appropriations for that acco strategy. Amend section 38 U.S.C. §7332, to authorize VA to share protected health information  under the same rules as all othe r HIPAA protected information. VA Administrative Changes Hire a CIO for the VHA IT transformation. The CIO should report to the CVCS, with  secondary reporting responsibility to VA CIO.  Establish a transformation strategy that addresses all of the following needs (as directed by the VHA CIO): - standardizes data elements in the current IT systems through the use of standard in order to promote the transition to a nomenclatures, terminologies and code sets 258 COTS EHR and to support interoperability - develops a robust cybersecurity plan for VH A IT infrastructure, in coordination with VA CIO and Chief Information Security Office, which addresses both current systems and defines - the requirements for new systems 257 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment H (Health Information Technology), 46, accessed May 3, 2016, act/documents/assessments/ ation_Technology.pdf. http://www.va.gov/opa/choice Assessment_H_Health_Inform 258 Ibid., 55. 78

93 C R OMMISSION ECOMMENDATIONS nal Coordinator for Health IT on national - collaborates with the Office of the Natio interoperability standards and implementation - limits any continued VistA development and associated spending to only those oning until a new system is in place upgrades required to keep VistA functi  nsive COTS electronic health platform Plan and implement procurement of a comprehe that executes all of the following requirements: 259 - establishes one logical version of an elec tronic health record platform in VHA - standardizes evidenced-based, best prac tice clinical order sets across VHA - to drive health and business outcomes and incorporates effective analytic capabilities offers the ability to interface with other tools for data management and 260 presentation - modernizes appointment scheduling so that it accurately measures wait times, is not susceptible to data manipula tion, and is focused on the individual needs of the 261 veterans - accomplishes a coordinated IT infrastructu re for appointment scheduling, coding, billing, claims payment, third party co llections, and other core VHA business processes, including the following specific capabilities: integration across patient intake, medical records, coding, and bill ing systems; single sign-on capability; -time estimate of out-of-pocket patient automated first-party claims matching; real 262 expenses; and automation to support algorithmic edits and claims correction supports the business processes required to implement integrated community care - ns, referrals and authorizations, care networks, including eligibility determinatio coordination, network management, claims and customer service promotes full interoperability with IT systems across VA (including VBA and - National Cemetery Administration) and between VA and DoD - supports the development of full interopera bility with integrated community care network facilities and providers 259 Technology, Chief Informati on Officer, Department of LaVerne Council, Assistant Secretary for Information & Veterans Affairs, briefing to Commi ssion on Care staff, April 27, 2016. 260 very Systems and Management Processes of the Independent Assessment of the Health Care Deli The MITRE Corporation, Department of Veterans Affairs, Assessment H (Health Information Technology), viii, accessed March 31, 2016, act/documents/assessments/ Assessment_H_Health_Inform ation_Technology.pdf. http://www.va.gov/opa/choice th 261 The Independent Budget—Veterans Agenda for the 114 The Independent Budget, Congress: Policy Recommendations for Congress and the Administration , accessed May 17, 2016, http://www.inde pendentbudget.org/ 2016/IB_FY16.pdf. 262 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 49, accessed February 16, 2016, integrated_report.pdf. http://www.va.gov/opa/choice act/documents/assessments/ 79

94 C F INAL R EPORT ARE OMMISSION ON C - enables automated abstraction and reporting of quality performance measures including process and outcome measures of clinical quality, access measures, and cost effectiveness that are the same as the private sector includes functionality to use a nat ional unique patient identifier - - integrates supply chain and financial systems with the electronic health records to 263 provide accurate operational data s so that IT procurement is expeditious, Streamline its current IT procurement processe  including lengthier contract vehicles with mo re options, the use of indefinite delivery indefinite quantity vehicles, blanket purchase agreements, time and material contracts, and flexible contract structures to allow for the onboarding of emerging technologies in a competitive fashion.  Increase health IT expertise within VHA. Other Department and Agency Administrative Changes  CMS and federal health care providers should collaborate to develop a national unique quire health care providers to use these patient identifier standard. CMS should re identifiers as a condition of participation in Medicare and HHS should require federally ition of participation. The President should qualified health centers to use them as a cond require all federal health care providers to adopt the standard. 263 on Officer, Department of LaVerne Council, Assistant Secretary for Information & Technology, Chief Informati ssion on Care staff, April 27, 2016. Veterans Affairs, briefing to Commi 80

95 C ECOMMENDATIONS R OMMISSION Supply Chain Recommendation #8: Transfor m the management of the supply chain in VHA. Problem The Commission Recommends That . . . Effective management of all aspects of executive chain supply for position an establish VHA  the supply chain has become a (CSCO), officer the chain supply chief VHA management, to competitive differentiator for health care individual in drive supply chain transformation VHA. This delivery systems. Modernization and be compensated should to market factors. relative automation of the supply chain in health VA VHA reorganize all procurement and and logistics  care have the potential to save hundreds to VHA under the CSCO for achieve a operations vertically of millions of dollars, if done well. VHA extending unit business integrated to line front the from business This office. central unit would be responsible for cannot modernize its supply chain in all a fully integrated procure ‐ to ‐ pay cycle functions management and create cost efficiencies policy includes that management contract procedures, and because it is encumbered with confusing development and solicitation, ordering, payment, logistics organizational structures, no expert relations inventory and management, vendor and leadership, antiquated IT systems that integration, data IT visibility, supply and analytics chain and clinician engagement alignment, value analysis, and inhibit automation, bureaucratic functions. talent management across these supply chain all purchasing requirements and integrated an establish VHA and VA  IT support to system procedures, and an ineffective approach chain supply management; functions business and to talent management. appropriately in staff train and contracting administrative chain management; and supply update supply chain The problems are systemic. The procedures management and policy with consistent be to organizational structure is chaotic, practice standards in health care. best contracting operations are not aligned to the Veterans Engineering Resource Center  VHA support business functions, and processes are Chain Modernization Initiative including Supply (VERC) poorly constructed, lacking consistent support from continued and funding leadership, plans of alignment the and personnel, within funding and standardization across the organization. OIT to accomplish the modernization goals. Information technology infrastructure is inadequate, and it lacks appropriate interopera bility among IT systems. VHA is unable to ilization and does not effectively manage the produce high-quality data on supply chain ut 264 process using the insights such data could provide. Background Health systems nationwide, under pressure from reforms driven by the Affordable Care Act, are looking at every aspect of their business to maximize cost savings, while maintaining 265 266 This effort includes examining the supply chain for ways to save money. quality services. 264 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies), vi, accessed April 29, 2016, http://www.va.gov/opa/choiceac ssment_J_Supplies.pdf. t/documents/assessments/Asse 265 Bob Kehoe, “Transforming Purchasing: Expect Sharp Focus on Comparative Effectiveness,” Health Facility Mana gement Magazine, 12, (2010): 34-37, accessed April 28, 201 6, http://www.hf mmagazine.com/inc- hfm/pdfs/2010/10HFM 12_Trends5.pdf. 266 “Supply Chain Efficiency Trends,” Rodney M oore, accessed April 28, 2016, http://www.health carefinancenews.com/news/supply-chain-efficiency-trends. “5 Ways Supply Chain Can Reduce Rising Health Care upply-chain-can-reduce- tant.net/2013/05/13/5-ways-s Costs,” Jasmine Pennie, accessed Apr il 28, 2016, http://hitconsul rising-health care-costs/. 81

96 C C F INAL R EPORT OMMISSION ON ARE and aggressive management of supply chain Price competition achieved through technology n are held up as just the kind of disruption efficiencies by retailers such as Walmart and Amazo 267 Health care organizations as diverse as Kaiser Permanente, that health care requires. Cleveland Clinic, Stanford Medicine, and John s Hopkins Health System have taken on the challenge of transforming their supply chains, re alizing savings of as much as hundreds of 268 VHA, which in FY 2014 spent approx imately $3.4 billion on clinical millions of dollars. supplies, medical devices, and prosthetic app liances, has an opportunity to realize similar 269 savings. n include reducing pricing for purchases and Opportunities for efficiency in the supply chai lowering operating costs of procurement proce sses. To achieve price savings, organizations they use, understand and reduce variability must have detailed information on what products negotiate pricing, usually by consolidating in the products purchased, and aggressively ors who are willing to offer volume discounts purchases to a small number of preferred vend side, cost savings are achieved by managing and improve service delivery. On the operations inventory lifecycle and restocking processes; or der management; and the logistics of shipping, receiving, and transportation to drive down costs and lower waste and breakage. In health care, it also pays to ensure that clinical staff, both nu rses and doctors, are treating patients rather than 270 conducting inventory checks or ordering and collecting supplies. To be successful in managing the supply chain in health care, a partners hip with clinical staff is key. Variability in device and supply purchases can be driven by clinician preferences and thus, to reduce variability, clinicians must be engaged in analyzing product options and examining data on 271 product effectiveness to determine what products to use with patients. ve supply chain management that can serve as VHA has a successful internal model of aggressi cal, surgical and other supplies: the VHA a model for improving the management of medi Pharmacy Benefits Management Service (PBM). PBM has taken a systems approach to 267 John Agwunobi and Paul London, “Removing Costs from th Lessons from Mass Retail,” e Health Care Supply Chain: , 28, no 5, (2009): 1336-1342, accessed April 26, 2016, http://content.healthaff Health Affairs airs.org/content/28/5/1336. 268 “In Age of Mergers, Hospitals Get Strategic with Medica l Supply Purchasing,” Jeff Laga sse, accessed April 27, 2016, http://www.healthcarefinancen ews.com/news/age-mergers-hos pitals-get-strategic-medical -supply-purchasing. “Supply Chain Management,” Clev eland Clinic, accessed April 27, 2016, http:/ /my.clevelandclinic.org/services/supply-chain- management. “Stanford Medicine Cuts Medical Supply Costs Through Value- Based Ordering,” Jeff Lagasse, accessed April 27, 2016, http://www.healthcarefi nancenews.com/news/stanford-medicine -cuts-medical-supply-costs-through- value-based-ordering. 269 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies) , 47, accessed April 29, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_J_Supplies.pdf. 270 “EY Provider Post: Choosing Your Innovat ion Pathway,” EY, acce ssed April 26, 2016, http://www.ey.com/US/en/Ind ustries/United-State s-sectors/Health-Car e/Provider-Post--Choosing-your-innovation- pathway. 271 “Supply Chain Efficiency Trends,” Ro ed April 28, 2016, dney Moore, access http://www.healthcarefinancen ews.com/news/supply-chain-efficiency-trend s. “Strategic Supply Chain Management,” Lee Ann Jarousse, accessed April 28, 2016, http://www.hhnmag.com/articles/ 4522-strategic-supply-chain-management. “Stanford Medicine Cuts Medical Supply Costs Through Value-Based Ordering,” Jeff Lagasse, accessed April 27, 2016, news/stanford-medicine-c uts-medical-supply-costs-through-value-based- http://www.healthcarefinancenews.com/ ordering. 82

97 C R OMMISSION ECOMMENDATIONS 272 logistics, and prescribing. managing pharmaceutical supplies, PBM has largely solved the idating its activities under just two contracting internal contracting deficiencies in VA by consol organizations that oversee all national-level co ntracts for pharmaceuticals. PBM also applies pplies through a national formulary, clinical effective mechanisms to drive standardization of su guidelines for prescribers and utilization review, and feedback to help clinicians identify outlier 273 prescribing practices. Vital to the success of this program is the involvement of clinicians and of engagement and decision making through pharmacists in a vertically integrated model Network (VISN)-level, and national-level PBM facility-level, Veterans Integrated Service ical guideline decisions and manage utilization committees that contribute to formulary and clin 274 review with local clinicians. PBM also has a sophisticated web of communications, education, aders across the system are helping drive PBM and engagement efforts to ensure clinical le 275 policy and practices. As a result, 90 percent of purchases are acquired through 276 pharmaceutical prime vendor contracts. PBM, taking advantage of standardized industry nomenclature and bar codes for pharmaceuticals, has implemented automated disp ensing, distribution, and ordering processes, 277 including VA’s Consolidated Mail Outpatient Pharmacy (CMOP). The use of CMOP, a system ess more than 460,000 prescriptions every work of seven highly automated pharmacies that proc r processing costs than would result if filling day, results in exceptional accuracy and lowe 278 Eighty percent of prescriptions in VHA are filled through prescriptions at each VAMC . 279 CMOP, s as the best or one of the best mail order which has been recognized for the last 6 year pharmacies in the country meeting or exceeding customer satisfaction scores of health care systems like Kaiser Permanente and on-line p harmacies like Express Scripts and Walgreens 280 Customer service, veteran satisfac tion, and patient safety delivered . Online Pharmacy 281 through team-based care are a hallmark of the mission of PBM, and are a useful reminder of the principles that must drive any successful transformation of supply chain management in VHA. 272 Independent Assessment of the Health Care Deli very Systems and Management Processes of the The MITRE Corporation, Department of Veterans Affairs, Assessment J (Supplies), 19, accessed April 29, 2016, http://www.va.gov/opa/choiceac ssment_J_Supplies.pdf. t/documents/assessments/Asse 273 Ibid., 20. 274 cess, VHA Handbook 1108.08 (2009). VHA Formulary Management Pro 275 1108.11, 28-30 (2015). The Clinical Pharmacy Services, VHA Handbook Independent Assessment MITRE Corporation, of the Health Care Delivery Systems and Management Processes of 32-34, the Department of Veterans Affairs, Assessment J (Supplies), tp://www.va.gov/opa/c _J_Supplies.pdf. sessments/Assessment accessed January 13, 2016, ht hoiceact/documents/as 276 Independent Assessment of the Health Care Deli very Systems and Management Processes of the The MITRE Corporation, Department of Veterans Affairs, Assessment J (Supplies), 13, accessed January 13, 2016, http://www.va.gov/opa/choice act/documents/assessments/ Assessment_J_Supplies.pdf. 277 Ibid. 278 “VA Mail Order Pharmacy,” U.S. irs, accessed April 29, 2016, Department of Veterans Affa http://www.pbm.va.gov/PBM/CMOP/ VA_Mail_Order_Pharmacy.asp. 279 Independent Assessment of the Health Care Deli very Systems and Management Processes of the The MITRE Corporation, Department of Veterans Affairs, Assessment J (Supplies), 13, accessed January 13, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/A ssessment_J_Su pplies.pdf. 280 il Order (2015),” J.D. Power, accessed April 29, 2016, “U.S. Pharmacy Study – Ma http://www.jdpower.com/rat ings/study/U.S.-Pharmacy -Study-Mail-Order/631ENG . 281 “Pharmacy Benefits Ma nagement Services,” U.S. De partment of Veterans Affair s, accessed April 29, 2016, http://www.pbm.va.gov/PBM/index.asp. 83

98 C F INAL R EPORT OMMISSION ON C ARE Analysis VHA’s supply chain for clinical supplies, medica l devices, and related services is inadequate n or to best practices in leading hospital compared to the agency’s pharmacy organizatio systems. slow, which can delay veterans access to Its contracting processes are bureaucratic and care. Purchasing processes are cumbersome whic h has driven VHA staff to work arounds and exacerbates the variation in prices VA pa ys for products. Utilization is difficult to n a lack of data which likely leads to significant avoidable expense measure or manage give 282 for VA. al Structure and Function Leadership and Organization Best-in-class supply chain org anizations typically have a sing le group responsible for the of clinical supplies and medical devices. The strategy, sourcing, procurement, and logistics l leader, such as a chief supply chain officer organization is typically led by an executive-leve (CSCO), and personnel are aligned along product categories to develop and use deep expertise 283 in the products and suppliers they manage. In contrast, the organizational structure for 284 in VA and VHA is complex and duplicative. contracting, logistics, and supply management Four contracting entities are located within VA central office but report to two different 285 management offices within VA’s office of acqu isition, logistics, and construction (OALC). ntracting and VISN offices report to VHA’s Procurement personnel within VHA’s regional co ility-based and VISN logistics personnel report to national office of procurement. In contrast, fac 286 their local VAMC or VISN director and not to the national VHA logistics office. To further complicate the management picture, clinical su pplies are managed by the logistics organization, 287 yet medical devices are managed by the Pr osthetics and Sensory Aid Service (PSAS) (see Figure 5). In most health care organizations, the supply chain chief operating officer and their integrated supply chain group manag es the procurement and distribu tion of all clinical supplies 288 and medical devices. This is not the case in VA. Senior leaders in VA’s and VHA’s supply chain organizations and field- based supply chain personnel in dicate current organizational structure is too complex and should be simplified. National supply chain leaders expressed lack of clarity regarding the scope of ey are responsible, which has led to some responsibilities of the entities for which th tension and what one leader described as a ‘turf war.’ Others described a vacuum of 289 ownership and accountability, and lack of clarity on roles and responsibilities. 282 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies), v, accessed April 29, 2016, t/documents/assessments/Asse http://www.va.gov/opa/choiceac ssment_J_Supplies.pdf. 283 Ibid., 57-58. 284 Ibid., ix. 285 Ibid., 96-97. 286 Ibid., 47-50. 287 Ibid., 58. 288 Ibid. 289 Ibid., 55. 84

99 C R OMMISSION ECOMMENDATIONS 290 rising VA’s Supply Chain Figure 5. Organizations Comp The separation of clinical supplies and pros thetics/medical devices causes issues in coordinating products needed for procedures. Frontline staff members indicate the time it takes to procure simple items through contracting (1 to 3 months) is problematic. For example, heart valve surgery may be delayed because some hear t valves cost more than the micro-purchase 291 threshold ($3,000), thus the purchase must be made through the contracting process. Medical center staff consistently expressed concern that VHA procurement offices are not responsive to 292 the needs of a health care organization and do not communicate effectively with them, 293 findings borne out by low customer satisfac tion scores given to these organizations. There is great overlap and redundancy in procur ement and logistics functions in VA and VHA and the reporting structures are not aligned to ensure that the needs of veteran patients and their clinical providers are met. In an environment with limited sharing of best practices and a rrent complicated reporting structures impede lack of transparent, open communications, the cu customer-service quality and effectiveness. The or iginal intent behind the current structure was to consolidate and strengthen purchasing power through the establishment of national contracts; however implementation of the visi on has been poor and the result has been a 290 Ibid., 49. 291 Ibid., 67. 292 Ibid., 68. 293 Ibid., 69. 85

100 C C F INAL R EPORT OMMISSION ON ARE 294 . complicated, bureaucratic system filled with redundancies These broken processes serve as a 295 precursor for catastrophic systems failures. streamline procurement and logistics for medical There is an immediate need to consolidate and and surgical supplies under one leader in VH A, the VHA chief supply chain officer (CSCO), who would be accountable for transforming VH A supply chain management. As identified gement is the first priority but the rest of under MyVA, medical and surgical supply chain mana the supply chain needs to be addressed by the CSCO in a staged approach. The VERC or other neering must be engaged to create a vertically aligned experts in business process engi organizational structure with clear delegated respon sibilities at each level of the organization to ts and logistics process which the VHA CSCO create an efficient and responsive procuremen would lead. Clinical Engagement and Value Analysis In contrast to pharmaceuticals, usage of c linical supplies and medical devices is not strictly monitored or managed in VA. In general, physicians and nurses can choose whichever products they believe are best f or patients and the supply chain organization’s 296 role is to make those items available. VHA does not have a means to determine what su pplies should be standardized or a feedback loop administrators and staff use to assess whether standards were being used when they did 297 n has been achieved across VHA, despite As a result, limited product standardizatio exist. er groups in 2001 responsible for identifying VHA establishment of national standardization us 298 To date, national product items for standardization based on national procurement data. 299 only a limited number of categories. standardization has been achieved in Since 2011, VHA required that medical centers establish Clinical Product Review Committees (CPRCs) to: (i) review and approve the use of new clinical items and reusable medical equipment (RME) at each medical center; (ii) maintain a list of approved expendable clinical supplies and RME by establishing and maintaining a Medical/Surgical Supply Formulary; and (iii) ensure compliance with nationally standardized contracts and blanket purchase agreements. In all sites vi sited, CPRCs exist and meet regularly but 300 reviews were generally formalities. 294 Ibid., 47-50. 295 Heather Woodward-Hagg, PhD, Acting Director, VERC, briefing to Comm ission on Care, February 8, 2016. 296 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies) , 54, accessed April 29, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_J_Supplies.pdf. 297 Ibid., xii. 298 VHA Handbook 1761.1, Standard ization of Supplies and Equipment Procedures, July 2003. 299 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies) , 81, accessed April 29, 2016, http://www.va.gov/opa/choiceac ssment_J_Supplies.pdf. t/documents/assessments/Asse 300 Ibid., 82. 86

101 C R OMMISSION ECOMMENDATIONS SN oversight committees was also required to Under this 2011 policy, the establishment of VI provide accountability and feedback to the local committees, but these committees were 301 apparently never established . gineering Resource Center (VERC), is making VHA, with the engagement of the Veterans En progress on clinician alignment to accomplish value-based purchasing decisions for medical and surgical supplies. VERC has recently rolled out a national clinical product review committee (CPRC-E) e-portal to better organize th is function. This portal provides a central system and standard processes for all new prod uct requests and approvals to inform the 302 procurement processes. In the area of medical and surgical supplies, clinician preference can drive variability in in VHA for pharmaceutical prescribing, a procurement and utilization. As has been done similar system to engage and align clinicians must be undertaken for medical devices and surgical supplies. VERC has started this proce ss, but requires further funding and leadership support to fully implement a clinician-driven so urcing process. Current and future leaders of VA and VHA must ensure that VERC continues to receive the funding support and leadership engagement it needs to fully accomplish this tr ansformation with support and direction from a VHA CSCO. Information Technology, Data Standards, and Analytics Information technology systems, data systems, and analytical capability for finance, inventory 303 management, and purchasing impede VHA’s abi lity to effectively manage its supply chain. the operational and financial performance of VHA needs greater “end-to-end visibility into their supply chain” and more effective me ans to accomplish supply chain budgeting, tion of at least some key supply chain forecasting, inventory management and automa 304 functions. VA lacks visibility into supplies and devices sp ending at the level of granularity usually e private sector, it is typically possible to seen in the private sector. For example, in th measure clinical supply spend and utilization at the service, patient, or physician level. However, this is not possible in VHA because it does not capture such data. Therefore, ated in aggregate, which is relatively supplies spend per case can only be calcul mparison across hospitals, services, or meaningless and does not allow for fair co nage utilization and to understand fully the physicians. This inhibits VA’s ability to ma 305 impact of product standardization efforts. rsions of VistA in place across the country so VERC is working to reduce the more than 130 ve 306 Funding was approved by OIT for the that the same data sets can be tracked and reported. Future Transformation Tool (FTT) graphical user interface that will standardize product names 301 Ibid., 54. 302 Heather Woodward-Hagg, PhD, email to Commission on Care, March 17, 2016. 303 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies), x, accessed April 29, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_J_Supplies.pdf. 304 Ibid. 305 Ibid., 60. 306 Ibid. 87

102 C INAL R EPORT OMMISSION ON C F ARE Point of Use Solution, a commercial off the shelf and provide data integration across all of VHA. purchased to achieve better inventory and supply management software product, has been demand management control and has been deployed to 32 percent of facilities, as of April 307 2016. driven process cannot be achieved with fragmented information True sustainment of a clinician systems that do not communicate. Leaders at a ll levels of the organization are not able to effectively identify and manage procurement requ irements or provide effective feedback to clinicians on utilization. Similarly, automated inventory control, ordering, billing, and payment cannot occur without a seamless information te chnology infrastructure. With a current IT system in which fiscal, supply chai n, and clinical informatics systems do not interface, the hopes ordering, equipment life cycle management, and of moving to automated processes for supply vendor communications cannot be realized. A plan for the transformation of supply chain management, developed by a VHA CSCO with su pport from VERC, must be fully integrated with planning and procurement within OI&T and fully financed to accomplish these important goals. Policy and Procedures 308 pplies are acquired using purchase cards Ninety-eight percent of all clinical su and 75 percent 309 of what VHA spends on clinical supplie s is made through this purchase mechanism. This is not a surprise given that the standard contra cting process can take anywhere from 150 to 310 180 days to complete, yet use of purchase cards is inefficient as this mechanism does not take advantage of economies of scale and potential co st savings an organization the size of VHA can 311 ions and strategic sourcing. achieve through price negotiat It can also be contrary to law, as use of purchase cards often necessitates orders be split to remain under the $3,000 purchase 312 card limit. An analysis of purchase records showed that 38 percent of supply orders were made through standing vendor contracts which is in stark contrast to the private sector of supply purchases from master contracts with benchmark of aiming to complete 80-90 percent 313 negotiated price discounts. Indeed, the private sector trend in health care has been for lliances in “group purchasing organizations” to hospitals and health care systems to form a 314 Weaknesses in logistic management have been achieve the scale that VHA naturally enjoys. 315 recognized in VHA for some time and still remain. For instance, a review of logistics business 307 Sloan D. Gibson, Deputy Secretar y of Veterans Affairs, briefing to Commission on Care, April 28, 2016. 308 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies), xi, accessed April 29, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_J_Supplies.pdf. 309 Ibid., xii. 310 Ibid., x. 311 U.S. Government Accountability Office, Strategic Sourcing: Improved and Expand ed Use Could Save Billions in Annual , accessed April 28, 2016, http:// Procurement Costs www.gao.gov/assets/650/648644.pdf. 312 U.S. Department of Veterans Affa Review of Potential Inappropriate Split Purchasing at VA irs, Office of Inspector General, th Care System ubs/VAOIG-11-00826-261.pdf. http://www.va.gov/oig/p New Jersey Heal , accessed April 28, 2016, 313 Independent Assessment of the Health Care Deli very Systems and Management Processes of the The MITRE Corporation, Department of Veterans Affairs, Assessment J (Supplies), xii, accessed April 29, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_J_Supplies.pdf. 314 Sharp Focus on Comparative Effectiveness,” Bob Kehoe, “Transforming Purchasing: Expect Health Facility Mana gement Magazine, 12, (2010): 34-37, accessed April 28, 201 6, http://www.hf mmagazine.com/inc- hfm/pdfs/2010/10HFM 12_Trends5.pdf. 315 U.S. Government Accountability Office, Veteran’s Health Care: VHA Has Taken Steps to Address Deficiencies in Its , accessed April 28, 2016, http:// /660/653886.pdf. www.gao.gov/assets Logistics Program, but Si gnificant Concerns Remain 88

103 C OMMISSION ECOMMENDATIONS R showed that none of the facilities achieved practices at 17 VHA medical facilities in 2014 100 percent compliance on the factors assessed, and the rate of noncompliance ranged from 316 53 to 88 percent, depending on the business metrics examined. acquisition regulations to take advantage of VA is inhibited by a failure to update its modernization made in 2014 to the governmentwide regulations to promote simplified 317 purchasing procedures. e intended to standardize business processes VERC initiatives to improve VHA supply chain ar and address the great price variations for the purchasing of medical and surgical supplies. A national medical surgical prime vendor (MSP V) contract has been established. This e (a) increased ability to leverage pricing development has several advantages to includ negotiations; (b) standardized pricing; (c) elim ination of redundant contract development, 318 VA has ility to integrate with CPRC E-Portal. bidding, and selection; and (d) future ab established a goal for 85 percent of all orde rs in FY 2016 be made under the prime vendor contract and has made 1,100 contracting officers available to meet demand against the 319 As of April 2016, an estimated $24.4 millio n in supply chain costs had already been contract. 320 avoided since January. The establishment of a new MSVP contract in April 2016, the assignment of 1,100 staff to support its use, and the expectation communicated to the field that 85 percent of all purchases be made from the contract are important steps in the right direction. For efficient ordering processes to take hold and be sustained across VH A, all of the policies and procedures from the bedside (or surgical suite) to the head contract ing office must be reworked to align with the desired business outcomes. Reworking policies and procedures must occur together with vels of the organization. Each staff member appropriate training and communication at all le be held accountable for meeting the new involved in the procurement process must requirements and expectations assigned to th em. Updating the VA Ac quisition Regulation (VAAR) is just one small piece of such a trans formational change. The VERC or others with esses within government should be assigned appropriate experience in aligning business proc ting plans for such a transformation under the responsibility to finish developing and implemen direction of a VHA CSCO. Contracting Analysis of the Independent Assessment Report confirmed issues with the responsiveness of contracting. For example, at one facility, if a request was submitted to contracting that was incomplete or inaccurate, it took on average 21 to 39 days from the date of initial submission to 316 Veterans Affairs, VA Supply Chain News , Issue 13, Jan/Feb 2015. U.S. Department of 317 Jonathan Miller, Director of Lo gistics Operations, VHA Procurement & Logistics Office, phone call with Commission on Care, December 9, 2015. 318 Heather Woodward-Hagg, PhD, Ac ting Director, Veterans Engineer ing Resource Center, phone call with Commission on Care, March 18, 2016. 319 Sloan D. Gibson, Deputy Secretar y of Veterans Affairs, briefing to Commission on Care, April 28, 2016. 320 Ibid. 89

104 OMMISSION ON C INAL R EPORT F C ARE receive the first response from contracting requesting, for example, additional information or 321 paperwork. This problem appears to be a widespread. In another instance, interviews conducted as pa rt of the independent assessment showed that VA vendor contracting processes to order equipm ent valued at less than $3,000, for example, scalers for dentistry, can be confusing and le ngthy, leading to shortages in equipment and delays in clinic as equipment is located. Delays in sterile processing were also indicated by 322 providers as an issue pertaining to equipment availability. antial challenge within VHA. In surveys that Communication with contracting is another subst assessed the effectiveness of VA’s contractin g organization, VHA employees’ customers rated the communications received from contracting offi cials the lowest of all contracting dimensions 323 that were evaluated. Several interviewees recommended th at VA provide more clarity on the 324 status of contracting requests to help them plan and schedule care. Individuals in contracting believed that VAMC st aff members were responsible for some of the that requests submitted to them from VAMCs delays in the contracting process. They reported were often incomplete or unclear and that facilit ies were poor at forecasting demand for items, leading to unpredictable peaks in demand for cont racting services that exceeded their capacity. The VHA Procurement and Logistics Organization (PLO) and facilities are seeking to address these challenges by placing contract liaisons in facilities to better support contracting officer 325 representatives throughout the process. Contracting compliance analysis showed substantia l opportunity for improvement. Analysis of percent of purchases were made on a government contract, purchase order data showed that 38 27 percent were made at open-market prices, and 34 percent did not have a source type 326 specified. to buy 80 to 90 percent of their clinical Private-sector organizations typically aim 327 supplies and medical devices on some type of negotiated contract. Interviews and observations unde rtaken as part of the independent assessment revealed that there are two primary reasons for VHA’s relatively high share of open-market purchasing. First, in contrast to pharmaceutical purchasing, VH A’s supply purchasing systems are not integrated 321 ansmission log received during a VAMC site visit (2015). The consulting team based this on an IFCAP/eCMS tr McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies), x, accessed June 1, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/A ssessment_J_Supplies.pdf. 322 stems and Management Processes of the Department of Grant Thornton, Independent Assessment of the Health Care Delivery Sy Veterans Affairs, Assessment G (Sta 91, accessed June 1, 2016, ffing/Productivity/Time Allocation), http://www.va.gov/opa/choi ceact/documents/assessme ng_Productivity.pdf. nts/Assessment_G_Staffi 323 The consulting team derived th ent metrics book. McKinsey & Company, Inc., Independent is from a VHA procurem Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies), )69, accessed June 1, 2016, http://www.va.gov/opa/choiceac ssessment_J_Supplies.pdf. t/documents/assessments/A 324 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies), x, accessed June 1, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/A ssessment_J_Supplies.pdf. 325 Ibid. 326 Ibid., xii. 327 Ibid. 90

105 C R OMMISSION ECOMMENDATIONS the purchasing process relies on buyers (often with contract or pricing catalogs. Therefore, contract and through which contract a purchase clinical staff) to research whether an item is on should be made. Because of that complexity, seve ral buyers reported that they bypass this step and buy products through the channel that is most familiar and convenient, for example, by their usual supplier, despite changes that may have occurred replicating previous orders to example). Second, VHA has limited ability to (new contracts and pricing arrangements, for monitor and drive compliance with the contract hierarchy because the required data are not captured electronically. In fact, more than 60 pe rcent of all clinical supply items do not have a 328 contract number listed. VHA’s fragmented inventory management systems and processes also create challenges. VHA’s current inventory management does not have a feedback loop to link inventory to product use, contracting, ordering, and vice n prevents optimal use of the versa. This lacking informatio unities to establish more effective volume- MSPV contract program and creates missed opport leads to peaks and troughs in demand for based national or regional contracts. It also 329 contracting services, which can ov erwhelm contracting’s capacity. There are pockets of good performance and innova tion in VHA that could be replicated across its supply chain. The Independent Assessment Report notes that the Denver Acquisition and Logistics Center (DALC) is a bright spot wi thin VHA’s supply chain organization in its acquisition and distribution of select devices such as hearing aids to veterans. It has developed an integrated operating model that brings together clinicians, contracting, finance, logistics, and makes decisions around product and supplier program management. That integrated team 330 selection based on a holistic view of what is best for veterans and for VHA. Talent Management s supply chain. In 2014, 20 to 30 percent of VHA is unable to hire good talent to manage it 331 logistics positions were unfilled, and 20 percen t of medical supply aide jobs were vacant. The causes were identified as lengthy time-to-hire, nonexistent internal career progression ladders for these individuals, and inability to provide competitive pay due to position downgrades 332 made by OPM under Title 5. Examples of recent downgrades include supply technician, mail 333 manager, administrative officer, and materials handler . It is well known in the health care industry th at there is a shortage of supply chain talent currently. The private sector organizations in terviewed during this assessment stated that they are recruiting more highly trained in dividuals than they did in the past and, em more than they used to. This may be because of competition for talent, are paying th 334 contributing to VHA’s recruitment and retention challenges. In Recommendation #15, the application of the more than 60-year old standards and processes used in the Title 5 personnel system does not se rve the needs of a modern health care delivery 328 Ibid. 329 Ibid. 330 Ibid., xiii. 331 Ibid. 332 Ibid. 333 Ibid., 87. 334 Ibid., 88. 91

106 C F INAL R EPORT OMMISSION ON C ARE organization. Health care supply chain management is a recognized field of study and a valued component of leadership teams at the highest pe rforming health care organizations. For VHA to compete for top leadership talent in this fiel d and frontline staff, lo gistics and procurement personnel must be included in a new excepted personnel system for VHA under Title 38 (see Recommendation #15). To address talent management issues, VERC has established a new VA Acquisition Academy (VAAA) Supply Chain Management School. School is to provide best-in-class The mission of the Supply Chain Management t, and certification of the VA supply chain education, training, professional developmen workforce. VAAA’s competency-based curricu lum addresses general and technical skills, VA-specific functional areas, and core activi ties for VA logistics professionals. Emphasis is on translating theory, fundamentals, and concepts to practical application with 335 realistic VA-based scenarios utilizing hands-on application of problem-solving skills. The supply chain management sch ool is organized under VAAA which has been recognized by 336 external organizations to o ffer high quality training. Implementation Legislative Changes Establish a new excepted personnel system under Title 38 to permit VHA to compete  nnel required to run a complex health care effectively with the private sector for perso system, including staff to manage and operate a modern supply chain system. VA Administrative Changes Establish an executive position for supply chain management, a VHA chief supply chain  officer (CSCO), to drive supply chain transform ation in VHA. This individual should be compensated relative to market factors.  Transform policy and procedures for suppl y chain management in parallel with identification and procurement of new ma nagement software: new software should support the new processes and not the exis ting, poorly organized business processes and requirements.  Establish a staged process for the transforma tion of all supply chain operations in VHA under the direction of a VHA CSCO, with support from VERC.  Reconcile the VAAR with the Federal Acquisit ion Regulation (FAR) to ensure the VAAR aligns with recent updates to the FAR to permit streamlined acqu isition processes. Provide consistent and standardized trai  ning to ensure those developing and administering contracts have updated information regarding FAR and VAAR 335 “Message from the Vice Chancellor,” Veterans A ffairs Acquisition Academy, accessed April 28, 2016, http://www.acquisitionaca demy.va.gov/schools/ scm/message.asp. 336 “VA Acquisition Academy Recognized as a 2016 Learning Elite Orga nization,” U.S. Department of Veterans Affairs, accessed May 13, 2016, http .gov/rss/index.xml#20160413b. ://www.acquisitionacademy.va 92

107 C R ECOMMENDATIONS OMMISSION ing of their responsibilities under the new regulations as well as a thorough understand approach to supply chain management and how to carry out these duties. Other Department and Agency Administrative Changes  None required. 93

108 C ARE INAL R EPORT OMMISSION ON C F Governance, Leadership, and Workforce Board of Directors Recommendation #9: Establish a board of directors to provide overall VHA Care System governance, set long-term strategy, and direct and oversee the transformation process. Problem The Commission Recommends That . . . The existence—and concealment—of establishment the for provide Congress  an of unacceptably long delays in care at the to accountable directors of board member ‐ 11 the Phoenix VA Medical Center (VAMC), and for overall VHA Care System responsible President, making governance, decision with and to authority ‐ similar problems at multiple other VAMCs, the transformation process and set long ‐ term direct had both direct and indirect causes. Weak Commission also recommends the The strategy. governance was found to be among those governing to the subject be not board Federal 337 As the authors of a root- indirect causes. be Act based structured and on Advisory Committee cause analysis of the Phoenix scandal the 5. Table in included elements key highlighted, “a governance gap in leadership a System The Board recommend  of VHA Care chief continuity and strategic oversight from one (CVCS) initial an for President the by approved be to 5 Commission the Additionally, appointment. year ‐ executive leadership team to another” the to empowered be recommends board governing 338 contributed to the wait-time problems. The reappoint second a for individual this ‐ year term to 5 report authors observed, “Unlike other continuity for allow CVCS the protect from to and health care systems, VHA does not have a political transition. If necessary, the CVCS can be governance mechanism to fill the role of a by mutual agreement and the removed President of 339 governing the board. board of directors.” The governance limitations made evident in the Phoenix scandal have profound implications for the lo ng term. As discussed in this report, the Commission believes VHA must institute a far-reac hing transformation of both its care delivery system and the management processes supporting it. Changes of the magnitude facing VHA would be difficult for any health care system to achieve. A transformation will take years to accomplish and must be sustained over time. Yet th e short tenure of senior political appointees, 340 each administration’s expectations for short-term results, and VHA’s operating in a “dynamic rge number of stakeholders, sometimes with environment [in which it is] answering to a la 337 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, xvi, accessed June 15, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 338 Veterans Health Administration (VHA) National Ce Booz Allen Hamilton, nter for Patient Safety (NCPS) Systems Review: , September 22, 2015, 3. Final Report 339 Ibid. 340 Ibid. 94

109 C R OMMISSION ECOMMENDATIONS 341 competing demands” offer little reason for optimism that real transformation could take hold without fundamental changes in governance. Background VHA, as an agency within a cabinet department, is accountable to the secretary of Veterans amework, when it works well, can provide VHA Affairs (SECVA) and to the President. This fr access to, and support from, the President and Wh ite House staff. Like other executive branch ement and Budget (OMB) oversight; must win agencies, VA and VHA undergo Office of Manag making, budgets, IT development, and performance plans; and OMB approval of proposed rule of such areas as procurement, personnel, and are also subject to governmentwide regulation property management. VHA health care and op erations are subject to close congressional 342 scrutiny. VHA undergoes oversight from several in dependent bodies, including the internal Office of the Inspector General audits and exte rnal Government Accountability Office audits. Within VA, VHA participates in the VA Execut ive Board (VAEB) and Se nior Review Group, 343 which are designated as the principal governance bodies of the department. VAEB serves as the department’s risk-governance board and de termines VA’s strategic direction. VAEB oversees the department’s planning, programming , budgeting, and execution. Notwithstanding certain strengths inherent in this framew ork, VHA governance can be paralyzed by 344 bureaucratic decision-making processe s and competing stakeholder concerns. Among its principal recommendations, the Independent Assessment Report calls for “establishing a governance board to develop fundamental policy, define the strategic direction, insulate VHA leadership from direct political intervention, and ensure accountability for the achievement of 345 established performance measures.” Analysis In recent years, VHA leadership priorities and strategic direction have been unclear. Leaders have been consumed by crisis and by responding to congressional demands, creating a reactive, 346 Additionally, the leadership vision has lacked rather than proactive environment. 347 continuity. rans Affairs may exer cise oversight of The SECVA and deputy secretary of Vete 341 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, xiv, accessed June 15, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 342 entatives, House Committee on Veterans ’ Affairs, accessed June 15, 2016, “Legislation,” U.S. House of Repres http://veterans.house.gov/leg islation?type=hearing&tid=All &tid_1=All&page=3. Over the course of calendar year 2015, the House Veterans Affairs Committe e and its subcommittees alone held 18 oversight hearings relating to the Veterans Health Administration, with VHA and/or VA offici als testifying as often as three times in a month. 343 , Department of Veterans Affairs Governance Structure VA Directive 0214 (2014). 344 The MITRE Corporation, very Systems and Management Processes of the Independent Assessment of the Health Care Deli 26, accessed June 15, 2016, Department of Veterans Affairs, Volume 1: Integrated Report, act/documents/assessments/ integrated_report.pdf. http://www.va.gov/opa/choice 345 Ibid., 23. 346 Booz Allen Hamilton, Veterans Health Administration (VHA) National Ce nter for Patient Safety (NCPS) Systems Review: Final Report, September 22, 2015, 52-54. 347 Independent Assessment of the Health Care Delivery Systems and Management Processes of the McKinsey & Company, Inc., Department of Veterans Affairs, Assessment L (Leadership), vi-viii, accessed June 15, 2016, http://www.va.gov/opa/choice act/documents/assessments/ Assessment_L_Leadership.pd f. Linda Belton, former VHA VISN Director and Director of National Center for Organizational Deve lopment, written submission to the Commission on Care Staff, January 19, 2016. 95

110 C INAL R EPORT OMMISSION ON C ARE F VHA and try to impose accountability, but incu mbents do not necessarily have experience in 348 federal health care administration or delivery. The SECVA has often lacked independent information and metrics on VHA performance, and the oversight, risk management, and compliance functions of VHA report to the undersec retary for health (USH) or to lower officials 349 in VHA. 350 Previous studies, dating back 20 years, have proposed fundamental change in VHA’s governance and government structure, to includ e a proposal that it be restructured as a 351 The earliest rationale for making VHA a government corporation government corporation. 352 was based on the view that the system needed a new service-delivery strategy, and envisioned specific legislation to permit the corporation to operate more expansively under a 353 wide range of reforms. Although the authors of the 1996 report presented a VHA government 348 Department of Veterans Affairs Governance Structure VA Directive 0214 (2014). McKi nsey & Company, Inc., , Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership), viii, accessed June 15, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_L_Leadership.pdf. Un der Secretary of Health, 38 U.S.C. § 305. While statute requires the USH of VHA to be appointed “solely on the basis of demonstrated ability in the medical profession, in health-care ad ministration and policy formulation, or in health-care fiscal management; and on the basis of substantial experience in c onnection with the programs of the Vetera ns Health Administ ration or programs of similar content and scope” there is no such selection criteria for the VA Secretary or VA Deputy Secretary. Of the etary of Veterans Affairs, only one, James Peake would qualify to be USH eight men to hold the position of Secr (“United States Secretary of Veterans Affairs,” Wikipe dia, accessed June 15, 2016, https://en.wikipedia.org/wiki/United_Sta tes_Secretary_of_Veterans_Affairs#List_of_Secretaries_of_Veterans_Affairs) and of the six men to hold the position of DEPSECVA, none would qualify to be USH. 349 Department of Veterans Affairs, 2014 Functional Organizational Manual v2.0: Descri ption of Organization Structure, Missions, Functions, Tasks, and Authorities , 57-58, accessed June 15, 2016, manual_version_2.0a.pdf. cs/va_functional_organization_ http://www.va.gov/ofcadmin/do 350 Veterans Benefits Improvement Act of 1994, Pub. L. No. 103-446, 108 Stat . 4645 (1994). In 1994, Congress in sec. tablishing an alternative 1104 of Public Law 103-446 called for an independent examinati on of the justifiability of es ices for veterans, culminating in the 1996 report. government structure to provide health care serv 351 Klemm Analysis Group, Lewin Group, Arthur Anderson LLP, Feasibility Study: Transforming the Veterans Health Administration into a Government Corporation (Washington, DC: Department of Vete rans Affairs, 1996), 23. A government vernment agency that is established by Congress to provide a market-oriented corporation has been described as “a go public service and to produce revenues that meet or approximate its expend itures.” Kevin R. Kosar, Congressional Federal Government Corporations: An Overview , 2, accessed June 15, 2016, Research Service, s/misc/RL30365.pdf. B Veterans Health Administration (VHA) National Center ooz Allen Hamilton, https://fas.org/sgp/cr for Patient Safety (NCPS) Systems Review: Final Report September 22, 2015. Concerne d Veterans for America, Fixing Veterans accessed June 15, 2016, http://cv4a.o rg/wp-content/uploads/2016/01/Fixing- Health Care: A Bipartisan Policy Taskforce, Commission on the Future for America’s Veterans , Preparing for the Next Generation , 3, accessed Veterans-Healthcare.pdf. June 15, 2016, http://s3.amazonaws.com/siteninja /site-ninja1-com/1438121489/or iginal/2014-05_Commission- Report-on-America-Veterans.pdf. That task force study, for example, called for an independent governance model and VHA does not lend itself to progress. stated that “the operational structure of Due to its size, governmental structure and geographic extension it does not readily foster innovation and faces challe nges in addressing the politics of changing ates, “VHA provides excellence in care in spite of its demographics and ancient facilities.” The study report st e, not because of it.” operations/governance structur 352 Klemm Analysis Group, Lewin Group, Arthur Anderson LLP, Feasibility Study: Transforming the Veterans Health Administration into a Government Corporation (Washington, DC: Department of Vetera ns Affairs, 1996), 23. The strategy was premised in part on the view that VH onstrained environment and lacked the A would be operating in a resource-c resources it would need to invest in making significant changes. 353 Ibid. The 1996 report proposed such me asures as providing VHA authority to seek additional re venue streams, to include billing and keeping funds from Me dicare, Medicaid, and othe r government sources; au thorizing it to invest nonappropriated funds; developing a trust fund for deposit of Medicare taxes by active-duty personnel; incorporating fits Plan selection; allowing it to VHA as a Federal Employee Health Bene become part of health maintenance organization (HMO) networks and open HMO enrollment to veterans; changing appropriation law to create 96

111 C OMMISSION ECOMMENDATIONS R objectives, those objectives were largely met corporation as a means of achieving specific (though ultimately not fully sustained) by refo rms within existing government structures and 354 processes set in place by former USH Kenneth W. Kizer. Nearly 20 years later, the report analyzing the root causes of delayed care at the Phoenix and other VA centers proposed creation of “gov ernance mechanisms to bridge ‘Secretary suite’ 355 le strategy, oversight, and stewardship.” leadership transitions and provide more stab mplexity of this organization requires a more Explaining that “the study team feels that the co stable and professionalized governance model that more closely resembles the governance of 356 the study authors proposed the creation of a large health care systems in the private sector,” board to set the strategy for the organization, define priorities, board-of-directors-type oversight provide operational oversight, and review budget requests. “The board would . . . create a body vision, providing institutional memory and that would be the steward of the organizational 357 continuity as senior political appointees transition.” Frequent turnover of the USH is a critical problem. Recently, each USH has served for only a relatively short period, leaving office with a ch ange in administration or sooner. This pattern has deprived VHA of vitally needed sustained leadership and has likely contributed to short- term decision making. VHA history shows a connection between longer tenure and 358 transformative accomplishment. As testimony to the Commission from three former USHs would indicate, brevity of tenure tends to limit le aders’ strategic horizon and create a pattern of leadership discontinuity. Because transformati ve change can only be realized through many years of focused leadership, VHA and those who depend on it cannot afford the senior ed with a change in administration. leadership turnover routinely associat The complex, sustainable transformation VHA need s will take years to implement. To succeed, governance framework that can assure effective VHA needs strong, consistent leadership and a plans over time. The current governance development and execution of transformation structure emphasizes operational, rather than strate gic priorities; experience has shown it to be incapable of sustaining transformational chang e. Establishing a well-designed, overarching- governance model would provide an opportunity to achieve objectives shared by both the ative branches. executive and legisl e model should be empowered with a governing To be effective, a VHA Care System governanc board that exercises fiduciary-like responsib ilities (not subject to the Federal Advisory Committee Act) to carry out the following key functions: multiyear/no-year appropriations; reform ing human resources management practice s for increased flexibility in hiring and firing, compensation, leave, and other functions; and reforming; and reforming procurement and contracting. 354 having greater capacity to focus on strategic as well as Ibid., 46, 48. The Klemm report saw a VHA corporation as short term goals; greater result s orientation; greater fl exibility; greater capacity to rep licate and develop best practices; upgraded staff competence and expertise at senior levels; and greater political independence. 355 Booz Allen Hamilton, Veterans Health Administration (VHA) National Ce nter for Patient Safety (NCPS) Systems Review: Final Report, September 22, 2015, 59. 356 Ibid. 357 Ibid. 358 See Dr. William S. Middleton, Chief Medical Director (1955-1963) and Dr. Kenneth W. Kizer, Under Secretary for Health (1994-1999). 97

112 C OMMISSION ON ARE F INAL R EPORT C select the chief of VHA Care System (CVC  S) and recommend the appointment of the CVCS to the President provide long-term, strategic direction for  VHA Care System and establish priorities, milestones, and timelines oversee, direct, and make critical deci  sions regarding the transformation process  business, and organizational plans review and approve major operational,  es and provide annual reports to Congress set VHA Care System performance objectiv and the President on VHA Care System performance budget request, and independently assess  review and make decisions regarding VHA’s and report to Congress on the adequacy of VHA budgets New governance and changes to assure continuity of leadership are critical to meeting the needs of VHA and veterans who depend on it. At the core of this foundational 359 recommendation, the Commission calls for establishing a VHA board of directors, referred to is independent of department leadership to as the VHA Care System governing board, which provide governance, strategic direction, decision making, and oversight of VHA Care System’s operations and transformation. Table 5 provid es details regarding the governing board. Table 5. Overview of VHA Ca re System Governing Board Detailed Outline for VHA Care System Governing Board speaker President, the majority leader of the Senate, The of the House, the minority leaders of Voting Members the Senate House would and each appoint two members. In addition, the SECVA would serve on the Board as a voting member. experience, would be selected to achieve collectively broad Qualifications expertise, and Members of as experience in senior management leadership, large, private, integrated health care such systems; systems; clinical expertise; extensive experience with federal government health care in) extensive with (though not current employment VHA; expertise in federal experience in expertise and leasing, and commercial property transactions; construction facility medical contracting; expertise in federal health care budgeting and finance; expertise in government equity and disparities; and veterans’ representation. Because of the importance health of congressional veterans’ at least one of each representation, leader’s two appointees would be receives who veteran a be of the appointees of the President would a least at veteran; one VHA care. 359 Michael A. Froomkin, “Reinventi ng the Government Corporation,” University of Illinois Law Review , (1995): 543, accessed June 15, 2016, http://osaka.l icles/reinvent.htm. Congre ss need not create a aw.miami.edu/~froomkin/art government corporation to meet VHA’s go vernance needs. The Commission notes that Congress has created entities it has called government corporations that are not predominantly commercial enterp rises, rely on appropriations, and do not have the potential to become self-sustaining. A principal intention behind assigning this status and title has been to provide insulation from centra l management oversight agencies and the appl ication of general management laws. When , Congress retains the power of the corporation relies in whole or in part on appropriations the purse, and the means of exercising it on matters large and small, and through formal and informal means. 98

113 C OMMISSION ECOMMENDATIONS R Detailed Outline for VHA Care System Governing Board Terms board members would serve staggered terms of up to 7 years, with the governing Governing members a chair and vice chair from among the membership (other than the board electing the who not be eligible to serve as would chair) for 3 ‐ year terms. SECVA, Personnel Compensation would be at a rate equal to the daily equivalent of annual pay prescribed for 360 Matters level. the executive IV level of Congress would provide a specific budget for the Funding operation of the governing board as a within account appropriations. separate VA’s its President Relationship Relationship to the CVCS: The governing board would provide the CVCS the to recommendation for a chief of VHA Care System (CVCS); the President would appoint that board a 5 ‐ year term; the governing would annually review the CVCS’s to executive allow to term, year ‐ 5 second official to a that to empowered reappoint be and performance continuity and to protect the CVCS from political transitions. The CVCS can be removed by for mutual of the President and the governing board. agreement f The chairperson Staf determine the size and compensation of the permanent staff of the would board, including an executive director responsible for governing board operations and a chief of The director of the proposed transformation office within VHA would report to the staff. through the CVCS. chairperson The board would have the power to do the following: Powers the CVCS and recommend the candidate to the President.  Select Review the performance of the CVCS on an annual basis.   the CVCS to a second 5 ‐ year term. Reappoint President. of the with the mutual agreement the  CVCS Remove and exercise  ‐ making authority regarding the transformation Direct process and decision operations related to transformation process. the  Establish priorities, milestones, and timelines for the transition process.  and approve major new initiatives; major operational and organizational plans Review strategic and business and facility management); regarding capital asset (including plans and goals and metrics for plans; performance and established priorities. operational  Oversee and manage facility and capital asset strategies and operations.  Review, approve, and/or amend VHA’s budget requests, and independently assess and President’s comment pertinent elements of the on budget, as deemed appropriate. Reporting The board would report annually to the President and Congress on VHA’s progress toward transformation. encies in the federal government requires not Navigating transformation of one of the largest ag sustained, long-range-focused governance. A only extraordinary leadership, but steady, governing board structured to provide continui ty of membership—as the Commission proposes through staggered terms among members—is vital. A second critical step toward assuring such continuity would be to address the tenure of th e CVCS and the process for selecting candidates 361 for that position. VHA, Congress, and the President would be better served by a VHA leader who holds a 5-year term of office, with the governing board empowered to reappoint that leader to a second 5-year term. 360 The rate of compensation provided for members of the Commission on Care. 361 Under Secretary of Health, 38 U.S.C. § 305. Current law provides that the Under Secretary is appointed by the President with the advice and consent of the Senate. When a vacancy in that position occurs or is anticipated, the Secretary is to convene a commission (the composition of which is set forth in the statute) which is to recommend at least three individuals to the Secretary, who is to forwar d those names, with any comments the Secretary considers appropriate, to the President. 99

114 C F INAL R EPORT OMMISSION ON C ARE It is important that that the CVCS report to the board and function as a chief executive officer of VHA. Although the Commission envisions that the President would appoint this official, it is critical that the governing board be empowere d to recommend to the President an individual for appointment when the office becomes vacant . This would replace the framework in current law that requires the establishment of a new co mmission convened solely to carry out the task 362 of recommending candidates to the President. 363 A governing board must be tailore d to the unique needs of VHA. It should include members of appropriate expertise and experience to provide strategic guidance and continuity of leadership and it should possess authority to exer cise the powers needed to realize and sustain 364 a VHA transformation. Although some might consider Congress to be VA or VHA’s board of directors and might question the appropriateness of establishing a VHA board of directors, this governance model does not diminish Congress’s role. Instead, a board that would report periodically to congressional committees would provide a level of close oversight and health care expertise that would complement, and in many ways enhance, Congress’s work. g about successful transformation. This A change in governance alone will not brin recommendation must be instituted in concert with many other Commission recommendations. For example, a board will require data, and data systems, to carry out its responsibilities, and establishing these and other appropriate systems, as addressed throughout this report, is key to empowering a board to drive and sustain transformation. Implementation Legislative Changes  Amend 38 U.S.C., Chapter 3 to establish a VHA Care System governing board.  Amend 38 U.S.C. § 305—which currently provides in subsection (a) for the President to appoint the USH by and with the advice and consent of the Senate, and subsection (c) for the establishment of a commission to provide recommendations for appointees for USH when a vacancy is expected or has occurred—as follows: - Amend subsection (a) to provide for the Pr esident to appoint the CVCS to a 5-year term of office. - Repeal subsection (c) of that section. Provide instead for the governing board to recommend a CVSC candidate. - - Authorize the governing board to reappoint the CVSC to a second 5-year term. VA Administrative Changes None required.  362 Under Secretary of Health, 38 U.S.C. § 305. 363 Booz Allen Hamilton, Veterans Health Administration (VHA) National Ce nter for Patient Safety (NCPS) Systems Review: September 22, 2015, 60. Final Report, 364 not be subject to the Federal Advisory Committee Act. The Board is not an advisory body, and as such would 100

115 C OMMISSION R ECOMMENDATIONS Administrative Changes Other Departments and Agency  None required. Leadership all levels of the organization to Recommendation #10: Require leaders at r, benchmarked strategy to transform VHA culture champion a focused, clea and sustain staff engagement. Problem The Commission Recommends That . . . High-performing organizations have healthy integrated cultural sustainable and an create VHA  cultures in which diverse staff members feel and programs all aligning by transformation activities respected and engaged at work. These concept. single, a around benchmarked workers, in turn, are better able to  VHA align leaders at all levels of the organization in demonstrate compassion and caring toward of support the cultural transformation strategy and customers in their delivery of high-quality accountable for change. them this hold services. Leaders at all levels of the  to office transformation a establish VHA drive progress organization are responsible for promoting a transformation and to this the chief of of the report positive organizational environment and VHA Care System and the new VHA Care System board ( governing also included in culture through how they treat staff and the Recommendation #12). systematic approach they take to decision making and management. VHA has among 365 the lowest scores in organizational health in government. For the past decade, VHA’s executives have not emphasized the importance of le adership attention to cultural health, and it ments, and performance accountability systems. has not been well integrated in training, assess Background Healthy organizations successfully align, execut e, and renew themselves through learning and 366 innovation. They are characterized by a high level of trust, accountability, and ownership among staff; high functioning, empowered teams; and an environment that provides psychological safety and open communication, fo cuses on the needs of customers, and instills 367 An inclusive workplace where diversity is valued, staff feel pride in performance. empowered and supported, are treated with fairness, and cooperation and open 368 communication helps engage employees and drive organizational performance. Engaged 365 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the nuary 26, 2016, Department of Veterans Affairs, Assessment L (Leadership), 56, accessed Ja t/documents/assessments/Asse ssment_L_Leadership.pdf. http://www.va.gov/opa/choiceac 366 “Organizational Health: The Ultimate Competitive Advantage,” Scott Keller an d Colin Price, McKinsey Quarterly, June 2011, accessed June 9, 2016, http://www.mckinsey. com/business-functi ons/organization/our- insights/organizational-health-the-u ltimate-competitive-advantage. 367 http://organizationalhealth.vssc .med.va.gov/Resource percent20Library/Forms/AllItems.aspx 368 “Diversity & Inclusion; Federal Workforce At-A-Glance, ” U.S. Office of Personnel Ma nagement, accessed May 13, ederal-workforce-at-a-glance/. 2016, https://www.opm.gov/policy-data-o versight/diversity-and-inclusion/f 101

116 C C F INAL R EPORT OMMISSION ON ARE attached to the organization and its mission employees who are dedicated to their work and 369 support a healthy organization. nizational culture or engaged st aff outperform those that do Companies that have a healthy orga t of organizational heal th metrics outperform not. Companies that score in the top 25 percen 370 Similarly, high comparable companies in the bottom 25 percent by more than two-fold. employee engagement is correlated with better staff and customer experiences that include , higher staff retention, better safety and quality, higher productivity higher patient satisfaction 371 Companies with engaged employees outperform those without by and lower absenteeism. 372 more than 200 percent. Leaders and supervisors play a key ro le in establishing and sustaining employee engagement and in establishing a positive environment and culture that supports a 373 healthy organization. Analysis 374 VHA staff and leaders are highly dedicated to the mission of VA and to serving veterans. This dedication is arguably VHA’s greatest strength, and it can be leveraged to create and sustain 375 There are substantial impediments to moving VHA forward, however, as positive change. Independent Assessment Report . There is a pervasive lack of trust throughout the noted in the 376 organization. Staff perceives VHA to be bureaucratic and political and to lack a systems 377 orientation. Employees want to work for an organization that is accountable and efficient, 378 The culture but instead they operate in a bureaucr atic, siloed, and political organization. creates risk aversion in staff, and when cultur al factors are measured in VHA, none of the 379 on of a healthy organization. metrics align with the definiti Staff find the work environment at VA challenging, with no connection to leader ship, and feel they receive little positive 369 U.S. Office of Personnel Management, Strategic Plan FY2014-2018: Recruit, Retain, and Honor , 22, accessed January 25, t-performance/strategic-plans/2014- 2016, https://www.opm.gov/about-us/budge 2018-strategic-plan.pdf. Office of Management and Budget, Memorandum for Heads of Executiv thening Employee Engagement and e Departments and Agencies: Streng , M-15-04, December 23, 2014, accessed May 16, 2016, Organizational Performance /memoranda/2015/m-15-04.pdf. https://www.whitehouse .gov/sites/default/files/omb 370 mpetitive Advantage,” Scott Keller an d Colin Price, McKinsey Quarterly, “Organizational Health: The Ultimate Co com/business-functi ons/organization/our- http://www.mckinsey. June 2011, accessed June 9, 2016, -ultimate-competitive-advantage. insights/organizational-health-the 371 irs, MyVA: Putting Veterans First, U.S. Department of Veterans Affa Employee Engagement Handbook: A Guide for ure and Drive Engagement, September 2015, 4. Melissa Bottrell, Ethics Quality He lps Build Healthy Frontline Leaders to Meas , VHA Organizational Health, Volume 19, Su mmer 2013, 4-5, access ed January 25, 2016, Organizations http://www.ethics.va.gov/docs /integratedethics/art_bottr ell_orghealth_v19_2013.pdf. 372 U.S. Department of Veterans Affa irs, MyVA: Putting Veterans First, Employee Engagement Handbook: A Guide for ure and Drive Engagement, , Improving VHA’s Culture: A Frontline Leaders to Meas September 2015, 4. Dee Ramsel Presentation Before the National Leadersh ip Council, Veterans Health Administra tion, December 2015, 7-9. U.S. Office of Personnel Management, ey: Employees Influencing Change, 6, accessed May 16, 2016, 2015 Federal Employee Viewpoint Surv https://www.fedview.opm.g ov/2015FILES/2015_FEVS_Gwi de_Final_Report.PDF. 373 Dee Ramsel, “Improving VHA’s Culture. A Presentation Befo re the National Leadership Council, Veterans Health Administration,” December 2015, 7-9. 374 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership), 43, accessed Ja nuary 26, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_L_Leadership.pdf. 375 Ibid., 44. 376 Ibid., 47. 377 Ibid., 46. 378 Ibid., 46. 379 Ibid., 49-51. 102

117 C OMMISSION ECOMMENDATIONS R 380 reinforcement or clear feedback on performance. As demonstrated in the Federal Employee t believe top leaders lead (only 47 percent Viewpoint Survey for 2015, VHA staff does no 381 positive ) and only 65 percent have a positive view of their immediate supervisor compared to 382 70 percent in other large federal agencies. Through the review of available documents and briefings from key staff, the Commission found tivities intended to support a positive environment and VA and VHA have a number of ac culture in VHA (see Table 6), but the efforts are not systematic, integrated, or broadly 383 deployed. The efforts are under-resourced to achiev e success. Specifically, the effort lacks quirements on the VHA mandatory positions at the facilities to lead th ese efforts and has no re 384 Central Office (VHACO) program offices to participate in the efforts. At the same time, the efforts are duplicative in that multiple offices communicate similar, but distinct messages to field staff and leaders. VHA appears to lack systematic mechanisms to ensure leaders at all levels of the organization have the knowledge, sk ills, and ability to create an effective culture; metrics are not comprehensive or aligned with a single-change model; and leaders in VHACO and the field are not consistently held accounta ble for their actions in support of a positive 385 organizational culture. 386 Table 6. Cultural Transformat ion Efforts in VA and VHA Responsible Office Program/Initiative Servant VHA National Center for Organizational Development Leadership Leaders MyVA Leaders Developing Culture VHA National Center for Just Patient Safety Civility, Respect, and in the Engagement National Development Organizational VHA Center for (CREW) Workplace MyVA Pilot Organizational Transformation Employee Engagement Playbooks MyVA Cultural and VHA Office of Patient Centered Care VHA Voices Transformation 380 Ibid., 53 and 60. 381 U.S. Office of Personnel Management, 2015 Federal Employee Viewpoint Survey : Employees Infl uencing Change, 47, accessed . iew.opm.gov/2015FILES/2015_FEVS _Gwide_Final_Report.PDF May 16, 2016, https://www.fedv 382 Ibid . 383 re the National Leadership Council, Veterans Health Dee Ramsel, “Improving VHA’s Culture. A Presentation Befo Administration,” December 2015, 29-31. , Veterans Health Administration, Dee Ramsel, Virginia Ashby Sharpe conference call with staff of the Commission on Care, November 9, 2015. 384 See “Ethical Leadership, Fostering an Ethical Environment for Ethics in Health Care, and Culture,” National Center terans Affairs, accessed June 22, 2016, http:// www.ethics.va.gov/integrat U.S. Department of Ve edethics/elc.asp. “Stop the Line for Patient Safety Initiati ve,” U.S. Department of Veterans Affairs, access ed June 22, 2016, http://www.qualityandsafety.va.gov/Stop zational Development,” theLine/StoptheLine.asp. “VHA Center for Organi U.S. Department of Veterans Affairs, accessed fr om VA Intranet, May 16, 2016, l_Health.asp. U.S. Department of Veterans Affairs, MyVA: Putting http://vaww.va.gov/NCOD/Organizationa Veterans First, A Guide for Frontline Leaders to Measure and Drive Engagement, September Employee Engagement Handbook: 2015. 385 Dee Ramsel, “Improving VHA’s Culture. A Presentation Befo re the National Leadership Council, Veterans Health Administration,” December 2015, 13-14. Veterans Health Administration, Draft Fiscal Year 2016 Performance Plan, Network Director and Medica l Center Director , November 20, 2015. 386 Dee Ramsel, “Improving VHA’s Culture. A Presentation Befo re the National Leadership Council, Veterans Health Administration,” December 2015, 29-31. 103

118 C F INAL R EPORT OMMISSION ON C ARE VHA must rebuild a high-performing, health y culture by cultivating greater employee 387 collaboration, ownership, and accoun tability to accomplish its mission. This cultural transformation needs to occur at all levels of th e organization (VA, VHACO, veterans integrated service network [VISN], VA medical center, and co mmunity-based outpatient clinic). To achieve vironment and culture, and sustain staff transformation in VHA, create a healthy en engagement, the solution must start with leader s. Leaders must understand and believe in the powerful effect they have on the climate and cu lture in their organization. Change occurs one employee at a time. Leaders at all levels must commit to this change process. They must be inspired by top executives and embrace the va lues and mission of VHA and then, in turn, inspire their teams, engaging with individual employees to make change. Leaders must be given the roadmap and tools to make such c hange and then be supported with training, coaching, and feedback to achieve success. They must also be held accountable for their personal behavior and for the actions they take to positively influence the environment and culture of their unit or facility. Leaders should not be on their own in this transformation. Fellow leaders, outside experts, national prog ram offices, and VA and VHA top executives rt, feedback, coaching, and, when needed, must provide them with incentives, suppo admonishment to support this cultural transformation. To align leaders at all levels with expectations for the cultural transformation, all leaders must understand the role they play in the process. VHA must create standards for the behavior and actions leaders adopt to accomplish the transfo rmation and widely publicize the standards among leaders and staff to establish uniform ex pectations across the organization and a single vision of cultural transformation. The CVCS and other senior leaders must model and reinforce these behaviors to further embed expectatio ns. These behaviors and actions should be integrated into leadership assessment tools su ch as a 360 evaluation, performance management frameworks, and coaching guides to ensure ex pected behaviors and actions are reinforced across the leadership development and advancement system. The strategy must include the development of tools, training, guidelines, and operating procedures that create a living curriculum to support leaders in developing and deploying these new skills and behaviors. Finally, to ensure leaders at all levels implem ent the behaviors and actions, the strategy must establish both explicit rewards and sanction s. The rewards and recognition (nonmonetary) should liberally acknowledge and publicize leaders and staff who embody the very best standards of behaviors and actions that support a positive organizational culture. At the same y understand what behavior and actions are not time, leaders and staff at all levels must clearl acceptable and be held accountable through disc iplinary action if they cross these boundaries. Expectations and repercussions should be clearly articulated. VA and VHA have a number of competing mo dels of organizational health and staff engagement. The models are not integrated with one another or with an overall leadership competency model. Some models are robust, co upling abundant resources and training, while others are not. To create a clear focus for engagement and organizational health and guide 387 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 55 accessed January 26, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 104

119 C R OMMISSION ECOMMENDATIONS lected for use in VHA. To do so, VHA must transformation effectively, one model must be se this decision. The team should include all of establish a cross functional executive team to make the stakeholder offices involved in current efforts, but none of them should lead the effort, to a single model is selected, the executive team avoid parochial interests driving decisions. Once must then outline a clear strategy, involving and engaging the offices in VHA with relevant expertise and resources to support the executio n, and put forward a single strategic plan. Consequently, each of those offices must also be required to stand down its own efforts that are not part of this new model going forward and align its work and budget behind a single focused model and strategy. Tools, training, and communication to support broad deployment must be part of the strategy, and the CVCS and the executive team must present a compelling, transparent rationale for what the model is, why it was selected, and how it is to be deployed. n must understand their roles in cultural All leaders and staff members in the organizatio transformation and what is expected of them. The strategy must establish and articulate a clea r set of behaviors and actions expected of staff to ensure their alignment around the transformatio n. The standards should be incorporated into the hiring process to ensure that VHA is hiring into the new culture and avoids a poor fit from the start. These behavioral expectations must be articulated clearly in the on-boarding process and reinforced on an ongoing basis in perfor mance evaluations, revi ews, and individual development plans. Leaders at all levels of the organization must also reinforce these behavioral expectations with staff and be provided with tools, messages, and communication support to reward the positive examples of the desired accomplish this. Leaders must also recognize and behaviors and sanction the worst examples, up to and including discipline and removal. ltural transformation and staff engagement go The change strategy should also recognize that cu beyond individual leader and staff behaviors. Systems and processes at both the local and national level can impede the realization of the po ure desired. As such, sitive organizational cult the transformation strategy must also anticipate changing systems and processes as an explicit ls must establish mechanisms to elicit staff component of transformation. Leaders at all leve ement tools in place to addr ess them, such as LEAN Six concerns and have quality improv Sigma. Line staff must be engaged as part of th e solution to these system issues. Leaders should be transparent about these issues and pu blicly track and report on progress. To ensure the effective execution of this strategy, specific responsibilities must be assigned to program offices. The program offices must al so support the VISN and facilities in their transformation effort by developing the standards and guidance for them to use and making coordination, coaching, and sharing of best program office expertise available to support practices across the institution. The program offi ces must be held accountable for supporting the application of these same standards and process within VHACO. Standards for facility implementation must incl ude a funded, full-time equivalent employee to 388 support each major facility director and be the point person to coordinate efforts with VHACO and other facilities. Facilities may take th e opportunity to consolidate related functions that currently exist in the facility. Each fa cility must have a local mechanism, such as an organizational health council, to integrate and drive transformation locally. But this does not 388 a facility director. This equates to one person at each of the approximately 141 VHA health ca re systems led by 105

120 C C F INAL R EPORT OMMISSION ON ARE mmittee or oversight group to accomplish the mean the facility should create yet another co transformation. Instead, facilities must look to existing leadership stru ctures and activities, consolidating similar efforts to create an efficient process. Finally, the executive team must oversee the deve lopment of a consolidated and meaningful set of metrics, using community standards where av ailable, to track cultural transformation, organizational health and staff engagement. The metrics should not only measure the desired outcomes but also provide insights to leaders on how to fix problems by providing sufficient detail and specificity to offer this insight. Once deployed, the metrics should be used by the executive team and responsible program offices to identify under-performing facilities and to provide additional expertise, re sources, and support to help those facilities improve. If, after much support, the continuing behavior and acti ons of the leaders at the under-performing facility are identified as the cause of the long-t erm culture problem, these individuals must be removed from leadership positions in VHA. Implementation Legislative Changes None required.  VA Administrative Changes ty over the next 36 months. To assist VHA in The following administrative changes are a priori the Commission has implementing these actions and to promote acco untability and oversight, provided a detailed timeline and assigned re sponsibility for action in Appendix B.  Develop and implement a strategy for cultural transformation. ive team reporting directly to the CVCS  Establish a cross-functional senior execut with long-term responsibility for creating , executing, and tracking the cultural transformation.  Align frontline staff in support of the cultural transformation strategy. Require standards and a strategy for execut  ion of the cultural transformation from every program office and facility and these efforts must be fully funded.  Develop consolidated, meaningful metrics for organizational health and staff engagements with input from experts and field users. Other Department and Agency Administrative Changes None required.  106

121 C R OMMISSION ECOMMENDATIONS ccession based on for leadership su Recommendation #11: Rebuild a system a benchmarked health care competency mo del that is consistently applied to recruitment, development, and advancement within the leadership pipeline. Problem The Commission Recommends That . . . VHA, like any large organization, requires VA as  an Office of Management and Budget establish, excellent leaders to succeed. Succession management priority for of goal the VHA, planning and robust structured programs to implementing management leadership effective an recruit, retain, develop, and advance high agency. system in the potential staff are essential to maintaining a prioritize  leadership system for executives VHA the pipeline of new leaders. In health care, funding, their of investment and planning, strategic leadership programs must prepare time own attention. and candidates with the specialized knowledge  VHA adopt and a implement comprehensive system and skills required of health care executives, for leadership development and management that diversity of priority a includes strategic inclusion. and while also helping to mature their leadership to  outside attract opportunities more create Congress traits. VHA does not use a single leadership experts and leaders and new through VHA in serve to competency model, and what it does use is and expanded rotations temporary for direct authority not specific to health care or benchmarked to of health care hiring management graduates, training the private sector. VHA also does not use military senior facility leaders, treatment and private competency models as a tool to establish and and for ‐ for ‐ not ‐ profit profit health care leaders standards for hiring, assessment, and experts. technical promotion. As a result, executive leaders and promising staff members do not have the tools they need to guide career transitions and ensure VHA has the leaders it needs for the future. Background Our Corps does two things for America: We make Marines and we win our nation’s the latter depends upon how well we do the battles. Our ability to successfully accomplish 389 former. nal success. Thus, attracting, growing, and Effective leaders are required for organizatio 390 The most urgent human advancing leaders is a key business imperative across all sectors. ing to one survey, is the development of capital management need worldwide, accord 391 leadership talent. This need is driven by a changing workforce that is motivated more by passion than by monetary incentives, a rapi d advance in knowledge that quickly creates obsolescence, and technology drivers that chang e business practices over months instead of 392 Investing in new supervisors and emerging leaders is critically important because years. 389 U.S. Marine Corps, Sustaining the Transformation , Foreword, accessed June 9, 2016, blications/MCRP percent206-11D pe rcent20Sustaining percent20the http://www.marines.mil/Portals/59/Pu percent20Transformation.pdf. 390 Jim Collins, Good to Great: Why Some Companies Make the Leap . . . And Others Don’t (New York, NY: HarperCollins Publishers, Inc., 2001), 17-40. Fred Kiel, Return on Character: The Real Reas on Leaders and Their Companies Win (Boston, MA: Harvard Business Review Press, 2015). st 391 Deloitte Consulting LLP and Bersin by Deloitte, Global Human Capital Tren ds 2014: Engaging the 21 Century Workforce , CapitalTrend 25, accessed June 10, 2016, http: //dupress.com/wp-content/ uploads/2014/04/GlobalHuman s_2014.pdf. 392 Ibid., 3. 107

122 C ARE INAL R EPORT OMMISSION ON C F employees report that when they quit a jo b they leave their supervisors and not their 393 organization. In an organization like VHA, with more than 300,000 employees but only a bit 394 more than 200 executives, VHA’s 28,000 supervis ors are responsible for leading the staff. Going back to at least 1998, the federal civi lian sector has had difficulty identifying and 395 Staff members who can produce results and promoting individuals with leadership skills. 396 meet organizational objectives are promoted into supervisory and leadership positions. Yet, the skills needed to be a successful leader are different than those needed to be a successful technical expert. Today, soft skills such as empa thy, effective listening, and team coaching are 397 The most effective leaders are those who consistently display integrity, valued in leaders. 398 high moral character, and the ability to inspire others. An effective leadership system develops leaders at all levels, from frontline supervisor to executives, and does so in all 399 dimensions of leadership: “knowing, doing, and being.” Analysis In a review of VHA’s approach to leadership development, the Independent Assessment Report noted the current system was not sufficient to meet VHA’s need for high-quality, prepared 400 leaders. VHA lacks a comprehensive approach to le adership development that would include formal structured programs such as networking, reflection, goal setting, learning, mentoring, experiential learning, and a clear career ladder. As a result, leaders are unable to fully prepare 393 , accessed June 10, 2016, “People Leave Managers, No t Companies,” Victor Lipman http://www.forbes.com/sites#/ 2015/08/04/people-leave-managers-not- sites/victorlipman/ companies/#78b15df216f3. 394 Department of Veterans Affairs, Veterans Health Administration, VHA Workforce Planning Report 2015 , 21-23, accessed June 10, 2016, http://vaww.succession.va.gov/Wor kforce_Planning/WorkforcePlanning Library/2015%20VHA%20Workforce%20Re port.pdf. 395 Federal Supervisors and Strategic U.S. Merit Systems Protection Board, Offi ce of Policy and Evaluation Perspectives, Human Resources Management , accessed June 10, 2016, http://www.mspb.gov/netsearch/vi ewdocs.aspx? pplication=ACROBAT. docnumber=280538&version=280868&a 396 Ibid. Sherry Heffner et al., sform Your Organization, accessed June 10, 2016, Develop Your Leaders, Tran http://www.harvardbusiness.org/sites 16843_CL_Whitepaper_Transform_Or ganization_0.pdf?trk=profil /default/files/ e_certification_title. 397 Sherry Heffner et al., Develop Your Leaders, Tran sform Your Organization, accessed June 10, 2016, http://www.harvardbusiness.org/sites 16843_CL_Whitepaper_Transform_Or ganization_0.pdf?trk=profil /default/files/ e_certification_title. “Creating an d Retaining Great Leaders,” Dominiqu e Jones, accessed June 10, 2016, http://www.hrreview.co.uk/analysis/an alysis-hr-news/dominique-jones-creating -and-retaining-great-leaders/60419. “The One Leadership Skill That Impacts Overall Su ccess,” Lydia Dishman, accessed June 10, 2016, http://www.fastcompany.com/3056176/hit-the- ground-running/the-one-leadership-sk ill-that-impacts-overall-success. 398 Return on Character: The Real Reas Fred Kiel, (Boston, MA: Harvard Business Review on Leaders and Their Companies Win Press, 2015). “The One Leadership Sk ill That Impacts Overall Success,” Ly dia Dishman, accessed June 10, 2016, ground-running/the-one-leadership- http://www.fastcompany.com/3056176/hit-the- skill-that-impacts-overall-success. Develop Your Leaders, Tran sform Your Organization, accessed June 10, 2016, Sherry Heffner et al., /default/files/ 16843_CL_Whitepaper_Transform_Or ganization_0.pdf?trk=profil http://www.harvardbusiness.org/sites e_certification_title. 399 Sherry Heffner et al., Develop Your Leaders, Tran sform Your Organization, accessed June 10, 2016, http://www.harvardbusiness.org/sites 16843_CL_Whitepaper_Transform_Or ganization_0.pdf?trk=profil /default/files/ e_certification_title. U.S. Marine Corps, Sustaining the Transformation , accessed June 9, 2016, http://www.marines.mil/Portals/59/Pu blications/MCRP percent206-11D pe rcent20Sustaining percent20the percent20Transformation.pdf. 400 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership), 37, accessed Ja nuary 26, 2016, hoiceact/documents/assessments/A rship.pdf. ssessment_L_Leade http://www.va.gov/opa/c 108

123 C R OMMISSION ECOMMENDATIONS 401 for future roles. ents of a development program, the Although VHA does have some compon activities are not connected to a career path and not well coordinated. Comprehensive development efforts are impeded by the use of multiple competing competency models in VA that make it impossible to align assessment and development with a cohesive standard. progression largely on their own and may be Emerging leaders are left to navigate career stymied because development opportunities are cancelled due to budget restrictions. Even activities, gaps remain in their experience when promising young leaders complete the current 402 and training because the traini ng programs are not coordinated. As a result, VHA does not 403 have a robust pipeline of young leaders ready to take on higher-level responsibilities. Included in the Independent Assessment Report is a recommendation that VA stabilize, grow, and empower leaders. This recommendation includes suggestions to fill current vacancies with the roles, ensure leaders are prepared to high-quality leaders, improve the attractiveness of assume their roles, and create a comprehensive strategy that connects top performers to leadership opportunities and development plans. There is little concrete information in the a ssessment to suggest how VA and VHA should accomplish these objectives. The commission exam ined VA’s and VHA’s current work to assess whether they have created plans to oper ationalize the leadership development recommendations articulated in the Independent Assessment Report . Neither VA nor VHA has rationalized the multip le competency models within the department. A competency model is the core driver inform ing recruitment, development, assessment, and 404 advancement in any comprehensive approach to leadership development and management. 405 Having a cogent competency model is a prerequisite to a coherent strategy. Leading a health care organization requires specialized knowledge and skills not required of leaders in other 406 fields. VHA must include health care specific Thus, any competency model applied in components. Health care execut ive competencies embrace such topics as an understanding of ng professionals (e.g., physicians, nurses), the ethics in health care, management of self-governi on and operational management, and leading technical knowledge of health care regulati 407 change, in addition to other leadership skills and knowledge. The current models used in VHA do not referenc e external benchmarks, and they are not health care specific. VHA plans to continue to use the High Performance Development Model (HPDM) 408 HPDM was developed by VHA and is not benchmarked to private- as its competency model. sector competency models for health care ex ecutives. VHA plans to use the model to drive 401 Ibid. 402 Ibid., 38. 403 Ibid., 37. 404 The American College of Healthcare Executives, ACHE Healthcare Ex , ecutive: 2016 Competencies Assessment Tool www.ache.org/pdf/nonsec ure/careers/co accessed May 16, 2016, https:// mpetencies_booklet.pdf. 405 Ibid. 406 Ibid. 407 Ibid. “Joint Medical Executive Skills,” Joint Medical Execut ive Skills Program, U.S. Depart ment of Defense, accessed May 16, 2016, http://www.au.af.mil/au/a d_exec_skills.htm. “NCHL Health Leadership wc/awcgate/leadership/me Competency Model,” National Center for Heal thcare Leadership, ac cessed May 16, 2016, http://www.nchl.org/sta tic.asp?path=2852,3238. 408 “NCHL Health Leadership Competency Model,” National Center fo r Healthcare Leadership , accessed May 16, 2016, tic.asp?path=2852,3238. http://www.nchl.org/sta 109

124 C ARE INAL R EPORT OMMISSION ON C F 409 The plan mentions management, and training content. position requirements, performance 410 coordination with VA Learning Un iversity but provides no detail. The plan also does not provide specific information about how the use of HPDM will link to formal recruitment, 411 performance assessment, and advancement of leaders. VHA is working to understand the current car eer progression of candidates who move into field-based executive positions. VHA field leaders are cultivated from within VHA with about 98 percent advancing from lower-level field position s such as associate director, service chief, or 412 As a result, field senior executives of ten lack outside experience and first-hand chief of staff. 413 Most companies look for a mix of internal knowledge of alternative management methods. 414 For and external hires, and the circumstances of the organization often drive the mix. instance, Henry Ford Health System, a successf ul growing company with a robust internal leadership development program has set a target of 70 percent internal promotions and 415 30 percent external hires. The VHA pool of internal candidates is also defi cient in racial and ethnic diversity with striking under-representation of women of color in all of the positions that constitute the pipeline for 416 tions (see Figures 6 and 7). medical center director posi VHA leadership development advance under-represented minorities with a programs have failed to effectively recruit and striking over-representation of White men in the leadership class that fe eds the senior executive 417 service (see Table 7). Minority women shoulder the bigge st burden of formal mentoring 418 VHA also has the lowest representation of veterans among its staff within the organization. nistration (52 percent) and National Cemetery (31 percent) compared to Veterans Benefit Admi Administration (74 percent). The number of ve terans among doctors and dentists in VHA is 419 only about 14 percent of the employees. Among leaders, 22 percent of senior executives are 420 veterans and a similar number (23.8 perc ent) populate the leadership pipeline. 409 Ibid. 410 Ibid. 411 Ibid. 412 Federal Equal Opportunity Re Under Secretary for Health, Veterans Health Administration, cruitment Program (FEORP) Report FY2015 Accomplishment Certification, Attachment A, November 23, 2015. Report and FEORP FY2016 Plan 413 Ibid. 414 : Look Outside or Seek Within?” HR Magazine, January/February 2015. Eric Krell, “Staffing Management 415 “NCHL Health Leadership Competency Model,” National Center fo r Healthcare Leadership , accessed May 16, 2016, http://www.nchl.org/sta tic.asp?path=2852,3238. 416 Department of Veterans Affairs, Administration, VHA Workforce Planning Report 2015 , 94, accessed Veterans Health June 10, 2016, http://vaww.succession.va.gov/Wor kforce_Planning/WorkforcePlanning Library/2015%20VHA%20Workforce%20Re port.pdf. 417 Under Secretary for Health, Veterans Health Administration, Federal Equal Opportunity Re cruitment Program (FEORP) Report FY2015 Accomplishment Certification, Attachment A, November 23, 2015. Report and FEORP FY2016 Plan 418 Ibid. 419 Health Care Talent Management Offi ce from PAID and NOA, September 17, 2015: Path to Medical Center Director, Healthcare Leadership Talent Institute. 420 VHA Health Care Talent Management Office, provided to Commission on Care for employees in VHA as of September 30, 2015 by re quest, March 8, 2016. 110

125 C OMMISSION ECOMMENDATIONS R Figure 6. Diversity of Senior-Level Hires in VHA = African American AA = Native NH/PI Islander Hawaiian/Pacific AI/AN = American Indian/Alaska Native Note: In FY 2015, VHA failed to select many candidates from diverse racial and ethnic backgrounds for senior executive positions. These data were drawn from employment the VHA annual equal opportunity (EEO) report. 111

126 C OMMISSION ON ARE F INAL R EPORT C Figure 7. Minority Women are Under Represented in Higher-Level Positions in VHA = African American AA = NH/PI Native Hawaiian/Pacific Islander = American Indian/Alaska Native AI/AN Note: Women and particularly minority women are ‐ represented in comparison to their participation under at in the U.S. workforce (relevant civilian labor force [RCLF]) and their participation in the VHA workforce in positions. level ‐ high represented ‐ under minority men are also higher organization. the Some in levels report. These data were derived from the VHA annual EEO 112

127 C OMMISSION ECOMMENDATIONS R Table 7. White Males are Over Represented in VHA SES Development Program, HCLDP VISN/CO HCLDP GHATP TCF LEAD Facility LEAD VHA 2015 2014 2015 2015 2015 Workforce (N) (N) (N) (N) (N) 41% 35% 22% 30% 19% Male White 23% (69) (160) (151) (78) (14) 39% 16% 41% 28% 41% Female 36% White (13) (342) (144) (35) (127) 15% 9% 8% 8% 4% American Male African 9% (24) (4) (14) (33) (66) 6% 16% 19% 22% 15% Female American African 15% (50) (42) (180) (23) (7) 4% 4% 4% 1% 3% Male Hispanic/Latino 3% (2) (5) (11) (10) (23) 3% 3% 2% 3% 1% Hispanic/Latina Female 4% (1) (10) (4) (29) (7) >1% 2% 4% 2% 1% Asian Male 3% (7) (1) (2) (9) (9) 9% 3% 2% 4% 2% Female Asian 5% (13) (4) (16) (12) (5) Native Hawaiian/Pacific 0% 0% 0% >1% 0% >1% (3) Male (0) Islander (0) (0) (0) Native 0% 0% 0% 0% 0% Hawaiian/Pacific >1% (0) (0) (0) (0) Female (0) Islander Indian/Alaska 1% >1% 2% American 0% >1% 1% (4) (1) Male (2) Native (3) (0) 1% 1% American 0% 1% 0% Indian/Alaska 1% (7) (0) Female (4) (0) Native (3) Note: VHA offers career development opportunities from entry ‐ level programs (TCF and GHATP) to an SES preparatory employees curriculum Overall, White men make up about 23% of VHA (HCLDP). but are over ‐ represented in the HCLDP same program. African American and Hispanic men and women are under ‐ represented in the program at 41%. TCF= Career Field; GHATP=Graduate Healthcare Technical Administration Training Program; LEAD=Leadership, Effectiveness, Accountability, and Development; HCLDP=Health Care Leadership Development Program. career progression mapping is occurring for No evidence was presented to indicate that 421 positions within VHA central office, where high-quality leaders are also required. 421 Department of Veterans Affairs, Veterans Health Administration, VHA Workforce Planning Report 2015 , 94, accessed June 10, 2016, http://vaww.succession.va.gov/Wor kforce_Planning/WorkforcePlanning Library/2015%20VHA%20Workforce%20Re port.pdf. 113

128 C F INAL R EPORT OMMISSION ON C ARE VHA has much work to do to produce an effective leadership management system. Recruitment, retention, development and ad vancement are key processes that require immediate and sustained attention from VHA leaders. Without substantial changes, high- potential staff will continue to struggle to unders tand their career trajectory. Without a driving competency model and coordinated training to guide advancement, hiring decisions will against which to measure applicants and new continue to be made without uniform standards executive hires will continue to struggle to un derstand VHA and their role in leading it. Without the committed engagement and support of the chief of VHA Care System (CVCS) and the other top VHA executives for the leader ship management system and their direct communications about and modeling of the lead ership competencies, VHA will continue to flounder. As a result, veterans will be denied th e high-performing health system they deserve. Executive Commitment The long-term success of any enterprise rests on having excellent leaders in key positions and sustaining them over time. To accomplish this goal, leadership management, development, and recruitment must be a core responsibility and a pr iority for VHA senior executives. To start, VA must include the goal of achieving an effectiv e leadership management system in VHA as a component of the department’s management agenda in the annual budget. The goal is a robust, needs to establish a credible operational plan high-quality, diverse leadership team in VHA. VA goal. Executive leaders are then held and accountability mechanisms for meeting this accountable for attaining the leadership managemen t goals, including personally investing time in meeting diversity targets, recruitment pl ans, and succession planning objectives. These targets are to be reviewed in the individual perfor mance of top leaders as well as in the Office of Management and Budget’s ongoing review of the department’s management objectives. Executive leaders need to also set and communicate clear expectations for the behavior of leaders and staff and to invest their own time in mentoring, coaching, and developing subordinate leaders and promising staff, includ ing under-represented populations. They must be visible and role-model leadership compet encies in meetings, training, and new-hire orientations. They must take an interest in deve loping leaders and help create opportunities for encies. The CVCS and senior executives must them to gain leadership experience and compet ge crises or to oversee a process or to manage up. keep in mind that their sole role is not to mana le. Their time and attention must reflect that Rather, their primary role is to lead their peop priority. Leadership Model To establish clear leadership standards to guid e hiring, development, and the advancement of alth care competency model. Currently, VHA leaders, VHA needs to adopt one benchmarked he is subject to the Office of Personnel Managem ent executive core qualifications, HPDM, and standards for servant leadership. Although all of the models have value, none provide a clear trajectory for high-potential staff to follow, and they do not provide opportunities for VHA to intersect with leaders in the private sector. VHA must stop using these varied competency models and instead adopt a single model that is benchmarked to private-sector standards. The out which model VHA should choose. Rather Commission is not making a recommendation ab VHA should apply the criteria below to select a model around which to base its leadership development program: 114

129 C OMMISSION ECOMMENDATIONS R hics and values, demonstrating character  The standard must embrace leading through et and concern for others, and creating a strong organizational culture. The standard must be health care based and describe the knowledge, skills, ability, and  leadership bearing and behaviors that health care leaders must master to be effective. The standard must be a robust competency model including aligned training and tools  to permit quick implementation.  The model must describe different career tr acks and the mastery requirements for key points in each career track. Key career tracks such as VISN director, facility director, and VHA Central Office (VHACO) program executive should fit into the competency model. A career path must specify the competencies that require mastery before moving to a  higher position. VHA may need to enhance the model with competencies in care and services to  Veterans and knowledge of military occupational health. Training and Assessment VHA needs to develop assessment tools based on the competency model, including 360, 180, s. Leaders and developing leaders should be self-assessment, and supervisory review processe required to use at least one of the assessments each year and to apply the results to identifying their training and development needs. Findings from the assessments should be rolled into an individual development plan (IDP) for each lead er or developing leader and enrollment in a leadership course should require a document ed need from one of these assessments. Figure 8. At Each Leadership Level, Mast ery of Leadership Competencies Increases 115

130 C C F INAL R EPORT OMMISSION ON ARE model career track. All current leadership Training must be mapped against the competency Gaps should be identified and filled with training should be mapped against the model. lly developed training. This training should commercially available, or where needed, interna include leadership competencies for the care of veterans, including an understanding of military occupational health, comb at injuries and exposure, comb at readjustments, and military sexual trauma. (See Appendix H for descriptions of such training material.) VHA should look for opportunities to partner with Department of Defense and the private sector to provide joint training and development opportunities to fill so me of the identified gaps. VHA must develop one or more face-to-face training series that a llow high-potential candidates to complete all the competencies required to move to the next ca reer stage. As VHA strengthens its partnership with community providers and health systems, ex ecutive and high-potenti al training resources from VHA should be made available to communi ty health care leaders and VHA should join training offered by these private-sector partners. Based on the benchmarked competency model, VHA should collaborate with Academic Affiliates to establish two new programs. The firs t is to create opportunities for VHA physicians to gain masters-level training in health care management to prepare them to lead a medical facility. Second, VHA should work to create ro tations in VHA for external physicians who are programs. Like academic affiliate residency completing graduate health care management training programs, VHA should collaborate with academic medicine to establish, fund, and run these programs with the goal that all particip ants rotate in management positions in VHA or more months during their training. Graduates VHA-partnered private-sector systems for six or of such programs would be candidates for recr uitment into the VHA leadership pipeline and VHA for any direct funding provided. would encumber a pay-back commitment to All training should include formal assessment to assure that learners have mastered the material and this mastery should be noted in their IDPs and training record. As part of the leadership development model, experiential learning opportunities and formal coaching are critical to exec utive learning. Individual and group coaching standards and programs must be established for all developing and new leaders. A program for senior leaders to pair them with private-sector health ca re leaders must also be supported. VHA must establish rotation opportunities for developing lead ers to rotate for substantial periods (e.g., 3 to 18 months) in not-for-profit hospital systems. Th is program could be structured as a certificate program that the employee and VHA jointly fu nd and include a payback commitment on the part of the trainee. Similar rotations from the pr ivate sector into VHA should be developed with health care system partners to help develop private-sector compet encies in care for veterans and inject private-sector approaches into VHA. Apply the Leadership Model VHA is required to apply the competency model in all hiring decisions for executive career field positions. Thus all functional statements must be based on the model, all interview protocols must incorporate the competencies, and all candid ates who are not internally certified to the standard of the job must undergo an assessment by a board to ensure they meet the position requirements. Conversely, internal candidates mu st be required to demonstrate mastery of the a position. VHA must adopt the strategies of competencies before qualifying to apply for eeded experts outside of government with the executive recruiters to identify and recruit n 116

131 C R OMMISSION ECOMMENDATIONS look to the pipelines the Commission has competencies VHA seeks. Recruiters can tment facility commanders and other senior recommended building to bring military trea leaders and private sector experts into VHA as a network for identifying additional recruits. arly help ensure diverse candidates are identified for open Executive recruiters can particul positions. VHA will require competency assessments and ID Ps for all existing executives, potential executives, and new hires. Current leaders and new hires who have an identified gap in any competency must have it included in their IDP and be required to fill these deficiencies by a specific deadline or face demotion or dismissal. Completion of IDP development opportunities is required for advancement in grade or promot ion to higher position within the leadership pipeline. VHA will aggressively manage its leadership cand idate pool by identifying and tracking all high-potential individuals. Diversity statistics should be tracked and diversity in this pool actively managed. This pool of candidates deri ves from annual ratings as well as leadership development program graduates. Supervisors and executive leaders must provide ongoing coaching for higher positions to this pool of de veloping leaders. VHA must identify anticipated succession needs and offer development opportunit ies that would help prepare candidates for these anticipated openings. Once the positions ar e open, individuals in the high-potential pool must receive notices of new job postings and de tail opportunities that provide experience into this pool should be required to enter into higher positions. Candidates who agree to be in formal mentoring relationships with leaders outs ide their chain of command to further advance tions (VISN director, facility director, VHACO their career development. For highest-level posi ecertified candidates should be established. chief officer) a formal pool of approved or pr To expand the perspectives and management experience in its leadership pipeline, VHA must develop explicit strategies to on-ramp diverse ca ndidates at critical midcareer transition points. This process includes creating pathways for re tiring commanders and other senior officers of military treatment facilities to compete effectively for leadership positions in VHA. To increase VHA understanding of private-sector health ca re, VHA must develop midcareer entry points for private-sector candidates. This could be a ccomplished through the use of temporary hiring authority and the ability to convert these position s to permanent staff positions if leadership competencies standards have been met by the c andidates. Such opportunities can be modeled on efforts recently announced by DoD and, wh erever practicable, should be developed collaboratively with DoD to establish the legal and policy requirements for implementing these programs. Finally, the current graduate health administration training program (GHATP) program should be expanded to include more sc hools and programs with diverse trainees. This expansion must allow high-performing residents to continue to convert to full time positions. On-boarding A formal on-boarding process should be instituted for all new executive hires. In addition to the transactional knowledge the individual will need, on boarding should establish the expectations for what it means for that executive to be succe ssful in VHA. The values of the organization and the expectations for ethical practice must be conveyed by the CVCS and the top leadership team. A formal assessment of knowledge and skills should be made during on-boarding and an new hires if any deficiencies are identified. IDP established to cover the probationary period of 117

132 C C F INAL R EPORT OMMISSION ON ARE Completion of the IDP is required for continue d employment. All new leadership hires should be assigned a coach based on their individual n eeds. Within their first 6 months of employment, the undersecretary for health and Secretary shou ld meet with these new executives to build a relationship with them and hear their fresh perspectives on the performance of VHA. Stabilize Leadership ranks by authorizing VA medical center and VHA should immediately stabilize its leadership veterans integrated services network (VISN) dire ctor details to last up to a year with no restrictions on an acting leader competing for the permanent position. VHA should also create flexible capacity by creating more assistant-lev el positions (e.g., assistant director, assistant VISN chief medical officer, assistant nurse exec utive, deputy chief officer). These individuals would comprise the pool of potential leaders and also allow for cross filling positions that are empty due to development assignments, training, or other leadership development opportunities. Implementation Legislative Changes  Establish direct-hire authority from the grad uate health care administration training private-sector fellow pools, clarifying program, military treatment facility, and cluding approaches to managing veterans’ application of merit-system principles, in preference in these programs. Establish Intergovernmental Personnel Act au thority for VHA to include the for-profit  private sector; this could be done as a pilo t program with a report to Congress before considering whether to make the authority permanent. VA Administrative Changes The following administrative changes are a priori ty over the next 36 months. To assist VHA in implementing these actions and to promote acco untability and oversight, the Commission has sponsibility for action in Appendix B. provided a detailed timeline and assigned re Fund and implement leadership assessments, training, coaching, and developmental  opportunities based on the new leadership competency model.  Aggressively manage leadership recruitment, retention, development and advancement using the new leadership competency model: All hires and promotions are required to demonstrate these competencies.  Require a formal on-boarding process for HP DM 3 and 4 leaders at all levels that reinforces the leadership competency model.  Take immediate steps to stabilize the continuity of leadership by extending the length of of leadership at medical centers and allow authorized details to extend the continuity leaders detailed to a position to compete for a permanent appointment to the position by removing the non-compete requirements. 118

133 C R ECOMMENDATIONS OMMISSION and include requirements for its use in  Establish the competency model in regulation hiring, promotion and dismissal and clarify th e application of veterans’ preference in executive development. Other Department and Agency Administrative Changes  None required. 119

134 C C F INAL R EPORT OMMISSION ON ARE ctures and management Recommendation #12: Transf orm organizational stru processes to ensure adherence to na rds, while also tional VHA standa level of the organization, eliminating promoting decision making at the lowest tion, and fostering the spread of waste and redundancy, promoting innova best practices. Problem The Commission Recommends That . . . Leadership structures and processes should create (VHACO) Office Central VHA redesign VHA  to be organized to promote agile, clear decision performing ‐ high functions that serve support Veterans making, the free flow of ideas, and facilities and in Networks Service Integrated (VISNs) zational priorities, as identification of organi of ‐ centric care. delivery their veteran well as make clear reporting relationships and define the roles and responsibilities of clarify VHA  and lines of accountability within the facilities, VISNs, the program VHA reorganized and organization. VHA currently lacks effective offices in relation to one within another, and national national policies, a rational organizational decision down making to push standards, lowest the structure, and clear role definitions that level with policies, executive and tools that budget, would support effective leadership of the support change. this organization. The responsibilities of VHA VHA mechanisms communication leadership establish  Central Office (VHACO) program offices are between and VHACO within to and VHACO the field unclear, and their functions overlap or are collaboration. and dialogue, transparency, promote duplicative. The role of the Veterans VHA establish a  transformation office, reporting the to Integrated Service Network (VISN) is not broad Care VHA and with of chief System authority a budget to supporting accomplish the transformation clear, and the delegated responsibilities of VHA outlined changes scale ‐ large manage and of the the medical center director are not defined. throughout this report (also included in Recommendation #10). Background A prerequisite of a successful, high- 422 performing system is having strong leaders and a strong leadership system. An organization’s leadership system is “the way lead ership is exercised, formally and informally, throughout the organization; the basis for key decisions and the way they are made, 423 It includes “structures and mechanisms for making communicated, and carried out.” decisions; ensuring two-way communication; se lecting and developing leaders and managers; 424 and reinforcing values, ethical behavior, directions, and performance expectations.” In an 425 organization the size of VHA, with a budget of $69 billion, more than 300,000 employees, and 426 more than 1,000 sites of care, strong leadership systems are essential. 422 Baldridge Performance Excellence Program, A Systems Approach to Improving 2015-2016 Baldridge Excellence Framework: (Health Care), (Gaithersburg, MD: U.S. Department of Commerce, National Institute of Your Organization’s Performance Standards and Technology, 2015), 50. (New York, NY: HarperCollins, 2001), James Collins, Good to Great: Why Some Compan ies Make the Leap and Others Don’t, 17-64. 423 Ibid. 424 Ibid. 425 Department of Veterans Affairs, VA 2017 Budget Request: Fast Facts , accessed March 10, 2016, VAsBudgetHighlights.pdf. http://www.va.gov/budget/do cs/summary/FY2017-FastFacts 426 “About VHA,” Department of Veterans February 5, 2016, Affairs, accessed http://www.va.gov/health/aboutVHA.asp. 120

135 C R OMMISSION ECOMMENDATIONS 427 In the last successful reorganization of VHA in 1995, sign and functional the organizational de roles of the leadership system were organized in to clear structures with clear functions. The 428 VISNs were responsible for operations and VHACO program offices were responsible for 429 The National Leadership Board (made up of VISN directors policy, guidelines, and outcomes. and all program office leaders) was responsible for collective, fact-based decision making and adership priorities and decisions directly to the Friday Hotline call was used to communicate le tiated performance measurement system based VA medical center (VAMC) leadership. A nego 430 on consistent, benchmarked, outcome-focused metrics was also established that was 431 supported by centralized functions t hat benefit from economies of scale. As part of the reorganization, VHA experienced a reduction in staff and consolidation of VHACO offices to 432 create a flat, agile leadership system. trix was not sustained, VHA Because this functional ma now faces the challenge of reinstitut ing an effective leadership system. Analysis Twenty years after the Kizer reorganization, VHA has a very different leadership system, under a lack of clear operating model, limited role which it “is intensely, unnecessarily complex due to 433 and overlapping responsibilities.” clarity, fragmentation of authority, The Independent 434 included the following findings about the VHA operating model: Assessment Report VHACO has grown rapidly since 2009 from 753 in FY 2009 to 1,990 in FY 2014.   The VISNs’ ability to manage and support their regions is heavily hampered by resourcing restrictions and direct VHACO control over VAMC operations.  The VAMCs’ operating model suffers from po werful silos, which prevent an effective end-to-end mission focus.  e, coupled with poor prioritization and the VA’s increasingly top-down management styl lack of clarity around strategic direction, external political environment, result in a reactivity to external headwinds, and flawed efforts to standardize. 435 The growth in central office was driven in VHACO has grown rapidly in the past few years. part by new ideas, new priorities, and new cris es being addressed through the creation of new 427 Best Care Anywhere: Why VA Health Care Would Work Better for Everyone (San Francisco, CA: Berret- Phillip Longman, Koehler Publishers, Inc., 2012), 54. 428 ration, Department of Vision for Change: A Plan to Kenneth Kizer, Veterans Health Administ Veterans Affairs, , 1995, 35. Kizer, Kenneth W and Ashish Jha, “Restoring Trust in VA Health Restructure the Veterans Health Administration New England Journal of Medicine , 371, (2014): 295-297. Care,” 429 Ibid. 430 Kenneth Kizer, Veterans Health Administ ration, Department of Vision for Change: A Plan to Veterans Affairs, , 1995, 61-72. Restructure the Veterans Health Administration 431 Ibid., 33. 432 Ibid., 60. Kenneth Kizer, Veterans Health Ad ministration, Department of Veterans Affairs, Prescription for Change: The Guiding Principles and Strategic Objectives Underlying the Transformation of the Vete rans Healthcare System, Objective 3 and 17 , 1996. 433 Independent Assessment of the Health Care Deli very Systems and Management Processes of the The MITRE Corporation, Department of Veterans Affairs, Assessment L (Leadership), 95, accessed Ja nuary 26, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_L_Leadership.pdf. 434 Ibid. 435 Ibid., 98. 121

136 C C INAL R EPORT OMMISSION ON F ARE 436 offices and new staff infrastructure to support it. A portion of the growth came from the centralization of functions that were previously managed in the field such as business office functions. The final component has come from the duplication in VHA of offices in which decision-making authority rests with VA, such as communications and regulatory management. VHA has also duplicated functions and responsi bilities between two or more offices in VHA, such as primary care, surgery, mental health, an d geriatrics and extended care. This increased growth in staff and offices has resulted in more complex and lengthy decision processes, often 437 with little clarity as to whom ultimate re sponsibility for decisions or follow up falls. One symptom of the top-down management is VHACO control of budgeting and resource ntrol” and the “increasing share of Specific management. “Support funding is outside local co 438 Purpose funding hinders” local leaders in their ability to use resources effectively. In FY 2015, 439 specific-purpose funds were spread across more than 450 line items, taking money away from general purpose funding and restricting how this money can be used. Both VHACO and Congress have been complicit in taking contro l away from medical center directors through 440 For instance, the congressional appropriation to fund VHA for 1998 these budget controls. included only five appropriation line items; me dical care, medical administration, construction 441 major, construction minor, and medical and prosthetic research. In contrast, the budget request to Congress for FY 2016 included 12 budget categories relevant to VHA with some of 442 In his testimony before the Commission and those accounts having four or five subcategories. Congress, Secretary McDonald made the point t hat such fragmentation of the VHA budget and the prohibition to reallocate across budget cate gories without first receiving Congressional 443 Greater approval was an impediment to effective and agile management of the department. Congressional control of VHA spending is unders tandable in light of VA’s lack of adequate 444 management systems and data analytic capabili ties to track expenditures in real time and ly means available to hold the medical centers report them to Congress and central office. The on 436 Ibid., 96-99. 437 Mike Mayo-Smith and Pat Vandenberg, Task Force on Improving Effectiveness of VHA Governance: Report to the VHA Under (Washington, DC, Veterans Health Secretary for Health, Administration, February 2015), 7-9. 438 , Independent Assessment of the Health Care Deli very Systems and Management Processes of the The MITRE Corporation Department of Veterans Affairs, Volume 1: Assessment L (Leadership), 102, accessed March 10, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 439 Ibid., 107. 440 The MITRE Corporation, very Systems and Management Processes of the Independent Assessment of the Health Care Deli Department of Veterans Affairs, Volume 1: Assessment L (Leadership), 102-108, accessed June 10, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 441 PL 105-65, October 27, 1997. 442 Department of Veterans A ffairs Fiscal Year 2016 Budget Submission, Vo lume II Medical Programs and Information Technology, Accessed June 10, 2016, h ttp://www.va.gov/bud get/products.asp. 443 On January 21, 2016, Se cretary of Veterans Affairs, the following testimony before Robert A. McDonald, provided et Authority: We need flexib hority to avoid the U.S. Senate Committee on Veteran’s Affairs “Flexible Budg le budget aut livery of care and benefits to Veterans. Currently, there are over 70 line items in artificial restrictions that impede our de VA’s budget that dedicate funds to a ibility to provide the best service to specific purpose without adequate flex Veterans. These include limitations within the same general ar eas, such as health care fu nds that cannot be spent on health care needs and funding that can be used for only one type of Care in the Community progra m, but not others. These restrictions limit the ability of benefits based on demand, rather than VA to deliver Veterans with care and specific funding lines.” accessed June 10, 2016, http://www.veterans.senate. gov/imo/media/doc/VA%20Sec% 20Testimony%2001.21.2016.pdf 444 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership), 105, accessed March 10, 2016, integrated_report.pdf. http://www.va.gov/opa/choice act/documents/assessments/ 122

137 C OMMISSION ECOMMENDATIONS R as separate budget lines or indicate allocations accountable was to fund the priority initiatives to be made under the specific-purpose process. Independent Assessment Report To fix the overly complex and bureaucratic structure of VHA, the suggests that VHA “redesign (its) operating mo del to create clarity for decision-making 445 authority, prioritization, and long-term support.” VHA must take a systems approach to ing and re-orienting VHACO program offices to reorient its leadership operations, restructur 446 ensure all of the following: fact based, innovative decision making that is responsive to the field, other offices,  and external stakeholder requirements  feedback mechanisms to incorporate system learning into policy development and operational guidance  communication mechanisms to effectively s hare information across offices and reach and tie decisions to organizational values VISN and facilities to explain expectations and goals effective execution of policy decisions th rough expert coaching, deployment of  resources, and guidance based on external benchmarks and sharing of internal best practices analytic capability and infrastructure to  effectively monitor progress and outcomes of all organizational priorities Such a reorientation will involve a different sk ill set and expertise than currently required in VHACO. Transformation will call for recruiting new expertise, making advancement decisions based on these new competencies, reinforcin g them through recognition and performance t staff through training and coaching. This skill assessment, and developing new skills in curren set includes a high level of technical expertise re levant to the program office; the ability to build eholders; demonstrated skills in coaching, staff development, relationships with external stak ement methodologies; analytic capabilities to and training; certification in quality improv develop and track metrics; and the ability to lead transformational change. VHA must fully fund the retraining and the hiring of skilled st aff in VHACO to accomplish this transformation. For the VHACO program offices to work effectiv ely with one another an d with the field, the specific authority of each office must also be defined. Where overlap and confusion exists between offices, programs must be combined and streamlined or eliminated with a ing the structure and orientation of VHACO corresponding reduction in force. In chang program offices, VHA leadership can take the opportunity to align functions to achieve its stated priority of patient-centered care. In a fully aligned operating structure, business processes from the VAMC front line to central o ffice must be organized to deliver important 445 Ibid., ix. 446 Baldridge Performance Excellence Program, 2015-2016 Baldridge Excellence Framework: A Systems Approach to Improving Your Organization’s Performance (Health Care), (Gaithersburg, MD: U.S. Department of Commerce, National Institute of 2015), 7, 34, and 50. Standards and Technology, 123

138 C C F INAL R EPORT OMMISSION ON ARE onal silos. For instance, instead of having an patient outcomes rather than aligned in professi for physician assistants, business offices should office of nursing, one for social work, and a lead patient aligned care teams, to deliver positive be aligned around the work they do together, like outcomes for veterans. The administrative operations of VHACO should also be flattened. Senior staff should be speaking directly to other senior staff to di scuss and make decisions rather than relying on bureaucratic, paper-based processes as a means of negotiation: It is neither a healthy culture nor an efficient process. At the same time, VHACO needs to take full advantage of being a large- scale enterprise by centralizing functions such as acquisition package development, recruitment package development, and account reconciliation so that staff is not required in each program office to take on these occasional but complex activities. The net savings resulting from this reorganization and delayering of the bureaucrac y must be reinvested in the transformation process. VISNs must also examine the skills needed to take on an expanded role as facilitators, coaches, and guides in improving services and sharing best practices across facilities. VISNs are critical players in the feedback loop between service delivery and VHACO to identify ineffective processes, problems, and emerging issues that need to be raised to VHACO for help in clearing to VHACO, VISNs must define the new skill set away barriers to effective operations. Similar tablish these requirements in hiring, promotion, and performance required by their staffs and es evaluation as well as training and coaching st aff to develop these competencies. Finally, the h a required staffing ratio for the VISN office chief of VHA Care System (CVCS) should establis and reduce the staffing in VISNs that exceed this standard. A new operating model also means that medical ce nter directors must control the budget, staff, supplies, and infrastructure required to deliv er needed health care. This model includes and expanded authority to reallocate funds consolidation of budget lines and new authority the new VHA Care System and ensure that across the remaining budget categories. To manage facility and network directors have the local cont rol needed to make decisions about how to deliver services, fewer restrictions should be placed on the VHA budget. To start, specific- purpose funds must no longer be used to direct obligations at facilities. Congress should also work with the administration to reduce the nu mber of budget lines and specific spending authorities back to a simpler system like that used in 1998. To support these changes and create ble for their expenditure of funds by ensuring transparency, medical centers should be accounta accurate, complete, and timely cost accounting. Th is last requirement, however, can only be met if it is supported by effective financial management data systems and fully trained staff and leadership who understand how to use such systems. To support the leaders, program offices, and th e field in this transformation, the CVCS must establish a transformation office that has appropriate expertise in business process reengineering and is fully funded to conduct th is work. Existing offices with the requisite expertise, including the Office of Strategic Integration and the Veterans Engineering Resource Center (VERC), should be rolled into the tran sformation office. This office would oversee transformation and incubate new initiatives with the goal of incorporating them into regular work of other program offices once the new initia tive is established. This mechanism, if used consistently, would prevent VHA from growin g new offices as new priorities arise. 124

139 C R OMMISSION ECOMMENDATIONS adership system, the CVCS, VISN directors, and Finally, as part of cultural change within the le productive dialogue am ong themselves about program office leaders must promote open and , leaders must address both the culture within problems and solutions. To accomplish this goal s and processes that support identification and the leadership ranks, as well as establish system is behavior by inviting input on problems and discussion of problems. The CVCS must model th rewarding leaders when they bring issues forw ard, including rewarding them with access to expertise, staff, and money; removing barrier s; and aligning other leaders in support of solutions. In its work to oversee change in VHA, the trans formation office will create an implementation plan for transformation, identifying key strategi es and milestones. This plan will drive data collection, development of strategic goals and supporting objectives to encourage effective planning, accountability, and the ability to unearth cr itical gaps that need to be addressed. The transformation office will require each new init iative to establish a project plan and provide periodic reports that include all of the following components: tactic/action, initiative owner, cost (i.e., operational, equipment, contracts), number of FTEs, start and completion dates, 447 outcome measures, strategic drivers, and milestone. The President’s Management Agenda Scorecard will serve as the evaluation model. The Office of Managem ent and Budget created this tool to evaluate new initiatives and trac k progress on outcomes ov er time with regular 448 stoplight reports (red, yellow, green) to leadership. Implementation Legislative Changes  Simplify the VHA budget to include fewer a ccounts while at the same time requiring more transparent and detailed accounting of VHA expenditures. VA Administrative Changes The following administrative changes are a priori ty during the next 36 months. To assist VHA in implementing these actions and to promot e accountability and oversight, the Commission has provided a detailed timeline and assigned responsibility for action in Appendix B. Responsibility for establishing a transformation plan with milestones, timelines, and evaluation of outcomes is assigned to the transformati on office that the Commission recommends be established in VHA.  lidate program offices to create a flat Eliminate duplication within VHA and conso anizational chart for accomplishing this goal. structure. Figure 9 is one model of an org This organizational chart shows how VHA can be streamlined to mirror the structure of large private-sector hospital systems. Figure 10 is the current VHA organizational chart, provided as a point of comparison and to emphasize the cumbersome nature of the current structure. 447 For example, see “VA Faith-based and Community Initiative President Management Agenda Scorecard,” September 30, 2008, 448 “Office of Federal Financia l Management President’s Ma nagement Agenda,” Office of Management and Budget, /financial_fia_pma/. accessed June 15, 2016, h ttps://www.whitehouse.gov/omb 125

140 C OMMISSION ON ARE F INAL R EPORT C 449 Figure 9. Proposed VHA Organizational Chart This organizational chart is an example of how to align VHA functions to Note: create a flatter organization, remove duplication, and streamline decision making as discussed throughout this chain section of the report. Of note, the placement of the Transformation Office, CIO, and supply in this diagram is consistent with recommendations made by the Commission elsewhere in this report. staff. In this chart, COS is chief of 450 Figure 10. Current VHA Organizational Chart 449 Modified from Appendix C, Mike Mayo-Smith and Pat Vandenberg, Task Force on Improving Effectiveness of VHA th Administration, February (Washington, DC, Veterans Heal Governance: Report to the VHA Under Secretary for Health, 2015), 41. 450 Ibid. 126

141 C OMMISSION ECOMMENDATIONS R een VHA and VA by closing VHA offices as  Eliminate the duplication of functions betw needed. Create innovative organizational structures that are aligned to patient’s needs rather  than professional silos, to support clinical care. Undertake a reduction-in-force in VHACO that facilitates delayering and efficiency in  communication and decision making.  Establish a transformation office implementation plan to ensure effective and formation across VHA. The transformation comprehensive implementation of the trans plan is to capture all of the transformatio n activities recommended in the Commission report, establish specific timelines and milest ones for accomplishing each objective, and report on both progress and outcomes at least quarterly to VHA leadership and the governing board. Periodic evaluation of the e ffect of these change initiatives on internal and external stakeholders would also be appropriate.  Clarify the roles and responsibilities of VI SNs and facilities and implement a change strategy to orient staff and leaders to these new expectations. Establish effective leadership communication mechanisms to promote transparency, dialogue, and collaboration among VHACO offices and with the field. Other Department and Agency Administrative Changes  None required. 127

142 C C INAL R EPORT ARE OMMISSION ON F Recommendation #13: Streamline and fo cus organizational performance that are identical to those used in measurement in VHA using core metrics personnel performance management the private sector, and establish a A that is distinct from performance system for health care leaders in VH ership competency model, assesses measurement, is based on the lead leadership ability, and measures the ac hievement of important organizational strategies. Problem The Commission Recommends That . . . To achieve the Commission’s vision of Measurement Organizational Performance quality, access, and choice for veterans, VHA streamline measures, performance organizational VHA  must effectively measure outcomes and hold and alignment strategic effect, emphasize meaningful leaders accountable for improvement. VHA a allow that measures benchmarked use and direct can measure itself against internal best comparison to private sector. the practices, but veterans deserve care that new Office for Organizational Excellence work  The uniformly meets or exceeds private-sector reorganize to experts with to structure internal its quality standards. A clear, concise, balanced needs field with functions business align and measure set, identical to private-sector ‐ low or redundant eliminate consolidate and priority activities. standards, will give leadership, staff, and administrators focus and direction for their Leadership Workforce and Management Performance System work. VHA leaders are responsible for delivering these quality outcomes for  system management performance new a create VHA for tied leaders, care health appropriate to health care veterans. They do so by exercising competencies, and benchmarked to leadership the leadership skills and traits in their private sector. management and direction to staff. Short-  raters primary raters secondary all and CVCS The hold term gains can be realized at the expense of accountable for in meaningful distinctions creating staff morale and well-being, but the long- among performance leaders. term health of the organization cannot. meaningful VHA recognize  distinctions in performance Therefore, organizations must be sure to awards. meaningful with assess leaders’ performance not just on what they achieve but how they achieve it. Background One of the criteria for performance excellence in health care is the measurement, analysis, and 451 improvement of organizational performance. Performance measurement is used to track daily operations, overall organizational performanc e, and progress in achieving organizational measurement is also used to benchmark objectives and action plans. Performance organizational performance against in ternal and external standards. not the same as workforce performance Organizational performance measurement is 452 management. intended to reinforce intelligent risk Workforce performance management is taking, help focus the workforce on the needs of patients and other customers, and support 451 Baldrige Performance Excellence Program, 2015-2016 Baldrige Excellence Framework: A Systems Approach to Improving (Health Care), of Commerce, National Institute of Gaithersburg, MD: U.S. Department Your Organization’s Performance Standards and Technology (2015), 16. 452 Ibid., 20. 128

143 C OMMISSION ECOMMENDATIONS R 453 achievement of action plans. health care delivery and the Although there is a relationship ent and workforce performance management, between organizational performance measurem they are not synonymous processes. Workforce performance management is made up of much more than just clinical outcome measures. As noted by the American College of (ACHE), performance Healthcare Executives must also evaluate leadership evaluations of hospital CEOs traits such as judgment, 454 communication, and diplomacy. Furthermore, ACHE emphasizes the inclusion of individual g ethical behavior, supporting professional objectives in perf ormance plans, such as promotin diversity and inclusion within the organizat ion, or fostering effective medical staff 455 456 ACHE and other leading practitioners emphasize that performance relationships. management is not a plan or an event, but rather a continuous, ongoing process and ewers. A workforce performance management conversation among the leaders and their revi 457 and promote high system must also make meaningfu l distinctions among individuals 458 gnition, and incentive practices. performance through rewards, reco Ideally, when coupled with a leadership competency model and development program, workforce performance management should also help to identify hi gh-performing potential leaders and provide 459 guidance to the workforce on how to move up in the leadership ranks. As deployed in Independent Assessment Report , VHA’s performance management FY 2015 and evaluated by the 460 system failed to effectively ac hieve any of these objectives. Analysis One of the findings in the Independent Assessment Report was that “hundreds of operational is, combined with limited transparency and performance measures overwhelm leaders and th inconsistent data availability, ma kes it difficult to focus on what is most important.” More than 300 measures spanned everything from critical clin ical metrics to political priorities introduced that it was tracking approximately 500 measures, to address the most recent crisis. VHA reports 453 Ibid. 454 “Policy Statement: Ev alth System CEO,” No vember 2013 (revised), aluating the Performance of Hospital or He 18, 2016, https://www.ache.o American College of Healthcare Exec utives, accessed February rg/policy/ceo-perf.cfm. 455 Ibid. 456 Ibid. NeuroLeadership Inst itute’s “Reengineering Performance Management: How Companies are Evolving Beyond led on January 14, 12-1. Ratings” webinar, schedu 457 “Implementing FCAT-M Performance Management Comp etencies: Differentiating Performance,” Office of Personnel Management, Performance Ma nagement: Performa nce Management Cycle, accessed June 10, 2016, -oversight/performance-manage ment/performance-management- https://www.opm.gov/policy-data iating-performance/. cycle/developing/different 458 2015-2016 Baldridge Excellence Framework: A Systems Approa Baldrige Performance Excellence Program, ch to Improving Your Organization’s Performance Gaithersburg, MD: U.S. Department of Commerce, National Institute of (Health Care), Standards and Technology (2015), 20. 459 Office of Personnel Manage r Leadership Competencies. https: www.opm.gov/policy- ment. Proficiency Levels fo data-oversight/proficiencylevels for leadership competencies/. “Joint Medical Executive Skills Institute,” Health.mil: The official website of the Military Health System and the Defense Health Agency , accessed June 13, 2016, https://www. Joint Medical Executive Skills Institute. mesi.army.mil/docume nts.asp, National JMESI Competency Model. https://j Center for Healthcare Leadership. NCHL He althcare Leadership Competency Model. www.nchl.org/static.asp?path=2852,3238. 460 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership), 78-79, accessed January 26, 2016, ssment_L_Leadership.pdf. http://www.va.gov/opa/choiceac t/documents/assessments/Asse 129

144 C INAL R EPORT OMMISSION ON C F ARE g employee engagement, 18 on high-performing including 156 related to access, 29 measurin 461 networks, 250 best practice measures, and seven related to trust. 462 is a cycle that Distinct from performance measuremen t, the performance management process begins with clear input from top leadership on the priorities of the organization, followed by clear targets, performance tracking, reviews, and rewards. The Independent Assessment Report noted that, “Individual performance managem ent processes are hindered by targets inconsistent with the VHA mission, delayed impl ementation, lack of meaningful performance 463 Many of the same system flaws that impede effective dialogue, and limited rewards.” organizational performance also im pede individual success. Performance plans are released late 464 in the performance cycle, metrics are hard to track in real time and lack the detail required for 465 individual performance assessment, and few plans are written to support shared ddition, participants observed that the current accountability and team-based solutions. In a senior executive performance ag reements and rating process (a) do not result in meaningful distinctions in performance between individual s, (b) do not drive me aningful conversations about individual performance, (c) and do not cons istently focus on key health care metrics of 466 quality, safety, patient experience, operatio nal efficiency, finance, and human resources. The Independent Assessment Report notes that the rewards currently offered to employees do not 467 motivate them to work toward exceptional performance. Information provided to the Commission indicate s that VHA has taken action to address some of these findings. First, the USH has reesta blished a performance accountability workgroup leaders from the field and VHACO to provide (absent for a number of years) comprising 468 performance measurement process. oversight and direction to the The workgroup has been VHA, dramatically simplifying metrics, and charged with aligning metrics to each level of 469 increasing the capacity of the organizatio n to focus on measures that truly matter. The group has created an aspirational vision of a perf ormance measurement system that describes cascading accountability from the top of th e organization with health system outcomes (reported annually) through strategic measures (reported quarterly), to tactical measures 470 It is critical that these (reported monthly) to transactional measures (reported in real time). aspirations become policy. 461 Carolyn Clancy and Joe Francis, Veterans Health Administ ration, meeting with Commission on Care staff, December 2015. 462 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership), 78, accessed Ja nuary 26, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_L_Leadership.pdf. 463 Ibid., 82. 464 Ibid., 82. 465 Ibid., 84. 466 Ibid., 84. 467 Ibid., 87. 468 David Shulkin, Charter of the Performance Accountability Workgroup , (Washington, DC, Veterans Health Administration, September 22, 2015). 469 ration, meeting with Commission on Care staff, December Carolyn Clancy and Joe Francis, Veterans Health Administ 2015. 470 Ibid. 130

145 C R OMMISSION ECOMMENDATIONS ance measurement, benchmarking, and reporting Starting in the 1990s, VHA has used perform 471 ality performance by individuals and teams. internally to motivate higher clinical qu As a large, national health care system, internal benchmarking can be a valid method to drive change, yet both internal and external audiences may ask how well VHA performance VHA currently posts some patient quality, safety, compares to that of private-sector providers. and outcome measures on both its website and on the Department of Health and Human 472 Services (HHS) Hospital Compare website. These measures allow patients to evaluate the quality of care they receive from VA and make informed health care decisions. They include measures of timely and effective health care; me asures of readmissions; complications of death, surgical complication measures and health-care related infection measures; survey data of 473 ed of hospitals participating in Medicare. patient experiences; and other measures requir Former USH Kizer believes this re porting is insufficient, noting the VA health care system has become inc reasingly insular and inward-looking. It now th care, and too often it has declined to has little engagement with private-sector heal make its performance data public. For example, it contributes only a small proportion of its data to Hospital Compare and has declined to participate in other public performance 474 reporting forums such as the Leapfrog Group’s efforts to assess patient safety. The Commission has reviewed VHA’s principal me asurement approach, Strategic Analytics for Improvement and Learning Value Model (SAIL) and has determined that although it is modelled on private-sector approaches to measur ement and rating, measures are not exactly the same as those reported in the private sector and consequently impede direct benchmark comparisons of VHA to the private sector. Updating these measures so they are consistent with the private sector will be especially important as integrated delivery ne tworks are established and more care is received in the communit y, as they will allow for making objective comparisons. Measurement, analysis, and improvement of or ganizational performance work together as a 475 key system. The USH has signed a new organizational chart for VHA that acknowledges the interconnection of these elements by establishi ng an office for organizational excellence that 476 To be effective, not only must all of the various units encompasses all of these functions. within this office work together but also they must work with personnel in the field to coach and develop their ability to effectively a pply performance measurement and improve organizational performance. 471 System Learn from the VA’s Quality and Safety Transformation?” Ashish K. “What Can the Rest of the Health Care and Quality, U.S. Department of Heal th and Human Services, September 2006, Jha, Agency for Healthcare Research hrq.gov/perspectives/persp ective/31/what-can-the-r accessed April 21, 2016, https://psnet.a est-of-the-health-care- system-learn-from-the-vas-quality-and-safety-transformation. 472 “Quality of Care: How Does Your Medical Center Perform?” Medical Center Performance Search (MCPS), terans Affairs, accessed May 16, 2016, http:/ /www.va.gov/qualityofcar e/apps/mcps-app.asp. U.S. Department of Ve 473 Title XVIII of the Social Securi ty Act 42 U.S.C. § 1395 et seq. 474 Kenneth Kizer and Ashish Jha, Restoring Trust in VA Health Care , N Engl J Med 2014; 371:295-297, July 24, 2014 475 2015-2016 Baldridge Excellence Framework: A Systems Approa ch to Improving Baldrige Performance Excellence Program, Your Organization’s Performance (Health Care), Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology (2015), 16. 476 art at end of Recommendation #12. See the proposed organizational ch 131

146 C C F INAL R EPORT OMMISSION ON ARE ent do not appear to be mirrored on the These improvements in performance measurem . The draft FY 2016 performance plan template performance management side of the equation 477 for network directors and medical center directors, although more streamlined than in n of performance measurement and performance previous years, continues to reflect confusio ll of the organization’s key (and not so key) management. It also continues to distribute a ns of leading change, leading people, business priorities under OPM executive core qualificatio acumen, building coalitions, and results driven . The new, streamlined performance measures described above could be considered results-driv en; however, the rest of the plan continues to be a confusing presentation of instructions to field leaders, restatements of policy, and performance objectives for action plans. Only th e last category is appropriate for workforce 478 performance management. The Corporate Senior Executive Management Office has implemented a new online performance management data tool that allows for tracking and assessment of the performance management proce ss for senior executive service and equivalent 479 leaders in VA. To improve performance measurement and organizational performance, the Independent Assessment Report recommends that VHA focus and si mplify organizational performance measurement to clarify accountability, actively support the mission, and promote continuous improvement. Specifically, VHA must create a simplified, focused, ba lanced scorecard that reduces the total number of metr ics to about 20; establish metric s that support cross-functional collaboration; cascade metrics down the organi zational hierarchy; and make data tracking , reliable, and meaningful down to the lowest transparent, timely, broadly available, credible level of the organization. Furthermore, lead ers should support continuous improvement, problem-solving, and the exchange of best practices across the organization rather than 480 focusing on only correcting poor performance. The Commission broadly agrees with this approach to performance measurement. In a ddition, the Commission emphasizes that VHA customers and stakeholders require public report ing of clinical quality measures that are the same as, and therefore directly comparable to, measures used by the private sector. Although VHA may require an enhanced set of measures that reflects services not broadly deployed in the private sector, or for which measures do not yet exist, a minimum set that are the same as private-sector measures must be used by VHA. As VHA expands integration of care with the community, the use of the same measures as the pr ivate sector will be important so that direct comparisons can be made of care delivered insi de VHA and that delivered under contract or partnership agreement by the VHA community care network. VHA also requires a cohesive, integrated personnel performance management system that is specific to the knowledge, skills, and abilities required of health care leaders; includes 477 Veterans Health Administration, Draft Fiscal Year 2016 Perf ormance Plan Template, Network Directors and Medical Center Director, November 20, 2015. 478 2015-2016 Baldridge Excellence Framework: ch to Improving Baldrige Performance Excellence Program, A Systems Approa Your Organization’s Performance Gaithersburg, MD: U.S. Department of Commerce, National Institute of (Health Care), Standards and Technology (2015), 20. 479 Sam Retherford, Principal Deputy Assistant Secretary for Human Resources and Admi nistration, Department of Veterans Affairs, speaking to the leadership workgroup of the Commission on Care, Decem ber 15, 2015. 480 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership), 81, accessed Ja nuary 26, 2016, t/documents/assessments/Asse http://www.va.gov/opa/choiceac ssment_L_Leadership.pdf. 132

147 C R OMMISSION ECOMMENDATIONS also assesses organizati onal and professional accountability to key organizational outcomes; but objectives. A new personnel performance management system must be free of OPM requirements for executive core qualificatio n and certification process and instead be 481 benchmarked to the private sector and consistent with the new leadership competency model. Congress required DoD to establish independent competency standards for the Commanders of 482 Military Treatment Facilities (MTFs) and sh ould consider doing the same for VHA. This new performance management model must be based on both evaluation of leadership competencies and demonstrated success in delivering on st rategic priorities. To break with current perceptions of the rating scales, it would be helpful to establish a new rating scale for the performance management system. Once the new system is developed, VHA must conduct training to describe the system, rating process, and expectations for both participants and raters. must also address the responsibilities of the rater. This A performance management system includes clearly establishing written performanc e requirements for subordinates that are both od) and meaningful. Raters must be required to timely (i.e., prior to the start of the rating peri provide continuous feedback and assessment throughout the year to recognize and reward progress and outstanding achievements as well as to coach and trouble shoot when needed. The CVCS must establish this expectation by clearly communicating what is required of raters, and most importantly, by modeling the behavior. Fi nally, raters must provide meaningful ratings that distinguish achievement based on object ive performance and demonstrated leadership skills. For instance, the Cleveland Clinic has moved to a system of forced rankings for which the top 10 percent of performers are celebrated and the bottom 10 percent are given intensive 483 coaching or, if justified, sanctioned. To accomplish the last point, raters themselves must be given feedback and oversight to understand how their approach to rating compares to other are not consistent with rating standards, their leaders in the organization. If raters’ assessments ion and include it in the performance assessment supervisor must bring this issue to their attent they receive. The newly established performance management data tool can be used to support the performance management process. The submission of written performance plans (or failure to do so) can be tracked and reported; and the qual ity of those plans can be audited to provide feedback to raters. Final ratings and a comparison of raters can be conducted and provided to all of the executive raters in the organization. Fi nally, such a tool can also be used to identify and track high performers who deserve further investment and development as leaders from VHA. 481 The American College of Healthcare Executives, 2016 Competencies Assessment Tool, accessed May 16, 2016, https://www.ache.org/pdf/nons ecure/careers/compet encies_booklet.pdf. “NCHL Heal th Leadership Competency Model™,” National Center for Healthca ccessed May 16, 2016 re Leadership, a http://www.nchl.org/sta tic.asp?path=2852,3238. 482 Department of Defense Appropriations Act of 1999, Pub. L. No 105-262, Section 8052 (1998): “None of the funds appropriated in this Act may be used to fill the commander’s position at any milit ary medical facility wi th a health care professional unless the prospective candidate can de monstrate professional administrative skills.” 483 Delos M. (Toby) Cosgrove, MD, CEO, Cleveland Clinic , statement during Commission on Care public meeting, March 22, 2016. 133

148 C ARE F INAL R EPORT OMMISSION ON C Implementation Legislative Change  Obtain legislative relief from the requ irement to use the OPM executive core qualifications system of competencies and ra tings and tied to new Title 38 pay authority for health care leaders (see Recommendation #15). VA Administrative Changes The following administrative changes are a priori ty over the next 36 months. To assist VHA in the Commission has untability and oversight, implementing these actions and to promote acco sponsibility for action in Appendix B. provided a detailed timeline and assigned re Establish a workgroup and engage outsid  e experts to create a new performance management system for VHA leaders that is appropriate for health care executives. raters accountable for creating meaningful  Establish standards and processes to hold distinctions in performance between subordinate leaders.  The new Office for Organizational Excellence should work with experts to reorganize their internal structure to align business fu nctions with field needs and consolidate and eliminate redundant or lo w-priority activities. Other Department and Agency Administrative Changes None required.  134

149 C OMMISSION R ECOMMENDATIONS Diversity and Cultural Competence cultural and military competence among all Recommendation #14: Foster s, and staff to embrace diversity, VHA Care System leadership, provider promote cultural sensitivity, and improve veteran health outcomes. Problem The Commission Recommends That . . . The VHA Care System must implement a approach systemic to a implement VHA  systemic approach to developing the cultural and cultural establishing competence military and military competence of its leadership, staff, VHA across and providers, community its and and providers, as well as measure the effects of required integrate fully to resources the provide these efforts on improving health outcomes for delivery. care veteran’s into strategy related the vulnerable veterans. Although VHA has made Cultural competency military and be training  some strides in specific program areas, cultural basis Care for a on VHA required System regular staff, leadership, and providers. competency is an essential part of providing effective care to veterans, and must become a be criteria for Cultural  and military competency the in participate to providers allowing community strategic priority throughout the organization, Care VHA System. because of the unique needs military service, combat operations, may cause. and especially participation in Background Cultural competence is the ability of health care organizations and their providers to al, language, and in VA’s case, military service understand and respond effectively to the cultur re encounter. It has been endorsed as a viable experience brought by the patient to the health ca which health care disparities occur. VHA has skill set to reduce, if not eliminate, the rate at recognized the problem of health disparities am ong its patient population and has taken steps to address it by tasking certain internal office s with building cultural and military competence throughout the organization. For example, VHA es tablished the Office of Health Equity (OHE) and charged it with championing the efforts to identify, understand, and address health care disparities among veterans. Analysis ing and sustaining organizational and systemic There are seven essential strategies for promot 484 cultural competence. These strategies include the following:  Provide executive-level support and accountability. Foster patient, community, and stakeholder participation and partnerships.   Conduct organizational cultur al competence assessments. ltural competence action plans.  Develop incremental and realistic cu 484 Miriam E. Delphin-Rittmon et al., “S even Essential Strategies for Promotin g and Sustaining Systemic Cultural 84, (2013), 53-64. Competence,” Psychiatric Quarterly, 135

150 OMMISSION ON C INAL R EPORT F C ARE  Ensure linguistic competence.  Diversify, develop, and retain a culturally competent workforce.  Develop an agency strategy for managing staff and patient grievances. VA has taken some steps to a ddress cultural and military comp etence strategies, but these programs are not sufficient to address the breadt h and depth of the problem. These strategies will not take hold and become fully ingrained in VHA’s culture unless VHA leadership makes them a key priority and commits the resources and on-going, comprehensive training required to build cultural competencies across the entire VHA workforce. Military Competency In addition to addressing the needs of minority veterans and vulnerable veterans populations, VA must address military-specific needs and ensu re that all providers in the VHA Care System have sufficient military competency (i.e., knowledge of specific issues and health care needs of those who served in the military). VHA’s Offi ce of Academic Affiliations developed a Clinician Pocket Card for providers that includes questions fo r clinicians to ask veterans about their 485 military health history. and similar resources should be given to all VHA and The Pocket Card community providers to leverage during veteran patient medical assessments and appointments. In addition, VA’s Office of Publ ic Health (OPH) provides information on VA exposed to environmental and occupational health care programs for veterans who were ange, chemicals leading to Gulf War veterans’ hazards during military service, such as Agent Or 486 illnesses, and Camp Lejeune water contamination. This military exposure information should al competency strategy. be leveraged in VA’s cultur Health care disparities often result from patients ’ lack of trust in their health care provider; therefore, enhancing the patient-provider rela tionship is paramount in overcoming these disparities. Stereotypical thinking on the pa rt of providers about certain patient groups, 487 Specific reasons for the ly influence their prognosis. including veterans, may unwitting increase of health care disparities in th e military population include the following:  the cultural norms of the military are such that to admit or display any signs of perceived weakness, especially related to mental health issues , discourages military personnel and veterans from seeking medical care and treatment  changes in the demographical makeup of th e civilian population result in similar changes to the military population  a small but gradual increase in the number of foreign born personnel who have joined the ranks of the military 485 Department of Veterans Affairs, Office of Acad emic Affiliations, Military Health History: Pocket Card for Health Professions Trainees and Clinicians, accessed June 12, 2016, http://www.va.gov/o aa/archive/Military-He alth-History-Card- for-print.pdf. 486 “Public Health: Military Exposures,” U.S. Department of Veterans Affairs Intran et, accessed June 12, 2016, http://vaww.publichealth.v a.gov/exposures /index.asp 487 G.L.A. Harris, “Reducing Healthcare ltural Competence,” JHHSA (2011), 148. Disparities in the Military Through Cu 136

151 C R OMMISSION ECOMMENDATIONS e become more immersed in the medical  a disengaged provider culture that may hav culture than the military culture VA must make cultural and military competence a strategic priority, provide the resources needed to execute the strategy, and hold lead ership and providers, both within VHA and implementation and integration into VA’s community partners, accountable for strategy culture. Women 488 Women are the fastest growing grou p within the veteran population. As of 2011, approximately 1.8 million (8 percent) of the 22. 2 million veterans were women. Data indicate that by 2020 women veterans will comprise nearly 11 percent of the total veteran population. As the number of women veterans increases, VHA continues to prepare for an increasing demand 489 for women veterans’ health care needs. To address the health disparities affecting women veterans, VHA must provide high-quality, equitable care on par with that of men, deliver that care in a safe and healing environment, provide seamless coordination of services, and actively 490 recognize women as veterans. In the past, VHA found gaps in its ability to provide comprehensive primary care for women veterans because many primary care providers had little or no exposure to women patients and women were often referred outside of primary care for gender-specific care. To close these gaps, VHA has implemented women’s health comprehens ive primary care clinic models with the goal of providing complete primary care fr om one designated women’s health provider (DWHP) at one site. An analysis of FY 2012 data revealed that women assigned to DWHPs had more positive overall experiences with care an d were more satisfied on six composite scores decision making, self-management support, including access, communication, shared 491 492 but VA has substantially reduced gender gaps in care, comprehensiveness, and office staff. accessing care. VHA leadership must support women veterans still encounter challenges when ogramming so that women veterans receive the the future planning of women’s services and pr 493 highest quality health. LGBT Equity competency, VHA should leverage best practices In its systemwide implementation of cultural uity leader: treatment of LGBT patients. Every from an area in which the agency is already an eq year since 2007, the Human Rights Campaign has published a Health Equality Index (HEI) report that aims to measure the quality of health care for LGBT patients based on core criteria 488 “Women Veterans Health Care ,” Department of Veterans Af fairs, accessed June 12, 2016, http://www.womenshealth.va.gov/. 489 Veterans Affairs, April 2015, accessed U.S. Department of Study of Barriers for Women Veterans to VA Health Care, June 12, 2016, http://www.womenshealth.va.gov/ lth%20Services_Ba rriers%20to%20Ca WOMENSHEALTH/docs/Womens%20Hea re%20Final%20Repor t_April2015.pdf. 490 Patricia M. Hayes, Chief Consultant Women’s Health Se rvices, VHA Office of Patient Services, briefing to the Commission on Care, October 19, 2015. 491 Ibid. 492 Ibid. 493 “Women Veterans Health Care ,” Department of Veterans Af fairs, accessed June 12, 2016, http://www.womenshealth.va.gov/. 137

152 C C F INAL R EPORT OMMISSION ON ARE 494 that require health care systems to couple strong policies with appropriate training. In 2016, VAMCs made up 20 percent of all HEI particip ants. Among participating VAMCs, 84 percent 495 were designated with Leader status. VHA hospitals publicize t hat discrimination against LGBT patients and employees is prohibited. Se ered for HEI training. nior managers are regist And equal visitation rights are granted to fam ilies and friends of LGBT patients. VHA hospitals play a critical role in promoting patient care equality in states where VHA is the only Equality 496 Leader. VHA should create strong policies and mandatory training, like that used to promote health equity for LGBT patients, to address equi ty issues for racial and ethnic minorities and women. Implementation Legislative Changes  None required. VA Administrative Changes to ask patients about their military health VHA Care System providers should be required  history and incorporate veterans’ respon ses into patients’ treatment plans.  VHA leadership should support the future pl anning of women’s services and programming so that women veterans receive the highest quality health care.  VHA should leverage the best practices developed in support of LBGT equity and implement them across VHA.  VHA Care System providers should be required to attend comprehensive, on-going cultural and military competency training. Other Department and Agency Administrative Changes  None required. 494 “How the VA is leading the way on LGBT patient care ,” Andrew Park, The Week, February 25, 2014, accessed June 12, 2016, http://theweek.com/articles/ 450361/how-va-leading-way-lgbt-patient-care. 495 “Office of Health Equity: He althcare Equality In dex,” U.S. Department of Veterans Affairs, access ed June 15, 2016, http://www.va.gov/HEA LTHEQUITY/Healthcare _Equality_Index.asp 496 February 25, 2014, accessed “How the VA is leading the way on LGBT patient care ,” Andrew Park, The Week, 450361/how-va-leading-way-lgbt-patient-care. June 12, 2016, http://theweek.com/articles/ 138

153 C R OMMISSION ECOMMENDATIONS Workforce alternative personnel a simple-to-administer Recommendation #15: Create verns all VHA employees, applies best system, in law and regulation, which go to human capital management, and practices from the private sector th the private sector. that are competitive wi supports pay and benefits Problem The Commission Recommends That . . . VHA has staffing shortages and that applies system personnel alternative new a  Congress create vacancies at every level of the to all VHA employees and falls under Title 38 The authority. organization and across numerous system must simplify human capital management in VHA; critical positions, including facility for employees; and improve flexibility to increase fairness leadership, clinical staff, supply market to respond benefits, compensation, to relating conditions and recruitment. chain personnel, and customer service staff. VHA lacks and VHA write  implement regulations for the new alternative partners, personnel system, in collaboration with union competitive pay, must use of following: the all employees, and managers, that does inflexible hiring processes, and Meets benchmark standards for - human capital management in continues to use a talent HR and the health care professionals sector and is easy for management approach from the administer. managers to last century. A confusing mix of hiring. - Promotes veteran preferences and personnel authorities and position principles system merit Embodies - ‐ nonpartisan, based, (merit standards make staffing and process) sensible simplified, through due nondiscrimination, work that processes employees. and managers for management a struggle for both - Creates one human all capital management process for supervisors and human resources compensation, VHA employees in for time and leave, personnel. Title 5 was not created evaluation, advancement, performance disciplinary and with a modern health care delivery standards/processes. system in mind and falls short of to adverse standards process - appeals and Provides due offering what is needed to create a personnel actions. pay - Allows for advancement based on expertise, professional high-performing health care training, and demonstrated performance (not time ‐ in ‐ grade). system. - Promotes flexibility in organizational structure to allow of needs the as organization the positions and staff to grow Background change and the success of each individual merits. During the 1990s, Congress passed consistent is Establishes simplified job that documentation - the Government Performance and staff for across job categories and describes a clear path 497 to correct Results Act trajectories for professional development and career advancement. shortcomings in the way - Eliminates most distinctions (except for part benefits) between ‐ government was managed and and time employees. full ‐ time assessed in an effort to bring - Grandfathers current employees with respect to pay and modern business management benefits. practices into the federal resources human include all positions, to ensure VHA  government. The law was updated duties. adequately fulfill to trained management staff, are 498 in 2011, yet one essential 497 Government Performance and Results Act of 1993, Pub. L. No. 103-62, 107 Stat. 285 (1993). 498 GPRA Modernization Act of 2010, Pu b. L. No. 111-352, 124 Stat. 3866 (2011). 139

154 C INAL R EPORT F OMMISSION ON C ARE component of modernizing the management of federal programs is still missing: reform of 499 human capital management. 500 The Civil Service Act was initially passed in 1883 and revised in 1978. The general schedule , which governs the pay and job classification proc ess, was codified by regulation in 1949. The U.S. workforce, including the federal workforce, has changed dramatically since these laws and regulations were implemented. As noted in a re cent report from the Partnership for Public Service, “the personnel system, designed more than 60 years ago, now governs more than reflecting a time when most federal jobs were 2 million workers and is a relic of a bygone era, 501 As of 2013, nearly two-thirds of federal clerical and required few specialized skills.” employees work in professional or administrati ve positions focused on knowledge-based work, with the Department of Veterans Affairs acco unting for the largest percentage of such 502 workers. The Partnership for Public Service calls for broad reform of the civil service system, noting that the sconnected from the larger talent market for the federal workforce has become an island di knowledge-based professional and admini strative occupations that are mission critical. . . . Federal employee pay . . . is not tied to the broader labor market, making it harder to compete with the private sector for ta lent. That disconnect is exacerbated by a 503 job classification system that describes a workplace from the last century. top performers, demoting or firing poor This system lacks mechanisms for rewarding 504 The unnecessarily complex hiring system is performers, and holding managers accountable. challenging for hiring managers to identify the difficult for applicants to navigate and makes it most qualified candidates, hindering the ability to bring in experienced candidates from the 505 private sector. The civil service system has be come a maze of rules and proc edures that are not perceived as rational by the people who serve in gov ernment or by the general public. . . . Rigid policies . . . are now a burden on a government that needs to encourage flexibility and 506 innovation to meet rapidly changing and difficult challenges. 499 U.S. General Accountability Office, Office of the Comptroller General, Human Capital – A Self-Assessment Checklist for Agency Leaders , accessed April 11, 2016, http:// www.gao.gov/assets/80/76520. pdf. U.S. General Accountability Office, Transforming the Civil Service: Buildi accessed April 11, ng the Workforce of the Future – Results of a GAO Sponsored Symposium, 2016, http://www.gao.gov/ assets/200/197256.pdf. 500 The Pendleton Civil Service Reform Act of 1883, Pub. L. No. 16, 22 Stat. 403 (1883). 501 Partnership for Public Service, Building the Enterprise: A New Civil Service Framework , accessed April 11, 2016, https://ourpublicservice.org/pu blications/download.php?id=18. 502 Ibid. The Department of Defense in total has more know ledge workers but the numbers for each service are reported independently and are below the total for the VA workforce. 503 Partnership for Public Service, Building the Enterprise: A New Civil Service Framework , accessed April 11, 2016, https://ourpublicservice.org/pu blications/download.php?id=18. 504 Ibid. 505 Ibid. 506 Ibid. 140

155 C R OMMISSION ECOMMENDATIONS ues to point to human capital management as The General Accounting Office (GAO) also contin 507 DoD has proposed walking away from the Title 5 civil a high-risk area across government. 508 President Barack service system to support modernization of human capital management, 509 Obama has repeatedly called for a commission to overhaul and modernize the civil service, 510 and Congress is considering whether the ti me is right for civil service reform. systems: Title 5 (the civil service/general VHA currently uses three different personnel ecutive service (SES) and other, mostly nonclinical, employees; schedule system) for senior ex 509 r specified health care professionals; Title 38 for physicians, dentists, and othe and Title 38 510 Hybrid for allied health professionals such as pharmacists and license d physical therapists. Each system has its own set of requirements, pr ocedures, and rules for the employees under its 513 A employees serve in the Title 38 Currently, about two-thirds of VH respective authority. 514 Hybrid occupations. VHA is not alone in having an excepted service system. More than a dozen agencies have system to fit their particular needs, including special legislative authority to create a personnel stitutes of Health, National Security Agency, the Federal Bureau of Investigation, National In U.S. Public Health Service, Defense Intelligen ce Agency, U.S. Nuclear Regulatory Commission, 511 In an acknowledgement of the failure of and National Aeronautics and Space Administration. certain professions, OPM has also instituted the general schedule process to meet the needs of governmentwide direct hiring authority for diff icult-to-recruit positions, including medical officer, nurse, pharmacist, radiologic techni cian, and information technologist—all positions critically important to VHA’s mission success. Modernizing human capital management is a global imperative for the private sector as well, with 92 percent of participants in one assessment of 7,000 businesses noting that a new 512 According to a approach to human resources is a crit ical organizational priority in 2016. report from Deloitte, which examined broad hu man resource (HR) trends, “HR is redesigning to performance management to onboarding to almost everything it does—from recruiting 513 reward systems” to learning and development. Younger workers are driving many of these 507 Federal Workforce—Human Capital Management Challenges and the Path to Reform, Testimony Before the U.S. GAO, Subcommittee on Federal Workforce U.S. Postal Service and the Census, Committee on Oversight an d Government Reform, House of GAO-14-723T, July 15, 2014, Washington, DC, 2014, accessed June 12, 2016, Representatives, Statement of Robert Goldenkoff, http://www.gao.gov/ assets/670/664772.pdf. 508 mp of DoD Civilian Personnel System,” ral News Radio, Jared Serbu, Fede “Draft Proposal Calls for Major Reva accessed April 8, 2016, http://feder alnewsradio.com/de fense/2015/09/draft-proposal-calls -major-revamp-dod-civilian- personnel-system/. 509 e, but Offers It Nothing New,” Eric Katz, Government “Obama’s Budget Touts Progress Within Federal Workforc Executive, accessed April 8, 2016, http://www.govexec.com/management /2016/02/obamas-budget -touts-progress- within-federal-workforce-offer s-it-nothing-new/125815/. The Offi ce of Management and Budget, Fiscal Year 2016 Budget of the U.S. Government , accessed May 13, 2016, se.gov/sites/default/files/omb/b /budget.pdf. https://www.whitehou udget/fy2016/assets 509 vil Service Reform,” Andy Medici, Fe “Brace Yourselves: Congress Preps Ci deral Times, accessed April 8, 2016, http://www.federaltimes.com/story /government/management/oversight /2015/01/19/congress-civil-service- reform/21458717/. 510 Ibid. 511 See, e.g. , 38 U.S.C. § 7401(1). 512 See, e.g. , 38 U.S.C. § 7401(3). 513 Joleen Clark, Jack Hetrick, and D onna Schroeder, “Leading Ac cess Scheduling Initiative – People: Assessment of ive Personnel System (2014). Hiring Barriers,” Alternat 141

156 C ARE INAL R EPORT OMMISSION ON C F changes with expectations for meaningful work, learning opportunities, and career 514 progression. These workers have been choosing the federal government in diminishing numbers, with only 6 percent of federal empl oyees currently younger than 30 years of age 515 In VHA, millennials (those 34 and (compared to 23 percent of the civilian workforce). younger) make up only 15 percent of the workforce, but are disproportionately over- 516 represented among staff that quit VHA, at 20 percent. As of January 2016, VHA had a vacancy rate of 16 percent for all positions, despite filling more 517 VHA faces the additional challenge that 40 percent of its than 40,000 positions in FY 2015. 518 overall workforce is eligible for retirement in the next few years. This problem occurs in the 519 face of acknowledged national shortages of physicians and geographic misalignment of the 520 current health care workforce that leaves many localities short of needed providers. Taken cellence in human capital management continues together, this information makes clear that ex to be a business imperative for VHA. Analysis The human resource function within VHA needs a fundamental overhaul to increase responsiveness, efficiency, and customer service, as well as to align its orientation to the 521 business needs of VHA. Medical center directors do not receive the support they need from 522 HR to accomplish hiring, disciplining, and planning for succession of employees. During exit barriers to career growth, insufficient interviews, staff members who leave VHA cite professional development, a lack of promotions , and poor on-boarding and training as reasons 523 In a recent national survey of VA employees, improving end-to-end hiring, for departing. recognizing stellar job performance, and prov iding professional development and career 514 April 12, 2016, U.S. GAO, The Excepted Servi ce: A Research Profile, GAO/GGD- 97-92, accessed http://www.gao.gov/ assets/80/79968.pdf. 515 Partnership for Public Service, , accessed April 12, 2016, Building the Enterprise: A New Civil Service Framework blications/download.php?id=18. https://ourpublicservice.org/pu 516 rkforce Management & Consulting Offi ce, Healthcare Ta lent Management, Veterans Health Administration Wo 9 and 13, accessed June 12, 2016, VHA Workforce Planning Report 2015, http://www.vacareers. va.gov/assets/common/print/2015_VHA_Workfo rce_Succession_Stra tegic_Plan.pdf. 517 “VA Struggles to Fill Medical Center Positions in Arizona , Across Nation,” Danika Worthington, Arizona Daily Sun, accessed April 5, 2016, http ://azdailysun.com/news/local /va-struggles-to-fill-medical-center-positions-in-arizona- across/article_a14e6937-ec c1-5415-9391-7a6d759e5025.html. 518 Joleen Clark, Jack Hetrick, and D onna Schroeder, Lead ing Access Scheduling Initia tive – People: Assessment of Hiring Barriers, Alternative Personnel System (2014). 519 The Complexities of Ph IHS Inc., ysician Supply and Demand : Projections from 2013-2025 , accessed April 12, 2016, https://www.aamc.org/d ownload/426242/data/ihsre portdownload.pdf. 520 “Shortage Designation: Health Pr Underserved Areas/Populations,” ofessional Shortage Areas & Medically Resources and Services Admini stration, accessed April 12, U.S. Department of Health and Human Services, Health .gov/shortage/. 2016, http://www.hrsa 521 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership) , x, accessed April 11, 2016, http://www.va.gov/opa/choiceac ssment_L_Leadership.pdf. t/documents/assessments/Asse 522 Ibid., vii. 523 Veterans Health Administration Wo rkforce Management & Consulting Offi ce, Healthcare Ta lent Management, VHA Workforce Planning Report 2015 , 9 and 13, accessed June 12, 2016, rce_Succession_Stra tegic_Plan.pdf. va.gov/assets/common/print/2015_VHA_Workfo http://www.vacareers. 142

157 C OMMISSION ECOMMENDATIONS R and nine respectively as top priorities for improving the planning ranked, numbers one, six, 524 employee experience at VA. rt a High-Performing Health System. The Civil Service System Does Not Suppo ly complex environment. Federal rules and Recruitment in VHA operates in an incredib 525 For example, g than it is in the private sector. regulations make HR more challengin interviews in 2014 with more than 500 VHA hiri ng managers and HR staff members pointed to the top problems with Title 5 recruitments as OP M classification standards , grading of position 526 The group and the ranking and rating process. descriptions, position characterization, specifically noted that there are many staff posi tions required in a health care delivery system that do not translate into a general schedule o ccupational series; theref ore, when the positions mpete with the private se ctor. Examples of such are graded, the grade and salary is too low to co ployees need to apply antiseptic cleaning positions are custodial workers (hospital em and general facilities and equipment maintenance techniques, but general custodians do not) tenance of such items as specialized medical (hospital employees need to understand the main equipment, positive pressure rooms, and sterile plumbing systems that are not requirements for 527 In another example, VHA managers noted general plant maintenance at an office building). that the OPM classification standard for suppl y chain positions rend ered VHA unable to 528 compete for local talent because the assigned grade was too low. 529 entified as a barrier to career advancement. The general schedule system also has been id annot advance in pay and responsibility without Clerical staff members in particular often c 530 Similarly, frontline customer leaving their positions and moving into a different job series. service staff under the general schedule cannot receive advanced steps within the grade for ifications or degrees, unlike nurses and allied better performance or completing job-related cert 531 health professionals who can receive adv ances in pay for these accomplishments. 532 “HR is expected to fill a position The hiring process in VHA is acknowledged to take too long. ents, even if perfectly executed, take about 49 within 60 calendar days . . . but process requirem 524 First,” MyVA Advisory Committee (MVAC), Meeting #4, February 1-2, 2016, 103. “MyVA, Putting Veterans 525 Independent Assessment of the Health Care Delivery Systems and Management Processes of the McKinsey & Company, Inc., , 110, accessed April 11, 2016, Department of Veterans Affairs, Assessment L (Leadership) t/documents/assessments/Asse ssment_L_Leadership.pdf. http://www.va.gov/opa/choiceac 526 Donna Schroeder, Veterans Health Administration Leading Access Scheduling Joleen Clark, Jack Hetrick, and of findings, July 29, 2014. Initiative – People. Powerpoint 527 Veterans Health Administration, “Lea ding Access Scheduling Initiative – Pe ople, Assessment of Hiring Barriers,” VHA Classification Workgroup, 2014. 528 Independent Assessment of the Health Care Delivery Systems and Management Processes of the McKinsey & Company, Inc., Department of Veterans Affairs, Assessment J (Supplies), xiii, accessed December 28, 2015, http://www.va.gov/opa/choiceac ssment_J_Supplies.pdf. t/documents/assessments/Asse 529 Ibid. 530 “Classification and Qualification: Classifying General Sche dule Positions,” U.S. Office of Personnel Management, accessed November 24, 2015, https:// fication-qualifications/classifying- www.opm.gov/policy-data-oversight/classi general-schedule-positions/. 531 Pay Administration, VA Directive 5007 ( 2002). Staffing, VA Directive 5005 (2002). 532 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership) , 109, accessed April 13, 2016, ssment_L_Leadership.pdf. http://www.va.gov/opa/choiceac t/documents/assessments/Asse 143

158 C C F INAL R EPORT OMMISSION ON ARE compared to private-sector hiring that takes to 62 days.” Hiring timelines can span 4-8 months 533 between 0.5 and 2 months. This finding was echoed in a Northern Virgin ia Technology Council report on information ss the board hiring of needed staff proceeds too technology challenges in VA that indicated acro of the delay can be traced to redundant, slowly. “The causes are complex, but much 534 One driver of extended VHA hiring times is inconsistent, and inefficient hiring processes.” the government background checks and the licensing and credential review for clinical staff that 535 is managed through VetPro, an internet-enabled data bank for credentialing VHA personnel. Although addressing recruiting and hiring problems will not be easy, doing so is essential to 536 maintaining VHA’s workforce. An internal VHA workgroup that examined HR concluded that a complete break with Title 5 and a rewo rking of current Title 38 hiring authority is required, stating: The existing Personnel system does not meet today’s market or demand. With VHA’s ificant turn-over rate in critical positions, it is tremendous volume of occupations to hire and sign organizational system to be able to hire qualified candidates as necessary to promote an efficient quickly as possible. The current classification syst em led to disparity across the systems and only looks at the duties of the position versus the qualifications of th e person. The VHA hiring system must be agile and attractive to recruit those th at just graduated or are entering the workforce... An agency specific excepted employment system would allow VHA to meet the unique staffing 537 demands that are required of a complex health care organization. VHA is Not Competitive in Pay for Many Positions Many VHA staff have substantially lower ea rning potential than their private-sector age and the possible opportunities for greater counterparts. Despite a generous benefits pack work–life balance, and for research and teaching in a system that serves the important role of caring for the nation’s veterans, lower salari es reduce VHA’s competitive edge in the 538 For example, although VHA is often able to marketplace when trying to attract top talent. provide physicians an entry salary that is comparable or better than industry standards, physicians’ long-term earning potential is dramat ically less in VHA than that of their private- sector peers. “At the top of the salary ranges, VHA providers made less than their counter parts 533 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment F (Workflow-Clinical), 45-49, accessed May 13, 2016, http://www.va.gov/opa/c ssment_F_Workflow_Clinical.pdf. hoiceact/documents/assessments/Asse 534 Northern Virginia Technology Council, Opportunities to Improve the Scheduling of Medical Exams for America’s Veterans, 12, accessed April 25, 2016, ht tp://www.va.gov/opa/choiceact/document s/NVTCFinalReporttoVA-revised3.pdf. 535 Grant Thornton, stems and Management Processes of the Department of Independent Assessment of the Health Care Delivery Sy Veterans Affairs, Assessment G (Sta ffing/Productivity/Time Allocation) , 37, accessed April 13, 2016, ceact/documents/assessme nts/Assessment_G_Staffing _Productivity.pdf. http://www.va.gov/opa/choi 536 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership) , 110, accessed April 13, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_L_Leadership.pdf. 537 Donna Schroeder, Veterans Health Administration Leading Access Scheduling Joleen Clark, Jack Hetrick, and Initiative – People, Alternative Personnel System Workgroup Report, August 2014. 538 Grant Thornton, Independent Assessment of the Health Care Delivery Sy stems and Management Processes of the Department of Veterans Affairs, Assessment G (Sta ffing/Productivity/Time Allocation) , 39, accessed April 13, 2016, ceact/documents/assessme nts/Assessment_G_Staffi ng_Productivity.pdf. http://www.va.gov/opa/choi 144

159 C R OMMISSION ECOMMENDATIONS only specialties for which VHA physicians made by up to $310,000 and on average, $74,631. The equal to or more than industry averages were anesthesiology, nephrology, ophthalmology, and 539 In another example of barriers to competit ive pay, current provisions in law limit psychiatry.” VA to a 60 percent level of market pay compensati on for allied health professionals, even when 540 As noted above in the recruitment failures demonstrate the need to offer higher salaries. to appropriately classify positi ons also leads to a salary that discussion on classification, failure is not competitive with private-sector health ca re organizations for positions such as customer service personnel. In the area of educational debt repayment re lief, VHA lags behind other federal and state agencies that use such programs to fill critical physician shortages in medically under-served 541 VHA can offer up to a maximum of $60,000 for 2 years ($30,000 per year). HRSA areas. three programs: the NHSC loan repayment National Health Service Corps (NHSC) runs yments, the Student-to-Student Loan Repayment program that provides up to $50,000 in loan pa Program for up to $120,000, and the State Loan Repayment Program with each state 542 These amounts range broadly establishing loan amounts that are administered by HRSA. from $80,000 in Arizona and Arkansas, $90,000 in Colorado, $100,000 in Georgia and Alabama, 543 and $190,000 in California. Clinic Staffing Is Impaired by Cu rrent Law, Regulation, and Policy Successfully reallocating staff to meet veter ans’ needs in a rapidly evolving health care environment is difficult in VHA. The Independent Assessment recommended that VHA use extended clinic hours and weekend clinics to be tter optimize space and increase access to care 544 VA policy currently prohibits full-time VA physicians from receiving fee-basis for veterans. h they are salaried, although they can, under compensation from the same VA facility in whic 545 certain circumstances, receive fee-basis appointments at other VA facilities. policy requirements for night and weekend These restrictions can make it hard to meet 546 without reducing staffing on inpatien t units or under-resourced primary care schedules clinics. Use of alternative work schedules and ov ertime pay for physicians to meet local patient demands should be under control of local medical center directors. 539 Ibid., 40. 540 sic Pay, 38 U.S.C. § 7455. Increases in Rates of Ba 541 Joleen Clark, Jack Hetrick, and Donna Schroeder, Veterans Health Administration Leading Access Scheduling Initiative – People, Alternative Personnel System Workgroup Report, August 2014. 542 “Loan Repayment Program,” U.S. Depa rtment of Health and Human Services , National Health Service Corps, accessed June 9, 2016, http:// nhsc.hrsa.gov/loanrepayment/. 543 “Physician Loan Repayment Guide,” Jimmy Karnezis, accessed April 13, 2016, https://www.credib le.com/blog/physician-lo an-repayment-guide/. 544 Grant Thornton, Independent Assessment of the Health Care Delivery Sy stems and Management Processes of the Department of Veterans Affairs, Assessment G (Sta ffing/Productivity/Time Allocation) , 136, accessed April 13, 2016, http://www.va.gov/opa/choi nts/Assessment_G_Staffi ng_Productivity.pdf. ceact/documents/assessme 545 VA Handbook 5005, pt. II, ch. 3, § A, para. 3b. 546 Extended Hours Access for Veterans Requiring Primary Care Including Women’ s Health and Mental Health Services at Department of Veterans Affairs Medical Centers and Se lected Community Based Outpat ient Clinics, VHA Directive 2013-001 (2013). 145

160 C C F INAL R EPORT OMMISSION ON ARE ning Including at Initial Hire VHA Staff Receive Inadequate Trai ing mandatory onboarding traini ng that introduces policies, Leading practices include provid rams include various activities that expose procedures, and necessary skills. Onboarding prog pectations based on roles and responsibilities. new hires to the culture of the organization and ex an Resources Management suggests, “Formal A report released by the Society for Hum orientation programs help new employees understand many important aspects of their jobs and organizations, including the company’s culture and values, its goals and history and its power 547 To make up for inadequate on-boarding and to fill current staff’s understanding of structure.” s, with 60 facilities having VA, VHA is providing VA 101 training for current employee 548 Employees in VA continue to desire a wide array of completed the training in FY 2015. training, including customer serv ice training, professional develo pment, peer-to-peer training, 549 le-specific training. hands-on training, and ro and Business Priorities Not Compliance HR Professionals Must Focus on People have unsatisfactory recruiting experiences, noting failures in VHA job candidates indicate they 550 VA human resources management and administration timely follow-up and communication. indicate that VA HR professio nals do not exhibit a uniform level of competency, frequently do not understand the employee recruitment process end-to-end, and fail to provide high quality consultative support to managers with respect to a ll HR functions, but particularly in the area of 551 Currently HR professionals in VA are largely progressive discipline and firing of employees. 552 rather than adding true value to the focused on compliance with a complex set of rules, rs in accomplishing VHA business objectives. organization and being able to be full partne Resolving these staffing issues would render the overall HR function more effective. tract and retain the very best health care VHA must become the employer of choice to at workforce. To help it accomplish this goal, VH A requires competitive pay and flexible hiring and talent management processes. VHA cannot achi eve that goal within its current personnel em under Title 38 for all VHA human capital systems. A uniform alternative personnel syst management would accomplish all of the following:  Meet the unique staffing demands of a health care delivery organization.  Allow market-based compensation and pay-se tting latitude using broad pay bands to support staff growth and progression with in their job. VHA must consider total compensation (with benefits), as compared to market rates because the government provides many more benefits than private- sector organizations. Consequently, VA may 547 2010, 9-10, Talya Bauer, Society for Human Resource Management, Onboarding New Employee s: Maximizing Success, accessed May 13, 2016, https://www.sh rm.org/about/foundati nboarding percent20epg- on/products/documents/o percent20final.pdf. 548 , Veterans Health Administration , Blueprint for Excellence: Fiscal Year 2015 Results: Co mmunicating Accomplishments presented to the National Leader ship Committee, March 22, 2016. 549 “MyVA, Putting Veterans First,” MyVA Advisory Committee (MVAC), Meeting #4, February 1-2, 2016, 103. 550 McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership) , 110, accessed April 13, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_L_Leadership.pdf. 551 Sam Retherford, Principal Deputy Assistant Secretary for Human Resources and Admi nistration, Department of workgroup of the Commission ber 15, 2015. Veterans Affairs, speaking to the leadership on Care, Decem 552 Ibid. 146

161 C R OMMISSION ECOMMENDATIONS position, but the total compensation (with pay less than private-sector employers for a to private-sector total compensation. benefits) may end up being equivalent Allow flexibility in the processes used to hire staff including direct hiring when needed.  Support career planning and professional development through the application of  competency models and training specific for he alth care as part of position management.  Simplify the management tasks for supervisor s and hiring managers who will only need to know one set of rules and processes instead of four. Simplify the job of HR professionals who will only need to know one set of rules and  processes instead of four.  Allow development and training of the HR workforce in VHA to focus on only one personnel system to create true end-to-end hiring expertise.  Reduce competition within government wher e shortages of HR professionals create competition for Title 5 trained HR professionals. approach to discipline and dismissal.  Create streamlined and uniform standards and  cation pay, salary, awards and bonuses, and Create fairness among staff in sick leave, va compensatory time off.  Support flow of staff between the field and VHA Central Office (VHACO) under a single personnel system. em in VHA will neither be easy nor quick, Establishing a new human capital management syst that is wrong with recruitment, retention, nor will it be a panacea that alone will fix all development, and advancement. In designing and implementing a new system, VHA must take full advantage of private-sector resources and expertise in human resource management and ensure that the new system is built to be co mpatible with the private-sector. As VHA moves toward greater integration of care delivery, with networks of community providers, compatibility in personnel systems and a resu lting greater flow of employees between VHA and community sites can help create closer linka ges between the two parts of the care delivery system. Implementation Legislative Changes  Create a simple-to-administer alternative personnel system, in law and regulation, which governs all VHA employees, applies best practices from the private sector to human capital management, and supports pay and benefits that are competitive with the private sector.  Update student loan reimbursement limits to be competitive with other federally administered programs and market conditions. 147

162 C F INAL R EPORT ARE OMMISSION ON C  Establish an appeals process that provides st aff appropriate due process that is based on the regulatory standards for the new alternative personnel system. VA Administrative Changes  Eliminate barriers to creating hiring pool s for positions with frequent turnover candidates can continue to be hired from a (e.g., extend the length of time over which completed certification until all of the qua lified candidates are hired or have declined offers). ies are anticipated;  Eliminate barriers to initiating a recruitmen t process when vacanc t ensues. In some cases, hires should also positions need not be empty before recruitmen nnel to allow for on-the-job training and be made before the departure of key perso mentoring of the replacement. Benchmark credentialing to private-sector  processes and consider outsourcing the process as much as practicable through centralized mechanisms. rmation to the field for all job categories  Release market pay and total compensation info using commercially available data and in formation, at least every 2 years. Administrative Changes Other Department and Agency OPM should continue to oversee and administ  er benefits for VHA but not impose any of the other existing conditions or requirements on the management of the new alternative personnel system. The new personnel system sh ould be governed by the new legislative the anticipated rulemaking process in VA. requirements and those established during pay, performance awards, or performance These requirements include market-based and disciplinary processes other than those imposed under Title 38. 148

163 C R ECOMMENDATIONS OMMISSION d VHA executives to lead the Recommendation #16: Require VA an transformation of HR, commit funds, an d assign expert resources to achieve an effective human capita l management system. Problem The Commission Recommends That . . . Effective planning for and management of holds who leader talent chief a hire VHA  human capital are core enabling for responsibility operation’s entire HR the enterprise, requirements for any organization. If the the with invested is authority budget to and system that supports the employees fails, the envisioned transformation, and accomplish then the organization fails. Executive leaders the CVCS. to reports directly must ensure the success of human capital VA  human of transformation the prioritize VHA and management; however, for too long in VA, attention, management capital with adequate human capital management has not been a funding, and continuity vision of executive from leaders. top priority for leadership time, attention, and functions HR align VA  consistent be to processes and funding support. Human capital with practice standards of high performing ‐ best management personnel must be equal health care systems. members of the leadership team, and Administration and Resources Human VA  the contributing fully to strategic decisions and of Office and should Technology create Information planning for future initiatives. technology HR information plan to support an of the modernization HR processes and to provide Background for meaningful data improvement, tracking, quality As recognized by GAO, “to attain the and accountability. highest level of performance and accountability, federal agencies depend on three enablers: people, process, and technology. The most important of these is people, because an agency’s people define its character and its 553 capacity to perform.” Human capital management, although often viewed as a cost, must be 554 viewed as an investment in business success. For too long, VA human capital management has been undervalued and under resourced. A 1993 report from GAO outlined many of the same deficiencies found in 2016: a focus on comp liance instead of outcomes, a lack of proactive human capital planning and management, and a weak system of rewards and incentives to 555 attract and retain qualified personnel. Today, VA Human Resources and Administrati on (HRA) shares responsibility for human capital management with VHA. Neither organi zation has been able to establish a high- performing, effective, human capital management system. For VHA to transform to a high- performing organization, human capi tal management must do the same. Analysis re support function s (including human VA “needs a fundamental overhaul of the co resources) . . . to increase responsiveness and efficiency and improve customer service. These functions should be aligned with the needs of the VHA organizations delivering care to 553 U.S. General Accountability Office, Human Capital: A Self-Assessment Checklist for Agency Leaders , GAO/OCG-00-14G, version 1, September 2000, 3, ac cessed June 10, 2016, http:// www.gao.gov/assets /80/76520.pdf. 554 Ibid. 555 U.S. General Accountability Office, Management of VA: Improved Human Resource Planning Needed to Achieve Strategic GAO/HRD-93-10, March 1993, accessed June 10, 2016, http://www.gao.g Goals, ov/assets/220/217512.pdf. 149

164 OMMISSION ON C R EPORT INAL C F ARE 556 Veterans.” an capital management is fragmented and Governance and responsibility for hum 557 complicated. Medical center directors appear to be largely on their own in addressing human capital management needs, without competen t and timely assistance to support hiring 558 Recruiting takes too long employees, planning for succession, and taking disciplinary actions. and is cumbersome because information is not various organizational shared freely among the 559 components. Candidates are not treated with respec t, experience lengthy intervals between contacts from VA, fail to receive timely follow-up once candidates are selected, and experience a 560 Human capital management also fails to effectively support the lengthy on-boarding process. 561 disciplinary process, which is percei ved as too long and too difficult. Insufficient resources 562 are devoted to training, leaving VHA vulnerable to failure. man resources function to be more responsive, VA requires a comprehensive redesign of the hu 563 more efficient, and more focused on customer service. Transforming HR will require “redesigning key processes, shifting the mindse t of [human resources] staff from compliance to effectiveness, training [human resources] and it s customers on key roles and responsibilities, 564 and rationalizing its technology systems.” Some progress has been made in updating hum an capital management functions. VA is in the process of implementing new talent management software to provide better process 565 566 HRA has also started a new HR Academy. The academy is management and analytics. 567 intended to demonstrate alignment between tr aining resources and competency requirements and to describe the experience needed to ad vance to the next position level in human 568 resources. VA instituted a new online senior ex ecutive service performance management system that permits real-time tracking of th e performance management process and analysis of 556 very Systems and Management Processes of the The MITRE Corporation, Independent Assessment of the Health Care Deli 37, accessed January 26, 2016, Department of Veterans Affairs, Volume 1: Integrated Report, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 557 The MITRE Corporation, very Systems and Management Processes of the Independent Assessment of the Health Care Deli Department of Veterans Affairs, Assessment L (Leadership), 110, accessed January 26, 2016, t/documents/assessments/Asse http://www.va.gov/opa/choiceac ssment_L_Leadership.pdf. 558 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, L3, accessed January 26, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 559 Independent Assessment of the Health Care Deli very Systems and Management Processes of the The MITRE Corporation, Department of Veterans Affairs, Assessment L (Leadership), 109, accessed January 26, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_L_Leadership.pdf. 560 Ibid., 110. 561 Ibid., 61. 562 Ibid., 67. 563 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the L5, accessed January 26, 2016, Department of Veterans Affairs, Volume 1: Integrated Report, act/documents/assessments/ integrated_report.pdf. http://www.va.gov/opa/choice 564 Ibid. 565 for Human Resources and Admi nistration, Department of Sam Retherford, Principal Deputy Assistant Secretary Veterans Affairs, speaking to the leadership workgroup of the Commission on Care, Decem ber 15, 2015. 566 Ibid. 567 Department of Veterans Affairs, HR Academy, TMS User eIDP Checklist, accessed January 25, 2016, www.vahracademy. va.gov/docs/TMSUsere IDPChecklist.pdf. 568 “VA HR Academy: Reso urces,” Department of Veterans Af fairs, accessed January 25, 2016, www.vahracadem y.va.gov/resources.asp. Depart ment of Vetera ns Affairs, VA HR Competency Model Reference Guide, va.gov/docs/VAHRCompetencyM www.vahracademy. odelReferenceGuide.pdf. accessed January 25, 2016, 150

165 C OMMISSION ECOMMENDATIONS R 569 performance outcomes; however, HR specialists must still use as many as 30 different IT 570 systems that do not communicate with each other to do their work. Although some new r them is not guaranteed by the Office of systems have been purchased, life cycle funding fo Information and Technology and no concrete plan has been approved to replace and consolidate the many current systems that are not interoperable. In addition, funding support for HRA initiatives overa ll are not planned, allocated, and maintained at consistent levels year- 571 to-year in the departmental budget, impeding long term transformation. A VHA workgroup was formed with HR subject matter experts and leadership to identify hiring barriers and develop recommendations for improvements. The workgroup fielded a VHA on the deficiencies in the management of survey in July 2014 to gather broad input from that VHA should move to a new alternative human capital in VHA. These experts concluded 572 personnel system under Title 38. (See Recommendation #15.) Substantial deficiencies in human capital management still remain in VA. The funding mechanism to support the departments’ human capital management does not support long- range planning and effective program implementa tion. The lines of authority and management ofessionals do not permit cons istency in the quality and skill for human capital management pr of the human capital management professionals hired and promoted, nor does the reporting gement staff accountable for effective service structure allow HRA to hold human capital mana delivery. The investment in human capital management information technology systems has 573 been inadequate for decades. Top leadership, including the SECVA, DEPSECVA , and CVCS, must make the transformation ed by investing their personal time in human of human resources a top priority as demonstrat capital management transformation; reviewing and endorsing a transformation plan including g regular progress updates; and engaging in the funding required to accomplish it; receivin management leaders to refine and advance problem-solving sessions with human capital transformation efforts. Top leadership must de monstrate to other leaders that human capital management transformation is an organizational priority by disseminating clear goals for transformation in planning documents, communicati ng expectations for change that are clear to subordinate leaders and employees. The CVCS all key employees, and sharing successes with e human capital management function has the must ensure that the executive who leads th in human capital management to competently demonstrated knowledge, skills, and experience lead the function and make this individual part of the executive leadership team on par with erations. (See suggested organization chart in other key functions like finance and clinical op Recommendation #12.) 569 Sam Retherford, Principal Deputy Assistant Secretary for Human Resources and Admi nistration, Department of Veterans Affairs, speaking to the leadership on Care, Decem ber 15, 2015. workgroup of the Commission 570 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Assessment L (Leadership), 24, 110, accessed January 26, 2016, http://www.va.gov/opa/choiceac t/documents/assessments/Asse ssment_L_Leadership.pdf. 571 for Human Resources and Admi nistration, Department of Sam Retherford, Principal Deputy Assistant Secretary Veterans Affairs, speaking to the leadership workgroup of the Commission on Care, Decem ber 15, 2015. 572 Ibid. 573 Ibid. 151

166 C C F INAL R EPORT OMMISSION ON ARE subordinate leaders in the transformation The SECVA, DEPSECVA, and CVCS must engage ve informed the transformation solutions; that process by ensuring the needs of these leaders ha onsibilities under the transformation plan; and subordinate leaders are assigned specific resp they are held accountable by the CVCS for ou tcomes. They must also ensure that the HR transformation and ongoing HR function is adequately resourced to be successful. The VA HRA and VHA Workforce Management Office must engage change management experts to undertake a review of human resour ce business processes, management structures, funding, and technology needs to create a transformation agenda and human capital management plan. As VHA is shifting to a new al ternative personnel system under Title 38, the human capital management plan should consolidat e in VHA the HR functions, responsibility, and authority required to hire, manage, develop, reward, and discipline staff and consider whether functions such as benefit managem ent remain with HRA or move to VHA. Furthermore, the plan should addr ess all of the following issues:  need for a chief of talent management  consistency with benchmark standards of private-sector health care systems  key organizational structures and roles and responsibilities of VA and VHA in human capital management that are clearly defined and consistent with benchmark organizations the full life cycle of human capital managem ent (i.e., planning, recruitment, hiring,  retention, development, performance management, and discipline), which should be anagement and fully meet the needs of supported effectively by human capital m managers and staff  federal sharing authority and the ability to outsource human capital management e sector are addressed functions to the privat  IT investments and analytical capability to provide meaningful, timely data to managing staffing, performance tracking, and accountability  meaningful performance metrics and risk mana gement indicators that are established 574 for human capital management  affing for human capital functions that funding and full-time equivalent employee st meet private-sector benchmark standards for health care  knowledge, skills, and ability required of hu man capital management professionals at each grade and within each series, which sh ould be clearly defined, and a requirement to assess current staff, new hires, and prom otions against this standard, which should include procedures for dismissal 574 U.S. General Accountability Office, Human Capital: A Self-Assessment Checklist for Agency Leaders, GAO/OCG-00-14G, ttp://www.gao.gov/assets/80/76520.pdf. 2000, 34, accessed June 10, 2016, h version 1, September 152

167 C R OMMISSION ECOMMENDATIONS be shared widely within the department to Once completed, this analysis and draft plan must gain feedback and input, and it must be shared with OPM, OMB, and Congress. After incorporating feedback and finalizing the plan, HRA should engage change management experts to fully implement the transformation agenda and new human capital management ributions from VA and VHA that the SECVA plan. Implementation will require funding cont must mandate. HRA must develop and implement an effective prog ressive discipline process for all staffing authorities (i.e., Title 5, Title 38, Title 38 Hybrid, Title 38 7306 , and SES). This process must include clear standards, guidelines, and traini ng for supervisors and managers on how to implement the new progressive discipline proc ess. All managers and supervisors and human capital management professionals must complete the training, and VA mu st establish a process for ensuring that new supervisors and managers complete the training on an ongoing basis. HRA must develop HR staff to be effective co aches so they can provide the coaching and support that managers need as they embark on disciplinary procedures to ensure timely and effective interventions. VHA supervisors and managers must be held acco untable for applying these procedures when poor performance or conduct occurs. To enab le accountability, VHA must have a technology infrastructure to actively track and manage p oor performance (annual ratings and disciplinary keep track of issues. actions) that both human capital managers and supervisors can use to The Commission notes GAO is launching a comp rehensive audit of human capital management 575 functions in VA to be delivered to Congress in September 2016. The review and resulting recommendations will provide further insights to promote meaningful transformation of human capital management in VHA. Implementation Legislative Changes  None required. VA Administrative Changes The following administrative changes are a priori ty over the next 36 months. To assist VHA in implementing these actions and to promote acco untability and oversight, the Commission has provided a detailed timeline and assigned re sponsibility for action in Appendix B.  Employ HR and change management experts to undertake a review of its business processes, management structures, funding, technology, and the legal authority needed in HR to create a transformation agenda and human capital management plan.  Require VHA to allocate budget to fully support the change plan and ongoing HR operations. 575 Ms. Frieda Stenzel, lead in vestigator, U.S. Government Accountability Office, during an initial meeting with VACO HR&A about a new study being undertaken by GAO, Decemb er 18, 2015. The study is intended to 1) assess VHAs capacity to perform its workforce planning and talent management, and 2) evaluate the effectiveness of VHAs human capital functions. 153

168 OMMISSION ON C F INAL R EPORT C ARE  Develop and implement an effective progressi ve discipline process for all staffing authorities. Other Department and Agency Administrative Changes None required.  154

169 C R OMMISSION ECOMMENDATIONS Eligibility a streamlined path to Recommendation #17: Provide eligibility for health rge who have substantial care for those with an ot her-than-honorable discha honorable service. Problem The Commission Recommends That . . . Addressing access issues is at the core of the to regulations its revise VA  tentative eligibility provide Commission’s charge. Veterans face a range to receive health care with members service former to honorable ‐ than ‐ other an to likely are who discharge of barriers to care, from geographic barriers be deemed eligible their substantial because of to facility-specific problems, such as long that extenuating circumstances or favorable service wait times for an appointment or lack of mitigate conduct. disqualifying of finding a evening or weekend hours. These barriers, which affect even those with service-incurred he alth conditions, can be overcome. Some former more fundamental barrier when applying for service members, however, have encountered a they are not considered veterans, and thus are care. Because of the character of their discharge, not eligible for VA care. ssed from military service with an other-than- In some cases, individuals have been dismi honorable (OTH) discharge because of actions that resulted from health conditions (such as traumatic brain injury, posttrauma tic stress disorder [PTSD], or substance use) caused by, or exacerbated by, their service. Under VA regu lations, these individu als do not meet the definition of a veteran, and are therefore ineligib le for VHA medical care. This situation leaves a group of former service memb alth issues (namely mental ers who have service-incurred he health issues) unable to receive the specialized care VHA provides. Background 576 eligibility for all VA benefits, Veteran status is the basis for and under law a veteran is a person who has met three criteria: active-duty milit ary service (subject to specified exceptions), 2 years of continuous service, and discharge or separation from the military under conditions 577 other than dishonorable. s into one of five categories: The military characterizes discharge honorable, general (under honorable conditions), OTH, bad conduct (adjudicated by a general 578 court or special court-martial), and dishonorable. Congress has established specific bars to VA bene fits. Those barred by statute include deserters, individuals sentenced by a general court-martia l, and conscientious objectors who refused to 579 perform military duty. VA regulations interpret the phrase “discharged or released . . . under conditions other than dishonorable” to mean that a discharge or release because of one of the been issued under dishonorable conditions: following offenses is considered to have (1) acceptance of an OTH discharge to escape tr ial by general court-martial, (2) mutiny or 576 Congressional Research Service, Veterans’ Benefits: The Impact of Military Discharges on Basic Eligibility , 3, accessed May 26, 2016, https://www.fas.org/sg p/crs/misc/R43928.pdf. 577 Veterans Benefits , 38 U.S.C. § 101(2). 578 Congressional Research Service, Veterans’ Benefits: The Impact of Military Discharges on Basic Eligibility , 3, accessed May 26, 2016, https://www.fas.org/sg p/crs/misc/R43928.pdf. 579 Certain Bars to Benefits, 38 U.S.C. § 5303(a). 155

170 C INAL R EPORT F OMMISSION ON C ARE spying, (3) an offense involving moral turpitud e, (4) willful and persistent misconduct, and 580 (5) certain homosexual acts invo lving aggravating circumstances. Limited exceptions to those statutory and regula tory bars permit VA to award of benefits. A claimant may be granted benefits if VA determin es that the claimant was insane at the time of 581 Benefits may be granted based on a prior period of other- the offense leading up to discharge. 582 than-dishonorable service fo r individuals with two or more periods of service. Former service members with an OTH discharge as a result of a regulatory (rather than a 583 Former service statutory) bar are eligible for VA ca re for service-incurred conditions. members with OTH discharges are not recognized as veterans, so they will be routinely denied treatment unless they initiate, and prevail in , an adjudication conducted by the Veterans their discharge. No routine mechanism exists to Benefits Administration as to the character of trigger adjudication to determine if such a disc harge is not dishonorable. In many instances, the character of an individual’s disc harge is predicated on behaviors that resulted from, or are linked to, behavioral health conditions that had th eir origin in service, yet VA regulation bars 584 the individual from receiving benefits. Analysis Veterans’ benefits are understood to be earned. The principle has been described as follows: In harsh environments in which lives may be on the line, serious breaches of conduct that interfere with the military mission should rightfully brand the offender for life and should likewise prohibit them from being eligible for the specia l military benefits and entitlements reserved for 585 honorable and meritorious service. of the misconduct must be taken into account Some argue the offender’s mental state at the time 586 when considering veteran status. For example, many servic e members have experienced combat and sustained psychological wounds of war that manifest behaviors that lead to 587 ccount for the role of those psychic VA regulations not only fail to a military discipline. wounds, but are themselves overbr oad, weak discriminators as to what is truly dishonorable fied two regulatory bars as particularly service. To illustrate, commentators have identi 588 589 problematic: those based on moral turpitude, and willful and persistent misconduct. 590 are defined; neither provides Neither of those two regulatory terms, which originated in 1944, 580 Characters of Discharge, 38 C.F.R. 3.12(d). 581 Certain Bars to Benefits, 38 U.S.C. § 5303(b). 582 Congressional Research Service, Veterans’ Benefits: The Impact of Military Discharges on Basic Eligibility , 3, accessed May 26, 2016, https://www.fas.org/sg p/crs/misc/R43928.pdf. 583 Sec. 2, Pub. L. No. 95-126, 91 Stat. 1106 (1977). 584 Certain Bars to Benefits, 38 U.S.C. § 5303(a). Characters of Discharg e, 38 C.F.R. 3.12(d). 585 Major John Brooker, Major Evan R. Rogall, “Beyond ‘T.B.D .’: Understanding VA’s Seamone, and Leslie C. s Benefit Eligibility Following Involunt ary or Punitive Di Evaluation of a Former Servicemember’ scharge from the Armed Forces,” Military Law Review, 214, Winter, (2012): 12-13, accessed June 25, 2016, https://www.loc.gov/rr/f rd/Military_Law/Military_Law_Review /pdf-files/214-winter-2012.pdf. 586 Ibid., 13. 587 Ibid. 588 Characters of Discharge, 38 C.F.R. 3.12(d). 589 Ibid. 590 Major John Brooker, Major Evan R. Seamone, and Leslie C. Rogall, “Beyond ‘T.B.D .’: Understanding VA’s ary or Punitive Di s Benefit Eligibility Following Involunt scharge from the Evaluation of a Former Servicemember’ 156

171 C OMMISSION ECOMMENDATIONS R covered. Both are ambigu ous and susceptible to criteria or examples of what is or is not 591 subjective judgment, regional offices reaching different with great potential for different VA 592 outcomes on the same facts. that these terms are broad and VA officials have acknowledged 593 and advocates have documented the resu ltant disparities in VA adjudicative imprecise, 594 decisions. the bar-to-benefits rules—that the person was The only specific mental-health exception to 595 insane at the time of the commission of offense —is very limited. VA regulations define the term insane , as follows: An insane person is one who, while not mentally defective or constitutionally een engrafted upon such basis condition, psychopathic, except when a psychosis has b exhibits, due to disease, a more or less prolonged deviation from his normal method of behavior; or who interferes with the peace so departed (become of society; or who has e community to which by birth and education antisocial) from the accepted standards of th further adjustments to the social customs of he belongs as to lack the adaptability to make 596 the community in which he resides. VA’s Office of General Counsel (OGC), in a no w almost 20-year old precedential opinion, has ng to a request for an opinion regarding the construed that regulation narrowly. Respondi parameters for behavior that would constitute insanity under the regulation, the General Counsel advised, as follows: The question of insanity arises in numerous legal proceedings, and its meaning may vary according to the jurisdiction and the object or purpose of the proceeding. However, in all contexts, the term indicates a condition invo lving conduct which deviates severely from the social norm. Black’s Law Dictionary, at 794, states that ‘[t]he term is more or less synonymous with . . . psychosis, which it self has been defined as “a mental disorder characterized by gross impairment in reality testing’ or, in a more general sense, as a mental disorder in which ‘mental functionin g is sufficiently impaired as to interfere 597 grossly with the . . . capacity to meet the ordinary demands of life.’ 214, Winter, (2012): 160-192, accessed June 25, 2016, Armed Forces,” Military Law Review, /pdf-files/214-winter-2012.pdf. rd/Military_Law/Military_Law_Review https://www.loc.gov/rr/f 591 Ibid., 164, 186. 592 Petition for Rulemaking to Amend 38 C. F.R. 3.12(d), 17.34, 17.36(d), Regulations Ibid., 10, 172. Swords to Plowshares, Interpreting 38 U.S.C. § 101(2), Re quirement for Service “Under Cond itions Other Than Dishonorable, accessed May 26, 2016, https://www.swords-to- lt/files/VA%20Rulemaking%20Petition%20to% 20amend%20regulations%20interpreting%2 plowshares.org/sites/defau 038%20USC%20101%282%292.pdf. 593 Major John Brooker, Major Evan R. Seamone, and Leslie C. Rogall, “Beyond ‘T.B.D .’: Understanding VA’s Evaluation of a Former Servicemember’ s Benefit Eligibility Following Involunt scharge from the ary or Punitive Di Military Law Review, 214, Winter, (2012): 67, accessed June 25, 2016, Armed Forces,” rd/Military_Law/Military_Law_Review /pdf-files/214-winter-2012.pdf. https://www.loc.gov/rr/f 594 Ibid., 68-70. 595 Characters of Discharge, 38 C.F.R. 3.12(b). 596 Determinations of Insanity, 38 C.F.R. 3.354(a). 597 “Office of General Counsel: Opinions Year 1997,” U.S. Departme nt of Veterans Affairs, accessed June 15, 2016, http://www.va.gov/ogc/opini ons/1997precedentopinions.asp. Vet. Aff. Op. Gen Couns. Prec. 20-97, VAOPGCPREC ww.va.gov/ogc/docs/1997/Prc20-97.doc. 20-97, 1997, accessed June 15, 2016, http://w 157

172 C C INAL R EPORT OMMISSION ON F ARE As understood by VA OGC at the time, insanity , with its emphasis on gross impairment, and as 598 reflected in practice, is a highly restrictive standard. That narrow standard is also limiting with respect to the range of symptoms that could be considered under the exception: insanity gross cognitive impairment or gross impairment in capacity to function in daily life. That limited range effectively excludes behaviors asso ciated with a widely pr evalent service-related condition, PTSD. Those behaviors, which often lead to disciplinary action s, include aggressive 599 behavior, substance-abuse, impulsivity, and risk-taking (including sensation seeking, 600 aggressive driving, interpersonal violence, and self-injurious or suicide-related behavior). Research has shown that combat veterans with PTSD and other psychiatric diagnoses have a 601 heightened risk of misconduct outcomes. insanity rule, the regulations provide Other than its as a likely cause of, or mitigating factor in, no specific opportunity to consider mental health disciplinary issues leading to an individual’s discharge. The following are illustrative examples of ho w these regulations have worked in practice:  John, a service member with multiple depl oyments to Iraq and Afghanistan and 7 years of service, received an OTH discharge afte r self-medicating with marijuana. He was 602 denied VA treatment for PTSD. Tim, a rifleman with two purple hearts and  four campaign ribbons for service in ars old, and had a nervous breakdown and Vietnam, was sent to combat while still 17 ye th birthday. He was sent back to Vietnam involuntarily for a suicide attempt before his 18 second tour, and had a third nervous breakdown that led to an AWOL and OTH n for PTSD because the nature of his discharge. He was denied service connectio discharge.  Tom, a combat infantryman in the first Gulf War, on his return, started experiencing symptoms of PTSD and attempted suicide. He was denied leave to be with his family, 598 Swords to Plowshares, Petition for Rulemaking to Amend 38 C.F.R. 3.12( d), 17.34, 17.36(d), Regulations Interpreting 38 U.S.C. § 101(2), Requirement fo r Service “Under Conditions Other Than Dishonorable,” accessed May 26, 2016, https://www.swords-to- lt/files/VA%20Rulemaking%20Petition%20to% 20amend%20regulations%20interpreting%2 plowshares.org/sites/defau 038%20USC%20101%282%292.pdf. 599 Deirdre MacManus et al., “Aggressive and Violent Be havior Among Military Personne l Deployed to Iraq and Afghanistan: Prevalence and Link wi th Deployment and Combat Exposure,” Epidemiologic Reviews, 37, no. 1, (2015): 196- 10.1093/epirev/mxu006. 212, http://doi.org/ Robyn M. Highfill-McRoy et al., “Psych Misconduct: The Effects of PTSD in iatric Diagnoses and Punishment for Combat-Deployed Marines,” BMC Psychiatry , 10, no. 1 (2010): 88, http://dx. doi.org/10.1186%2F1471-244X-10-88. 600 Lisa M. James, Thad Q. Strom, an d Jennie Leskela, “Risk-Taking Behavior s and Impulsivity Among Veterans With and Without PTSD and Mild TBI,” Military Medicine , 179, no. 4, (2014): 357 – 363, http://publications.amsus.org/doi /pdf/10.7205/MILMED-D-13-00241. 601 chiatric Diagnoses and Punishment for Misconduct: The Effects of PTSD in Robyn M. Highfill-McRoy et al., “Psy Combat-Deployed Marines,” BMC Psychiatry , 10, no. 1 (2010): 88, http://d x.doi.org/10.1186%2F1471-244X-10-88. 602 Swords to Plowshares, presentation to Commission on Care, January 21, 2016, accessed June 25, 2016, on-on-OTH-Discharges.pdf. No te, in the interest of https://commissiononcare.sites.us a.gov/files/2016/03/Presentati privacy the paper has used fictitious names to identify the former service members. 158

173 C OMMISSION ECOMMENDATIONS R returned and was given an OTH discharge. but left anyway. After a 60-day absence, he 603 He was denied services for 20 years. ine whether the character of a veteran’s OTH In short, the VA regulation used to determ discharge is disqualifying does not take into account behavioral health problems associated with military service. As a result, former serv ice members who were discharged for disciplinary problems that cannot be disassociated from PT SD or other behavioral health disorders are routinely barred from VA treatment for those disorders. 604 matic exposure are at heightened risk of substance abuse, Individuals with PTSD and trau 605 606 607 608 depression, and suicide. Access to VA health care premature mortality, homelessness, is vital to successful reintegration of combat-t raumatized veterans into society because it 609 provides “the only reservoir of combat PTSD expertise.” t for behavioral health conditions like PTSD The importance of early access to needed treatmen 610 are reluctant to seek treatment for yet many former service members cannot be overstated, 611 behavioral health problems. Those with unfavorable discharge records who finally come forward to seek medical care must not only in itiate a request for a character of discharge 612 adjudication, but be prepared to confront a lengthy process if they elect to do so. 603 Petition for Rulemaking to Amend 38 C.F.R. 3.12( d), 17.34, 17.36(d), Regulations Interpreting 38 Swords to Plowshares, r Service “Under Conditions U.S.C. § 101(2), Requirement fo 42, 44, accessed May 26, 2016, Other Than Dishonorable, https://www.swords-to- lt/files/VA%20Rulemaking%20Petition%20to% plowshares.org/sites/defau 20amend%20regulations%20interpreting%2 038%20USC%20101%282%292.pdf. 604 Association Between Substance Use Diso Kipling M. Bohnert et al., “The rders and Mortality among a Cohort of Veterans with Posttraumatic Stress Disorder: Va riation by Age, Cohort, and Mortality Type,” Drug and Alcohol Dependence , rticle/pii/S0376871612003328. 128, no. 1-2, (2013): 98-103, http://www.scien cedirect.com/science/a 605 Leo Sher, Maria Dolores Braquehais, and Miquel Casas, “P osttraumatic Stress Disorder, Depression, and Suicide in Cleveland Clinic Journal of Medicine, 79, no. 2 (2012): 92-97, http:/ Veterans” /doi.org/10.3949/ccjm.79a.11069. 606 Military Eve B. Carlson et al., “Traumatic Stressor Exposure and Post-Traumatic Symptoms in Homeless Veterans,” Medicine , 178, no. 9, (2013): 970-973, http://doi.org/10.7205/MILMED-D-13-00080. 607 Joseph A. Boscarino, “Posttraumatic Stress Disorder and Mortality Among U.S. Ar my Veterans 30 Years After Annals of Epidemiology , 16, no. 4 (2005): 248-256, http://www.science Military Service,” direct.com/science/a rticle/pii/S1047279705001109. 608 Holly J. Ramsawh et al., “Risk for Su , Depression, and their Comorbidity in icidal Behaviors Associated with PTSD the U.S. Army,” Journal of Affective Disorders , 161, no. 1, (2014): 116-122, http://www.sciencedirect.com/ science/article/pii/S0165032714001189. 609 Major John Brooker, Major Evan R. Seamone, and Leslie C. Rogall, “Beyond ‘T.B.D .’: Understanding VA’s Evaluation of a Former Servicemember’ s Benefit Eligibility Following Involunt ary or Punitive Di scharge from the Armed Forces,” Military Law Review, 214, Winter, (2012): 14, accessed June 20, 2016, rd/Military_Law/Military_Law_Review https://www.loc.gov/rr/f /pdf-files/214-winter-2012.pdf. 610 : The Burden to the Indi vidual and to Society,” Journal of Clinical Ronald C. Kessler, “Posttraumatic Stress Disorder , 5, Suppl. 5, (2000): 4-12, acce ssed June 20, 2016, http://www.nc bi.nlm.nih.gov/pubmed/10761674. Psychology 611 American Public Health Association, “Removing Barriers to Mental Health Services for Veterans,” accessed May 27, 2016, http://www.apha.org/policies-and-advoca cy/public-health-polic y-statements/policy- database/2015/01/28 -health-services-for-veterans. /14/51/removing-barriers-to-mental 612 Swords to Plowshares, Petition for Rulemaking to Amend 38 C.F.R. 3.12( d), 17.34, 17.36(d), Regulations Interpreting 38 U.S.C. § 101(2), Requirement fo r Service “Under Conditions Other Than Dishonorable, 74-78, accessed May 26, 2016, https://www.swords-to- plowshares.org/sites/defau lt/files/VA%20Rulemaking%20Petition%20to% 20amend%20regulations%20interpreting%2 038%20USC%20101%282%292.pdf. 159

174 C C F INAL R EPORT OMMISSION ON ARE re exposed to combat trauma and continue to Several generations of former service members we live with the psychological wounds of war. Lack of access to treatment for those who sustained psychological wounds that went untreated an d were manifest in undesirable behavior in service is concerning. Although Congress could address this concern, VA has the means to s own regulations. VA could remedy the problem without congre ssional action by amending it afford former service members needed treatment for their conditions when they are able to 613 establish that their health pr oblems were incurred in service. In other circumstances, when it is likely an individual could establish eligibilit y for VA care, current regulation permits the 614 This individual to receive the care on the ba sis of a tentative eligibility determination. regulation permits VA to provide treatment wi thout prior adjudication of the character of discharge. VA should revise its regulations to lift the i mmediate bar to health care for former service VA should award tentative eligibility for health care to members who have an OTH discharge. e an OTH discharge. The criteria for awarding at least some former service members who hav tentative eligibility for care could include serv ice in a combat theater, more than a single enlistment, duration of service, or some combi nation thereof. This approach would allow VA to provide meaningful access to treatment without dela y for those likely to be granted eligibility. For health care purposes, VA should also revise its regulations by recognizing that the severe punishment of characterizing a person’s serv ice as OTH is not justified when extenuating circumstances (to include behavioral health issu es at the time) explain or mitigate that misconduct that resulted in the OTH discharge. Implementation Legislative Changes  None required. VA Administrative Changes  e eligibility determinations applicable to Amend 38 C.F.R. 17.34 to provide for tentativ individuals with OTH discharge s who have had substantial honorable service, including service in a combat theater.  Amend of 38 C.F.R. 3.12(d) to provide for re cognition of extenuating circumstances that show, for purposes of health care elig ibility, that service was not OTH. Other Departments and Agency Administrative Changes  None required. 613 Sec. 2, Pub. L. No. 95-126, 91 Stat. 1106 (1977). 614 inations, 38 C.F.R. 17.34. Tentative Eligibility Determ 160

175 C OMMISSION R ECOMMENDATIONS expert body Recommendation #18: Establish an to develop recommendations for VA care e ligibility and benefit design. Problem The Commission Recommends That . . . Although VHA continues to offer the another task Congress to or President The  body promise of health care to all veterans, its care VA for eligibility in changes for need the examine capacity to meet that promise is constrained design, would which benefits and/or include 615 pilots include may and criteria, eligibility simplifying by appropriated funding. Congress and eligibility expanded for to use nonveterans for VA leadership must work to identify who underutilized VHA providers and facilities, providing VHA will serve, and what services it will through private payment insurance. provide, yet eligibility criteria have not been  The that provide SECVA revise VA to regulations 616 examined in 20 years. veterans ‐ connected ‐ disabled service be afforded access priority to care, subject only to a higher Background priority needs. care clinical by dictated VHA’s core mission is to care for veterans who has borne the battle. But its secondary mi ssion of caring for veterans’ non-service- connected health care needs is longstanding, dating back to Civil War origins. Congress has included veterans without service-connected need s among those eligible as highlighted below:  In March 1865, Congress incorporated th e National Home for Disabled Volunteer Soldiers and Sailors, originally intended for Union veterans who suffered economic distress from disabilities incurred during the Civil War. The National Home constructed the first hospitals for Civil War veterans in 1866, and after a series of acts of Congress, terans suffering economic distress from those hospitals were opened in 1887 to ve 617 disabilities not incurred in military service. 618 The World War Veterans Act of 1924, which established the Veterans Bureau  (the predecessor to the Department of Veterans A ffairs), authorized its director to provide veterans whose services dated back as far hospitalization and related travel expenses to as 1897, regardless of the type or cause of thei r disabilities, as long as those veterans who 619 ed preferential admission. were unable to pay receiv  Public Law 85-56 (1957), which codified prio r VA laws and regulations, effectively wars, providing needed hospital care for expanded eligibility to veterans of future veterans with service-connected disability incu rred or aggravated during war, or for any 620 other disability if the veteran is unable to pay for hospital care. 615 The MITRE Corporation, Independent Assessment of the Health care Delivery Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 24, accessed April 11, 2016, http://www.va.gov/opa/choice integrated_report.pdf. act/documents/assessments/ 616 Ibid., 25. 617 th st Veterans Administration, Medical Care of Veterans , report prepared by Robinson Adkins, 90 sess., 1967, Cong., 1 House Committee Print 4, 62. 618 lidated the National Home and other vetera The Veterans Bureau conso housed in different ns-related functions government bureaucracies. 619 World War Veterans Act, 192 4, Pub. L. No. 68-242, (1924). 620 Veterans Benefits Act of 1957, Pub. L. No. 85-56, 71 Stat. 83 (1957). That law provided separate authority in t for a service-connected disability. section 512 for outpatient medical trea tment, which was limited to treatmen 161

176 C C F INAL R EPORT OMMISSION ON ARE peacetime veterans (of service In 1966, Congress expanded eligibility for hospital care to  621 after January 1955). In 1970, Congress extended eligibility for hospital care to veterans 65 and older for a  622 exempting that group of veterans from taking the non-service-connected disability, then-required oath affirming their inability to defray the expense of care for non-service- 623 connect ailments.  With the Veterans Health Care Expansion Act of 1973, Congress eliminated the distinction between wartime and peacetime veterans for purposes of eligibility for lity to outpatient care. It granted veterans outpatient care, and further expanded eligibi disabled eligibility for treatment of any who are 80 percent or more service-connected hospital care to receive outpatient care to condition, and authorized others eligible for lization or to complete treatment initiated prepare for or preclude a need for hospita 624 during hospitalization.  Congress expanded eligibility again in 1976, authorizing hospital care for treating a non-service-connected condition of any veteran 65 or older (without regard to ability to pay), authorizing outpatient care for any di sability to any veteran 50 percent or more service-connected disabled, and directing VA to ensure, by regulation, special treatment priority to service-connected veterans and othe rs receiving benefits because of a need for 625 aid and attendance, or being permanently housebound. ged substantially during the past century, yet Eligibility laws for veterans’ health care have chan the commitment to serving service-connected ve terans and veterans in financial need has remained constant. 626 Prior to enactment of the Veterans’ Health Care Eligibility Reform Act of 1996, VHA was a ility rules for hospital care than for outpatient hospital-based model with entirely different eligib transforming access to VA care from a 1950s care. The eligibility reform law was aimed at hospital-based model to one that erased dist inctions between eligibility for hospital and 627 It essentially provided that all veterans are eligible for VA hospital care and outpatient care. 628 medical services . 621 Veterans Readjustment Bene fits Act of 1966, Pub. L. No. 89-358, 80 Stat. 12 (1966). 622 Pub. L. No. 91-500. 623 S. Rep. No. 91-481. 624 nsion Act of 1973, Pub. L. No. 93-82, 87 Stat. (1973). Veterans Health Care Expa 625 Veterans Omnibus Health Care Act 90 Stat. 2842 (1976). The patchwork of eligibility of 1976, Pub. L. No. 94-581, anges set the stage for development and enactment of the provisions resulting from a succession of incremental ch Veterans’ Health Care Eligibility Re form Act of 1996, Pub. Law 104-262. 626 Veterans’ Health Care Eligib ility Reform Act of 1996, Pub. L. No. 104-262, 110 Stat. 3177 (1996). 627 Ibid. 628 clude in addition to medical examination and treatment, The term “medical services” was broadly defined to in preventive health services; surgical serv ices; wheelchairs, artificial limbs, and similar appliances; optometric and podiatric services; noninstitutional extended care services; and rehabilitativ e services (including services to restore physical, mental, and psychological functioning. Hospital, Nursing Home , Domiciliary, and Medical Care; General, 38 U.S.C. VA is to provide pa § 1701(6),(8). VA regulations more fully set out the “medical benefits package” that tients, as needed; VA regulations detail that the benefits package includes servic es ranging from emergency care and prescription drugs to 162

177 C R OMMISSION ECOMMENDATIONS h VHA might lack capacity to provide timely Recognizing there could be circumstances in whic quirement to provide care would be in effect care, Congress noted in the reform act that the re 629 only to the degree to which there were appropriated funds to pay for such care. This qualified health care is not an entitlement. Congress went availability of care clearly indicated veterans’ further, though, and established a statutory patient enrollment mechanism for VA to manage 630 The law specifically requires VA to esta blish and operate a patient enrollment system access. managed in accordance with statutory priori ties and within any additional priority classifications established by VA. The eligibility reform act gave VA tools both to limit demand ge veterans from seeking VA care simply to consistent with available funding and to discoura 631 fill an occasional need not met by a private health plan. The act also requires the SECVA to 632 manage the enrollment system such that care is timely and of acceptable quality. The enrollment system the department establishe d is not being used today to calibrate supply 633 Although law and VA regulation require a system of annual and demand as envisioned. 634 patient enrollment, VHA last curtailed enrollment in 20 03, and then only for veterans who were deemed eligible based on the category 8 criteria (see Table 8) that include those with higher-level incomes who lack any higher priority. In 2009, the Obama administration eased access for higher income veterans. Under that policy, veterans whose gross household income exceeds VA’s current geographic income limit by 10 percent or less may enroll for VA care, 635 subject to cost-sharing requirements. In 2014, Congress established the Choice Program to expand availability of care through contracts wi th community providers. Veterans’ choice was limited by reference to distance and wait-time issues, but was otherwise broadly open to any 636 enrolled veterans. services, hospice care, and comprehensive rehabilitative services, ho me health services, nonins titutional extended care pregnancy and delivery services and newborn care . Medical Benefits Pack age, 38 C.F.R. 17.38. 629 iliary, and Medical Care; General 38 U.S.C. § 1710(a)(4). Hospital, Nursing Home, Domic 630 1705. As explained in the report of the House Management of Health Care: Patient Enrollment System, 38 U.S.C. § veloped the legislation, “[T]he Act would...provide the VA with an important Committee on Veterans Affairs which de tool, the authority to design and manage access to care through a system of patient enrollment...Enrollment...would help the VA plan more effectively, so that facilities can be tter calculate and dedicate the resources needed to provide the ary...to establish and operate a system of annual patient care its enrollees require. The Act would direct the Secret enrolled in a manner giving relative degrees of preference in accordance with enrollment and require that veterans be tion in the Secretary to determine the manner in which such specified priorities. At the same time, it would vest discre enrollment (or registration) system would operate. For exam ple, the VA would be able to establish a system which or part of a fiscal year, or could em ploy a time-limited registration period. simply registers patients throughout all es within the specified priority classifications established i n Significantly, the Act would permit the Secretary to set prioriti the Act. The Secretary could, for example, establish a policy wh ich, within any priority clas sification, gives veterans who have previously been ‘‘enrolled’’ as VA patients priority over new applicants. However, the Committee expects any that any veteran with a service-connected condition would enrollment system to be designed and administered to assure ion whether or not that veteran had enro lled for VA care.” H. Rep. No.104-690, receive priority treatment for that condit 6-7. 631 Veterans’ Health Care Eligib ility Reform Act of 1996, Pub. L. No. 104-262; 110 Stat. 3177 (1996). 632 Management of Health Care: Patient Enrollment System , 38 U.S.C. § 1705(b). 633 H. Rep. No. 104-690, 16. 634 Enrollment, 38 C.F.R. sec. 17. 36(c). VA regulations state that “[i]t is antici pated that that each year the Secretary will consider whether to change the categories and subcategories of veterans eligible to be enrolled.” 635 Enrollment, 38 C.F.R. 17.36(b)(8)(ii),(iv). 636 Veterans Access, Choice, and Acco untability Act of 2014, Pub. L. No. 113-146 (2014). Surface Transportation and t Act of 2015, Pub. L. No. 114-41 (2015). Veterans Health Care Choice Improvemen 163

178 C OMMISSION ON ARE F INAL R EPORT C Table 8. Priority Groups Priority Definition Group Veterans with VA ‐ rated service ‐ connected 50% or more disabling disabilities  1 determined by VA to be unemployable due to service ‐  conditions Veterans connected  Veterans with VA ‐ rated service ‐ connected disabilities 30% or 40% disabling 2 Veterans who are  prisoners of war former  Veterans awarded a Purple medal Heart  Veterans whose discharge was for a disability that incurred or aggravated in the line of duty was  Veterans with VA ‐ rated service ‐ connected disabilities 10% or 20% disabling 3 1151, for “benefits § U.S.C. under Title 38,  eligibility special awarded Veterans classification disabled by treatment or vocational rehabilitation” individuals Veterans awarded the Medal of Honor   Veterans who are receiving aid and attendance or housebound benefits from VA 4 Veterans who have been determined by VA to be catastrophically disabled   Non ‐ service ‐ connected veterans and noncompensable service ‐ connected veterans rated 0% disabled by VA with annual income below VA’s and geographically (based on resident zip code) adjusted income limits 5 Veterans receiving VA pension benefits  eligible  for Medicaid programs Veterans Compensable 0% service ‐ connected veterans  testing Veterans exposed to ionizing during atmospheric or during the occupation of  radiation and Nagasaki Hiroshima  112/SHAD (shipboard hazard and defense) participants Project between who served in  Republic of Vietnam Veterans January 9, 1962 and May 7, 1975 the 1998 11, November and 1990 the Persian Gulf War who served between August 2, of Veterans  for  who served on active duty at Camp Lejeune *Veterans at least 30 days between August 1, 1953 and December 31, 1987 as follows: combat served in a theater of operations after November 11, 1998  Veterans who duty – Currently enrolled veterans and new enrollees who were discharged from active on or after January 2003, are eligible for the enhanced 28, benefits for five years post discharge. **Combat veterans who were discharged between January 2009 and – January 2011, and did not 6 year year one VA health care during their five ‐ period of eligibility have an additional the in enroll 2015 to enroll and receive care. The additional one ‐ year eligibility period began February 12, Suicide with signing of the Clay Hunt the Prevention for America Veterans Act. be will veterans period time placement group enrollment priority this of end the At Note: enhanced assigned to the highest Priority Group (PG) their unique eligibility status at that time qualifies for. changes *Note: While eligible for PG 6; until system would are implemented you be assigned to PG 7 or depending on 8 your income. 8c, eligible for PG 6; due to system limitations, veterans will be manually assigned to PG While *Note: for yet the eligible enhanced benefits their  Veterans with gross household income below the geographically ‐ adjusted income limits for 7 copays resident location and who agree to pay 164

179 C OMMISSION ECOMMENDATIONS R Priority Definition Group the Veterans gross household income above VA and with geographically ‐ adjusted income limits for  resident location their and who agrees to pay copays eligible for enrollment: Veterans 0% service ‐ connected: Noncompensable – Subpriority a: Enrolled as of January 16, 2003, and who that have remained enrolled since status eligibility in this sub changed priority due to date placed and/or 15, – Subpriority b: Enrolled on or after June 2009 whose income exceeds the current VA or geographic income limits by 10% or less Non ‐ service ‐ connected and: 8 that since enrolled Enrolled of January 16, 2003, and who have remained c: Subpriority – as due placed in this sub priority to changed eligibility status date and/or Subpriority d: Enrolled on or after June 15, – whose income exceeds the current VA or 2009, geographic income limits by 10% or less not eligible Veterans for enrollment: Veterans not meeting the criteria above: Subpriority – e: Noncompensable 0% service ‐ connected (eligible for care of their service ‐ condition only) connected Subpriority connected g: Non service ‐ – Analysis Two decades have passed since Congress last reexamined VHA eligibility and benefits, and health care have occurred in that time. In more many far-reaching changes that affect veterans’ 637 than a decade of war, 2.75 million troops have deployed to Iraq and Afghanistan where many have faced long and repeated deployments; constant risk of injury and death; and high levels of 638 Post-9/11-era psychological disorders, substance abus e issues, and physical health problems. 639 veterans are enrolling for VA care at historically high levels. Under current law and VA policy, enrollment is open to a relatively broad spectrum of 640 As discussed veterans, though some veterans with hi gher incomes are not eligible to enroll. e whose health problems have been adjudicated above, the law draws distinctions between thos as service-connected and those whose problems are deemed non-service-connected. If Congress substantially reduced funding for VA medical ca re, the distinction would be important because those with service-connected i enrollment. Under VA’s current ssues have higher priority for th higher incomes from receiving care, the enrollment policy, which bars only veterans wi 637 Defense Manpower Data Center, Contingency Tracking System (CTS) Deployment File, (Dec. 31, 2015). 638 Institute of Medicine of the National Academies, Returning Home from Iraq and Af ghanistan: Readjustment Needs of (Washington, DC: The National Academ ies Press, 2013), accessed June 25, Veterans, Service Members, and Their Families, 2016, http://www.nationalacademies.org/hmd/Reports/2013/Re turning-Home-from-Iraq-a nd-Afghanistan.aspx. 639 Department of Veterans Affairs, National Ce nter for Veterans Analysis and Statistics, Profile of Post-9/11 Veterans: 2014 .gov/vetdata/docs/SpecialReports/Po st_911_Veterans_Pro file_2014.pdf. , accessed May 27, 2016, http://www.va 640 Veterans Health Administration, Enrollment Determinations, VHA Handbook 1601A.03, 9-10 (2015). Veterans with gross household income that do not exceed VA’s means te st threshold and a geographic means test by more than ecial eligibility may not. 10 percent may enroll for care, while those with high er income and no other sp 165

180 C OMMISSION ON ARE F INAL R EPORT C 641 iority has little practical significance. statutory service-connected enrollment pr Future budget 642 constraints could result in more restrictive enrollment criteria or recurrence of lengthy wait times that hinder service-connected, disabled veterans’ ability to receive timely care. to veterans who deployed to a combat theater. Current eligibility law does afford special status It grants a 5-year window of eligibility for care to those veterans who are not otherwise 643 eligible. All combat veterans are also eligible for readjustment counseling services at VHA Vet 644 Centers without needing to enroll in VHA care and without time limitation. It is questionable, however, if the 5-year time limit takes suffi cient account of continued reluctance of some 645 or of the difficulties of establishing veterans to seek care for behavioral health problems service-connection years later for conditions that may be linked to wartime exposures to toxic 646 substances. It is challenging for veterans to estab lish service-connection for health conditions th a long-distant exposure for which there may that may have been caused by or associated wi that combat exposure should be considered a be no documentation. Given emerging evidence 647 it has been suggested that combat exposure may not risk factor for coronary heart disease, 648 , but may exert a physiologic toll as well. only take a toll on psychological health Congress has attempted to remedy the challenge of documenting toxic exposures and establishing that particular illnesses are linked to wartime or other service exposure. It has, for example, enacted statutes that provide certai n veterans eligibility for health care on the 649 presumption that they were expose d to particular toxic substances. Congress went a step Caring for Camp Lejeune Families Act of 2012 further in the Honoring America’s Veterans and which provided eligibility for care for several ty pes of cancer and other specified conditions for family members of veterans who had been exposed to drinking water contaminated with 650 industrial solvents and other toxic chemicals at the Marine Corp base. Congress has made only limited provision for VA to cover care for family members of certain 651 veterans, but with research suggesting that long combat deployments can take a 641 Prior to 1996, provisions of law required VA to ensure spec ial priority to service-connect ed veterans in furnishing § 1712(i), repealed by § outpatient care. 38 U.S.C. 101(c), Pub. L. No. 104-262. 642 Enrollment, 38 C.F.R. 17.36(c)(1). 643 by Sec. 7, Pub. 38 U.S.C. § Hospital, Nursing Home, Domic iliary, and Medical Care; General, 1710(e)(3), as amended L. No. 114-2 (2015), accessed June 20, 2016, https://www.govtrack.us/ congress/bills/114 /hr203/text. 644 Readjustment Counseling Service, 38 U.S.C. § 7309. 645 Mental Health Services for Veterans,” accessed May 27, American Public Health Association, “Removing Barriers to 2016, http://www.apha.org/policies-and-advoca cy/public-health-polic y-statements/policy- database/2015/01/28 /14/51/removing-barriers-to-mental -health-services-for-veterans. 646 Matthew S. King et al., “Constric tive Bronchiolitis in Soldiers Retu rning from Iraq and Afghanistan,” New England Journal of Medicine , 365, no. 10 (2011): 222-230, accessed June 20, 2016, http://doi.org/10. 1056/NEJMoa1101388. 647 Nancy F. Crum-Cianflone et. al., “Impact of Combat Deployment and Posttraumatic Stress Disorder on Newly US Active Duty and Reserve Forces , 129, (2014), accessed ” Circulation Reported Coronary Heart Disease Among , June 20, 2016, http://doi.org/ NAHA.113.005407. 10.1161/CIRCULATIO 648 Rachel Lampert, “Veterans of Combat : Still at Risk When the Battle is Over , ” Circulation , 129, (2014): 1797-1798, accessed June 20, 2016, http://doi.o rg/10.1161/CIRCULATIONAHA.114.009286. 649 Hospital, Nursing Home, Domic iliary, and Medical Care; General, 38 U.S.C. § 1710(e)(10). 650 Honoring America’s Veterans and Cari ng for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, 126 Stat. 1165 (2012). 651 §§ 1781-1787. her Than Veterans, 38 U.S.C. Health Care of Persons Ot 166

181 C OMMISSION ECOMMENDATIONS R 652 psychological toll on family members, there may be circumstances under which it might be ers behavioral health services. Studies indicate argued that VA should afford such family memb , and posttraumatic stress disorder in military that longer deployments, deployment extensions 653 Long-term effects are personnel are associated with psyc hological problems for the spouse. htened risk for psychosocial issues during unknown, yet studies suggest children may have heig 654 a parent’s deployment. increased options available under the Affordable The experience of the nation’s longest war and Care Act (ACA), particularly to previously uninsured non-service-connected veterans, may 655 VHA’s most recent survey of enrollees showed that raise new questions for policymakers. 656 20 percent of enrollees reported that they were uninsured, down from 22 percent in 2014. ACA requirement for health care coverage, Enrollment in VHA-provided care meets the 657 creating pressure to continue to provide care to those enrolled. Given that VHA serves large numbers who are poor or near poor and have ch ronic medical conditions and behavioral health 658 it is important to note that receiving care under an ACA plan would not necessarily problems, be a substitute for the rich benefits afforded thro ugh VHA. In addition, adults in this population under ACA through state expansion of Medicaid that 19 states are only eligible for coverage have elected not to accept, making this option u navailable to poor or near poor veterans in 659 many parts of the country. Over time Congress has expanded VA health care eligibility to increasingly more cohorts of riability among different cohorts in the extent non-service-connected veterans. There is wide va to which veterans rely on VA care. Those at th e higher-income levels (priority categories 7 and care prior to 1996, for example, rely on VA for 8) who were generally not eligible for ambulatory 652 chiatric Diagnoses and Punishment for Robyn M. Highfill-McRoy et al., “Psy Misconduct: The Effects of PTSD in Combat-Deployed Marines,” BMC Psychiatry , 10, no. 1 (2010): 88, accessed June 20, 2016, http://dx.doi.org/10.1186%2F1471-244X-10-88. Swords to Plowshares, presentation to Commission on Care, January 21, 2016, https://commissiononc are.sites.usa.gov/files/ 2016/03/Presentation-on-OTH-Discharges.pdf. Note, in the interest of privacy the paper has used fictitious names to identify the former servicemembers. Swords to rpreting 38 U.S.C. § 101(2), Plowshares, Petition for Rulemaking to Amend 38 C.F.R. 3.12(d), 17. 34, 17.36(d), Regulations Inte Requirement for Service “Under Co nditions Other Than Dishonorable, 42, 44, accessed May 26, 2016, https://www.swords-to- 20amend%20regulations%20interpreting%2 lt/files/VA%20Rulemaking%20Petition%20to% plowshares.org/sites/defau 038%20USC%20101%282%292.pdf. 653 istan on Partners and Wives of Military H. Thomas De Burgh et al., “The Im pact of Deployment to Iraq or Afghan , 23, no. 2 (2011): 192-200, http:// www.ncbi.nlm.nih.gov/pubmed/21521089. International Review of Psychiatry Personnel,” 654 and Elizabeth Hisle-Gorman, accessed June 20, 2016, “Wartime Military Gregory H. Gorman, Matilde Eide, diatric Mental and Behavior Pediatrics , 126, no. 6 (2010): 1058–1066, al Health Complaints,” Deployment and Increased Pe accessed June 20, 2016, http://doi.o rg/10.1542/peds.2009-2856. Anit a Chandra et al., “Children on the Homefront: ary Families, Pediatrics,” 125, no. 1 (2010): 16-25, accessed June 20, 2016, The Experience of Children from Milit http://doi.org/10.1542/peds.2009-1180. 655 and the Affordable Care Act,” Journal of the American Medical Association, Kenneth W. Kizer, “Veterans 307, no. 8 (2012): 789-790, accessed June 20, 2016, http://doi.org/ doi:10.1001/jama.2012.196. 656 Westat, Health and Use of Health Care , accessed May 27, 2016, 2015 Survey of Veteran Enrollees’ YPLANNING/SoE2015/2015_ http://www.va.gov/HEALTHPOLIC gs_Report.pdf. VHA_SoE_Full_Findin 657 “Affordable Care Act & Veterans,” Department of Veterans Affairs, accessed May 27, 2016, http://explore.va.gov/health-car e-affordable-care-act?show=all. 658 and the Affordable Care Act,” Journal of the American Medical Association, 307, no. 8 Kenneth W. Kizer, “Veterans (2012): 789-790, accessed June 20, 2016, http://doi.or g/doi:10.1001/jama.2012.196. 659 “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update,” Rachel Garfield and Anthony Damico, Kaiser Family Foundation, access ed March 29, 2016, http://k ff.org/health-reform/issue- -expand-medicaid-an-update/. brief/the-coverage-gap-uninsured -poor-adults-in-states-that-do-not 167

182 C C F INAL R EPORT OMMISSION ON ARE less than 22 percent of their outpatient care-needs , based on VA’s most recent survey of veteran 660 enrollees’ health and use of care. One consideration, as suggested by a few Commissi oners, is the feasibility of allowing veterans’ family members and currently ineligible vetera ns to purchase VHA care through their health plans in areas where VHA hospitals and other fac ilities might otherwise need to close. In many itals and other health care facilities that are parts of the country, VHA currently maintains hosp underutilized or in danger of becoming so. A re lated challenge is maintaining safe volume of care when patient loads decline. As an extensiv e literature attests, surgeons and other health 661 care professionals tend to lose profic iency when they treat too few patients. Similarly, VHA may be unable to continue offer specialty care in certain areas if it forced to close facilities. quire a full spectrum of routine and nonroutine Patients in a polytrauma unit for example, re health care. Closing a low-volume hospital may be the answer in some instances. But closing VHA facilities reduces the choices available to veterans. Increasi ng the volume of patients treated by VHA in areas where it currently has ex cess capacity may ameliorate these challenges. See Appendix C for a further discussion of the challenge of fu ture VHA hospital closures and an outline of suggested pilot programs. last comprehensively examined eligibility for Substantial changes have occurred since Congress 662 VHA care. These changes merit a reexami nation of VA health care eligibility. The Commission did not, however, view its charge of examining veterans’ access and how best to 663 organize VHA, locate health care resour ces, and deliver care in the years ahead as calling for it to make recommendations on this fundamental policy issue, and recommends that the body to develop recommendations for VA care President or Congress consider tasking another eligibility and benefit design. The Commission’s work, however, has illuminated the fact that nnected, disabled veteran of priority for care. nothing in law or regulation assures a service-co ide for such priority, subject to a necessarily VA can and should amend its regulations to prov higher priority for urgent and emergent care. Implementation Legislative Changes Task another body to examine the need for changing eligibility for VA care and benefits  design, which would include simplifying elig ibility criteria, and may include exploring 660 2015 Survey of Veteran Enrollees’ Health and Use of Health Care , 75, accessed May 27, 2016, Westat, http://www.va.gov/HEALTHPOLIC YPLANNING/SoE2015/2015_ VHA_SoE_Full_Findin gs_Report.pdf. 661 Ninh T. Nguyen et al., “The Relationship Between Hospit al Volume and Outcome in Bariatric Surgery at Academic Medical Centers,” Annals of Surgery , 240, no. 4 (2004): 586-594. D. R. Urbach and N. N. Baxter, “Does It Matter What a Hospital Is ‘High Volume’ For? Specifici ions for Surgical Procedures: Analysis ty of Hospital Volume-Outcome Associat of Administrative Data,” Quality and Safety in Health Care, 13, no. 5 (2004): 379-383, http://doi.org/10.1136/bmj.38030. 642963.AE. Edward L. Hannan et al., “Coronary Angioplasty Volume-Outcome Relationships for Hospitals and Cardiologists,” Journal of the American Medical Association, 277, no. 11 (1997): 892–898, http://doi.org/10.1001/jama.1997.03540350042031. 662 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, 25, accessed April 11, 2016, http://www.va.gov/opa/choice act/documents/assessments/ integrated_report.pdf. 663 ility Act of 2014, Pub. Veterans Access, Choice, and Accountab L. No. 113-146 (2014). 168

183 C R ECOMMENDATIONS OMMISSION pilots for expanding eligibility for nonvet erans to use underutilized providers and facilities when paid for through private insurance. VA Administrative Changes establish that veterans with service-  SECVA should amend 38 C.F.R., chapter 17 to connected disabilities shall be afforded priority for access to care, subject to the priority dictated by clinical care needs. Other Departments and Agency Administrative Changes  None required. 169

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185 APPENDIX A: FINANCING THE VISION AND MODEL Estimating the Cost of Al ternative Policy Proposals This chapter presents estimates of the costs of allowing veterans access to expanded community ll as a range of other options. In the Recommended care through integrated networks, as we , the one chosen by the Commission and described in Recommendation #1, veterans Option would be eligible to receive community care for primary and standard specialty care with a referral from any primary care doctor in the VHA Care System. Special emphasis care, care provided in a distinctive fashion by VHA, is not included in community networks. In addition to the , we considered three alternatives that are based on a Recommended Option similar concept of integrated networks, but which have potential costs that could vary dramatically due to differences in the openness of access to community care and the breadth of services eligible. We also estimated the costs of three options that differ in focus from the integrated network options, including options t hat move selected services entirely to the community, set up a premium support model, and expand access to all Priority 8 veterans. Finally, we estimated costs for two additio nal policies: expanding nurse navigator/care coordinator staff to help guide and coordinate ve terans’ care in the integrated networks of expanded community care and granting temporary eligibility for VA health care to those with other-than-honorable discharges. Baseline Projections We used projections from the Enrollee Health Care Projection Model (EHCPM) produced by VHA and Milliman as the baseline upon which to build our estimates. However, with the ort and an expansion of Priority 8 enrollment, exception of the options involving premium supp we use separate analyses and not the EHCPM to derive the estimates. Costs of VA care are modeled as the product of utilization and cost per unit of care (unit cost). Utilization is dependent on both enrollment in, and reliance on, the VA health care system, total demand for health care, and other factors. Enrollment me asures how many people enroll to receive VA health care, and reliance is the percentage of th eir medical care that enrollees receive through VA or VA-financed community care. Unit costs me asure the cost of each health care service. Unit costs can be calculated for care in VA facilitie s, for care outside of VA facilities, or for both, depending on the scenario being estimated. Utilization Utilization depends on enrollment, reliance, total demand for health care, and characteristics of the health care system, such as medical te chnology and practice patterns. We discuss enrollment and reliance in further detail below, bu t overall demand for health care is similarly and each have a multiplicative effect on important. Enrollment, reliance, and overall dem 171

186 EPORT C F INAL R ARE OMMISSION ON C utilization and total costs. For example, if enrollme nt increases by 10 percent, costs will increase me characteristics as existing enrollees). by 10 percent (assuming new enrollees have the sa the effect of any policy change on enrollment, Thus, it is important to consider carefully reliance, and overall demand for health care. Each of these factors is subject to effects by policies that make care more convenient, less expensive, or less restricted. Enrollment Currently there are 22 million veterans, 9 million of whom have enrolled and 7 million of whom are eligible to enroll but have not done so. Even though the number of ve terans is decreasing, projected numbers of enrollees and patients shou ld remain relatively stable during the next high rates, and once enrolled, they remain 20 years. Younger veterans enroll at particularly continuously enrolled until death. This enrollment trend is subject to change based on various inputs. Enrollment rates are changes, the number of enrollees and patients projected based on current policy, and if policy will change. For example, an increase in cost sh aring would likely decrease enrollment and the number of patients, yet easing access to care would likely increase enrollment and the number of patients. Changes to other health insurance po licies outside of VA can also affect enrollment and the number of patients (for example, changes to the Affordable Care Act). Figure A-1. Changes in Number of Vete rans, Enrollees over a 20-year Period Reliance On average, enrolled veterans receive 34 perc ent of their health care through VHA, and approximately 80 percent of enrollees have other heal th insurance in addition to VA health care. Many factors affect reliance rates including, age, income, service-connected disabilities, distance from VA facilities, cost-sharing levels, and charac teristics of other insurance options. Any policy that affects the cost of receiving VA care, the convenience of receiving VA care, the cost or convenience of other health insurance held by enrollees, or demographic or health characteristics of enrollees, is likely to change reliance. Any increase in reliance will increase 172

187 A A PPENDIX F V M ODEL INANCING THE ISION AND In the absence of a policy change, VHA predicts costs to VHA, and the effect can be very large. that reliance will decline slightly from 34 perc ng the next 20 years. ent to 32 percent duri Unit Cost Unit cost measures how much a particular servic e, procedure, or drug costs to provide. Unit costs can measure the cost of the unit of care in the VHA system or in the community, depending on where veterans receive care. We us ed unit cost projections from the EHCPM for 78 Health Care Service Categories (HSCs). The unit of measurement depends on the service. Examples include office visits, pathology procedur es, vision exams, and inpatient surgical days. Unit cost projections reflect anticipated changes in price inflation and health care practice patterns, as well as historical trends. EHCPM projects separate unit costs, depending on whether veterans receive a service in a VA facili ty, in the community at historic Care in the Community (CITC) rates, or in the community at Medicare allowable rates. Any policy that affects the quantity of care provided in VA fa cilities, as opposed to the community, will have an effect on the total cost of care. If veterans re ceive care in the community, the rate of provider reimbursement will also affect costs. Baseline Cost Projections The baseline cost projections, produced by the EHCPM, show how cost will change in the future. They incorporate projected changes in enro llment, reliance, unit costs, and other factors. rd to enrollment eligibility and VA health care The projections reflect current policy with rega benefits, with the exception of the Choice Program , which is assumed to continue for veterans 664 living more than 40 miles away from a VA medical care facility. flation and anticipated effects of changes in We based the projections on assumptions about in health care practice on the cost of VA health care in the next 20 years. New military conflicts, ctors, such as economic recession, can occur and policies, legislation, regulations, and external fa ng this period. The projections do not include change projected demand for VA health care duri requirements for several activities/programs not projected by the VA EHCPM, including nonrecurring maintenance; readjustment coun seling; state-based, long-term services and support programs; and some components of the CHAMPVA program. In the absence of any policy changes, costs increa se from $53 billion in 2014 to $125 billion in 2032. This growth is largely due to inflation and how health care practices are expected to change over time, which reflects factors that affect the cost of both VA and non-VA health care. These trends increase the cost of VA health ca re regardless of changes in enrollment growth and demographics. Within enrollment, the increasing number of enrollees adjudicated for service- connected disabilities by the Veterans Benefit Administration (VBA) is the most significant driver of cost increases. Enrollees will likely in crease their reliance to reflect the substantially higher reliance of enrollees in the service-connected Priorities 1-3. These baseline estimates, along with our scenar io estimates presented below, carry some key limitations. First, the EHCPM does not track capaci ty at VA facilities. We assume health care 664 wait times or excessive travel burdens are not included. Veterans qualifying based on 173

188 C C F INAL R EPORT OMMISSION ON ARE utilization will increase or decrease at the average unit cost, when in fact it is the marginal cost that would be relevant for cost estimates. This marginal cost could be smaller or larger than the g on existing capacity. Although we did make some assumptions about average cost, dependin fixed and variable unit costs when care leaves VA facilities in our policy estimates below, precise estimates are not possible given data availability. Second, the EHCPM does not consider health care capacity in local communities. For these and other reasons, the EHCPM is best for the near future and for policy scenarios that do not stray dramatically from current policy. 2008 RAND review of the EHCPM highlighted these limitations, which are particularly A 665 important for analyzing policy changes such as expanded community care. In light of the types of policy choices VHA is likely to consider in the future, it would be particularly beneficial for VHA to collect and incorporate the data necessary to mitigate these limitations. - term changes in Due both to these limitations and to the general uncertainty regarding any long the health care system, we suggest focusing attention on the 2019 estimates of the scenarios - in effects of the scenarios. below, as 2019 is the first year to incorporate the fully phased Policy Estimates In this section, we present results for the Recommended Option and three alternative options for expanding access to providers outside of VA through integrated networks. These options expand community care for different categories of care and vary by whether referrals are required to receive specialty care. We present estimates for several other scenarios we network options. Finally, examined, each with a design or focus that differs from the integrated we estimate costs for two other policies discussed in this report: (1) expanding the use of nurse navigators to help patients coordinate their care in VA and in the community, and (2) expanding eligibility to all veterans with an other - than - honorable (OTH) discharge until the adjudication process is complete to determine whether they will remain eligible. Community- Delivered Services Networks t least Recommend ed Option and the first three alternative options. A This section describes the initially, all care currently provided by VA would continue to be provided by VA. In addition, expanded community care, also called Community - Delivered Services (CDS), will be provided by an integrated network consisting of providers (medical practitioners including physicians, midlevel practitioners and therapists, and hospitals and clinics) vetted by VA. CDS will focus on tertiary and quaternary care, and may include primary care and all standard specialty care, depending on the scenario considere d. CDS will not include special - emphasis care and some types of specialty care provided in a distinctive fashion by VHA. The network of CDS providers that VA will coordinate varies by community. To make the flow of service both appropriate and smooth in op eration, there will be navigators who will help guide veterans to the best and most appropriate providers inside and outside VA. The Commission’s recommendation to crea te the VHA Care System (see Recommendation 1 ) considers the ways in which health plans c an vary the size and scope of networks as a means of managing costs. It highlights that broad, open networks offer greater choice, but narrow, well - 665 Katherin e M. Harris, James P. Galasso, and Christine Eibner, “Review and Evaluation of the Enrollee Health Care Projection Model,” RAND Corporation, Santa Monica, CA, 2008. 174

189 A A PPENDIX F V M ODEL INANCING THE ISION AND managed networks potentially result in lower costs. It discusses ways in which, after networks are designed, VHA could exercise additional cost controls by steering patients to different providers within the networks. Finally, the recommendation regarding the VHA Care System emphasizes that access and local needs are important considerations in setting up the in tegrated networks, and that governance of the networks should be a process of ongoing management and evaluation. In the estimates that follow, we assume that networks are designed and governed in a way that gives major consideration to cost, choice, and ac cess. We assume that management of the integrated networks would be an iterative process that involves continual evaluation of resulting outcomes, including cost outcomes, and that networks would be adjusted in light of those outcomes. We also assume that local communities and services with poor access would require more community providers and/or expanded capacity within VHA than those that already have adequate access. Finally, we assume that the networks will be integrated, relatively narrow, and well - ma naged with the aim of controlling costs effectively. One exception is that for the Recommended Option , we added an estimate that assumes less - managed, broader networks to illustrate that costs are sensitive to network size and management. Technical Assump tions for Community- Delivered Services Options We based our estimates on utilization and unit cost data and projections for 78 HSCs that we obtained from the VHA Office of Policy and Planning. Starting from a base year of 2014, we projected utilization and unit costs through 2034. For HSCs that are eligible for CDS networks, we assume a certain fraction of care, depending on the option, shifts from VA facilities to the 666 networks. We assume traditional CITC will be offered and used at baseline levels. We assume that the Choice Program ends and that those formerly in the Choice Program will take advantage of the community care offered in the CDS networks. All effects are phased in during the first 5 years. Both CDS networks and CITC are priced at Medicare all owable rates by matching Medicare fee 667 schedule data to VA HSCs. A few benefits that are not covered by Medicare, such as dental, are priced at historic CITC unit costs. Cost sharing for CDS networks is assumed to be the same as that for care in VA facilities. For care shifting into the CDS networks, we use data on the components of HSC unit costs that we obtained from the VA Allocation Resource Center. We assume VA is able to adjust resources such that only the equipment and national overhead portions of u nit costs remain in VA facilities. These portions, which together averaged approximately 10 percent of care in 2014, form our proxy for the portion of unit costs that VA will not be able to shed in scenarios for which, on net, care leaves VA facilities for CDS networks. Note that unit costs do not include costs associated with the physical building or nonrecurring maintenance. These costs are not part of the EHCPM, and costs and/or savings associated with changes to facilities and nonrecurring maintenance a re not included in our estimates. 666 CITC accounted for approximately 11 percent of modeled expenditures in the base year 201 4. 667 Medicare Allowable rates were provided by Milliman at the request of VA. They were produced using repricing -specific level for inpatient, outpatient, and professional care. For services that were not repriced performed at the area care amounts were estimated. within an HSC, Medi 175

190 C INAL R EPORT F C OMMISSION ON ARE Improving access, choice, and/or quality of serv ices is likely to induce greater reliance and enrollment in the VA system. Although relianc e and enrollment increases result in greater budgetary costs for VA, it is important to note that these increases do not represent societal tary cost increases may be associated with costs or costs to the government. The VA budge reductions in out-of-pocket expenses and improved health care benefits for patients, as well as savings to Medicare, Medicaid, and other government programs. Our cost estimates are confined solely to the VA budget. Approximately 52 percent of eligible veterans have enrolled in VA health care, and enrolled veterans receive 34 percent of health care th rough VA. There is little data from which to anticipate how reliance and enrollment might ch ange under the scenarios, and our estimates use wide ranges of assumptions for these parame ters. In forming our assumptions, we consider and other characteristics of eligible veterans a variety of factors, such as insurance coverage (both enrolled and unenrolled), survey responses of veterans (both enrolled and unenrolled) on re, and research on take-up of health insurance use and reasons for lack of use of VA health ca 668 coverage. We are confident that enrollment and reliance would increase more with greater patient choice and access. For all options, we present low, middle, and high estimates. t, reduced cost sharing, increased convenience In addition to increases in reliance and enrollmen of receiving community care, and the removal of a requirement to get a referral for specialty care can increase the total amount of medical care that a patient receives. Depending on the option considered, some health care is subject to reduced cost sharing from levels typical of private insurance coverage and Medicare to the very small levels of cost sharing found in the VA system. We assume utilization increases for he alth care subject to lower cost sharing and/or our estimates based in part on the literature removal of a requirement to get a referral, with 669 examining how cost sharing affects health care demand. Caveats There are a number of caveats a ssociated with all of our estimates. These caveats are important, and to the extent that these assumptions do not hold, the estimates will be inaccurate. The estimates do not include savings and costs of redu cing or repurposing infrastructure, or effects on VA’s teaching, research, and emergency pr eparedness missions. Medicare allowable rates are assumed adequate to provide all veterans with robust CDS networks in their local areas. For care priced at historic CITC rates, national av erage rates are assumed to represent future rates. Shifting care into CDS networks does not affect the unit cost of care that remains in VA facilities. Reductions in the volume of care with in VA facilities, and potentially adverse effects quality, are not addressed. Other than equipm ent and national overhead, the costs of care shifting out of VA facilities are phased out conc urrently with other effects in the model. New Alternative enrollees are assumed to cost slightly less than existing enrollees for CDS 3 and the 668 Examples of sources include: the 2014 American Community Survey; the 2010 National Survey of Veterans; the 2015 Survey of Veteran Enrollees’ Health and Use of Health Care; Katherine Baicker, W illiam J. Congd on and Sendhil Behavioral Economics,” Take-Up: Lessons from The Milbank Quarterly, Mullainathan, “Health Insurance Coverage and 90(1) (2012), 107-134. 669 Congressional Budget Office , “Key Issues in Analyzin g Major Health Insurance Pr oposals,” Washington, DC, 2008. Willard G. Manning, Joseph P. Newhouse , Naihua Duan, Emmett B. Keeler, Arleen Leibowitz, and M. Susan Marquis, American Economic “Health Insurance and the Demand for Medical Ca re: Evidence from a Randomized Experiment,” 77(3) (1987), 251–77. Review 176

191 A A PPENDIX F V M ODEL INANCING THE ISION AND 670 Finally, we CDS same as existing enrollees in the 2. Recommended Option and Alternatives 1 and do not estimate any administrative costs a ssociated with CDS networks other than the additional RN care managers hired to handle th e increased clinical and administrative burden of expanded community care. These additional , nonmodeled administrative costs could be substantial. Commission Recommended Option The would expand community care. At least initially, all care currently Recommended Option e through VA. In addition, expanded community provided by VA would continue to be availabl an integrated network consisting of providers care, also called CDS, would be provided by (medical practitioners including physicians, midl evel practitioners and th erapists, and hospitals and clinics) vetted by VA or a third-party ad ministrator. The CDS network would include all primary and standard specialty care; it would not include special-emphasis care (care that is 671 In 2014, 68 percent of care would have been eligible for provided in VA in a distinct fashion). CDS networks at current VA prices. A referral fr om a primary care provider would be required to receive specialty care. This referral could come from a provider either at VHA or from the community network. In this scenario, we assu med all other characteristics of the VHA Care System would remain the same as under current policy. We assume that the Choice Program ends and that those formerly in the Choice Program will take advantage of the community care offered in the CDS networks. We expect that allowing enrollees to get prim ary and standard specialty care in the community will increase reliance for care provided in th e community because many veterans would have a choice among a larger number of providers and would be more likely to have the option to receive care at a more convenient location. We also expect enrollment to increase because some the prospect of having VA pay for them to see a eligible veterans would be induced to enroll by doctor in the community. We assume that 60 percen t of eligible care shifts from VA facilities to der this scenario, we model reliance levels of CDS networks. Currently reliance is 34 percent. Un 40, 50, and 60 percent, which correspond to reliance rates increases of approximately 18, 47, and 76 percent, respectively. These reliance increases apply only to CDS care, not CDS-eligible care that is provided in VA facilities. Although the choice of providers is expanded and wait times are potentially reduced in VA, there continues to be a requirement for a referral to access specialty care, as there is in the current system . We modeled enrollment increases of 5, 15, and 20 percent for the low, middle and high estimate s, which assume integrated, narrow, and well- managed networks that are designed and managed with cost as one of the major considerations. We also modeled an enrollment increase of 50 percent, more consistent with a less-managed, relatively broad network for which cost is a le ss important consideration. Finally, we assume that newly entering veterans who receive trea tment in CDS networks because of this policy have a 20 percent utilization increase for new dem and in CDS networks. Much of this care was 670 Assumptions based on previous analysis by VHA and Milliman. 671 etics and orthotics, recreational therap y, rehabilitative ca re, pharmacy, home- Special-emphasis care includes: prosth based primary care, spinal cord injury an d disorders, some categories of long-t erm services and supports, mental health and homeless care. We count all mental he alth as special-emphasis because mental health categories cannot easily be ecial-emphasis and care that is not. differentiated by care that is VA sp 177

192 C ARE F INAL R EPORT C OMMISSION ON formerly subject to sizable cost sharing with private insurance or Medi care, and now it would be subject to little if any cost sharin g associated with VA-financed care. Figure A-2 displays estimates for the . Estimates for well-managed, narrow Recommended Option networks range from $65 billion to $85 billion in 2019 , with a middle estimate of $76 billion. The middle estimate is moderately above the baselin e projection of $71 billion. Although reliance and enrollment increases push VA budgetary costs up, the switch from VA unit costs to the less costly Medicare allowable rates for CDS netw orks and CITC mitigate the increases. The estimate for the less-managed, broader network sc enario is $106 billion in 2019, illustrating that costs could increase markedly if governance of th e network places less importance on cost or if ghtly managing the network. VA were unsuccessful in ti Figure A-2. Projected Costs of Recommended Option 178

193 A PPENDIX A F INANCING THE ODEL V ISION AND M COST on Care Scenarios Commission ESTIMATES Enrollment Reliance 2034 FY Cost FY Cost 2019 FY 2014 Cost Increase (low, Utilization Projected Projected Actual (low, Brief Description middle, Increase (billions) (billions) (billions) middle, high) high) Actual 9,078,615 34% $53 71 Baseline 138 $ 2014 $ (68% Based Care in VHCS Referral +20% of new eligible as of current VHA care demand in CDS) Recommended (low) Care 5% 40% 65 $ 132 $ CDS (middle) same 50% 76 $ 155 $ Recommended same 15% 173 same 60% 85 $ 20% $ (high) Recommended same ‐ managed) same same 50% 60% 106 $ 213 $ Recommended (less Recommended but to Similar care, inpatient med and primary new of +20% specialty surg and some standard in demand in remain care not eligible CDS for 128 CDS Care $ 0% 10% 66 $ CDS) eligible care of for (47% VHA (low) Alternative 1 Alternative 1 (middle) same same 5% 35% 73 $ 140 $ 1 (high) same same 10% 50% 78 $ 151 $ Alternative Similar to Alternative but primary 1 only care coordinator must be CDS +20% required consulted; referral no 97 60% 5% Care $ 191 eligible $ (low) 2 Alternative care CDS) eligible of (47% for Alternative 2 (middle) same same 10% 80% 123 $ 243 $ Alternative (high) same same 20% 100% 154 $ 307 $ 2 primary Alternative 2 to but Similar care, inpatient med/surg and specialty care eligible for CDS and CDS +20% (low) 3 Alternative required consult eligible Care 75% 80% 167 $ 320 $ no (level) $ 395 same (middle) same 85% (level) 90% 206 $ Alternative 3 $ same same 95% (level) 100% 250 $ 479 (high) Alternative 3 +20% of new most standard ambulatory Move demand in community Selected Services (low) specialty care Keep to CDS Care 0% 10% 64 $ $ 128 Keep Selected Services (middle) same same 4% 25% 70 $ 136 $ 145 Keep (high) same same 8% 40% 75 $ Services $ Selected of 42% 65 can choose <65 enrollees Enrollees under age premium insurance a subsidized choose of VHA with cost sharing in lieu premium care support 6% $ 158 $ 82 Premium Support to increase 30% market share among enroll Eligibility Expansion Allow all eligible veterans to priority 8 5% 72 $ 140 $ $ 138 for CDS care 71 $ Initiatives navigators Nurse Make veterans with Other than Honorable Discharges Temporarily Eligible for VA Health Care While 72 Claims are Adjudicated $ 139 $ 179

194 EPORT C F INAL R ARE OMMISSION ON C Additional Sample Cost Models CDS Alternative 1 above. The main CDS Alternative 1 is similar to the Commission’s Recommended Option is available in the CDS networks. Primary care, difference is that a narrower subset of services inpatient medical and surgical care, and some st andard specialty care are not eligible for CDS networks and must be accessed within VA. The CDS network for CDS Alternative 1 would focus on tertiary and quaternary care; it would no t include primary care, some specialty care, hasis care (care that is provided in VA in a inpatient medical and surgical care, and special-emp distinct fashion). In 2014, 47 percent of care would have been eligible for CDS networks. Recommended Option , less care will Because less care is eligible for CDS networks than in the shift to CDS networks, reliance increases will be smaller, and enrollment increases will be smaller. We assumed that 50 percent of eligible ca re shifts from VA facilities to CDS networks. We modeled increases in reliance of 10, 35, and 50 percent, which correspond to reliance rates of approximately 37, 46, and 51 percent. These reliance increases pertain only to CDS care, not llment increases of 0, 5, and CDS-eligible care provided in VA facilities. We modeled enro 10 percent. As in the we assume newly entering veterans who receive Recommended Option, treatment in CDS networks because of this polic y have a 20 percent utilization increase for new demand in CDS networks. native 1. Estimates range from $66 billion to Figure A-3 displays estimates for CDS Alter $78 billion in 2019, with a middle estimate of $73 billion. As in the Recommended Option, the tion of $71 billion. Although reliance and middle estimate is close to the baseline projec the switch from VA unit costs to Medicare enrollment increases push VA budgetary costs up, allowable rates for CDS networks and CITC offsets these effects. 180

195 A PPENDIX A F INANCING THE ISION AND M ODEL V Figure A-3. Projected Costs of CDS Alternative 1 CDS Alternative 2 CDS Alternative 1 , CDS care in Alternative 2 Like would focus on tertiary and quaternary care. CDS networks would not include primary care, special-emphasis care, inpatient medical and surgical care, and some types of specialty care. This option differs from the Recommended Option and in that veterans must CDS Alternative 1 consult their VHA primary care provider in some way before seeking specialty care, but they do not ether they receive it in or out of VA. Some need a referral to receive CDS eligible care wh specialty care, all primary care, and all special- emphasis care are only provided in VA unless wever, after the primary care consultation, the the veteran is eligible for traditional CITC. Ho choice of whether to seek eligible care in CDS networks is entirely up to the veteran. As in CDS , the care eligible for CDS networks comprised 47 percent of total modeled Alternative 2 expenditures in 2014. We expect reliance increases to be relatively hi gh, and we apply these reliance increases to CDS eligible care regardless of where veterans receiv e it because referrals are not required for any CDS eligible care. Further, we expect en Recommended rollment increases to be higher than the Option and CDS Alternative 1 because the absence of a referral requirement makes this a more attractive policy for potential enrollees. We mode l reliance rates of 60, 80, and 100 percent for care eligible for CDS networks; en rollment increases of 5, 10, and 20 percent; 70 percent of VA facility care shifting into CDS networks; and a 20 percent utilization increase for CDS eligible care. 181

196 C ARE F INAL R EPORT OMMISSION ON C Estimates are displayed in Figure A-4. In 2019, the baseline projection is $71 billion. CDS Alternative 2 estimates range from $9 7 billion to $154 billion, with a middle estimate of $123 billion. The potential for considerable relia nce and enrollment increases could push costs substantially higher than the baseline. Figure A-4. Projected Costs of CDS Alternative 2 CDS Alternative 3 a broader array of care is in two main ways. First, Alternative 2 CDS Alternative 3 differs from eligible for CDS networks. CDS would include primary and standard specialty care, including t include special-emphasis care (care that is inpatient medical and surgical care. It would no provided in VA in a distinct fa shion). This array of eligible ca re is the same as that for the Recommended Option , and comprised 68 percent of total modeled expenditures in 2014. Second, enrollees do not need to consult with a primary ca re doctor in order to access CDS eligible care. CDS Alternative 3 would offer an extremely generous benefits package for patients. With no referral or consultation, no premiums, and little if any copayments, patients would have access to a robust network of high-quality providers in their area. Although care within VA facilities would be available, no clinical contact woul d be necessary for those seeking care in CDS networks. Even within VA facilities, care is mo re attractive because patients would no longer need to consult their primary care doctors to rece ive specialty care. The benefits of this option contrast with the 10 to 30 percent cost sharing typical in Medicare and private coverage, the low 182

197 A PPENDIX A F INANCING THE M ODEL V ISION AND 672 and the provider reimbursements, stigma and access barriers often associated with Medicaid, requirements for referrals and/or prior author izations that are widespread among health insurance plans. Few veterans would have reason to turn down such an attractive option. Consequently, we model high ranges for relianc e, enrollment, and care shifting into CDS and 100 percent for all CDS eligible care; networks. We model reliance rates of 80, 90, enrollment shares of 75, 85, and 95 percent; and a 70-percent rate of eligible care shifting from liance increases to all care eligible for CDS VA facilities to CDS networks. We apply the re networks, even if the care is provided in VA fa cilities or traditional CITC, because this option eliminates the need for consultations with pr imary care doctors for all CDS eligible care. ived by veterans from Additionally, we assume that the total amount of CDS eligible care rece any provider and payer increases by 20 percent du e to the lack of a referral requirement and/or reduced cost sharing. Estimates are displayed in Figure A-5. In 2019, when effects are fully phased-in, estimated costs on, with a middle estimate of $195 billion. This compares to range from $156 billion to $237 billi mates are highly uncertain, a key takeaway is a baseline projection of $71 billion. Although esti that this option could result in very large co st increases relative to the baseline scenario, , and CDS Alternatives 1 and 2 Recommended Option . Figure A-5. Projected Costs of CDS Alternative 3 672 Yu-Chu Shen and Stephen Zuckerman, “The Effect of Medicaid Payment Generosity on Access and Use among Beneficiaries,” Health Services Research 40, no. 3 (2005), 723-44. Jennifer Stuber an d Karl Kronebusch, “Stigma and Other 23, no. 3 (2004), 509-530. Determinants of Participati on in TANF and Medicaid,” Journal of Policy Analysis and Management 183

198 C ARE F INAL R EPORT OMMISSION ON C Keep Selected Services The scenario would move most standard ambulatory specialty care Keep Selected Services (KSS) entirely into the community, yet keep the remainde r of care entirely within VA facilities or traditional CITC. Although VA would no longer provide most standard ambulatory specialty care in VA facilities, it would continue to provide primary care, inpa tient care, and special- term services and supports, prosthetics and emphasis care in VA facilities, including long orthotics services, inpatient and outpatient me ntal health and substance abuse, inpatient medical and surgical care, prescription drugs, medication management, recreational therapy, and immunizations. Under this scenario, approximat ely 35 percent of the cost of care currently provided in VA would be provided solely in the community. Providers in the community would receive Medicare rates. We modeled increases in reliance of 10, 25, and 40 percent, which correspond to reliance rates of approximately 37, 43, and 48 percent. These reliance increases pertain only to care that moves into the community. We modeled enrollmen t increases of 0, 4, and 8 percent. Estimates are displayed in Figure A-6. In 2019, when effects are fully phased-in, estimated costs le estimate of $70 billion. This estimate range from $64 billion to $75 billion, with a midd compares to a baseline projection of $71 billion. Although estimates are highly uncertain, a key ty care, cost increases are constrained when takeaway is that even with expanded communi r they receive care in VA facilities or in the community. veterans cannot choose whethe Figure A-6. Projected Costs of Keep Selected Services Scenario 184

199 A A PPENDIX F V M ODEL INANCING THE ISION AND 673 Premium Support Premium Support (PS) scenario, all current and future enrollees younger than age 65 Under the can choose a subsidized insurance premium with cost sharing (for some priorities) in lieu of their current VHA benefit. Enrollees electing th e premium and cost sharing subsidy no longer have access to any VA services, including the spec ial services VA offers. Under this scenario, there is an annual election peri od, and VA actively engages with enrollees to make a decision. Enrollees ages 65 and older receive no additional benefit options. surance program, the cost sharing varies by For those enrollees choosing the subsidized in priority level: 10 percent for priorities 1 and 2; 20 percent for priorities 3 and 4; 30 percent for priorities 5 and 6; and 40 percent for pr iorities 7 and 8. Veterans would buy Silver policies on the state individual insurance exchang es, and VA would provide additi onal cost sharing assistance to meet the target subsidy. If enrollees purchased plans offered with lower cost sharing, such as Gold (20 percent cost sharing) or Platinum plans (10 percent cost sharing), the additional premium costs would likely exceed the cost of pu rchasing a Silver plan and subsidizing the cost sharing. The cost estimates did not consider the potential effect of adding a large number of considerations for veteran morbidity as well as veterans on exchange plans. Were VA to do this, the proposed cost sharing subsidies would need to be accounted for within the purchase of state exchange plans from commercial insurers. To determine participation rates in the su bsidized premium program, we summarized enrollees’ FY 2014 baseline data into cost brac kets by attaching 2015 EHCPM unit costs to workload and then summarizing the total cost of workload provided to each enrollee. Overall, 42 percent of enrollees younger than age 65 we re assumed to select the subsidized premium participation depending on enrollees’ priority option, but the model assigned different rates of little to no costs were assumed to participate level and historical VA utilization. Enrollees with in the program at a higher rate as compared to those who had larger levels of VA costs. Participation rates for priority 5 veterans were a ssumed to be half the rates set for other priority levels. This assumption was made because many of these lower-income enrollees already have the option of participating in a highly subsidized state exchange plan with low cost sharing. It is also assumed that offering this option will motiva te additional nonenrolled veterans to enroll to receive the subsidized premium plan. To estimate this effect, we analyzed the proportion of veterans by priority level with either no insur ance or individual insuranc e plans, as reported in recent years of data captured by the Americ an Community Survey (ACS ). We estimated that this potential subsidy would lead to an addition al 577,000 enrollees over the projection period. Finally, it is assumed that the subsidized prem ium plan serves as a primary payer and does not supplement other coverage available to the enroll ee, such as Medicare or employer sponsored insurance. 673 Analysis developed by Milliman for VH A Office of the Assistant Deputy Un dersecretary for Health (ADUSH) for Policy and Planning. 185

200 OMMISSION ON C F INAL R EPORT ARE C Figure A-7. Projected Costs of Premium Support Scenario 674 Eligibility Expansion Under the (EE) scenario, the VA health care system expands to allow all Eligibility Expansion 675 f of veterans eligible under priorities 1-7, 8b, veterans to enroll in VA health care. In 2014, hal 676 and 8d were enrolled, representing a 50 percent market share, with the highest market share among those with service-connected priorities. The market share among Priorities 8a and 8c was an estimated 21 percent, reflecting enrollm ent from before suspension began in January 2003 and from enrollees who initially enrolled in another priority and later transitioned to w priority 8 enrollment had never occurred, we Priorities 8a and 8c. If the suspension of ne estimate that the market share would be 28 percent in 2014 and 30 percent in 2021 under natural growth and priority transition rates. suspension beginning in FY 2017, we estimate Under a scenario of lifting priority 8 enrollment that the market share would climb steadily during a 5-year phase-in period to reach 30 percent in 2021, which equates to 464,000 new priority 8 enrollees. The market share is not expected to reach the level observed among other prioriti es because Priority 8 veterans have higher incomes, are not service-connected disabled, are more likely to have employer-sponsored coverage and individually purchased health plans, and are less likely to be uninsured relative to other priorities. Further, regression analysis of market shares among veterans in census data demonstrated that higher income veterans, nond isabled veterans and veterans with employer- sponsored health insurance are all less likely to enroll. To develop the cost estimates, newly 674 Analysis developed by Milliman for VH A Office of the Assistant Deputy Un dersecretary for Health (ADUSH) for Policy and Planning. 675 Priority 8b and 8d were enrolled on or after June 15, 2009 and have in comes that exceed the current VA or geographic income limits by 10 percent or less. 676 Market share is the percentage of veterans who are enrolled in VHA out of all veterans. This differs from the who are enrolled. of eligible enrollees enrollment share, which is the percentage 186

201 A PPENDIX A F INANCING THE ISION AND M ODEL V eligible priority 8 veterans are assumed to have the same morbidity and reliance as current priority 8 enrollees. we project an additional 368,000 priority 8 By 2032, based on the estimated market share, $1.8 billion in costs. enrollees with an additional Figure A-8. Projected Costs of Eligibility Expansion Scenario Additional Cost Factors Nurse Navigators VHA already has a robust care manager program t hat largely overlaps with the proposed nurse navigators in the CDS scenarios. VHA patient aligned care teams (PACTs) were created to coordinate care and maintain long-term relation ships with patients. Most PACTs exist in a primary care setting, but there ar e also special-emphasis PACTs, such as those for spinal cord All patients may choose to be assigned to a injury and disorders, geriatrics, and HIV care. primary care PACT, and the vast majority do so: There are approximately 5.3 million unique patients in primary care PACTs out of a total of 5.8 million. The primary care PACT typically consists of a provider, an RN care manager, a clinical associate, and a clerk. This team is assigned to a panel of approximately 1,200 patients. There are also expanded team member s who are assigned to multiple panels, such as clinical pharmacy specialists, nutritionists, and behavioral health professionals. The RN care manager is the lynchpin of the primary care PACT. One of the tasks of the care manager is to coordi nate care received in VHA facilities with care received in the community. Because this coor dination role would increase with the CDS scenarios, we provide a notional estimate fo r expanding the number of care managers to ical burden of an increase in community care. account for the additional administrative and clin 187

202 C F INAL R EPORT ARE OMMISSION ON C Based on discussions with VHA primary care oper ations and policy staff, we assume that one additional RN care manager per five panels woul d be necessary to handle a substantial increase 677 community care such as that a ssociated with the CDS scenarios. Based on 2014 data on the number of patients in PACTs and the recommended panel size, we estimate that 882 RN care managers would need to be hired if the CDS scen arios were fully phased in. Incorporating the ($94.4 thousand in FY 2014) and inflating costs average total compensation of RN care managers using the projected patient population and pe rsonnel inflation trend from the EHCPM, we generate the following cost estimates. These estimates are assumed to be fully phased in. The cost of this policy is $100 million in 2019 and rises to $158 million in 2034. Figure A-9. Cost of Hiring Additional RN Care Managers Other-than-Honorable Discharges We also consider a policy for which those with an OTH discharge are made temporarily eligible judicated. The adjudication process would for VA health care while their claims are ad determine whether these individuals would remain eligible for care or would lose eligibility. r the discharge. For example, if the discharge Adjudication would be based on the reason fo were due to behavior associated with a mental health condition caused by serving in the military, that person would likely be positively adjudicated. However, the specific criteria for adjudicating cases still needs to be determined. me all people with an OTH discharge who would To model the cost of this proposal, we assu are initially eligible. We assume that, consistent with the rest otherwise be eligible for VHA care an OTH discharge are eligible for VA health care of the population, 73 percent of veterans with based on income and disability criteria. During a period of 5 years, their cases are examined, and 50 percent are positively adjudicated. Whether this number is actually higher or lower than policy as well as the specific circumstances of 50 percent will depend on the exact details of the veterans with an OTH discharge. In our model, the number of eligible veterans with an OTH discharge who enroll increases during the first 5 ye ars as they become aware of the new rules. It 677 pursued, but we provide a si ngle notional estimate to These estimates would differ depending on the CDS option give a sense of the magnitude of costs involved. 188

203 A PPENDIX A F INANCING THE M ODEL V ISION AND hare of veterans who are currently eligible. In increases to 52 percent, which is the enrollment s those with an OTH discharge if they are different reality, this rate could be higher or lower for from those who are already eligible. We assume co sts per patient are similar to other veterans of the same age. The cost of this policy increases from $264 millio n in 2014 to $1.23 billion in 2033. Fully phased- in, the cost is $864 million in 2019. The shape of the cost curve reflects increasing enrollment t the new rule and sign up. It also reflects during the first 5 years as veterans learn abou ans are initially eligible and then their eligibility is adjudicated adjudications as all enrolled veter during the 5 years. These calculations reflect estimates that the number of veterans with an OTH discharge for active duty military has fa llen from a high of 8.8 percent in 2002 to 2.1 percent in 2015. We assume that the rate continues at 2.1 percent of discharges throughout the projection window. y Covering Veterans with OTH Discharges Figure A-10. Projected Costs of Temporaril Conclusion receive expanded community care through The estimated cost of allowing veterans to integrated networks varies dramatically depend ing on the specifics of the policy, including which categories of care are eligible for the community and whether referrals are required to Recommended Option , which provides increased access specialty care. We estimate that the re allowable rates but maintains referrals for community care that is reimbursed at Medica specialty care, increases costs modestly, assuming that networks are narrow and well-managed with cost as a major consideration. CDS Alternative 1 , which offers a more restricted array of services eligible for CDS care, yet maintains a referral requirement, does not substantially increase costs. However, CDS Alternative 3 and to a lesser degree Alternative 2 , which eliminate the need for referrals for standard specialty care , potentially lead to very high costs. The small to substantial, though these costs would estimated costs of the other scenarios range from 189

204 C F INAL R EPORT ARE C OMMISSION ON ultimately depend on the details of the propos als (e.g., the premium supp ort schedule). Finally, we find that the costs of introducing expanded nurse navigators/care coordinators and making those with OTH discharge temporarily eligible are comparatively modest. 190

205 APPENDIX B: LEADERSHIP IMPLEMENTATION Table B-1. Organizational Health and Cultural Transformation Responsible Timeline Action aligning VHA create a comprehensive, coordinated, sustainable cultural transformation by programs and That effort a single, around benchmarked concept. activities the charter for the cross ‐ functional SE team Establish responsible for mos) 6 SECVA/DEPSECVA or CVCS ‐ (0 Now level on depending transformation. cultural model. transformation models and decide Assess a single cultural Chartered SE team Now (0 ‐ 6 mos) on Create an execution strategy for cultural transformation. Chartered SE team Now (0 ‐ 6 mos) Develop strategy and materials and release. Chartered SE team Near (18 mos) communication aligns leaders at all levels in That support of the cultural transformation strategy. VHA Establish a subcommittee under the SE team to drive leadership mos) Chartered SE team Near (6 transformation. SE standards for behaviors and actions. Chartered Establish leadership team mos) Near (6 ‐ 9 Subcommittee Publicize the standard. Chartered SE team mos) Near (12 Subcommittee/CVCS/HTM Develop assessment tools. SE mos) Near (12 ‐ 24 Subcommittee/NCOD, NCEHC, HTM expectations policy) for use of leadership standards in Establish (in mos) 36 ‐ (12 HTM/CVCS Near promotions. hiring, review, performance IDPs, coaching to the standard. (Current HCM office Provide Near (24 mos) responsible) curriculum training, support Collect into a living standards, mos) EES/HTM Near (24 materials leaders. for (36 Future HRA/HTM mos) Modify to VA Directive 5021 (Employee/Management Relations) behavior performance unacceptable and unacceptable include responsibilities of related to standards organizational transformation of penalties to correspond. leaders and update table That align frontline staff in support VHA of the cultural transformation strategy. Establish subcommittee to support staff transformation. Chartered SE team Near (9 mos) Establish expectations/requirements for staff. Subcommittee behavioral Near (9 ‐ 18 mos) Develop tools against the staff standard. Subcommittee Near (18 ‐ 36 mos) hiring Establish requirements (in policy) for use of the standard for IDP, mos) 36 ‐ (18 Near and HTM/HRA/nursing similar/unions in grade/promotions. advancement reviews, performance 191

206 C OMMISSION ON ARE F INAL R EPORT C Timeline Responsible Action mos) Near owner) (Policy (18 all levels of the organization to Support leaders and supervisors at (see align communicate and with standards these reinforce staff above). leaders, program office and VAMC standards and strategy Establish for execution. Establish subcommittee to develop VAMC and PO execution mos) Chartered SE team Near (18 standards. and Establish execution strategy mos) policy requirements. Chartered SE team 36 ‐ (18 Near Subcommittee/NCEHC/ NCOD meaningful metrics with input from experts and field users. Develop consolidated, SE Assign for metric development. Chartered responsibility team/CVCS Near (6 mos) mos) Develop and test metrics. Organizational Excellence Near (6 ‐ 18 mos) Deploy metrics. Chartered SE team/CVCS/ (18 Near (policy owner) mos) Identify outliers and SE team/CVCS/(policy (24 Near intervene. owner) 192

207 A PPENDIX B L EADERSHIP I MPLEMENTATION , Development, and Advancement Table B-2. Recruitment, Retention Timeline Action Responsible are required to make the leadership system a top priority for funding, strategic planning, and executives VHA their own time and attention. investment of leadership management goal for inclusion in the VHA a VHA Human Capital Establish mos) (3 Now targets. budget with specific Management/NLC 2018 targets, including diversity subcommittee leadership the of committee HR the leadership management goal to VA for inclusion in the Submit mos) (3 Now VHA OPP and CVCS 2018. for budget submission VHA Adopt management goal and submit to OMB/White mos) VA OPP and SECVA Now (3 leadership House. Capital operational plan and accountability mechanisms for Establish Human VHA an mos) (4 Now meeting these Management/NLC goals. subcommittee leadership of HR committee the yearly targets in the performance plan of the CVCS and SES Include mos) VHA NLC subcommittee (4 Now planning performance on members. ongoing CVCS Now – quarterly) to the that Schedule regular communication (at least field and expectations for ethical to mission, speaks vision, values, behavior. ongoing – Now CVCS field senior staff that and VHACO Schedule regular meetings with mission, vision, values and expectations for allows for of discussion a behavior. ethical opportunities for developing leaders to participate in the Develop mos) (6 Now executive NLC /ask CVCS of processes and committee to develop VHA. leadership and management decisions plan a implement and Adopt and implement a comprehensive system for leadership development and management. Now & NCOD, with NCEHC ACHE and the National Center for Health (6 mos) Convene a group to review Human Capital model benchmarked a devise meets that the Executives and Care to report Management; sector. of health care executives in VHA as well as the needs private the NLC subcommittee leadership for development new Create tracks for key positions based on this career 12 (within HTM Near model. competency mos) and Fund implement leadership assessments, training, coaching, and developmental opportunities based on the new competency model. leadership 18 (within Near (360, 180, self ‐ assessment, supervisory) support Develop assessment as tools HTM with mos) required from other model. competency to support the NCOD, e.g., offices, EES existing training against the Assess and identify gaps. EES Near (18 mos) model Develop and implement a plan to fill these gaps. EES/reporting to NLC to – mos Near (plan 20 36 ensure fill gaps funding mos depending on $) 193

208 C OMMISSION ON ARE F INAL R EPORT C Responsible Timeline Action opportunities Assess share additional leadership training with to mos) (9 Near HEC/JEC a it. to plan create and implement DoD fund a face ‐ to ‐ face Develop to fulfill competencies for and mos) (24 EES Near training positions. career critical a Develop masters level training program for clinical leaders in mos) (36 Near EES/Academic Affiliations academic with partnership medicine. sharing with non ‐ profit institutions to permit agreements EES/Academic Affiliations Near (18 mos) Establish rotations. exchange of the executives for extended an experiential learning program to parallel the competency Create EES, HTM reporting to mos) (24 Near model. leadership the development of subcommittee NLC the mos) a program. HTM/EES Near (18 coaching Establish mos) (18 Near assessment, training, coaching, Incorporate tracking of competency HRA/EES/Workforce appropriate IT platform (e.g., TMS). an Management and and into IDP completion Consulting is required to VHA manage leadership recruitment, retention, development and advancement using the aggressively new leadership competency model: all hires and promotions are required to demonstrate these competencies. statements for all key positions based on Create the mos) (18 HTM Near functional model. competency mos) Create interview questions incorporating competencies for all key (12 HTM Near positions. a for certifying internal candidates for process Human Capital Near (18 mos) Establish the Management advancement next position. to the of competency achievement with mos) (18 Near Capital Human Incorporate tracking tracking mechanisms and pool of create Management and ratings performance a high potential candidates. mos) (36 Near Capital Human use of the competency Create regulatory requirements for the VHA in Management opportunities, hiring, and model in promotion, development preferences. veterans for procedures incorporate and discipline; mos) Establish an IDIQ, PBA or similar contract for executive recruitment. Human Capital (6 Now Management policy for all ECF, SES / SES in equivalent to Human Capital Future (following Establish requirement complete IDP. regulatory change) Management mos) (6 Now retiring MTF. Human Capital Create ‐ ramp for on DoD / Management Coordination Now Expand program. EES (GHATP) (6 mos) Establish a plan mos) for developing and managing the candidate pool. NLC subcommittee for (6 Now leadership model. Require a formal on boarding process for leaders at all levels that re ‐ enforces the leadership competency Capital an onboarding curriculum and process. Establish Human Now and Near (18 mos) Management, EES, HTM 194

209 A PPENDIX B L EADERSHIP I MPLEMENTATION Timeline Action Responsible is required to VHA immediate steps to stabilize the continuity of leadership. take Extend authority for length of details and ability to compete for the mos) (6 Human Capital Now position. detail Management Establish and fund assistant level positions in all key career mos) (18 CVCS Now tracks. development 195

210 C C F INAL R EPORT OMMISSION ON ARE Table B-3. Organizational Structure and Function Action Timeline Responsible duplication structure. within VHA and consolidate program offices to create a flat Eliminate duplication of functions between VHA and VA by closing VHA offices. Eliminate the innovative organizational structures to support clinical delivery that are Create to patient’s needs aligned rather than professional silos. reduction ‐ in ‐ force (RIF) in VHACO that promotes delayering and efficiency in Undertake communication and a decision making. Figure new organizational chart consistent Publish a 9. CVCS Now (1 mos) with Prepare an initial RIF for offices eliminated. VHA Human Capital mos) Now (3 Management mos) 12 ‐ (3 Near Office/ Transformation expertise business with resources other (or VERC in Engage VERC the design ‐ re to processes reengineering) process and ‐ structures support with remaining offices to ensure end ‐ to end duplication; including reduce further and function field for to organization. clinical function re ‐ Each program office in collaboration with VERC or other mos) 12 ‐ (3 Near Office/ Transformation of work” with transformation resources identifies areas “stop PO/ CVCS savings. budget and staffing mos) Publish clear roles, responsibilities and expectations that apply (1 Now Office/ Transformation offices. VHACO CVCS all to Develop service training to orient existing VHACO staff to the in mos) ‐ (1 Now Office/ Transformation VHACO. of role EES the expectations new for training curriculum to support VHACO staff in Develop mos) (18 Near Office/ Transformation competencies EES and skills the developing required. an engagement strategy to inspire VHACO staff to mos) (1 Now Office/ Transformation Develop in ‐ service training roll out. tie and role CVCS new their embrace to and ‐ service training Modify implement in on ‐ boarding mos) in (6 Now Office/ Transformation EES VHACO employees. new for process customer Adopt mos) service training in VHACO and roll it out; (12 Near Office/ Transformation new employee on ‐ boarding in VHACO. of part EES as include Transformation mos) (12 Near Office/ staff Draft competencies for VHACO program basic HCM customer service, quality improvement, coaching, (e.g., data leadership, analytics). change communication, effective Require the basic competencies in functional mos) statements as a (18 Near Office/ Transformation and hiring Each PO for basis promotion. mos) (18 Near Organizational of Office Acquire, on data analytics PO staff train configure, and Excellence/OIT field infrastructure of to support program office and tracking metrics. performance key 196

211 A B PPENDIX L I EADERSHIP MPLEMENTATION Responsible Action Timeline the define the roles and responsibilities and of specifically VISNs and facilities, pushing decision Clarify down to the making lowest level. roles, responsibilities and expectations that apply Publish clear mos) (1 Transformation Office/ Now CVCS VISNs. to the in ‐ service training Develop to orient existing VISN staff to the mos) (1 Now Office/ Transformation of VISN. role the EES for expectations new to engagement strategy to inspire VISN staff Develop an VISN directors Now (1 mos) to in ‐ service training roll out. their new role and embrace tie Modify in ‐ service training and implement in on ‐ boarding mos) (6 Now Office/ Transformation employees. VISN EES new for process mos) (12 Near Transformation Office/ Draft quality basic competencies for VISN staff (e.g., HCM effective communication, improvement, change coaching, analytics). data leadership, Require the basic competencies in functional statements as a mos) (18 Near Office/ Transformation promotion. and each PO hiring for basis three from Congress to institute Gain appropriation mos) agreement (12 Near CVCS/SECVA/OMB construction, major research. medical, only: lines Eliminate segregation of specific ‐ purpose funds to the VISNs mos) (6 CVCS/Office of Finance Now and facilities. Modernize financial management system (FMS) to mos) permit OIT/Office of Finance Future (36 priority spending. effective cost accounting and tracking of Develop training support effective use of FMS to permit post TBD to Finance/EES roll it out. reporting and tracking account procurement effective and Finance TBD post Office all priority areas Establish quarterly spend reports covering procurement mental health, minor, purchased facility IT, NRM, (e.g., care, release to women’s health, administration) by facility and the and public. Congress decisions in recruitment, retention (1 and advancement Delegate mos) CVCS/HCM Now market pay) for staffing to (e.g., hiring bonus, retention bonus, facility. the training and travel decisions. CVCS/EES/OAA Now (1 mos) Delegate USH establishes leadership communication mechanisms The within VHACO and between VHACO and the field and to transparency, dialogue collaboration. promote (3 Now CVCS mos) frontline leadership and Improve communication with field of social media, town halls employees through the liberal use a dedicated channels with engagement direct other and USH and senior staff in this endeavor. champion to help the mos) (6 Now CVCS/EES/NLC at least semi ‐ Reestablish ‐ person in leadership conferences, communication building and relationship to annually, foster facility leadership. between VHACO, VISN and Add behavioral competencies to performance plans that mos) (12 Near CVCS communication amongst leaders. effective promote 197

212 C F R EPORT OMMISSION ON C INAL ARE Responsible Timeline Action Now CVCS mos) (3 for program office Establish expectations and requirements leadership messages, the communicate to leaders USH the USH and with one coordinate PO communications with another. Establish a transformation office with broad authority and a supporting budget to accomplish the change. mos) (6 Now CVCS transformation office in the organizational Establish the new expertise business process re ‐ with populate chart, in and savings from closure initially fund and engineering, using in VHACO and a budget reduction to all consolidation of offices VHACO other offices. mos) Create a Transformation Office strategic Transformation to educate and 6 ‐ (3 Near Office plan initiatives and support the goals provide guidance to the new VA of VHA. and 6mos) (3 Near Office Transformation ‐ ‐ to include follow implementation Create a new initiative plan and Transformation Office The tasks priorities, on milestones. and the plan moving forward. will support the operation Transformation Office Transformation Office will be responsible 6mos) evaluating all (3 Near ‐ The for using the President’s new initiatives and programs or model that emulates its Scorecard Agenda Management a success; yellow for mixed Green of standards rating represents unsatisfactory. These ratings are indicative results; and red for failure. success of or standards of 198

213 A B PPENDIX L I EADERSHIP MPLEMENTATION Table B-4. Performance Metrics and Management Action Timeline Responsible a new performance management Create system for VHA leaders appropriate for health care executives. mos) (6 Now Transformation outside experts to create the and workgroup a Establish engage Capital Office/Human to new is benchmarked that performance management system new leadership private ‐ sector models, is consistent with the Management both recognizes leadership and competency model, competencies and success in delivering strategic priorities. The model rating new a include should scale. 12 ‐ (6 mos) Near Human Capital performance Develop and conduct training on the new Management the system, management system for all participants to describe expectations. and process, rating Now (3 mos) capture performance assessment a Human Capital mechanism to Establish ‐ potential staff. and track Management/HRA and outcomes high manage (3 mos) Now Capital Human plan annual guidance on Establish project a to deliver Management/CVCS/Sec/ advance of the new a least at month performance plans in OMB the new rating period). fiscal year (i.e., at the start of Hold for creating meaningful distinctions between leaders. raters accountable Future (12 mos) new the application of the to Human Capital raters on training Provide ratings. performance management Management system and expectations for mos) (3 Now Capital Human subordinates that are Require raters to establish plans for Management/HRA and meeting feedback and provide on track meaningful; timely goal. this CVCS Now (3 mos) the requirement, and communicating behavior the modeling By and secondary ‐ level raters, establish expectations that raters, and with subordinates engage in continuous dialogue coaching year, not at mid ‐ year the throughout performance about just the rating period. and at the end of Now (12 mos) process for raters oversight Establish Human Capital and feedback and performance evaluation. incorporate this Management/CVCS into the raters mos) (12 Near Supervisors and focused reviews if their rating Provide coaching to raters meaningful distinctions in performance. provide doesn’t profile 199

214 C OMMISSION ON ARE F INAL R EPORT C tion: Human Capital Management Table B-5. Leadership Implementa Timeline Action Responsible ‐ HR functions and processes to be consistent re with best align practice standards of high ‐ performing VA care systems. health mos) 6 ‐ (0 Now SECVA/DEPSECVA transformation and Charge study HRA to undertake an HR customer of solicitation and budget requirements. ensure HRA Now (0 6 mos) ‐ develop a HR and change management Engage to experts VA. benchmark human capital management plan for Now (6 mos) plan for feedback and finalize. new human capital Circulate from input with HRA Congress, OPM, VHA, OMB, SECVA/ DEPSECVA, CVCS Capital VHA leaders make transformation of Human and management a priority, with adequate VA That funding and continuity of vision. attention, mos) (9 Near and SECVA/DEPSECVA ensure human Endorse capital management plan and applicable CVCS, as alignment of budget, IT system funding, training resources, and support to mechanisms accountability it. mos) 30 ‐ (12 HRA Near to fully Employ HR and change management experts new human the transformation agenda and implement the plan. management capital Create mos) an HR IT technology plan. HRA & OIT Near (9 mos) (24 HRA Future Establish for VA meaningful measures and risk indicators management. capital human mos) (18 Near systematic reporting to CVCS Incorporate HR measures into HRA, DEPSECVA, plans for key leadership; and performance into appropriate as appropriate as subordinate leaders. develop and implement an effective progressive discipline process for all staffing authorities VA (i.e., Title 5, Title 38, Title 38 Hybrid, 38 7306, and SES). Title Now mos) (6 guidelines, and training on Develop clear support HRA (with from standards, OPM) discipline. progressive training. and HR professionals complete Managers, supervisors mos) (12 Near DEPSECVA SECVA/ and office) (HTM CVCS Train HR staff to be coaches in progressive discipline. HRA Now (6 ‐ 12 mos) mos) (12 Near HRA HR professionals and client Establish performance metrics for effective coaching and support feedback mechanisms to ensure process. progressive for discipline mos) (12 Near CVCS DEPSECVA, SECVA/ for and supervisors VA expectations performance Establish discipline process. managers to apply the progress 200

215 APPENDIX C: PILOT PROJECTS FOR EVALUATING EXPANDED CARE As discussed in Recommendation #18, some Co mmissioners support the idea of developing pilot programs to test the feasibility of avoiding VA hospital closures by allowing veterans’ spouses and currently ineligible veterans to purchase VA care in selected areas. Problem tains hospitals and other health care facilities In many parts of the country, VHA currently main so. This trend is driven by four main factors: that are underutilized or in danger of becoming (a) the overall decline in the si ze of veterans population, (b) the migration of veterans away from some parts of the country, such as New England and the Upper-Midwest, (c) the general trend in health care toward less intensive use of acute-care hospital beds, and (d) increased use of purchased care, which now accounts for 27 percent of all appointments. A related challenge is maintaining ent loads decline. As extensive safe volume of care when pati literature attests, surgeons and other health care professionals tend to lose proficiency when 678 they treat too few patients. Simply closing a low-volume hospital is someti mes the answer. But closing a local VA hospital may mean that area veterans will have reduced acce ss not only to routine, but also to specialty care related to their military service, such as for spinal cord or traumatic brain injuries. In many areas, such care is not available or is in short supply outside VHA. At the same time, it may not be clinically feasib le for VHA to engage in highly specialized care if it lacks the ability to offer other forms of care tients in a polytruama in the same setting. Pa unit for example, require a full-spectrum of routine and nonroutine health care. VHA in areas where it currently has excess Increasing the volume of patients treated by rd that end, VHA could develop pilot programs capacity may ameliorate these challenges. Towa to test the feasibility of enabling veterans’ spou ses and currently ineligible veterans in these areas to purchase VHA care through their heal th plans. These pilots could be tested in conjunction with the growth of the high-performance, integrated VHA networks recommended w VHA far more flexibility than in the past to elsewhere in this report. These networks will allo expand or contract its local capacity in different markets as appropriate. 678 Ninh T. Nguyen et al., “The Relationship Between Hospit al Volume and Outcome in Bariatric Surgery at Academic Medical Centers,” Annals of Surgery , 240, no. 4 (2004): 586-594. D. R. Urbach and N. N. Baxter, “Does It Matter What a Hospital Is ‘High Volume’ For? Specifici ions for Surgical Procedures: Analysis ty of Hospital Volume-Outcome Associat of Administrative Data,” Quality and Safety in Health Care, 13, no. 5 (2004): 379-383, http://doi.org/10.1136/bmj.38030. 642963.AE. Edward L. Hannan et al., “Coronary Angioplasty Volume-Outcome Relationships for Hospitals and Cardiologists,” Journal of the American Medical Association, 277, no. 11 (1997): 892–898, http://doi.org/10.1001/jama.1997.03540350042031. 201

216 C F INAL R EPORT OMMISSION ON C ARE Background Current Nonveteran Access to VHA Care VHA already treats many nonveterans. VHA es timates it treated 694,120 unique nonveteran 679 680 or 3.6 percent of total VHA obligations. patients at a total cost of $1.9 billion in 2015, By far the largest subgroup within the nonveter an patient population are participants in the partment of Veterans Affairs (CHAMPVA). Civilian Health and Medical Program of the De CHAMPVA beneficiaries are the dependents of permanently and totally disabled veterans, survivors of veterans who died from service-conne cted conditions or while on active duty, or spouses of veterans who at the time of death we re rated permanently and totally disabled from a service-connected condition. Congress authorized CHAMPVA in 1973. The authorization specifies that VHA is the secondary payer for those with Medicare Part A and B coverage. In cases for which VA medical facilities are equipped to provide the care, VA ma y use facilities not being used for the care of veterans to provide services to the dependent or survivor. Congress has also directed VHA to offer specific health care services to many other classes of nonveterans. These include mental health and co unseling services for family caregivers of seriously injured veterans of post-9/11 service. Se veral provisions of law also authorize VA care for certain family members of veterans who were exposed to toxic substances. In the case of nnected disability, VHA must provide by law veterans with 50 percent or more service-co e and family counseling, training and mental “consultation, professional counseling, marriag 681 health services as are necessary in connection with” the veteran’s treatment. Analysis e long-term future of VA health care have Others who have developed strategic plans for th ecifically by allowing currently ineligible recommended expanding upon these precedents, sp 682 veterans and the spouses of veterans to purchase VHA care. In effect, providing such care would allow VHA to operate as an accountabl e care organization, capable of receiving reimbursement from patients co vered by Medicare, Medicaid, as well as by private insurance plans. Among the potential benefits envisioned are the following: optimizing patient safety, productivity, and cost-effectiveness by ensuring sufficient  patient volumes in currently under-utilized facilities  preserving mission critical veterans’ programs that would otherwise need to be terminated in many parts of the country  non-VHA care within communities optimizing the integration of VHA and 679 Allocation Resource Center, information provid ed to Commission on Care, December 8, 2015. 680 Department of Veterans Affairs, “Volume II: Medical Programs an d Information Technology Programs, Congressional Submission, FY 2016 Funding and FY 2017 Advance Appropriations,” accessed May 27, 2016, http://www.va.gov/bud get/products.asp. 681 Counseling, Training, and Mental Heal th Services for Immediate Family Me mbers and Caregivers, 38 U.S.C. § 1782. 682 Concerned Veterans for America, Fixing Veterans Health Care: A Bipartisan Policy Taskforce , accessed May 27, 2016, uploads/2016/01/Fixin http://cv4a.org/wp-content/ g-Veterans-Healthcare.pdf. 202

217 A PPENDIX C P ILOT E VALUATING E XPANDED C ARE P ROJECTS FOR providing a public option  for health care to a wider range of veterans as well as nonveterans in communities where health care choices are currently limited bute to the funding for veterans’ healthcare  bringing in new sources of revenue to contri ically evaluate whether such a strategy will The pilot projects described below would specif eness of its health care system by avoiding allow VHA to optimize the quality and cost-effectiv n sections of the country. These pilot projects low volumes of routine and specialty care in certai would also allow VHA to evaluate whether su ch a strategy could provide new revenues for sustaining the VA health system while providing other benefits to veterans and the public at large. ts designed to test different specific policy The chart below sketches six possible pilot projec configurations. The configurations include projects in which VA care is marketed to health care plans on fee-for-service (FFS) basis, and plans in which VA facilities are markets to health care plans as Accountable Care Organizations that pr ovide integrated health services to a fixed population of insured patients for a fixed cost. Demonstration Projects to Assess VHA’s Capability to Treat Nonveteran Spouses and Ineligible Priority 8 Veterans Capitation/Fee For Timing Eligibility Service 1: 7 ‐ 2 Years FFS Non ‐ veteran spouses of Demonstration (not CHAMPVA FFS plan covering spouses veterans Private With eligible) Insurance 2: 7 ‐ 2 Years FFS now Priority veterans 8 Demonstration FFS for enrollment ineligible veterans covering plan private insurance currently ineligible VA for care with of Demonstration 3: 8 ‐ 3 Years FFS Non ‐ veteran spouses veterans (not CHAMPVA FFS plan covering spouses private with eligible) insurance 4: 8 ‐ 3 Years FFS now veterans 8 Demonstration Priority FSS covering for enrollment ineligible plan veterans with care insurance currently VA for ineligible private Medicare and/or 9 Demonstrations 5 and 6: ‐ 4 Years choose May Enrollment: and 8 Priority Ineligible Accountable health more with plan non ‐ veteran spouses cost higher care coverage organization for spouses plans and less ineligible and copayment; lower veterans currently cost less coverage option with higher and copayments. 203

218 C C F INAL R EPORT OMMISSION ON ARE Capitation/Fee For Eligibility Timing Service 10 Demonstrations 7 and 8: 5 ‐ choose May Enrollment: and 8 Years Ineligible Priority ‐ veteran spouses with Accountable care non higher cost plan with more health organization spouses private insurance and/or for plans coverage and less currently Medicare ineligible veterans copayment; or cost lower and with option less coverage copayments. and higher be Pilot sites would Accountable deemed Organizations Health Care for Advantage Medicare plans. Certification of Access: Any participating VHA fa cility must certify that its waiting times for primary care, specialty care and behavioral health are less than 30 days. in different regions with various population Site selection: Sites should include facilities of service complexity. VHA may also consider densities (urban, suburban, rural) and levels such factors as stability of medical center leadership, and whether local markets are underserved or subject to high degrees of ma rket concentration amon g either providers or payers. Assumptions  Many provisions are subject to Congressional authorization.  Participating VHA facilities will be able to re tain any “profit” associated with treatment of new users without offset;  Congress will (preferably) waive the current prohibition on Medicare funding federal health care programs,  VHA will not be subject to proving “level of e ffort” in order to receive Medicare funds Assessment assess these projects according the following After the first year of operations, VHA will criteria:  Was access to care or patient satisfaction am ong veterans already enrolled in the system affected by the demonstration?  What was the level of patient satisfacti on among new users purchasing VA care?  Did VHA cover the costs of delivering care to its patients purchasing care? If so, what were its net revenues and how were they used? funding cover costs of delivering care? If VHA collected Medicare funds, did  204

219 A PPENDIX C P ARE ROJECTS FOR E VALUATING E ILOT C P XPANDED  Were there administrative challenges in op ening the VHA to new users? If so, what lessons were learned?  How did VHA promote the demonstration project to those eligible?  What are the recommended strategies for further implementation?  Were there non-financial benefits to treatment of new users, such as diversifying case mix, providing sufficient volume to allow cert ain VHA services to remain available, or keeping scarce health professionals employed in an area that is medically underserved?  How did the demonstrations affect the overall quality of care, market structure, pricing, and range of health care options available to both veterans and nonveterans in the surrounding community? 205

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221 APPENDIX D: HISTORY AS A CONTEXT FOR SYSTEMIC TRANSFORMATION History provides opportunities to see the prob lems and challenges facing VHA today through the lens of recurring themes from the past. Vete rans’ health care has, over the course of its ress and problems. Understanding the challenges history, been marked by periods of both prog of the past and the solutions used to addre ss them provides context for building a plan for reforming veterans’ health care in a manner that is flexible and sustainable. Challenges and Growth The federal government’s role as a care provider for veterans has evolved, paralleling, to some extent, medicine’s evolution. Prior to World Wa r I, the only benefits afforded then-eligible veterans were pensions and domiciliary care (which involved only incidental medical treatment), provided under the National Home for Disabled Volunteer Soldiers and Sailors 683 established after the Civil War. , no single agency was responsible for the World War I brought real change. At the time anticipated deluge of sick and wounded soldiers. The more than 200,000 wounded who returned home from battle quickly exceeded capaci ty of the U.S. Public Health Service (PHS), the National Home, and other agencies. According to one account of the period, “[c]haos and confusion reigned for more than two years . . . [n]ew hospital construction languished,” and 684 “[b]y 1921, veterans’ care had become a national embarrassment.” At the recommendation of a presidential committee, Congress passed legislation in 1921 to consolidate the several veterans-related bureaucracies into a single Veterans Bureau, to which the President Warren Harding transferred 57 PHS hospitals. A new admini strator, Frank T. Hines, proposed care and treatment of veterans’ non-service-connected ailments when facilities and bed space were 685 available. Congress adopted the proposal in the World War Veterans Act of 1924. Under Hines’ tenure, VA grew from 64 to 91 ho spitals, nearly doubling bed capacity. Civil d to generally poor quality VA physicians, Service Commission personnel rules and low pay le 686 With many physicians yet Congress rebuffed VA proposals to set up a VA Medical Corps. more lucrative practice, the VA health care having left VA to serve in World War II or for 687 system was left critically understaffed. 683 th st , report prepared by Robinson Adkins, 90 sess., 1967, Cong., 1 Veterans Administration, Medical Care of Veterans House Committee Print 4, 4. 684 James Rife, Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: Department of Veterans Affairs, 2014), 13-14. 685 Ibid., 19. 686 Ibid., 21. 687 th st Veterans Administration, Medical Care of Veterans , report prepared by Robinson Adkins, 90 Cong., 1 sess., 1967, House Committee Print 4, 149. 207

222 C C INAL R EPORT OMMISSION ON F ARE of service members, in cluding 671,000 wounded, World War II and the need to care for millions highlighted the problems facing VA. Scathing reports of shoddy veterans’ care, including an 688 backwaters of medicine, magnified the problems. exposé characterizing veterans’ hospitals as leadership and General Omar Bradley was Congressional hearings led to a shakeup in 689 Dr. Paul appointed to head the agency, with its network of 97 hospitals, and a need for more. Magnuson, who served as VA’s ch ief medical director (CMD) from 1948 to 1951, later described the conditions at the time: The majority of Veterans Administration hosp itals were stuck in far off places, some of as fifty miles from the nearest through-line them on Indian reservations, others as much railway stop. The doctors were all full-time Civil Service employees, hemmed in by y research, attend any medical meetings or regulations and practically forbidden to do an rogress. Operating rooms cl osed at noon so otherwise keep in touch with scientific p doing required paperwork, while patients everybody could spend the afternoon happily 690 waited days and weeks for surgery. With President Harry Truman’s statement that “the Veterans Administration will be modernized,” new VA leadership worked with Co ngress to pass far-reaching legislation, Public Law 293, which created a VA Department of Medicine and Surgery (DM&S), and freed VA 691 Within physicians, dentists, and nurses from th e Civil Service Commission and its rules. weeks, the chief medical director of the new DM &S issued a policy memorandum that outlined a cooperative affiliation agreement between VA and medical schools under which deans’ committees would recommend consultants and a ttending physicians for appointment to VA, lished at VA hospitals. The law, and Policy and residency-training programs would be estab Memorandum #2, broke a recruitment logjam and enabled the short-staffed department to hire medical professionals needed fo r the dozens of new VA hospitals being built. Soon after, medical students and residents began working in 32 VA hospitals. The reforms instituted under 692 Bradley and his team were palpable, with the physician staff at VA hospitals increasing from 2,300 (1,700 of whom were detailed by the military) in June 1945 to 4,000 full-time staff a year 693 later. By 1948, VA had 125 hospitals in operatio n with 60 medical school affiliations and 694 2,000 residents. Army Chief of Staff, and under his successor, After this turn-around, Bradley left to become “who did not enjoy the same level of prestige and support that Bradley did . . . VA quickly 688 Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: James Rife, Department of Vetera ns Affairs, 2014), 22. 689 Ibid., 23-25. 690 Ibid., 22. 691 “31: The President’s News Confer ence,” Harry S. Truman Library & Museum, accessed June 3, 2016, http://trumanlibrary.org/publicp apers/viewpapers.php?pid=38. 692 James Rife, Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: Department of Vetera ns Affairs, 2014), 27. 693 st th , report prepared by Robinson Adkins, 90 Medical Care of Veterans Cong., 1 Veterans Administration, sess., 1967, House Committee Print 4, 214. 694 VA Health Care in the Late 20th Century James Rife, Not Your Father’s VA: The Transformation of (Washington, DC: Department of Vetera ns Affairs, 2014), 28. 208

223 A PPENDIX D H ISTORY AS A S YSTEMIC T RANSFORMATION C ONTEXT FOR 695 according to reverted to its pre-Bradley ways and remained that way for the next forty years,” one account. 696 By the early 1950s, the veteran population had grown to more than 20 million. VA was 697 A VA historian e census of more than 104,000 patients. operating 162 hospitals, with an averag observed that “waiting lists contained 22,613 applicants awaiting admission, none of whom were service-connected, although some of the ed in other than VA latter were hospitaliz 698 hospitals.” ans seeking care had to state under oath At the time, non-service-connected veter that they could not afford to pay for hospitalization, and admission was granted only when 699 Critics called for reducing free medical beds were available in VA or other federal hospitals. care of non-service-connected veterans, and questioned whether some were getting care that they could afford. This issue led VA to inst itute a policy of formal counseling under which hospitals would supply the veterans with an estimated cost of care to assist them in 700 determining their ability to pay. In contrast to the generous Bradley-era fundin g, the 1950s funding cuts necessitated layoffs, 701 bed-closures, and moth-balling of newly constructed hospital wards. During this period, the number of beds VA should operate. VA annual debates over the DM&S budget centered on 000, yet the director of the Bureau of the leaders contended that the number should be 125, Budget (the predecessor to the Office of Management and Budget [OMB]) asserted 87,000 was 702 sufficient. The expiration of the incumbent CMD’s term led to the appointment in 1955 of medical educator Dr. William Middleton, dean of th e Wisconsin Medical School, and a long-time One of his first acts as CMD was to champion member of a VA special medical advisory group. medical research in VA and broaden its scope to include geriatric research. Soon after, Congress began earmarking funds for VA research, and expanded DM&S’ statutory role to include 703 medical research. to 1963, VA research funding grew During Middleton’s tenure, from 1955 704 from some $6 million to more than $30 million. Middleton’s work laid the foundation for a research program long recognized for pioneer ing important medical technologies, including medical use of radioisotopes, dialysis, cardia c pacemakers, liver transplantation, as well as seminal studies that documented the benefits of coronary artery bypass surgery and drug 705 treatment of hypertension. The program also stood out for its capacity to design and rapidly implement large-scale cooperative trials, first mo unted in the 1950s with successful evaluation 695 Ibid., 29. th 696 st , report prepared by Robinson Adkins, 90 Veterans Administration, Cong., 1 Medical Care of Veterans sess., 1967, House Committee Print 4, 254. 697 Ibid. 698 Ibid. 699 Ibid., 253. 700 Ibid., 253-254. 701 Ibid., 256. 702 Ibid., 258. 703 Ibid., 262-263. 704 Ibid., 263-264. 705 Stanley Zucker et al., “Veterans Ad ministration Support for Medical Research : Opinions of the Endangered Species of Physician-Scientists,” The FASEB Journal, 18, no. 13, (2004): 1481-1486, http ://doi.org/10.1096/fj.04-1573lfe. 209

224 C C INAL R EPORT OMMISSION ON F ARE 706 of chemotherapy for tuberculosis. Working on issues relevant to veterans, VA researchers developed functional electrical stimulation syst ems to allow patients to move paralyzed limbs, helped develop the first ankle-foot prosthesis , and launched the largest-ever trial of 707 psychotherapy to treat pos ttraumatic stress disorder. Middleton expanded the VA educational progra m. In addition to growing the number of medical residents it helped train, VA provided trai ning to a large share of clinical psychologists, graduate dentists, student nurses, occupational and physical therapists, social work students, and dietetic interns. Middleton instituted numero us advances in VA care such as introducing outpatient care for preadmission workups and post-hospital treatment that allowed earlier from operating hospitals for specific diseases release from inpatient stays. He moved VA away 708 (as had been done for tuberc ulosis and mental illness). The enactment of Medicare in 1965 raised ques tions about the effect that program would have on the VA health care system. The House Veter ans Affairs Committee sent a questionnaire to a group of 10,000 veterans explaining the new pr ogram and asking the veteran to if they 709 preferred VA care or treatment in a community hospital under Medicare. Some 59 percent 710 of respondents preferred VA. responded, and nearly two-thirds At the time, the policy governing those eligible for VA ca re based on financial need was t hat Medicare benefits were to 711 al’s ability to pay for needed care. be considered in determining an individu The enactment of Medicare and other changes in health care in 1977, led to a commission being established by the National Academy of Sciences (NAS) which issued a report pursuant to a congressional directive to evaluate the VA health care system. Among its findings, the commission reported that VA had a surplus of acute beds and recommended that new facilities bility in the community. It also recommended be constructed only after examining bed availa converted to long-term care facilities, and that underutilized VA hospitals be closed or resources redistributed to permit a shift from inpatient to outpatient care. The NAS commission 712 models for community-based integrated care. also recommended that VA experiment with g the VA system into the nation’s civilian The commission’s recommendation for integratin 713 714 provoked objection, particularly in Congress. Hearings produced health care program sharp rejections of the NAS commission findings and its call to end VA’s role in providing health care to veterans. 706 Ibid. 707 Veterans Health Administration, History of VA Resear ch Accomplishments , accessed June 3, 2016, http://www.research.va.go v/researchweek/press_pac ket/Accomplishments.pdf. th 708 st Veterans Administration, Medical Care of Veterans , report prepared by Robinson Adkins, 90 sess., 1967, Cong., 1 House Committee Print 4, 265-267. 709 Ibid., 390. 710 Ibid. 711 Ibid. st 712 th Hearings before the Subcommittee on Medical Facilities and Benefits of the Committee on Veterans Affairs, 95 Cong., 1 Sess. (July 21, 1977), Statement of Dr. Saul Farber. 713 J. William Hollingsworth and Philip K. Bondy, “The Role of Veterans Affairs Hospitals in the Health Care System,” New England Journal of Medicine , 322, no. 10, (1990): 1851-1857, http ://doi.org/10.1056/ NEJM199006283222605. th st 714 Hearings before the Subcommittee on Medical Facilities and Benefits of the Committee on Veterans Affairs, 95 Sess. Cong., 1 (July 21, 1977), Statement of Dr. Saul Farber. 210

225 A PPENDIX D H ISTORY AS A S YSTEMIC T RANSFORMATION C ONTEXT FOR bureaucratic, reliant on paper health care The VA of the 1970s and 1980s is remembered as 715 records, and driven by patient admissions (on which budgets were based). The quality of VA care was also an issue. Complaints from Vietnam veterans and critical media accounts fueled s broken. The question, how to fix it, reopened outrage, and led to the view that the system wa t-level department, a view strongly supported an earlier dialogue around making VA a cabine rans’ leaders in the House of Representatives. by veterans service organizations (VSOs) and vete from administration offices and advisors, In 1988, after years of debate, and opposition 716 The new President Reagan signed legislation creati ng a Department of Veterans Affairs. department, with DM&S now renamed the Veterans Health Services and Research Administration (to emphasize its re search legacy in such fields as infectious disease, pacemaker 717 194,000 people with a $12 billion budget. technology, and prosthetics), employed some 718 Facing an aging veteran population e system by 2010, the new expected to overwhelm th secretary, Edward Derwinski, in 1989 requested Congress establish an independent commission to review the alignment and mission structure of VA’s hospitals. Congress rebuffed the request 719 Derwinski created his own ose hospitals, lobbied against it. after VSOs, suspecting a plan to cl “Commission on the Future Structure of Vete rans Health Care” that was to review all VA hospitals and recommend needed mission changes. Instead, the so-called Mission Commission called for expanding eligibility law to enable veterans to obtain the full continuum mmission identified the need for fundamental of VA health care services. Although the co restructuring of the VA health care system, th e subject was soon overtaken by national health 720 reform proposals, and what role VA migh t have under a universal coverage system. Dr. James Holsinger, a new under secretary for he alth (USH), made care quality a top goal and issued a Blueprint for Quality tool in 1992, se tting the stage for more far-reaching changes instituted by his successor, Dr. Kenneth Kizer. Care quality, a perennial topic, had led to the previous under secretary’s resignation following reports of multiple veterans’ deaths under 721 questionable circumstances at VA ’s North Chicago medical center. Two years later, Derwinski lost his job after creating ire amon g veterans’ organizations in response to his 722 proposed pilot program to open two VA hospitals to poor, rural nonveterans. 715 VA Health Care in the Late 20th Century James Rife, Not Your Father’s VA: The Transformation of (Washington, DC: Affairs, 2014), 30-31. Department of Veterans 716 Ibid., 33-40. 717 Ibid., 50. 718 Department of Veterans Affairs (VA) faces a major As the General Accounting Office reported in 1990, “The -term care needs of a rapidly aging vete ran population. The nu mber of veterans challenge: planning how to meet the long illion by 2000-a 50percent increase over the 1988 level. 65 years old and over is projected to grow to 9 m U.S. Government Ac countability Office, VA Health Care: Improvements Needed in Nursing Home Planning , GAO/HRD-90- 98 (Washington, DC, 1990), access ed June 20, 2016, http://www.ga o.gov/assets/ 150/149139.pdf. 719 U.S. Government Accountability Office, , GAO/HRD- VA Health Care: Improvements Needed in Nursing Home Planning accessed June 20, 2016, http:/ /www.gao.gov/asse ts/150/149139.pdf. 90-98 (Washington, DC, 1990), 51, 720 U.S. Government Accountability Office, Veterans’ Health Care: Veterans’ Perceptions of VA Services and VA’s Role in Health Care Reform , GAO/HEHS-95-14 (Washington, DC , 1994), accessed June 20, 2016, http://archive.gao .gov/f0902a/153054.pdf. 721 Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: James Rife, Department of Vetera ns Affairs, 2014), 53. 722 “Angry Veterans Groups Say They Made Bush Oust Agency’s Head,” Er ic Schmitt, access ed June 3, 2016, st-agency-s-head.html. http://www.nytimes.com/1992/09/ 29/us/angry-veterans-grou ps-say-they-made-bush-ou 211

226 C C F INAL R EPORT OMMISSION ON ARE Transformational Leadership VA’s second secretary, Jesse Brown, brought his passion as a veterans advocate to the 723 Among Brown’s most important early acts was selecting department’s leadership. Dr. Kenneth Kizer, a prominent California phys ician-administrator and educator, from among 724 90 candidates identified by a search committee for the USH post. With experience heading the California department of public health, Kizer saw he alth care as a system, and data as a tool to 725 improve it. Kizer, in essence, launched a major reengineerin g of the VA health care system through better use of information technology, measurement and reporting of performance, integration of 726 His vision was large and bold, underscored by his services, and realigned payment policies. belief that “we have to be able to demonstrate that we have an equal or better value than the 727 At VA, Kizer found a workforce trapped in a private sector, or frankly we should not exist.” 728 in which there was little accountability. micro-managerial, command-and-control system He set the tone for what was to come at a meeting with senior managers at which he stated, The old culture must give way to a new culture . . . that is based on innovation and creativity; a culture based on personal initiative and individual and collective accountability; a culture that is based on ou tcomes and heightened productivity; and a 729 culture that is committed to change. Among his first steps was the development of what was to become a Vision for Change , a new organizational model to restructure both field op erations and central office management. At its core was the creation of 22 veterans integrated service networks, or VI SNs, (replacing four regions which had been responsible for overseei ng 40 to 45 hospitals each), with decision O) to the new VISN directors. VISNs were to making shifted away from VA Central Office (VAC be the basic budgetary and planning unit, and to have staffs of no more than 7 to 10 730 Each VISN was in charge of all the care provided to veterans in that network, and employees. 731 The VACO ther than based on historical costs. each was funded on a capitated basis ra 732 structure would be marked by its flatness , foregoing a tiered hierarchy. 723 James Rife, Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: Department of Vetera ns Affairs, 2014), 89. 724 Ibid., 92. 725 Phillip Longman, Best Care Anywhere: Why VA Health Care Would Work Better for Everyone (San Francisco: Berrett- Koehler Publishers, Inc., 2012), 50-51. 726 Ashish K. Jha et al., “Effect of the Transformation of the Veterans Affairs Health Care System on the Quality of Care ,” New England Journal of Medicine accessed June 20, 2016, , 348, no. 22, (2003): 2218-2227, http://doi.org/10.1056/NEJMsa021899. 727 Best Care Anywhere: Why VA Health Care Would Work Better for Everyone (San Francisco: Berrett- Phillip Longman, Koehler Publishers, Inc., 2012), 51. 728 Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: James Rife, Department of Veterans Affairs, 2014), 97-8. 729 Ibid., 105. 730 Ibid., 110. 731 “What Can the Rest of the Health Care System Learn from the VA’s Quality an d Safety Transformation,” Ashish K. Jha, accessed June 3, 2016, https://psnet.ahrq.gov/per spectives/perspective/31. 732 (Washington, DC: James Rife, Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century Department of Vetera ns Affairs, 2014), 111. 212

227 A D PPENDIX H C S YSTEMIC T RANSFORMATION ISTORY AS A ONTEXT FOR 733 Kizer s characterized by a multitude of problems. The system Kizer and his team inherited wa and his team literally reengineered the veterans’ health care system based on a set of ent accountability, integrate and coordinate transformation strategies: to create managem system finances with desired outcomes, and services, improve the quality of care, align 734 modernize information management. Kizer also launched a technological revoluti on in VHA with deployment of a powerful 735 electronic medical record, and development of systems such as medication bar-coding to 736 tackle medical errors and ensure patient safety. pport within the administration and from Some of Kizer’s successes involved winning su concession from OMB that VA savings could be Congress for bold initiatives. He won a critical reinvested into VA, permitting his transformatio n efforts to be funded through internal cost- 737 savings rather than new funding, and garnered support from Congress for a dramatic 738 These steps and reduction of acute care beds and fo r closing massive regional offices. congressional passage of legislation to reform health care eligibility laws paved the way for establishing universal primary care in VA and developing community-based clinics across the 739 country. Sweeping Reform During a 5-year period, Kizer dramatically changed almost every major VHA management system and improved operational performance through the use of performance measures and contracts. He closed nearly 29,000 acute care beds, merged 52 medical centers into 25 multi– campus facilities, reduced staffing by almost 26,000, opened more than 300 community-based bringing measurable outpatient clinics, and treated 24 percent more patients. In addition to quality into VA health care, Kizer achieved ma rked reductions in waiting times and medical 740 errors. lly improved quality, service, and operational efficiency to Kizer’s tenure brought dramatica VHA yet threatened powerful interests. As he noted, “...places like Florida, Arizona, and the 733 ansformation of the Veterans Health Care System,” Kenneth Kizer and R. Adams Dudley, “Extreme Makeover: Tr Annual Review of Public Health , 30, (2009): 316, accessed June 20, 2016, v.publhealth.29.020907.090940. http://doi.org/10.1146/annure 734 Ibid., 318-323. 735 VA in 2006 won the Harvard Innovations in Govern ment Award for its VistA system. James Rife, Not Your Father’s th Care in the Late 20th Century (Washington, DC: Department of Veterans Affairs, VA: The Transformation of VA Heal 2014), 211. 736 Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century James Rife, (Washington, DC: Department of Veterans Affairs, 2014), 157-165. 737 Kenneth Kizer and R. Adams Dudley, “Extreme Makeover: Tr ansformation of the Veterans Health Care System,” Annual Review of Public Health , 30, (2009): 323, accessed June 20, 2016, v.publhealth.29.020907.090940. http://doi.org/10.1146/annure 738 James Rife, Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: Department of Veterans Affairs, 2014), 128-129. 739 ansformation of the Veterans Health Care System,” Kenneth Kizer and R. Adams Dudley, “Extreme Makeover: Tr Annual Review of Public Health , 30, (2009): 319-320, accessed June 20, 2016, http://doi.org/10.1146/annure v.publhealth.29.020907.090940. 740 James Rife, Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: ns Affairs, 2014), 170. Department of Vetera 213

228 OMMISSION ON C INAL R EPORT F C ARE Sun Belt States were not getting their fair s hare [of funds] and their elected officials were unhappy about it. People from Pennsylvania and Illinois and New York were not about to give 741 their money away, so there was this big disconnect.” Kizer’s team developed a capitation system to more equitably allocate funds across th e system. Aware of the political ramifications, he implemented incremental changes during a 2- to 3-year period to make them as painless as possible. But the congressional goodwill he had enjoyed unraveled when Kizer and his VISN directors began cutting and consolidating fac ilities to accommodate VISN funding cuts. The threat of hospital mergers and consolidations ultimately led several senators to block his 742 confirmation to a second term. Under new eligibility reform law, all veterans became eligible for VA health care, though its authors did not envision that the system could or would serve all eligible individuals, or even all who might someday seek VA care. The law’s priority-based enrollment system was intended 743 The law instead unleashed to give VA a tool to align demand for care with its funding level. ing the door to an influx of veterans who political pressure to expand enrollment, open historically had not been VA health care user s and many of whom were already covered under 744 military retirement benefits, pr ivate insurance, or Medicare. That expansion led to a tremendous demand for prescription drug bene fits by new enrollees and in 2003, Secretary Tony Principi ended enrollment for higher income (category 8) veterans “to keep the system 745 At about the same time, other related pre ssures led Principi to establish an advisory solvent.” Services (CARES) Commission, to develop a body, the Capital Asset Realignment for Enhanced comprehensive capital asset plan. Principi cited the age of VA facilities and the changes in medical practice, but also reminded a congressi onal oversight committee of a 1999 Government obsolete or duplicative structures diverts Accountability Office finding that “maintaining year, away from the care of veterans.” Principi did not want $1 million a day, every day, every 746 to repeat Kizer’s experience and hoped to avoid political backlash. The CARES Commission released a final report in February 2004 that recommended relatively few actual facility closures, though it proposed substantial facility mission changes at a number 747 As the then USH later recounted, “CARES , like so many things in Washington, of facilities. once it began moving toward actual targeted was well-intended, but it was derailed politically 748 action within specific congressional districts.” Despite such defeats, Principi and VA unde r secretaries following Kizer met formidable challenges, left legacies, and saw the veterans’ he alth care system continue to be heralded for 749 several years. A cascade of other events muddied, and even blackened, VHA’s reputation: 741 Ibid., 133-134. 742 Ibid., 168-169. 743 alth Care Eligibility Reform Act of 1996, H. R. Rep. No. 104-690 (1996), Veterans Affairs Comm., Veterans’ He congress.gov/congressional-report/ 104th-congress/house -report/690/1. accessed June 3, 2016, https://www. 744 James Rife, Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: Department of Vetera ns Affairs, 2014), 193. 745 Ibid., 194. 746 Ibid., 195. 747 Ibid., 196. 748 Ibid. 749 “The Best Care Anywhere,” hly, accessed June 3, 2016, Phillip Longman, Washington Mont 214

229 A D PPENDIX H ISTORY AS A S YSTEMIC T C ONTEXT FOR RANSFORMATION accounts of veterans’ suicides (and an allege d cover-up); incompetent surgeries and patient 750 deaths at a high-visibility VA medical ce nter (VAMC); failed software acquisitions; hard- hitting inspector general audit reports on issues su ch as system flaws, quality of care issues, and lack of timely care that fueled congressional oversight and other constr aints. The 2014 scandal that erupted at the Phoenix VAMC represented a decisive turning point and set the stage once again for transforming veterans’ health care. Among initial steps on that long road to transforming the system, the Senate in July 2014 unanimously confirmed Robert A. McDonald, fo rmer chief executive officer of Proctor & Gamble, as secretary of veterans affairs. With a business career of delivering better results, McDonald, along with DEPSECVA Sloan Gibs on and USH Dr. David Shulkin, has been service delivery, and to set a framework for working to improve VA’s health care system and long-term reform. Days after McDonald’s confir mation, Congress passed the Veterans Access, gislation to improve veterans’ access to care. Choice, and Accountability Act of 2014, omnibus le This legislation established the Choice Program , mandated an independent assessment of VHA, and established the Commission on Care. /features/2005/0501. longman.html. “Revamped Veterans Health Care Now a http://www.washingtonmonthly.com Model,” Gilbert Gaul, accessed June 3, 2016, http://www.wa shingtonpost.com/wp- dyn/content/article/2005/08/21/AR2005082101073.ht the U.S.: How Veterans Affairs ml. “The Best Medical Care in Transformed Itself—and What it Me ans for the Rest of Us,” Cather ine Arnst, accessed June 3, 2016, http://www.bloomberg.com /bw/stories/2006-07-16/the-best-med ical-care-in-the-u-dot-s-dot. 750 James Rife, Not Your Father’s VA: The Transformation of VA Health Care in the Late 20th Century (Washington, DC: Affairs, 2014), 216-217. Department of Veterans 215

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231 APPENDIX E: THE EVOLVING HEALTH CARE INDUSTRY Health care has evolved in major ways since th e federal government began providing care to veterans after the Civil War, and it will continue to evolve substantially in the future. There are a number of factors that drive ev olution in health care, such as population and lifestyle changes, changes within the various health care pr ofessions, medical and information systems 751 technology, and systems changes in management and operations. IBM Center for Applied 752 These trends closely Insight reports that there are 18 trends to watch in health care. encompass those highlighted below. The categori es in which the trends fall mirror key topic addressed in the Commission’s report to includ e data system interoperability (10 trends), consumer technology (two trends), health care providers (two trends), government regulations (two trends), and human resources and leadership (two trends). With health care changing so rapidly, and in so many different ways, it is im perative that veterans’ health care continually rrent and future trends. This section highlights key trends that, evolve to remain aligned with cu based on past experience and current practice, w ill likely shape health care in the future, were ’s recommendations, and will likely affect considerations in formulating the Commission transformation of veterans’ health care. Emergence of Large Health Care Systems The health care industry is moving away from stand-alone community hospitals that serve the 753 needs of a local constituency to large, The industry will multiple-campus health care systems. 754 see more high profile mergers and acquisitions in the second half of 2016. The December 2015 Health Research Institute’s report indicates that well-known health care systems may have a market advantage as Americans are willing to trav el further for care from a well-known system. for Mayo Clinic in Arizona and Florida, and This may explain the development and affiliation Cleveland Clinic opening in Florida. The report also states that althou gh people are willing to drive for care they are not willing to pay pric es higher than the local market. Because of increasing use of outpatient services and same-d ay surgery, facilities within these health care 755 systems require fewer inpatient beds. With the advancement of psychotropic drugs, the 756 perceived need for large mental hospitals has declined. Because of shorter recovery stays, other monitoring programs, and new medical increased outpatient services, telemetry and ies with parts or sections that can be quickly inventions, hospitals are now built as smaller facilit 751 Lynn Etheredge, Stanley B. Jone s, and Lawrence Lewin, “What is Driving Health System Change?” Health Affairs, 15, 4, (1996): 93-104. 752 “Healthcare Internet of Things 18 Trends to watch in 2016,” Bill Chamberlain, IMB Ce nter for Applied Insights, https://ibmcai.com/2016/ 03/01/healthcare-internet-of-things-18-trends-to- March 1, 2016, accessed June 20, 2016, watch-in-2016. 753 “Top Health Industry Issues of 2016: Thriving in a New Health Economy,” PwC, accessed April 29, 2016, https://www.pwc.com/us/en/health-ind ustries/top-health-ind ustry-issues/asse ts/2016-us-hri-top-issues.pdf. 754 Ibid. 755 Ibid. 756 “How Release of Mental Patients Bega n,” Richard Lyons, accessed May 1, 2016, f-mental-patients-began.html?pagewanted=all. http://www.nytimes.com/1984/ 10/30/science/how-release-o 217

232 C C F INAL R EPORT OMMISSION ON ARE 757 es and medical advances. VHA will need to consider this trend in modified for future chang and planning for future facility needs. evaluating its current physical plant Management Changes As health care systems become increasingly complex, there is a need to manage these 758 During the past few decades, institutions using current management theories and models. hospital and health care management changed from being managed by a traditional top-down model to continuous quality improvement mode ls that respond to issues such as staff satisfaction, medication errors, safety matters, an d wasteful use of supplies. To address errors, hospitals have implemented Six Sigma prin ciples. To address waste, hospitals have implemented LEAN principles. Embracing th ese changes in management approach and ill support VHA’s transformational process. implementing Six Sigma and LEAN principles w Health Care Payment The health care industry is in the midst of tr ansforming its payment model away from a fee-for- 759 ed health outcomes. service model to value-based payments, a syst This em that drives improv transformation is tied to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which health care experts expect to shape care delivery and payment reform across the des. Congress created MACRA as a transformative U.S. health care system over the coming deca law to fast track the health care system’s trans ition from a traditional fee-for-service payment 760 model to new risk-bearing, coordinated care models. Because this legislation is still in rulemaking, it is premature for the Commission to weigh in on its potential effect on VA. The MACRA legislation expands the trend toward cr eation of accountable care organizations (ACOs) and bundled payments for care. ACO models have been reported to drive reduced 761 hospitalization and generate cost savings. Specialty Care Facilities With changes in the federal payment for hospitals, some high-cost and longer-stay care treatments have been moving out of community hospitals to specialty hospitals. For example, patients on ventilators ; rehabilitation facilities long-term acute care hospitals primarily treat treat short-term, post-acute patients who need primarily physical and occupational therapy services for orthopedic or stroke incidences; and cancer hospitals provid e innovative treatments for Stage 4 cancer. As a result, community hospital s may no longer need beds to take care of these special patients. VHA will need to consid er this trend in planning integrated care networks and evaluating its facility need s in conjunction with these networks. 757 Shati Matambanadzo, accessed May 3, 2016, “The Small Hospital of the Future,” http://www.healthcaredesignmagazine.c om/article/small-hospital-future. 758 S. Kaplan and Michael E. Porter, accessed May 2, 2016, “How to Solve the Cost Crisis in Health Care,” Robert https://hbr.org/2011/09/how-to-solve-th e-cost-crisis-in-health-care. 759 “The Medicare Access CH IP Reauthorization Act (MACRA)” Nationa l Partnership for Families and Women, ://www.nationalpartnership.org accessed June 6, 2016, http /issues/health/macra.html. 760 “MACRA: Disrupting the health care system at every level,” Deloitte, accessed June 23, 2016, http://www2.deloitte.co m/us/en/pages/life-scie nces-and-health-care/a rticles/macra.html. 761 “Health Care Trends in 2016 Impact Pa tients While Seeking to More Efficien tly Deliver Care,” Jinger Jarrett, 2, 2016, http://www.inquisitr.com/ 2710622/healthcare-trends-in-2016-impact- Inquisitr: Medicine, accessed May patients-while-seeking-to-more-efficiently-deliver-care/. 218

233 A PPENDIX E T HE H EALTH C ARE I NDUSTRY E VOLVING e-oriented Venues for Care Outpatient Care and Lifestyl procedures, many surgeries that required post-surgery hospital With improvements in surgical 762 stays are now routinely performed in outpatient settings. Many nonsurgical procedures are ch as medical imaging, cardiac catheterization, being performed in outpatient clinics as well, su 763 substance abuse treatment, gastrointest inal screening and cancer treatment. As care that was once provided only in hospitals is now provided in specialized medical clinics, care that was once provided only in physicians’ offices is now being provided in alternative settings. As reported in Health Affairs, “another health care trend consumers are using to save both time and money is that rather than making appointments with their doctors, they are choosing to use 764 walk-in clinics.” Many of these clinics are located in pharmacies, retail chains, or 765 supermarkets, allowing consumers quick, convenient, less-costly care. Do-it-yourself health care is also a trend, with increasingly more pe ople taking responsibility for their health care. vital signs, medication adherence, and even Consumers are using smart phone apps to monitor 766 urinalysis. As part of a commitment to continuous improvement, VHA will need to consider alternative venues as it creates integrated health care networks. Medical Technology Medical technology companies create life-changi ng innovation, and “advanced medical devices 767 and diagnostics allow people to live long er, healthier and more productive lives.” In fact, during the past 30 years, medical advancements helped add five years to U.S. life expectancy 768 and reduce fatalities from heart disease, st roke, and breast cancer by more than half. These advancements also yield savings across the heal th care system by replacing more expensive 769 procedures, reducing hospital stays, and allowi ng people to return to work more quickly. Ensuring veterans receive care that employs cutting-edge technology will be an important part of establishing integrated care networks. Telemedicine According to the American Telemedicine Associ ation, “telemedicine is the use of medical information exchanged from one site to another via electronic communi cations to improve a 770 Telemedicine includes a growing variety of applications and patient’s clinical health status.” 762 Mehul V. Raval et al., “The Importance of Assessing Both Inpatient and Outpatient Surgical Quality,” Annals of , 253, 3, (2011): 611-618, accessed June 20, 2016, http://www.ncbi.nlm.nih.gov/pubmed/21183845. Surgery 763 “The Strategy That Will Fix Health H. Lee, MD, acces sed May 2, 2016, Care,” Michael E. Porter and Thomas e-strategy-that-will- fix-health-care. https://hbr.org/2013/10/th 764 “Health Care Trends in 2016 Impact Pa tients While Seeking to More Efficien tly Deliver Care,” Jinger Jarrett, sitr.com/2710622/healthcare-trends-in- 2016-impact-patients- accessed May 2, 2016, http://www.inqui while-seeking-to- more-efficiently-deliver-care/. 765 Ibid. 766 a New Health Economy,” Pw C, accessed May 2, 2016, “Top Health Industry Issues of 2016: Thriving in ustries/top-health-ind https://www.pwc.com/us/en/health-ind ts/2016-us-hri-top-issues.pdf. ustry-issues/asse 767 “Value of Medical Technology,” Advanced Medica l Technology Association, accessed May 2, 2016, http://advamed.o rg/page/74/value-in-med ical-technology. 768 Care Institute of New Jers ey, accessed May 2, 2016, http://hinj.org/value-of- “Value of Medical Innovation,” Health medical-innovation/. 769 Ibid. 770 “What is Telemedici ne,” American Telemedicine Asso ciation, accessed May 2, 2016, is-telemedicine#.VwFrqfkrJaQ. http://www.americantele med.org/about-telemedicine/what- 219

234 C C F INAL R EPORT OMMISSION ON ARE phones, wireless tools, and other forms of services using two-way video, email, smart lemedicine has spread rapidly and is now telecommunications technology. The use of te becoming integrated into hospitals, specialt y departments, home health agencies, private and workplaces. The following are examples of physician offices, as well as consumers’ homes how telehealth is being used:  A specialist assisting the primary care phys ician in rendering a diagnosis might use interactive video or store-and-forward transmissi on of diagnostic images or information.  Home-use devices might be used to remotely collect information such as vital signs, blood glucose, or heart electr ocardiogram data and transfer it in real time to a home health agency or a remote diagnostic testing facility for interpretation. t be used to obtain specialized health  Consumers’ internet and wireless devices migh information or participate in online peer-to-peer support groups. should expand upon its work in this area. VHA already excels in the use of telehealth and Midlevel Practitioners During the past few decades, new categories of health care professionals have become increasingly commonplace in hospital settings. For example, hospitalists, physicians who specialize in the practice of hospital medicine , take over when the community-based physician 771 admits his/her patient to the hospital. The hospitalist does not perform the surgery but rather takes on the monitoring of the hospital servic es needed by the patient. Another example is medical technicians, who monitor the specia lized medical equipment and devices that previously were under the purview of nurses in specialty units such as intensive care units. The ance on mid-level health care providers. According to growing physician shortage has led to reli National Provider Iden the Centers for Medicare and Medicaid Services’ tifier dataset, there actitioners and 70,000 practicing physician were approximately 106,000 practicing nurse pr 772 assistants in 2010. Provider trends may play into ways VHA can address its current staffing shortage. Electronic Patient Health Information th Health records have undergone transformation from free-form physician notes of the 17 st century to electronic health records (EHRs) of the 21 century. Today, providers are using clinical applications such as computerized phys ician order entry systems; EHRs; and radiology, pharmacy, and laboratory systems to track pa tient care and progress. Health plans are 773 providing access to claims and care management, as well as member self-service applications. These advances allow the medical workforce to be more mobile and efficient (i.e., physicians erever they are). Though their use comes with can check patient records and test results from wh 771 spital Medicine,” Society of Hosp ital Medicine, accessed May 2, 2016, “Definition of a Hospitalist and Ho http://www.hospitalmedicine.org/Web/About_SHM/Hospi talist_Definition/Web/About _SHM/Industry/Hospital_ Medicine_Hospital_De finition.aspx. 772 “The Number of Nurse Practitioners and Physician Assistants Practicing Primary Care in the United States,” Agency for Healthcare Resear ch and Quality, accessed May 2, 2016, http://www.ahrq.gov/researc h/findings/factshe ets/primary/pcwor k2/index.html. 773 “The Strategy That Will Fix Health Care,” Michael E. Porter and Thomas H. Lee, MD, acces sed May 2, 2016, https://hbr.org/2013/10/ the-strategy-that-wi ll-fix-health-care. 220

235 A E PPENDIX T E EALTH C ARE I H HE VOLVING NDUSTRY will surely play a substantial role in shaping inherent potential security and privacy risks, they 774 Interoperability of these sources of patient information will be a continuing future health care. key issue in private-sector, military, and veterans’ healthcare organizations. Population Health Population health refers to considering incidence and prevalence of diseases in a given area to ntributing to the illness. Physicians and other determine if the area or the environment is co mographics to determine what types of care are health care providers may look at a region’s de needed within the population. For example, if 65 percent of the region is older than age 65, then a series of wellness programs that address the chro nic care concerns of this population may be needed. From a population health perspective, communities and their respective populations are as important as the individual patients who comprise them when it comes to keeping issues may revolve around populations of residents healthy. For VHA, population health veterans who served in particular wars and oper ations and the respective injuries and illnesses associated with them. Geriatric Care 775 In the United States and Western Europe the birth rate has slowed and people are living 776 . American makes it to age 65, he/she should Demographic researchers report that if an longer 777 have about 17 to 20 additional years of life Nursing homes and assisted living facilities are . now seeing increasingly more of residents’ firs t-time admissions occurring at age 80 or older. Some congregate care retirement facilities repo rt that even with admission in the 80s, the 778 average life expectancy is another 12 or 13 years . The aging population accounts for a result, hospitals rely on more revenue from increasingly more hospital admissions, and as 779 Medicare. the general U.S. population, and older The VHA beneficiary population mirrors cker than their private-sector counterparts. veterans receiving care through VHA may be si Chronic Disease Care Chronic conditions now account for more than 50 percent of the death rate. Acute problems had 780 previously been the primary causes of death. Even HIV/AIDS has moved away from being with proper treatment, is considered by considered an immediate death sentence, and now, 774 ,” U.S. Department of Health and Human Services, acce ssed May 2, 2016, “Summary of the HIPAA Privacy Rule onals/privacy/laws- regulations/. http://www.hhs.gov/hipaa/for-professi 775 “Fact Sheet: The Decline in U.S. Fert ility,” Mark Mather, a ccessed May 2, 2016, ions/datasheets/2012/world-population-data -sheet/fact-sheet-us-population.aspx. http://www.prb.org/publicat 776 National Center for Health Statistics, Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities , accessed May 2, 2016, http://www.cdc.gov/nchs/data/hus/hus15.pdf. 777 National Center for Health Statistics, Life Expectancy at Birth, at Age 65, and at Age 75, by Sex, Race, and Hispanic Origin: , accessed May 2, 2016, ht tp://www.cdc.gov/nchs/da ta/hus/2011/022.pdf. United States, Selected Years 1900-2010 778 Kathleen Harris, CCRC Resident Demographics and Health Care Utilizatio n: An Analysis , accessed May 3, 2016, http://www.avpowell.com/ docs/Fall1997.pdf. 779 “The Strategy That Will Fix Health Care,” Michael E. Porter and Thomas H. Lee, MD, acces sed May 2, 2016, https://hbr.org/2013/10/ the-strategy-that-wi ll-fix-health-care. 780 “Chronic Disease Overview,” Centers for Diseas e Control and Prevention, accessed May 2, 2016, cdisease/overview/. http://www.cdc.gov/chroni 221

236 C INAL R EPORT C OMMISSION ON F ARE 781 The Centers for Disease Control reports that since 2014, more most to be a chronic disease. itions and diseases than from acute diseases. Americans are dying as a result of chronic cond Most chronic diseases result from lifestyle choice s. Lifestyle diseases result from choices that 782 individuals make. Health care systems invest resources in addressing lifestyle-related issues 783 caused by behaviors such as smoking, using opiates, and overeating. Lifestyle diseases such as cancer caused by smoking, addiction caused by drug use, and diabetes caused by obesity, are 784 costly to treat. Because lifestyle diseases change over ti me, they are important to consider in thinking about the future of veterans’ healthca re. Treating chronic diseases can be costly because care is ongoing, and assuming this tren d continues to become more prominent, it will 785 affect the cost of care and how it is provided. Needs-based Health Care The Affordable Care Act requires all not-for-pr ofit hospitals to complete a survey of the community (community health n eeds assessment, or CHNA) to show what entities in the community will address identified needs (asset mapping) and then report on how the hospital 786 will address these needs in a community heal th care implementation program (CHIP). Starting in 2016, hospitals must post these reports on their websites and conduct these health needs can lead to evaluations every 3 years ther eafter. Monitoring community For example, scarcity of quality food has been preventing or stopping the spread of disease. 787 documented to result in poor sc hool attendance and increased illness. Some Americans getables and fruits because they live in areas simply have not been exposed to how to prepare ve that are called food deserts , where healthy foods are not readily available. Identifying such needs 788 and how they will be addressed can help improve health for specific populations. In new treatments and protocols for addressing Washington, DC, such a health assessment led to 789 is brought in by a group of legal immigrants. the appearance of a rare strain of tuberculos Using CHNA and CHIP could be part of VHA’s ongoing planning process. 781 Steven G. Deeks, Sharon R. Lewin, and Diane V. Havlir , “The End of AIDS: HIV Infection as a Chronic Disease,” , 382, 9903, (2013): 1525-1533. Lancet 782 Causes of Chronic Dise ases,” Cleveland Clinic , accessed May 2, 2016, “Lifestyle Choices: Root linic.org/health/transcripts/ 1444_lifestyle-choices-root-cau ses-of-chronic-diseases. https://my.clevelandc 783 D. B. Resnik, “Responsibility for Health Journal of Medical Ethics , 33, 8, (2007): : Personal, Social, and Environmental,” 444-445. 784 “How to Save a Trillion Dollars,” cessed May 2, 2016, Mark Bittman, ac http://opinionator.blogs.ny times.com/2011/04/12/how-to-sa ve-a-trillion-dollars/. 785 “Why We Need Public Health to Improve Healthcare,” Na tional Association of Chronic Disease Directors, accessed May 2, 2016, http://www.chronicdisea se.org/?page=WhyWeNeedPH2impHC. 786 “New Requirements for 501(c Act,” Internal Revenu e Service, accessed )(3) Hospitals Under the Affordable Care rities-&-Non-Profits/Charitable-Org anizations/New-Requirements-for- May 2, 2016, https://www.irs.gov/Cha the-Affordable-Care-Act. 501%28c%29%283%29-Hospitals-Under- 787 “Hunger In Our Schools: Breakfast Is A Crucial ‘School Supply’ For Kids In Need,” Tom Nelson, accessed May 2, 2016, http://blogs.usda.gov/2015/ 03/03/hunger-in-our-schools-breakfast-is-a-c rucial-school-supply-for-kids-in-need/. 788 rts,” Jeremy Moorhead, accessed May 3, 2016, http://eatocracy. cnn.com/2012/03/14/the- “The Capital’s Food Dese capitals-food-deserts/. 789 District of Columbia Department of Health HIV/AIDS, Hepatitis, STD, and TB Administration, District of Columbia HIV/AIDS, Hepatitis, STD, and TB (HAHSTA) Annual Report: 2010, accessed May 3, 2016, dc/sites/doh/publication/ port_FINAL_0_0.pdf. attachments/2010_Annual_Re http://doh.dc.gov/sites/default/files/ 222

237 A E PPENDIX T NDUSTRY EALTH C ARE I H HE E VOLVING Behavioral Health referred to as behavioral health, has changed Treatment for mental health, now more commonly dividuals be cared for in the least restrictive dramatically since a 1968 federal law required in 790 This law lead to an expectation that mo st patients would receive care in out- environment. that requires insurance companies to increase patient facilities. Recently legislation was passed the amount of payment for behavioral health, whic h could add more patients to the health care 791 VHA is a leader in mental health treatment and should continue to be a trendsetter in system. this regard. Preventive Medicine ss and to restore the sick to health. The trend, Traditionally, physicians were trained to cure illne trained in prevention and are more active however, is changing, and physicians are now 792 participants in the prevention of illness. Additionally, insurance and Medicare now cover 793 preventive care and annual physic als, further supporting prevention. Preventive medicine is a key component of integrated health care and will need to be considered as VHA works to transform veterans’ healthcare. Pharmacy Changes Health Affairs reports that “in 2015 . . . an alarmi ng trend of new high-cost specialty pharmaceuticals entered the market. . . . Overall drug spending increased 12.2 percent last year, 794 the highest rate of increase in more than a decade.” Escalating drug prices account for some of this increase, including more than 3,500 gene ric drugs that at least doubled in price from 795 Newly emerging and very 2008–2015 and about 400 drugs that increased in cost 1000 percent. expensive developments in the area of genomic me to the increase. “One dication also contribute ilar drugs. These drugs ar way to combat skyrocketing prices will be biosim e near substitutes for 796 original brand drugs and could br ing significant price discounts.” Because many of VHA’s beneficiaries seek only prescription benefits, prescription drug trends will be important to consider in the transformation process. 790 “How Release of Mental Patients Bega n,” Richard Lyons, accessed May 2, 2016, http://www.nytimes.com/1984/ 10/30/science/how-release-o f-mental-patients-began. html?pagewanted=all. 791 “Implementation of the Mental Health Parity and Addi ction Equity Act (MHPAEA),” Substance Abuse and Mental Health Services Administration, ac cessed May 2, 2016, http://www.samhsa .gov/health-financing/implementation- mental-health-parity-a ddiction-equity-act. 792 ,” American Medical Associ “Opinion 8.075 – Health Promotion and Preventive Care ation, accessed May 2, 2016, http://www.ama-assn.org/ama/pub/phy de-medical-ethics/opinion8075.page. sician-resources/medical-ethics/co 793 “Preventive Services Covered Under the Affordable Care Act,” U.S. Department of Health and Human Services, /healthcare/facts-and-fe atures/fact-sheets/preve ntive-services-covered- accessed May 2, 2016, http://www.hhs.gov under-aca/. 794 Anne Martin et al., “National Health Spending In 2014: Faster Growth Driven By Coverage Expansion And Prescription Drug Spending,” Health Affairs , 35, 1, (2016): 150-160. 795 Quickly on the Rise,” Anthony L. Komaroff, accessed May 2, 2016, “Generic Drug Prices http://www.spokesman.com/stor ies/2016/feb/18/generic-drug-pric es-quickly-on-the-rise/. 796 “Top Health Industry Issues of 2016: Thriving in a New Health Economy,” Pw C, accessed May 2, 2016, ts/2016-us-hri-top-issues.pdf. https://www.pwc.com/us/en/health-ind ustries/top-health-ind ustry-issues/asse 223

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239 APPENDIX F: THE COMMISSION’S PROCESS Commission Meetings From September 2015 to June 2016, the Commiss ion held convened 12 sessions of public ch meeting is listed in the following table. meetings (26 days). The content addressed at ea September 21 ‐ 22, 2015 A: RAND Corporation Assessment Demographics Christine Eibner  Assessment Health Care Capabilities RAND Corporation B:  Peter Hussey, PhD of VA Department Veterans Affairs Leadership  Bob McDonald, Secretary  Gibson, Deputy Secretary Sloan  MD, Under David Secretary for Health Shulkin, Assessment C: Care Authorities RAND Corporation  Michael D. Greenberg Assessment I: Business Processes Grant Thornton LLP  Lane Jackson Aamir Syed   Sharif Ambrose Assessment Scheduling Workflow McKinsey & Company E: Kurt Grote, MD  Alex Harris  Pooja Kumar  McKinsey Assessment Clinical Workflow F: & Company Kurt Grote, MD  Gretchen Berlin  Grant Assessment G: Staffing/Productivity/Time LLP Thornton Allocation Peter Erwin, PhD  Peabody  Hillary Erik Shannon  McKinsey J: Supplies & Company Assessment  Kurt Grote, MD  Robin Roark, MD Assessment K: Facilities McKinsey & Company  Vivian Riefberg  John Means 225

240 C OMMISSION ON F INAL R EPORT C ARE 21 September 2015 (continued) ‐ 22, Leadership Department of Veterans Affairs VHA Assistant Deputy Vandenberg, Under  Patricia for Health for Policy and Planning Secretary CMS Alliance to Modernize Health care Assessment Leadership Stephen Kirin  Jay Schnitzer, PhD, MD  & McKinsey Company Riefberg  Vivian Assessment H: Health IT MITRE Corporation  Durvasula Aparna Glenn  Himes & Company McKinsey  Huber Celia Vivian  Riefberg 2015 October 6, Eligibility Health Administration Veterans Stephanie Mardon, Chief Business Officer  Cunningham, Director, Business Policy Kristin  Affairs 2014 Choice Act/2015 Enhancement to Veterans Health Administration the Community, Current State Officer Choice/Care in  Stephanie Mardon, Chief Business Business  Cunningham, Director, Kristin Policy Affairs Future State of VA Community Care/ Administration Health Veterans Community the in Care  Joe Dalpiaz, Director, VISN 17  Baligh Yehia, MD, Senior Health Advisor to the Secretary of Veterans Affairs  Gene Deputy Migliaccio, Chief Business Officer, Managed Care Health Academic Veterans Affiliations Administration Robert  MD, Chief, Office of Academic Jesse, Affiliations  Karen Sanders, MD, Deputy Chief, Office of Academic Affiliation Long ‐ Term Care  Allman, MD, Chief Consultant, Geriatrics Richard Services and Extended Care 226

241 A PPENDIX F T HE ’ S P ROCESS C OMMISSION 19–20, October 2015 Assessment, Independent Policy Health Fellow, Senior MD, Brett  Giroir, Perspective on VA Care, Health Medical Institute, Texas Center and Discussion Q&A/Panel Gail Wilensky,  Senior Fellow at Project HOPE PhD, Perlin, MD, Chief Medical Officer and  Jonathan Clinical Services at Hospital President, of America Corporation Health Women’s Veterans Health Administration Patricia Hayes, PhD, Chief Consultant,  VA Women’s Health Services Mental Veterans Health Administration Health David Executive Director, Mental Carroll, Health  Operations Harold Kudler,  Chief Mental Health MD, Consultant Veterans Administration Homelessness Health Anne Dunn, Deputy Director,  VHA Homeless Program Office Assessment Access Institute of Medicine D: Michael McGinnis, MD  Marianne Hamilton  Lopez Section 203 Northern Virginia VACAA Council Technology  Ken Mullins Scheduling Veterans Health Administration  Davies, MD, Executive Director of Access Michael Clinic Administration Program and Department Services MyVA Overview Support of Veterans Affairs Excellence Bob Snyder, Executive Director, MyVA Task Force  Muir, Director, Support Services Tom  16–17, 2015 November Health Care Economics/Finance  Mark Yow, Acting Chief Financial Officer, VHA Mango, McKinsey Paul & Company  Gail Wilensky, PhD, Senior Fellow at Project  HOPE Academic Affiliations Association of American Medical Colleges Chief Grover, PhD, MD,  Public Policy Officer Atul E. Prescott, MD, John Chief Affiliations Officer   Matthew Schick, JD, Director, Government Regulations Regulatory Counsel & Veterans VHA Matters Health Administration Clinical  Lucille Beck, PhD, Deputy Chief Patient Care and Services Officer, Rehab Prosthetic Services  Donna Gage, PhD, RN, Chief Nursing Officer 227

242 C OMMISSION ON ARE F INAL R EPORT C 14 16, 2015 December ‐ and Health Equity Department of Veterans Affairs Affairs Minority Ward, Director, Center for Minority Barbara  Affairs Health Administration Veterans Uchenna S. Uchendu, MD, Executive Director,  Health Equity Office of the Future of Veterans Health  Garry Framework Augustine, Disabled for American Veterans Blake, Paralyzed Carl of America  Veterans Carlos Fuentes,  Veterans of Foreign Wars  Ray Kelley, Veterans of Foreign Wars Veteran Organizations  Louis Celli, The American Legion Service Association Renee Campos, Military Officers of  America National Health Information Operability  Dr. Jon White, Deputy National Coordinator, Department of Health and Human Services DoD I Procurement: Lesson  Chris Miller, Program Executive Officer, Defense Program Office Systems, Department Health Care Management Learned/Interagency of Defense Health Information Exchange  Elaine Hunolt, Do ‐ Director Interoperability Office, Veterans Administration Health Chief Harry  Leider, Dr. Medical Officer, Walgreens  James Wood, VP ‐ Federal, Walgreens Officer,  Yeager, Chief Executive Mariann The Sequoia Project Vision for OI&T/Collaboration with VHA  LaVerne Council, Chief Information Officer, Department of Veterans Affairs Leadership and Transformation  Charles Rossotti, Former Commissioner, Internal Revenue Service and 21, 2016 January 19 VHA Leadership  Dr. Michael Kussman, former Undersecretary for Health, Veterans Health Administration former  Kenneth Kizer, Dr. Undersecretary for Health, Veterans Health Administration Government Perspectives American Federal of Employees Labor  Marilyn Park National Association of Veterans Affairs Physicians and Dentists  Samuel Spagnolo Nurses Organization of Veterans Affairs  Joan Clifford Johnson  Sharon 228

243 A PPENDIX F T HE ’ S P ROCESS C OMMISSION 19 21, 2016 (continued) January and Health Leaders Association of Veterans Affairs Psychologist Behavioral Kirchberg  Thomas Russell Lemle   ‐ Rivera Edgardo Padin Antonette Zeiss  Psychiatric Association American Jenny Boyer  L. of Affairs Social Veterans Workers Association LeAnn Bruce  Jerry Satterwhite  San  Keith Homeless Armstrong, Veterans Francisco Veterans Affairs care Health System ‐ Than ‐ Honorable Discharges  Branford Adams Other 8 9, 2016 February ‐ Director,  Lisa Freeman, Construction Center Management Palo Alto Medical care System Health VISN and Field Leadership Perspectives  Joleen Clark, Former Director, VISN 8 Network  Jon Gardner, Former Medical Center Director, Medical Center Tucson VA Lisa Freeman, Medical  Director, Palo Alto Center Health care System Implementation of the Choice Program  Billy Maynard, President HealthNet Federal Service David McIntyre, Jr., President J. and Chief  Officer, TriWest Healthcare Alliance Executive Update on VHA  Dr. David Shulkin, Undersecretary for Health, Health Administration Veterans Determining  Patrick Ryan, Former Feasibility Staff Director and Chief House Veterans Affairs Committee Counsel, – March 29 1, 2016 February Lukens, Economist Briefing  Gideon PhD, Staff Economist  Taber, PhD, Staff Economist Jamie ‐ 23, 2016 March 21 Conversation with HVAC  Rep. Jeff Miller (R ‐ FL) Chairman Conversation with HVAC Member  Rep. Beto O’Rourke (D ‐ TX) Health Administration  Dr. David Shulkin, Undersecretary for Veterans Health of  Barbara Manning, Office Policy and Planning  Lyn Stoesen, Office of Policy and Planning 229

244 C OMMISSION ON ARE F INAL R EPORT C 21 23, 2016 (continued) March ‐ PhD,  Gideon Lukens, Staff Economist Economist Briefing Merideth Randles, FSA, MAAA,  Inc. Milliman, Taber, PhD, Staff Economist Jamie  18 ‐ 19, 2016 April Veterans Service Organizations  Garry Augustine, Disabled American Veterans  Dickinson, Disabled American Veterans Peter Verna Jones, American Legion  Rick Vietnam Veterans of America  Weidman, Bill Rausch, Got Your  6  Ray Kelley, Veterans of Foreign Wars  Campos, Military Officers Rene Association of America Economist Economist Briefing  Gideon Lukens, PhD, Staff Staff  Taber, PhD, Economist Jamie VA Leadership Department of Veterans Affairs Bob McDonald,  Secretary  Sloan Gibson, Deputy Secretary Yehia, Care  Baligh Community MD, Assistant Deputy Under Secretary for Community Care, VHA 9 ‐ May 2016 11, Office of General Counsel  Leigh Bradley, VA General Counsel  Jessica Tanner, Staff Attorney Economist Briefing  Gideon Lukens, PhD, Staff Economist Economist  Jamie Taber, PhD, Staff June 7 ‐ 8, 2016 speakers No 230

245 A PPENDIX F T HE ’ S P ROCESS C OMMISSION Commission Workgroups rkgroups in order to complete an analysis of The Commission on Care organized itself into wo st recommendations to the full Commission for relevant issues, consider options, and sugge with each responsible for sections of the debate. The Commission formed five workgroups by the group. In establishing each workgroup Independent Assessment or other topics taken on an effort was made to balance perspectives and expertise, although Commissioners expressed interests were also taken into account in forming the membership of each group. The ken on by each is summarized in Table F-1. membership of each workgroup and the topics ta Table F-1. Workgroup Structure and Topics NAME TOPICS MEMBERSHIP WORKGROUP Care Alignment  Demographics Health Blecker   Gorman Health care Capabilities  Johnson  Khan   Care Authorities  Longman McClenney  Standards Access   Selnick  Governance Health Operations  Access Standards Care Cosgrove   Gorman Scheduling Workflow   Harvey  Hickey Clinical  Workflow Longman  Taylor  Productivity Staffing  Webster  Data, Health Care T Tools & I  Health  Blom  Cosgrove Processes  Business Infrastructure Harvey  Johnson  Supplies  Steele  Taylor   Facilities Organizational Leadership  Care Health Health Blecker   Cosgrove  Hickey Systems  Leadership McClenney   Selnick  Schlichting Steele  Health Care Trends  Market Trends  Blom  Cosgrove  Technology  Johnson  Khan Financing  Schlichting   Webster Vision  Each workgroup, together with any staff a ssigned to it, reviewed the findings and recommendations of the Independent Assessment and the Integrated Report; investigated heard testimony in public meetings (with the external benchmarks and best practice models; full Commission); met in workgroup session with VA employees, leaders, former staff and external experts to gather addi tional insights and explore rele vant questions. Commissioners reviewed white papers and strawman proposals prepared by staff and by one another. Based on the assessments and group deliberations, each workgroup developed recommendations for consideration by the full Commission. Details of the process and outputs from each workgroup are described in the following sections. 231

246 C OMMISSION ON ARE F INAL R EPORT C Health Care Alignment Workgroup The alignment workgroup organized its work arou nd six main topics: governance, realignment of facilities and services, medical sharing, elig ibility, other than honorable discharges, and the organization of provider networks . The workgroup met in a face-t o-face session on October 7, 2015 to review the charge of the workgroup, orie nt one another to the task envisioned for the group, and decide how the workgr oup would function to complete its work. In general, each topic was introduced through a summary paper or summary points which then were used as the basis for a conference call or a face-to-face di scussion. For most topics, subsequent calls were held to discuss more detailed papers or to re-visit outstanding issues not yet resolved. Commissioners also reviewed draft papers and pr ovided additional feedback, revisions, and comments through written comments. The papers were finalized for inclusion in the draft summary of the work completed on each topic Commission report for discussion on April 19. A is provided in the table below. Table F-2. Alignment Workgroup Activities ACTIVITY WORKGROUP EXPERT INPUT C=call with S=met staff WORKGROUP TOPIC review E=email workgroup W=met with M=face meeting ‐ to ‐ face testimony F=full Commission Type Date Expert Date Type 11/17/2015 M Governance Vivian Riefberg 9/22/2015 F 1/7/2016 C Kirin Stephen 9/22/2015 F C 1/28/2016 Schnitzer 9/22/2015 F Jay 2/18/2016 C 10/30/2015 Light Paul S 3/3/2016 C 12/16/2015 F Rossotti Charles C 3/10/2016 F 1/19/2016 Kussman Michael C 3/17/2016 F Ken Kizer 1/19/2016 4/7/2016 C Miller Jeff 3/21/2016 F C 1/7/2016 Realignment of Facilities and F 9/22/2015 Riefberg Vivian Services C 1/28/2016 9/22/2015 F Means John C 3/10/2016 C 3/17/2016 4/7/2016 C C Medical Sharing 1/28/2016 F 11/16/2015 Gover Atul 3/3/2016 C Prescott F John 11/16/2015 C 3/10/2016 Schick F 11/16/2015 Mathew C 3/17/2016 4/7/2016 C 11/17/2015 M Eligibility F Eibner Christine 9/21/2015 C 12/10/2015 9/21/2015 Greenberg Michael F C 1/28/2016 F 9/21/2015 Pat Vandenberg 2/25/2016 C 10/6/2015 F Mardon Stephenie 3/10/2016 C F 10/6/2015 Cunningham Kristin 3/17/2016 C F Gail Wilensky 10/19/2015 4/7/2016 C McGinnis 10/20/2015 F Michael Lopez Marianne Hamilton 10/20/2015 F Michael Kussman 1/19/2016 F F Jeff Miller 3/21/2106 232

247 A F PPENDIX T ’ P ROCESS HE OMMISSION C S ACTIVITY WORKGROUP EXPERT INPUT C=call staff with S=met WORKGROUP TOPIC review E=email W=met with workgroup to ‐ face meeting M=face ‐ F=full Commission testimony Date Type Expert Date Type Other ‐ Than ‐ Honorable C 1/28/2016 F 1/20/2016 Adams Bradford C Discharge 2/18/2016 3/10/2016 C 3/17/2016 C C 4/7/2016 Organization of Provider C 1/28/2016 F 9/21/2015 Hussey Peter 2/25/2016 C Networks Dalpiaz F 10/6/2015 Joe 3/10/2016 C F 10/6/2015 Baligh Yehia C 3/17/2016 Gene Migliaccio 10/6/2015 F C 4/7/2016 1/19/2016 F Michael Kussman Gardner 2/8/2016 F Jon Billy 2/8/2016 F Maynard David McIntrye 2/8/2016 F Jeff Miller 3/21/2016 F 3/22/2016 F Beto O’Rourke Health Care Operations Workgroup organized around five main topics: access The health care operations workgroup was standards, scheduling, clinical workflow, sta ffing (HR), and productivity. The workgroup (select Commissioners and support staff) first met face-to-face on October 7, 2015 to: introduce the staff, review guiding principles and business ru les, orient one another to the task envisioned for the group, and decide how the workgroup woul d function to complete its work. In general, each of the main topics was discussed. During the larger public sessions the Commissioners and staff heard directly from Veterans Affairs staff or outside experts to inform future deliberations. In follow-on meetings the workgroup continued to present research on the four main topics; and cover other issues that may have come up du ring sessions (i.e., Best Practices) or from questions posed by Commissioners. To su pplement the Commission conferences, the workgroup held teleconferences to cover additi onal research or present information from subject matter experts or emailed informational briefs and write-ups for review before a workgroup teleconference. Feedback from the Commissioners was addressed and the potential recommendations were refined. These papers were finalized and readied for presentation to the full Commission for deliberation and feedback. A summary of the work completed on each topic is provided in the table below. 233

248 C OMMISSION ON ARE F INAL R EPORT C Table F-3. Health Care Operations Workgroup Activities ACTIVITY WORKGROUP EXPERT INPUT C=call with S=met staff WORKGROUP TOPIC review email E= workgroup W=met with M= face ‐ meeting to ‐ face F=full Commission testimony Type Date Date Type Expert Standards 10/20/2015 M Access F 10/6/2015 Mardon Stephanie C 12/3/2015 F 10/6/2015 Kristin Cunningham 2/25/2016 C S Institute of Medicine 10/13/2015 C 4/27/2016 of Medicine 10/20/2015 F Institute Scheduling M McKinsey Co 9/22/2015 F 10/7/2015 Mardon 10/6/2015 F Stephanie Cunningham 10/6/2015 F Kristin Michael Davies 10/14/2015 S Dr. Monder 10/14/2015 S Gary 10/14/2015 S Steve Green McGinnis 10/14/2015 S Michael Ken 10/14/2015 S Mullins Hamilton Lopez 10/14/2015 S Marianne Medicine 10/20/2015 F Institute of Michael Dr. 10/20/2015 F Davies Michael Davies 11/18/2015 W Dr. Clinical Workflow 10/27/2015 C 9/22/2015 Co. & F McKinsey C 2/18/2016 Nora Socci 12/29/2015 S C 4/6/2016 Diane 2/3/2016 S Pulphus Hugh 2/26/2016 S Scott Staffing 11/4/2015 C F 9/22/2015 Co McKinsey C 12/3/2015 10/19/2015 Perlin Jonathan Dr. F 1/20/2016 M S 12/7/2015 Ward Barbara C 2/18/2016 2/25/2016 C C 4/6/2016 Productivity 12/15/2015 M McKinsey Co 9/22/2015 F Gene Migliaccio 10/6/2015 F Boston VAMC 12/7/2015: S Michael Charness Dr. Melanie Gilhern Walker Meredith Vielhauer Dr. Melanie Conlon Rosemary Practices 1/6/2016 C Best F 9/22/2015 McKinsey Co 1/20/2016 M W 12/2/2015 Dr. Theresa Cullen C 2/25/2016 Dr. Daniel Bochicchio 12/3/2015 S E 3/14/2016 Atkins David S 1/5/2016 Linda Lipson 1/5/2016 S Amy Kilbourne 1/5/2016 S Bob Monte 1/5/2016 S Rachel Goffman 1/5/2016 S Dr. Daniel Bochicchio 1/20/2016 S W Barbara Meadows 2/25/2016 W Barbara Meadows 3/17/2016 234

249 A F PPENDIX T OMMISSION P ROCESS C ’ HE S Health Care Data, Tools & Infrastructure Workgroup The Health Care Data, Tools & Infrastructure (D TI) workgroup organized its work around four siness Processes, Supplies and Facilities. DTI main topics: Health Information Technology, Bu first met face to face on October 7, 2015 to: introd uce the staff, review the charge of DTI, orient group, and decide how the workgroup would one another to the task envisioned for the of the main topics were discussed. During the function to complete its work. In general, each larger public sessions the Commissioners and staff heard directly from Veterans Affairs staff or outside experts to inform future deliberations. In follow-on meetings the workgroup continued to present research via white papers on the four main topics; and cover other issues that may have come up during sessions or from questi ons posed by Commissioners. To supplement the p held teleconferences to cover additional Commission face-to-face meetings, the workgrou matter experts. Feedback from the Commissioners research or present information from subject was incorporated into the white papers and the potential recommendations were refined. Commissioners then reviewed the draft papers derived from this process and provided through meetings and written comments. These additional feedback, revisions, and comments papers were finalized and readied for presenta tion to the full Commission for deliberation and feedback. A summary of the work completed on ea ch topic is provided in the table below. Table F-4. Data, Tools & Infrastructure Workgroup Activities ACTIVITY WORKGROUP INPUT EXPERT C=call S=met staff with TOPIC WORKGROUP review email E= workgroup with W=met meeting M= face ‐ to ‐ face F=full Commission testimony Date Type Date Type Expert I T 10/7/2015 M Health MITRE Co F 9/22/2015 C 11/18/2015 Brett Dr. S 10/19/2015 Giroir 12/2/2015 C Council, LaVerne HVAC 10/27/15 3/7/2016 C Burns Brian Hearing Miller, Chris C 3/14/2016 11/6/2015 S Brookings Institution M 3/21/2016 LaVerne 11/25/2015 S Council E 4/4/2016 & C Dr. Theresa Cullen 12/2/2015 W Chris 12/15/2015 F Miller Hume 12/15/2015 F Chuck Hunolt Elaine 12/15/2015 F Jim 12/15/2015 F Wood 12/15/2015 F Mariam Yeager Council 12/15/2015 F LaVerne Bennett Jamie 3/2/2016 S Margaret Donahue 3/11/2016 S Kai Miller 4/12/2016 S Business Processes 10/20/2015 M F 9/21/2015 McDonald Bob SecVA 10/26/2015 M C 3/14/2016 M 3/21/2016 C 4/4/2016 235

250 C INAL R EPORT OMMISSION ON C ARE F WORKGROUP ACTIVITY INPUT EXPERT C=call S=met staff with WORKGROUP TOPIC review E= email with W=met workgroup ‐ M= face meeting face ‐ to testimony F=full Commission Date Type Date Type Expert (Pharmaceutical Supplies & 10/7/2015 M Co McKinsey 9/21/2015 F M 10/26/2015 Medical Devices) S Jonathan 12/4/2015 Miller E 2/23/2016 S 12/4/2015 Taylor Tucker C 2/24/2016 3/7/2016 C C 3/14/2016 3/21/2016 M 10/7/2015 M Facilities 9/21/2015 McDonald Bob F 11/18/2015 M S Jim 11/11/2015 Sullivan C 12/2/2015 Mark W. Johnson 12/21/2015 S 12/22/2015 M S Kyle Reinhardt 12/22/2015 2/16/2016 E Kurmel S Thom 12/22/2015 S 12/22/2015 2/17/2016 C Rick Bond John 12/22/2015 S Bulick 2/24/2016 E & C John Kay S 12/22/2015 C 3/7/2016 2/16/2016 S Sullivan Jim 3/14/2016 C S 2/16/2016 Ed Bradley 3/21/2016 M W 2/17/2016 Jim Sullivan 4/4/2016 C Jim S Sullivan 3/15/2016 4/11/2016 C 4/27/2016 C Other 11/5/2015 E 11/6/2015 E 3/11/2016 E Health Care Leadership Workgroup The leadership workgroup organized its work ar ound five main topics: organizational health and cultural transformation and four leadersh ip system issues: recruitment, retention, nal structure and function; performance development and advancement; organizatio management and performance measurement; an d human capital management. The workgroup to review the charge of the workgroup, orient met in a face-to-face session on October 7, 2015 one another to the task envisioned for the group, and decide how the workgroup would function to complete its work. In general, each topic received an evidence review and summary which was the basis for a conference call or a face-to-face discussion. On a few topics, Commissioners or staff heard directly from VA staff or outside experts to inform the deliberation. Then, in a second meeting on the topic, the Commissioners debated a strawman proposal and alternative recommendations ba sed on the evidence review and the prior Commission discussion. Feedback from the Commissioners was incorporated into the strawman and the potential recommendations were refined. Commissioners then reviewed the ovided additional feedback, revisions, and draft papers derived from this process and pr comments through meetings and written comments. The papers were finalized and presented back on March 22, 2016. A summary of the to the full Commission for deliberation and feed work completed on each topic is provided in the table below. 236

251 A F PPENDIX T C S P ROCESS HE OMMISSION ’ Table F-5. Leadership Workgroup Activities ACTIVITY WORKGROUP INPUT EXPERT C=call S=met staff with TOPIC WORKGROUP review email E= workgroup W=met with meeting M= face ‐ to ‐ face F=full Commission testimony Date Type Date Expert Type Organizational Health and C 12/2/2015 F Kirin 9/23/2015 Stephen Transformation 12/9/2015 C Cultural Jay F 9/23/2015 Schnitzer 2/9/2016 M 9/23/2015 Riefberg F Vivian 2/17/2016 C S Dee Ramsel 11/9/2015 3/11/2016 E Ashby Sharpe 11/9/2015 S Ken 11/9/2015 S Berkowitz 2/8/2016 F Lisa Freeman Clark 2/8/2016 F Joleen 2/8/2016 F Gardner Jon Retention, Recruitment, 11/17/2015 M Kirin F 9/23/2015 Stephen Development, and 11/25/2015 C Jay F 9/23/2015 Schnitzer Advancement 2/17/2016 C F 9/23/2015 Vivian Riefberg 2/24/2016 C Volney S 11/9/2015 Warner C 3/9/2016 Red Lisa 11/17/2015 W 3/11/2016 E Payton Rica ‐ Lewis 11/17/2015 W Lisa Freeman 2/8/2016 F Joleen Clark 2/8/2016 F 2/8/2016 F Gardner Jon Georgia S Coffey 2/22/2016 Perry 2/24/2016 S David Oatis ‐ Newsome 2/24/2016 S Audrey Structure and 10/27/2015 C Organizational Stephen 9/23/2015 Kirin F 2/9/2016 Function M Jay F 9/23/2015 Schnitzer 2/19/2016 E 9/23/2015 F Riefberg Vivian 3/9/2016 C Jon F Perlin 10/20/2015 E 3/11/2016 Rossotti F Charles 12/16/2015 Kussman 1/19/2016 F Michael Ken 1/19/2016 F Kizer 2/8/2016 F Lisa Freeman Clark 2/8/2016 F Joleen F 2/8/2016 Gardner Jon Robin Hemphill ¾/2016 S Performance and Management C 11/4/2015 F 9/23/2015 Kirin Stephen 11/12/2015 Measurement C Performance 9/23/2015 F Jay Schnitzer 2/19/2016 E 9/23/2015 F Vivian Riefberg C 3/9/2016 10/20/2015 F Jon Perlin E 3/11/2016 10/30/2015 S Peter Almenoff Francis 1/8/2016 Joe S Carolyn Clancy 1/8/2016 S Ken Kizer 1/19/2016 F Lisa Freeman 2/8/2016 F Clark 2/8/2016 F Joleen Jon Gardner 2/8/2016 F Noel Baril 3/9/2016 S 237

252 C C R EPORT OMMISSION ON ARE F INAL WORKGROUP ACTIVITY EXPERT INPUT C=call staff with S=met TOPIC WORKGROUP E= email review with workgroup W=met face meeting M= face ‐ to ‐ testimony F=full Commission Date Type Expert Date Type M 12/15/2015 Human Capital Management Kirin F Stephen 9/23/2015 C 12/23/2015 9/23/2015 Jay F Schnitzer E 3/11/2016 Vivian Riefberg 9/23/2015 F 12/15/2015 Sam Retherford W Clark 2/8/2016 F Joleen Leadership Vision 1/6/2016 C 1/21/2016 M 2/3/2016 C 2/4/2016 E E Leadership Pre ‐ amble 3/14/2016 238

253 A PPENDIX F T HE ’ S P ROCESS C OMMISSION Site Visits Background mand for accountability in health care and In the coming decades there will be increased de d measurements, and VHA will need to rise to increased emphasis on health care outcomes an meet these expectations to survive and remain competitive in the demanding and turbulent 797 The changing nature of health care organizations, including health care environment. pressure to reduce costs, improve the quality of care, and meet stringent guidelines, has forced 798 health care professionals to reexam ine how they evaluate performance. Although many the need to look beyond financial measures health care organizations have long recognized when evaluating performance, many still struggle with what measures to select and how to use 799 the results of those measures. As the nation’s largest health care system in 2016, VHA employs more than 305,000 health care professionals and support staff at more than 1,0 00 sites of care, including hospitals, community- 800 homes, domiciliaries, and 300 Vet Centers. based outpatient clinics (CBOCs), nursing Given the scope of this health care system, the Commi ssion recognized the importance of direct lines of communication and interaction with VHA leader s, staff, and patients, to include conducting facility site visits. Commissioners cond ucted facility site visits to their local VA facilities to assist in the evaluation of the findings identified by the Independent Assessment Report, to contribute to 801 an environmental scan of the VHA, and to inform the development of recommendations. Scope of Site Visits Commissioners conducted site visits to the VA In January and February 2016, most of the 15 medical centers (VAMCs) and CBOCs proximal to their respective residences. The Commissioners approached these si te visits with a collaborative and information-seeking tone with VAMC leadership, staff, and patients. with the purpose of having open discussions Individual Commissioners visi ted 12 VAMC facilities or CBOCs in 7 out of 19 Veteran onally, all the Commissioners who attended the Integrated Service Networks (VISNs). Additi llas, TX, toured the Dallas VAMC. February 29, 2016, meeting in Da 797 partment of Veterans Affairs, Prescription for Change: The Guiding Principles and Kenneth W. Kizer, M.D., M.P.H/De mation for the Veterans Healthcare System, accessed March 1, 2016, Strategic Objectives Underlying the Transfor http://www.va.gov/healthpol icyplanning/rxweb.pdf. 798 Kicab Castaneda-Mendez/Quality Digest, Performance Me , accessed, March 1, 2016, asurement in Health Care t.com/magazine/1999/may/ar http://www.qualitydiges ent-health-care.html#. ticle/performance-measurem 799 Ibid. 800 Department of Veterans A ffairs, Undersecretary for He alth, accessed March 1, 2016, http://vaww. ush.va.gov/. 801 The MITRE Corporation, Independent Assessment of the Health Care Deli very Systems and Management Processes of the Department of Veterans Affairs, Volume 1: Integrated Report, v, accessed March 11, 2016, integrated_report.pdf. http://www.va.gov/opa/choice act/documents/assessments/ 239

254 C OMMISSION ON ARE F INAL R EPORT C Table F-6. VA Facility Site Visit Locations VISN Name VA Facility VISN VISN VA Hudson Valley Health 2 Care System (Montrose, NY) 2 VA Mid ‐ Atlantic Health Care Network Fredericksburg 6 ‐ based Outpatient Center, Community ‐ part of Hunter Holmes McGuire VA) VA (Fredericksburg, Center, Richmond, VA Medical VA 7 Network Ralph H. Johnson VA Medical Center (Charleston, NC) Southeast Wm. Jennings Bryan Dorn VA Medical Center (Columbia, SC) Health Care System VA Ann 10 Arbor Health care System (Ann VA Arbor, MI) John D. Dingell VA Center (Detroit, MI) Medical TX) 17 VA Heart of Texas Health Care System Dallas VA Medical Center (Dallas, 21 Pacific Network Southern Nevada Health Sierra care System (Las Vegas, NV) VA Northern California Health Care System (Mather, CA) VA Palo Alto Health Care System (Palo Alto, CA) 22 Desert Pacific Health Care Network Greater Los Angeles Health care System (Los Angeles, CA) CA) VA Diego Health care System (San Diego, San basic agenda as guidance, though they had The Commissioners were provided with a generic appropriate for the locations they visited. The the latitude to determine their own agendas as model agenda included the following activities: a welcome and overview of the VA health care facility; tour of the facility; veteran discussi on session (informal or formal); VHA employee session (e.g., informal or small group discussion); a di scussion with the facility leadership, and were provided the recommended questions listed below:  What does the medical center do well?  What unique resources can the medical center draw on?  What do others see as the strengths of the medical center? What could the medical center improve?   Where does the medical center have fewer resources than others?  What are others likely to see as weaknesses of medical center?  What opportunities are open to the medical center?  What trends could the medical center take advantage of?  How can the medical center turn it s strengths into opportunities?  What threats could harm the medical center?  What obstacles does the medical center face? What threats do the medical center’s weaknesses expose it to?  240

255 A PPENDIX F T HE ’ S P ROCESS C OMMISSION What is the impact of MyVA?  How do employees view working at VA compared to two or three years ago? If there is  a change, what is driving it?  In your view, what is the most important fa ctor affecting patient satisfaction with the care you provide?  perception of the quality of care provided In your view, has there been a change in the by the medical center? If so, what migh t be driving this different perception? they provided the data they gathered to Once the Commissioners completed their visits, Commission staff to be organized in a strengths-weaknesses-opportunities-threats (SWOT) analysis framework. A SWOT analysis is a simple but useful framework for analyzing the four factors as they are faced by an organization. It helps organizations develop strengths, minimize 802 threats, and take the greatest advantage of available opportunities. Findings VHA leadership and staff enthusiastically shared their time, insights, perspective, and data on organizational and operational pr ocesses with the Commissioners . The site visits provided insight and reinforced the findings of the Independent Assessment Report . Independent Assessment Report Confirming what the stated, the Commissioners found VHA facilities’ staff members exhibit a deep commitmen t to serving veterans, but that VHA’s health tient experiences, apply inconsistent business care facilities deliver strikingly different pa 803 asures of performance and efficiency. processes, and differ widely on key me Based on Commissioners’ observations of weaknesses, challe nges, and threats related to daily operations, VAMC staff members appear to be searching for suitable solutions. Anecdotal responses e following systemic problem areas at the provided to the Commissioners illuminated th VAMCs:  Care authorities: health care capabilities (i.e., purchased care)  Staffing: productivity (i.e., human resources) , health care capabilities, access standards, clinical workflow  Leadership: staffing, producti vity (i.e., human resources)  .e., patient-centered community care) Facilities: health care authorities (i organized into a SWOT analysis chart based Data from Commissioners’ observation notes were ility site visits. The purpose of this exercise on the common themes of the Commissioners’ fac was to gather information to inform the Commission’s recommendations and to confirm or 802 “SWOT Analysis,” Mind T ools, accessed March 15, 2016, https://www.mindtools.com/pa ges/article/newTMC_05.htm. 803 “Veterans Integrated Service Networks (VISN)”, Department of Veterans Affairs, VHA, accessed March 14, 2016 /guide/division.asp?dnum=1. http://www.va.gov/directory 241

256 C ARE R EPORT C F OMMISSION ON INAL dispute the findings of the Independent Assessment Report . The Commissioner site visit inputs are summarized in the table below. ssioner Site Visit Observations Table F-7. SWOT Analysis of Commi Weaknesses Strengths Opportunities Threats between Misalignment   HR Inefficient/ineffective medical  VA center Modernization IT VA of  policies customer care health workforce Congress’s Customer  service dedication for plans and service operational of staffing  High levels training/standards and VHA veterans vacancies Research national  and VHA  Strategic focus on strategic plans care health databases space; Lack  of clinical mission core Competing  stakeholders of configurations inefficient service –  Veterans funding flexibility  Local health interests care space clinical services connected Congress from Office of  Personnel programs and  for care VA to access Poor mission  vision and New outdated Management  with Partnerships veterans rural health care VHA for standards/policies medical schools and an of  Lack financial effective Process/systems  VHA  Insufficient training programs ‐ provide time to system real reengineering leadership development veterans process to payment Recruitment of  outside funding IT Insufficient  Purchased Choice and Care leader and candidates Programs shortages physician The  ‐ high of retention nation has around the  Lack of effective VHA VHA performing severely the care impacted leadership workforce leaders patients of Lack of  to capacity/access VHA in appointments  Insufficient federal health care government appropriation rules Conclusions ensure optimal delivery of veteran-centered, Fundamental transformation of VHA is needed to high-quality care. Essential to laying the path to excellence and strategic planning is a comprehensive understanding of the current state as well as the opportunities and threats facing the system. A robust connection between leaders in VHA Central Office and leaders in eeds of the veteran population served. the field is critical to meet the n As part of the strategic planning process, VA/VHA leadership should make recurring site visits quarters, and CBOCs to obtain current insight to VHA facilities, including VAMCs, VISN head of the following critical areas: health care tr ends, health care operations, facility management contracting, and other trends or issues and renovation/replacement, business processes and affecting VAMCs. VA/VHA leaders should use performance management tools and activities to ensure the strategic goals are being met in an effective and efficient manner. It is a constant challenge to continuously and reliably measure the pulse of the organization. Site visits promote a healthy culture of sharing and build ing an understanding of organizational mission. 242

257 APPENDIX G: VETERAN FEEDBACK In addition to the more than 4,000-page the Commission Independent Assessment Report, examined dozens of other reports, studies, and presentations as cited in the hundreds of footnotes dispersed throughout this Final Repo rt. Collectively, these many sources provide a wealth of information on the challenges VHA confronts in realizing a vision for veterans’ healthcare that leverages the strengths of VA an d capitalizes on the potential non-VA providers offer. A key source the Commission considered was the views of veterans themselves. Given the Commission’s brief tenure, it was not possible to conduct a survey representative of the views of millions of veterans receiving health care from VHA. Instead, the Commission encouraged veterans to offer feedback on their health ca re experiences and the work of the Commission through its website. Many veterans service organizations (VSOs) also provided views representing their members in open sessions wi th the Commission and in formal letters and position statements directly to the Commission. The feedback offered by veterans through the Commission’s web site covered a range of health care topics, such as whether and to what extent care should be privatized, how much choice veterans should have in deciding on their care , and their assessment of the quality of care a few who were also VA employees) are quite received. Not surprisingly, veterans (including passionate about their views on health care. For the most part, veterans’ feedback from the web privatize VHA, although a few did want more access to site expressed opposition to efforts to non-VA providers. The Choice Program was frequently criticized for long delays in ity criteria, and issues with how providers appointments, convoluted or misapplied eligibil the veteran should pay. When the quality of should be reimbursed for treatment and how much care was noted, on balance veterans praise d the care received from VHA, with a few disappointed, especially when ca re was outsourced to non-VA providers. Because the feedback was unstructured, veterans could offer any observations they found pertinent. The Disabled American Veterans (DAV) shared with the Commission a compendium of more than 4,000 verbatim comments on veterans’ health care experiences gathered from their members during April 2016. The DAV reviewed the comments and categorized 82 percent of 804 the comments as “overall positive experiences.” The Commission staff reviewed the comments from DAV, with findings consistent to DAV’s. 804 Comments from veterans about their experiences as user s of the VA health care system, printout provided to American Veterans, April 2016. Commission on Care by Disabled 243

258 C F INAL R EPORT OMMISSION ON C ARE VA Efforts to Gather Input on Veterans Views on Health Care Like most institutions that provide products and services to customers, VA/VHA solicits input from veterans on their health care needs and their views on specific services VA/VHA provides. Surveys, focus groups, and in-depth interviews are the more typical means for like most agencies, encourages veterans and gathering input from veterans. On occasion, VA, 805 others to submit comments on a particular aspect of VA services and benefits. The following sections describe the more typi cal methods employed by VA/VHA to gather input from veterans. VHA Survey of Veterans’ Health and Use of VHA Conducted by the assistant deputy undersecreta ry for policy and planning, the survey of veteran enrollees’ health and use of health care (Survey of Enrollees) is an annual survey of more than 40,000 veterans who are enrolled in VA’s health care system. The Survey of Enrollees was initially designed to give VHA the informatio n it needed to predict the demand for services in the future. The data are used to develop health care budgets and to assist VA with its annual enrollment decisions. Over the years, the data ha ve also been used to analyze policy decisions, provide insights into specific populations and their perspectives, and inform management decisions affecting delivery of care. In addition to collecting basic demographic information, the verage, use of health care inside and outside of VA, survey explores insurance co out VHA services, perceived health status, and pharmaceutical use, attitudes and perceptions ab 806 trends in smoking among veter ans enrolled in the VHA system. 807 Survey of Healthcare Experiences of Patients The Survey of Healthcare Experiences of Patients (SHEP) program was initiated in 2002 in an effort to create standardized survey instrume nts administered monthly to assess ambulatory and inpatient care. In an effort to standardize its survey instruments with other health care providers, SHEP now employs the Consumer A ssessment of Healthcare Providers and Systems (CAHPS) survey methodology for VHA’s primar y care and inpatient medical and surgical services. These surveys are supported in the pu blic domain by the CAHPS Consortium, Agency for Healthcare Research and Quality, Centers fo r Medicare and Medicaid Services, and National Committee for Quality Assurance. Although SHEP deployed the standardized CAHPS surveys, 805 “Quality of Care Feedback Fo rm,” Department of Veterans Affairs, accessed June 20, 2016, http://www.va.gov/QUALITYOFCARE VA web site provides a Quality of Care /apps/contact.asp. As an example, the feedback page for veterans an d others to enter comments on the care a veteran received. 806 Westat, 2015 Survey of Veteran En rollees’ Health and Us e of Health Care, ac cessed June 6, 2016, http://www.va.gov/healthpolicyplanning/SoE 2015/2015_VHA_SoE_Full_Find ings_Report.pdf. 807 For more details on SHEP and VHA’s re cent initiatives to expand the scope of the program, see “Health Services Research & Development, Commentary: Listening to Veterans about Access to Care,” Steven M. Wright, VHA Office of Analytics and Business Intelligence , U.S. Department of Veterans Affairs, ac cessed June 20, 2016, h.va.gov/publications/f ?ForumMenu=nov15-1. orum/nov15/default.cfm http://www.hsrd.researc 244

259 A G PPENDIX V EEDBACK F ETERAN the access questions were limited and did not evaluate the full scope of services used by veterans. VHA intends to expand the SHEP program with additional surveys in 2016 and beyond. These s specialty care services and experience with surveys will focus on satisfaction with variou Access, Choice, and Accountability Act of 2014. community care available through the Veterans VHA has also launched a survey that focuses on new veteran enrollments and their experience with first clinic appointments. Veteran Insights Panel VHA also established a Veteran Insights Panel, comprising more than 3,200 veterans that are 808 representative of users of VA health care. VHA interacts with the panel through email notification and a special access website (mobile device enabled). This approach provides VHA discussions, including real time feedback via an opportunity to engage panel members in direct live chat, about important themes and issues, an d survey development and testing. The panel can be engaged collaboratively with operational program offices and researchers to prompt direct discussions with our veterans. Voices of Veterans: On-going Research Initiated in the spring of 2014, the VA Center fo r Innovation (VACI) sponsors an on-going effort 809 to employ human-centered design (HCD) concepts in a pilot to explore veterans’ experience 810 with VA through the eyes of 40 veterans across a range of demographics and locations. The pilot had two goals: To test the usefulness and application of an HCD methodology within the context of VA.   To better understand veterans’ experiences inte racting with VA, identify pain points in explore opportunities to transform these the present day service delivery model, and interactions into a more veteran-centered experience. Developing Veteran Personas fy high-level trends in ways veterans seek out As a part of this pilot, VACI set out to identi assistance, use technology, take advantage of se rvices, and react to challenging interactions. four profiles, or personas, that represent the Based on these patterns, VACI created a set of 808 Ibid. 809 Human-centered design (HCD) is a di scipline in which the needs, behaviors and experiences of an organization’s sign processes. It is a prac uct, service, or technology de tice used heavily across the customers (or users) drive prod private sector to build a strong understanding of users, generate ideas fo r new products and services, test concepts with liver easy-to-use products and positive customer experiences. real people, and ultimately de HCD is a multi-disciplinary methodology which draws from the practi ces of ethnography, cognitive psycholog y, interaction and user experience design, service design, and design thinking. It is closely tied to “user-centered design,” which applies parallel processes to technology projects, and “service design” whic h address the service specific experiences. 810 U.S. Department of Veterans Affairs, Center for Innovation, Toward a Veteran-Centered VA: Piloting Tools of Human- Centered Design for America’s Vets, Findings Report, July 2014, accessed June 20, 2016, d_VA_JULY2014.pdf. http://www.innovation.va.gov/docs/Towar d_A_Veteran_Centere 245

260 C F EPORT ARE C INAL OMMISSION ON R kinds of users within the set of 40 veterans engaged in the pilot (see Table G-1). Each persona is an archetype based on commonalities observed among veterans who exhibited similar es. They are not categorized by positive or behaviors and approaches to accessing VA servic and needs. These personas were designed to negative experiences, but by shared expectations rving users who are seeking not just different help VHA begin to understand that it is se services, but also varied degrees of contact, suppo rt, information, and so forth. For this exercise, , channels, frequency, stated and observed VACI assessed veterans’ modes of communication needs, reactions to service experiences, milit ary service, and analyzed observed behavior and service experiences. 811 Table G-1. Veteran Profiles Developed by the VA Center for Innovation LIFER THE THE TRANSACTIONAL services and plans to continue doing Frequently use VA on Joined the military largely based the promise of the VA to play a supporting, community ‐ building so. Look to to life. in provide would Plan it use VA opportunities frustrated get but benefits, VA for Grateful life. in role be to Tend service. ‐ post track” on life “get in to services when problems arise which break up the continuity of the younger generation of veterans (OEF, OIF, OND). doctors change when too frequently and care—like other see community, veteran the in engaged Often cannot they when to transportation get helping veterans allies, and as advocates in folks facilities. VA and understand use their benefits. VA of highly speak to try Generally, to wants and share Will veterans. fellow for better work it making to contribute not is VA like feels promised. as helping if frustrations Expectations Expectations understand to time the takes and cares VA That  its VA That help and promises  on deliver will veteran’s needs story and veteran earned benefits the access rise won’t  That cost of services VA VA That  families veterans to available benefits has That veteran  someone reach can headache, and veterans will  That it will be a have at VA anytime help the with their own on out of it figure to Needs network  Does not want to tell over, and story over Needs using VA for so long especially after  Accurate expectations know what is going on with services and  Wants to times, family for especially  Financial support at especially benefits  To community feel a part of a health care nurturing patient, Likes  811 Ibid. 246

261 A PPENDIX G V ETERAN F EEDBACK THE JUST IN CASE ‐ INFREQUENT THE ‐ of Proud service, but does not need VA and plans on VA used Have VA. about much very think not Does it only as a using backup. Mature and organized by benefits between by go will years often yet lifetime, in papers good a have and VA with has all order nature, in might these because This be those interactions. for Grateful idea of services for which they are eligible. live VA access to difficult is it where places veterans in VA benefits available, but the see working with are services, because veterans financially comfortable, a as seems like too much because hassle. Tend to or it and lean on VA as a time for will tradeoff likely only or a few prefer interaction—a short call phone quick backup plan. clicks on website. a Expectations Expectations never will need That  VA benefits likely is VA That  any slow—like bureaucracy  That VA will be there if needed injured “other, for VA That  is it need who veterans benefits there That are  available to family more” of private  benefits are That higher quality and  That someone will tell veterans they if and when greater ease something are eligible for Needs Needs Peace  of mind be To  navigate processes quickly to able  be assured that all To documents are in order  To be reminded every few years of how VA might get To easily in touch with one person about one  to help able be question Vantage Point: VA’s Official Blog In addition to surveys, focus gr oups, and town-hall sessions, VA in stituted a blog on its website and invites veterans and others interested in vete rans matters to submit guest posts of potential interest to others in the community. Like most blogs, the content offered is vetted by the VA. Since 2010, Vantage Point includes hundreds of cont ributors with articles on various health care 812 topics. Veterans’ Views Gathered by VSOs Like VHA, the VSOs solicit input from their memb ership and other stakeholders on a variety of topics and issues relevant to veterans. Occasio nally surveys and polls are undertaken, but most VSO efforts to gather input take place at th e grassroots level during town halls, chapter meetings and other gatherings. While these venues often suffer from self-selection bias and non- or under-represented participant samples, these are nevertheless an important source of timely information on topics of interest and concern to veterans. What follows is a selection of VSO efforts to gather input on issues important to veterans. 812 “Vantage Point: Official Blog of the U.S. Department of Veterans Affairs,” Department of Veterans Affairs, accessed ogs.va.gov/VAntage/. June 20, 2016, http://www.bl 247

262 C F INAL R EPORT OMMISSION ON C ARE The DAV Veterans Pulse Survey (2015) In mid-2015 the DAV surveyed a nationally represen tative sample of veterans to solicit their 813 The survey includes questions on various aspects of views on issues important to veterans. veterans’ healthcare. The survey consists of a national probability samp le of 1,701 veterans intended to represent the veteran population in the United States. Oversampling occurred in d veterans age 18-40 to allow for more precision certain subgroups, such as female veterans an in the response estimates for these subgroups. Veterans of Foreign Wars Our Care Veterans Survey (2015) In the fall of 2015, the Veterans of Foreign Wars of the U.S. (VFW) published a report on its 814 veterans 2015 Health Care Options, Preferences and Expectations Survey. In response to the intensified debate over reform of veterans’ healthcare, the VFW launched a survey in the summer of 2015 designed to evaluate veterans’ options, expectations, and preferences when The survey did not just focus on VA se rvices, but sought to paint a picture seeking health care. of how the veterans’ community at large interacts within the American health care infrastructure, and the choices they make in toda y’s health care marketplace. According to the rvey, with 92 percent eligible for care and VFW report, 1,847 veterans responded to the su 815 g that they utilize VA health care. 83 percent of those eligible reportin Respondents’ average age was 65, with about two-thirds Vietnam War veterans. VFW Survey of Women Veterans (2016) ans face when accessing their earned veterans’ In an effort to identify barriers women veter a survey of women veterans that will guide benefits and services, the VFW has commissioned 816 the VFW’s policy priority goals for women veterans. Though the survey data collection phase is completed, results have not been published pr ior to release of the Commission’s Final Report. 813 Disabled American Veterans (DAV), The DAV Veterans Pulse Survey: A landmark study of the attitudes and perceptions of Report-Final.pdf. The America’s veterans, accessed June 20, 2016, https://www.dav.org/wp-c ontent/uploads/DAV-Pulse- ® survey survey was conducted on behalf of DAV by GfK K nowledge Networks, Inc. using their KnowledgePanel participants in November 2015. 814 Veterans of Foreign Wars, Our Care: A Report on Veterans’ Options, Pr eferences and Expectatio ns in Health Care, September 22, 2015, accessed June 20, 2016, Files/VFW.org/VF http://www.vfw.org/uploaded W_in_DC/VFWOurCa reReport2015.pdf. 815 Ibid., 4. 816 “VFW Survey of Women Veterans: Help Hold the VA Accountable,” Veterans of Foreign Wars, December 22, 2015, 015-Articles/VFW-Survey-of-Women- vfw.org/News-and-Events/Articles/2 accessed June 20, 2016, http://www. Veterans/. 248

263 A G PPENDIX V F ETERAN EEDBACK The American Legion Survey of Patient Health Care Experiences (2014) This survey of 3,116 opt-in, self-reported veterans focuses on satisfaction and levels of perceived /traumatic brain injury (PTSD/TBI) programs, benefits with VA’s posttraumatic stress disorder 817 including alternative and complementary treatments. Survey questions include veteran status; gender ; era of service; number of times deployed; diagnosis of TBI and/or PTSD; availability of appo intments; time and distance to care facilities; treatment type (therapy, medication and comple mentary and alternative medicine); reported symptoms; efficacy of treatment; and side effects. The American Legion Women Veterans Survey Report (2011) This survey of 3,012 women veterans, and the resulting report, was prepared by ProSidian Consulting, LLC on behalf of The American Legion . The survey assessed the perceptions of and and other benefits delivered to women veterans satisfaction with women veterans’ health care ey sought to determine the factors driving through the VA system. Additionally, the surv as opposed to other private or public health women veterans’ decision to use the VA system 818 care systems. Iraq and Afghanistan Veterans of America Member Survey (2015) During the first half of 2015, 1,501 Iraq and Afghanistan Veterans of America members completed a wide-ranging on-line survey coveri ng such issues as employment, education, GI Bill usage, health (including mental health), VA utilization, VA benefits, reintegration and more. The survey was composed of approximat ely 300 questions, with respondents answering only questions relevant to their experiences. He alth care topics included percent enrollment in and reliance on VA care; health insurance coverage by type; and experience rating for VA care. 819 Choice Program was also covered separately. Usage percent and experiencing rating for the VA ® The 2015 Wounded Warrior Project Alumni Survey This web-enabled, opt-in survey of 23,200 Wo unded Warrior Project (WWP) members measures a series of outcome domains within the fo llowing general topics about WWP Alumni: background information (military experiences an d demographic data), physical and mental 820 This WWP membership survey has been conducted well-being, and economic empowerment. s, Westat conducts the survey and population- annually since 2010. As it has done in prior year 817 “Legion survey to measure effectiven ess of PTSD/TBI treatment,” The Amer ican Legion, July 29, 2015, accessed June 20, 2016, http://www.le gion.org/pressrelease /229354/legion-survey-measure-effec tiveness-ptsdtbi-treatment. 818 ProSidian Consulting, LLC, March 9, 2011, acce ssed June 20, 2016, The American Legion Women Veterans Survey Report, http://www.legion.org/docume nts/legion/pdf/womens_veter ans_survey_report.pdf. 819 “Media Advisory: IAVA to Release Gr oundbreaking Veterans Survey,” Iraq and Afghanistan Veterans of America (IAVA), May 23, 2016, acces sed June 20, 2016, http://iav a.org/press-release/media- advisory-iava-to-release- groundbreaking-veterans-survey-2/. 820 Westat, 2015 Wounded Warrior Project Survey, Report of Findings, August 14, 2015, ac cessed June 20, 2016, i_survey_full_report.pdf. https://www.woundedwarriorproj ect.org/media/2118/2015_wwp_alumn 249

264 C F INAL R EPORT C OMMISSION ON ARE weights the reported results, to include adjustments for potential non-response bias, to be representative of the WWP member ship base (approximately 59,000). Right to Care: Voices of Swords to Plowshares’ Veteran Community (2015) The Swords to Plowshares, Institute for Vete ran Policy interviewed in-person or by phone 821 22 veterans. d in advance, Swords to Plowshares Although the topics were establishe as individual “conversations” with a preselected group of characterized these interviews veterans. The veterans were chosen to represen t a cross-section of combat eras and VHA usage levels. The topics covered included: navigatin g VA care, reliance on VA and non-VA care, comprehensiveness of care, and rating quality of care. The study includes extensive verbatim comments from veterans on these topics. Comments from Veterans About Their Experiences as Users of VHA (DAV, 2016) During April 2016, DAV reached out to veterans around the United States and asked them to share their experiences with the VA health care system. As a result, DAV received (as of April 2016) more than 4,000 responses from veterans s haring their own stories about the care they 822 The Commission’s review of the material showed that a majority of the received from VHA. veterans’ comments were positive in nature. DA V’s own analysis concluded that 82 percent of the comments could be categorized as “overall positive experiences.” Other Surveys on Veterans Issues In addition to efforts by VA and VSOs to gather feedback from veterans on their health care, other organizations have also addresse d veterans’ health care issues. Concerned Veterans for America Survey of Veterans’ Healthcare (November, 2014) The Concerned Veterans for America commission ed The Tarrance Group to conduct a national 823 survey of 1,000 veterans during November 2014. This survey used a random, demographically representative sample of veter ans. Four survey items addressed health care, including: knowledge of any problems at VA; need for reform of veterans’ healthcare; importance of more choice (or options) in heal th care for veterans; and importance of best possible veterans care, even if outside VA. 821 Megan Zottarelli, RIGHT to CARE: Voices of Swords to Plowshares’ Veteran Community, Swords to Plowshares, Institute for Veterans Policy, April 2016. 822 Comments from veterans about their experiences as user s of the VA health care system, printout provided to Commission on Care by Disabled American Veterans, April 2016. 823 Concerned Veterans for America, Fixing Veterans Health Care, A Bipartisan Policy Taskforce, accessed June 20, 2016, http://cv4a.org/wp-cont eterans-Healthcare.pdf. ent/uploads/2016/01/Fixing-V 250

265 PPENDIX A G V ETERAN EEDBACK F Vet Voice Foundation Survey of Veterans (October, 2015) Chesapeake Beach Consulting and Lake Research Partners conducted 800 phone (landline and cell) interviews of veterans during October 2015. The results were population weighted by demographics. Topics included rating the job VA hospitals are doing in their area and the extent they favor/oppose privatizing some of VA’s health care. 251

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267 APPENDIX H: ADDITIONAL RESOURCES The VHA health care system is immense and comp lex. This report provides background for the areas for which the Commission has made recommendations, yet this information is but a re. The resources below may serve as a starting glimpse at the intricacies of veterans’ health ca point for those who would like to develop a deeper understanding of the topic than the Commission could address in this report. Independent Assessment Report The MITRE Corporation, Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Vete rans Affairs, Volume 1: Integrated Report, http://www.va.gov/opa/choiceact/docume nts/assessments/integrated_report.pdf. RAND Corporation, Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment A (Demographics), http://www.va.gov/opa/choiceact/document s/assessments/Assessment_A_Demographics.p df. RAND Corporation, Independent Assessment of the Health Care Delivery Systems and Management Processes of the Departme nt of Veterans Affairs, Assessment B (Health Care Capabilities), http://www.va.gov/opa/choiceact/document s/assessments/assessment_b_health_care_capa bilities.pdf. RAND Corporation, Care Delivery Systems and Management Independent Assessment of the Health Processes of the Department of Veterans Affairs, Assessment C (Care Authorities), http://www.va.gov/opa/choiceact/document s/assessments/Assessment_C_Care_Authoritie s.pdf. Institute of Medicine of the National Academies, Transforming Health Care Scheduling and Access: Getting to Now, http://www.va.gov/opa/choiceact/docume nts/assessments/Assessment_D_Access_Standar ds.pdf. Independent Assessment of the Health Care Delivery Systems and McKinsey & Company, Inc., Management Processes of the Department of Veterans Affairs, Assessment E (Workflow—Scheduling), http://www.va.gov/opa/choiceact/document s/assessments/Assessment_E_Workflow_Sched uling.pdf. McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment F (Workflow—Clinical), http://www.va.gov/opa/choiceact/document s/assessments/Assessment_F_Workflow_Clinic al.pdf. 253

268 C C F INAL R EPORT OMMISSION ON ARE Grant Thornton, Care Delivery Systems and Management Independent Assessment of the Health Processes of the Depart ment of Veterans Affairs, Assessment G (Staffing/Productivity/Time Allocation), http://www.va.gov/opa/choiceact/document s/assessments/Assessment_G_Staffing_Product ivity.pdf. The MITRE Corporation, Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment H (Health Information Technology), http://www.va.gov/opa/choiceact/document s/assessments/Assessment_H_Health_Informat ion_Technology.pdf. Grant Thornton, Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment I (Business Processes), http://www.va.gov/opa/choiceact/document s/assessments/Assessment_I_Business_Process es.pdf McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs, Assessment J (Supplies), nts/assessments/Assessment_J_Supplies.pdf. http://www.va.gov/opa/choiceact/docume McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and partment of Veterans Affai rs, Assessment K (Facilities), Management Processes of the De http://www.va.gov/opa/choiceact/document s/assessments/Assessment_K_Facilities.pdf. McKinsey & Company, Inc., Independent Assessment of the Health Care Delivery Systems and terans Affairs, Assessment L (Leadership), Management Processes of the Department of Ve s/assessments/Assessment_L_Leadership.pdf. http://www.va.gov/opa/choiceact/document Veteran Health Competency Resources American Nurses Foundation The American Nurses Foundation, the philanthrop ic arm of the American Nurses Association, is launching an innovative web-based PTSD Toolki t for registered nurses. The toolkit provides easy to access information and simulation base d on gaming techniques on how to identify, assess and refer veterans suffering from PTSD. www.nurseptsdtoolkit.org American Osteopathic Association The American Osteopathic Association (AOA) re presents osteopathic physicians, many of whom are in primary care practice, and essentia lly all of whom treat America’s veterans and their families. The AOA is ra ising awareness in the oste opathic community about the importance of having a comprehensive understandin g of the unique physical and mental health care needs of our service members, veterans, and their families. The AOA is committed to ensuring that medical students, physicians, and other health care providers understand that an ntal health condition may be linked to his or her military individual’s physical and/or me experience. www.osteopathic.org/inside-aoa/public-po licy/Pages/federal-initiatives.aspx 254

269 A H PPENDIX A R DDITIONAL ESOURCES Center for Deployment Psychology iformed Services University of the Health The Center for Deployment Psychology of the Un ychology offer a wide variety of on-line courses Sciences, Department of Medical and Clinical Ps and other resources to help uniformed clinic al providers, VHA providers, and community clinicians provide care consistent with the n eeds and experience of military service members, veterans and their families. http://deploymentpsych.org/online-courses http://deploymentpsych.org/military-culture-course-modules Rural Clergy Training Program The Rural Clergy Training Program, an initiative of the VHA National Chaplain Center and the Office of Rural Health, offers training and info rmation to clergy providing pastoral services to veterans and their families. http://www.ruralhealth.va.gov/docs/ruralcl ergytraining/The_Clergy_Connection_December 2015.pdf Swords to Plowshares Combat to Community Training Swords to Plowshares is nationally recognized for its expertise in providing comprehensive services and promoting and protecting the ri ghts of veterans. Swords to Plowshares’ Combat to ® Community ural competency curricula developed by its training is a series of accredited cult Institute for Veteran Policy team with the purp ose of educating the community to address the reintegration challenges veterans face and the unique skill sets they acquire in service. The training was developed for law enforcement, first responder, mental health, and service professionals to teach:  Commonly shared attitudes, values, goals, and practice that often c haracterize service in the military Recruitment and retention strategies for veteran employment   How deployment, combat experience, service related injuries, and disability can impact veterans  How veteran or military family status can inform interactions and services  Potential resources to refer veterans and families to for supportive services The training incorporates knowledge developed by experts in the fields of veteran culture and direct services with practical tools and reso urces to increase understanding and improve interactions with veterans. https://www.swords-to-plowshares.org/combat-to-community 255

270 C C F INAL R EPORT OMMISSION ON ARE VA Military Culture Training Courses on TMS The resources below are available to VA employees and contractors. Versions of these courses ers through an alternative to TMS that allows should be made available to community provid access the training. outside providers to  Military Culture Training for Health Care Professionals – Organization and Roles (VA 19332) The first module of this online course prov ides an overview of the differences between y culture and describes the characteristics of the explicit and implicit features of militar implicit military culture. The next module identifies four sources of information about implicit military culture and describes six de fining characteristics of warrior ethos. The learner is provided information about the infl uence of military guiding ideals and values on the lives of service members and veter ans. The final module offers an overview regarding the connotations of implicit militar y culture on the health care professional.  Military Culture Training for Health Care Professionals: Self-Awareness and Military Ethos (VA 19333) This online course, sponsored by the Departme nt of Veterans Affairs and Department of Defense, helps health care pr ofessionals understand the role that military culture plays is comprised of four modules: 1) Self- in the lives of those they serve. The course Assessment and Introduction to Military Et hos, 2) Military Organization and Roles, 3) Stressors and Their Impact, and 4) Treatment Resources and Tools.  Military Culture Training for Health Ca re Professionals: Stressors & Resources (VA 19334) ion of how stress can be either helpful or This online course offers the learner an explanat harmful depending on the nature of the pr ovoking stressor and the availability of ational deployment cycles is presented in resources. The four phases of modern oper les describe the charac teristic operational great detail in module 3. The next two modu stressors and the spectrum of operational stress states and outcomes experienced by service members and their families duri ng each deployment cycle phase.  Military Culture Training for Health Care Professionals: Treatment Resources, Prevention & Treatment (VA 19335) This online course in the military culture curr iculum outlines the military culture impact nal’s role and explains the range of DoD and on patient care and the health care professio VA psychological health services. The course also provides information on interpreting military culture knowledge into patient assessm ent and treatment. Finally, the learner is exposed to the military culture implications of VA/DoD clinical practice guidelines relevant to the care of service members and veterans and the strategies for identifying current military culture relevant patient an d health care professional resources.  Military Cultural Awareness (NFED 1341520) This military cultural awareness online course provides a common foundation for all VA employees. This course offers an overview of common military culture and courtesies, roles and ranks within the military, diffe rences between the branches of the armed services, some of the conflicts in which ve terans have served, and why this information 256

271 A H PPENDIX A R DDITIONAL ESOURCES is important in helping VA employees bette r serve the needs of veterans and their ants will understand the perspective of the families. After taking this course, particip areness of the military experience, and the veterans they serve by having a greater aw customs and courtesies that are co mmon in the military environment.  PTSD 101: Understanding Military Culture When Treating PTSD (VA 9494) This online web-based course is part of the PTSD 101 education series which is presented by subject-matter experts to incr ease provider knowledge related to the assessment and treatment issues of PTSD. Ea ch course specifically addresses trauma events, treatments, or special population issues, not normally addressed in general therapy protocols. This course is specifica lly designed to familiarize clinicians with military culture, terminology, demographics, and stressors. It also provides an overview of programs offered by DoD for managing combat or operational stress, as well as implications for assessment and treatment.  Why Military Culture Matters (Mobile Accessible) (VA 16353) This independent online study activity is de signed to help the learner better connect military experiences influence their health. with veterans and understand how veterans’ This course is formatted to be accessible using a VA networked mobile device. Additional Sources Hogan, Rodney A. Hayward, Paul Shekelle, Asch, Steven M., Elizabeth A. McGlynn, Mary M. Lisa Rubenstein, Joan Keesey, John Adams, and Eve A. Kerr. “Comparison of Quality of Care for Patients in the Veterans Health Admini stration and Patients in a National Sample.” Annals of Internal Medicine , 141, no. 12 (2004): 938–945. http://doi.org/10.7326/0003-4819- 141-12-200412210-00010. onyssios Tsilimingras, Pierre N. Tariot, Joe Berlowitz, Dan R., Amy K. Rosen, Fei Wang, Di l. “Purchasing or Providing Nursing Home Engelhardt, Boris Kader, and Dana B. Mukame Care: Can Quality of Care Data Provide Guidance.” Journal of the American Geriatrics Society , 53, no. 4 (2005): 603–608. http://doi.org/10.1111/j.1532-5415.2005.53207.x. Bohnert, Kipling M., Paul N. Pfeiffer, Benj amin R. Szymanski, and John F. McCarthy. “Continuation of Care Following an Initial Primary Care Visit with a Mental Health Diagnosis: Differences by Receipt of VH A Primary Care-Mental Health Integration Services.” General Hospital Psychiatry , 35, no. 1 (2013): 66–70. http://doi.org/10.1016/j.genhosppsych.2012.09.002. Borzecki, Ann M., Cindy L. Chri stiansen, Susan Loveland, Priscilla Chew, and Amy K. Rosen. “Trends in the Inpatient Quality Indicato rs: the Veterans Health Administration Experience.” Medical Care , 48, no. 8 (2010): 694–702. http://doi.org/10.1097/MLR.0b013e3181e419e3. Chi, Ru-Chien, Gayle E. Reiber, and Kathl een M. Neuzil. “Influenza and Pneumococcal the Behavioral Risk Factor Surveillance Vaccination in Older Veterans: Results from 257

272 C C F INAL R EPORT OMMISSION ON ARE Journal of the American Geriatrics Society , 54, no. 2 (2006): 217–223. System.” http://doi.org/10.1111/j.1532-5415.2005.00577.x. De Luca, Susan M., John R. Blosnich, Elizabeth A. W. Hentschel, Erika King, and Sally Amen. “Mental Health Care Utilization: How Race, Et hnicity and Veteran Status are Associated , 52, no. 2 (2016): 174–179. with Seeking Help.” Community Mental Health Journal http://doi.org/10.1007/s10597-015-9964-3. Hoffmire, Claire A., Janet E. Kemp, and Robert M. Bossarte. “Changes in Suicide Mortality for Veterans and Nonveterans by Gender and History of VHA Service Use, 2000-2010.” Psychiatric Services , 66, no. 9 (2015): 959–965. http://doi.org/10.1176/appi.ps.201400031. Jha, Ashish K., Jonathan B. Perlin, Kenneth W. Kizer, and R. Adams Dudley. “Effect of the Transformation of the Veterans Affairs Health Care System on the Quality of Care.” New England Journal of Medicine , 348 (2003): 2218–2227. http://doi.org/ 10.1056/NEJMsa021899. Jha, Ashish K., Steven M. Wright, and Jonathan B. Perlin. “Performance Measures, Vaccinations, and Pneumonia Rates Among High-Risk Patients in Veterans Administration Health Care.” , 97, no. 12, 2167–2172. American Journal of Public Health http://doi.org/10.2105/AJPH.2006.099440. Trockel, Darby Cunning, Antonette M. Zeiss, Karlin, Bradley. E., Gregory K. Brown, Mickey and C. Barr Taylor. “National Disseminatio n of Cognitive Behavioral Therapy for Depression in the Department of Veterans Affairs Health Care System: Therapist and Patient-Level Outcomes.” Journal of Consulting and Clinical Psychology , 80, no. 5 (2012): 707– 718. http://doi.org/10.1037/a0029328 Karlin, Bradley E., Josef I. Ruzek, Kathleen M. Chard, Afsoon Eftekhari, Candice M. Monson, Elizabeth A. Hembree, Patricia A. Resick, and Edna B. Foa. “Dissemination of Evidence- Based Psychological Treatments for Posttrauma tic Stress Disorder in the Veterans Health Administration.” Journal of Traumatic Stress , 23, no. 6 (2010): 663–673. http://doi.org/10.1002/jts.20588. Keating, Nancy L., Mary Beth Landrum, Elizabeth B. Lamont, Samuel R. Bozeman, Steven H. Krasnow, Lawrence N. Shulman, Jennifer R. Br own, Craig C. Earle, William K. Oh, Michael re for Older Patients with Cancer in the Rabin, and Barbara J. McNeil. “Quality of Ca Veterans Health Administration Versus the Private Sector: A Cohort Study.” Annals of , 154, no. 11 (2011): 727–736. http://doi.org/10.7326/0003-4819-154-11- Internal Medicine 201106070-00004. Kerr, Eve A., Robert B. Gerzoff, Sarah L. Krein, Joseph V. Selby, John D. Piette, J. David Curb, William H. Herman, David G. Marrero, K. M. Venkat Narayan, Monika M. Safford, Theodore Thompson, and Carol M. Mangione. “Diabetes Care Quality in the Veterans Annals of rcial Managed Care: The TRIAD Study.” Affairs Health Care System and Comme , 141, no. 4 (2004): 272–281. http://doi.org/ 10.7326/0003-4819-141-4- Internal Medicine 200408170-00007. 258

273 A H PPENDIX A R DDITIONAL ESOURCES Kilbourne, Amy M., Rosalinda V. Ignacio, Hy ungjin Myra Kim, and Frederic C. Blow. rious Mental Illness Dying Younger?” Psychiatric “Datapoints: Are VA Patients with Se , 60, no. 5 (2015): 589. http://doi.org/10.1176/appi.ps.60.5.589. Services Krein, Sarah L., Timothy P. Hofer, Christin e P. Kowalski, Russell N. Olmsted, Carol A. Kauffman, Jane H. Forman, Jane Banaszak-Holl, and Sanjay Saint. “Use of Central Venous Catheter-Related Bloodstream Infection Pr evention Practices by US Hospitals.” Mayo Clinic Proceedings , 82, no. 6 (2011): 672–678. http://doi.org/10.4065/82.6.672. Parikh-Patel, Arti, Cyllene R. Morris, Robert Mart insen, and Kenneth W. Kizer, “Disparities in Stage at Diagnosis, Survival, and Quality of C ancer Care in California by Source of Health Insurance.” California Cancer Reporting and Epidemiolo gic Surveillance Program, Institute for Population Health Improvement, University of California Davis , October, 2015. http://escholarship.org/uc/item/8xc078vj. Petersen, Laura A., Sharon-Lise T. Normand, Jenn ifer Daley, and Barbara J. McNeil. “Outcome of Myocardial Infarction in Veterans Health Administration Patients as Compared with Medicare Patients.” New England Journal of Medicine , 343, no. 26 (2000): 1934–1941. http://doi.org/10.1056/NEJM200012283432606. an L. Leape, Barbara J. McNeil. “Comparison Petersen, Laura A., Sharon-Lise T. Normand, Luci of Use of Medications After Acute Myocardi al Infarction in the Veterans Health Circulation Administration and Medicare.” , 104, no. 24 (2001): 2898–2904. http://doi.org/10.1161/hc4901.100524. Rehman, Shakaib U., Florence N. Hutchison, Katharine Hendrix, Eni C. Okonofua, Brent M. Egan. “Ethnic Differences in Blood Pressure Co ntrol Among Men at Veterans Affairs Clinics Archives of Internal Medicine and Other Health Care Sites.” , 165, no. 9 (2005): 1041–1047. http://doi.org/10.1001/archinte.165.9.1041. Reiber, Gayle E., Thomas D. Koepsell, Charles Maynard, Linda B. Haas, and Edward J. Boyko. “Diabetes in Nonveterans, Veterans, and Vete rans Receiving Department of Veterans Affairs Health Care.” Diabetes Care , 27, Suppl. 2 (2004): B3–B9. http://dx.doi.org/10.2337/diacare.27.suppl_2.B3. Ross, Joseph S., Salomeh Keyhani, Patricia S. Keenan, Susannah M. Bernheim, Joan D. Penrod, M. Krumholz, and Albert L. Siu. “Use of Kenneth S. Boockvar, Alex D. Federman, Harlan Recommended Ambulatory Care Services: Is th e Veterans Affairs Quality Gap Narrowing?” Archives of Internal Medicine , 168, no. 9 (2008): 950–958. http://doi.org/10.1001/archinte.168.9.950. Selim, Alfredo J., Dan Berlowitz, Lewis E. Kazis, William Rogers, Steven M. Wright, Shirley X. Qian, James A. Rothendler, Avron Spiro III, Dona ld Miller, Bernardo J. Selim, and Benjamin G. Fincke. “Comparison of Health Outcomes for Male Seniors in the Veterans Health Administration and Medicare Advantage Plans.” Health Services Research , 45, no. 2 (2009): 376–396. http://doi.org/10.1111/j.1475-6773.2009.01068.x. Selim, Alfredo J., Lewis E. Kazis, William Roge rs, Shirley Qian, James A. Rothendler, Austin rdon, Donald Miller, Avron Spiro III, Bernardo Lee, Xinua S. Ren, Samuel C. Haffer, Russ Ma 259

274 C F INAL R EPORT ARE OMMISSION ON C J. Selim, and Benjamin G. Fincke. “Risk-Adju sted Mortality as an Indicator of Outcomes: Comparison of the Medicare Advantage Program with the Veterans’ Health , 44, no. 4 (2006): 359–365. Medical Care Administration.” http://doi.org/10.1097/01.mlr.0000204119.27597.f1. Trivedi, Amal N., and Regina C. Grebla. “Quality and Equity of Care in the Veterans Affairs Medical Care Health-Care System and in Medicare Advantage Health Plans.” , 49, no. 6 (2011): 560–568. http://doi.org/10.1097/MLR.0b013e31820fb0f6. Trivedi, Amal N., Sierra Matula, Isomi Miake-Lye , Peter A. Glassman, Paul Shekelle, and Steven Asch. “Systematic Review: Comparison of the Qu ality of Medical Care in Veterans Affairs , 49, no. 1 (2011): 76–88. http://doi.org/ Medical Care and Non-Veterans Affairs Settings.” 10.1097/MLR.0b013e3181f53575. ylor, Gregory K. Brown, and Rachel Manber. Trockel, Mickey, Bradley E. Karlin, C. Barr Ta “Effects of Cognitive Behavioral Therapy for Inso mnia on Suicidal Ideation in Veterans.” , 38, no. 2 (2015): 259–265. http://doi.org/10.5665/sleep.4410. SLEEP Watkins, Katherine E., Brad Smith, Ayse Akinci gil, Melony E. Sorbero, Susan Paddock, Abigail Woodroffe, Cecilia Huang, Stephen Crystal, and Harold Alan Pincus. “The Quality of the Department of Veterans Affairs and in Medication Treatment for Mental Disorders in Psychiatric Services, 67, no. 4 (2016): Private-Sector Plans.” http://doi.org/10.1176/appi.ps.201400537. Weeks, W. B., A. N. West, A. K. Rosen, and J. P. Bagian. “Comparing Measures of Patient Safety for Inpatient Care Provided to Veterans With in and Outside the VA System in New York.” Quality & Safety in Health Care , 17, no. 1 (2007): 58–64. http://doi.org/10.1136/qshc.2006.020735. Wright, Steven M., Laura A. Petersen, Rebecca P. Lamkin, and Jennifer Daley. “Increasing Use , 37, no. 6 Medical Care of Medicare Services by Veterans with Acute Myocardi al Infarction.” (1999): 529–537. 260

275 APPENDIX I: ENABLING DOCUMENTS Veterans Access, Choice, and Accountability Act of 2014 — HEALTH CARE TITLE II ADMINISTRATIVE MATTERS SEC. 201. INDEPENDENT ASSESSMENT OF THE HEALTH CARE DELIVERY SYSTEMS AND MANAGEMENT PROCESSES OF THE DEPARTMENT OF VETERANS AFFAIRS. (a) INDEPENDENT ASSESSMENT.— the date of the enactment of this Act, (1) ASSESSMENT.—Not later than 90 days after the Secretary of Veterans Affairs shall enter into one or more contracts with a private sector entity or entities described in subsection (b ) to conduct an independent assessment of the hospital care, medical services, and other health care furnished in medical facilities of the Department. Such assessment shall address each of the following: (A) Current and projected demographics and unique health care needs of the patient population served by the Department. bilities and resources of the Department, (B) Current and projected health care capa including hospital care, medical services, and other health care furnished by non- the Department, to provide timely and Department facilities under contract with accessible care to veterans. (C) The authorities and mechanisms under wh ich the Secretary may furnish hospital care, medical services, and other health care at non-Department facilities, including whether the Secretary should have the authorit y to furnish such care and services at such facilities through the completion of episodes of care. (D) The appropriate system-wide access standard applicable to hospital care, medical services, and other health care furnished by and through the Department, including an identification of appropriate a ccess standards for each individual specialty and post-care rehabilitation. (E) The workflow process at each medical facility of the Department for scheduling appointments for veterans to receive hospital care, medical services, or other health care from the Department. (F) The organization, workflow processes, and tools used by the Department to support clinical staffing, access to care, e ffective length-of-stay management and care transitions, positive patient experience, accu rate documentation, and subsequent coding of inpatient services. 261

276 OMMISSION ON C F INAL R EPORT ARE C (G) The staffing level at each medical fac ility of the Department and the productivity of each health care provider at such medical facility, compared with health care industry performance metrics, which may include an assessment of any of the following: (i) The case load of, and number of patien ts treated by, each health care provider at such medical facility during an average week. (ii) The time spent by such health care provider on matters other than the case load of such health care provider, includin g time spent by such health care provider as follows: (1) At a medical facility that is affiliated with the Department. (II) Conducting research. (III) Training or supervising other health care professionals of the Department. of the Department with respect to (H) The information technology strategies ing an identification of any weaknesses and furnishing and managing health care, includ opportunities with respect to the technology used by Department, especially those strategies with respect to clinical document ation of episodes of hospital care, medical services, and other health care, including any clinical images and associated textual reports, furnished by the Department in Department or non-Department facilities. (I) Business processes of the Veterans He alth Administration, including processes relating to furnishing non-Department health care, insurance identification, third- party revenue collection, and vendor reimburs ement, including an identification of mechanisms as follows: (i) To avoid the payment of penalties to vendors. s owed to the Department for hospital (ii) To increase the collection of amount care, medical services, or other health ca re provided by the Department for which ized and to ensure that such amounts reimbursement from a third party is author collected are accurate. (iii) To increase the collection of any ot her amounts owed to the Department with and other health care and to ensure that respect to hospital care, medical services, such amounts collected are accurate. (iv) To increase the accuracy and timeliness of Department payments to vendors and providers. (J) The purchasing, distribution, and use of pharmaceuticals, medical and surgical supplies, medical devices, and health care re lated services by the Department, including the following: (i) The prices paid for, standardization of, and use by the Department of the following: (I) Pharmaceuticals. (II) Medical and surgical supplies. 262

277 A I PPENDIX E D NABLING OCUMENT (III) Medical devices. (ii) The use by the Department of gr oup purchasing arrangements to purchase pharmaceuticals, medical and surgical suppl ies, medical devices, and health care related services. (iii) The strategy and systems used by the Department to distribute pharmaceuticals, medical and surgical suppl ies, medical devices, and health care related services to Veterans Integrated Se rvice Networks and medical facilities of the Department. (K) The process of the Department for carrying out construction and maintenance projects at medical facilities of the Departme nt and the medical facility leasing program of the Department. (L) The competency of leadership with re spect to culture, accountability, reform readiness, leadership development, ph ysician alignment, employee engagement, succession planning, and performance management. (2) PARTICULAR ELEMENTS OF CERTAIN ASSESSMENTS.— (A) SCHEDULING ASSESSMENT.—In carrying out the assessment required by or entities shall do the following: paragraph (1)I, the private sector entity (i) Review all training materials pertaining to scheduling of appointments at each medical facility of the Department. (ii) Assess whether all employees of the Department conducting tasks related to for conducting such tasks. scheduling are properly trained (iii) Assess whether changes in the tec hnology or system used in scheduling to the system to only those employees appointments are necessary to limit access d in conducting such tasks. that have been properly traine (iv) Assess whether health care provider s of the Department are making changes to their schedules that hinder the abilit y of employees conducting such tasks to perform such tasks. (v) Assess whether the establishment of a centralized call center throughout the medical facilities of the Department Department for scheduling appointments at would improve the process of scheduling such appointments. (vi) Assess whether booking templates for each medical facility or clinic of the Department would improve the process of scheduling such appointments. (vii) Assess any interim technology chang es or attempts by Department to internally develop a long-term scheduling solutions with respect to the feasibility and cost effectiveness of such inter nally developed solutions compared to commercially available solutions. (viii) Recommend actions, if any, to be taken by the Department to improve the tments, including the following: process for scheduling such appoin 263

278 OMMISSION ON C F INAL R EPORT ARE C (1) Changes in training materials provided to employees of the Department with respect to conducting tasks related to scheduling such appointments. (II) Changes in monitoring and assessment conducted by the Department of wait times of veterans for such appointments. schedule such appointments, including (III) Changes in the system used to changes to improve how the Department— (aa) measures wait times of veterans for such appointments; (bb) monitors the availability of heal th care providers of the Department; and (cc) provides veterans the ability to schedule such appointments. (IV) Such other actions as the private sector entity or entities considers appropriate. (B) MEDICAL CONSTRUCTION AND MA INTENANCE PROJECT AND LEASING the assessment required by paragraph PROGRAM ASSESSMENT.—In carrying out entities shall do the following: (1)(K), the private sector entity or (i) Review the process of the Department for identifying and designing proposals medical facilities of the Department and for construction and maintenance projects at leases for medical facilit ies of the Department. (ii) Assess the process through which the Department determines the following: (1) That a construction or maintenance project or lease is necessary with respect to a medical facility or proposed medical facility of the Department. (II) The proper size of such medical fa cility or proposed medical facility with hment area of such medical facility or respect to treating veterans in the catc proposed medical facility. the Department with respect to the (iii) Assess the management processes of capital management programs of the departme nt, including processes relating to the medical facilities of the Department, the methodology for construction and design of management of projects relating to the constr uction and design of such facilities, and the activation of such facilities. (iv) Assess the medical facility le asing program of the Department. tities carrying out the assessment required (3) TIMING.—The private sector entity or en by paragraph (1) shall complete such assessment not later than 240 days after entering into the contract described in such paragraph. (b) PRIVATE SECTOR ENTITIES DESCRIBED.— A private entity described in this subsection is a private entity that— 264

279 A PPENDIX I E NABLING D OCUMENT outcomes in optimizing the performance of the health (1) has experience and proven care delivery systems of the Veterans Health Administration and the private sector and in health care management; and (2) specializes in implementing large-scale organizational and cultural transformations, especially with respect to health care delivery systems. (c) PROGRAM INTEGRATOR.— to contracts with more than one private (1) IN GENERAL.—If the Secretary enters in sector entity under subsection (a), the Secret ary shall designate one such entity that is zation as the program integrator. predominately a health care organi designated pursuant to paragraph (1) (2) RESPONSIBILITIES.—The program integrator shall be responsible for coordinating the ou tcomes of the assessments conducted by the private entities pursuant to such contracts. (d) REPORT ON ASSESSMENT.— ter completing the assessment required by (1) IN GENERAL.—Not later than 60 days af subsection (a), the private sector entity or en tities carrying out such assessment shall submit to the Secretary of Veterans Affairs, the Co mmittee on Veterans’ Affairs of the Senate, the Committee on Veterans’ Affairs of the House of Representatives, and the Commission on Care established under section 202 a report on the findings and recommendations of the with respect to such assessment. private sector entity or entities ter receiving the report under paragraph (2) PUBLICATION.—Not later than 30 days af (1), the Secretary shall publish such report in the Federal Register and on an Internet website s that is accessible to the public. of the Department of Veterans Affair D.—In this section, the term ‘‘non- (e) NON-DEPARTMENT FACILITIES DEFINE Department facilities’’ has the mean ing given that term in section 1701 of title 38, United States Code. SEC. 202. COMMISSION ON CARE. (a) ESTABLISHMENT OF COMMISSION.— (1) IN GENERAL.—There is established a commission, to be known as the ‘‘Commission on Care’’ (in this section referred to as the ‘‘C ommission’’), to examine the access of veterans to health care from the Department of Veter ans Affairs and strategically examine how best to organize the Veterans Health Administration , locate health care resources, and deliver health care to veterans during the 20-year peri od beginning on the date of the enactment of this Act. (2) MEMBERSHIP.— (A) VOTING MEMBERS.—The Commission shall be composed of 15 voting members who are appointed as follows: (i) Three members appointed by the Speake r of the House of Representatives, at least one of whom shall be a veteran. 265

280 C F INAL R EPORT ARE OMMISSION ON C (ii) Three members appointed by the Minority Leader of the House of Representatives, at least one of whom shall be a veteran. (iii) Three members appointed by the Majori ty Leader of the Senate, at least one of whom shall be a veteran. (iv) Three members appointed by the Minori ty Leader of the Senate, at least one of whom shall be a veteran. ent, at least two of whom shall be (v) Three members appointed by the Presid veterans. (B) QUALIFICATIONS.—Of the members appointed under subparagraph (A)— (i) at least one member shall represent an organization recognized by the Secretary of Veterans Affairs for the repres entation of veterans under section 5902 of title 38, United States Code; ence as senior management for a private (ii) at least one member shall have experi integrated health care system with an annual gross revenue of more than $50,000,000; (iii) at least one member shall be familia r with government health care systems, including those systems of the Department of Defense, the Indian Health Service, and Federally-qualified health centers (as defined in section 1905(l)(2)(B) of the Social Security Act (42 U.S.C. 1396d(l)(2)(B))); (iv) at least one member shall be familiar with the Veterans Health Administration but shall not be current ly employed by the Veterans Health Administration; and (v) at least one member shall be familia r with medical facility construction and entities and have experience in the leasing projects carried out by government building trades, including constructi on, engineering, and architecture. I DATE.—The appointments of members of the Commission shall be made not later than 1 year after the date of the enactment of this Act. (3) PERIOD OF APPOINTMENT.— (A) IN GENERAL.—Members shall be appo inted for the life of the Commission. (B) VACANCIES.—Any vacancy in the Commission shall not affect its powers, but shall be filled in the same manner as the original appointment. (4) INITIAL MEETING.—Not later than 15 days after the date on which eight voting members of the Commission have been appointe d, the Commission shall hold its first meeting. (5) MEETINGS.—The Commission shall meet at the call of the Chairperson. (6) QUORUM.—A majority of the member s of the Commission shall constitute a quorum, but a lesser number of members may hold hearings. 266

281 A I PPENDIX E D NABLING OCUMENT N.—The President shall designate (7) CHAIRPERSON AND VICE CHAIRPERSO airperson of the Commission. The Commission a member of the commission to serve as Ch shall select a Vice Chairperson from among its members. (b) DUTIES OF COMMISSION.— (1) EVALUATION AND ASSESSMENT.— The Commission shall undertake a comprehensive evaluation and assessment of access to health care at the Department of Veterans Affairs. —In undertaking the comprehensive (2) MATTERS EVALUATED AND ASSESSED. evaluation and assessment required by paragr aph (1), the Commission shall evaluate and assess the results of the assessment conducted by the private sector entity or entities under section 201, including any findings, data, or recommendations included in such assessment. (3) REPORTS.—The Commission shall submit to the President, through the Secretary of Veterans Affairs, reports as follows: (A) Not later than 90 days after the date of the initial meeting of the Commission, an interim report on— (i) the findings of the Commission with respect to the evaluation and assessment required by this subsection; and (ii) such recommendations as the Co mmission may have for legislative or prove access to health care through the Veterans Health administrative action to im Administration. (B) Not later than 180 days after the date of the initial meeting of the Commission, a final report on— (i) the findings of the Commission with respect to the evaluation and assessment required by this subsection; and mmission may have for legislative or (ii) such recommendations as the Co administrative action to im prove access to health care through the Veterans Health Administration. (c) POWERS OF THE COMMISSION.— (1) HEARINGS.—The Commission may hold such hearings, sit and act at such times and places, take such testimony, and receiv e such evidence as the Commission considers advisable to carry out this section. (2) INFORMATION FROM FEDERAL AGEN CIES.—The Commission may secure directly from any Federal agency such information as the Commission considers necessary to carry out this section. Upon request of th e Chairperson of the Commission, the head of such agency shall furnish such information to the Commission. (d) COMMISSION PERSONNEL MATTERS.— (1) COMPENSATION OF MEMBERS.— (A) IN GENERAL.—Each member of the Commission who is not an officer or compensated at a rate equal to the daily employee of the Federal Government shall be 267

282 C C F INAL R EPORT OMMISSION ON ARE y prescribed for level IV of the Executive equivalent of the annual rate of basic pa Schedule under section 5315 of title 5, United States Code, for each day (including travel time) during which such member is engaged in the performance of the duties of the Commission. (B) OFFICERS OR EMPLOYEES OF THE UNITED STATES.— All members of the the United States shall serve without Commission who are officers or employees of compensation in addition to that received fo r their services as officers or employees of the United States. (2) TRAVEL EXPENSES.—The members of th e Commission shall be allowed travel expenses, including per diem in lieu of subsis tence, at rates authorized for employees of agencies under subchapter I of chapter 57 of ti tle 5, United States Code, while away from their homes or regular places of business in th e performance of services for the Commission. (3) STAFF.— (A) IN GENERAL.—The Chairperson of the Commission may, without regard to the civil service laws and regulations, appoint and terminate an executive director and such ary to enable the Commission to perform its other additional personnel as may be necess ecutive director shall be subject to confirmation by the duties. The employment of an ex Commission. (B) COMPENSATION.—The Chairperson of the Commission may fix the compensation of the executive director and other personnel without regard to chapter 51 and subchapter III of chapter 53 of title 5, United States Code, relating to classification of positions and General Schedule pay rates, exce pt that the rate of pay for the executive director and other personnel may not exc eed the rate payable for level V of the Executive Schedule under section 5316 of such title. (4) DETAIL OF GOVERNMENT EMPLOYEES.—Any Federal Government employee may be detailed to the Commission without reimbursement, and such detail shall be without interruption or loss of ci vil service status or privilege. (5) PROCUREMENT OF TEMPORARY AND INTERMITTENT SERVICES.—The Chairperson of the Commission may procure temporary and in termittent services under at rates for individuals that do not exceed the section 3109(b) of title 5, United States Code, daily equivalent of the annual rate of basi c pay prescribed for level V of the Executive Schedule under section 5316 of such title. e Commission shall terminate 30 days (e) TERMINATION OF THE COMMISSION.—Th after the date on which the Commission subm its the report under subsection (b)(3)(B). (f) FUNDING.—The Secretary of Veterans Affa irs shall make available to the Commission from amounts appropriated or otherwise made av ailable to the Secretary such amounts as the on jointly consider appropriate for the Secretary and the Chairperson of the Commissi Commission to perform its duties under this section. (g) EXECUTIVE ACTION.— ident shall require the Secretary of (1) ACTION ON RECOMMENDATIONS.—The Pres Veterans Affairs and such other heads of relevant Federal departments and agencies to 268

283 PPENDIX A I E NABLING D OCUMENT implement each recommendation set forth in a re port submitted under subsection (b)(3) that the President— (A) considers feasible and advisable; and (B) determines can be implemented without further legislative action. (2) REPORTS.—Not later than 60 days after the date on which the President receives a report under subsection (b)(3), the Presiden t shall submit to the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans’ Affairs of the House of Representatives and such other committees of Congress as the President considers appropriate a report setting forth the following: (A) an assessment of the feasibility and advisability of each recommendation contained in the report received by the President. (B) For each recommendation assessed as feasible and advisable under subparagraph (A) the following: requires legislative action. (i) Whether such recommendation (ii) If such recommendation requires legislative action, a recommendation gislative action. concerning such le (iii) A description of any administrative action already taken to carry out such recommendation. (iv) A description of any administrative action the President intends to be taken to carry out such recommendation and by whom. H.R. 4437: Extension of Deadline for Submittal of Final Report by Commission on Care th [114 Congress Public Law 131] [[Page 130 STAT. 292]] Public Law 114-131 th Congress 114 An Act To extend the deadline for the submittal of th e final report required by the Commission on Care. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SECTION 1. 38 USC 1701; EXTENSION OF DEADLINE FOR SUBMITTAL OF FINAL REPORT BY COMMISSION ON CARE. 269

284 C C ARE F INAL R EPORT OMMISSION ON Section 202(b)(3)(B) of the Veterans Acce ss, Choice, and Accountability Act of 2014, 128 Stat. 1775 (Public Law 113-146; 128 Stat. 1773) is amended by striking “Not later than 180 days after the date of the initial meeting of the Commission” and inserting “Not later than June 30, 2016”. Approved February 29, 2016. 270

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289 APPENDIX J: COMPOSITION OF THE COMMISSION Nancy M. Schlichting, Chairperson Appointed by President Barack Obama cer of Henry Ford Health System (HFHS), a Nancy M. Schlichting is Chief Executive Offi ganization with 27,000 empl oyees and recipient of nationally recognized $5 billion health care or the 2011 Malcolm Baldrige National Quality Aw ard, 2011 John M. Eisenberg Patient Safety Quality Award, and 2004 Foster G. McGaw Award. She is credited with leading the health system through a dramatic financial turnarou nd and for award-winning patient safety, customer service and diversity initiatives. Schlichting joined HFHS in 1998 as its Senior Vi ce President and Chief Administrative Officer, served as Executive Vice President and Chief Operating Officer, President and CEO of Henry Ford Hospital and was named President and CEO of the System in 2003. Her career in health care administration spans over 35 years of experience in senior level executive positions. Schlichting serves on several national and comm unity boards including The Kresge Foundation, ank of Chicago – Detroit Branch, the Detroit Walgreens Boots Alliance, the Federal Reserve B Regional Chamber, the Detroit Economic Club, and the Downtown Detroit Partnership. Nancy is also a Fellow of the American College of Healthcare Executives. In 2015, Schlichting was honored as one of the 100 Most Influential People in Healthcare by Modern Healthcare magazine, the eighth time she received this recognition. She was also rn Healthcare, the fourth time she received named to the Top 25 Women in Healthcare by Mode to the list. Her other awards include: NCHL this recognition and the only Michigander named Gail L. Warden Leadership Excellence award, ACHE Senior-Level Healthcare Executive Regent’s Award, AHA/HRET 2014 TRUST Award, Becker’s Hospital Review “40 of the Smartest People in Healthcare-2014,” Crain’s Detroit Business “2012 Newsmaker of the Year,” HealthLeaders Media “20 People Who Make Healthcare Better-2012,” and most recently was named one of “Crain’s 100 Most Influential Women in Michigan.” Author of the acclaimed book, Unconventional Le adership, Schlichting is a highly regarded expert and accomplished speaker on strategic le adership, quality, patien t/family-centered care, and diversity. Schlichting received her A.B. in Public Policy Studies, Magna Cum Laude from Duke University and her M.B.A. from Cornell University. She has also been the recipient of honorary doctoral University and Central Michigan University. degrees from Walsh College, Eastern Michigan 275

290 C C F INAL R EPORT OMMISSION ON ARE Delos M. (Toby) Cosgrove, MD, Vice Chairperson Appointed by Speaker of the House John Boehner Toby Cosgrove, CEO of Cleveland Clinic, pres ides over a $6.2 billion health care system comprising Cleveland Clinic, ei ght community hospitals, 16 family health and ambulatory surgery centers, Cleveland Clinic Florida, the Lo u Ruvo Center for Brain Health in Las Vegas, Cleveland Clinic Toronto, and Cleveland Clinic Abu Dhabi. His leadership has emphasized patient care and patient experience, including the re services into patient- organization of clinical centered, organ- and disease-based institutes . He launched major wellness initiatives for patients, employees, and communities. Under his le adership, Cleveland Clinic has consistently been named among America’s top four hospitals by U.S. News & World Report and is one of only two hospitals named among America’s 99 Most Ethical Companies by the Ethisphere Institute. Cosgrove was a surgeon in the U.S. Air Force and served in Da Nang, Republic of Vietnam, as the chief of U.S. Air Force casualty staging flight . He received the Bronze Star and the Republic of Vietnam Commendation Medal. He has published nearly 450 journal articles, book chapters, one book, and 17 training and continuing medical education films. He performed more than 22,000 operations and earned an y, especially valve repair. As ise in all areas of cardiac surger international reputation for expert an innovator, Cosgrove has 30 patents filed for developing medical and clinical products used in surgical environments. Cosgrove received his medical degree from the Un iversity of Virginia School of Medicine in Charlottesville, VA, and completed his clinical training at Massachusetts General Hospital, Boston Children’s Hospital, and Brook General Hospital in London. He received a BA in biology from Williams College in Williamstown, MA. Michael A. Blecker Appointed by House Minority Leader Nancy Pelosi Michael Blecker has been associated with Swords to Plowshares since 1976 and has served as Executive Director since 1982. The agency was st arted in 1974 by returning Vietnam veterans and VISTA volunteers assigned to the VA regional office in San Francisco. In the 1980s, when homelessness exploded, Swords to Plowshares started a transitional housing program with funding support from VA and the city and county of San Francisco. Swords to Plowshares continues to provide housing, employment, case management, and benefits advocacy for veterans from offices in San Franc isco and Oakland. In 2005, the Iraq Vet Project (IVP) was established to help veterans of th ose wars and to shape policies affecting them. Recognizing Swords to Plowshares’ long and effective history of challenging and shaping public policy with regard to veterans, in 20 11, the IVP became known as the Institute for Veterans Policy. es’ annual budget has grown from $75,000 to Under Blecker’s leadership, Swords to Plowshar for dedicated service and as an authority on nearly $16 million. He has a nationwide reputation 276

291 A J PPENDIX C C OMPOSITION OF THE OMMISSION veterans’ services and veterans’ rights. He served on the Advisory Committee on Homeless Veterans Affairs. He is cofounder of both Veterans (2002-2007), which advises the Secretary of and the California Association of Veterans’ the National Coalition for Homeless Veterans Service Agencies. He has served on the Cong ressional Commission on Service Members and Veterans Transition Assistance, the California Senate Commission on Homeless Veterans, the San Francisco Mayor’s Homeless Planning Comm ittee, the National Agent Orange Settlement Advisory Board, The Agent Orange Information Center, and the Veterans Speakers Alliance. Blecker served in the U.S. Army as a combat infantryman in Vietnam in 1968-69 with the st 101 Airborne Division, achieving the rank of E-5. He received an AB degree in criminology from University of California, Berkeley and a JD degree from New College of California Law School. David P. Blom Appointed by Speaker of the House John Boehner David Blom has been instrumental in the deve lopment and growth of the OhioHealth system. He has served as president of OhioHealth’s central Ohio hospitals—Grant Medical Center, Riverside Methodist Hospital, and Doctors Hosp ital—while also serving as executive vice Health. He was named president and CEO of president and chief operating officer of Ohio OhioHealth in March 2002. He has a track record of achievement with a solid understanding of has expertise in leading strategic initiatives, complex issues facing health care delivery. He managing and developing human capital, improv ing profitability, and improving quality of care and customer experience. Blom maintains many professional and community affiliations, currently serving as a board (VHA), a member and treasurer of Columbus’ member of the Voluntary Hospitals of America mber of the Columbus Partnership, and Downtown Development Corporation (CDDC), me member of the local World President’s Organi zation (WPO). In 2001, he was named a Top 100 Business Leader by Smart Business and in 2012 CEO of the Year by Columbus CEO Magazine. He received a BA from Ohio State University and an MA in health care administration from The George Washington University. David W. Gorman Appointed by President Barack Obama David Gorman is a retired, combat-disabled veteran of the Vietnam War, who was appointed executive director of the Disabled American Ve terans (DAV) National Service and Legislative Headquarters in Washington, DC in 1995. His responsibilities include oversight of the DAV National Service, Legislative, and Voluntar y Service Programs. He is the organization’s principal spokesperson before Co ngress, the White House, and the U.S. Department of Veterans Affairs. rd Airborne Brigade, the famed Gorman entered the U.S. Army in 1969 and served with the 173 mpaign to secure an area in Central Vietnam “Sky Soldiers” of the Vietnam War. During a ca 277

292 C C F INAL R EPORT OMMISSION ON ARE where U.S. forces suffered extremely high casu alties, Mr. Gorman was severely wounded. His wounds required amputation of both legs. Discharged from the Army in 1970, he immedi ately joined the DAV and is currently a life member of the DAV’s National Amputation Chapter and DAV Chapter 39 in Greer, SC. Gorman retired from his post executive director at the Washington Headquarters for Disabled American Veterans and now resides in Si mpsonville, SC. Gorman attended Cape Cod Community College. The Honorable Thomas E. Harvey, Esq. Appointed by Senate Majori ty Leader Mitch McConnell Thomas Harvey is a Vietnam combat veteran wh ose decorations include the Silver Star, the Purple Heart and 12 others for valor and service. In Vietnam, he spent a year as a company rd Airborne brigade and a year and a half as an advisor with the commander with the 173 Vietnamese Airborne Division. A lawyer by training, Harvey has spent much of his professional career working with veterans Chief Counsel and Staff Director of the Senate and issues of concern to them. He has served as rator of the Veterans Administration, and Veterans Affairs Committee, Deputy Administ Assistant Secretary for Congressional Affairs of the Department of Veterans Affairs. Following 5 years with a major Wall Street law firm, Harvey came to Washington, DC, in 1977 as a White House fellow, serving as an assistant to ADM St ansfield Turner, then director of the Central Intelligence Agency. He has also served in the Department of Defense and as General Counsel and Congressional Liaison of the United States Information Agency. For 5 years, he was Senior cation, which administer Counselor of the Institute of International Edu s the Fulbright Program on behalf of the U.S. Department of State, as we ll as a number of other international educational exchange programs. He currently serves on the boards of the Milbank Memorial Fund, the focus of which is public health policy, and of the Art Students League of New York, where he studies watercolor painting. He holds both BA and JD degrees fr om the University of Notre Dame and a LLM degree from the New York University School of Law. Maj. Stewart M. Hickey, USMC (ret.) Appointed by Senate Majori ty Leader Mitch McConnell Since 2011, Stewart Hickey has served as Amer ican Veterans (AMVETS) National Executive Director, operating the nation’s fourth larges t congressionally chartered veterans service organization and its subordinate organizations, and the daily advocacy of issues affecting veterans, national security, foreign affairs, and the economy. Previously, Hickey was chief executive officer for the Hyndman (Pennsylvania) Area Health Center, a multisite community health center prov iding medical and dental services to several counties of Pennsylvania, West Virginia, and Maryland. His health care administration experience includes serving as chief human re sources officer and chief operating officer of 278

293 A PPENDIX J C OMPOSITION OF THE C OMMISSION town, Maryland, a 123-bed Joint Commission on Western Maryland Hospital Center in Hagers Accreditation of Healthcare Organizations accr edited, long-term care and sub-acute hospital with rehabilitation, occupational therapy, physical therapy, and respiratory care. Hickey enlisted in the U.S. Marine Corps Reserve in February 1977, in Cumberland, MD, as an infantryman, and transferred to platoon leaders class in the summer of 1978. He served in Operation Desert Storm and Desert Shield and was awarded a Bronze Star Medal with Combat Company D, Third Tank Battalion, Task Force “V” for his achievements as commanding officer, st y Force, Saudi Arabia from September 1990 Marine Division, I Marine Expeditionar RIPPER, 1 es the Basic School, Armor Officer Basic, to February 1991. His military education includ vanced Course, and Marine Corps Command Amphibious Warfare School, Armor Officer Ad and Staff College. nd Valley Township in McConnellsburg, PA. He Hickey resides on his family farm in Cumberla Ali, Charles, Andrew, an d Bryce. Three of his and his wife, Ellen, have five children: Monroe, sons, Andrew, Monroe, and Charles, followed thei r father’s path and currently serve in the U.S. military. e University and an MA in management from Hickey received a BA in history from Penn Stat Webster University. Rear Adm. Joyce M. Johnson, DO, US PHS (ret.) Appointed by President Barack Obama health leadership experience in civilian and Joyce Johnson is a physician with senior public military sectors. Johnson served in the U.S. Public Health Servic e (Rear Admiral, Upper Half). Her last active- d as Director, Health and Safety (“surgeon duty assignment was with the U.S. Coast Guar general”). She managed the Coast Guard’s health care system, including 150 sickbays and clinics, and coordinated both medical and behavio ral health care for the beneficiary population. She also had responsibility for the Coast Guard’s safety and work-life programs. She held a Top Secret security clearance. Other government assignments included senior scientific and management positions with the Food and Drug Administration (pharmaceutical safety and post-market surveillance) and the Substance Abuse and Mental Health Services Admi nistration. She has held clinical positions at the National Institute of Mental Health and the Department of Veterans Affairs. At the Centers for Disease Control and Prevention, she was an Epidemiologic Intelligence Service (EIS) Officer and staff epidemiologist in the Center for Infectious Disease. In the private sector, Johnson served as vice pres ident, health sciences and chief medical officer for a large research organization, where she ma naged a portfolio of government contracts, including laboratory and social sciences resear ch, and held a top secret security clearance. Johnson is an osteopathic physician board certif ied in psychiatry and public health/preventive cologist and certified addiction specialist. In medicine. She is also a certified clinical pharma 279

294 C C F INAL R EPORT OMMISSION ON ARE addition to her medical degree, she earned a master’s degree in hospital and health administration. She has been conferred six hono rary doctoral degrees. She is a Distinguished Life Fellow of the American Psychiatric Association. Johnson has extensive international health experien ce on all seven continents. She has particular s development, infectious disease, and disaster interests in global mental health, health system relief. She has led five Flag Expeditions with the Explorers Club. For more than a decade she has been a consultant to the National Scienc e Foundation on the health care system in Antarctica. Johnson recently coauthored the book, Lizard Bi tes and Street Riots, Travel Emergencies and Your Health, Safety and Security, and writes a monthly medical column. She is a Clinical Professor and Adjunct Professor at Georgetown University. She has served on expert committees including the Committee on Substance Abuse in the Military, National Academy of Medicine. She is active in numerous profe ssional associations including the American Psychiatric Association, serving on the Committee on Psychiatric Dimensions of Disasters; the the Bureau of International Osteopathic American Osteopathic Association, serving on serving on the Medical Committee. Medicine; and the Explorers Club, The Honorable Ikram U. Khan, MD Appointed by Senate Minority Leader Harry Reid Ikram Khan currently, he is president and 50-pe rcent partner of Quality Care Consultants, LLC, founded in March 1992. The company provides cons ultant services in health care strategy and policy development for employers and other heal th care organizations. The company assists clients in development and implementation of wellness and disease-management programs. The company also develops quality improvement initiatives and techniques and assists in development and implementation of programs for cost-effective utilization of medical resources. Major emphasis is on clinical outcomes and date monitoring analysis. of Peace (USIP) Board of Directors; he was Khan is a member the United States Institute nominated by President George Bush, and confirmed by the U.S. Senate on June 5, 2008. He is also currently a member of the Nevada Homeland Security Commission, having been appointed by the Governor of Nevada. He was nominated by President Clinton and confirmed by the U.S. Senate to serve as member of The Board of Regents Uniformed Services Univ ersity of Health Sciences, an advisory board to U.S. Secretary of Defense (1999-2006). re to Former Nevada Governor Gibbons, was a Khan also served as Special Advisor on Healthca member of the Nevada Academy of Health (appo inted by Nevada Governor Gibbons), and is a past member of the Nevada Academy of Heal th Sciences (appointed by Nevada Governor Kenny Guinn). He is past member of Nevada Governor’s Commission for Medical Education, Research and Training and was a member of th e Nevada State Board of Medical Examiners for eight years. Dr. Khan received “Special Congre ssional Recognition” for invaluable community U.S. Senate – Honoring Dr. Ikram Khan”— on service in 1994 and a Congressional citation—“ April 25, 1994. 280

295 A J PPENDIX C C OMPOSITION OF THE OMMISSION trustees at Sunrise Hospital Las Vegas-a 600 Khan currently serves as member on the board of bed hospital. He has received recognition as “Most Influential Man in Southern Nevada” in s Chamber of Commerce community achievement 2000. He is also a recipient of a Las Vega award (October 1999), and a “Distinguished Commu nity Service Award” from Anti-defamation League of B’nai B’rith (1994). November 30, 1999 was declared “Dr. Ikram U. Khan Day” by the Governor of the State of Nevada, Mayor of Las Vegas, and the Bo ard of Commissioners of Clark County. During the course of his practice as General Su rgeon, Khan has served in multiple leadership positions at various hospitals in Las Vegas. Ikram Khan is president of quality Care Consul tants LLC in Las Vegas Nevada. He received a doctor of medicine and surgery (MBBS) degr ee from University of Karachi, Pakistan. Khan received a Doctor of Medicine and Surger y (MB, BS) in August 1972 from the University of Karachi, Pakistan. He completed post-graduat e surgical residency in General Surgery in New York from 1974 through 1978, and practiced as a General Surgeon in Las Vegas through 2005. Phillip J. Longman Appointed by Senate Minority Leader Harry Reid policy institute. He is also a senior editor Phil Longman is a director at New America, a public at the Washington Monthly and a lecturer at Johns Hopkins University, where he teaches a course in health care policy. Longman has written extensively on issues rela ted to health care delivery system reform, including in his book Best Care Anywhere (currently in its third edition). The book chronicles the ministration during the 1990s and applies its quality transformation of the Veterans Health Ad lessons to the broader U.S. health care system. Longman received a BA in philosophy from Oberlin College. Col. Lucretia M. McClenney, USA (ret.) Appointed by House Minority Leader Nancy Pelosi Lucretia McClenney is a consultant with the Department of Defense Vietnam War Commemoration Office and Executive Coach with the Brookings Institute Executive Education Program. Previously she served as director of the Department of Veterans Affairs Center for Minority Veterans. As director, she served as th e principal advisor to the Secretary of Veterans Affairs on policies and programs affecting minori ty veterans. Prior to her appointment, she served as special assistant to the assistant secretary for policy, planning, and preparedness, Department of Veterans Affairs (VA). She led the department’s emergency exercise planning, training, and evaluation program, and served as liaison to other government agencies. She has served on numerous working groups to incl ude the congressionally mandated National oyment of Women at VA, and as the Secretary Commission on VA Nursing, Task Force on Empl 281

296 C F INAL R EPORT OMMISSION ON C ARE of Veterans Affairs’ representative on the Am erican Red Cross Board of Governors and Disaster and Chapter Services Committee. Serving 30 years in the Army, McClenney retired as a colonel in November 2001. She served in various medical treatment facilities and on sta ffs worldwide serving as director, population health integration team, TRICARE management activity; chief nurse, European regional r nursing, Landstuhl Regional Medical medical command and deputy commander fo ef Army Community Hospital, Fort Jackson, Command; deputy commander for nursing, Moncri South Carolina; assistant deputy for human resour ces, Office Of The Assistant Secretary Of The Army for Manpower and Reserve Affairs, the Pent agon; chief ambulatory nursing, Walter Reed Army Medical Center; senior policy analyst, Office of the Secretary of Defense (Health Affairs), The Pentagon; and member of the President’s National Health Care Reform Task Force. McClenney’s military and civilian awards/decorations include the Legion of Merit (two oak leaf clusters), Defense Meritorious Service Meda l, Meritorious Service Medal (seven oak leaf clusters), Army Commendation Medal (two oak leaf clusters), Navy Commendation Medal, Army Achievement Medal, Army Good Conduct Medal, the Army Staff Identification Badge, d “9A” designator, in Office of the Secretary of Defense Staff Identi fication Badge, the covete recognition of numerous achievements at the pinnacle of nursing excellence, and The Outstanding Civilian Service Medal for her signific ant contribution to the mission of the United For States Army and Department of Defense in assisting with the production of the book, Her professional affiliations include the Children of Valor – Arlington National Cemetery. Association of Military Surgeons of the United States, Sigma Theta Tau, National Nursing Honor Society, Alpha Kappa Alpha Sorority, Inc., Top Ladies of Distinction, Inc., The ROCKS, President, Federal Health Care Executives Inc., the Order of Military Medical Merit, Past rmer Board Member of the Bon Secours Health Interagency Institute Alumni Association, and fo Care System and Chair, Quality Committee. S he is a graduate of the Command and General Staff College and the United States Army War College Fellowship Program at George Washingt on University, Washington, DC. She is also a graduate of the Johnson & Johnson–Wharton’s Fellows Program in Management for Nurse Executives, Wharton School of Business, University of Pennsylvania; Federal Health Care Executives Interagency Institute at George Washington University, Washington, DC; Leadership VA 2004; and Brookings Institute Ex ecutive Fellowship Program. She received a BSN from Murray State University and an MS in psychiatric/mental health nursing from Catholic University. Capt. Darin S. Selnick, USAF (ret.) Appointed by Speaker of the House John Boehner Darin Selnick is an independent consultant who pr ovides a variety of services to organizations in the areas of government and community re lations, business development, and veterans’ issues. He is currently the seni or veterans affairs advisor for Concerned Veterans for America and served as executive director of the Fixing Veterans Health Care Bipartisan Taskforce. He also volunteers his time as Chairman of th e West Los Angeles Veterans Home Support Foundation and as the Vice President of Development for the GI Film Festival. 282

297 A PPENDIX J C OMPOSITION OF THE C OMMISSION From 2001–2009, Selnick was an appointee at the Department of Veteran Affairs. From 2004– r faith-based and community initiatives. In this 2009 he served as the director of the center fo role he was responsible for the management and operations of the Center and was the VA liaison to the White House Office of faith-based and community initiatives. From 2001–2004 arning University. In he served as Special Assistant to the Secretary and Associate Dean, VA Le ram and operational oversight of VA Learning this role he was responsible for providing prog University. Selnick is a retired Air Force offi cer who attained the rank of Captain. He has been very active terans in 1994. Since that time he has taken in veterans’ issues and joined the Jewish War Ve various leadership positions and is the past department commander of the Department of California. Mr. Selnick is also a member of the American Legion, AMVETS, Air Force ciation of Uniformed Services. Association, and National Asso ans’ affairs advisor for Concerned Veterans for Darin Selnick currently serves as senior veter America and served as executive director of the Fixing Veterans Health Care Bipartisan retired from the U.S. Air Force. He received a Taskforce. He lives in Oceanside, CA. Selnick is BS in health science from California State Un iversity, Northridge and an MA in political science/public management from Midwestern State University. Lt. Gen. Martin Steele, USMC (ret.) Appointed by Senate Majori ty Leader Mitch McConnell nuary 1965 and rose from private to three-star Martin Steele enlisted in the Marine Corps in Ja general, culminating his military career in Augus t 1999 as the deputy chief of staff for plans, Marine Corps, in Washington, DC. A decorated policies, and operations at Headquarters, U.S. a recognized expert in the integration of all combat veteran with 34½ years of service, he is elements of national power (diplomatic, econom ic, informational, and military) with strategic military war plans and has served as an executiv e strategic planner/policy director in multiple theaters across Asia. His extraordinary career was chronicled as one of three principals in the award winning military biography, Boys of ’67 , by Charles Jones. Upon his retirement from active duty in 1999, he served as president and CEO of the Intrepid Sea-Air-Space Museum in New York City. Curr ently, Steele serves as The Associate Vice President for Veterans Partnerships, the Execut ive Director, Military Partnerships, and Co-chair of the Veterans Reintegration Steering Committee at the University of South Florida in Tampa, Florida. Additionally, Steele is the chairman and CEO of Steele Partners, Inc., a strategic advisory and leadership consulting company. He has led a philanthropic transition program assisting exiting Marines into private-sector jobs throughout the country, at no cost to the Marine participants, the Marine Corps, or the companies that provide employment opportunities. Steele serves proudly on several boards across th e country. He is currently the Chairman of the Board, Marine Corps Scholarship Foundation. He was appointed to the Board of Directors of Florida is for Veterans, Inc., a not for profit, stat e legislated organization designed to assist both Veterans and businesses throughout Florida in no t only hiring Veterans but also developing He is a member of Fisher House Foundation; entrepreneurship programs designed for veterans. 283

298 C C F INAL R EPORT OMMISSION ON ARE chairman of the advisory committee, Stability In stitute; advisory committee member, Call of Duty Endowment; advisory board member, Stay in Step Foundation; advisory council member, Operation Helping Hand; member, Veterans Advantage; board member, University of Arkansas Veterans Resource and Information Center; and advisory committee member, Jesse Lewis Choose Love Movement. Steele is a graduate of the University of Ark ansas where he obtained a bachelor’s degree in history and was recognized as a distinguished gr aduate of the Fulbright College of Arts and Sciences. He is a recipient of the 2013 Arkans as Alumni Award Citation of Distinguished Alumni, which recognizes exceptional prof essional and personal achievement and extraordinary distinction in a chosen field. He also holds master’s degrees from Central Michigan University, Salve Regina College, and Naval War College. Charlene M. Taylor Appointed by House Minority Leader Nancy Pelosi Charlene Taylor joined Kaiser Permanente in 1997 as the director of specialty services for the Permanente Medical Group at South Sacramento. In 2002 she became the service director for Kaiser Foundation Hospitals, responsible for perioperative and perinatal services at South Sacramento. In 2008, she was promoted to chie e Sacramento Medical f nursing officer at th Center where she was responsible for a 287-bed tertiary acute care hospital that conducted more ersaw 800 full-time employees and a budget of than 11,000 operations per year. There, she ov $150 million. Taylor was promoted to chief oper ating officer in 2010 and retired from Kaiser Permanente in 2013. rved as assistant hospital administrator for Before working for Kaiser Permanente, Taylor se Sutter Health at the Sutter Amador Hospital from 1988 to 1997. She is a member of the Veterans of Foreign Wars, Reserve Officers Association, and the Society of Air Force Nurses. Taylor’s patriotic and adventurous nature led her to join the Air Force as a reserve officer at the age of 40, rising to the rank of Lieutenant Co lonel. She was commissioned as a Captain in the October 1993, earning her flight nurse wings in United States Air Force (Reserve Command) in 1994. She subsequently was selected to be a flight nurse instructor followed by a promotion to evaluator status. Her last squadron assignment wa s that of chief nurse at the 349 AMDS, Travis Air Force Base. aeromedical evacuation missions throughout the In addition to years of experience conducting world, Taylor was activated in support of Op eration Enduring Freedom from March 2003 to th March 2004. In January 2005 she was selected to be the chief nurse of the 379 Expeditionary Aeromedical Squadron in support of Operatio n Iraqi Freedom. While transporting the injured out of Mosul, Iraq in a C-130, the aircraft took enemy fire, landing without casualties. Due to the demands of her civilian position, Taylor transferre d to inactive status in the Air Force Reserve Command. Taylor is the recipient of two Merito rious Service medals, Expert Marksmanship (2), and multiple other medals. d. In 2012 she was appointed to the Board by Taylor currently serves on the Veterans Boar Gov. Jerry Brown and approved by the Senate. She became chair in 2014 and continues to serve 284

299 A PPENDIX J C OMPOSITION OF THE C OMMISSION as an advocate for veterans affairs, identifying in that role. The California Veterans Board serves needs and working to ensure and enhance the righ ts and benefits of California veterans and their dependents. Taylor is a diploma nurse graduate from the Kaiser Foundation School of Nursing. She e State University of New York in Albany, continued her education receiving a BSN from th ing administration from the University of New York. She earned a master’s degree in nurs California, San Francisco. Taylor lives in Elk Grove, CA. Marshall W. Webster, MD Appointed by Senate Minority Leader Harry Reid Marshall Webster is a senior vice president of the University of Pittsburgh Medical Center (UPMC), and a distinguished service professor of surgery at the University of Pittsburgh. A graduate of Penn State University and the Johns Hopkins Medical School, he trained in surgery served 2 years as a surgeon on active duty in at the University of Pittsburgh, and subsequently the U.S. Navy. Webster returned to the University of Pittsbu rgh as a faculty vascular surgeon, including the Pittsburgh VA Medical Center for 3 years. He initially, a part-time attending staff position at and has had a long academic career of clinical has held the Mark M. Ravitch Chair in Surgery, strative leadership roles. From 2002–2012, he practice, research, and service in varied admini ent of UPMC’s physician services division, and was an executive vice president of UPMC, presid president of the University of Pittsburgh Physici ans, the clinical practice plan of the university faculty. His current focus is primarily strategic developm ent: building clinical relationships and care models throughout the region with a large nu mber of community hosp itals and providers. Webster has oversight of UPMC’s graduate me dical education program, which sponsors a substantial number of resident rotations at the Pittsburgh VA Medical Center. He recently served for 2 years as the interim chair of the Department of Anesthesiology at UPMC. He has had a long-standing interest in patient safety and quality initiatives, and recently completed a 6-year term on the board of the Pennsylvania Patient Safety Authority. 285

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301 APPENDIX K: COMMISSION STAFF Susan M. Webman, Esq. Executive Director Michael Bargmann ... Program Analyst Robert Burke, PhD ... Program Analyst Donald Cicotte ... Program Analy st Pauline Cilladi-Rehrer ... ... DFO John Clinton ... Staff Assistant Monica Cummins ... Program Analyst, ADFO Christopher Danns ... Program Analyst Stephen Dillard ... Program Analyst, ADFO Susan Edgerton ... Program Analys t Beth Engiles ... Program An alyst Sharon Gilles ... Program Analyst, DFO Wilmya Goldsberry ... Program Analyst John Goodrich ... Executive Officer, DFO Sherri Hans, PhD ... Program Analyst Daniel Huck ... Program Anal yst t Ralph Ibson, Esq. ... Program Analys Wendy J. LaRue, PhD ... Editor-in-Chief Gideon Lukens, PhD ... Economi st Sonia Mastrogiuseppe ... Staff Assistant Jennifer E. McKinney ... Document Specialist Osita Osagbue ... Program Analy st Bernadette Philpot ... Staff Assis tant Patrick Ryan, Esq. ... Program Analyst Jamie Taber, PhD ... Eco nomist SaKeithia Taylor ... Staff Ass istant Linda (Yvonne) Williams ... Staff Assistant DFO – Designated Federal Officer ADFO – Assistant Designated Federal Officer 287

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303 APPENDIX L: ACRONYM LIST ACRONYM DEFINITION ACA Affordable Care Act ACHE American College of Healthcare Executives APRN Advanced Practice Registered Nurse BRAC Base Realignment and Closure CAHPS Consumer Assessment of He althcare Providers and Systems CARES Capital Asset Realignment for Enhanced Services CDS Community Delivered Services CHAMPVA Civilian Health and Medical Program of the Department of Veterans Affairs CITC Care in the Community CMD Chief Medical Director CMIO Chief Medical Information Officer CMOP Consolidated Mail Outpatient Pharmacy COTS Commercial Off-The-Shelf Clinical Product Review Committee CPRC CPRS Computerized Patient Record System CVA Concerned Veterans for America Chief of VHA Care System CVCS Disabled American Veterans DAV DEPSECVA Deputy Secretary, Department of Veterans Affairs DHP Digital Health Platform DM&S Department of Medicine and Surgery DoD Department of Defense DUSH Deputy Under Secretary for Health ECF Executive Career Fields EES Employee Education System Equal Employment Opportunity EEO 289

304 OMMISSION ON C F INAL R EPORT ARE C ACRONYM DEFINITION EHCPM Enrollee Health Care Projection Model eHMP Enterprise Health Management Platform EHR Electronic Health Record FFS Fee-for-Service FY Fiscal Year GAO Government Accountability Office GHATP Graduate Health Admini stration Training Program GUI Graphic User Interface HCD Human-Centered Design HEC Healthcare Executive Council High Performance Development Model HPDM HR Human Resources HRA Human Resources and Administration HSC Health Service Category Healthcare Talent Management HTM Iraq and Afghanistan Veterans of America IAVA IDIQ Indefinite Delivery/Indefinite Quantity IDN Integrated Delivery Network IDP Individual Development Plan IT Information Technology JC Joint Commission JEC Joint Executive Committee JLV Joint Legacy Viewer MSA Medical Support Assistant MTF Military Treatment Facility NAS National Academy of Sciences NCEHC National Center for Ethics in Health Care NCOD National Center for Organization Development NLC National Leadership Council NVTC Northern Virginia Technology Council OAA Office of Academic Affiliations 290

305 A L PPENDIX A L CRONYM IST ACRONYM DEFINITION OEF Operation Enduring Freedom OGC Office of General Counsel OI&T Office of Information and Technology OIF Operation Iraqi Freedom OMB Office of Management and Budget ONC Office of the National Coordinator OND Operation New Dawn OPM Office of Personnel Management OTH Other Than Honorable (Discharge) PACT Patient Aligned Care Team PC3 Patient-Centered Community Care PG Priority Group U.S. Public Health Service PHS PO Program Office PTSD Posttraumatic Stress Disorder Quality Enhancement Research Initiative QUERI Relevant Civilian Labor Force RCLF Reduction in Force RIF SCI Spinal Cord Injury Secretary, Department of Veterans Affairs SECVA SE Senior Executive SES Senior Executive Service SHEP Survey of Healthcare Experiences of Patients TBI Traumatic Brain Injury TMS Talent Management System USH Under Secretary for Health VA U.S. Department of Veterans Affairs VACAA Veterans Access, Choice, and Accountability Act of 2014 VACI VA Center for Innovation VACO VA Central Office VA Executive Board VAEB 291

306 OMMISSION ON C ARE F INAL R EPORT C ACRONYM DEFINITION VAMC VA Medical Center VERC Veterans Engineering Resource Center VFW Veterans of Foreign Wars of the U.S. Veterans Health Administration VHA VHA Central Office VHACO VISN Veterans Integrated Service Network VSO Veterans Service Organization WWP Wounded Warrior Project 292

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