McDonald: Academic affiliations a source of strength for VA, medical schools

On Sunday, March 29, VA Secretary Bob McDonald spoke to the Association of American of Medical Colleges Council of Deans spring meeting in San Diego, California. Below are his remarks.

Good evening, everyone, and thank you for sharing this time with me.

Not long ago, VA Deputy Secretary Sloan Gibson—my good friend and West Point classmate—observed about VA, “There’s simply no other health care system that does as much to shape and influence how doctors and other health professionals think about, and deliver care. None.”

Sloan’s right. But, that’s not VA exceptionalism.

That couldn’t be the case without our collaboration and partnership and shared commitment to excellence in health care: for Veterans, and for all Americans.

We owe that preeminence to great people who went before us—with vision and leadership, courage and conviction.

After World War II, they helped change the way VA delivered care and how medical schools trained and conducted research.

They were physicians like World War I Veteran and University of Cincinnati School of Medicine’s Dr. Paul R. Hawley. Dr. Hawley was Eisenhower’s Chief Surgeon in the European Theater of Operations during World War II.

They were professionals like Dr. Paul B. Magnuson, once VA’s Chief Medical Director. He was also the chairman of Northwestern’s Department of Bone and Joint Surgery, the founder of the Rehabilitation Institute of Chicago, a Fellow of the American College of Surgeons, and a Founding Member of the American Board of Surgery.

Experts like Dr. Michael E. DeBakey, World War II Veteran and Legion of Merit recipient.

And they were great leaders like General Omar Bradley, Administrator of the VA.

In 1946 when General Bradley was leading the VA, 16 million troops were being demobilized, and there were 670,000 casualties of World War II—many on waiting lists at VA hospitals.

General Bradley had an access problem like we can hardly imagine. And the quality of care available for Veterans was unacceptable. Bradley assessed the VA care like this:

“. . . the quality of VA medicine . . . . was not literally ‘medieval.’ . . . but it was—and always had been—mediocre.”

VA was short on doctors. Bradley estimated they were at about 30 percent of what they’d need. And for hiring, their hands were tied by Civil Service that was offering what Bradley described as “the dregs of the medical profession . . . . some doctors on the list had been committed to mental institutions for insanity or alcoholism.” And he couldn’t hire the doctors he wanted without miles of red tape.

A bureaucratic nightmare.

Hawley, Magnuson, DeBakey, Bradley and their teams devised a solution as simple and common sense as it was visionary and revolutionary: establish non-monetary affiliations between VA and medical schools.

And that’s what brings us together today.

Those members of the greatest generation are why VA spends over $650 million annually on medical and nursing school alliances—from Massachusetts General to San Diego.

They’re why about 70 percent of all U.S. physicians received at least some professional training at a VA hospital.

They’re why, together, we train 62,000 medical students and residents, 23,000 nurses and 33,000 in other health fields, annually.

They are why the chief of staff of our Boston VA Medical Center is one of the deans at Harvard Medical School, why the entire faculty at the University of California, San Francisco, medical school is credentialed to practice in VA and all VA’s physicians there are members of the university’s staff.

We pride ourselves on the close collaborative affiliations like that. It’s a source of strength for the VA and for the medical school.

Just this week, Dr. Brian Kwan, San Diego’s coordinator of the third year medicine rotation shared with Jeff Gering, Director of VA San Diego, some unsolicited student observations describing their VA training experience.

Here are a few:

• “The emphasis on teaching was fantastic, and far superior to most other rotations.”
• “The Vets were a wonderful patient population who really allowed us a great opportunity to learn.”
• “The VA is the best place for medical students to work.”
• “I would highly recommend, if not require, students to do at least one of the medicine rotations at the VA.”
• “The autonomy we’re given with patients and the active roles we play in patient care was great for learning. I loved the team atmosphere.”

So, seventy years after General Bradley and his team revolutionized medicine in the United States, the alliances they started sound like they’re in pretty good shape.

In Bradley’s day, the Veterans Administration and its partners could function on a handshake. Activities at VA hospitals were governed and guided by a Dean’s council. Faculty were jointly recruited and moved seamlessly between institutions. And patients received care in the most appropriate environments for their needs at any given time.

But the health care landscape has changed radically, and today, there are major impediments that interfere with the relationships.

Today, because of modern acquisition laws and concerns about conflict of interest, there’s little that can be accomplished with only a handshake.

Shared care now often requires multiple contracts with multiple entities, slowing the process and introducing more opportunity for error.

There’s no one uniform model of an academic affiliate—neither in structure nor in process.

And in a world of hyper-competition, everyone’s scrambling to adapt, to survive, as health care and how we pay for it and deliver it rapidly changes.

For all of us, delivery methods have vastly expanded. For VA specifically, we’re a full service provider with inpatient and outpatient care, remote care and community care.

We provide services from primary care to polytrauma care to complex specialized procedures like organ transplants and neurosurgery.

We employ psychologists, physical therapists, pharmacists, recreation therapists, social workers and a long list of other health care professionals.

We train, educate and provide practical clinical experience for nearly 120,000 people each and every year—and that health care force provides services to many Americans, not just Veterans.

We’re affiliated with over 1,800 of your educational institutions—affiliations that have helped VA make unique contributions in the areas of traumatic brain injury (TBI), prosthetics, post-traumatic stress and other mental health conditions.

VA researchers pioneered modern electronic medical records, the implantable cardiac pacemaker, the first successful liver transplants, the nicotine patch and artificial limbs that move naturally when stimulated by electrical brain impulses.

They demonstrated that patients with total paralysis could control robotic arms using only their thoughts, and they identified genetic risk factors for schizophrenia, for Alzheimer’s, and for Werner’s syndrome, among others.

In 2014, alone, we completed over 55 million appointments—an average of more than 150,000 a day.

So those who fully understand the value of our affiliations in research, training and clinical care understand that Veterans and all Americans need the strong, productive, vibrant relationship we’ve enjoyed for so long.

But we can be better.

Last summer in the early days of VA’s access crisis, former president of the Institute of Medicine Dr. Harvey Fineberg told us, “VA can accomplish things now it never could have accomplished.”

His point: right now, we all have an extraordinary opportunity.

And we’d better take full advantage of it. Opportunities like these don’t come along often.

VA’s strategy to capitalize on this opportunity is called MyVA. It focuses on five objectives that re-orient us on Veteran outcomes, and three of the five are directly related to our discussion today:

• First, indirectly related: improve Veterans’ experience—a seamless, integrated, responsive customer-service experience, every time.
• Second, indirectly related: improve employees’ experience—eliminate barriers to excellent customer service.
• Third, directly related: achieve support services excellence. That means identifying and optimizing common services performed in support of VA mission components where we can increase efficiency and eliminate duplication. Among services we’re targeting relevant to our affiliation are information technology, acquisitions and logistics, legal services, human resources, and budget and finance.
• Fourth, directly related: establish a culture of continuous performance improvement. We want to set conditions at the local level to eliminate impediments and find solutions that can be replicated across as many facilities as needed to achieve enterprise level results.
• And fifth, directly related: enhance strategic partnerships. We want to make better matches between community, nonprofit and other organizations and the work being done for Veterans at VA facilities across the country.

Those are VA’s commitments to Veterans. They’re our commitments to our employees and our commitments to the American taxpayers and their representatives. And they’re my commitment to reinforcing our affiliations.

So we need to get to work and figure out how, together, we can strengthen our partnership and improve education, patient care, research, and take full advantage of this opportunity.

In my view, part of that process will include

• Building a vision of what the VA-affiliate partnership should look like in the 21st century health care delivery system;
• Identifying the specific goals to realize that vision;
• Designing the training systems necessary to support those goals;
• Determining how we can most effectively use VA resources;
• Identifying places where we can forge joint ventures with affiliates to collectively care for Veterans and their families.

And there are many, many more.

We have to put our energy and intellect behind the ideas that are going to make the most difference.

Now, there are some issues that are particularly challenging to the excellence we seek in our affiliations.

We’re too encumbered by laws, regulations, policies and rules related to acquisition and affiliation that slow the pace we need to achieve positive change. That’s everything from Federal Acquisition Regulation to—for our own part—some of VA’s departmental policies and directives.

Our own sole source contracting policies are impeding, rather than promoting, academic collaboration. For our part, we’re looking to see where we can waive specific parts of the regulations and change internal policies to streamline acquisition processes. And we’re looking at what legislative changes might improve contracting with affiliates.

Understandably, standards related to information and data security are becoming more and more stringent. Our task is to figure out how we can protect data while enhancing the free flow of autonomous information that research requires.

When it comes to sharing research data and information, we haven’t been smart about risk management. We have some self-imposed IT policies that are disproportionately burdensome, that don’t fairly balance risk with requirements for productivity, efficiency, and best outcomes for Veterans.

Along those same lines, our research information technology is not invariably cutting edge, and it needs to be—we can’t risk projects like the Million Veterans Program and others because of shortfalls in data availability.

A lot has changed over the 70 years since General Bradley and his team initiated our first affiliations. So if we are going to achieve support services excellence, optimize common services, increase efficiency and eliminate duplication, we have to work through the bureaucracies—that means changing them where we can or seeking necessary legislative changes from Congress.

But in all that we do, in every effort, we cannot forget that our primary objective is to take care of the people depending on us now, and prepare for those we’ll treat in the decades to come.

Thanks for giving me the opportunity to speak; I look forward to your questions and discussion.