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Office of Public and Intergovernmental Affairs

Remarks by Former Deputy Secretary W. Scott Gould

VHA National Leadership Board 2010 Strategic Planning Summit
Washington, DC
March 19, 2010

It is great to see you confirmed and in place as the Under Secretary for Veterans’ Health. It has been more than six months since the Secretary charged the selection committee to find the best candidate for VHA. We found a physician with tremendous heart and intellect, an innovator, a dedicated colleague and a gentleman.

My thanks to all of you for attending the three-day summit. You are the basis for VHA’s, and, therefore, VA’s mission success. Over the past three days, you’ve been immersed in plans, strategies, breakout sessions, and productive discussions all geared to the goal of creating a Veteran-centric health care delivery model.

On Wednesday, Dr. Petzel addressed the question, “Where Should We Go?” and opened up a wide-ranging discussion on issues ranging from allowing all Veterans back into the VA, to strengthening VA care, to homelessness among Veterans, to seamless transition and fully-funded VA medical care. Randy laid out the mission overview—what we need to do to achieve a Veteran-patient-centric organization that is forward-looking and results-oriented.

He spoke to the issues of evidenced-based care, team care, continuous improvement, reducing variance, an organization of excellence, and, most important, patient-centered care—a system where patients are in control of their own care—a system designed around the need of the patient. A system at once revolutionary, sensible, and humane.
What Randy’s observations tell me—and the message he clearly is sending across VHA, through summits like this—is that VA health care is not going to settle for the status quo. Creating Dr. Petzel’s “Organization of Excellence,” is an achievable challenge, and, there is no better team in VA to take on this challenging model than the team right in front of me.

You are the senior cadre—the gold standard of leadership across VHA. In the past year, you have advanced mental health, VLER, homelessness, and systems redesign. You have logged in more years in the VHA trenches than I have, and I respect your time-in-service for America’s Veterans. Few know more about the system than you do. And that is why Secretary Shinseki and I have invited Under Secretary Petzel to articulate his vision and to do it by tapping into your institutional and professional knowledge.

We have already sketched the broad outlines together: Veteran-centric; results-focused; future-oriented. Now is the time to complete the description—to check our assumptions, lay out our vision, and refine the strategies that will help us achieve our goal. Secretary Shinseki and I want you—we expect you—to be leaders who create and implement this vision, to own it, and, through it, build a greater VA for today’s and tomorrow’s Veterans.

Here are some of the elements as we see them:

VA’s health system is not separate from nation’s health care system; it is an integral part of it. Our system influences, and is affected by, the nation’s system. Maintaining VA status quo in a changing and demanding environment equates to failure to recognize and plan for the future. We cannot afford the consequences of inaction—we must seize the opportunity to lead change in health care to the benefit of Veterans, the country, and the world. Our current model is utilization-driven; the assumption that more care is better care isn’t valid. More utilization doesn’t equate to quality or better outcomes; it leads to higher costs. To improve quality and access, while controlling costs, we must design a health care system that drives and measures quality and access outcomes—not utilization. Veterans should not pay for health care already earned through their service, but government also has a responsibility to balance its priorities, its competing needs for, example, children, education, and defense. Our goal is to optimize, not simply maximize health care for Veterans, so we can, and must, responsibly use public resources.

Let me share with you three quick analogies about maximization versus optimization to draw a very clear picture of what we must do in VHA to succeed with our mission’s vision: The railroads; the Interstate Highway System; and the Internet.

In the early 1800s, railroads were barely advancing—in 1827, there were 13 miles of operating railroad in the United States. By 1842, 15 years later, that number had increased to more than 4,000 miles. In 1857, another 15 years, there were 24,500 miles of railroad, and by 1861, four years later, there were 31,000 miles of operating railroads. By 1873, that number doubled to 70,000-plus. By the turn of the century, there were 170,000 miles of railroads, running on more than 221,000 mile of track.

So what happened to generate this nearly vertical curve of development, particularly after 1865? Two things—standardization of track width, and the creation of uniform time zones. The variations in track width, and the hodge-podge of more than 100 time zones, inhibited the growth, and success, of the American railroad system. In 1865, as the Civil War wound down, the Lincoln administration supported a standard width track to tie the country together, and once the standard was set, the mileage of track laid exploded. That evolution was supported by one more brilliant standardization: in 1883, the time zone system as we know it today was established by the railroad industry to keep trains running on time from city to city, and region to region. The variance was reduced, the system advanced by leaps and bounds.

Jump ahead to the creation of the Interstate Highway System—the visionary Eisenhower plan of defense highways that made uniform the highway construction standards across state lines. With the road width and construction quality variance reduced and the standards set in 1956, it was possible, for the first time, to travel coast-to-coast, non-stop except for gas, along a ribbon of highway that opened up new vistas to travelers, and better opportunities for highway-dependent commerce. America was on the move, and expanding along new pathways. Variance was down, standards were up.

And, finally, the Internet—one of the great variance reducers of all time; in virtually the blink of an eye as far as revolutions are measured, millions, and then billions, of people, in every corner of the world, could communicate through a system built around worldwide standards that allow the Internet to help a child in Mumbai with her homework, or a Veteran in rural Iowa with a need to communicate remotely with a his VA doctor.

From the iron-track highway of the 19th century, to the concrete highways of the 20th, to the virtual highways of the 21st, society has advanced along very clear paths laid down by visionaries who embraced, and built upon, the value of standards and variance reduction.

Which brings me back to the Secretary’s and Dr. Petzel’s vision for VA’s health care system. The old system, and much of what still passes for “new,” is based on a traditional model of delivery and utilization that are not in line with the needs of Veterans today. We must get to the heart of the matter—embrace new ideas, reduce the variances, focus on the quality, and adhere to patient-centric standards. We must innovate and align ourselves with the evolving health care system of tomorrow—even better, we must be the model for that system, in the lead, out in front. Prevention and health maintenance must be the cornerstone of the new care model. It is right morally to prevent suffering; it is right fiscally, to avoid unnecessary costs.

Here is the banner headline under which we write the new story of VA health care: “VA BUILDS SYSTEM TO HELP VETERANS AVOID GETTING SICK”
Prevention of illness and comprehensive health management is the most efficient, highest quality, safest and economically most responsible way to promote health and avoid disease. Our definition of care encompasses physical, mental, and spiritual needs of Veterans.

Health is a balance of all three. Mental health cannot take a backseat to physical health—both must ride up front. No stigmas in a system that increases access to mental health care. We must manage system risks downward and the likelihood of positive outcomes upward. Quality-based approach must test assumptions, and collect and use data to continuously improve performance. We need to welcome new treatments based on integrative medicine.

We must apply the scientific method to prove treatments and compare their effectiveness, but we must not use the lack of initial data, as a reason to avoid trying new approaches. We must innovate, and appropriately test new methods and new treatments that can prevent disease and reduce suffering. This approach must also embrace end of life situations—where the limits of medicine are apparent, and the emotion and mystery of life are overwhelming.

We—and I really mean you and the health care professionals across VHA—must reassess and reset our strategies for how we deal with the end-of-life realities that face all-too-many Veterans and their families.

VA will create the “next generation of health care quality, access, and cost improvement in America. We will become the preferred source of care for Veterans. We will establish, and maintain, the gold standard of the highest quality care. VHA campuses and facilities will be safe, secure places. And VHA will be open to competition, and willing to leverage private sector medical care against a common standard of quality and positive outcomes. As easy as the Internet is to access a world of information, so, too will VA services be as easy to use as the leading customer service organization. All management infrastructure will be brought to bear in our mission—IT, acquisition, logistics, financial management, construction and facilities management, and HR, so that our back-office support is as strong as our direct patient-centered care.

How do we meet this challenge? Leadership direction on the new vision; delegation of decision-making authority at VHA; the new leadership team, with clear expectations, room to implement, and strong accountability for results; resources; and training. We must be players and active participants in the national policy debate. We must create a culture of openness necessary to promote quality. At the same time, we must demand accountability for meeting Veterans, and other stakeholder expectations. We will improve performance measures, including client satisfaction, improved health outcomes and value, measures for inpatient care to complement VHA’s good measures for outpatient care, and much more.

I know we will meet these challenges, rise to even greater heights for Veterans, and create a VA health care system worthy of the title, “Best in the World.”

You are the change agents to make it so. Secretary Shinseki and I look forward to sharing that journey with you, providing the support and resources to make it a reality.

Thank you.