Office of Public and Intergovernmental Affairs
Remarks by Deputy Secretary Sloan Gibson
National Association of State Directors of Veterans Affairs (NASDVA) Annual Conference
Lake Buena Vista, Florida
September 1, 2015
The privilege, opportunity, and freedom Americans cherish is bequeathed to us by great leaders like retired General and Commissioner Pete Wheeler.
Veterans, VA . . . we were all saddened by the news of General Wheeler’s passing in April.
But there is comfort knowing that his devotion will shape Veterans’ care for decades. And, in spite of day-to-day and longer-term national and international security challenges our country may face, we nurture a justifiable hope knowing there are many other men and women like General Wheeler—following his footsteps and emulating his example of service and sacrifice.
Our mission—yours and mine and all Americans’—is, to care for those who have “borne the battle,” and their families and survivors. General Wheeler epitomized that ideal.
May God bless him, his family, and everyone sharing in his loss.
Les [Beavers, NASDVA Executive Director], thanks for that kind introduction, thank you for inviting me, and thank you all for that warm welcome.
I’ve been at VA now for 18 months, but I still know what it’s like to look at VA from the outside in—to think about what the American people expect of government:
- Goals and objectives based on measurable outcomes for those served;
- Sustained effort and steady progress reported year-by-year against those goals;
- Programs tackling significant challenges and providing appropriate support to those among us in greatest need;
- Governmental departments working collaboratively, rather than functioning as silos;
- Processes engaging NGOs and the private sector in meaningful public-private partnerships;
- Federal agencies working with states and counties and cities in true inter-governmental collaboration.
In my view, those are the characteristics of good governance, of best-in-class collaboration and partnership, exactly the kind of partnership VA’s shares with NASDVA. With the challenges we face today, our partnership—focused squarely on Veteran outcomes—can accomplish things for Veterans we never could have accomplished in the past.
This morning, I want to report to you on a number of important areas. Along the way, I’ll note some areas where we need to leverage the full potential of our partnership on behalf of the Veterans we serve. It’s important that Veterans and the American people know that their VA is making progress.
It’s equally important that they know we still have work to do, and we own those challenges.
- We deliver hundreds of thousands of great Veteran outcomes every day, but we lack the rigor in our systems and processes to ensure we replicate those outcomes every single time.
- Veterans’ demand for care and benefits still exceeds VA’s capacity to meet that demand, and, as a result, Veterans wait too long.
- We need to streamline the six different channels for Care-in-the-Community that have evolved over the last 20 years into a single program that Veterans, private-sector providers, and VA staff can understand.
- In IT, we have to manage our way through technical debt accumulated over decades so we can build the technology platform needed for state-of-the-art care and service.
Think about this: We’re running the largest healthcare organization in America with a 20-year-old financial management system, no integrated logistics management system, and Veterans can’t seamlessly transition from one medical center to another and can’t get a simple prescription filled.
- We still struggle with insufficient funding and little financial flexibility to meet the needs of Veterans.
We’ll spend a billion dollars this year curing Veterans of Hepatitis C using drugs that weren’t even approved by the FDA when we first submitted our FY15 budget to Congress.
- We have to change a culture where, too often, frontline staff are reluctant to offer suggestions to improve day-to-day operations and where many still define success as following the rules rather than meeting the needs of the Veterans we serve.
- We have to work through the construction challenges resulting from poor decisions made years ago, improve our leasing processes to be more responsive to the needs of Veterans, and be better stewards of taxpayer dollars.
We still have work to do in Denver.
Construction continues on the new medical center in Colorado, and I’m heading back out there Thursday. Our priorities are to finish the complex, make the best use of resources needed to do the job, and put in place sound construction management processes to ensure this never happens again.
But the cloud of uncertainty hovering over the project—that is, the incremental approach to funding and uncertainty about Congress’s commitment to completing Denver at all—means progress is slower than it could be, and more costly.
I expect the Corps of Engineers will be ready to award a new contract in October. But our hands are tied until Congress authorizes the cost and gives us the flexibility to fund it.
These are lessons learned and actions we’ve taken:
- Incorporating integrated master planning;
- Requiring major medical construction projects to achieve at least 35 percent design —prior to establishing cost and schedule estimates or requesting funds;
- Implementing a rigorous requirements control process;
- Institutionalizing a Project Review Board (PRB) similar to that used by Corps of Engineers District Offices;
- Using a Project Management Plan—from planning to activation—to ensure clear communication throughout the life of every project;
- Establishing a VA Activation Office to ensure the integration of facility activation into the construction process;
- Conducting pre-construction reviews of major construction projects throughout the design process—a private construction management firm evaluates design and engineering factors for constructability;
- Integrating Medical Equipment Planners into construction project teams from concept through activation;
- Piloting a Predictive Analysis tool that will help identify and monitor emerging risks on large projects.
Last spring, we named Greg Giddens our new Executive Director of Acquisition, Logistics, and Construction. Greg has extensive experience in both acquisition and construction.
In addition to measures in place, the Corps of Engineers is conducting a broader examination of VA’s largest construction projects.
An independent third-party organization is conducting a comprehensive assessment of VA’s entire construction program as part of the Choice Act legislation. They’re releasing their findings as we speak.
We’ll use the Corps’ report and the independent assessment’s findings to further strengthen VA’s construction management practices. And, we have agreed to retain the Corps of Engineers to act as construction agent on future projects of this size and complexity.
So, we still have work to do—fundamental and comprehensive transformation. But, we owe Veterans, stakeholders, and the American people progress.
Too often, people measure progress by sound-bites and sensationalized headlines, not by the steady rhythm of change necessary to prepare VA for the decades ahead.
Accountability discussions are a perfect example. There isn’t any way to change VA’s culture without accountability. And larger numbers of people than we’ve historically seen have been removed for reasons associated with misconduct or management negligence.
By the way, none of the senior people in the chain of responsibility in 2010 and 2011 when Denver construction went off the rails are still at VA.
Bob and I know from our private sector experience that to effect transformational change, you often have to change leaders. Of VA’s top 17 leaders, 13 are new. My 18 months at VA give me the longest tenure of those 13.
But in all my years of experience in the private sector, I never encountered any organization where the measure of leadership and management excellence was based on how many people you fire.
The accountability that matters most for VA or any large organization is sustainable accountability—accountability that shapes Veterans’ outcomes over the long-term.
Sustainable accountability is making sure employees understand our mission, values, and strategy. Sustainable accountability is rewarding good work and calling poor performance to account. And it’s meaningful performance goals and the resources and tools to meet those goals.
Here’s an example. We have a tool called Strategic Analytics for Improvement and Learning (SAIL). SAIL measures and reports the care quality, patient safety, and other care metrics for all of our medical centers. Most healthcare industry report cards are updated annually. SAIL’s updated quarterly so our leaders and staff can track and improve performance in a timely manner.
How good is SAIL?
The chief medical officer of one of the largest healthcare organizations in America told me that if he had SAIL in his organization, he’d implement it tomorrow.
And here’s how it’s driving sustainable accountability. This fiscal year—for the first time—SAIL’s Veteran healthcare outcomes are included in every medical center director’s performance evaluation.
Does it make a difference? 61 percent of VA medical centers improved quality of care over the past 12 months. These are improvements in key measures of patient care like mortality rates, length of stay, ambulatory care sensitive condition hospitalizations, and avoidable re-admissions for congestive heart failure.
So Veterans can make the right decisions about their healthcare, we have to make sure people know that Veterans have a lower risk of dying of heart failure in their VA hospital than in the private sector. They have to know that VA exceeds private and public-sector hospitals in prescribing beta-blockers after a heart attack, controlling high blood pressure, and conducting colorectal cancer screening. They need to know that VA hospitals match or are better than the best private sector healthcare systems for patient safety and preventing hospital-acquired infections. Tina Rosenberg explained it in a January New York Times article:
Hospital-acquired infection is one of the country’s leading causes of death, killing 75,000 people per year—more than car accidents and breast cancer combined. . . . [H]ospitals have only started to take prevention seriously in the last decade, most in the last five years. . . . One hospital group, however, has done more than all others. It’s not the Mayo Clinic’s hospitals, nor the Cleveland Clinic’s, nor Kaiser Permanente, nor Sutter, nor Geisinger. . . . all hospital chains known for their quality, but another big name leaves them in the dust: the V.A.
She goes on to say, “VA’s achievement is even more remarkable because its patients are older and sicker than patients in other hospitals.”
The message we have to get out is that VA care compares favorably in many categories of patient outcomes, and most Veterans are satisfied with their VA care.
It’s not me saying that. Since 2004, ACSI has reported that Veterans receiving VA health care give us higher satisfaction ratings than patients at most private hospitals—inpatient and outpatient. Last year, the Joint Commission recognized 24 VA medical centers as “top performers.”
So accountability is important. But it’s sustainable accountability that shapes our future and enables our progress in improving Veterans’ outcomes and experiences.
Let me give you an update on benefits.
You know the claims backlog dropped under 100,000 last Monday. We’re down to around 92,000 this morning. We’re at the lowest point in backlog claims since we started keeping track—reduced by 85 percent since the 2013 peak of 611,000.
The claims inventory is the lowest since 2008, and productivity has risen by 81 percent since 2009.
Average days pending for all claims is 103 days. Remember, backlog claims are those over 125 days.
How’d VBA do it? First, it’s thanks to our strong partnership with NASDVA and Veterans Service Organizations.
So, it was you all who helped VBA complete a record-breaking 1.17 million claims in 2013. In 2014, you helped them beat that with another record year—1.32 million claims.
And, thanks again to you, we’re on track to complete nearly 1.4 million claims by the end of this fiscal year.
I want anyone to tell me of another major part of the federal government that has transformed more in the last three years than VBA.
This is real progress. But we still have Veterans waiting too long, so we have more work to do.
Access to care—here’s where we are. A little over a year ago, we had 300,000 appointments that couldn’t be completed within 30 days of when the Veteran needed or wanted to be seen.
Question: How much capacity would we have to create in our healthcare system to be able to timely meet that additional demand? Simple logic says that if we could complete 300,000 more appointments each month, or about 3.5 million annually, we should be able to absorb that demand.
How’d we do? In the following year, we completed seven million more appointments both inside VA and in the community.
How did we do that? We expanded capacity by focusing on staffing, space, productivity, and VA Community Care.
Over the last year our net VHA staffing is up more than 13,000—over 1,100 more physicians and 3,500 more nurses.
To increase access over the last year, we activated over 1.7 million square feet last year, and we’re more productive—clinical output increased 8 percent.
We’re identifying unused capacity, optimizing scheduling, heading off “no-shows” and late appointment cancellations, and extending clinic hours at night and on weekends—the 1.5 million encounters during extended hours was a 10 percent increase. We have dramatically expanded virtual care: telehealth, telemental-health, secure messaging, and e-consults.
And we’re aggressively using Care-in-the-Community. One-and-a-half million Veterans were authorized Care-in-the-Community in the last year—a 36 percent increase.
Notwithstanding the increase, VA community care has been confusing to Veterans, community providers, and staff. So, we’re developing a plan to submit to Congress that consolidates and simplifies all our Care-in-the-Community programs. I met yesterday with some healthcare industry leaders as part of that work.
So, with all that progress in improving access, how are we doing on wait times? Nationally, we complete 97 percent of appointments within 30 days. But we know, in many instances, Veterans need to be seen sooner than that. We complete 92 percent within 14 days, 87 percent within seven days, and 22 percent same day.
Average wait times? Five days for specialty care, four days for primary care, and three days for mental health.
What happened to 300,000 appointments over 30 days? They’re up by 50 percent to about 450,000.
How could that be? We completed 7 million more appointments—twice what should have been required.
What we have come to understand is that as we improve access, more Veterans are coming to VA for more of their care.
As all of you know, Veterans want to come to VA for care—because of personal preference or economic advantage: 78 percent of Veterans receiving care at VA have either Medicare, Medicaid, Tricare, or private insurance; often, out-of-pocket cost is lower with VA.
So, we have more work to do.
We’re changing VA’s culture—making Veterans the center of all we do. As you know, we call this transformation MyVA. I know you got a briefing on our five MyVA objectives. Imagine what MyVA can mean to America’s Veterans.
Imagine Veterans talking about timely access to great care, customer service that matches anything in the private sector, thoughtful and caring employees, and state-of-the-art technology making it easy for Veterans to use VA services.
Imagine our 350,000 staff directly engaged in improving the customer experience in their own area—a dedicated workforce committed to the mission of serving Americas’ Veterans.
Imagine support services like Human Resources, Information Technology, supply chain, and construction as critical enablers to our frontline staff, all delivered at better value for taxpayers.
Imagine a vital network of collaborative relationships across the federal government, across state and local government, and with both non-profit and for-profit organizations, much like the excellent work you have seen on Veteran homelessness—much like the special partnership we have with all of you and for-profit and non-profit stakeholders sponsoring your conference here in Florida.
That’s where we’re going.
Congress acted recently to give VA limited flexibility to use money appropriated for Veteran Care-in-the-Community to pay for Veteran Care-in-the-Community. But that flexibility only lasts until the end of this fiscal year—30 more days.
The clock’s ticking.
Importantly, they have come to understand that having multiple Care-in-the-Community programs with different funding sources doesn’t make sense for Veterans, community providers, or VA. We’re committed to working together to simplify those programs.
And we need adequate funding and further flexibility to meet the challenges ahead.
We need your help.
If the House cuts the President’s budget request by $1.4 billion, as they proposed, that means $688 million less for Veterans Medical Care—the equivalent of over 70,000 fewer Veterans receiving VA medical care—no funding for four Major Construction projects and six cemetery projects.
All of this—the lack of flexibility, the cuts, discussions about whether Veterans actually deserve a medical system to call their own—leads to a place where the needs of Veterans are secondary to other agendas.
It’s unacceptable to VA leadership, and it should be unacceptable to anyone claiming to care about our Nation’s Veterans.
So, again, we need your help.
I started with challenges, and I’ll end with one more—telling the whole story, making sure Veterans and the American people know the whole story.
I need you to help by telling your congressmen, your state legislators . . . the media . . . the whole story about the things VA’s doing extraordinarily well—and there are many—at the same time we take ownership, publicly, for things we must do better.
It’s not about defending VA. It is about putting both the challenges and the progress in context.
So, we have work to do—all of us.
With your support and continued great partnership, and the support of many others, we will succeed.
I look forward to your questions.