Office of Public and Intergovernmental Affairs
Remarks by Deputy Secretary Sloan Gibson
Disabled American Veterans Mid-Winter Conference
February 21, 2016
Last December, at our Denver medical center, a distraught Veteran took VA Nurse Practitioner Kathy Rittenhouse hostage. Armed with a loaded pistol and two boxes of ammunition, the Veteran’s stated purpose was to be killed by police—suicide by cop.
Experienced and highly trained, Kathy calmed the Veteran and persuaded him to let her make a phone call.
When VA Police Officer Greg Crenshaw arrived, Greg persuaded the Veteran to take him as the hostage and to let Kathy go. In taking Kathy’s place, Greg disarmed the Veteran and resolved the crisis without any physical harm to anyone. The whole process took 13 minutes.
They could have waited for police who were already on their way. But they didn’t. They acted based on their commitment to caring for Veterans, their desire to do the right thing, and their considerable training in de-escalating just such situations. In doing so, I believe they saved lives.
A quick postscript: After the crisis, the team got together and requested that this Veteran not be sent somewhere else for his inpatient mental health care. They want to care for him there.
This is who we are.
You wouldn’t know that by reading headlines. We live in a world where bad news, crisis, or scandal are more captivating. So it’s no surprise that we don’t see press reports about how many lives are saved by the dedicated health professionals who work for VA.
But that’s the kind of story I often hear in my visits to VA facilities across the country. Bob and I have visited hundreds of VA facilities in less than two years. We visit with frontline staff at every facility and I’ll tell you what we find:
- Employees that care deeply about our mission;
- That do the right thing;
- And that work hard every day serving and caring for our Veterans.
When I took over as Acting Secretary 21 months ago, one of things I did was consult with people who knew more about running a large healthcare system than I did, and one of the first people I talked to was Dr. Harvey Fineberg, who had just stepped down after 12 years as the president of the Institute of Medicine.
I told him that because of the healthcare crisis, VA could accomplish more in two-to-three years than we could otherwise have done in two-to-three decades. Dr. Fineberg immediately corrected me. “No!” he said. “VA can accomplish things now it never could have accomplished!”
Harvey was right: VA has an extraordinary opportunity and we are seizing it!
We are taking ownership of our problems and building back the trust of Veterans by making lasting progress, including in access to VA care.
We expanded capacity by focusing on staffing, space, productivity, and VA Community Care.
- VHA staffing is up more than 14,000—including 1,400 more physicians and 4,000 more nurses,
- We’ve activated nearly four million square feet in the past two years,
- We’ve increased authorizations for care in the community 46 percent, and
- Clinical workload is up 10 percent, as measured by the same productivity standard used by private-sector healthcare systems.
- This 10 percent increase in a system the size of VHA translates to roughly 20 million additional hours of care for Veterans.
- 96 percent of appointments are now completed within 30 days of the Veteran’s preferred date; 85 percent are within 7 days; 22 percent are same-day appointments.
- Average wait time last month? Five days for primary care, seven days for specialty care, and three days for mental health.
What do Veterans think?
We’re asking that question constantly, using automated kiosks at our facilities to let Veterans provide us immediate feedback. Nearly half a million have responded in recent weeks. The question we ask: “How satisfied are you that you got today’s appointment when you wanted it?”
- 89 percent tell us that they are “Satisfied or Completely Satisfied.”
- Less than 3 percent say they are “Dissatisfied or Completely Dissatisfied.”
Not sure what this would look like in the private sector, but I’ve got a hunch this compares favorably.
But guess what? As we improve access to care, more and more Veterans are choosing VA care—for the quality, for the convenience, or for the cost-savings. Even though we’re completing millions more appointments, the number of Veterans waiting for appointments has actually gone up. So we have more work to do.
Since 2009, we’ve hired nearly 9,000 more mental health clinicians, boosting their ranks by 65 percent. Staffing for our Veterans Crisis Line has grown by one third since 2014. It now has 388 employees, and we’re in the process of hiring 85 more to handle the growing volume of calls.
Since its launch in 2007, the crisis line has answered nearly 2 million calls. Almost a quarter of those calls were answered in just last fiscal year—490,000. The same is true for referrals to local VA Suicide Prevention Coordinators: One quarter of the 320,000 referrals made so far by crisis-line counsellors were made in FY 2015.
Crisis-line counsellors dispatched emergency responders to callers in crisis over 11,000 times last year and over 53,000 times since 2007. Since adding chat and text services, they have engaged nearly 300,000 Veterans or concerned family members through chat or text.
These aren’t just numbers. I’ve been there, and I’ve seen crisis-line responders on the phone, saving lives. It’s happening every day.
This past Christmas, a crisis-line counsellor answered a request for chat from a Veteran whose wife had died in the past year. This was the first Christmas in 27 years she wouldn’t be with him, and he was depressed and needed someone to talk to. It turned out that he had called the Veterans Crisis Line before, and that time he had already decided to end his life before his daughter woke up, but talking to Cynthia, a crisis-line counsellor, changed his mind. Remembering that moment made him want to contact the crisis line again to thank Cynthia for bringing him back, he said, “from the dark side to the bright side.”
This is who we are.
Maybe you saw the recent USA Today article about the Veterans Crisis Line. What the article didn’t say was: The IG report was based on two-year-old data. It didn’t mention the staffing increases I’ve just told you about or the crisis-line’s recent leadership changes. It didn’t go into added space or extra training or our improvements in call-center technology and business practices—all the things we’re doing to make sure that every Veteran who calls the crisis line talks to a trained, experienced VA responder dedicated to getting callers the help they need.
Think about that, next time you read about VA in the papers or hear about us on television.
What about the Veterans Benefits Administration?
The backlog of disability claims pending more than 125 days peaked in 2013 at 611,000. It’s now down nearly 90 percent. Average days pending for all claims is now just 91 days, and we finished 2015 with the lowest claims inventory since 2008. Tell me of another major part of the federal government that has transformed more in the last three years than VBA.
What about Veterans homelessness?
We’ve built a strong, productive collaboration among the Department of Housing and Urban Development, the U.S. Interagency Council on Homelessness, Veterans Affairs, partners at state and local government, and both non-profit and for-profit organizations in the private sector.
Since 2010 we’ve seen a 36 percent decline in the estimated number of homeless Veterans. There’s been a nearly 50 percent drop in the number of Veterans sleeping on the street. We have a winning strategy. It’s called the “Housing First” approach: Get Veterans into permanent housing, then meet their clinical and other needs.
Since 2010, over 260,000 Veterans and family members have been permanently housed, rapidly rehoused, or prevented from falling into homelessness by our programs and HUD’s targeted housing vouchers.
For the homeless Veterans we’ve housed: Emergency room visits are down 28 percent, and inpatient hospitalizations are down 30 percent. So we’re not just getting Veterans off the streets—we are healing minds and bodies and making better use of resources, so we can serve more Veterans.
Accountability has been an issue. For a lot of folks, this is about how many people we’ve fired. I have to say: In all my years in the private sector, I’ve never encountered an organization where leadership was measured by how many people you fired.
There’s a simple reason for that: You can’t fire your way to excellence. To turn any organization around, you have to inspire people to do better, and you have to recruit new talent. And you can’t do either by capriciously punishing people on the basis of rumors, innuendo, or press reports.
We are holding people accountable and firing those whose actions warrant firing—2,400 in just the past 18 months for misbehavior or poor performance. We’re also taking other disciplinary actions, appropriate to the offense and supported by evidence that (we hope) will withstand appeal.
Here’s where we stand on access-related cases:
- The Office of the Inspector General has closed out 77 investigations related to misuse of scheduling systems.
- In 62 cases, it found some issue requiring follow-up by our Office of Accountability Review, or OAR.
- But in the vast majority of these cases, the IG found no misconduct. Instead, they found that people just weren’t trained adequately.
- OAR found evidence of intentional misconduct warranting discipline at just 10 facilities.
- Twenty-eight employees were implicated; all 28 have been disciplined. Two were removed, three were demoted, 10 were suspended without pay, five received written reprimands, five received written admonishments, and three received counseling letters.
Where evidence confirms misconduct, employees are being held accountable.
But remember: Discipline isn’t all there is to accountability. To transform an organization, you have to practice what Bob and I call sustainable accountability, which means making sure people understand what needs to be done, providing them the wherewithal to do it, helping them overcome obstacles, providing regular feedback on performance, rewarding exceptional performance, and taking corrective action when warranted.
Let me give you an important example of sustainable accountability in action.
SAIL stands for Strategic Analytics for Improvement and Learning. SAIL’s the tool we use to measure Veteran healthcare outcomes at every VA medical center—measures around quality, safety, and patient satisfaction, among others.
Shortly after arriving at VA, I learned about SAIL and looked into the correlation between hospital directors’ performance ratings and the healthcare outcomes being delivered by their facilities, as measured by SAIL. I found stellar performance ratings at some of the lowest performing facilities.
So beginning in October of 2014, we integrated Veteran healthcare outcomes, as measured in SAIL, into every medical center directors’ performance objectives.
What happened? SAIL has become one of the most widely used management tools in the Department, and roughly 60 percent of VA medical centers improved healthcare outcomes for Veterans over the course of the year.
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.
That’s sustainable accountability: delivering better outcomes for Veterans—not just now, but for the long term.
That’s some of our recent progress. Here’s where we’re headed:
We have begun a major cultural and organizational transformation. It’s called MyVA, and it’s focused on five objectives:
First, improve Veterans’ experience—a seamless, integrated, responsive customer-service experience, every time.
Second, improve employees’ experience by eliminating barriers to excellent customer service.
Third, improve internal support services.
Fourth, grow a culture of continuous improvement to identify and correct problems faster and replicate solutions nationwide.
Fifth, strengthening strategic partnerships. That is, building vital and innovative networks of collaborative relationships across federal, state, and local governments, and with both non-profit and for-profit organizations.
One way we’re doing that is by helping communities around the country form Community Veteran Engagement Boards to bring together local Veteran service providers and advocates to improve outcomes for Veterans and their families. These are community-driven networks, run not by VA but by local civic and business leaders. They give Veterans and their families a forum to address issues and promote opportunities for collaboration. And they aim to resolve issues and help all of us better meet Veterans’ needs.
Thirty-nine are already up and running, and 16 more are in development. We expect to have a hundred in place by the end of the year.
We’ve made the necessary leadership changes to effect the MyVA transformation.
Ten of our top 16 executives have joined VA since the summer of 2014, and all ten have substantial business experience. We’ve also identified 12 breakthrough priorities to continue improving care for Veterans, and we’ve include those priorities in our 2017 budget request.
The President has proposed $182.3 billion for the Department in 2017. It’s a strong budget—very similar to the Independent Budget you proposed with PVA and the VFW.
Our budget requests $65 billion for Veterans’ medical care—a 6.3 percent increase over 2016.
- It includes $12 billion for Care in the Community and nearly $8 billion for Mental Health. One of our priorities is to ensure that when Veterans call for new mental health appointments, they receive suicide risk assessments and immediate care if needed.
- It supports modernizing Veteran Contact Centers and the Veterans Crisis Line, so Veterans can more easily access VA systems.
- It funds Hepatitis C treatment for an expected 35,000 Veterans.
- It provides $8.5 billion for long-term care and $725 million for 36,600 caregivers—a nearly 20 percent increase.
- It supports increased disability exams at all Regional Offices.
- It includes a 42 percent increase in funding for the Board of Veterans Appeals and a 35 percent increase in Board staffing to work the growing inventory of pending appeals.
Funding isn’t all we need. The budget request also includes more than 100 legislative proposals to overcome obstacles we face in trying serve Veterans better. Over 40 proposals are new for this year—some absolutely critical to even maintain our current ability to purchase non-VA care.
Here are six of the most important ones:
- Top-to-bottom transformation and streamlining of VA’s Care in the Community programs, based on the roadmap we provided Congress in October.
- Urgent changes to VA’s purchased care authorities—provider agreements and individual authorizations—so thousands of Veterans can continue receiving care, without interruption, from community doctors, hospitals, nursing homes, and State Veterans Homes.
- General Transfer Authority that allows us the flexibility to transfer up to 2 percent of discretionary funding to address emerging needs and overcome artificial funding restrictions on providing Veterans care and benefits.
- Flexibility on the maximum 80-hour pay period requirement for certain medical professionals. The private sector has this flexibility. We need it to improve hospital operations and attract the best hospital staff, who need more flexible schedules.
- Authorization of 18 leases and 8 major construction projects included in previous budget requests, plus 6 additional leases, 2 major construction projects, and 4 cemetery projects.
- Finally, legislation and funding to implement a modernized appeals process.
Let’s talk about appeals.
The present process was conceived over 80 years ago, and it’s unlike any other appeals process in the federal government. It’s complicated, opaque, unpredictable, and feels like an adversarial encounter between Veterans and VA. The average processing time for all appeals in FY 2015 resolved was three years. The average processing time for appeals that go before the Board was five years. Many appeals are much older. Last year, the Board was still adjudicating an appeal that originated 25 years ago—which had been decided 27 times.
That’s not right, and it will only get worse with the increasing number of claims we’re now processing. We have over 430,000 appeals pending right now. Without more resources—or major changes in the system—pending appeals are projected to soar more than 2 million in the next decade.
Veterans deserve timely appeals decisions produced by a process that is fair, transparent, and easy to understand. The current system is failing Veterans. The status quo is not an option.
We think Veterans deserve an appeals decision within a year. We’ve proposed a strawman process in our budget request. As Garry Augustine and I have discussed, it’s simply our marker for the kind of process we want to see crafted by VA and the VSOs in partnership. We’ve already met with VSO leaders and agreed to come together to try to craft a modernized claims and appeals process we can all support. The time to act is now.
Let me close with another quick story:
Back in December, VA nurse Sharon Levenson in Battleboro, Vermont, noticed that one of her regular patients didn’t show up for a scheduled appointment. She could have done nothing and just enjoyed the lighter workload that day, but instead she called the patient, and when he didn’t answer, she call the VA Police.
Now, the VA Police doesn’t do house calls, but in this case Police Chief John Richardson tasked an Officer Guy Gardner to investigate. Officer Gardner also couldn’t reach the Veteran, so he called the patient’s emergency point of contact, and when that person reported back saying no one answered the door at the Veteran’s house, Officer Gardner called the local police and requested a welfare check.
Local police entered the home and found the Veteran unconscious, but alive. He was rushed to the hospital where he was revived and began his recovery to good health.
He likely would have died, but for three VA employees who cared enough to go the extra mile.
This is who we are.
We still have a lot of work to do to ensure that every Veteran is treated with the same consideration, but we’re making great progress. And with your continued advice and support, we will succeed.
When you meet with your representatives in Congress, remind them of things Veterans need Congress to do as soon as possible: Veterans need Congress to grant the President’s budget request for VA; Veterans need Congress to act on our legislative priorities, especially on provider agreements; and finally, Veterans need Congress to legislate and fund a modernized claims and appeals process serving Veterans the way they deserve to be served.
One more thing: Let them know that you know there’s more to VA than what makes the news—that there are 350,000 VA employees dedicated to saving lives and changing lives every single day.
Thank you for all you do—for disabled Veterans, for all Veterans, and for their families, survivors, and caregivers.