Remarks by Former Deputy Secretary W. Scott Gould
2010 Veterans Health Administration National Leadership Conference
Las Vegas, NV
August 26, 2010
It’s truly a pleasure for me to be here today, to talk about my favorite issues—our Veterans and the transformation that will better serve them. First, I want to acknowledge the previous speaker, my good friend and colleague John Berry, Director of the Office of Personnel Management.
John’s list of achievements in public service is broad and deep, and his ties to VA and to Veterans are close. OPM is a critical provider of HR services to VA, and John continues to be very generous in sharing his valuable time with us for the good of Veterans.
I know John from our days together at Treasury. Take it from me, America's civil servants could not have a more innovative or effective leader than John Berry.
I thank him for joining us today. Now for a few words about our host, Dr. Petzel:
I want you all to know how excited Secretary Shinseki and I are to have Randy Petzel heading VHA. It took us a long time to fill the position of Under Secretary for Health. The selection committee searched for more than six months, and in that time it evaluated some tremendously able executives. But Dr. Petzel stood out among them for three things: his vision of transformation, his passion for realizing the vision, and his sense of urgency in getting started.
You can’t lead others through a major transformation of an organization as large and complex as VHA without all three of those qualities. You have to know where you want to go, you have to really want to get there, and you have to have the energy and initiative to seize the day and take advantage of the window of opportunity while it’s open—because it won’t stay open forever.
Randy Petzel has what it takes. Importantly, he has the trust of the Secretary and our entire leadership team. He’s lived all his life to be where he is now. He is a physician first and foremost, deeply committed to caring for our Veterans. He’s the right man at the right time, and we couldn’t be happier than to have him leading the change Veterans need to see at VHA.
My thanks to all of you for attending this three-day conference. Over the past couple of days, you’ve been immersed in plans and strategies, breakout sessions and panel discussions. You’ve heard all about the change in store—data-driven, 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. And you’ve figured out that the one essential ingredient in making all this happen is all of you working together to make it happen.
Let me take a moment to explain my own motivation for serving at VA. Many of you know I am a Veteran of 26 years in the Navy, active and reserve. But you may not know that one of my principle reasons for leaving active duty was a call I got from my father when I was 28.
We got on the line together and he told me he had been diagnosed with Alzheimer’s. His view was that he was failing fast, and he wanted me to come home, and I did. I was his primary caregiver for 14 months. And a man who looks like me, went from being a fully functioning investment banker, going to work on the train every day, to confinement and lying in a bed for 14 months.
Now those of you who have cared for somebody in those circumstances know that it can be heartbreaking and it is also very physically demanding. At the end of those 14 months, my father who was also a Veteran of the Navy, of World War II and Korea, qualified in every way for care at the VA hospital in Bedford. I remember the morning we got into the car and put the seatbelt on him and had to tuck him in—Alzheimer’s takes that ability to navigate even the simple tasks—and drove him to the Bedford VA. And how we were welcomed. And how the team came to the curb and the car with a wheelchair to bring him in. He lived there for 11 years. He was the oldest surviving member of his cohort group when he passed. I came to appreciate something about our VHA that I would not otherwise have understood—that the care that was given to him was the product of the nurses and the RNs, and the frontline staff who fed him every day, and ground his food up and put him on the winch to bathe him at night.
When I come to work each morning, I remind myself that today someone else is going through that experience. I’d like VA to be there for them too. To be there for all Veterans, both today and tomorrow, and to do that, we can’t settle for the status quo.
We are working in a very uncertain environment. I’ll give you four reasons why that is so. First and most obviously, our nation is at war. If you will, the hurt factory is open for business. You know it when you see the casualty figures in the paper. You know the ratio of wounded to those casualties is 10 to 1. And you know that beyond that there are the thousands that suffer from PTSD and the invisible wounds of war. You know that World War II, now fought 65 years ago, only ushered in Korea, Vietnam, the first Gulf War, Iraq, Afghanistan. The total of armed conflicts in which our country has been involved since that time is over 300. So we will be open for business for a long while. And the injuries of war that we are fighting are changing. They are creating a gap between what we understand as our deeply held commitment to serve all Veterans no matter what their need and our knowledge of what those injuries are and what to do about them. There is also a growing demand for our services as economic uncertainty forces more and more Veterans to turn to VA.
And finally, Veterans’ needs and expectations are changing due to rapidly emerging technologies; instant evolving communications; comparative standards of services that we in our lives and they, in theirs, experience day after day. So we have to match all this change with our enduring commitment to care for the Veterans who fought on our behalf. In order to meet these overarching challenges and make a difference in the lives of Veterans, we not only have to leverage our passion for what we do; and develop enhanced skills, abilities, and competencies; but also commit to change dramatically our organization quality, access, client satisfaction, and cost. We have to reset our axis of advance and change our direction. In short, we need to transform.
You’ve heard a lot about transformation this week already. Under President Obama and Secretary Shinseki’s leadership, it’s VA’s operative word.
Basically, VA’s transformation can be defined in three sentences: Change VA’s culture from adversary to Veteran advocate; deliver improved services and benefits in a demanding operating environment to achieve high standards of quality; build strong and flexible management systems to help us achieve these results for Veterans and their families.
There’s no question about it, these three overarching goals present us with significant challenges. Not the least of which is how we go about making them a reality.
First, we start with three basic principles that define our thinking and our actions, and I know by now that you’re familiar with them: Veteran-centric, results-driven, and forward-looking.
Second, we need to take a tough, hard look at our current organization, from top to bottom, to identify areas for improvement in quality, access and value. We need to question our assumptions.
And last, we must field initiatives that will dramatically improve how we interact with each other, and with the Veterans we serve. These initiatives must change our behavior and, in so doing, they will change our mindset. These principles of transformation apply to all of VA including VBA, NCA, Office of Information Technology, Acquisitions and Logistics, Construction, and Human Resources.
Your work is to apply these principles of transformation to the largest integrated healthcare system in America in order to improve the quality, access, and value of healthcare for Veterans.
What Randy has done is apply these principles to develop the VHA mission, vision, and goals. In so doing, they meet your unique needs and align with the transformation in the rest of VA. 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.
So we have to positively influence Executive branch and Congressional decision-making about resources—we do that by delivering quality, access, and value.
Our goal is to optimize, not simply maximize, healthcare 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 very clear picture of what we must do in VHA to achieve our vision: the railroads, the Interstate Highway System, and the Internet.
Railroads revolutionized commerce in the 19th century, but their impact was stymied by the lack of a standard gauge for tracks. For most of the century, track width varied from three feet to six feet, causing tremendous inefficiencies that slowed transportation and increased costs.
Until 1854, passengers and freight traveling east or west between Buffalo and Cleveland had to stop in Erie, Pennsylvania, to change trains—because the tracks east of Erie were 6 feet wide, while the tracks west of Erie were 4 feet 10 inches wide. The citizens of Erie were making out like bandits, charging the railroads to load and unload freight, and charging passengers for food and other comforts during their layovers.
When the railroads decided to standardize the tracks, the people of Erie rose up in arms, starting what became known as the “Erie Gauge War.” First, the city council passed an ordinance barring the railroads from crossing city streets. Then it passed an ordinance authorizing the city’s police department to dismantle the railroad bridges in the city, which it did.
New track laid outside the city was torn up by local citizens, road beds were plowed over, and shots were fired at railroad officials, though nobody was hurt. Railroad traffic through Erie came to a screeching halt—but only for about seven weeks. With no trains moving through Erie, nobody was making any money, so the people of Erie were forced to give in—for their own good.
The moral of this tale of transformation is this: Standing in the way of progress will cost you more in the long run. Or, as Secretary Shinseki is fond of saying, “If you don’t like change, you’ll like irrelevance even less.”
Over the years, more and more railroads had the good sense to adopt a standard gauge, increasing pressure on the isolated holdouts. The last holdouts gave way in 1886, when over 11,500 miles of track in the South were adjusted to the standard gauge in just 36 hours.
Time zones also presented a problem for railroads. At first, each railroad kept its own time. Train stations used different clocks for different railroads. The main station in Pittsburgh used six clocks.
As railroads spread across the country, this made less and less sense. So in 1883, the railroads adopted the standard time zones we know today, replacing over 100 existing time zones. Most cities and counties followed suit, though the borders of the new time zones remained a matter of dispute. It took an act of Congress—Standard Time Act of 1918—to finally put the matter to rest.
With these two improvements—standardization of track width, and the creation of uniform time zones—variance was reduced, and the system advanced by leaps and bounds. The country went from 31,000 miles of railroad in 1861, to 170,000 miles by the end of the century.
Jump ahead to the creation of the Interstate Highway System: In 1919, it took an Army convoy 62 days to drive from Washington, D.C., to San Francisco. A young lieutenant colonel named Dwight D. Eisenhower rode along with that convoy, and reported on the poor conditions of the roads, which between Illinois and California were still largely unpaved.
As president, Eisenhower proposed a network of interstate highways of uniform design, laid out according to a national plan. 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. America was on the move, and expanding along new pathways. Once again, 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.” And when they are ill or injured, returns them to health quickly, safely, conveniently, and efficiently.
Prevention of illness and comprehensive health management is the most efficient, highest quality, safest, and economically 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 such as meditation, yoga, diet, and exercise, that can prevent disease and reduce suffering. Where are the clinicians and researchers ready to step forward with the larger scale, better designed studies to determine which of these practices could reliably help our Veterans?
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 further develop, and implement our strategies for how we deal with the end-of-life realities that face all-too-many Veterans and their families.
I have no doubt that with the commitment of all of you here, VA will create the next generation of healthcare 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 organizations in America. All of our management infrastructure will be brought to bear on our mission—including IT, acquisition, logistics, financial management, construction and facilities management, and human resources, so that our back-office support is as strong as our world-class direct patient-centered care.
So how do we meet these challenges?
- 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;
- additional resources, strong budgets;
- and more and better training.
We want a people-focused culture where employees are valued; where there’s a commitment to performance and initiative; and where there’s a premium on trust and competence. We are incorporating the “people factor” in the way we manage. We are ramping up investment in our employees: In my view, people rank as government’s most important resource. We need to treat that national resource better than we would any other—as the vital factor worthy of our ongoing development.
We are transforming potential into performance through professional growth. VHA employees should take advantage of ample training opportunities like ADVANCE, one of HR & A’s transformation initiatives. And we are implementing government-wide hiring and personnel reforms.
Of course, an important part of leveraging the people factor is engaging labor in meaningful communication and collaboration. Both management and labor want positive results for Veterans. Both also have rights and responsibilities under contracts and general laws. We need to embrace our common objectives and build on the combined, non-adversarial strength of labor and management, to leverage a joint commitment to progress.
In conclusion, Veterans rightfully expect us to meet their needs in increasingly efficient, convenient, and customer-friendly ways. “Business as usual” will no longer do. We’re changing to better serve the evolving needs of America’s Veterans whether he or she is: The 20-year old Veteran of Afghanistan; the 40-year old Veteran of Kuwait; the 60-something Veteran of Vietnam; or the 90-year old Veteran of Normandy.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 stakeholders’ expectations. We will improve performance measures, including client satisfaction, 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 healthcare system worthy of the title, “Best in the World.” 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. 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.
But in the event that all of the discussion and speechifying of the last few days have not broken through, I would offer you these words of Lord Nelson, who said before a great naval battle, “in the case that the signals can neither be seen nor perfectly understood, no captain can do very wrong if he places his ship alongside that of the enemy.” And our enemy is ineffectiveness, inefficiency, inequity, and worst of all ingratitude for the service of our Veterans.
So to close with the enemy, if you do not already have a list of things that you intend to do when you get back, I would offer these three suggestions:
First that you take a piece of paper out now, that you jot down two or three bullets that comprise the things in this moment that in your judgment most need to be done in your organization to move it forward on the vision that Randy Petzel has presented to you here at the conference. Once you have those two to three key points, I would suggest you add one at the top that says, “communicate to your employees all that we talk about here.” All of the rich ideas, all of the resolutions that you make personally—don’t matter at all if the 2,000 people here today don’t go back home to VHA tomorrow and communicate to your employees what happened, what was decided and what is the direction for our organization—number one. Then your main points, and then the last: tell about your success and tell about your failures but share the information with each other and back up the chain of command so that we as a team know what is working and how we are going to get to our goal.
I know your commitment to, and respect for Veterans is without question. And I want to take this opportunity to thank each of you for what you do every day for Veterans, and for your contributions to positive change at VA. And now I’d be happy to hear your thoughts and take your questions.