Remarks by Deputy Secretary Sloan Gibson
Friends of Veteran Health Research Annual Lecture
Marines’ Memorial Club, San Francisco, CA
October 15, 2014
Remarks by Deputy Secretary Sloan Gibson Friends of Veteran Health Research Annual Lecture Marines’ Memorial Club, San Francisco, CA October 15, 2014
Last year, I went to West Point for the first home game of the season. At lunch before the game, I was seated next to a young Army sergeant first class. His dad, Craig, introduced me to his son, Cory Remsburg. All of America got to meet Cory in January during the President’s State of the Union address.
Five years ago this month, Cory was an Army Ranger in Afghanistan, on patrol with nine other Rangers when a 300-pound IED exploded along their route. One Ranger was killed, and the other eight were all wounded. Cory was blown into a nearby canal, the right side of his head crushed and caved in. He underwent six surgeries at military hospitals in Afghanistan, Germany, and Bethesda, Maryland, before arriving at the VA Polytrauma Rehabilitation Center in Tampa, Florida—comatose and in a state doctors described as vegetative.
But VA’s remarkable medical staff weren’t about to give up: They went to work trying to “jump-start” his brain. Supported by the latest medical know-how, they tried a wide variety of sensory approaches to awaken his consciousness—everything from aroma therapy to TV sitcoms.
Three months later, Cory became one of the seven-out-of-ten patients with severe TBI who come back to life through VA’s Emerging Consciousness program. Thanks to the miracle workers at the polytrauma center, the loving support of his family, and his own fighting spirit, Cory’s made steady progress. How much progress? Well, his proud dad, Craig, emailed me a few months ago to tell me that Cory just walked a full mile without crutches or a walker.
By the way, when I gave that update at the ribbon-cutting for the Tampa center last April, there was a cheer from the crowd. It was from a particular group sitting together—the nurses and doctors that cared for Cory, who became like family while he was there.
Please permit me a brief digression: VA is the second-largest federal department, with over 340,000 employees serving 22 million Veterans.
- We provide $66 billion in annual compensation for disability, dependency, and indemnity;
- We provide $10 billion in educational benefits annually;
- We guarantee two million home loans—with the lowest foreclosure rate and highest satisfaction rate in mortgage lending;
- We’re the Nation’s ninth-largest life insurance enterprise with $1.3 trillion in coverage and 6.7 million clients;
- We operate the Nation’s largest cemetery system, with 131 cemeteries that earn the highest customer-satisfaction ratings of all major public and private enterprises in the U.S.; and
- We’re the largest integrated healthcare system in the country—8.9 million Veterans enrolled, 150 medical centers affiliated with over 1,800 educational institutions; 819 community-based outpatient clinics; nearly 90 million outpatient visits each year; 300 Vet Centers providing readjustmentcounseling; 135 nursing homes (we call them Community Living Centers); 104 residential rehabilitation treatment centers; and 70 outreach and mobile clinics, serving more remote and rural areas.
Let me provide some further institutional context:
Since 2009, VA has had three main priorities: increasing access to benefits and services, eliminating the disability claims backlog, ending Veterans’ homelessness. We’ve made progress on all three priorities: We’ve added two million Veterans to the VA healthcare system since January 2009, we’ve cut the claims backlog almost 60 percent, and Veterans’ homelessness is down 33 percent.
It is well documented that, earlier this year, serious problems surfaced: process issues, like improper scheduling practices and an antiquated scheduling system; leadership failures, like our misuse of metrics and failure to hold people accountable for negligence and misconduct; and finally, resource shortfalls—our persistent lack of sufficient clinicians, patient-support staff, space, IT resources, and purchased-care funding to meet current demand for timely, high-quality healthcare.
As a result, Veterans were and still are waiting too long for care. There were widespread attempts by VA schedulers to “game the system,” which only masked the problem, making Veterans wait even longer for care. Employees who pointed out problems in the system or wrongdoing by others were often punished for doing so. Managers who hid their poor performance or retaliated against whistleblowers were not held to account, and senior leaders failed to adequately assess the resources needed to provide the care they were obligated to provide.
Clearly, VA lost the trust of Veterans, the American people, and their elected representatives—trust we have to earn back, while everyone is focused on the most serious crisis in more than a generation.
Many fail to see that we are presented with our greatest opportunity to enhance care for Veterans in our history. I wasn’t the only one who thought that. In June, I met with Dr. Harvey Fineberg, distinguished clinician and healthcare executive, who had just completed 12 years as the president of the Institute of Medicine. When I told him that I thought VA could accomplish more in the next two to three years than we could have in two to three decades, he immediately corrected me: “No! VA can accomplish things now it never could have accomplished.”
He was right: We are in an extraordinary position. We all understand the seriousness of the problem. The President, Congress, Veterans’ organizations, the American people, and VA’s rank and file all understand the need for reform. What is needed is for us to seize the opportunity and make the most of it.
How are we going about seizing that opportunity?
In early June, I started making the rounds of VA medical centers, seeking out the on-the-ground truth. What struck me was the contrast between places like Phoenix and San Antonio.
In Phoenix, I spent an hour listening to employees share their frustrations—surgeons, nurses, physical therapists, custodians, IT staff. Half of those who spoke were holding back tears. These people really cared—they cared about the mission, they wanted to do the right thing, and they worked really hard taking care of Veterans. The many problems and shortcomings I found were the result of leadership failure, mismanagement, and chronic under investment.
In San Antonio, it was a whole different story. Everywhere I looked I saw excellence. The employees were very upbeat and had a sparkle in their eyes as they talked about the care they were providing. At the press conference in San Antonio, I told the media I wished every Veteran in America could have been at my side as I toured the medical center. They would have been so proud.
Ironically, the harder of these two visits for me was San Antonio, because everywhere I looked I realized that—but for leadership—Phoenix could have looked just like that. But for leadership.
Everywhere else I went, I challenged VA leaders to explain to me the difference between Phoenix and San Antonio. I never heard an explanation that didn’t boil down to one thing—leaders failing to take ownership of the problems, both large and small, facing their employees.
Let me explain what I mean by ownership with an example: A surgeon in scrubs stood up and said he didn’t have much time before heading off to surgery, but could I please fix the two x-ray machines in the OR, which hadn’t worked since an attempted computer upgrade months earlier. All they needed was someone going down to the OR to work the problem, but somehow that hadn’t happened yet. It has now, and they’re both working.
That is a leadership and cultural change we are working on. We made accelerating care to Veterans waiting the longest our top near-term priority:
- We reached out to over 300,000 Veterans to get them off wait lists and into clinics.
- We deployed mobile medical units and used temporary staffing resources to provide more care where needed most.
- We accelerated hiring of clinical and key medical support staff.
- We began the process to acquire a new, state-of-the-art, “commercial off-the-shelf” scheduling system, and while that process proceeded. . .
- We extended clinic hours into nights and weekends and worked to make better use of appointment slots.
- We started work on a more robust system for measuring patient satisfaction.
- We increased referrals to private-sector providers by 369,000 over the same period in 2013. Each referral, on average, results in seven appointments. That’s an increase of 2.5 million appointments over 2013.
- We suspended all VHA senior executive performance awards for fiscal year 2014 and removed wait-time metrics from all individual performance goals.
- We began posting regular, detailed data updates to wait times and care-quality statistics for every medical center.
- I personally visited 20 VA medical centers to see firsthand the actions being taken to get Veterans off wait lists and into clinics, and met with employee and the media during each of those visits to encourage and model the openness and transparency we must pursue.
I also made several senior leadership changes:
- Dr. Carolyn Clancy as Interim Under Secretary for Health—formerly Director of the Agency for Healthcare Research and Quality at the Department of Health and Human Services.
- Dr. Gerry Cox as interim director of the Office of the Medical Inspector—formerly Assistant Inspector General of the Navy for Medical Matters.
- Dr. Jonathan Perlin as Senior Advisor—on loan from the Hospital Corporation of America, where he is Chief Medical Officer and President for Clinical Services.
- I also brought in Leigh Bradley, former VA General Counsel and head of DoD’s ethics office, to lead our work around accountability actions.
The President soon nominated—and the Senate quickly confirmed—former Procter & Gamble CEO Bob McDonald to be Secretary of Veterans Affairs. Bob and I have been friends for 40 years beginning during our time together as cadets at West Point. He’s a proven leader and manager, and he’s got one of the strongest moral compasses I have ever seen. This combination of executive skills and values are ideal for VA at this critical time.
Since his arrival, we’ve have moved out smartly on three fronts: First, rebuilding trust with Veterans and other stakeholders; second, improving service delivery focusing on better Veteran outcomes; and third, setting the course for longer-term excellence and reform. We have recommitted the department to our mission, to care for those who have “borne the battle,” and to our values: Integrity, Commitment, Advocacy, Respect, and Excellence—“I CARE.”
We are also working hard to create a climate that embraces constructive dissent, welcomes critical feedback, and ensures accountability where misconduct or management negligence have occurred. As investigations have been completed, personnel actions have been announced, including a number of senior executive removals. Many investigations are ongoing—by the VA Inspector General, the Department of Justice, the Office of Special Counsel, and others. In each case, when the facts and evidence are known, we will take appropriate disciplinary actions.
As we move forward, our focus is on sustainable accountability, which means, not just adverse personnel actions, but also requiring supervisors to provide feedback to subordinates, acknowledging what’s working well and what’s not, and identifying needed improvements. We’ll also have to change our hierarchical culture to encourage more collaboration and innovation, and we have work to do to refocus the entire organization on delivering Veteran outcomes.
As we refocus the organization, we apply two tests to everything we do, to every decision we make: First, do the right thing for Veterans; second, be good stewards of taxpayer resources.
Another major development has been the passage of the new Veterans Access, Choice, and Accountability Act of 2014. Among its many provisions, it provides VA an additional $15 billion—$10 billion to expand purchased care for Veterans living more than 40 miles from a VA facility or waiting more than 30 days for care, under a program called Veterans Choice. Most importantly, in my view, it also provides $5 billion for infrastructure and clinician hiring to increase our internal capacity to care for Veterans.
To support our hiring effort, Secretary McDonald has approved the first increase in three years in the minimum and maximum rates of annual pay for eligible VA physicians and dentists. With more competitive salaries, we’ll be better positioned to attract more healthcare providers. The Secretary has also been making the rounds of medical schools, including UC San Francisco, telling VA’s story. It’s a great story, and we are both telling it every chance we get.
VA has led the medical world with many “firsts.” Our medical professionals pioneered electronic medical records, developed the implantable cardiac pacemaker, conducted the first successful liver transplants, created the nicotine patch to help smokers quit, proved that a daily aspirin cuts in half the risk of heart attack for angina patients, applied bar-code technology to medications administered to patients, and found a way to animate artificial limbs with electrical impulses from the brain.
For these and other achievements, VA researchers and clinicians have received three Nobel Prizes, seven prestigious Lasker Awards, and many other awards and recognition. Just last month, the Partnership for Public Service awarded the Samuel J. Heyman Service to America Medal to two VA employees—Dr. Bill Bauman and Dr. Ann Spungen—for their 25 years of work helping paralyzed Veterans.
Veterans who suffer spinal cord injuries can incur a host of other medical problems—breathing difficulties, bone loss, pressure ulcers, and higher risk of heart disease. Such complications can greatly shorten the life expectancy of people with spinal cord injuries. But for a long time, little was known about the connection between the complications and the injuries.
Bill Bauman and Ann Spungen helped change that. They met at the VA hospital in the Bronx. He was a medical researcher and internist in endocrinology; she was an exercise physiologist sent to train Bill in the use of a metabolic cart—a device to measure energy expended. When Bill shared his dream of learning how spinal cord injuries caused respiratory and other problems, Ann quit her private-sector job to join him in studying every system in affected patients.
Together, they led a multi-talented team of doctors—specialists in internal medicine, neurology, rehabilitation medicine, and other fields—to investigate what happens to the body after a spinal cord injury. Their research verified connections between spinal cord injury and heart disease, breathing problems, and other threats to health. It also led to new approaches to therapy, reducing complications and improving the lives of paralyzed Veterans.
But here’s a little known fact: For her first 13 years researching spinal cord injuries, Dr. Spungen wasn’t funded by VA—she was funded by the Icahn School of Medicine at Mount Sinai. She didn’t start receiving VA funding until 2003—two years after she and Dr. Bauman established VA’s National Center of Excellence for Medical Consequences of Spinal Cord Injury, at the Bronx VA Medical Center, where they recently tested a new bionic system that enable persons with paralysis to stand, walk, and even climb stairs. She and Dr. Bauman still maintain teaching positions at Mount Sinai, though most of their work is for VA.
Their success points to the importance of VA’s partnerships with over 1,800 academic institutions nationwide. Those partnerships are important not just to Veterans but to the whole Nation—and they’re important for two reasons.
One is training: Each year, VA helps train nearly 120,000 health professionals—62,000 medical students and residents, 23,000 nurses, and 33,000 trainees in other health fields. More than 70 percent of all U.S. doctors have received training at VA. No single institution trains more doctors or nurses than VA.
The other reason is research: The Bronx VA’s work on spinal cord injury is just one of many examples of partnerships advancing medical science not just for Veterans but for all Americans. Another example is the research on rehabilitation for traumatic brain injury at the Tampa Polytrauma Center that treated Cory Remsburg—a collaboration with the University of South Florida.
Then there’s the work done here by the great faculty and staff of UC San Francisco and the San Francisco VA—which boasts the largest research program in VA: $79 million spent on research in 2013, 230 principal investigators, 965 researchers, 790 research projects, six clinical Centers of Excellence, doing research on post-traumatic stress, HIV infection, epilepsy, cardiac surgery, renal dialysis, and primary care education. The San Francisco VA is one of the few hospitals in the world equipped for studies using both whole-body magnetic resonance imaging (MRI) and spectroscopy. It’s also the site of VA’s National Center for the Imaging of Neurodegenerative Diseases.
Incidentally, only about 16 percent of the $79 million the San Francisco VA spent on research last year came from VA. The rest came from NIH, DoD, NASA, foundations, and corporations. That alone tells you how important partnerships are to VA research.
The support of its partners helps make VA the NASA of the healthcare industry. Like NASA in its early days, we have an important national mission, worth all the effort we can put into it. But also like NASA, our efforts yield significant benefits beyond the Veteran population, promising to improve the lives of all Americans for generations to come.
That’s important to remember when weighing private-sector alternatives to the Veterans healthcare system. Sure, we can purchase care from the private sector for many Veterans. But purchased care alone will not achieve the advances in medical science needed to give Veterans, like Cory Remsburg, the care they deserve. Nor will it benefit the Nation and the world through those same advances.
My thanks to Dr. Carl Grunfeld, Louise Renne, Bob Obana, and John Swensson for the invitation to speak tonight. Thanks also to MG Mike Myatt and the Marines’ Memorial Association for hosting this event. Finally, my thanks to all present for your concern for Veterans. It’s an honor to be here, and I look forward to your comments and questions.
