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Veterans Crisis Line Badge

Office of Public and Intergovernmental Affairs

Remarks by Former Deputy Secretary W. Scott Gould

VA Hospice and Palliative Care Conference
Arlington, VA
May 4, 2010

Good afternoon, everyone. I’m delighted to be here to honor a few outstanding individuals and to thank you all for the work you do everyday, caring for Veterans in their last days.

It’s been a great honor for me to be part of the President’s team at VA. When Secretary Shinseki asked me to help him transform the Department, I saw a real opportunity to make a difference, and to support his tremendous drive for change and progress on behalf of our Nation’s Veterans.

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 …

  • He was sick and needed help;
  • I was his primary caregiver for 14 months;
  • The day came when we could not meet his needs at home. We had to admit him to a VA long-term care facility;
  • He was a patient there for 11 years;

People like you set the standard of care that helped my Dad through the end of his life and our family through that long good-bye. 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.

So this is my reason for serving here. I know that many of your have stories about your choice to be here—to provide this “Indivisible Care” for Veterans.

Challenges and Uncertainties

I would share with you that our ability to render care is being challenged from many quarters. We are working in an unstable, even turbulent environment:

  • Veterans’ needs and expectations are changing.
  • There is growing demand for our services as economic uncertainty forces more and more Veterans to turn to VA.
  • The political environment is also uncertain, creating an imperative for us to improve our performance.

VA is facing some important challenges:

  • Combating homelessness … with an eye toward vulnerable Veterans.
  • Extending health care to a half million Veterans who lost that entitlement in 2003.
  • Enhancing outreach/services for mental health care and cognitive injuries … focus on rural locations.
  • Providing greater benefits for Veterans medically retired from military service.
  • Providing comprehensive education benefits under the new, Post-9/11 GI Bill.
  • Improving technology—not just for the sake of technology, but to improve access, transparency, and outcomes—across the board.

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.
  • Develop enhanced skills, abilities, and competencies.
  • And commit to change dramatically our organization’s quality, access and cost. We have to reset our axis of advance and change our direction. We need to transform.


President Obama’s management agenda is clear—build a “high-performing government.” At VA, that means transforming our agency into a 21st century organization, and ensuring that we provide high-quality care and timely delivery of benefits to Veterans over their lifetime, from the day they take the oath of allegiance until the day they are laid to rest.

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 tough 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.

The President has demonstrated his commitment to VA transformation with strong budgets for 2010 and 2011 that boost VA’s discretionary funding almost 20 percent. These budgets provide us the resources required to increase Veteran access to benefits and services, reduce the backlog, and end Veteran homelessness within five years.

We Are Making Progress

  • We’re attacking the backlog on three fronts:
  • more trained Veteran service representatives
  • re-designing the process by which claims are adjudicated, and
  • professional, focused, and sensible use of information technologies that promise to slash the backlog significantly.
  • We have instituted a Performance Management and Accountability System (PMAS) to oversee the performance of our IT project, while also working to add staff and upgrade the skills of our IT workforce.
  • We are working with DoD to create a Virtual Lifetime Electronic Record (VLER) that would provide every member of our Armed Forces and every Veteran with a record that would stay with them from the day they put on the uniform until the day they are laid to rest.
  • We’ve recently begun a new initiative to recruit, train, develop, and retain a dedicated corps of highly qualified Acquisition professionals, certified competent according to new VA standards.
  • We are investing a record $300 million in Human Resources this year including $200 million in training alone. Employees are the lynchpin to achieving both VA transformation and the outcomes we want for Veterans. We have identified 42,000 positions that are essential to accomplishing VA’s mission and require additional critical skills training. We are also looking to train 22,000 people in change management and transformational leadership, and another 22,000 in leadership, management, and supervision.

These are just a few examples of the ways we are working to make VA more Veteran-centric, results-oriented, forward-looking, and advocacy-minded. Still a lot to do, but we’re picking up steam and gathering the momentum for a transformation push to last through 2012 and beyond.

Hospice and Palliative Care

Now to the transformation you and I are both personally invested in—

For some time now, the health-care community has been evolving its thinking about end-of-life care—moving away from a sharp division of labor between fighting the disease on one hand and comforting the dying on the other, toward a more integrated approach, combining curative or restorative care with palliative support from the early stages of illness.

As a major provider and purchaser of end-of-life care, VA has been evolving its thinking, too. Along with the change in thinking toward an integrated approach, we’re also seeing a generational shift in the Veterans needing care—from World War II and Korea Veterans, to Vietnam Veterans, who sometimes have different medical, emotional, and spiritual needs as well as different expectations of end-of-life care. As frontline care-givers, you adjust as needed at the bedside, but the change also requires an organizational response.

So we’ve partnered with community leaders in end-of-life care, including —

  • The National Hospice and Palliative Care Organization
  • The Hospice and Palliative Care Nurses Association
  • The Center to Advance Palliative Care
  • The City of Hope
  • And Northwestern University,

And we’ve planned and begun a three-year Comprehensive End-of-Life Care Initiative, or CELC, aimed at integrating palliative care across and beyond the VA health-care system. We’re about half-way through the initiative’s three years now, but we’re well on our way to achieving the goals set out for it.

We are more than half-way through the Five Phases of Organizational Change described by Quint Studer in his 2003 book Hardwiring Excellence:

  • The first phase is the Honeymoon. You know what that means: Everyone’s doing their best to get along and to go along, and change is looking easy.
  • Then Reality Sets In. That’s the next phase. You discover that not everybody’s on the same sheet of music. People start getting anxious about the changes they’re in for. Vested interests assert themselves, and lines are drawn between Us and Them.
  • Once the lines are drawn, an Uncomfortable Gap appears, between those who are still with the program, who are making things happen, and those who are digging in and going nowhere. The longer this lasts, the more uncomfortable the gap gets—for those still not on board—until one by one they come around.
  • The fourth phase is Consistency. The leadership team is in control, everybody’s on aboard, and the objective is clearly in sight.
  • The final phase is ultimate success. The change has been made. The new way of doing things is now hardwired into the organization.

So, where are we now with the CELC? Somewhere between the third and the fourth phases, between the Uncomfortable Gap and Consistency—still a few isolated points of resistance, but by and large the VISN’s are on board, and we’re making great progress.


  • We now have palliative care teams at every VAMC. That’s been the requirement since 2003, but it’s only been fully funded since 2009. 150 of these teams have received leadership training from the Center to Advance Palliative Care and our CELC’s Implementation Center.
  • We have trained 360 nurse educators at 144 VAMCs, who have in turn trained over 1,000 nursing assistants at VA and state Veterans facilities. And we expect to train another couple hundred nurse educators in the coming year.
  • We have funded staffing for 54 new hospice and palliative care units, with a total of 530 beds. We estimated that funding would support 630 professional caregivers, but the 54 units have actually exceeded this staffing level, with 805 people on board.
  • We have provided 24 grants to community agencies to improve access to hospice for rural and homeless Veterans.
  • We have published an updated directive on Hospice and Palliative Care Consult Teams (VHA Directive 2008-066), with a more inclusive definition of VA Hospice and Palliative Care and an enhanced definition of a Palliative Care Consult and the Palliative Care Consult Team.
  • We have also developed a Veteran-specific curriculum based on Northwestern University’s internationally acclaimed “Education in Palliative and End-of-Life Care” curriculum. This new VA curriculum is the centerpiece of our training effort in the CELC initiative.

For reasons beyond anyone’s control, it’s been held up for several months, but I am pleased to announce that the core of this new curriculum—minus the ethics module—has just been approved for use inside and outside VA. We will hold the first “train-the-trainer” sessions this September for some 250 VA staff members. By the end of next year, we expect to have every VA palliative care team—over 400 personnel—trained according to the new curriculum.

We have also just approved the Community Provider Awareness Campaign, which will use the new curriculum to train non-VA caregivers. Two out of three Veterans die at non-VA facilities. This campaign will help ensure that they receive better care at the end of life, tailored to their special needs as Veterans.


         Of course, all this effort is only meaningful if it improves care for Veterans and their families. So as part of the initiative, we’ve begun surveying bereaved families on their perceptions of the care received. Thankfully, those surveys show the worth of what you’re doing:

  • Ratings of “excellent” were 19 percentage points higher from families of Veterans who received a palliative care consult, compared to those who did not receive a consult.
  • Ratings of “excellent” were 13 percentage points higher from families of Veterans who died in a hospice or palliative care unit, compared to families of Veterans who died in an ICU, acute care facility, or nursing home.
  • Ratings of “excellent” were 16 percentage points higher from families contacted by palliative-caregivers after the death of their Veteran, compared to those who were not contacted.

We have also reviewed over 5,000 cases and found that Veterans who received palliative care consultations were —

  • More likely to have discussed with caregivers their goals for care (94% vs. 84%)
  • More likely to have completed an advance directive (56% vs. 46%)
  • More likely to have been visited by a chaplain (38% vs. 24%), and
  • More likely for there to have been some contact with the Veteran’s survivors after death (42% vs. 8%)

The trend toward increased use of hospice care at the time of death continues, with most VISN’s reporting increases in the percentage of in-patient Veterans dying in hospice beds in the first quarter of FY 2010, compared to FY 2009. The overall total of in-patient Veterans ending their days in hospice beds was nearly 35% in the first quarter of 2010, compared with 28% in FY 2008 and 12% in FY 2004.


The results are clear: Veterans and their families often prefer hospice care at the end of life, and our Comprehensive End-of-Life Care Initiative is increasing VA’s success in honoring that preference.

We’re not exactly where we want to be yet. There are still some gaps in care that need to be closed, and some facilities that still need to be fully brought on board. We’ve got designated teams at every VAMC, but not all teams are at full strength. There’s also the need to make sure all teams are fully trained. Some training is already available to team members, free of charge, and, as I mentioned earlier, about 150 teams have already been trained. But the new Veteran-specific training curriculum will add substantially to the training efforts, filling in whatever gaps there are in existing training.

In sum, there’s still some work to be done, but we’re making great progress, and Veterans and their families appreciate it.

For all your work in bringing us this far, you have my sincere thanks and firm support. You are an example to the rest of VA of the transformation that’s needed. Let’s keep up the good work—caring for those who have “borne the battle” in the last battle of their lives.

Thank you for having me here today. I wish you all the best.