Consulo Indicium - 4/2/18

Information for your Consideration…

The Pace Of Blogging – For many of us – who are news junkies – one of the first things we do in the morning is turn on the news. Over coffee and breakfast, we ponder all of the changes that have occurred overnight and the Tweet storms on the horizon to gain a better view on the lay of the land.  But, it’s difficult.  The change of direction, the requirements for fact-checking on many items, the incomprehensible blizzard of changes in staffing are all distractors to the many issues facing America.  As my readers know, “health care” is at the top of my list as an issue that needs resolution.  It also needs consistency of policy over time.  It needs leadership with integrity.  It needs bipartisan solutions.  And, for these reasons – I’m sending a “special” blog because of the recent changes at the Veterans Administration.  As always, your thoughts and perspectives are valued.  Send them to This email address is being protected from spambots. You need JavaScript enabled to view it..  They will be read, reviewed and appreciated.  Now…on to the reason for the special blog…

The Discontinuity Of Continuity – At the outset, let me say that this note is out-of-character for me.  In fact, it’s a first!  I don’t usually comment on people changing positions or moving from or to various roles.  I view those types of changes as the inevitable outcome of what happens in modern day corporations.  However, the decision by President Trump to fire US Veterans Affairs Secretary David Shulkin, MD deserves some commentary. 

There are a couple of items you should be aware of before reading my thoughts.  First, I’ve known David for nearly 25 years.  We “grew up” together in the world of health care systems as Chief Medical Officers for various care delivery organizations.  As part of that club, we got to see one another’s warts, scars and traumas as we all moved from working as clinicians to becoming administrators and then, working diligently to become leaders – a process that most of us continue to work on to this day. 

Second, David is a person who is driven by facts and data.  One of the reasons the VA has turned the corner in recent years is because of the measured philosophy he has brought to the agency.  When push comes to shove, an approach to solving problems where “just the facts, Ma’am” is the dominant model creates an environment of accountability – and, transparency – that is difficult to argue against. 

Third, on a good day, taking on the challenge of remodeling the VA is a gargantuan task.  On a bad day, it can seem impossible.  Change is difficult but in an organization like the VA – it requires a degree of perseverance that is inestimable.  Yet, David has slowly but surely moved the chess pieces forward in an effort to provide veterans with the health care they deserve. 

Finally, any person looking at the capabilities of the VA and those of other health care systems would easily come to the conclusion that forming some type of alliance between this large, cumbersome bureaucracy and local health care delivery organizations would make sense.  But, there is clearly not a cookie cutter model and anyone that goes down that road will likely be doomed to failure.  The potential integration and/or collaboration with local providers is a move that requires the careful consideration of the types of services available locally to support not just the run-of-the-mill medical problems of veterans but also the unique veteran disabilities whether physical or mental.  It also makes sense to have some defined proof points recognizing that the initial models will likely be variable and not deployed on a uniform basis across the entire nation.  Such was the approach of Dr. Shulkin…

While Dr. Shulkin’s departure will no doubt be absorbed – just as the departure of most leaders in government or private industry – his methodical movement toward “solving the problem” will likely result in a backward slide within the VA.  It is unfortunate.  When one considers the data, it’s obvious that progress was once again occurring within the VA after a 10+ year hiatus.  Efforts were being made to enhance quality; initiatives, to enhance service; and, projects, to increase access.  And, at the end of the day – increasing the quality/service/access triad is one of the important requirements for “making health care better” (my personal mantra for why I get up in the morning for nearly 40 years).   

So, what should be done about the VA?  Here are a couple of steps that require serious consideration and which the next Secretary should put on the table as part of the requirement for taking the job.  It’s probably not a complete list and – more importantly – is a list that is devised as an “observer” of the VA rather than as “consultant” or “employee” or “advisor” to the VA.  These are purely my high-level thoughts in considering how our nation can best honor its commitments to veterans and also drive efficiency and effectiveness in a large, bureaucratic organization.  The thoughts include:

1. Initiate a Revised Structure for the VA – Congress should seriously consider re-establishing the VA as a separate “Public-Private Partnership” (P³) corporation. One of the issues that Dr. Shulkin mentioned in his departure interviews was for Congress to address how the problem of the “revolving door of leaders” at the VA can be resolved.  Political appointees to leadership positions is the last thing that is needed to solve the problems.  In a large organization that is complex and spans the entire nation – consistent, focused and reliable leadership is essential.  It will require a strong, diverse team that moves in concert philosophically and managerially to solve problems.  Large, diverse corporations require such leadership to be successful.  There are good examples that serve our nation well.  Two examples come immediately to mind.  In the shipping industry, our nation’s ports are mostly managed by P³ arrangements – and, quite successfully.  Having open, high quality operations at the ports has been a cornerstone of our successful economy for many years.  A second example is the increasing use of P³ approaches for managing our nation’s transportation infrastructure.  Whether it is roads, bridges or interstate highways – such an approach has been successful.  It’s not easy and the approach of shipping is different than transportation so, again, there are no cookie cutter models.  On the international level, we’ve seen the use of P³ arrangements for managing “public” health care systems and organizations in the United Kingdom, for example.  So, the idea has merit, it is being used internationally and, it should be considered.
2. Establish a Functional Governance Model – While the P³ model is a potential solution, the requirements for making it work – in my estimation – will never be met if Congress serves as the “Board of Directors.” I don’t care whether it is a Democrat or Republican Board that is in control. Congressional governance will only continue to exacerbate the ongoing problems of the VA.  Rather, appropriate “oversight” should be put in place that represents true governance – like a large health care system.  The delivery of quality, reliable, cost-effective health care for veterans is not a political process.  It requires a governance oversight that can resolve the very significant problems faced in providing care to veterans.  If I were a Czar and able to make the changes, the Board of Directors would be something like: 3 veterans, 3 health system leaders, 3 “open” positions; and, 3 Congressional appointees.  The positions would be staggered and be for 6 – 9 years in duration.  They would be required to provide a report to Congress every year.  I’m sure there are other parameters but this is a good starter kit.
3. Deploy Tele-Technology – The VA has actually been one of the leaders in exploring the use of tele-technologies for enhancing the ability of the agency to delivery services. In particular, the use of VA systems has been shown to be very effective in delivering care to rural areas and to those veterans with mental health issues such as PTSD.  What’s needed; however, is for Congress to support a national infrastructure plan for enhancing the digital capacity of all geographic areas across the USA on a ubiquitous basis.  The fact of the matter is that many rural areas – which are large swaths of the nation – have inadequate digital capacity for supporting the types of communication required for effective telecare. 
4. Continue the Focus on Service – One of the areas Dr. Shulkin emphasized was enhancing the service capability of the VA. This is a cultural phenomenon and does not simply occur because of declarations.  The efforts that he initiated should be continued and expanded. And, in my experience, culture starts at the very top with leaders.  So, continuing that focus from the Office of the Secretary will be crucial or it will hit the dustbin of talked about strategies that never become reality.
5. Continue the Drive for Transparency – When problems are hidden or covered over, they are unseen. Dr. Shulkin has really pushed the “transparency” agenda which has been very good for the VA.  The ideas and efforts need to be continued.  Continued use of metrics and comparisons to private health care providers should also be expanded.  Let’s hope that this effort does not slide into oblivion with the passing to a new leadership team…

Let me offer a final comment on Rear Admiral Ronny Jackson, MD who has been named by President Trump to replace Former Secretary Shulkin.  Dr. Jackson has a strong medical pedigree.  He is a graduate of the Uniformed Services University of the Health Sciences, a graduate of an Emergency Medicine program and a Fellow with the Beth Israel Deaconess Medical Center Disaster Medicine program.  Plus…he has lots of military medals and awards.  But, does that prepare him for the role?  While there is every indication that Dr. Jackson is an outstanding clinician – that does not necessarily provide the grounding for leading large, complex organizations – despite the support he is receiving from various sectors.

I will never forget when I took on my first role as a Senior Vice President and Chief Medical Officer.  This was after nearly 10 years of some managerial experience in leading smaller groups of 10 – 20 people.  Early in the experience, I remember an issue coming forward where I decided I needed to take action.  I reached for the metaphorical handle on the decision lever and pulled it with bravado and action.  Nothing happened.  This is what happens in large, complex organizations.  Change does not happen by pulling on the metaphorical handle.  Rather it comes through providing a vision, through being the type of leader you want others to be and, by setting a direction and encouraging your followers to step up and refine the ideas.  I question whether Dr. Jackson is ready for the challenges of the VA.  All the training and skills of an outstanding clinician do not solve the problems of management and leadership.