[Senate Hearing 114-742]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 114-742
 
  VHA BEST PRACTICES: EXPLORING THE DIFFUSION OF EXCELLENCE INITIATIVE

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 7, 2016

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Richard Blumenthal, Connecticut, 
John Boozman, Arkansas                   Ranking Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Jon Tester, Montana
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia
                       Tom Bowman, Staff Director
                 John Kruse, Democratic Staff Director
                 
                 
                            C O N T E N T S

                              ----------                              

                           September 7, 2016
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from 
  Connecticut....................................................     2
Boozman, Hon. John, U.S. Senator from Arkansas...................    19
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    21
Rounds, Hon. Mike, U.S. Senator from South Dakota................    23
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    24
Heller, Hon. Dean, U.S. Senator from Nevada......................    27
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    29
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    31
Moran, Hon. Jerry, U.S. Senator from Kansas......................    33

                               WITNESSES

Clancy, Carolyn M., M.D., Deputy Under Secretary for Health for 
  Organizational Excellence, U.S. Department of Veterans Affairs; 
  accompanied by Shereef Elnahal, M.D., Senior Advisor to the 
  Under Secretary for Best Practices; Kimberly Garner, M.D., 
  J.D., Associate Director for Education and Evaluation for VISN 
  16, Central Arkansas Veterans Healthcare System Geriatric 
  Research Education and Clinical Center in Little Rock, 
  Arkansas; and Scott Bryant, Innovation Specialist and Chief of 
  Quality, Safety, and Value, Chillicothe VA Medical Center, 
  Chillicothe, Ohio..............................................     2
    Prepared statement...........................................     4
        Diffusion of Excellence posters..........................    13
    Response to request arising during the hearing by:
      Hon. Dan Sullivan..........................................    32
      Hon. Richard Blumenthal....................................    40


  VHA BEST PRACTICES: EXPLORING THE DIFFUSION OF EXCELLENCE INITIATIVE

                              ----------                              


                      WEDNESDAY, SEPTEMBER 7, 2016

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:31 p.m., in 
room 418, Russell Senate Office Building. Hon. Johnny Isakson 
presiding.
    Present: Senators Isakson, Moran, Boozman, Heller, Rounds, 
Sullivan, Blumenthal, Brown, Tester, Hirono and Manchin.

      OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 
                   U.S. SENATOR FROM GEORGIA

    Chairman Isakson. I call this meeting of the Veterans' 
Affairs Committee of the U.S. Senate to order. I want to start 
out by thanking Senator Brown and Senator Boozman for calling 
the VA's Diffusion of Excellence Initiative, what they are 
doing, and for asking us to have this hearing today.
    You know, I was a businessman for 33 years. I was not a 
franchisee or a franchisor, but I ran a company that had a lot 
of branch offices. I know that if you can replicate where 
people--you have predictable quality and predictable service 
and predictable image wherever you go, you can build your brand 
and you can build your business. I think that is true also in a 
services business like VA health care.
    I think this effort to find out the best practices that 
work in admissions and whatever it may be, and then to 
replicate them around the country, can help to build the brand 
of the VA. Unfortunately, for all our sake, the tragedies that 
took place in Phoenix, Denver, and in other places, the brand 
of the VA has been tarnished, not because of best practices but 
because of bad practices. That is the only image the public 
really has right now.
    I am personally delighted to have this hearing so VA can 
talk about the success stories that it has discovered and the 
whole Diffusion of Excellence program they have. I want to 
underscore the fact that this is something that needs to be a 
continuation within the VA and throughout the VA health systems 
around the country so we have a brand that is recognized for 
the good things that it does, its quality and its 
predictability, rather than the stories we see on the news 
today.
    I am glad you are all here today. Welcome to our members of 
the VA. Welcome, Dr. Clancy, for being here. I will introduce 
you in just a second, but I want to turn to the Ranking Member 
for any comments he may have.

 OPENING STATEMENT OF HON. RICHARD BLUMENTHAL, RANKING MEMBER, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thanks, Mr. Chairman, for holding this 
hearing.
    Today's hearing focuses on two words, ``the VA'' and 
``excellence,'' not often mentioned in the same sentence, 
probably unfairly, but that is our world today. Giving us an 
opportunity to hear about some of the best practices, some of 
the success stories is really to give credit to the thousands 
of men and women who work in the VA day in and day out with all 
too little appreciation and thanks. Many of them are veterans 
who have served and sacrificed for this country. And they have 
been tarnished because of a small few in the bad practices.
    Those bad practices deserve a spotlight and accountability. 
Accountability is very much needed and merited, but at the same 
time we should showcase the success stories because they will 
inspire others to follow them, to model them, and to replicate 
them, as our veterans truly deserve.
    So, thank you for being here; and thanks to our colleagues, 
Senator Boozman and----
    Chairman Isakson. Senator Brown.
    Senator Blumenthal [continuing]. Senator Brown, for 
bringing us here today.
    Chairman Isakson [continuing]. Thank you, Senator 
Blumenthal.
    I would like to welcome Dr. Carolyn Clancy, the Deputy 
Under Secretary for Health for Organizational Excellence, U.S. 
Department of Veterans Affairs. We are glad you that you are 
here.
    You are accompanied by Dr. Elnahal, which we are glad that 
you are here, sir. Thank you for being here. Dr. Garner, 
welcome, and glad you are here. Mr. Bryant, you are the only 
non-doctor here, so we are glad to have you. [Laughter.]
    As a non-doctor, I am glad to see somebody else with my 
status, so we are glad to have you today.
    Dr. Clancy, we welcome your testimony of about 5 minutes. 
Anything you submit for the record will be accepted without 
objection.

 STATEMENT OF CAROLYN M. CLANCY, M.D., DEPUTY UNDER SECRETARY 
 FOR HEALTH FOR ORGANIZATIONAL EXCELLENCE, U.S. DEPARTMENT OF 
VETERANS AFFAIRS; ACCOMPANIED BY SHEREEF ELNAHAL, M.D., SENIOR 
 ADVISOR TO THE UNDER SECRETARY FOR HEALTH FOR BEST PRACTICES; 
 KIMBERLY GARNER, M.D., J.D., ASSOCIATE DIRECTOR FOR EDUCATION 
     AND EVALUATION FOR VISN 16, CENTRAL ARKANSAS VETERANS 
  HEALTHCARE SYSTEM GERIATRIC RESEARCH EDUCATION AND CLINICAL 
 CENTER IN LITTLE ROCK, ARKANSAS; AND SCOTT BRYANT, INNOVATION 
SPECIALIST AND CHIEF OF QUALITY, SAFETY, AND VALUE, CHILLICOTHE 
              VA MEDICAL CENTER, CHILLICOTHE, OHIO

    Dr. Clancy. Thank you.
    Chairman Isakson, Ranking Member Blumenthal, and 
distinguished Members of the Committee, thank you for the 
opportunity to discuss how the VA is improving veterans' health 
care by systematically spreading best practices.
    Ensuring superb care through replicating best practices is 
one of Dr. Shulkin's top priorities. I am accompanied today by 
Dr. Shereef Elnahal, Senior Advisor, who led this initiative, 
the Diffusion of Excellence; Dr. Kimberly Garner, a recognized 
geriatrician from Little Rock; and Mr. Scott Bryant, Innovation 
Specialist and Chief of Quality, Safety, and Value at the 
Chillicothe, Ohio, VA medical center.
    Spreading best practices is a challenge for all of American 
health care. Studies have shown that it takes, on average, 
about 17 years for new medical evidence to reach patients in 
the clinic or at the beside, and the VA is not exempt from this 
problem. But at the same time, large systems in the private 
sector face the same challenge. We have built a process of 
business rules and a governance structure that is solving this 
problem.
    Diffusion of Excellence is designed to incorporate all 
organizations that identify best practices and offer a 
standardized path for front-line employees to learn about what 
is already being done well in other parts of the country. In 
this initiative, dedicated front-line employees are influencing 
VA care far beyond their individual workplaces. The goal is to 
identify clinical and administrative best practices, 
disseminate them to other sites of care, and achieve their 
standardization to deliver positive outcomes for veterans.
    We have already seen 50 completed best-practice 
replications, hundreds of ongoing projects, and over 70 
facilities participating in this initiative, all within less 
than 1 year since Dr. Elnahal's Diffusion Team began to work. 
We are changing culture, and doing so by celebrating the people 
who have dedicated their careers to serving veterans.
    Dr. Garner and Mr. Bryant are outstanding examples of such 
employees, but they are not alone. They have taken it upon 
themselves to improve the system around them. These employees 
represent the best of American health care. Frankly, it is an 
honor to spread their--celebrate their accomplishments. Their 
energy, enthusiasm, and dedication have been the rocket fuel 
enabling this initiative to take off.
    We are also breaking down cultural barriers like 
competition by creating systematic incentives to share what has 
worked with others in the system. The initiative identifies the 
best projects and prototypes that can be replicated. With the 
support of Innovators Network, front-line employees are 
designing new practices with veterans and other stakeholders.
    Diffusion of Excellence also has a governance structure 
that cuts across organizational silos and reforms the 
bureaucracy to enable progress and allows for resources to be 
targeted to the front line, where they are really needed. We 
have also leveraged a Diffusion Hub to enable front-line 
employees to track their progress as they implement new 
practices, and to provide national visibility for all of us as 
they do their work. The result has been to enable employees to 
impact the system nationwide.
    In Little Rock, Dr. Garner gathered veterans and groups to 
teach them about advance care planning and discuss their goals 
of care and what is important to them. This model empowers 
veterans to discuss how they would like to be cared for in the 
future, should they be too ill to communicate their wishes.
    By having veterans work through these issues in groups, 
this practice provides them with the tools they need to discuss 
their wishes with family and caregivers in an efficient manner, 
expanding access to this high-value service. With Dr. Garner's 
help, this practice has been successfully replicated in 
Bedford, MA, and is being adopted rapidly in VISN 1 (VA New 
England Health Care System), and has been selected for national 
standardization.
    In Chillicothe, OH, Mr. Bryant is a champion for the 
reapplication of a best practice developed at the VA San Diego 
called eScreening. In San Diego and other sites, this practice 
allowed clinicians to rapidly identify if there is a suicide 
risk and increase same-day access to mental health care and 
triage for urgent services by 21 percent simply by using an 
iPad questionnaire that veterans complete in the waiting room.
    These electronic questionnaires allow clinicians to see 
responses to questions even before they walk into the veteran's 
room, helping them to make appropriate referrals. The practice 
has been successfully replicated in six other facilities and is 
in demand at another 50 sites, with a clear path to national 
spread.
    We have created a path to standardization of best practices 
that have been developed by the front line for the front line 
to impact countless more veterans than individual employees 
could otherwise do by themselves. This is restoring trust in 
our system in line with both the MyVA and Under Secretary's 
priorities. We believe this will benefit millions of veterans 
and offer a model for other health systems.
    Mr. Chairman, this concludes my testimony. Thank you again 
for the opportunity. We appreciate your support and are pleased 
to take questions you might have.
    [The prepared statement of Dr. Clancy follows:]
Prepared Statement of Carolyn Clancy, M.D., Deputy Under Secretary for 
 Organizational Excellence, Veterans Health Administration (VHA), U.S. 
                     Department of Veterans Affairs
    Chairman Isakson, Ranking Member Blumenthal, and distinguished 
Members of the Committee, thank you for the opportunity to discuss how 
the Department of Veterans Affairs (VA) is improving Veterans' health 
care by systematically diffusing operational best practices. As you may 
know, ensuring consistency and scale of best practices is one of Under 
Secretary for Health Shulkin's top priorities. We are delighted to 
discuss the main program addressing this priority, the Diffusion of 
Excellence Initiative. I am pleased to be accompanied today by Dr. 
Shereef Elnahal, Senior Advisor to the Under Secretary for Health and 
Initiative Lead for Diffusion of Excellence; Dr. Kimberly Garner, 
Associate Director for Education and Evaluation at the Veterans 
Integrated Service Network (VISN) 16/Central Arkansas Veterans 
Healthcare System Geriatric Research Education and Clinical Center in 
Little Rock; and Mr. Scott Bryant, Innovation Specialist and Chief of 
Quality, Safety, and Value at the Chillicothe, Ohio VA Medical Center.
    With more than 1,700 sites of care and over 300,000 employees, it 
is inherently challenging to deliver care with consistent processes and 
outcomes across the Veterans Health Administration (VHA). Large systems 
in the private sector also face this challenge. While decentralized 
leadership provides discretion for individual facilities to address 
local issues, VHA and U.S. health care at large have experienced 
challenges standardizing practices that maintain local flexibility, as 
appropriate, and consistently deliver value, no matter where they are 
applied.
    Through the Diffusion of Excellence Initiative, dedicated front-
line employees are now changing that story and influencing the system 
far beyond their individual workplaces. The goal of this initiative is 
to identify clinical and administrative best practices, disseminate 
these practices to other sites of care, and encourage standardization 
of practices that deliver positive outcomes for Veterans and their 
families. Ultimately, identifying and spreading best practices can be a 
major driver of consistent, high-quality health care for Veterans.
    Because of the hard work, dedication, and passion of front-line 
employees like Dr. Garner and Mr. Bryant, Dr. Elnahal and his team have 
built an infrastructure that leverages our scale as a system to deliver 
positive outcomes to thousands of Veterans across the Nation. This 
infrastructure begins with innovation, proceeds to implementation, and 
after much vetting and analysis, crafts a pathway to standardization.
    There are many program offices at VA that fuel innovation. One is 
the VA Center for Innovation, which sponsors the VA Innovators Network, 
a collaboration of highly-skilled change agents who lead and facilitate 
best practice implementation at VA's front lines. The Innovator's 
Network plays a key role in the first phase of innovation 
implementation and in the second phase, helping to scale practices once 
they have delivered positive outcomes for Veterans. Other offices, such 
as VHA's Office of Rural Health, play a key role in driving field-based 
innovation and best practice standardization for priority groups, 
including rural Veterans. The Diffusion of Excellence Initiative has 
created a governance structure that removes bureaucratic hurdles and 
allows for resources to be targeted to the front line in places where 
they are most needed.
    Armed with successful innovation pilots, the Diffusion of 
Excellence Initiative identifies the best projects and prototypes that 
can be replicated. And, with the support of the Innovators Network, 
front-line employees are co-designing new practices with Veterans and 
other stakeholders, allowing VA to respond rapidly to Veterans' needs 
in front-line settings and accelerating our service delivery. This 
enables the best practices to rise to the top and spread. We have also 
leveraged a technology platform, developed by the Veterans Engineering 
Resource Center, that is useful for front-line employees as they begin 
implementation and allows for national-level oversight and transparency 
about progress.
    In just the past year, this model has generated over 260 ongoing 
innovations in 70 facilities, including over 40 completed replications 
of 13 Under Secretary for Health Gold Status Best Practices (described 
in full below).
    Identifying, selecting, and diffusing best practices is changing 
Veterans' lives. For example, in Madison, Wisconsin, Clinical Pharmacy 
Specialists (CPS) practicing at the top of their licenses furnished 
direct patient care that resulted in increased access for Veterans. CPS 
monitored patients with chronic diseases and managed medication in 
their own clinics, collaborating closely with Veterans' primary care 
physicians. As a result of this practice, the CPS were able to save 
primary care providers 20 minutes per new patient appointment, and were 
able to convert 27 percent of patient appointments from the primary 
care provider to the CPS, opening access on the primary care providers' 
schedules for other Veterans with acute care needs. Currently, over 30 
VA and non-VA sites are either planning or have begun implementing this 
practice.
    In Little Rock, Arkansas, Dr. Garner gathered Veterans to teach 
them about advance care planning and to discuss their goals of care. 
This model empowered Veterans to decide how they would like to be cared 
for in the future, should they be too ill to communicate their wishes. 
It also provided Veterans with tools to discuss their wishes with their 
families and loved ones. With Dr. Garner's help, this practice was 
successfully replicated in Bedford, Massachusetts and is likely to be 
adopted rapidly in VISN 1 (New England). Using the process described 
later in this testimony, this practice was selected for national 
standardization.
    In Chillicothe, Ohio, Mr. Bryant championed the reapplication of a 
best practice developed at the VA San Diego Healthcare System through 
an Innovators Network grant. This best practice decreased the time to 
document suicide risk by half, and increased same-day access to mental 
health care and triage for urgent services by 21 percent, simply by 
using an iPad questionnaire that Veterans completed in the waiting 
room. These electronic questionnaires allow clinicians to see responses 
to questions before walking into the Veteran's room, helping them to 
make appropriate referrals. This practice has been successfully 
replicated in 6 other facilities and is in demand at another 50 sites.
    Additionally, Mr. Bryant is in the process of implementing a bike-
sharing program that helps Veterans and employees quickly commute 
across the large Chillicothe campus. In addition, through a partnership 
with the Small Business Administration, this program gives Veterans 
entrepreneurial experience to start their own small businesses. The 
goal of this program is to help support Veterans in vocational 
rehabilitation and provide an opportunity for Veterans to learn an 
employable skill and start their own businesses. Mr. Bryant completed 
most of this program as an Innovation Specialist within the Innovators 
Network, and it will become an Under Secretary for Health Gold Status 
Best Practice.
    In just the few sites where these best practice innovations 
originated, the results have been impressive. The potential is great to 
provide better health care to many more Veterans when these best 
practices are scaled across the system. For example, if direct patient 
care by a CPS is instituted nationally, this practice alone could open 
up more than 35,000 primary care appointments per year.
    VA can also learn from the best academic and private sector medical 
centers. To that end, VA is partnering with the American College of 
Physicians (ACP) to exchange ideas. VA Innovators, like Dr. Garner and 
Mr. Bryant, who, without prompting, sought to improve the system for 
Veterans, will serve on regional advisory panels to guide ACP best 
practice infrastructure. Likewise, ACP will appoint clinicians and 
systems improvement experts to a Diffusion External Advisory Board, 
consisting also of Veterans and Veterans Service Organization 
representatives. This exchange is designed to diffuse VA best practices 
into the private sector and to enable VA to learn what some of the 
highest-performing and most prestigious institutions are doing to 
address emerging operational challenges in health care.
    Another example of how VA is sourcing and learning from the private 
sector is through a recent VA partnership with the YMCA. VHA's Office 
of Community Engagement developed a Memorandum of Understanding with 
the YMCA that allows VA facility staff to partner with YMCAs locally to 
expand and enhance services for Veterans in their communities. These 
services include wellness and fitness programs, sports, recreation, and 
other activities that speak to veterans' holistic needs. In less than a 
year, 36 sites have developed or are in the process of developing local 
partnerships. Other partnerships are being fostered to achieve the same 
objectives: to educate private sector medicine about VA best practices, 
and to obtain best practices from American medicine that will improve 
our performance in VA.
                how are we achieving all of this at va?
    We are building an Innovation Ecosystem comprised of mutually 
reinforcing parts: the VA Center for Innovation (VACI), the Innovators 
Network, and the Diffusion of Excellence Initiative. VACI is an 
enterprise entity that works with all lines of business and focuses on 
delivering operational breakthroughs for strategic priorities, building 
innovation as a capability at VA, and driving future thinking. The 
Innovators Network, a VACI program, empowers front-line innovators with 
training; a tiered grant program, which seeds and cultivates specific 
innovations; and continued integration into agency strategy. The 
Diffusion of Excellence Initiative provides a critical link in this 
chain by identifying, prioritizing, and driving the dissemination of 
top innovations and best practices across VHA. Each element in this 
ecosystem performs a vital function.

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                   Figure 1: Innovation and Diffusion

    We are also implementing a permanent and sustainable diffusion 
process that allows us to continually identify and diffuse best 
practices across the system. VHA has achieved success in implementing 
this model by leveraging the following organizing principles: Process 
(a consistent framework for evaluation and reapplication of practices, 
with clearly-defined roles); Governance (ensures vertical 
accountability to agency priorities, with regular engagement to achieve 
consistency and sustainment of high performance) *; and Technology 
(enables rapid, transparent information flow across organizational 
boundaries and regions). These foundational elements underlie five 
steps to achieving a high performance, learning health system. Below, 
we describe the process we developed and how we are leveraging these 
principles to drive organizational improvement, enabling VHA to better 
serve our Veterans.
---------------------------------------------------------------------------
    * Pronovost PJ, Armstrong CM, Demski R, et al. Creating a high-
reliability health care system: improving performance on core processes 
of care at Johns Hopkins Medicine. Acad Med. 2015 Feb;90(2):165-72.
---------------------------------------------------------------------------
      5-step process for identifying and diffusing best practices

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                       Figure 2: Diffusion Model

Step 1: Identify Promising Practices
    We sought to identify promising practices by launching a national 
solicitation through an internal social media platform. This 
solicitation attracted over 250 submissions from front-line employees, 
each of whom changed their local environments to improve care. 
Selection criteria included: 1) sustained high-performance or 
improvement along strategic priorities; 2) efficient resource 
utilization; 3) applicability to different care environments; and 4) 
implementation feasibility within 6-12 months. The submissions were 
reviewed by subject matter experts and senior leaders, as well as other 
front-line employee stakeholders across the system to assess 
feasibility for wide application. The selection process leveraged both 
technology and effective governance: evaluations occurred at every 
level of the organization, but in a structured manner.
    A Diffusion Council of mid-level managers and subject matter 
experts; a Governance Board of senior leaders; and most importantly, a 
community of practice of front-line providers all had an equal stake in 
identifying the 13 Under Secretary for Health Gold Status Best 
Practices (fully described below) to be disseminated across the system, 
assuring both value assessment at the point of care and alignment with 
leadership priorities. We used the same technology platform for swift 
data collection from hundreds of employee evaluators. By the end of 
2016, every regional service network will use similar criteria to 
identify promising practices in their own forums.
Step 2: Find the Champions
    Local champions, or ``early adopters,'' are crucial for front line 
implementation of best practices. VHA held a competition to identify 
locations where Under Secretary for Health Gold Status Best Practices 
would be replicated initially. Nineteen innovators pitched best 
practices to 28 VA Medical Center directors, and directors had to bid 
resources, including employee time, space, and funding needed to enable 
implementation. Most importantly, they had to identify a champion to 
own the initial phase of implementation at their facility. This format 
solidified leadership commitment at field sites, ensuring alignment to 
local priorities and the resources necessary to inculcate the practice. 
Because participating facilities spanned the entire Nation, the 
competition was held virtually, enabling efficient information transfer 
and communication, without any cost. As noted previously, 13 of 19 
finalists were ultimately chosen as Under Secretary for Health Gold 
Status Best Practices, based on bids from the VA Medical Center 
directors and national leadership endorsement.
Step 3: Adapt and Replicate
    Before national deployment, the Diffusion model calls for ``phase 
1'' implementation of each practice in at least one other location to 
learn about implementation challenges in different contexts. To achieve 
this, we brought local implementing champions together with innovators 
(who initially developed the practices) in person for a planning summit 
to engage in intensive project planning. The two-day intensive session 
allowed for rapid-fire planning, minimizing time away from clinics and 
overall cost. Along with a lean-trained project manager, these 
individuals constituted Action Teams, which conference regularly and 
track implementation. Four Action Teams, defined by strategic priority 
(access, care coordination, quality and safety, and employee 
engagement), report to an operational body called the Diffusion 
Council.
    The Diffusion Council is a governance body composed of different 
operating units that span from central program offices to local 
leadership. Its purpose is to recommend policy changes or resource 
allocation decisions to a Governance Board composed of senior VHA 
leadership, specifically to enable Under Secretary for Health Gold 
Status Best Practice implementation. This structure provides ongoing 
operational support to Action Teams, but also accountability for 
progress at each level. An online tool called the Integrated Operations 
Platform (IOP) allowed both innovators and local implementing champions 
to conduct lean implementation against milestones, useful for local 
project execution. The IOP also serves as a knowledge hub that is 
searchable by any employee in the system. This allows champions to find 
projects that have worked at other sites of care for similar 
challenges. In addition, registration of milestones generates 
structured data, allowing the Diffusion Council and Governance Board 
transparency into progress (or lack thereof) when data is aggregated 
for national view. Systemic barriers are therefore identified and 
addressed proactively with resources or policy changes.
Step 4: Establish Consistency and Standardize
    After initial replication efforts, certain Under Secretary for 
Health Gold Status Best Practices are chosen for national 
standardization based on two parameters: 1) relative success with 
initial implementation, and 2) similar outcomes achieved when 
replicated, in a reasonable timeframe. Within just five months, 12 of 
13 practices have been replicated at more than 14 sites (and the 13th 
is in the process). With this success, Action Teams have begun 
developing national roll-out plans for several of the practices that 
leverage shared resources (e.g., central information technology servers 
for applications) and system-wide channels of communication (e.g., 
national communities of practice for clinicians or social workers). 
Because the Diffusion Council is composed of representatives from many 
program offices, national roll-out can be supported for most practices. 
To enable consistent execution operationally, champions must be 
identified in both regional service networks and individual facilities, 
which use a road-map generated by the Action Teams during the first 
phase of implementation to ensure consistency. Standardization is 
defined by the equivalence of Veteran or employee outcomes, rather than 
strict adherence to a defined process, allowing for facility and 
network champions to use human-centered design and adapt practices to 
their local environments. Finally, because the IOP cumulatively records 
every facility's experience with implementation and barriers, data 
about system-wide resource needs allow the Governance Board to make 
targeted investments accordingly.
Step 5: Sustain and Improve
    Even before a best practice is scaled nationally, Diffusion of 
Excellence engages staff, resources, and technology to ensure 
sustainment once it is scaled. ``Practice-based service lines'' will 
combine the original innovators with an appropriate, national level 
executive partner for ongoing validation and monitoring. This combines 
content knowledge of the practices with the operational expertise 
required to monitor for variation or changes in performance. VISN and 
facility champions in every site of care will continue to monitor the 
sustainment of practices that achieve implementation and adapt to 
changing needs as necessary. To ensure sustainment, lagging indicators 
(outcome data) must be tied and correlated with already-established 
implementation metrics in the IOP, combining self-reporting with 
objective analytics. This allows for proactive assessments of 
performance shortfalls, now incorporated into a centralized operations 
center that will be replicated at every level of the organization.
    In addition to a diffusion process based on implementation and 
dissemination science best practices, a fail-safe governance process 
and a technology platform that promoted information sharing were key to 
success.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


 Figure 3: Integrated Operations Platform: VA Diffusion of Excellence 
                                  Hub

                     gold status practice summaries
    Brief descriptions of each practice are provided below, including 
information about the fellow(s) that designed it and their facility, 
and the facilities that are replicating this practice.
    Improving Same-Day Access Using Registered Nurse (RN) Care Manager 
Chair Visits. At the Boise VA Medical Center (VAMC), the primary care 
team created a process where same-day appointment requests are triaged 
and scribed by RN Care Managers, saving primary care providers' time 
when they see patients between appointments to assess and confirm the 
care plan. The originators, a primary care physician and nurse duo, Dr. 
Henry Elzinga and Debra Hendricks Lee, took this practice on the road, 
providing real-time coaching to their peers to support implementation, 
including the Albany Community-Based Outpatient Clinic (CBOC). 
Together, these facilities serve many rural Veteran patients.

      Gold Status Fellows: Dr. Henry Elzinga and Debra 
Hendricks Lee, Boise VAMC
      Implementing Facilities: Central Alabama Veterans Health 
Care System (Montgomery, Alabama),Carl Vinson VAMC (Dublin, Georgia), 
Albany CBOC (Albany, Georgia)

    Access Data Dashboard to Improve Clinic Management. As VA staff 
continues its dedication to the core ICARE values, transparency, and a 
``we can fix that'' attitude, the data analysis team at Harry S. Truman 
Memorial Veterans' Hospital (Columbia, Missouri) implemented a 
dashboard for clinic access metrics (no shows, completed appointment 
wait times, clinic utilization, etc.). These metrics are posted monthly 
on an accessible dashboard that can be used by staff to solve problems 
and make key decisions that help Veterans get timely access to care. 
This dashboard encourages thoughtful discussion on ways to improve 
measures and mutual accountability for results. For example, clinic 
teams use the no-show data to actively engage in preventing future no-
show appointments. Use of the dashboard has shown positive results 
include improved no-show rates and improved wait times. This team 
helped to design a similar dashboard for the Kansas City VAMC, and has 
been working closely with VHA's clinical analytics and reporting team 
to integrate this model into the national Health Care Operations 
Dashboard.

      Gold Status Fellow: Michelle Pruitt, Harry S. Truman 
Memorial Veterans' Hospital (Columbia, Missouri)
      Implementing Facility: Kansas City VAMC

    Planning for Future Medical Decision via Group Visits. When a 
patient is critically ill or mentally incapacitated, family members or 
even staff may be forced to make difficult, life-altering decisions. 
This interactive and patient-centered group visit approach to engaging 
Veterans in planning for future medical decisions allows patients' 
wishes to be honored while reducing unwanted treatments. Now, thanks to 
Dr. Garner and a social worker-led team at the Bedford VAMC, more 
Veterans are having those important discussions early, bringing peace 
of mind to themselves, their families, and those who care for them. 
This team has also been working tirelessly with VHA's Social Work 
Office and the National Center for Ethics to develop a toolkit for 
implementing this practice throughout the VA.

      Gold Status Fellow: Dr. Kimberly Garner, Central Arkansas 
Veterans Healthcare System (Little Rock, Arkansas)
      Implementing Facility: Edith Nourse Rogers Memorial 
Veterans' Hospital (Bedford, Massachusetts)

    Increasing Access to Primary Care with Pharmacists. At the William 
S. Middleton Memorial Veterans' Hospital (Madison, Wisconsin), Dr. 
Ellina Seckel, a CPS, and her colleagues knew that VA's CPS, when 
authorized by their scope of practice, may prescribe medications and 
monitor patients with diabetes and other chronic diseases. They are 
also key members of the Patient Aligned Care Team (PACT). The facility 
matched CPS with multiple PACTs to conduct New Patient Intake calls one 
week before a new patient has his or her first appointment with a 
provider, collecting medications, noting any formulary conversions, and 
orienting the patient to VA. This effort has saved the provider an 
average of 20 minutes during the initial appointment. The team was also 
able to convert 27 percent of appointments from the primary care 
provider to the CPS, opening up hours of access for acute care 
patients. By practicing true team-based care, the facility has shifted 
the chronic disease workload off the primary care providers. The CPS 
are able to work to the top of their scope of practice as pharmacist 
providers. Primary care providers have more time to spend with patients 
and Veterans can get the care they need more quickly. With the support 
of the innovating team, the El Paso VA Health Care System has begun 
integrating CPS into PACTs to practice true team-based care. In just 4 
months of implementation with one CPS paired with three PACTs, El Paso 
VA Health Care System has already seen improved access to care for 
Veterans, and is expanding the practice to include all PACTs. This 
practice has also achieved significant recognition in the private 
sector, with health systems in the U.S. and United Kingdom requesting 
to shadow and learn from the William S. Middleton Memorial Veterans' 
Hospital team.

      Gold Status Fellow: Dr. Ellina Seckel, William S. 
Middleton Memorial Veterans' Hospital (Madison, Wisconsin)
      Implementing Facility: El Paso VA Health Care System (El 
Paso, Texas)

    Unit Tracking Board. Michael Finch, a clinical nurse leader at the 
C.W. Bill Young VAMC saw that key clinical unit data were not being 
presented and shared effectively with nursing staff. He developed a 
simple and accessible Unit Tracking Board to post on floor units. Now, 
all staff involved in care can quickly see important data about their 
patients. They are empowered to use that information to make the best 
decisions that help improve the care experiences of Veterans. This 
practice also supports VA's mission to foster a culture of transparency 
since the board is posted publicly. Michael helped a nurse-led team at 
the White River Junction VAMC develop a similar board for the Intensive 
Care Unit, and similar boards will soon be placed in all inpatient 
units at White River Junction. This team is also working with the 
national nursing leadership at VHA to standardize a model for all 
medical centers.

      Gold Status Fellow: Michael Finch, C.W. Bill Young VAMC 
(Bay Pines, Florida)
      Implementing Facility: White River Junction VAMC (White 
River Junction, Vermont)

    Journey to Open Access in Primary Care. Using system redesign 
principles and VA's PACT model, this practice focuses on implementing 
new protocols that increase same-day access opportunities for Veterans. 
Dr. Michael Tom, Chief of Primary Care Services at the VA Central 
California Health Care System (Fresno, California), has worked hand-in-
hand with the team at Gulf Coast Veterans Health Care System (Biloxi, 
Mississippi), a facility with significant access to care challenges, to 
mentor and help with this significant transformation.

      Gold Status Fellow: Dr. Michael Tom, VA Central 
California Health Care System (Fresno, California)
      Implementing Facility: Gulf Coast Veterans Health Care 
System (Biloxi, Mississippi)

    eScreening. The eScreening Program was developed to facilitate the 
screening process and improve care coordination and measurement-based 
care for Veterans. eScreening is a mobile technology that can 
significantly improve care coordination and business processes. It 
offers Veteran-directed screening, real-time scoring, individualized 
patient feedback, instantaneous medical record clinical documentation, 
immediate alerts to clinicians for evaluation and triage, and 
monitoring of treatment outcomes. Put simply, the Veteran is handed an 
iPad when he or she checks in for an appointment, and can complete any 
required screening on the iPad. The information is then transferred 
directly from the waiting room to the patient's medical record. The 
tool can be used in any clinical setting from primary care to urgent 
care to mental health. This best practice has already spread to three 
facilities organically and to three other facilities through Diffusion 
of Excellence. There are 40 more facilities ``on deck'' and ready to 
implement.

      Gold Status Fellows: Dr. Niloofar Afari, and Liz Floto VA 
San Diego Healthcare System
      Implementing Facilities: Lebanon VAMC, Ann Arbor VAMC, 
Edith Nourse Rogers Memorial Veterans' Hospital (Bedford, 
Massachusetts)

    Code Tray Redesign. Certified Pharmacy Technician Kristine Gherardi 
at VA Boston Healthcare System noticed that the current code tray was 
not set up in a way that made it easy to find life-saving drugs in an 
emergency. She created a simple and compelling solution to reduce the 
time it takes to find a certain drug during a code. This easy-to-
implement, low-cost strategy reduces medication distribution errors, 
improving outcomes for Veterans. The Loma Linda VAMC is already 
implementing this code tray and more are quickly following.

      Gold Status Fellow: Kristine Gherardi, VA Boston 
Healthcare System
      Implementing Facility: VA Loma Linda Healthcare System

    Regional Liver Tumor Board. The hepatology team at the Philadelphia 
VAMC combined a regional telehealth-supported Liver Cancer Tumor Board 
model, a web-based submission process, and a consolidated database to 
manage and track communications for patients with liver cancer. This 
practice has shortened the time for Veterans with liver cancer to 
receive their evaluation and first treatment, as well as reduced 
unnecessary biopsies--easing the minds and experiences of patients and 
their families in an incredibly stressful time. Jackson VAMC, a 
facility without a dedicated hepatologist, is now implementing this 
practice in partnership with the Central Arkansas VA Healthcare System, 
giving Veterans faster access to top-notch clinical care.

      Gold Status Fellow: Dr. David Kaplan, Corporal Michael J. 
Crescenz VAMC (Philadelphia, Pennsylvania)
      Implementing Facility: G.V. (Sonny) Montgomery VAMC 
(Jackson, Mississippi)

    Using External (Non-VA) Comparative Data to Achieve Excellence and 
Engage Employees. To do a better job of comparing outcomes, not only 
against the VA average, but also against ``the best,'' the Mountain 
Home VAMC expanded non-VA benchmark data to provide indicators of how 
Veteran and caregiver stakeholders view VA care and services in 
relation to other health care choices in their region. This results in 
higher performance and employee engagement, so staff can seize 
opportunities to improve, while also instilling pride in the fact that 
VA truly provides world-class care for our Nation's Veterans. Using 
this model, the San Francisco VA Health Care System is replicating the 
practice for its Engineering service, ensuring that top notch support 
services are provided at the facility.

      Gold Status Fellow: Jill Stephens, James H. Quillen VAMC 
(Mountain Home, Tennessee)
      Implementing Facility: San Francisco VA Health Care 
System

    WAKE Score for Recovery from Anesthesia/Sedation. The WAKE Score 
replaces a previous anesthesia recovery scoring system, which would 
often leave patients with nausea and vomiting, lightheadedness, and 
pain. The WAKE Score takes a ``zero tolerance'' approach to anesthesia 
side effects, improving patient experience and outcomes. Developed by 
anesthesiologist Dr. Brian Williams, the WAKE Score has been evaluated 
and the results have been published in several peer-reviewed academic 
journals. To improve post-surgery outcomes at Martinsburg, the 
anesthesia team adapted this model. VHA surgery senior leadership are 
currently assessing the options based on this replication and other 
models to determine the best standardized model that will improve 
optimize Veteran outcomes post-surgery.

      Gold Status Fellow: Brian Williams, VA Pittsburgh 
Healthcare System
      Implementing Facility: Martinsburg VA Medical Center

    Direct Scheduling for Audiology and Optometry Services. Previously, 
Veterans had to see their primary care provider to receive a referral 
for simple audiology and optometry services, such as new eyeglasses. 
This new model, piloted first at Bay Pines VA Healthcare System (Bay 
Pines, Florida), allows direct scheduling for certain appointment 
types. This direct scheduling process eliminates redundant 
consultations, consolidates clinic profiles, and standardizes 
communications, leading to greatly reduced overall wait times for 
Audiology and Optometry. It has been rolled out to several VA 
facilities, and will be in all VA facilities by the end of this year. 
Next, VA is looking to implement a similar policy and process for other 
services--for example, podiatry services.

      Gold Status Fellow: Michelle Menendez, Bay Pines VA 
Healthcare System
      Implementing Facility: Multiple Sites

    Flu Self-Reporting Desktop Icon to Capture Employee Vaccinations 
Received Outside the VA. The Flu Self-Reporting Desktop Icon was 
created by the occupational health team at the VA Boston Healthcare 
System. This icon allows staff to quickly report with the click of a 
button on their computer's desktop when they've received the flu 
vaccine outside VA. Capturing an average of 500 vaccinations annually, 
not only does this tool help encourage staff to take care of 
themselves, but it also protects the health of patients and their 
families. The Boston team worked closely with the Mountain Home and 
VISN 12 teams to replicate this practice, and to develop a national 
model for rolling this out at every medical center as a standard. 
Seeing the potential, more than 40 leaders at other facilities took the 
initiative to roll this out in their facilities over the last several 
months.

      Gold Status Fellow: Vanessa Coronel, VA Boston Healthcare 
System
      Implementing Facility: VA Great Lakes Health Care System 
(VISN 12), Mountain Home VA Medical Center
                               conclusion
    While VA historically operated as a siloed system, we are 
transforming that legacy through the Diffusion of Excellence Initiative 
and the broader innovation ecosystem. This lack of strict 
standardization has, in part, created fertile ground for innovation, 
prompting VA's recent listing as a top organization for innovation. The 
Diffusion of Excellence Initiative has added a critical capability to 
VA's Innovation Ecosystem and will play a vital role ensuring that 
Veterans get the best care that the Nation has to offer.
    Giving front-line employees the opportunity, resources, guidance, 
leadership support, and where needed, some bureaucratic relief to re-
apply best practices is crucial for standardizing top quality health 
care. Success requires striking a balance that creates a path to 
standardization, but also rewards and elevates innovation at the point 
of care. Dr. Garner and Mr. Bryant exemplify the innovation ecosystem 
that exists in our system that we are finally able to leverage. While 
many large systems face similar challenges, especially as they acquire 
smaller hospitals and sites of care, to our knowledge, no operational 
system has been able to achieve diffusion or consistency of best 
practices to this scale. In addition, it is impossible to overstate the 
excitement and energy of employees serving Veterans every day seeing 
their great ideas translated into better access and outcomes for all 
Veterans.
    Moving forward, VHA will continue to refine the model to meet VHA 
needs, while encouraging continued innovation and best practice 
development to meet the needs of Veterans across the Nation.
    We, therefore, believe that this is not only an initiative that can 
benefit millions of Veterans across the Nation, but a model that can be 
used by any health system facing similar challenges in providing 
consistent care. In the meantime, we will continue to empower front-
line employees like Dr. Garner and Mr. Bryant, both of whom have 
contributed to an effort that allows them to impact countless more 
Veterans than they otherwise could have themselves.

    Mr. Chairman, this concludes my testimony. Thank you for the 
opportunity to testify before the Committee today. We appreciate your 
support and are pleased to take questions that you or the other Members 
of the Committee may have.
               Diffusion of Excellence Posters (5 slides)

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                         
                                 

    Chairman Isakson. Well, thank you, Dr. Clancy.
    I think what I want to do is focus on Dr. Garner and Mr. 
Bryant for a second because you are the two all-stars that 
brought us to this hearing. I did not now where Chillicothe, 
OH, was until I met Sherrod Brown. I did not know who you were 
until I met Senator Brown. So, I am glad you are here in 
person. Glad to have you.
    Dr. Garner, my aunt was in Little Rock, where I went for 
many a summer back in the 1950s. It is a great town. I 
appreciate what both of you have done.
    To start with, Dr. Garner--you are probably aware of this, 
though you may not be--but one of my passions since being in 
Congress is advance care planning for end-of-life as a standard 
practice that everybody ought to do--something you do not want 
to do, but it is so much better for the quality-of-life that 
you have or the quality-of-life that your families have. I 
commend you for doing this--because that is your program, if I 
am not mistaken, is it not?
    Dr. Garner. Yes, sir.
    Chairman Isakson. Would you like to expand a little bit on 
how you got into it and what the results of it are?
    Dr. Garner. Yes, sir.
    We were aware that a lot of the veterans and adults in 
general are not aware what an advance directive is and how it 
may help them and their families. So, we were brainstorming 
about how we might be able to better efficiently get that 
message out and we came up with the idea of doing it in groups. 
Since then, we have been able to develop it with veteran 
feedback, veteran focus groups, asking veterans to help us: 
What is the best way to interact with you about this topic?
    We have been able to come up with a program that is very 
satisfactory to veterans and that allows a discussion to occur 
to talk about: Have you ever thought about this? Have you ever 
had an experience of making a decision for someone else?
    Through that process, they are able to actually engage and 
think about what it might be like for them if they were ever in 
a situation where they could not speak for themselves. Who 
would they trust to make decisions for them? What would they 
want that person to know and be prepared to do if they were 
ever in that situnation?
    Another thing that we emphasize is it is not just about end 
of life. This durable power of attorney for health care, which 
is part of an advance directive, allows someone--if it is a 
surgery or even if a veteran is just very sick because--and are 
expected to recover but for a period of time cannot make 
decisions for themselves.
    As a health care provider, I want to know who this veteran 
trusts, and I want to provide the care that is consistent with 
who they are as a person. This allows us to engage veterans in 
this discussion, because doing it as a group we have more time, 
we are able to get into a pretty detailed discussion about how 
this might benefit them and their families.
    Chairman Isakson. Well, it is ironic that you have ended up 
with a program that is based in doing it in a group rather than 
doing it individually, but it must be easier for the veterans 
to talk early on in a group than it would be if there were just 
one individual veteran and a nurse or a practitioner. Is that 
right?
    Dr. Garner. Yes, sir. What we hear from the veterans is 
that having--discussing this as a group is a little bit less 
intimidating. A one-on-one discussion, you pretty much have to 
say something, but veterans feel that they can come to the 
group and they do not have to say something if they do not want 
to.
    The other thing that we hear time and time again is: I 
heard something from another veteran that I do not think I 
would have thought of myself. That is very beneficial to them 
to hear what their peers have to say and what their peers think 
about this process. We have also been told multiple times: You 
need to be doing this with every veteran. You should not have 
such a small program. We want you doing this with everyone.
    Chairman Isakson. What is so ironic about your best 
practice is it is exactly the opposite of what Mr. Bryant is 
doing. If I am not mistaken, your e-evaluation is a one-on-one, 
with the veteran answering questions on a computer, is that 
correct--or a laptop or an iPad?
    Mr. Bryant. Yes, that is correct.
    Chairman Isakson. The military learned with the Warrior 
Transition Units from Afghanistan and Iraq that a lot of times 
soldiers will not tell you they are having bad dreams, they 
will not tell you they are having flashbacks, they will not 
tell you they are having symptoms of post-traumatic stress 
disorder (PTSD) or traumatic brain injury in a group meeting or 
group session like that. But, you put them in a room with a 
computer where they are answering questions on the touch pad, 
they will tell you those things.
    In your case, Dr. Garner, the group therapy actually helped 
to bring out people's discussion on the subject, which is a 
difficult subject. In your case, Mr. Bryant, you did exactly 
the opposite but found a way to give them privacy, which makes 
it easier for them to talk about very difficult subjects. Would 
you address that for 1 second, Mr. Bryant?
    Mr. Bryant. Sure.
    Actually, the veteran will be able to use the iPad. When 
they use the iPad, they answer simple yes/no questions. When 
they answer a yes question, that automatically alerts the 
provider to focus their appointment on those yeses.
    The appointment time that you spend is very valuable to the 
veteran. That is why they are there. They want to see the 
physician. So, by doing this, it allows it to be more focused 
on what they are there for rather than all those other 
questions.
    Chairman Isakson. Well, thanks to both of you for being 
great leaders.
    Ranking Member Blumenthal.
    Senator Blumenthal. Thanks, Mr. Chairman.
    Let me ask you, Dr. Clancy, what is the innovation or a few 
innovations that you would recommend most widely and most 
highly to health care facilities?
    West Haven has adopted the hepatitis C infection 
detection--hepatitis C carcinoma tracking system that, I am 
told, has been replicated across the country. That is the kind 
of innovation that the VA has brought to that particular 
illness. Are there others that you would recommend?
    Dr. Clancy. Yes. There are a number that I am very excited 
about and probably more I do not know about yet, which is 
really the whole point of this initiative.
    Given the imperative of addressing our access problems, it 
is very, very hard not to be incredibly excited about any 
initiative, whether it is group visits for advance care 
planning or for some other topic--we do a fair amount of that--
or in the case of what Mr. Bryant has, a way to make sure that 
we are rapidly identifying those at increased risk of suicide, 
but there is a number of other best practices related to 
access.
    I might just ask Dr. Elnahal to amplify.
    Dr. Elnahal. Thank you, Dr. Clancy and Ranking Member 
Blumenthal.
    Personally, I am proud of all 13 of our Gold Status 
practices and all of the fellows, the implementing fellows, 
that are getting them done.
    You see, Dr. Garner and Mr. Bryant sitting to my left, they 
are too humble to tell you that they are extremely invested in 
the practices that they have espoused. For example, Dr. Garner 
offered to pay her own way to DC to come teach the entire 
country how to do the practice. We found funding for her, but 
she offered that. Mr. Bryant has been late to some of our 
sessions to prepare for this hearing because he was finding his 
way to help veterans find their way to get in the Chillicothe 
campus. So, these people are very focused, and that is what 
everyone is doing with our practices.
    Two examples that I will just highlight for your benefit 
that could really help the health care system generally: 
clinical pharmacy specialists. Our best practice improved 
access to primary care by 28 percent by allowing clinical 
pharmacists to have their own clinics, their own consult 
service to manage medication issues.
    I am a diabetic, so I was actually taught how to use my 
insulin from a clinical pharmacist when I was first diagnosed. 
If we have expanded practice authority for these professionals, 
that could really improve access not just within the VA, which 
we are doing now, but throughout the American health care 
system.
    We also have a Virtual Tumor Board that is currently being 
held in Little Rock, AK, serving patients in Jackson, MI. That 
is a model that will allow all of the experts for a particular 
disease to evaluate your case and discuss the case that you 
have together in the same room, allowing you to get your 
treatment plan much sooner and to start treatment within 30 
days, which is the evidence-based guideline for treatment.
    These are just two examples of practices that can really 
help, and are targeting rural veterans as well.
    Senator Blumenthal. Let me ask you about some of the drugs 
that are used in VA facilities--insulin, Narcan, my guess is 
EpiPens. Are you finding--I know that the VA can negotiate 
prices, but are you affected by practices in the private sector 
and by shortages in those drugs which exist in the private 
sector? Hospitals tell us about shortages in those drugs and 
many others. How does that affect health care in our VA system?
    Dr. Clancy. I will say that, given the recent publicity 
about EpiPens in particular, I asked our lead chief pharmacist 
about this the other day and, in fact, it has not affected the 
price that we get at all. Whether it will I think is an unknown 
question, but because we have the capacity to negotiate, we 
have--we clearly get the best deal for hepatitis C in the 
country. That is an ongoing practice. Narcan, I think that we 
are doing OK right now, but that is obviously another example 
of one that is going up quite a bit.
    Shortages where you simply do not have supplies available, 
yes, we are going to get impacted by that, but again, because 
we are a predictable customer and have negotiated arrangements 
long in advance, in general we are going to avoid the worst of 
all of this.
    Senator Blumenthal. The fact that the VA can negotiate, 
unlike Medicare, for example----
    Dr. Clancy. Yes.
    Senator Blumenthal [continuing]. Unlike our hospitals, 
keeps down the cost of health care----
    Dr. Clancy. Yes.
    Senator Blumenthal [continuing]. And has spared you, at 
least until now, the effects of those astronomically-rising 
prices for EpiPens and a number of other pharmaceutical drugs.
    Dr. Clancy. Yes.
    Now, I will also say that when the market gives us an 
advantage--for example, once there was more than one highly-
effective, very-few-side-effects treatment for hepatitis C. 
That brought prices down for everyone and we were able to 
further negotiate an even much better deal.
    Senator Blumenthal. So, it is all relative?
    Dr. Clancy. Yes.
    Senator Blumenthal. You may not be paying 600 to 700 
percent higher----
    Dr. Clancy. Yes.
    Senator Blumenthal [continuing]. But your prices may be 
higher----
    Dr. Clancy. Yes.
    Senator Blumenthal [continuing]. Simply because 
negotiations are not a one-way street. You have to give and 
take, so your prices will rise but just not the same as in the 
private market.
    Dr. Clancy. Correct, greatly muted.
    Senator Blumenthal. Thank you.
    Chairman Isakson. Senator Boozman.

         HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Senator Isakson and Senator 
Blumenthal, for holding this really important hearing.
    As was mentioned, you will hear a lot of problems at the 
VA, and this and that, but it is good to sit back and, you 
know, talk about some of the successes. The good news is that 
there really are many of them. We certainly appreciate you 
being here, Dr. Garner and Mr. Bryant--the entire panel, but 
especially you all--telling us about some of these things.
    Dr. Garner, your reputation in Little Rock is excellent. We 
just appreciate, besides your innovation ability, your ability 
also to take care of people in a very, very caring, very 
excellent way. You have described what you have done and your 
idea. Tell us if you see any problems with the national rollout 
of that.
    Dr. Garner. I think it will be fairly easy, as I have 
made--I hope that I adequately stated that most of these groups 
are held by not-physicians. Because we want physicians taking 
care of veterans and access issues, these were not designed to 
be led by physicians. Social workers, nurses, chaplains, 
psychologists, many different health professionals run these 
groups after their training with us.
    We know that different VAs are variable, and so we are 
going to have to be flexible as how we roll this out, so that 
we get the personnel and the staff and have the staff to be 
able to do this. That is one of the things that we will be 
working diligently with, with multiple different service lines 
around the country, to do.
    I think as far as just--the veterans really love it. They 
tell us all the time that they want this information. They like 
being proactive and having people come tell them what their 
rights are and what are the opportunities for them to make sure 
that they take care of themselves and their families.
    The biggest issue is that many VAs are different, so we are 
going to have to be flexible in how we roll this out.
    Senator Boozman. With the veterans communicating that they 
like the group setting, have you thought about any other areas 
that the group setting would be helpful in regard to----
    Dr. Garner. Well, I think there are a lot of complex topics 
where a veteran could benefit from having a longer discussion 
that sometimes can occur in a short period of time. We do see a 
lot of groups in the VA--like there are some diabetes groups, 
there are PTSD groups, there are other groups, and we think 
that those could be expanded with some of the other topics that 
are kind of complex, that need a little bit more time than you 
can get in a traditional appointment.
    Senator Boozman. Right.
    Dr. Clancy, you looked like you wanted to jump in on that. 
Have you got any other thoughts on that?
    Dr. Clancy. No, I think I was just very positive about her 
response. [Laughter.]
    Senator Boozman. Oh.
    Dr. Clancy. Many, many of our facilities have group visits 
for PTSD, mental health, and so forth.
    Senator Boozman. Right.
    Tell me, in the sense of being a winner in the innovation 
efforts, is there the mechanism for you to stay involved? Will 
you stay involved as--are we going to do something with winners 
in the future?
    Go ahead.
    Dr. Elnahal. Senator Boozman, yes, absolutely. We really 
see our fellows in this program as being permanently involved 
in the improvement of the VA health care system, and Dr. Garner 
is really no exception.
    We are partnering her with an accountable executive in our 
Central Office in DC to come up with a comprehensive national-
scale plan for the advance care planning best practice. We have 
already started that process. In fact, we had our first meeting 
several weeks ago.
    By pairing the subject matter expert, Dr. Garner, with 
somebody with resources and accountability over professionals 
in social work across the entire country, we are going to start 
our national implementation very soon, where everybody at every 
facility who is owning the project is going to design the 
implementation as it best fits them.
    Dr. Garner is very flexible in saying it may be a social 
worker doing these classes, may be a physician, may be a nurse, 
but the whole point is that the outcome is achieved for the 
veteran.
    Senator Boozman. That is great.
    So, in regard to that, the metrics in place then--can you 
talk a little bit about, specifically, how are you going to 
judge the outcome of these things as time goes by?
    Dr. Elnahal. Certainly.
    First and foremost--I will let Dr. Garner supplement this 
answer, but--really we want to increase the rate of filed 
advance directives, just getting the service to as many people 
as possible, expanding that access, and really just to start 
the conversation. So, the more classes the better. That means 
the more veterans are being exposed to it.
    Dr. Garner, I do not know if you had more comments.
    Dr. Garner. We actually have been working on a method of 
doing that where--in the VA there are certain titles that you 
use that can--we can be tracked to say that a certain 
discussion was had, an example being advance directive. It is 
used when an advance directive is actually filled out, or if 
you just had a discussion, you say advance directive 
discussion. Pairing that with the actual group clinic visits, 
we will be able to see how many people had that group visit 
discussion about advance directives.
    We are actually working diligently right now to make sure 
that that is something that we can track and make sure we are 
getting the outcomes that really benefit the veterans.
    Senator Boozman. Good. Very good.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Boozman.
    Senator Brown.

           HON. SHERROD BROWN, U.S. SENATOR FROM OHIO

    Senator Brown. Thank you, Mr. Chairman. You should know 
that Chillicothe was Ohio's first capital in 1803. [Laughter.]
    You should know that if you see the Great Seal of the State 
of Ohio, it is a picture of the hill in Chillicothe with the 
sun rising over it, correct?
    Mr. Bryant. Yes.
    Senator Brown. So, as a 500-acre tree farmer--Mr. Bryant's 
other job--he knows that. [Laughter.]
    Thank you. Chairman Isakson and Ranking Member Blumenthal 
thanks for this hearing very much and for, more than any 
Committee I have ever served on in the Senate--six or seven--
although when I was on the Ethics Committee and Senator Isakson 
was co-chair it was different kinds of subjects but good 
cooperation. I so appreciate how you run things.
    I appreciate the VA. Late last week I spoke to Keith 
Sullivan, who is the director of the Chillicothe VA, who so 
applauds your work, Mr. Bryant. Chillicothe has a particularly 
good, strong image serving homeless veterans in a very remote, 
Appalachian part of Ohio. People come from a long ways away and 
it makes a difference in their lives.
    You are about halfway--my understanding--through the 
planning and the preparation stage to enable veterans to do the 
medical questionnaire on an iPad. This whole eScreening process 
obviously seems to be something that is going to work well. If 
you would, so we really understand sort of from start to 
finish, walk through additional steps needed before the 
eScreening practice is fully operational.
    If you would, at the same time, explain how you ensure that 
veterans understand the technology. Do you have sort of the--
how employees work with them--how VA employees work with them. 
And what are barriers you see as you study this to 
implementation so that this can serve every veteran that comes 
in and can be adapted to VA centers around the country?
    Mr. Bryant. Thank you, Senator Brown.
    Well, on the eScreening, a few things that we need to do 
yet before implementation are a training program with our 
staff--in other words, let them go in, let them actually do 
eScreening themselves and get an idea for what it is asking, 
how it is going to print out, the types of things the veterans 
will see.
    As far as the veterans go, we are planning on having people 
at the front desk when they walk in to help them through the 
process. We will have some veterans that will not want to do 
it. It is high-tech. They will not want to have anything to do 
with that process, and that is fine. We will revert to what we 
currently do. But for the ones that do want to do that, we are 
going to have people stationed there to walk them through it, 
show them----
    Senator Brown. Do you----
    Mr. Bryant. Sure.
    Senator Brown. Do you have any indication on how many 
veterans will not choose to do this, that you will continue the 
present practices with? Do you have any way of knowing that?
    Mr. Bryant. We really do not, in the fact that many of our 
veterans, they range different age groups. So, ones that you 
might think would not want to be part of that are the ones that 
will. And they are very much into Facebook and different 
things, so they are going to be onboard with high-tech kind of 
things.
    The other piece that we need to work on is our 
communication plan in letting our veterans know it is coming, 
letting our staff know it is coming. We are going to spread it 
out to 21 clinics starting in our primary care and our 
community-based outpatient clinics (CBOCs), where our rural 
veterans can get to the----
    Senator Brown. Those are the CBOCs initially in southern 
Ohio or throughout the State, throughout the----
    Mr. Bryant. Initially in southern Ohio----
    Senator Brown. OK.
    Mr. Bryant [continuing]. Chillicothe community-based 
outpatient clinics.
    Senator Brown. OK.
    Are you seeing any resistance from employees to this idea? 
I mean resistance--you know, it is kind of human nature that 
some people are resistant to change. Are you happy with the 
cooperation you have seen in that way?
    Mr. Bryant. We are. The one thing that is very clear at 
Chillicothe VA Medical Center is we all are behind the mission 
and we all believe in the mission very strongly. We have had 
many outside people come in and say that is the one thing they 
really see there. So, if it is better for our veterans, our 
staff get on board and they want to make that change.
    Senator Brown. OK.
    If I could, in the last few seconds, Mr. Chairman, shift to 
the bike share program, which I know you have been part of in 
Chillicothe. Talk to me about the transition from a bike repair 
shop idea to a vocational rehabilitation sort of writ large, or 
a vocational rehabilitation and entrepreneurial training 
program. Explain sort of how that happened, and walk through 
what it is exactly.
    Mr. Bryant. OK.
    The bike share program was actually initially a byproduct 
of, let's have a bike shop; let our veterans run the bike shop 
in our voc rehab areas. The concern that I had initially was, 
how many bike shops can you have in Chillicothe, OH? 
[Laughter.]
    We worked on that a little bit and started to think, what 
if I want to run a flower shop or a motorcycle shop or any 
other kind of business? That is where we need to go with this.
    So, we then contacted the Small Business Administration and 
we have been working with them. They offer all the 
entrepreneurial training for free to our veterans. They come to 
our site, and they are able to not only teach the veteran that, 
but then we use the bike share as a practicum for the veterans 
so they can not only take what they learn but actually put it 
into play.
    Senator Brown. Good.
    Thank you, Mr. Chairman. Thank you again for holding this 
hearing.
    Chairman Isakson. Thank you, Senator Brown.
    Senator Rounds.

        HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA

    Senator Rounds. Thank you, Mr. Chairman. First of all, let 
me add my congratulations for putting this together today with 
Ranking Member Blumenthal, but also for the work that both of 
you did in getting the Veterans First Initiative moving forward 
and getting the legislation out of here and moving down. I just 
think that is very, very important and I appreciate all the 
work that you have done so far, sir. Hopefully we will have a 
very fruitful end of the year and we will be able to get some 
more stuff done as well and actually have results.
    Dr. Clancy, I will address my questions to you, and you can 
redirect if you feel appropriate.
    One of your Gold Status best practices is increasing access 
to primary care with pharmacists. Now, that leads me to suspect 
that the Veterans Health Administration (VHA) staffing and 
management is included in the Diffusion of Excellence 
Initiative.
    If that is so, one of the most controversial issues with 
the VHA staffing right now is the practice of authority granted 
to advanced practical registered nurses. I know that currently 
VHA grants these authorities very differently depending on a 
number of different factors, including local State laws.
    Has there been any discussion about the differing levels of 
access, quality of care, and staffing efficiency between 
hospitals that treat advance practice registered nurses (APRNs) 
differently? And, would a high-performing hospital that grants 
full practice authority to APRNs be able to submit their best 
practices to the Diffusion of Excellence Initiative in order to 
produce a more effective workforce across the VHA?
    Dr. Clancy. I think that we will be learning a great deal 
as this authority is implemented. It actually exists right now 
in some parts of our system. As you know, State laws in terms 
of scope of practice vary a bit across the country.
    Frankly, as I think you also know but I think it bears 
restating, this is all about improving access to care. That is 
why we are excited about the best practice related to clinical 
pharmacy specialists, because a huge proportion of primary care 
visits are about medication management. Pharmacists are often 
better at it, as Dr. Elnahal noted a little bit earlier in 
citing his own care as an example. I think we have all been in 
pharmacies where we watch people actually go up to ask the 
pharmacist: Yeah, the doctor told me this, but give me the real 
story here. [Laughter.]
    I have every expectation that advanced practice nurses will 
do a terrific job. It will be something that we will continue 
to be looking for best practices in that area as in others. We 
are probably going to continue to do research in that area as 
well to make sure that veterans get great care and timely 
access to that great care wherever we take care of them.
    Senator Rounds. Well, I know in rural areas it is critical 
that we have that available, simply because we do not have the 
numbers without them. I appreciate your thoughts on that and I 
am happy to hear that.
    If I can just change subjects just a little bit. The VA 
Office of Suicide Prevention has worked very hard over the past 
few years to capture accurate, comprehensive data on the number 
of veterans committing suicide. Recently the VA released the 
most comprehensive report that we have seen in years on veteran 
suicide.
    I am told in the upcoming weeks and months this data will 
be broken down by region and State, at which time we will be 
able to compare VISNs and facilities on their suicide 
prevention efforts. As that data continues to be made public, 
can we expect to see results-driven best practices from high-
performing mental health facilities in the Diffusion of 
Excellence Initiative?
    Dr. Clancy. Absolutely. One initiative that we are going to 
launch very soon--and, again, this comes from our own 
researchers--is actually testing the reliability and utility of 
using a suicide risk stratification--in other words, 
identifying veterans who we have reason to believe are at the 
highest risk of suicide--with the idea that if clinicians know 
about those veterans ahead of time, they will be able to 
actually provide extra efforts and make sure that they get the 
help that they need as rapidly as possible.
    That is going to launch either this month or next month. I 
think that is going to be a very, very exciting--we are going 
to be careful about it, in other words evaluating as we go, but 
this for us is a very, very high imperative. Frankly, I am 
looking forward to seeing some of the results broken out by 
State and region, some of which will give us good information 
about what is going on at our facilities and what kinds of 
interventions and services we are providing, some of which may 
give us other clues as to what is behind the increased suicide 
risk for veterans and, frankly, the rest of the country, 
because there is a lot we have to learn.
    Senator Rounds. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Rounds, and thank you 
for your comment. Ranking Member Blumenthal and I appreciate 
the fact that this Committee passed out, unanimously, the 
Veterans First bill. We hit a few roadblocks leading up to the 
election in November, but I am hoping that when November 8th is 
over we get that put to bed. I appreciate very much the 
Committee's full support and everything everybody did to make 
that happen.
    Senator Manchin.

     HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA

    Senator Manchin. I want to thank you, Mr. Chairman, also 
for the fine job you do and allowing all of us to participate. 
It comes out with unanimous--usually unanimous cooperation.
    Dr. Clancy, all over our State we have an epidemic of 
opiate addiction, and it is not immune to the veterans 
community. With that being said, the amount of our veterans 
that are coming in with chronic pain that have been addicted or 
are committed--you know, are committed to pain management, what 
are you--what are your efforts to incorporate the pharmacy 
specialist in to the Patient Aligned Care Team (PACT) for 
veterans who suffer from that?
    Also, what we are doing--I was told that--by one of--in one 
of our veteran hospitals in West Virginia, the lady who was in 
charge, she says, if you just would not let the patients call 
you politicians all the time and raise Cain about it when we 
will not give them something, they would be a lot better off. 
If you let us do our job--and she was just--I loved her for 
it--very frank. She said: Let me deny the person who I know is 
addicted. Let me try to help that person. But, if they know 
they can call a politician and raise Cain about not getting 
quality of service because they did not get the prescription 
they wanted, how much of a problem is that?
    Dr. Clancy. That is a problem. Obviously it is a problem 
that I think gets to a lot of people. We are here to serve 
veterans, so if someone calls one of you or calls one of us----
    Senator Manchin. Sure.
    Dr. Clancy [continuing]. And says, I am in extreme pain and 
you are denying me----
    Senator Manchin. It gets to our level. Basically, they 
think they can----
    Dr. Clancy. Yeah. We take that seriously, but we also get 
that it is very, very difficult to stop taking these 
medications.
    Senator Manchin. We are trying to pass legislation not only 
in the VA but across the board that basically they cannot do 
that, to rate hospitals or rate the quality----
    Dr. Clancy. Yes.
    Senator Manchin [continuing]. If opiates are being given 
out, prescribed. Would that be helpful?
    Dr. Clancy. I know that many, many physicians believe that 
incorporating questions about pain management has been part of 
the problem fueling this epidemic.
    Senator Manchin. How many would you say, a percentage--
maybe any of you all doctors--how many of the patients that you 
have coming in, you all see in your practices, are because of 
addiction? How much is opiate addiction in your patient load?
    Dr. Elnahal. I can start to answer that.
    I am an oncologist, so a lot of the patients that I have 
seen in my career are on pain medications because of cancer 
pain, which is significant pain. There is dependency in that 
setting, so it is difficult----
    Senator Manchin. PTSD.
    Dr. Elnahal. I have not seen many PTSD patients but, you 
know, the whole point is----
    Senator Manchin. Maybe Dr. Garner has. She is on the front 
lines, right?
    Dr. Elnahal. Yes, absolutely.
    Dr. Garner. I will say that I take care of the older 
veteran, the 80s and 90-year-olds, and we----
    Senator Manchin. Hopefully, they are out of that league.
    Dr. Garner. We just do not see that much in them.
    Senator Manchin. Right.
    Dr. Garner. I do have some primary care colleagues where 
pain management is a significant issue for them.
    Senator Manchin. Are you all using other methods rather 
than prescribing? We have alternative methods as far as pain 
management, right?
    Dr. Garner. Yes, we have the clinics where they go to where 
they learn touchy--massage, acupuncture----
    Senator Manchin. Everything else.
    Dr. Garner [continuing]. Everything else that we can give 
them. But I do know that my--just from hearsay that my 
colleagues say that that is a significant issue.
    Senator Manchin. Well, we want to work with you any way we 
can, Doctor--all of you all--to solve that.
    Dr. Clancy. Just to mention, we also have a new National 
Director for Complementary and Integrative Health Options, 
which I think will help a lot. In addition to that, we are 
sponsoring a state-of-the-art scientific conference on non-
pharmacologic approaches to pain management a little later this 
fall.
    Senator Manchin. Good.
    Dr. Clancy. We will certainly make you all aware of that.
    Senator Manchin. It is my understanding that both 
Martinsburg and Clarksburg, in my State of West Virginia, our 
VA medical centers, will be sites where the Journey to Open 
Access in Primary Care Practice will be implemented in the 
future.
    Dr. Clancy. Yes.
    Senator Manchin. You and I both know how critical access to 
primary care is in the preventing long-term and more serious 
illnesses and conditions from developing from that.
    Both Martinsburg and Clarksburg both serve rural areas. And 
I think my question would be, are there differences in 
implementing this Gold Star practice in rural and urban 
settings? Do you need any new authority from us in Congress to 
allow you to be able to cover both the rural and urban 
settings?
    Dr. Elnahal. Thanks for that question, Senator Manchin. I 
think it is a really important topic.
    I do want to say that this initiative could not have been 
possible without collaboration with the Office of Rural Health 
and the statutory authority you have given that office to be 
able to provide great care for veterans.
    One thing that could really help a lot of these practices--
the Liver Cancer Tumor Board, the primary care access practices 
you were talking about--is legislation around telehealth and 
expanding the access that rural veterans can have to that 
service from their own home across State lines.
    An example that I can give you is that the Tumor Board that 
we are actually running out of Little Rock is serving patients 
in Jackson, Mississippi, and so those patients actually have to 
go to that Jackson facility right now in order to receive that 
service. If we were able to receive legislation that expanded 
that scope of practice, that access from the patients' home, 
the veterans' home, we would be able to expand the access to it 
to many more veterans, and so that would be very helpful.
    I do want to also thank you for hosting a facility that has 
been an incredible participant in this initiative. Martinsburg 
has already implemented the WAKE score, which has expanded 
access to OR services because patients are able to be 
discharged more quickly and safely. Also, they have already 
implemented the flu icon, which allows patients--sorry, 
employees to register that they have gotten the flu vaccine, 
which is an important public health initiative. Thank you for 
that.
    Senator Manchin. Thank you all. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Manchin.
    Senator Heller.

           HON. DEAN HELLER, U.S. SENATOR FROM NEVADA

    Senator Heller. Mr. Chairman, thank you. I want to thank 
you and the Ranking Member for your work and efforts on behalf 
of this Committee. If I could echo what has been said and how 
pleasant it is to work on a Committee like this when everybody 
is working together.
    I also want to thank our panel. I came onto this Committee 
four or 5 years ago and I had a very different attitude than I 
have today. I say that because I see a couple of hospital 
directors in Nevada, both in the north and in the south--and 
they have changed recently--and seen the improvements of some 
of these changes.
    Mr. Chairman, I know that through hearings that we have had 
here, the need for that has been emphasized. Fortunately, the 
VHA has helped us over this time in getting this work done. It 
is not just the fact that they communicate better with my 
office, which they do, and I certainly do appreciate that they 
are available to us, but more important, they are available to 
the veterans and their families in their time of need. I 
certainly do appreciate that also.
    Now I want to go to this Diffusion of Excellence. Because 
of the improvement that I see in leadership in our hospitals, I 
am wondering if, during this Diffusion of Excellence, if 
leadership development is part of this process. Dr. Clancy?
    Dr. Clancy. We do not have a specific practice around that, 
but it has been a very, very high priority for the Secretary. 
In fact, we will be having some 600 senior leaders from across 
the system convene together next week, because he believes, as 
does Dr. Shulkin, that this is our number-one priority in terms 
of restoring trust and, as Senator Isakson said earlier, brand.
    Leadership stability and getting the best people and the 
right people in leadership positions is absolutely essential. 
So, I was thrilled when you said a moment ago that Veterans 
First passed unanimously out of this Committee, because that is 
going to give us a lot more flexibility.
    We have also changed how we are approaching hiring medical 
center directors. It used to be if one facility in Nevada 
needed a new director, they would start their process, and then 
if the other one did, they would do their process. Now we are 
saying, look, we have a lot of vacancies.
    We have actually put out announcements where people can 
apply to one of a number of opportunities. They are then 
interviewed consistently by leaders from Central Office, from 
networks, and from other facility directors. We just had a big 
round of this last week. I led a team and we interviewed about 
ten people, but there were about six other teams doing the same 
thing. This is the initial screening phase.
    We have been encouraged by the interest. Frankly, we will 
not stop or rest until we have good people in all the right 
leadership positions.
    Senator Heller. Thank you.
    Dr. Clancy, as part of your initiative that--I am looking 
over there on that board--did you reach out to the VA hospitals 
to find out what they are doing right, specifically the Nevada 
hospitals, to see--as part of this initiative effort?
    Dr. Clancy. Yes. I am going to turn that to Dr. Elnahal. 
Thanks.
    Senator Heller. If you would, please. Thank you.
    Dr. Elnahal. Senator Heller, thanks for that question.
    We actually did a broad solicitation from every facility 
throughout the country to see what was done right--what was 
being done right in all of the important areas that the Under 
Secretary and the Secretary have found in terms of priorities.
    I will tell you that in Nevada we have eScreening already 
implemented, which is a practice that Mr. Bryant is owning in 
Ohio, and it is achieving great results there. In fact, it has 
been shown that so far, on the site that it has been reapplied, 
that it is increasing mental health referrals from primary care 
for really concerning findings around PTSD and suicide by 20 
percent. Those results are being reflected every single day in 
southern Nevada. The flu icon is also operating in Reno right 
now. Your facilities in Nevada have been great participants.
    To answer a little bit about your first question in terms 
of leadership, we just described that Dr. Garner is leading now 
a national implementation of a practice that she is an expert 
in. What our goal was, was to set up a system where the best 
practice fellows got an incredible leadership experience just 
by virtue of participating and allowing their practices to be 
elevated throughout the country.
    Senator Heller. The question I guess--and I will stay with 
you for just a minute--is what could I go back--I look at the 
board there, implementing 300 ongoing--sorry, I have to use my 
glasses here--replications at over 70 facilities. What is going 
on in the Nevada facilities right now? What can I tell the 
families--veterans and their families of how this initiative is 
actually helping them?
    Dr. Elnahal. The two facilities that I mentioned in terms 
of the facilities that have implemented eScreening and the flu 
icon, you can say that if you are a veteran who is having 
concerns about their mental health or thinks that they are not 
well, they will be found much more often now in these 
facilities than many others who do not have it, and we are 
trying to expand that service, as we speak. Southern Nevada has 
been a major example of success in that area.
    In terms of just simply public health and proper 
occupational health practices, Reno now has an easy way for 
employees to report that they have gotten the flu vaccine. You 
can just rest assured that if you are a patient in that 
facility, you are probably less likely to get the flu.
    Senator Heller. Thank you.
    If the Chairman will indulge just for one more minute, one 
more question, which has to do with doctor shortages. This 
Diffusion of Excellence, how does it address this particular 
issue that probably is at the forefront in Nevada, trying to 
get the doctors necessary in these hospitals?
    Dr. Elnahal. I think a lot of that relates to overall 
access. You know, if you have a shortage of physicians, 
obviously you will be waiting longer to see them. Five of our 
13 best practices are access-related for that reason.
    In many places throughout the country, it has been brought 
up that a lot of providers need to be practicing at the top of 
their license. We are trying to spread those practices through 
clinical pharmacy specialists by way of a Patient Aligned Care 
Team, which originated in Fresno, and through nurse Case 
Manager Chair visits, which are available at many of the States 
of the Senators sitting on this Committee now. That is why we 
have taken a particular focus on access as a priority for both 
the Secretary and the Under Secretary.
    Senator Heller. Doctor, thank you, and to the panel, thank 
you very much for being here.
    Mr. Chairman, thanks for holding this hearing.
    Chairman Isakson. Thank you, Senator.
    Senator Hirono.

              STATEMENT OF HON. MAZIE K. HIRONO, 
                    U.S. SENATOR FROM HAWAII

    Senator Hirono. Thank you, Mr. Chairman.
    Dr. Clancy, the regional Liver Tumor Board is one of the 
best practices highlighted in your testimony today. And in the 
past 10 years, the number of liver cancer patients among the 
veteran population has increased tenfold, and at some point I 
would like to understand better why that is happening. Maybe we 
have an aging veteran population. I am not sure.
    In any event, I am pleased to see VA taking aggressive 
steps to treat liver cancer. I am also pleased to see the 
creative use of telemedicine, as I have supported legislation 
to expand VA's utilization of telemedicine. I know that the VA 
has requested legislative action when it comes to increasing 
the use of telemedicine. Can you speak on the importance of 
telemedicine and VA's efforts to improve access to high-quality 
health care for the veterans?
    Dr. Clancy. I am going to refer to this Dr. Elnahal, who 
just gave a brilliant summation of this, particularly as it 
relates to the Tumor Board.
    Some piece of the increase in liver cancer, by the way, is 
almost certainly due to the increased prevalence of hepatitis 
C. I cannot tell you how excited all our folks are about being 
able to provide these effective treatments and to thank all of 
you for your support to be able to do that.
    Dr. Elnahal. Senator Hirono, thanks so much for that 
question.
    When we did our solicitation of best practices, we got many 
of them around telehealth, and some networks in our system 
provide pretty robust telehealth services and wanted to spread 
that to other places.
    We found that, unfortunately, in our effort to find 
facilities that were willing to reapply them, that a major 
limitation was certain restrictions on the use of telehealth, 
and namely the following: If I am a physician at one facility 
in the VA and I want to provide care for a patient who is at 
home and they are not in my State, I cannot do that. That 
prevents adequate load-balancing in terms of me being able to 
see a patient across the country in a situation where that is 
convenient for them, especially for rural veterans who may live 
very far away from our nearest site of care.
    There are efforts to pass legislation on this that would be 
helpful. For example, Senator Ernst had a bill last year called 
the Veterans E-Health----
    Senator Hirono. Which I cosponsored, by the way.
    Dr. Elnahal [continuing]. And you as well, Senator Hirono--
that really put this effort at the forefront to allow 
physicians within the VA to see patients in their homes across 
State lines. That would help with the Liver Cancer Tumor Board; 
it would help us to adopt more of our best practices in 
telehealth, which would be extremely helpful for this effort.
    Senator Hirono. I would anticipate that the VA would 
continue to push for this because I think that, at this point, 
especially those of us who represent rural areas--and basically 
all of the neighbor islands, apart from Oahu, are rural areas. 
I think that our veterans there could very much benefit. So, 
please continue to push for the kind of legislation that you 
must mentioned.
    Dr. Clancy, for the eScreening best practice, you describe 
that the veteran is handed an iPad when he or she checks in for 
an appointment, and can complete any required screening on the 
iPad. Do you have any idea about the extent to which different 
generations of veterans are comfortable using the iPad? What 
sorts of safeguards are in place to ensure the protection of 
sensitive information that will be obtained through this 
eScreening process?
    Dr. Clancy. I am going to refer this to Mr. Bryant, who is 
right up to his eyeballs in making sure that this all works 
well.
    I would just make one comment before having him jump in, 
which is, in general--and Senator Isakson hit this point in his 
opening comments, or questions--many people find telling an 
iPad or a computer about their symptoms far less intimidating 
than they do telling a person. That is one more reason behind 
it.
    Do you want to talk about generational difficulties and the 
others?
    Mr. Bryant. Sure. Thank you for the question.
    One of the things we have decided to do as we break this 
out is to offer staff and volunteers in the waiting room, so 
when the veteran comes in, someone is there to walk them 
through the process. We did the same kind of thing with kiosk 
when they first came to the VA system and it worked very well. 
Veterans felt at ease. The questions that they are asked are 
yes/no questions, so they are not very difficult.
    In the eScreening, the iPad itself is a dummy box, 
basically, so it is not going to go across the network. 
Basically it goes right into our Computerized Patient Record 
System (CPRS). The veteran will get a printout at the desk. 
They take that back with them. The provider is given an alert. 
So, when the veteran says ``yes'' to one of the questions, it 
alerts the provider to kind of tailor that appointment to their 
needs.
    Senator Hirono. Thank you.
    I see, Mr. Chairman, I am out of time, yet I want to 
commend the VA for doing everything they can to make their 
process much more accessible, efficient, and effective to our 
veterans. Thank you.
    Chairman Isakson. Thank you.
    Senator Sullivan.

          HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA

    Senator Sullivan. Thank you, Mr. Chairman. I want to thank 
you and the Ranking Member for holding the hearing, and the 
panelists for the hard work they have been doing on this 
initiative. I think it is a great undertaking and I want to 
commend you for it.
    I want to talk about the consistency of accessibility in 
rural communities. I know, like a lot of my colleagues here in 
the Senate when we were home over the summer, I spent a lot of 
time out in the rural communities in Alaska. And, for those of 
you who have been--you know, we hear the talk of ``rural'' but, 
as you know, there is rural America and then there is Alaska. 
[Laughter.]
    It is very, very extreme rural--no roads to hundreds of 
places, limited telecoms, challenging terrain, small 
communities--but we have a huge veteran population, which we 
are very proud of, more vets per capita than any State.
    When I travel to even the smallest communities in Alaska, I 
always meet with our veterans, no matter where--try to. It is 
very humbling because you will go to a small rural village in 
Alaska and you ask for a town hall with veterans, and there 
will be, you know, 10 or 15 Vietnam vets, combat vets, who come 
out to these meetings--great Americans.
    One of the things I asked during this recent recess is, 
let's say you are a Vietnam vet, you live in a very extreme 
rural community in Alaska, so you are 100 miles away from 
anywhere--you are maybe a thousand miles away from Anchorage--
in the same State--and you have a problem, a health problem. My 
question was, well, what do you do? Literally, you could be 
sitting with five veterans in the same community and their 
answers were different.
    Some said, well, they had the opportunity to just go to a 
local Native Alaskan health clinic, if you were a Native 
Alaskan. Some said, no, I can go to the Native Alaskan health 
clinic myself even though I am non-Native. Others said they 
could go to the local clinic. A lot of our clinics in rural 
Alaska do not have any doctors, even the clinics. So, responses 
were all over the place, literally in the same community.
    Others said, well, the VA told me I can go to Anchorage to 
get, you know, my health. That is maybe, you know, 500, 600, 
700 miles; easily $1,500 round trip, maybe $2,000 and if you 
are staying at a hotel, maybe $3,000. Sometimes those veterans 
were told the VA will pay for that whole trip and the hotel and 
the airfare. Other times--literally the same community--the VA 
would say, you are going to Anchorage, you have an appointment, 
but good luck; get there yourself.
    So, here is my question--and I have already blown 3 minutes 
of my time so I know you cannot answer it in the remaining 2 
minutes. What I would really like is a written answer. If you 
can help me and my veterans and maybe this Committee 
understand, what is the right answer?
    Maybe it depends on your veteran status--if you are a 
combat veteran, if you are retired--but if you live in an 
extreme rural community in Alaska or Hawaii, you know, extreme, 
like, no roads--you guys know what I am talking about--what is 
the answer, because right now the answer is literally all over 
the place. I asked probably dozens of veterans this question 
just in the last 6 weeks and everybody had different answers, 
including people sitting next to each other who lived in the 
same small community.
    I did not have an answer for them, which, you know, I did 
not think was appropriate, but I need help from you on what 
that answer is for the veteran who lives in the extreme rural 
community and maybe does not have a doctor in that community, 
maybe one Native health clinic. You know, Dr. Clancy, can you 
just give me a sense of what that answer is?
    Again, I would really like it in a detailed written-out 
response from you guys, but, maybe just real quick, what is the 
answer?

    [Responses were not received within the Committee's 
timeframe for publication.]

    Dr. Clancy. Senator, it is an incredibly important 
question. About one-third of the veterans we serve are in rural 
areas, most not quite as rural as what you are describing.
    Senator Sullivan. Remember, most rural places in America 
you can get in a car and you can drive to.
    Dr. Clancy. Yes.
    Senator Sullivan. In my State----
    Dr. Clancy. You need a road, yes.
    Senator Sullivan [continuing]. We do not have roads, 
unfortunately.
    Dr. Clancy. Yes.
    Senator Sullivan. That is a whole other issue, but----
    Dr. Clancy. Yes.
    The good news is that we have a growing number of options 
to help those veterans. We have a terrific Office of Rural 
Health. We would be delighted to follow up with you with a more 
detailed answer, because what I am worried about, from what you 
are telling me, some of what you are hearing I think does track 
back to some eligibility rules.
    Senator Sullivan. Yeah.
    Dr. Clancy. I am thrilled that we are working with you, 
frankly, at much of your enthusiasm on making Choice as 
effective as possible----
    Senator Sullivan. Yeah.
    Dr. Clancy [continuing]. For the constituents you 
represent, but I also am wondering how effectively we are 
communicating or not, possibly, to the veterans you are hearing 
from when you are having these town halls.
    Senator Sullivan. OK, thank you.
    Just one final thing. I commend you again on your map. It 
is a little weighted heavily on the Northeast, I would say. I 
am not sure why. I do have a suggestion: I strongly encourage 
you to set up a project of excellence in the great State of 
Alaska.
    There is no big dot over Alaska here, which is a little 
disappointing. But if you guys are looking at extreme rural 
issues to deal with in terms of a project of excellence, there 
is literally no better place in the country to undertake such a 
project. I would love, you know, next time you guys come here, 
to make sure there is a big blue dot over Alaska.
    Dr. Elnahal. Senator Sullivan, we will be heavily weighting 
all submissions from Alaska in this. [Laughter.]
    Senator Sullivan. That is a good answer. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Sullivan.
    Senator Moran.

           HON. JERRY MORAN, U.S. SENATOR FROM KANSAS

    Senator Moran. I assume you will not forget Kansas either, 
Doctor. [Laughter.]
    Mr. Chairman, thank you very much. Thank you to you and the 
Ranking Member for having this hearing. It is always pleasing 
to know that the VA is working hard to find better ways of 
doing more things to care for those who served our country.
    I want to raise a circumstance we find ourselves in, in 
Kansas. And this is a topic that I have raised with Mr. Missal 
as well as a letter to the Secretary, but a tragedy has 
occurred in our State that involves the Leavenworth VA. That 
tragedy is that a physician assistant is accused of sexually 
harassing and molesting veterans, particularly those with PTSD, 
and has been discharged from--has terminated his employment 
with the VA.
    The facts now indicate that the knowledge of this person's 
history could have--or perhaps it was known. He indicated in 
his application for licensure in our State that he had past 
circumstances involving sexual crimes, yet this individual 
still gets hired by the Department of Veterans Affairs. The 
reports continue to come in. Criminal prosecution is ongoing.
    Again, those are the circumstances we find ourselves in. As 
we look at best practices, obviously having the best personnel 
in place is a requirement for us to implement best practices. I 
want to ask a set of questions that are related to the 
circumstance that we now have in our State.
    Again, it is outrageous that someone with a criminal record 
would be hired and put in a position to care for veterans. We 
are uncertain as to how long this circumstance was known before 
the termination occurred. There were several investigations 
that apparently resulted in no termination.
    While you are here to talk about improvements in best 
practices at the VA health care system, we obviously have some 
immediate circumstances that we need to take care of. My 
question--there are a couple. My questions are these: What best 
practices to improve the vetting and hiring process, and what 
are the best practices that come in regard to background 
checks? Are there things afoot at the VA that would improve the 
circumstances that these kind of circumstances, this 
circumstance in particular, cannot or would not happen again?
    Dr. Clancy. Senator, first, we share your sense of outrage 
on behalf of the veterans you serve and, frankly, all veterans. 
It is our responsibility to learn from this so that we can 
prevent anything that we could have done differently from 
happening in the future. That is a big priority for the group 
that I am leading at VA. I appreciate your comments very much.
    I think that you have stated very eloquently why 
credentialing of the providers that we hire is such an 
important function for us and for any health care system. We 
are striving for ways to improve that at all times, including 
working with the Federation of State Medical Boards and so 
forth.
    It used to be because State licensing is a State authority, 
right, that you--someone might leave one State and it would be 
hard to get information. Well, this federated group makes 
information about prior incidents and reports much more easily 
available, and the people who do credentialing at VA are taking 
advantage of that opportunity. We will certainly be most 
attentive to these specific responses you need around this 
incident, while it is something that we are always looking to 
improve.
    Senator Moran. What about best practices when it comes to a 
complaint being alleged, a concern raised? What about best 
practices in how you then treat that employee and his or her 
potential termination or--I guess I will leave it at that--in 
this circumstance the termination and ultimate prosecution, 
best practices in place once we know something has happened to 
terminate that person?
    Dr. Clancy. Certainly we are going to do everything in our 
power to try to learn, again, if there is something that we 
could have and should have done differently in the past with 
respect to this individual employee.
    The phenomenal part of an integrated health system is that 
we have the potential and, in fact, do share information about 
this system-wide, so that where we do make decisions that might 
have been done differently we can share that system-wide, and 
you have my commitment that we will do that.
    Senator Moran. Dr. Clancy, I appreciate what you just said. 
I would tell you that I have had the sense over a period of 
time that, seemingly too often, when there is a problem with an 
employee, a health care provider within the VA, my impression--
and you can convince me that I am wrong--is the most likely 
outcome is that that professional is transferred to some other 
facility within the Department of Veterans Affairs. It seems to 
me that the likelihood of termination is minimized and often an 
individual is transferred.
    Dr. Clancy. Having been personally involved with a couple 
of fairly senior clinicians in this circumstance, I can tell 
you that it was my highest priority to make sure that that did 
not happen. I cannot speak to what has happened in the past, 
but that is not fair to veterans or to anyone else.
    Frankly, it is our responsibility to report to State 
licensing authorities. In cases I have been involved with 
directly, we have made sure that we have done that. It is a 
lengthy process, both because of due process and also making 
sure that we have enough evidence to uphold everything that 
goes forward; but that is what we need to do, period.
    Senator Moran. Doctor, I use this hearing as an opportunity 
to raise this issue----
    Dr. Clancy. Yes.
    Senator Moran [continuing]. For its importance. In this 
particular circumstance, justice needs to be had.
    Dr. Clancy. Absolutely.
    Senator Moran. Individual veterans need to be cared for as 
a result of this individual's actions, but also that this needs 
to come to an end. This should never be the circumstance we 
find ourselves in, in any VA facility across the country. I 
would ask your commitment that we achieve that goal.
    Dr. Clancy. You have my full commitment to that.
    Senator Moran. Thank you, Doctor.
    Chairman Isakson. I want to thank Senator Moran for 
bringing up the subject, and I want to make a comment, if I 
can.
    What you have just said is exactly the evidence that 
testifies to the fact that we have got to pass Veterans First. 
You have got to be able to fire employees and make it stick. 
There are certain crimes or certain practices or certain 
illegal activities for which there should be zero tolerance, 
period. Sexual predators is one of them.
    There is a recent series in the Atlanta Journal-
Constitution that has run for about 16 weeks on the number of 
physicians who have abused the doctor-patient relationship and 
have been sexual predators, and even the boards of medical 
examiners in the States have returned their licenses to them 
rather than disciplining them.
    I would just add this comment: We need to give the VA the 
ability to fire and make it stick, and that is why Veterans 
First is so important, number 1, first at 434-level employees 
and then all the way down.
    Second, there ought to be a complete attitude of zero 
tolerance for certain things, and sexual abuse or sexual 
predators is one of them. You should not move them around 
somewhere else in the agency to get rid of them. You should get 
rid of them entirely so they cannot ever come back in the 
agency again. That is something I hope the VA will work on.
    I am going to work on seeing that Veterans First gets done 
so you can fire and make it stick. I want you to work on 
policies and practices that have a zero tolerance for those 
types of activities.
    Thank you for bringing that up.
    Senator Moran. Thank you, Mr. Chairman.
    Chairman Isakson. I thank our guests for being here today.
    Senator Blumenthal. Can I----
    Chairman Isakson. Sure.
    Senator Blumenthal. Mr. Chairman, with your permission, may 
I ask another couple of questions?
    Chairman Isakson. I will give you 4 minutes because I have 
got to go to another meeting.
    Senator Blumenthal. Four minutes or I will be fired? Is 
that----
    [Laughter.]
    Chairman Isakson. No, no, no, no. No, I am leaving. You can 
stay. [Laughter.]
    No, you go right ahead.
    Senator Blumenthal. I can do it in 4 minutes.
    Chairman Isakson. You go right ahead.
    Senator Blumenthal. First of all, I want to join the 
Chairman's comments about zero tolerance; and the record should 
note that Dr. Clancy was nodding, so I assume that means 
agreement.
    I want to come back--not to exhaust but to suggest the need 
for more information--to the topic of drug pricing and the VA's 
negotiation practices, and how maybe those practices can help 
our hospitals and other providers do better. They will not have 
the same kind of organized weight or market power that the VA 
has, but maybe some of your, for lack of a better word, tactics 
and practices can be modeled by other private buyers.
    I also would like to know whether those prices have 
changed, how you track those prices, and whether they can--that 
data can be made available to us. In other words, we were 
talking earlier about how the impact of drug shortages can 
affect even your prices. You can negotiate but you still have 
to reach an agreement. You cannot dictate the results. You have 
to have bargaining.
    So, I would like to explore whatever information you have 
about those price trends on some of those medicines that we 
mentioned, and others, that have been raised with me from my 
constituents and others around the country in response to the 
EpiPen controversy. They affect not only EpiPens and insulin 
and Narcan but certain kinds of inhalers and other everyday 
kinds of medicine, where the cost of health care could be 
dramatically affected by the prices that we pay, and the VA's 
success relative to others in the market may provide some 
guidance for us.
    I want to join the Chairman in thanking you today, and look 
forward to continuing this conversation.
    Dr. Clancy. We would be delighted to follow up on that. And 
just to make sure it is captured for the record, you have my 
full commitment that we will pursue it on the policy front, the 
issue of zero tolerance.

    [This information was provided by VA by way of a phone 
call.]

    Senator Blumenthal. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Ranking Member Blumenthal.
    Thank you, Dr. Clancy, Mr. Bryant, Dr. Garner, Dr. Elnahal. 
Thank you very much for being here today. I thought it was a 
great hearing.
    I want to thank Senator Boozman and Senator Brown for 
raising this issue to our attention and for forcing us to call 
this hearing today.
    With no further business, we stand adjourned.
    [Whereupon, at 3:43 p.m., the Committee was adjourned.]