[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
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
26-818 PDF WASHINGTON : 2018
____________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Publishing Office,
Internet:bookstore.gpo.gov. Phone:toll free (866)512-1800;DC area (202)512-1800
Fax:(202) 512-2104 Mail:Stop IDCC,Washington,DC
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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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.]