VA secretary assesses challenges, progress

VA Secretary Robert McDonald, the former chief executive officer of Procter & Gamble, visited The American Legion National Headquarters in Indianapolis on July 23. During an interview, McDonald spoke about the challenges VA faces, and its progress in technology and patient care.

Q: How does your experience in corporate leadership help you lead the VA?

A: The leadership in the private sector and government are the same. If you look across my core leadership beliefs that I have codified over the last 30 years or so, they are the same. They are about leading a purpose-inspired life, the idea that everybody wants to succeed. I’ve never met anybody in the world who wants to fail. These things are the same in government and the private sector. I think the difference is that in government the role of purpose and inspiration is greater. You can’t have a better purpose than to take care of the veterans in this country. One percent of people have protected 100 percent of people in this country. In that sense, it is not difficult to find purpose and leverage that when I get groups together. Always start with the purpose. Always start with the values. And always start with the amazing history of our country and VA.

Q: The complaints with VA focus on the backlog, medical appointments, etc. Once patients get in, they have a lot of great things to say about the VA care. The issue is trying to get people through a very crowded system. Is VA too big and unwieldy to change in order to address the problems with patient access, etc. Why or why not?

A: I don’t think so at all. In fact, it is my mission – and the mission of the employees of the VA – to be the most customer-friendly organization in government. This is a different concept in government. It is one I am bringing from the private sector. For the best customer service organizations in the world, size doesn’t matter. What matters is the culture of how you deal with customers. What we are trying to do as part of the MyVA transformation is to put the customer first. In fact, our very first strategy is to give the veteran a better experience. To do that we are learning from the private sector, we are learning from Disney, we are learning from Ritz-Carlton, we are learning from Starbucks. We also know what’s going on (with complaints). So we are training people in good customer service.

The second important point is that we have to do a better job of caring for our employees . There are not good customer service companies in the world that have bad relationships with their employees. When I arrived at the VA, I discovered a not very positive relationship with employees. We weren’t meeting with union leaders. We weren’t asking for or giving responsibility to staff to make the change. I would guess that if you looked at Fortune’s list of best companies and matched it with the list of best places to work, you would find it to be pretty congruent. I know that at my company, Procter & Gamble, the relationship with employees is essential. That’s why the first few strategies of the VA are putting veterans first and secondly improving the employee experience. We have got to do that.

Q: Recently LaVerne Council took over technology office leadership at VA. In her words, she plans "to bring core capabilities to the VA and create a fiscally responsible organization led by employees that have the ability to quickly drive to the expected results." What are the expected results and what is the path to get there?

A: Better veterans experience and better employee experience. Internal support systems which help employees get the job done. Right now our internal support systems, especially IT, are broken. Creating a culture of continuous improvement. Taking advantage of strategic partnerships.

We have not been a very good strategic partner. There is a lot of good will for veterans in this country, and we need to take advantage of that. Those are the outcomes we’re looking for in terms of MyVA. Relative to IT specifically, I have been recruiting LaVerne virtually since I became secretary. Now that she is in place, we have a big transformation in IT to make. We are the second largest department in government, yet we have one of the lowest – probably the lowest – per capital IT budget in government. When I asked David Shulkin, our new undersecretary for health, what a medical system spends on IT, he told me they spend about 3 percent of their budget. At the VA, we spend about 1.5 percent – Congress gives us 1.5 percent. We have to more than double our investment in IT to include enterprise systems like our financial management system. The financial management system, which I testified in Congress about yesterday, is a system which dates back 30 years. It’s a Cobalt system that runs on a mainframe computer. Whereas good customer service companies have real-time systems to tell what their customers are buying on a given day. Virtually, I could click on a computer and scroll to any country in the world and know how are products were selling. We don’t have that capability. We need that capability. And that’s what LaVerne is about. She is also going to be about customer interface. Now that we have veterans who use apps, we have a number of phone apps under development that will improve our service dramatically.

Q: There has been much interest shown in developing accessible online medical records that can follow the servicemember from enlistment through leaving the service and beyond. Where is VA in this process and how much of a priority is this?

A: It’s an extraordinary high priority. It’s a priority not just to care for veterans, but this is a priority that makes VA valuable to the American public. What I have said many times before is that VA is not only important to veterans but it is essential to medicine and the American public. I can go through the reasons why. The first is research. We spend $8 billion on research, we have won three Nobel Prizes and seven Lasker awards, did the first liver transplant, did the first implantable pacemaker, first electronic medical record, first to use a bar code to connect patients with medicine. We know more about prosthetics, we know more about traumatic brain injury than anyone else. We know more about spinal cord injuries than anyone else. This research benefits the American people. Secondly, we train over 70 percent of doctors in the country. We are the largest employer of nurses, the largest trainer of nurses. Third, the clinical work that we do. Everything that we do benefits the American people. The fact that we have medical records on veterans that virtually – as the Army likes to say, the 'soldier in life period' – gives us the ability to see things in medicine that nobody else can see.

So, for example, our main vet project. We have blood samples of 400,000 to 500,000 veterans. We will be to a million very quickly. We are doing the genome mapping of all of those samples and making that available to researchers who want to do research what the president calls 'precision medicine.' That is the ability to use a genome map to better prescribe medicine for people. That project is a tremendous piece of innovation that no one else can do. But it is dependent on the fact that we have our veterans and these 40 years of records, fortunately they are digitized. Now we are at a point where the VA record can talk to the DoD record, and vice versa. It’s absolutely essential. Why is it essential? The partnership between DoD and VA is important for veterans but it is important for the American people as well.

Q: Let’s talk a little bit about PTSD and TBI, which many of today’s servicemembers are coming home with. How is VA dealing with these injuries and what are the best solutions for our veterans? Polytrauma centers or other solutions?

A: There are a number of things we need to do. Number one is to get the American public informed. I don’t want the American public to think that every veteran is dangerous, or every veteran has post-traumatic stress. Or that somehow they need to worry about hiring or caring for a veteran. So we are trying to get the facts out. A lot of studies show that somewhere between 8 and 15 percent of veterans who served in combat may have post-traumatic stress. Those are what the numbers are saying. So this idea that every veteran who served in combat has a mental health problem is simply not true. Number two, we are treating them. We have data-based, evidence-based solutions to treat it. Whether it is helping a veteran revisit cathartic moment in our polytrauma centers or whether it is using stimulation, acupuncture or equine therapy, or yoga.

The nice thing about the VA, unlike a for-profit hospital system, we will try anything that works as we gain evidence that it works. I’ve seen equine therapy being a very effective method. I’ve seen acupuncture work – we’re one of the largest users of acupuncture. What we can do, and what we have done, is that we need to do is inform the American people. One of the studies we’ve recently published is just because you’ve left combat and don’t have post-traumatic stress doesn’t mean you won’t get it. In fact, what we have been able to show is, unfortunately, as the body ages, you can pick up post-traumatic stress from events that occurred 40, 50, 60 years ago. That knowledge and research is important. The last part is that I have been working with the Department of Health and Human Services Secretary Sylvia Burwell to make sure that medical professionals, not in VA, are asking the appropriate questions. For example, if a patient comes in and the doctor doesn’t ask if they have been in the service, they may never find out what is the cause of their illness. We are trying to get that built in the American medical protocol. Not: 'Are you a veteran?' because we know that many women don’t consider themselves veterans even though they are. We know that many veterans who didn’t serve in combat don’t consider themselves veterans, even though they are. The better question is, 'Have you ever served your country in the military?' We have to train private-sector doctors to understand the military culture and how to deal with that.

Q: Entitlement spending is increasing dramatically. How do you intend to balance the need for continuous improvement in patient care while being fiscally responsible?

A: During my testimony yesterday, what I said was, Congress passes the laws to give the benefits and the veterans have already earned those. On any given day, I get five to 10 letters from members of Congress to increase benefits. I never get a letter to reduce benefits. On the other hand, we have to have the budget to do that. I put in a budget request for $168.8 million. I also put in for budget flexibility because we have all these various pockets of budget, and I can’t move the money from one to the other, even though the demand may be there. And the House cut it. They cut it by $7,000 per veteran per year. They cut the construction budget by 50 percent. Well, it doesn’t do any good to have a law for the benefits if you don’t provide the budget.

And that’s the situation VA has historically been in. In fact, independent budget work shows that we have undercapitalized the budgets of VA by about $9 billion over 10 years. And most VA buildings are over 50 years old. And we have to get those right sized. What I am trying to do is to make sure Congress gets a couple of messages. Number one, the problems in 2014 were not because of Afghanistan and Iraq. Every American thinks they were. They aren’t. It’s because of the aging of the Vietnam veteran. We went from 2 million veterans over the age of 65 in 1975 to 10 million veterans over the age of 65 in 2017. As we age, issues when we were young become more chronic and more difficult. Number two, don’t send people into combat unless you are already thinking of the cost of caring for them when they come out. The way a country takes care of its army says a lot about the country. I think we as a country, we may have been too quick to send people onto the battlefield with only thinking about the cost of doing that, rather the cost of what happens after. Number three, Congress has a moral and ethical responsibility to provide the money, not just the benefits.

Now, in exchange for that, I am going to do everything I can to improve the productivity of VA. Yesterday, at our hearing we talked about the fact our medical productivity is up 8 percent, our physician productivity is up 8.5 percent. We measure it and track it. I have identified 10 million square feet of unused buildings or unused spaces. A lot of these buildings we have abandoned long ago, and I need Congress to help me close them. This costs the American taxpayers $25 million a year. I have testified in front of Congress that we can save that money, but I need their help. Many of these buildings are in members’ districts and of course, some of the letters I get are from these members asking for the building to stay open, even though there is no activity going on in there. We’re happy to make VA more productive. IT is another way we can become more productive. When you look at what’s been done in the Veterans Benefits Administration moving to digital work, rather than paper, has been a key enabler in getting the number of backlog claims down from 611,000 at its peak to 119,000 today and zero by the end of the year.

Q: There are lots of Americans, veterans and non-veterans who get benefits in one form or another from the federal government. In some of these cases, benefits are distributed in a really efficient manner. In others, they are not. Can VA improve to the degree to match other departments in their ability to get benefits to people who are eligible for them?

A: Our intent is to get people the benefits they have already earned. In my mind, this isn’t something that a veteran earns over time. They’ve already earned it. My strategy is to push us upstream. For example, two weeks ago I was in Hawaii where I attended two transition assistance program briefings. One was at Pearl Harbor Hickam Air Force Base, and the other was at Schofield Barracks where the 25th Infantry is. This was, in my mind, game-changing. For the first time I had the officers of those facilities, standing up in front of the soldiers saying that you will be transitioning to civilian life and we will make you ready. We need to do these pension exams while they are still in the military. We need to get them signed up for their benefits while they are in the military. While we were there, we had a job fair. We had employers like JP Morgan, Microsoft and other companies. By the time they leave the military, everything should be set up with no gaps. Right now, there is too big of a gap. Many servicemembers will go on unemployment insurance because that is what it was designed for. But I would rather see the member have a job. That is becoming more possible. I have great hope that by pushing upstream, we can make the transition seamless.

Q: Let’s look into the future. When the day comes that you leave this office, what do you want to look back and see as your top two or three accomplishments?

A: There’s only one accomplishment that is important and it is making sure that every single veteran who has earned a benefit, who has earned a medical care outcome, who has earned a burial gets what they want. And I measure that by numbers of veterans. One at a time. We try to provide individual service, getting the veterans the benefits they earned. I believe in the starfish story. An old man on a beach, with the tide out. There are starfish lying on the beach and are going to die because of no water. The old man is picking them up and throwing them back in the water. A young man comes up and is rather cynical and asks the old man what he is doing. 'How can you possibly make a difference? Look down the beach, there are thousands and thousands of starfish.' The old man says, 'Well, I may not be able to clean up the whole beach, but it makes a difference for just this one.' And I remember that each day. I want to put a system in place to help hundreds of thousands, but I want every veteran served by the VA to feel like they are the only veteran we serve.