of meth sillen resistance. in general, that pioneering effort to protect patient safety that i saw in the '90s has disappeared somewhat from the culture. that, and as i pointed out before, how can you have a focus on the patient when you have 316 pages of rules about what employees can and cannot do just for one union? just for one. this contract governs the work rules for 200,000 people who work at the v.a. and it is preventing a focus on the patient. >> thank you. next question, do you believe the v.a.'s shortcomings and failed benchmarks was the result of inadequate funding or management or resources. mr. mcclain. >> i personally don't think it was the result of inadequate funding. the v.a. budget has really increased significantly in the

past five or six years. but i think pretty obviously it's a misallocation of the those resources. >> mr. collard. >> not only a misallocation, but perhaps just looking the other way when you have the resources. i think i heard on monday night the fact, chairman miller, that you raised a specific financial number that's been invested or been provided for i.t. and i.t.-related services. the question was raised, where's the money? and so whether it's -- whether it's misallocation or just, perhaps, an ignoring of those funds available, perhaps, leads to the current state. >> dr. mccaughey. >> yes. the v.a. budget has increased 173% from the year 2000 through 2012. that in inflation adjusted terms is 72%. the increase in total v.a. patients was 69%. so the funding increased at a faster pace than the number of patients who had to be treated. and the number of acute care

patients who need costly care increased only 49%. so the v.a. funding should have been adequate to meet the increased demands on the system. >> last question. very important question. how would you rate v.a.'s urgency to change its culture and become more patient-centered for the veteran? we'll start with mr. mcclain again. >> i don't see any urgency. >> mr. collard? >> could i have you restate the question again? >> okay. how would you rate v.a.'s urgency to change its culture and become more patient-centered for the veteran? >> on a numeric scale, very low. if we're rating it in current state. >> dr. mccaughey. >> i agree with that. >> thank you very much. i yield back, mr. chairman. >> thank you. mr. tokano, you're recognized for five minutes. >> thank you, mr. chairman. mr. mcclain, your testimony encouraging the v.a. to adopt a more inclusive approach to

contract care along the lines of the kaiser permanente model and the, quote, kaiser experience. how do you respond to vha concerns with the continuity of care and record transfers? >> well, i respond it, and we have some direct experience in this having done project hero and currently doing project arch. is that v.a. doesn't favor outside care for the most part. in other words, they favor the biases to treat everything within the walls. the success of the kaiser experience is that they view all care that is delivered in one of their networks as part of kaiser care. that's part of the kaiser experience. in other words, the people who are going outside into a community provider feel that that is just part of the kaiser system. part of the issue is that currently, v.a., although the vista system is a terrific

system for electronic health records, it does not have the ability to collect those consults and primary care charts that are on the outside. and that is one of the things in my written testimony that i proposed. is there is i.t. currently available that will consolidate and aggregate all of the care of a veteran. whether it's delivered inside of a v.a. medical center or outside. so that the provider in the vamc has a complete picture of the veteran's health. >> could you comment on the capacity of the private sector care providers, what percentage of them are ramped up to be able to utilize the software? i've heard that, you know, a relatively small percentage of providers have the capacity or have updated to electronic records. >> i don't have that number in front of me. i couldn't testify to that, sir.

>> well, thank you. mr. collard, mr. mcclain, do you -- regarding cost management, would you find that the veterans -- the vha and the way they deal with prescription drugs and pharmaceutical costs is a good thing? i've heard that they actually use their size to leverage down those costs. >> the answer is yes. i think they do a pretty good job. by statute, v.a. actually purchases drugs in bulk for dod and v.a. and the indian health and coast guard. by statute the manufacturer is required to give them a discount off of commercial rates. so, actually, v.a. does a very good job in purchasing drugs. >> mr. collard? >> i would concur. >> so does that same sort of approach exist with medicare? >> not to my knowledge.

>> would that contribute to out-of-pocket costs for senior citizens generally, do you think? >> you know, i haven't -- sir, i haven't looked at that. i don't have an opinion on that. >> you know, well, thank you. you know, mr. walls, is there -- would you like to -- i yield my time to you if you have any question. i'm kind of done. >> we can come back to it. mr. mcclain, you're right. i really appreciate some of the ideas that are coming out of this. this idea that is being brought up of how do we get to the big idea? i guess one of my concerns is, and i would ask on a comparison, this is to you, dr. mccaughey. you carried around this. this is the selective agreement between st. mary's hospital, the mayo clinic and their health care providers. it doesn't make as good a theater as a big one but it's still there. i would make the argument the mayo health care provides quality health care. your assertion is the -- i don't

believe in any way moves this argument forward. my question to you is, when was the last time you personally were in a v.a. hospital. tell me about your experience there as you talked to the viders and talked to those nurses a at the nursing station. >> i actually just talked to some of the people at the v.a. hospital here in d.c. a few minutes ago. and let me explain that they are -- i haven't been to their hospital yet. but i have talked to them. and let me explain that they are also concerned about the mismanagement or misallocation of staff resources. it's so bad, for example, that at some of the v.a.s, and i know you'll probably confirm this, the physician has to spend a lot of time going out to the waiting room, getting the patient, explaining how to disrobe, doing a lot of things that in a -- in another hospital or clinic, would be done by ancillary staff. so that doctors can see not two patients an hour or three, but

maybe six. some of this is a problem with union rules. and to say that it isn't is just preposterous. i haven't read their agreement. but to say that unions are not part of this problem is just -- read -- read the american federation of government -- just let me finish. you asked me to come here. >> you answered. >> mr. chairman, i'll yield back my time. >> time is expired. >> thank you. >> i would like to explain, sir. >> i apologize. we're very short on time. dr. row? >> thank you, mr. chairman. mr. mcclain, i think you're 100% correct when you -- the v.a. needs to go through a top down look from an outside agency. it doesn't need to be evaluated within anymore. it needs to have an outside look. and what i -- what mr. michaud said is absolutely correct. the v.a. could do one thing today. i said this monday night at the

hearing. the years i spent in clinical practice in medicine, i knew who i worked for, and that was the patient. that was the center of why i was there. if i didn't have patients to see, i had no reason to be in an office. and if you ask anybody on a v.a. campus who they work for, they'll say the v.a. the answer should be we work for veterans. that should be the answer. and that's a simple change in philosophy. i don't have any reason to be at this v.a. if they're not veterans there for me to care for. i think you could do that one thing. i think the top down approach, i think you're spot on. several things were brought up. just interestingly, mr. mcclain you mentioned in a cboc you ran at the v.a. had four to five personnel to help, ancillary people to help. in our office, and i practiced for 31 years, it's about three people. and you can even get more efficient the bigger you get. you don't need another scheduler if you add another doctor.

need another medical assistant. you may need another lab person, whatever. but you get much more efficient. typically, it's three to one. sometimes even less if you're very good at it. we were very good at it and very efficient. the incentives that the v.a. has, doctor, you mentioned this about -- about consults. i said this monday night. this is really simple. we had almost 100%, 95% of our consults that we saw, kept their appointment. why? because if i miss that appointment, that's a slot that wasn't filled. i didn't have any revenue. so we made sure that we contacted that patient over and over to be sure that they kept their appointment and came in. almost all of them did. if you mailed a letter out two months ahead, three months, your appointment is august 7th, you don't ever check up, you should expect a huge number. for someone at a v.a. if you don't have anybody show up, that's a snow day. it's perfectly -- it's free time. you're not doing anything. i've heard over and over and

over again from my doctor friends who are at the v.a. that they do all kinds of things that ancillary people ought to be doing. and if you go to a private doctor's office, they're going to have those people calling to make the appointments. all of those things. your time is focused on seeing the patients and taking care of patients. i think also something that's mentioned in this bill that absolutely has to change, there's no way on this earth that a veteran can go get a letter and do all of this and then go to my office and me do 1-800-hold. that's what it's going to be. and you're going to spend an hour and a half trying to get somebody in my office. the doctors are not going to see them. we can't afford to waste our time doing that. we're able to see the patient, we ought to be able to do the care. that's something, mr. chairman, we go to conference, has to be changed or this will be a waste of time. i certainly don't mind the sunset. i think many laws ought to be sunset and be looked at after that length of time. i certainly appreciate your all's frank testimony. it's refreshing to hear someone

from the outside not tell us how great everything is on the inside, and we find out it's really a disaster on the inside. also, mr. collard, you mentioned something that i totally agree with. there are many hard working, good, dedicated people working at v.a.s today. they're seeing veterans, taking great care of them. but there's a culture there that does need to be changed. and i certainly -- i'm going to stop and let you make any comments you want to. >> dr. roe, i agree completely. i would like to make a comment regarding the no-show rate. dr. mccaughey has mentioned it and you've mentioned it in a commercial setting how important that is. our experience for 5 1/2 years, we provided services under project hero, which was a contract with v.a. where we provided administrative services. and we set the appointments. we essentially would get the veteran on the line with the doctor's office and do a

three-way conference call to set the appointment. and then not only send a letter, but we would follow up within 48 hours before the appointment to remind the veteran of the appointment, plus the directions to the doctor's office. our no-show rate in project hero was less than 5%. >> same as ours. i think you show right there, that's a metric in the private world that you use because, again, your incentives are different in the private sector versus where you have just a v.a. budget that you have this much money to spend at the end of the year and you spend it, you send it back. >> that's exactly right. we were not compensated at all for a no-show. that was not part of the contract. we knew that. but we were very diligent in getting the veterans to their appointment. >> thank you, mr. chairman. i yield back. >> thank you, dr. roe. mr. brownly, you're recognized for five minutes. >> thank you, mr. chair. my first question is to mr. mcclain. i certainly agree with your assessment of the culture and,

as you described it, personal gain over -- over the veterans. and if we're really going to create a system that is truly veteran centric, then i think certainly i think we could all agree that we need to hear from the veterans. so my question is, are there any specific recommendations made by the vsos at this time that you would actually endorse? >> ma'am, i am not familiar with all of the recommendations from the vsos. i have not listened to all of their testimony nor read their resolutions. >> but in terms of, as you described, a great need for outside assessment of the organization before we begin to make any of the big changes that we need to make, you would include vsos -- >> oh, that's part of the voice

of the -- they're a huge stakeholder. there isn't any question about it. >> thank you. and, mr. collard, i certainly agree, i think we all probably agree of your assessment that the i.t. system for scheduling is archaic. is there -- are there systems out there that you would recommend? >> not a particular system, but just knowing that they're present and they're used. and if i could just extend upon an i.t. element or a pre-call or a post-call, what we're really talking about is not fundamentally the reimbursement around or the productivity that's impacted like a snow day for a no-show. what we're really talking about is that quality outcome again. so if a precall is made and we know the veteran shows up fully prepared for the procedure or the treatment. they know where to come, they know when to come, that's going to drive quality. the post-call efforts that are in place also, again, not just a

unit of a box checked, but the imempirical evidence on the private sector side that reduces readmissions, improving medication compliance rate. there was a study in the annals of sbesintern medicine about a and a half ago that -- improved just the propensity to stop at walgreens and cvs and fill the script. again, private sector example. i think we all have to eventually come -- we're doing a really good job today talking about the what and the how. we've always got to return to the why. i think each of us have recognized the why of these conversations. >> thank you. mr. collard, again, from your vantage point, how do you think we can better instill integrity into the v.a. management? i mean, how do we instill, you know, starting yesterday, starting today, how do we begin to instill a sense of urgency within the -- within the veterans health administration?

>> as with any organization, urgency begins at the top. accountability begins at the top. what we have to be able to do is narrow the focus. the one big idea, again, i come back to monday. this doesn't have to leave a committee and take on 50 things. but the one big idea that could create momentum and confidence in our veterans, provide clear expectations out of that sense of urgency, out of an assessment that could be done. make sure that the training is adequate for those, asked, perhaps, to do something new or do something differently. then make sure that we just utilize methods of verification and validation like any other industry would do to ensure in realtime that things are happening so that we don't find the firestorms that exist when either whistle blowers make a call or finally data reaches its -- its peak. >> thank you. and you -- i think in your testimony you talked about, you know, big change with proven outcome solutions.

and that if the v.a. -- we can't -- the v.a. is unique, but we can't say -- we can't be terminal about its uniqueness. that we have to look to better outcomes. >> mm-hmm. >> so is there anything about the v.a. medical system -- i'm not quite sure how to ask this, because i agree with your assessment, but that is unique? that we don't have another place to look to for best practices? >> i just think we have to get beyond that as the question that would be asked from internally. the single most improved hospital in the united states of america is trinitybirmingham, a. they're in a 40 to 50-year-old physical plant. they don't have private rooms. they have a call light system. when it rains to the patient rooms it rings to the pbx operator of the hospital. they ring the nurse's station. they've decreased call light time in excess of 60% to 70% with the hand that's dealt them.

>> thank you. i yield back. >> mr. flores, you're recognized for five minutes. >> thank you, mr. chairman. i thank all the witnesses for being here today. dr. mccaughey, thank you for the quick feedback on the senate bill. that's very helpful. mr. collard, one of the things i would ask you to do in future testimony, when you use the word "standardized" be sure to mean that doesn't mean centralized. one of the issues we've got is centralization sometimes cannot be the solution. mr. mcclain, you hit the nail on the head today. you said we have a unique opportunity to reform the v.a. and that if we don't do it well we'll be here again. and with that in mind, that generates my question. i'd like each of you to spend about 90 seconds telling me what the v.a. of the 21st century would look like. and totally disregard what the v.a. is today. disregard the people, the bricks and mortar. disregard everything. what does the v.a. of the 21st century look like? but what does it have in terms of people, culture, systems,

leadership, use of private sector resources? is there a need for a union in the v.a.? and so let's touch on that. i'm down to actually about a minute for each of you. and i'd really appreciate it if you would provide some feedback in writing afterwards. i know you're doing this as volunteers. but you have the best interest of our veterans at heart. so if you can follow up in writing that would be awesome. just a minute from each of you. let's start with you, mr. mcclain. >> thank you, sir. to put it in as few words as possible, i would say it has to be veteran centric. in other words, you put the veteran in the middle and you build the system around. so you have teams in an integrated fashion providing care coordination and integrated care to the veteran. and the metric is outcomes. health outcomes. how long did you extend the life of this particular veteran? how long did you extend the quality of life of this particular veteran? and right now we're not measuring any of that. >> okay.

mr. collard. about a minute. >> i think it's a veterans health care administration that has as one of its chief focal points the ability to reduce variance in all practices or as many practices as can be. what that can mean is the -- the acts, the practice of access for our veterans, the practice of care, the practice of care environment for our physicians. on the private side we joke a physician typically works in four hospital ps p the daytime hospital, nighttime hospital, weekend hospital and holiday hospital. i can just imagine how many different versions there are in veterans hospitals too today. the ability to reduce that variance, standardize those practices. when identified as a true vetted best practice, the ability to move very quickly across the system to implement those best practices. >> okay. dr. mccaughey. >> yes. let me point out, and i'm very grateful to be here today. that your time is valuable. but time is also extremely valuable for these vets who are

waiting, who are stuck in these waiting lists. 3 63,000 who waited a decade and never got a first appointment. now 57,000 currently waits for their first appointment over 90 days. i would point out that this bill that you will be considering establishes two commissions. one, to study the issue of v.a. construction. what's gone wrong, the delays, the cost overruns and where construction is needed. >> i don't want to talk about -- >> i wanted to make this point. don't waste your time with another commission. in 2012, you had a commission do that. read the report. i'm sure that the new commission will find exactly what the commission found two years ago. they discussed las vegas, denver, st. louis, all the places that had those construction problems. and, secondly, this bill calls for another commission to discuss staffing and health care

needs, particularly the need for physicians. you had a study like that done two years ago in 2012. i urge you to read it. it will save you a lot of time if you want to fix this while the vets who are sick are waiting for care. >> again, i'd ask each of you to think about this. you know, back out of the weeds a little bit and think about this from a $50,000 review put on you. what does the v.a. of the 21st century look like? if we could start all over again and not worry about any of the past sins or postmortems or any of that crud. what does the v.a. of the 21st century look like? again, i agree, it should be veteran centric. so if that's the vision, i want you guys to tell me what the structure is. i'm going to -- i don't have time for that. so if you can follow up in writing, that would be awesome. thank you. i yield back. >> thank you very much, mr. flores.

m ms. titus. >> over the past week we've had a lot of discussion about how to integrate metrics into evaluating the system. we keep hearing metrics this, metrics that. then just recently the v.a. said they're dropping the metric of 14 days as a way to measure the scheduling appointments because that was unrealistic. now they've changed it to 30 days. i know we can't abandon performance metrics. but when i talked to the people at the las vegas hospital and they go into all these details, then they tell me, but this doesn't really measure what we're doing because it doesn't count the first appointment that they have when they come in on the very same day. so it's not an accurate reflection. i wonder if we're not suffering from the ecological fallacy. we just can't see the forest for the trees. do you have some suggestion about how we better use metrics or we get rid of some metrics or how we can do evaluation better? anybody? >> yeah. you know, in our industry, we tend to be gluttons for

punishment when it comes to metrics. i think it's important that we create a stop doing list. if you look at the medicare value based purchasing formula even itself, just in the last couple of rounds, is that there's been a decreased focus on process measures and a very much increased focus on outcomes measures. so not did you give the aspirin with an acute mi in the e.d. we've all gotten pretty good at that now. how about mortality index? how about mortality rates? how about surgical site improvement initiatives there? again, narrowing a focus and a much more -- a much fervent shift from process to outcomes. >> i would like to second that. i fully agree with that. and, in fact, the -- the article in the new england journal of medicine that the chairman referred to in his opening remarks underscores how besieged, how suffocated doctors are by the requirements to enter so many metrics in the charts. that you lose sight of the really important ones, and not

only that, but you lose the doctor/patient relationship. i'm sure you've experience third-degree ed this recently. you go to see your cardiologist, internist. instead of having a face to face conversation the doctor is there trying to get everything into the computer while you're in the office with him or her. so we need fewer metrics. we need outcomes measures instead of process measures. and i'd like to applaud those involved in formulating this bill and working with the v.a. to make their metrics transparent. because for a long time, they have not made available to the public their outcomes measures, just to the distress of all of us who wanted to see them. >> thank you. >> i think that the one thing i would say is that we have to obviously measure the right thing. there's a lot of things out there in medicare that i think show some quality outcomes. indicators of quality outcomes.

even though v.a. is a fairly unique system just by the way that it is structured, it is delivering health care just like a lot of other systems are delivering health care. and they shouldn't be afraid to take a look at those metrics from the outside. >> one other question. we keep feeling this push to send veterans out of the v.a. into the private sector for care, where they can get doctors who may be available to them that aren't in the v.a. and that's fine. but in the areas like las vegas and some rural parts of the country, you've got a shortage of doctors. so pushing them out there on already overloaded doctors is not going to solve the problem. i've got a bill working with some members of this committee to create more residences at v.a. hospitals and areas where there aren't enough doctors. do you think that's a good idea or do you have other ideas how we might address that? >> i think that's one thing you can do. certainly there are several other things we're currently

looking at to discuss with v.a. in order to provide some solutions. especially in the rural health areas. tele health is a big one. there are, perhaps, mobile facilities that might go around to service some veterans. there are a lot of different things that you can hire what are known as locums or locem doctors in a particular area to serve for a particular period of time. and there are some innovative solutions that i know v.a. is looking at, but they haven't pulled the trigger yet on some of it. this may be the opportunity to do it. >> doctor? >> yes. i was just going to add to that that most m.d.s in training at a teaching hospital do rounds at a v.a., do some of their training at a v.a. hospital. it's just standard practice. and, of course, in rural areas it's a bit different. but i would change the use of one word you chose. we're not pushing them out of

the v.a. we're just allowing them out. giving them the choice if they wait so long or don't have another place. if they can't get an appointment at a convenient v.a. so i don't think anybody in this room wants to push vets out of the v.a. or eliminate the v.a. >> well, my point is, if they go out into the private sector, we need to have some doctors out there who are available to help them. >> you are so right. >> and there are shortages of doctors and you have v.a. hospitals that might be a place where you could do additional residencies. i yield back. thank you, mr. chairman. >> thank you very much, ms. titus. mr. runon, you're recognized for five minutes. >> thank you, mr. chairman. mr. mcclain, it's in some of your written testimony. can you give me a couple metrics that the v.a. uses that are the most harmful? >> well, i think the most obvious was the 14-day. when you say harmful, i guess you're talking about harmful to

health care delivery? >> yes. >> i would point to most of the metrics that just measure process and check a box, rather than health care outcomes. >> okay. and this really for all of you to touch on. i know it's been touched on. and i just want to confirm it and have it on the record. because i think -- we'll start with mr. collard. i think you've said it a couple times here. some of the stuff, health care record, the v.a. does very well. we've only scratched the surface on what this is. i cha ir the subcommittee on disability claims. so that is the next step. okay. now we're tying in the private sector, the v.a., and another government agency, the dod, that

don't communicate very well. are there private sector platforms today that you could buy out of the box that could accomplish that. >> not that i'm aware. i think what we have to be able to do, if you look at the v.a. electronic health record which, again, is hailed as cutting edge, clearly there's an architecture there that even the private sector could look towards for some learning. the trouble in the private sector is you have a number of vendors that are positioning themselves as the most prolific electronic health record. what that does is that actually stifles the layers of communication, the ability to communicate between private health systems. so, again, it's an opportunity for us to look to the v.a. where there could be some good things going on. and perhaps move from there. but on the private sector, it's probably as fragmented as can be. >> chairman, i think it goes to what mr. johnson was saying the other night. they won't show us what their architecture is a lot of times. so no one could even build a system that could be even remotely compatible with it. it's part of the problem.

really i just want to make this point. then i'll yield back my time. i want to let some other people -- i think we've came to the conclusion also we do this in government all the time. continuing to throw money at a system that is broken structurally is not going to solve the problem. i know you all agree with that. i just wanted to make that statement. until we fix it, throwing money at it is going to do nothing but cause us to throw more money at it. so with that, what i remembchai back. >> thank you very much. dr. reese, you're recognized for five minutes. >> thank you, mr. chairman. thank all of you for being here and giving your input to this very important topic. there are some terminologies that have been said that are very important to me. the most important is to be veteran centered. to be patient centered. and i appreciate dr. roe's

comments on that. because as a physician, it's our life blood. it's what we live for. it's the outcome that we see. it's to make sure that our patients, we reduce their suffering and promote their wellness in whatever we do. and at that moment, that patient is our world and our universe. and i believe that is the sentiment that we should have here in congress as well with our constituents, but also in the v.a. with the whole apparatus focusing on that. and i believe that the urgency is very much needed. and i believe that with the working in collaborations with the v.a. and this committee can make sure that that urgency is highlighted. you mentioned things that are also very important. which is standardization. and i'm familiar with that as an emergency medicine physician. you know, you come in with a patient. they don't know -- you don't have any information. it's a multiorgan trauma or

emergency, medical emergency. and you just have to figure it out. the way we do is we have clinical guidelines and training after training after training to help us with a framework to treat that patient. and i believe that in standardizing the care with the v.a.s throughout the system is very important. but when i did my veterans initiative back home in the coachella valley in california, some of my veterans there said they have to reregister and they have difficulties going from one v.a. to another v.a. even if they, you know, are here for the summer or the winter break or whatnot. and so how do we create that intraoperability within the v.a.s throughout the country. >> i guess that's more of an i.t. question. i know that that's been a goal of v.a.'s that they haven't accomplished yet. i think that several years ago,

there was the vler. the veteran lifetime electronic record. which was a composition of all of the v.a. benefits that a veteran could get in one place. in other words, you could go for your health care, but if you had a disability claim, it would also be reflected. and if you had a v.a. home loan, it would also be reflected. i think that's still a great goal. i don't know where v.a. is along the timeline for doing that. but just getting a single medical record where you do not have to reenroll every time you, you know, go north or south or wherever you're going in the v.a., i think has to be a goal that would really assist veterans across the board. >> wonderful. and the next question, mr. collard, is we talked just now about the difficulties of communication and sharing of

that information from one v.a. hospital to another. but how about the communication structures with non-v.a. providers with the v.a.? we know there are some barriers to doing that. and what can we do to minimize those barriers so that the family doc in the rural area, if there are enough physicians, can receive the information from the v.a. that they need to provide the continuity of care that the veterans need, but also provide those same standards of reporting to the v.a. so that they can enter that information to their outcomes measurements that they -- that they need for the patient? >> so being as far from an i.t. expert on the panel today, i would say from what mr.clain referenced before in terms of a more open source environment with the v.a.'s system itself. let me go off the answer for just a little bit. because a lot of this also has

to do with the manner with which a veteran is received at a different facility. let's just call it first impressions. if i go from the veteran to the person on the other side of the desk as well, i think many of us have -- whether it's at an airline counter with b whether it's a a hospital, an emergency room, sometimes we get an impression that the person on the other side of the counter doesn't have quite the empathy that they would need to project to a new veteran. i think we have to even be able to go -- this is a little bit of a hearts and minds conversation as well. it's off the hearts and midnind perspective. >> thank you. i ran out of time. i yield back whatever i had. >> thank you very much. dr. benner scheck, you're recognized. >> thank you, mr. chairman. well, i really appreciate your testimony this morning. i completely agree with you that

we cannot waste this opportunity to revamp the entire v.a. system. as i think you said, mr. mcclain, we'll be back here once again. you know, i was just looking at the v.a. health administration organizational chart. what is it going to take? do we have to get a -- i mean, arraign for bidding for outside consultants to tell the v.a. how to reorganize itself? obviously, they can't -- i don't believe that they can reorganize themselves. mr. mikulski, the assistant deputy undersecretary was here on monday. he seemed to think that a few fixing here and there in the system is going to make everything honky dory. i completely agree with as all of you sort of said, the whole system needs to be evaluated and a structure of management put in place that allows more

communication between the management and the people that actually deliver care. as a physician, i worked a t the v.a. i, by the way, don't think that the health record is all that great. but it's often better than many of the other health records. we need to have better communication between, i feel like the physicians would actually take care of patients and the top management. because often physicians are put in circumstances that waste their time, are bad for patients and, you know, don't get things done in an efficient manner. so how do we make that happen? what -- can anybody give me some more ideas? expound upon what you said before? maybe each of you could take a minute of this? how could we make this happen, the v.a. change the entire structure so that it's much more efficient. >> doctor, i would start off with contracting with people who are expert in organizational design. there are companies out there

that that's exactly what they do. it is a skill. it's an expertise. and i really wouldn't expect the v.a. to be able to determine exactly what that next organization should be. because that's not their expertise. but there are companies that that's all they do and they do it very well. so that's where i would tart sto look. >> all right. mr. collark. >> if i can extend mr. mcclain's comments, we can assess all day lo long. once the assessment is final -- we used aspirin with an acute mi earlier. that's probably a pretty successful metric across the united states. then let's talk about hand washing. we've been talking about hand washing for as many centuries as they are medicine essentially out there. for some reason we've not gotten good at hand wash. the difference between one metric like aspirin with an

acute mi and hand washing is we continue to talk about it. and those organizations that find a way to put the structure in place for clear expectations, execution, verification and validation are those organizations that find themselves the ability to reduce infections by just improving something as common sense, uncommonly practiced, as hand washing. >> now you're really close to my heart. but i would say in addition to looking at the top down structure, and we know leadership is important from the top, spend more time listening to what the doctors in the v.a. say. here's what i hear. they're very frustrated when they see a patient and they say, i'd like to see this patient again in 30 days. right? then all that malarky goes on and they never see that patient again. patient never gets an appointment with that doctor again. there's not enough continuity of care with the same physician. and when dr. ruiz said before, this has got to be patient centered, it's really got to be patient centered, it's really

got to be the doctor/patient relationship. that is what is being lost in this huge bureaucracy. we really have to make sure that it's protected. because that's, in essence, what's going to make these vets better. that's what's going to save their lives. and so in addition to looking at the top down structure, i would really make sure you're talking to the physicians who are working inside the organization. >> well, i don't disagree with you at all. as a physician that worked there, i was very frustrated by the fact that ideas that i had, you know, just weren't taken up. were dismissed because they were my ideas and they weren't coming from the management. that's what needs to be fixed by this basic restructuring of the entire system. i'm out of time. thank you. >> thank you, doctor. mr. gretay mccloud, you're recognized for five minutes. >> okay. thank you, mr. chair. i have found out that the v.a.

audit of loma linda, we actually have three members on this committee that while it's not directly for -- okay. four, mr. cook. we have four members that it doesn't sit right in our district, but all of our people around it is where they focused their care about. it has right now current patients only have to wait four days for rescheduling of an appointment. new patients have to wait an average of 43 days for primary care. and appointment. 50 days for specialty care. only 28 days for mental health care. loma linda has the lowest wait time for mental health care. and coming as a kaiser member for 42 years, myself, i remember that when i first joined kaiser, people used to say, oh, you're a kaiser member. now people say, oh, you're a kaiser member.

so, you know, being there i have seen the evolvement of kaiser from those kind of negative remarks to those kind of glare -- really favorable remarks. because it -- kaiser has evolved, in california, at least. i don't know about other states. but that is the -- the plan that everybody wants to emulate. because they have got all of their stuff together. their medical records are on time. everything. i have had the same physician for 30 years. so i get to see my own physician. and so i don't know why the -- the v.a. couldn't emulate something like kaiser. and while now we have had tons of hearings of what is wrong with the system, we as a policy committee, and there's a whole lot of physicians on here, we're the policy committee. we should find out how we fix it. and then all of our focus should be on how we fix it and no more

about recriminations. but let's get -- let's move forward as the nation's policy committee on this particular issue. thank you. >> thank you very much. mr. hults camp, you're recogn e recognized for five minutes. >> thank you. a couple follow-up questions on comments that were made. particularly, mr. mcclain, mr. collard. your companies have apparently either operated multiple facilities or oversaw those and looked closely at those in reports. have you found any other health system in this country which is similarly situated and so poorly situated as the v.a. is today? start with mr. collard whose company has done many, many, many of these examinations. >> sure. the first ones that come to mind would be organizations that might even look a lot like the v.a. the safety net hospitals. so organizationing that are typically, perhaps, inner city serve a particularly disadvantaged patient

population. they typically tend to be trauma center. they tend to have all the right reasons not to succeed. and yet those are the organizations that we can show time and time and time again when decisions are made, when strong leadership leading with good cultures around alignment and accountability succeed. which, again, just causes the question, why couldn't with emulate that? >> i'm looking for -- i'm trying to determine how -- how bad off the system is. >> mm-hmm. >> when you say that, boy, if we just did a -- a good review and looked closely, we'd have a whole cultural of nonaccountability p p so if you make a bunch of recommendations, we've got stacks and stacks and stacks of them. the doctors mentioned those. tell me how you would implement those. that's another study if you have leadership or that's pretty -- not a very descriptive term in my opinion of what's going on. how do you actually implement? we know what the answers are. the doctor mentioned that. we need to put the veterans back

in the driver's seat. get the administrators out of the way. let them see their doctors. whether they want to do it in a clinic or in hospital or elsewhere. so how do you -- would you implement them? maybe mr. mcclain, how would you implement any suggested reforms? i think we know what we need to do, it's nobody's done it. >> well, it's very difficult. anyone that's done any sort of changed management realizes that trying to do it from the inside is very difficult. so i would think that a -- some company that specializes in this to assist v.a. in making the change to the veterans centric system i think would be a good investment for v.a. >> mr. mcclain, i understand your company, if i read correctly, operates a number of try-care facilities? >> in my segment of v.a. wp we have the tri-care south region. so we're the managed care

support contract for tricare. >> if a tricare subscriber, customer, whatever you call them, doesn't like the care they're getting what do you do? >> well, we're an administrative services organization for tri-care. in other words, we maintain a network of provider and specialists for the tri-care beneficiary. and we also have a -- a patient advocate. if they don't like the care that they're providing, they can come back to us and we can try and resolve the issue. >> do they have to get permission from the facility you've assigned them to. >> no. >> so they actually have a choice? >> yes. they can -- >> well, very good. i think the v.a. might learn from that as well. one thing, doctor, i'd like to hear from one question on the union rules, how they should provide those to us. i've heard stories like that. >> they make good reading. let me point out your very interesting question, however.

competition usually provides improvement. and if we develop some avenue that provides broader choice for vets on where they receive care, not dismantling the v.a. by any means, but whether it's a medigap card just for v.a.s or -- versus older vets, whatever it is, to give more vets a choice. right? you hear on the radio and on television, you see the hospitals advertising. come to our hospital. we have the best care. right? the cleanest room. whatever it is. the v.a. doesn't have to do that. but their budget every year is dependent on how many vets are enrolled in that system. it is absolutely by statute dependent on that. so they don't want to see their vets going other places for care. competition will improve system. >> yeah. that would be great to see the v.a. having to advertise. and actually, i would argue

their budget's not dependent on their standard of care. what i think we've determined here, the last few months, is there's a standard of care. it's just ridiculously low. >> although some v.a. hospitals are quite good. there are some that are really good. they have great leaders. >> but the veterans -- and i could believe that. but we have 70 criminal investigations going on right now. so as a member of congress awaiting data, the data has been tampered with. it's hard to accept anything from the v.a. because the data is being falsified. thank you, mr. chairman. i yield back. >> ms. custer, you're recognized for five minutes. >> thank you, mr. i remembchair. thank you all for being here with us today. and i share your concerns that came out of the v.a. oig report. it does seem that the vha has lost its focus on the primary

mission of safe, quality care for our veterans. i want to focus in on this discussion about competition and get at the notion of veterans having choice. because in my district, i had -- i meet with veterans every time i'd go home. and just recently around these issues, we had a veterans round table to talk about the quality of care in new hampshire. my veterans go to manchester to our veterans health center and also white river junction on the border with vermont. and the question that came up was the one you've raised about going outside of the network. i was presuming that that was a logical conclusion. but the veterans actually that i spoke with want to have their care at the veterans facility. they feel more comfortable there. they feel that they're going to be better understood there. so my question is, how -- and i

like this idea of the medigap card. i'm interested in that. beyond that, how can you use -- let's just start with you, mr. mcclain, about the tri-care. when you're working with that network, what are the wait times there for someone that seeks an additional appointment? >> depending on what the specialty is or what the follow-up is, we can get them in within 30 days. >> and that's similar -- that's actually very similar to what it is in new hampshire in the veterans system. i guess the question is, are there things that we could be doing with the facilities in terms of one of the issues was about residencies brought up with representative titus. are there other ancillary care providers? could we be doing something? is there something that you do in the private sector that we could be doing with nurse practicers or people other --

because i agree with you. we need to focus in on the relationship with the patient and their health care provider. can you give us examples of what we can be doing from the private sector and maybe, mr. collard, do you have a suggestion on that? >> sure. a couple quick fixes that have been mentioned in numerous testimonies. just the ability to recruit at a more rapid pace mid-level providers. if you take a look at the private sector folks whose names typically make the headlines, every single one of those folks today are talking about access to care. it's not a different issue. one of the ways they accomplish improved ak soesz to care is the provision of mid-level providers as that first wave of patient intersection. it just, again, steeems to work. outcomes tend to be there. >> do you think it would make a difference to have a policy of alleviating debt for people who come out of medical school or other schools for health care providers providers that they serve within the veterans

system and that we would aleavate that debt, would that make a difference? >> it's already been proven to work. having operated hospitals in some of the medically underserved counties in the southeast united states, we have programs when residents will come and agree to practice in rural or underserved areas. that's a proven program. i think this is no less noble a cause than for these veterans. >> that would certainly describe my district in the rural parts in the north country. i'm very pleased by the way we were working hard to get increased access to telemedicine for vets that have to travel. we have bad weather, mountains, such, but we also were successful and will be opening two new health clinics in the northern parts of my district. i want to focus in on this issue about hiring. one of the most troublesome things that i've heard about the

vha has to do with how positions are filled and that there's not a priority for clinic positions. i was shocked by that. the leadership can make a decision about filling administrative positions. how can a surgery team operate and function at a high efficient level if they lose a nurse and that position isn't filled. what is your comment, for any on the panel the way positions are filled in the vha and how can we do better? this is the most bipartisan committee in the entire congress. trust me, we know a lot about institutions that do not function well, but we can function together. help us understand a policy that

we could change that put a priority on the filling positions on the front line. >> it indicates the danger of levels of bureaucracy. behavior follows incentive. i bet if we looked at how folks are driven for performance reviews, et cetera, would you find perhaps not a disconnect between the ability to fill administrative position versus the ability to fill a clinical position. >> if we focus on those outcome measures rather than these process measures? >> outcome is getting the physicians and caregivers in place. >> if the outcome is good results, you are going to need to have those positions filled. >> yeah. >> i want to point out a report that was presented in 2012 deals specifically with this issue of assessing how many physicians are needed. i have it in my purse and will give it to you at the end of the session because you'll find a lot of answers there.

the other point i want to make is there is in other state that has been short changed more about va facilities than new hampshire. there are so many vets in new hampshire who ride way over 100 miles to go to a va hospital in boston or white river because there is no really acute care hospital for vas in the state. that needs to change. whatever decisions you make about constructing another hospital, new hampshire should be near the top of the list. >> well, i'm pleased to report to you that the surgery is going to be resumed in manchester. i used to think 100 miles was a long way until i met my colleague o'rourke who told me his veterans travel ten hours to get to any type of facilities. we have a great deal of discussion being the only state in the country that does not have a full service hospital, we are very, very fortunate that the two hospitals that serve our

veterans are very high quality. we do have an issue about people going to boston, but i am well past my time. >> thank you very much. mr. kauffman, she just ate half your time. >> thank you, mr. chairman. thank you for yielding to me. i've got a question. i'm intrigued by this notion of this metagap policy. i become eligible for tricare next year when i reach age 60. as a reserve military retiree. i think when i would be 65 then, i go on to medicare then does tricare pay for supplemental? how does it work for military retirees? >> tricare for life. that is a program when a military retiree reaches age 65, becomes a medicare fee-for-service patient. there is no more tricare prime,

extra, whatever. you are a medicare fee-for-service patient. you do have a tricare wraparound. it's one of the richest programs out there for medicare. >> most vets aren't eligible for tricare. >> tell me about the system you're advocating here today. then i would like you to also reflect on it. >> this is a simple proposal, as i pointed out. almost half the vets using the va are on medicare. they are 65 and older, virtually all covered by medicare. the out-of-pocket expenses under medicare are too much for many of them. so they continue to get care at the va even when they have an age-related problem like they need a bypass surgery, and there is a teaching hospital down the street where they could be getting the care. they are worried about not so much inpatient deductible but outpatient deductibles and co-pays.

if we gave them a medigap card just for vets, a special red, white and blue one to pick up those out-of-pocket expenses, then they would have the choice of going to another type of hospital for that care. if you look at the outcomes measures, particularly for these age-related procedures, with the exception of just a couple of the va hospitals, other teaching hospitals are producing better survival rates. we would get a two-for. it's budget neutral because it's all coming out of federal dollars, and they would have a better chance surviving their procedure. >> my two colleagues at the table are much more resident experts on the notion of payer sources and what the structure looks like. i want to come back to the choice issue a while ago though. there is a demonstration project under way as a structure for those of you that would be familiar with the captain james lowell federal health center in chicago which is one of the

first demonstrations of the ability to combine veterans health with active military health. i remember one of the very first conversations i was part of two years ago, interestingly enough the leaders of the lovell federal health care center were less worried about the veterans being forced to come there and more about the choice to have advocate health care at the time. i think there is another opportunity to look within the industry. i couldn't say what their results are today, but this was a conversation two years ago where federal health care leaders were already focused on this notion of patient choice. >> i just want to say that i want to preserve the system right now until we fix the va by whatever means, we are keeping our wounded coming back from afghanistan out of the va system by virtue they do their rehabilitation on active duty, unlike those who came home from vietnam who were stabilized in the military system then sent on

to the va and our morale of our wounded is much higher, keeping them all in the military system. mr. mclean? could you comment on this notion of providing this supplemental, paying for a supplemental social security, not the co-payments, whereby veterans 65 or over meet the income qualifications for care or have service connected issues would qualify. >> i think it could be part of the solution. really you are talking about funding here. you're talking about appropriations as to what bucket it comes out of. there's been a lot of discussions over the years about medicare as to whether va can be reimbursed by medicare. the answer so far has been no. it would take significant legislation for that to occur. i do want to make a point. i know we are short on time. one of the things that baffles me about some of the waiting lists, i certainly get the fact

that if the veteran wants to go to the va for care, we need to honor that. as long as he or she understands this is going to be a little bit of a wait, that's great. but there were so many other means that some of these waiting lists could be taken care of by sending it out to fee-based care, sending it out under a contract, sending it to an affiliate, there are a lot of different ways this could have been handled. for some reason, which i haven't heard anybody talk about yet, not sure why those other sources of care were not used. >> why mr. chairman, i yield back. >> i can tell you why they didn't want to use it because the va thinks it's their money. they don't want to relinquish it. the problem is it belongs to the veteran. instead of saying we took an $8 million hit for non-va care to their budget, they need to say we took and gave $8 million worth of health care to the

veteran. mr. o'rourke, you're recognized for five minutes. >> thank you, mr. chairman. to add to the point dr. rowe made earlier and mr. mcclain made about the success that hospitals and health organizations have and reminding patients of their visits, in the midst of this hearing i got a text telling me my appointment june 16th is at 9:00 a.m. to confirm hit c and reply. i hit c, confirmed the appointment, give me a phone number to call up if i had a question. those systems are out there not to beat the horse any more, but let's get that done. it works. and mr. chairman, i would like to thank you and the ranking member who is currently not here, but you all in this committee have done such a great job in responding to this crisis. i think showing excellent leadership. we heard from the va directly.

we've heard from the gao, the office of inspector general, hearing from the private sector. each of us in our individual capacities are listening directly to the veterans in our community. i ask we have a panel of vet vans and veterans service organizations if we are talking about veteran-centered care, we need to hear from them. and add to mr. mcclain's excellent suggestion of having a management organization identified structural and organizational weaknesses and complement that with the veterans and what they are missing in their care right now. i think one of the issues that has to be included in that review is the issue of accountability. we've talked about and described our frustrations with the amount of money that's been authorized and appropriated. virtually lost within that system and not making its way to those veterans. i think that really is an issue of accountability. we see it throughout the performance of the va.

an issue i would like to get your thoughts on, and i really loved ms. titus' idea about getting more residencies in rural or hard to serve communities like ours. is this a question of where we are going to get the doctors in the capacity we need? already in el paso, which as my colleague mentioned is about a ten-hour round trip drive from the nearest vha hospital. we have a va clinic, but do not have a hospital. our patient-to-doctor ratio is on par with syria or panama. it's a developing country's doctor-to-patient ratio. we are having a hard time already. i like the idea of more incentives and ways to attract doctors and providers to our community, but when i meet with doctors, to your excellent suggestion of listening to the providers, they complain of having to perform functions that could much better be done by

clerical staff. one doctor told me he actually had to write out a prescription for a veteran to be picked up by a van, taken to the greyhound station where he boards a bus to go to albuquerque, new mexico, five hours upstream on the rio grande. he says why can't somebody else do that? i would love to get each of your comments and thoughts about how we do more to support the current providers we already have, who by the way i think are doing be a excellent job. i do spot inspections in the parking lot of our vha clinic and talk to veterans leaving. i have not heard from a veteran yet who told me they had a bad experience. they feel they are treated like kings and queens, princesses and princes by providers there. they have nothing but good things to say. what can we do to better support those providers? maybe 20 seconds down the line starting with mr. mcclain. >> i think once again you could bring in some people that really

understand process reengineering and reengineer that process. there are a lot of things a doctor does not have to do and it's still within the standard of care. could easily be done by a physician's assistant or rn or lvn. >> you begin with that voice of the provider. we have to make sure none of this testimony sounds like we demonize the provider. the nonvalue added work steps those providers are going through today. this is not unique to any industry. >> thirdly, in section 301 of this bill, there are two provisions that will make it more difficult for doctors, civilian doctors to provide the care that a vet is asking for with the choice card. so i would hope that you read those two passages. it's about like page 24. read those two passages and see if you can alleviate some of that paperwork burden that the

civilian doctor would face if he agreed to treat that veteran. >> thank you. >> mr. chair, yield back. >> thank you very much. for the committee's knowledge, our intent is to have a single hearing in a couple of weeks with just the vsos, to not have them in these hearings, but give them the entire hearing to be able to look at all the testimony that's been provided. so they obviously are the stake holders in all this. dr. winstrup, you are recognized. >> i am grateful for this day to have arrived. it took disastrous findings within the va to get to this point. it's a step in the right direction. i can tell you as a physician, face to face with secretary three times how we could do things better. every time i was told, yeah,

we'll do that, never happened. right before this broke we set up a meeting with the four doctors on this committee, bipartisan, with several of the administrators, with the va, to talk about efficiency and access to care and quality to care. there is a different in different systems. if you have a system where many people work there are saying that's not my job, that's a problem. what you have mentioned many times today i couldn't agree with more. that's the physician input. if they can have the input how things could be better, you've got to go that route. the difference in responsibility in private practice and in other settings which is the va. if i had a patient that missed an appointment, i want to know why. also, if they were post-op, i tell them, they've got to be here, i've got to see them. it's my responsibility. that tends to be missing if you don't know who's coming or going. measures such as standard of care are great. obviously, we need to do that.

if you're seeing one patient a day and giving outstanding care, it doesn't mean very much. you also have to look at the access to care and the efficiency of operations. what you're saying today is spot on. the problem i found within the va system is you had too many people who don't know what they don't know. because they have always been in that system. they've never seen anything different. they think they are doing something great, but they don't know that others are doing it much better. that's where we need the outside input and the best practices. we are hearing a lot of the same things here today. i think that's great. ronald reagan once said if you have a message that's important, tell it over and over again. to me the best practices and efficiencies are driven by choice, which we heard so many times today. when a patient is a liability rather than an asset, we have a problem. patients need to have choice. for me, my level of success and how well i was doing is how many wanted to see me when they know

they have a choice. that's really where we need to be redriven. was mentioned before, too. the aca and throughout, we are really not addressing the doctor shortage. if you don't have providers, and not just doctors, could be nurses, pas, et cetera, you need to address those shortages in our country, and oftentimes in the rural areas especially. those are other things we need to focus on. i'm pleased the door is open to change. everybody here is open for change. i didn't know this day would come. again, i'm sorry it took what it took to get to this day. we've got to drive on. i like what mr. wahl says, get the big idea out there. one thing i found interesting several months ago, i asked dr. petzel if va was reimbursed 500% of medicare rates with you be in the black? he said yes. some of the doctors on this

committee politely disagreed they would be able to pay their bills and be in the black with the system they're running. from your observations, what is your opinion on that? >> i really don't have any data. i have not looked at that. i have no idea. >> lift up the hood on the question. when you compare yourself to yourself, there's probably not a lot of accuracy you can get. when you take a look at those organizations in the va that actually do submit data to publically-reported bases you have a way to measure against the other. when we continue to, whether it's patient perception, they use a tool called shep versus hcaps, when you see those simply don't submit the data, outcomes data, we are stuck in this vicious cycle of, as you said, you don't know what you don't know because you are comparing yourself only to yourself. it would be like taking a blood pressure on a patient without

any degradations. >> medicare used to pay 92 cents for every $1 of care delivered. after the affordable care act they are paying less than that. the reason i raise that, one provision of the bill you are going to be considering this week says that civilian doctors who take the choice card will be paid not more than the medicare rate. so it's important to alert everyone to what you probably heard from your constituents back home, that finding a doctor to take medicare is getting harder and harder. >> mr. walsh, you are recognized for five minutes. >> thank you, mr. chairman. thank you for being here today. dr. wenstrup is hitting on it. i thought you brought up really great points. i see the books there. in our office every new employee reads good to great and we talk

about organizational design and system performance and trying to get there. this was a description of a high-performing medical institution. multidisciplinary team work, patient-centered culture. is it about that simple? they followed up. this is commonwealth. i don't want to bait you on this. they followed up with this. information continuity, care coordination, transition, system accountability, peer review, team work for high valued care, continuous innovation and easy access to appropriate care with multiple entrants into the system. >> the data i shared with you today comes 100% from the commonwealth fund site. at the risk of being oversimplified, yes. >> very good. you agree? >> i don't have any comments. >> all right. i bring this up because we've got to believe we see this and it's not as if jim collins is all of a sudden the va. they read it and they've seen

it. what i'm trying to get at it is how do we incentivize this? there is first and foremost the care of veterans. there is a cost factor that figures into this. how, when we do this big idea -- i do believe if we get this wrong now, we are going to set the care for veterans the next two decades will be very difficult to change. this is an opportunity, but it must be thought out and right. it must not be driven by ideology. your position this is not the issue, if you simplify this into the public versus private sector, we are going to go down a road that looks just like this. why do you think this never went into the scheduling because this is, again commonwealth. we've seen this in practice in hospitals. patient scheduling system uses auger rhythms. it takes into account patient availability, time and sequencing, laboratory tests

procedures and travel time between appointments. if you've been in a medical system that does this, you leave with a sense of wonder. they were there to move from you place to place. is this a cultural barrier why this wasn't implemented? >> one of the issues is just that. the notion of patient flow. whether it's flowing the patient through a facility or through a series of recommendations and consults through different facilities, part of this is the efficient of patient flow, which again is a whole other hearing. >> when we do this, and we are going to have -- human nature, incentivize, oversight and everything else that goes into this, this goes back to you and the work, i see this representing the district that the mayo clinic and hospital-acquired infections, hundreds of thousands of

americans die by these every year. it's incentivized on this hospitals that don't get a handle on this and bring it down are going to be penalized in reimbursement to medicare. does that make sense? >> makes absolute sense. the data beneath that, those incentives and the outcomes with which are just irrefutable. if you look at a patient's perception of a hospital's responsive knopf while the patient is in the hospital, there is almost a linear correlation between the patient's perception. we get hung up on that. it's just perception. how does the patient know how good we are? when you pull the data, across 3,900 facilities you see a linear correlation between patient's perception and actual cases per 1,000 patient days, associated infections. >> why do you think it took us so long for the private sector in states to be willing to put that information up? >> actually, it's our perversion

to the data. when you go to the website you go to the experience or go to the quality. it's the very same data set. so when you pull the entire data set and look at those correlations, it's right there in front of our eyes. >> how do we meld va experiences in that? it does seem like we are on two parallel realities here on reporting and experiences. what would be your suggestion? >> we won't suffer from a shortage of data. it's how we bring the data together. it's the ability to bring some organizations. if you go on the commonwealth fund site, you will pull 83 or 84 va hospitals that submit that data. >> that's right. that's what i was able to do. >> i ran the custom report prior to the hearing to make sure we had a good current sense. that's only 83 or 84 of the va hospitals. where are the others and how could we get away from this comparing ourselves to ourselves? >> the solution is out there. the will of the american people to get it, and now it's a matter of getting it in place, is

that -- >> you bet. we have folks that have md and d.o. on their name badges. they are scientists and driven by good credible data, not anecdote. as well as our physicians in the va could lead to these answers. >> very good. i yield back. >> thank you very much. >> thank you, mr. chairman. i am grateful, as well, as most of the members you heard from that you're here today. i feel like we have a co-pilot now and the solution is there. we can see light at the end of the tunnel. it's been a very dark story. i don't have questions. i wanted to thank you for being here. i wanted to echo what mr. walsh just said. you see the relief in this room around most of this place today that the solutions are there. i would agree, the attention of the american people is on this. the continuing drive by the american people to seek out the

absolute best solution, the big idea, the step forward, and i think many of us today see light at the end of the tunnel. i'm grateful. when we saw the story getting darker and darker and 69 criminal investigations and kinds of things happening, i think most of us knew there are solutions there there are private sector, private industry folks that certainly are here to come alongside and guide this into the kind of success we know the va can be. i wanted to add my comments that you coming today and just broadening the light here, for us to be able to see how it can work and give us something to shoot for as our jurisdiction of oversight continues is the most welcomed news i think i've seen since we got into this whole situation. on behalf of the veterans in my district, we're grateful. i do see light at the end of the tunnel. mr. chairman, thank you for your leadership. i yield back my time. >> thank you very much.

ms. brown, you're recognized five minutes. >> thank you. i want to thank the veterans to work at the va hospitals for their service because basically the veterans to tell us over and over again once they get in the system, they are very satisfied with the service. so that's not a misnomer. ms. mccaughey. we are looking at advantaged care and tricare. >> you are referring to medicare advantage? >> exactly. >> okay. >> in your testimony, it seems as if you are recommending that as -- >> no. i was pointing out that a large number of vets have enrolled in

medicare advantage, and yet they are going to the va hospital for their care. so, in fact, we are paying for it twice. i was pointing out that literally 10% of the va budget is going to vets who have another kind of coverage. it's a tragic inefficiency when you look at we are discussing money and where to get enough money to care for vets, then you find something like that which was documented recently in the "new england journal of medicine." i'm happy to show you the article. why aren't people figuring out that such a large number of vets are paying for care, we're paying for their care twice? we are paying to the insurance companies that run medicare advantage plans and paying again to the va system. let's at least sort it out and get it straight. that's what i was suggesting. >> i'm trying to be clear that the va system is a system that the veterans prefer.

part of the challenges we experience, for example, people that don't have hospitals in their areas, all of this is form-driven. we may need to come up with additional ways to serve veterans. until recently, we have not built a va hospital in 15 years. we have not built additional hospitals. are we going to build additional hospitals for veterans or come up with a partnership that the veterans and the va -- because the testimony we had last week when we sent a veteran outside of the system, we've got to make sure it's a certain quality of care. >> of course. >> if that continuity is not there, you are still going to have the exact same problem we are experiencing today.

in addition to that, i'm a person if i have an appointment and i don't keep that appointment, there is a charge. we don't do that to veterans. if they have an appointment, and they don't make that appointment, there isn't a penalty to them. >> there is a terrible penalty to them. it's not a monetary penalty. it means they are waiting longer and longer for care. when vets don't show up for their appointments, i'm not blaming the vets. in many cases they waited as long as six month for that appointment. the fact is that they, the va hospitals and clinics should be calling the vets 24 to 48 hours or e-mailing them ahead of time to remind them of their appointments. it is unrealistic to think a vet will remember an appointment four months ahead. >> i am saying on the other side of the world, if you don't make

that appointment, there is a financial penalty you receive. >> mm-hmm. and what is your point, madam? >> i made my point. >> thank you. >> the point is we have additional veterans in the system because we open the va system up to the vietnam veteran. each one of them did not have to prove they had a certain disability. so we got thousands of additional veterans into the system. the secretary did it, and i'm very grateful he did it. now we have to figure out how to serve them. i am saying that the va system is one of the best systems in the united states. that is what i'm saying. i read your expertise which is in the area of infectious diseases, which is a problem. the bill we have before us and i'm hoping and the chair's

recommendation, and the senate bill, i hope we can work out what is the best way to move forward with the va system. thank you for your kindness and time. >> thank you. >> mr. jolly, you're recognized. >> no question. >> thank you very much. >> i want to thank the chairman and committee for allowing me to participate in the hearing. i heard some excellent ideas here. i've seen a real bipartisan spirit finding real solutions. i think it's a great morning. we accomplished a lot. i have a hypothetical question. if the no-show rate were reduced to 5% which we heard is attainable, and physicians were relieved of the nonvalue-added requirements, which is a phrase mr. collard used, would there be

enough to provide the health care needed to our veterans? >> i haven't done the math, but it would help. that would bring it closer to what the commercial expectation would be in health care delivery. >> we probably don't know this. none of us at the table have the math. it's a question answerable because the variables are real variables. >> i'll give you the 2012 report that was provided to congress on just this issue, assessing how to assess the need for additional physicians at each location. >> please are brief. >> i'm just going to give you the report. >> okay, thank you. >> mr. mcclain would you talk about the current state of affairs regarding the transfer data between the private sector and the va, and if there are barriers, how could we reduce those barriers? >> we had a problem when we started out in project hero, we

were not able to immediately input any data into the va's medical record. we maintained a network of specialists, so a veteran would be referred out to a specialist and you would get a consult and you would get a written consult report, that we ended up faxing back to the va. apparently then it was detached in a pdf form and attached to the cprs to the veterans' record. in the c box it's a different thing. we are part of vha health care system and we have access to vista and to cprs. it's very difficult. i understand the firewalls, the privacy issues, i understand the i.t. issues that come up, but there has been a lot of work done in these commercial and

civilian sector on exchange of information. i think the answer to your question is dod and va have been trying over ten years to exchange information and have been successful. >> thank you. in your testimony you used a new term, evidence-based leadership. are there models for identifying evidence-based leadership? is there some way to move forward? >> i think what you would find as you look at the models and structures that parallels to evidence-based world and that is evidence-based care. you begin with the diagnosis before prescription. the notion of an assessment prior to jumping into the fray becomes key. then the alignment towards an eventual outcome is where evidence-based care goes. alignment of goals or desired outcomes which includes the proper training a physician would receive that provides evidence-based care. aligning of behaviors.

so the agreed upon behaviors to produce the outcome. a topic we have not come close to talking about today but has been shown in the latest bills, the ability to manage the performance gap much better. whether it's -- we'll push the organized labor issue aside for a second because we have organizations that are highly organized that are very successful in managing performance and they don't let the presence of a union stand in the way. but the ability to first and foremost re-recruit the highest performers in the enterprise, ability to look for those that seek and can benefit from development and the ability to quit hanging on to the low performers that drag the rest of the industry down. we can argue the ends, if it's nf-1, nf-2, but if it's my grandmother in the bed, that low performer is causal to a lack of good care. what that brings us to, much like evidence-based care is through research, through vetting of the data and the

outcomes, the ability to standardize, the ability to accelerate that standardization. that is a quick model of evidence-based leadership. >> thank you. i thank the committee for allowing me to participate. >> thank you. welcome back. great to have you with us. members, we have a series of votes that have been called what we are going to do is thank our panelists who are with us today. we look forward to communicating with you off mike, as well. we want to help the va solve this problem. you have helped bring some information to us today that i think is very worthy of consideration. we cannot fail. as we've already talked about, we do have an opportunity that does only come about once in a lifetime to be able to fix this for the veterans. dr. jesse, i apologize. i would rather us go vote. i don't want any members to miss a vote. we will reconvene at the end of

the last vote. it probably will be an however. -- it will probably be an hour. owers to refinance their loans at lower rates. the republicans in the house and senate, both houses -- >> joining us on our second panel from the department of veterans affairs, is dr. robert jesse, acting undersecretary for health. thank you for being with us today. thank you, also, for indulging the committee members while they went to vote. and with that, you are now recognized for your opening statement for five minutes. >> thank you, sir. i thank the ranking member

michaud and the committee. i'm actually really pleased to be here. i sincerely mean that. i thought this morning's session was fantastic. there were a lot of incredible topics that were discussed. as you know, i have a prepared statement. i'm not going to read that. because i want to respond to some things from this morning. i do want to say a couple things up front. >> your statement will be entered into the record. >> thank you. i would be remiss if i didn't start by just saying, we know that we have let veterans down, but we're going to make it right. there's been a breach of trust. many patients have been waiting too long. we need to fix that. it's unacceptable to the veterans, it's unacceptable to the american people and we apologize for that. we apologize to the veterans, to the vsos, congress, you all deserve better from us. we own this, we're going to fix it. we'll do it with diligence, we will do it with haste, and we'll do it with integrity and

unparalleled transparency. i think from several of the hearings we've had, and moving forward, you will begin to hear certainly how va's moving to provide care for patients. we believe we've identified patients who are still waiting through the processes you have. we're bringing them in. if we can't get them in for care in 30 days, we'll find care for them on the outside. that's the most important thing that we have to do. it's our most important focus. you mentioned that there are ongoing investigations, people will be held accountable. i want to say one thing, that i am very concerned. i care deeply about the other employees in this organization that have been doing it right. there are 270,000 employees in vha. and the majority of them come to work every day, driven on a mission. a sacred mission. they have to do the right thing for veterans. they work for veterans.

close to 40% of them are themselves veterans. we have to acknowledge them, and their health and well-being are very important. we need to know how this organization failed. and i think and i hope that's the topic for the discussion today. how did the va bureaucracy -- i don't like that word -- how did the va organizational structure get to where it is today, and how has that impacted on what's happening in the va. we are going to need help. we're not going to fix this by being a little better ourselves, we'll fix it by the robust discussions that were held here this morning, and learning from the mayo clinics, learning from the kaisers and others. we're, frankly, having those discussions going on now. this really is a time to reset. this is the, i think a crucial moving forward moment. if we don't take the opportunity of that, we'll be remiss. there was a lot of talk this morning about patient centered care. our plan moving forward, which

is we've been inculcating across the organization for the past year, is that we are going to have patient proactive personalized, not just patient center care, patient driven care. i think that's a very important distinction. with eneed to move from being the model of finding a faster and fixing it better to one that treats the front end of disease prevention and wellness. standardizations is incredibly important. i agree absolutely with mr. collard, that people say, well, standardize, you can't innovate. you can't innovate if you don't standardize. we're still processing around the structure that provides a level of standardization, that allows disciplined improvement. centralization is important. it's best when it's standardized. it's not equivalent to standardization. if you standardize business practices, that's great.

you get efficiencies of scale. and you get an operational consistency that's important. but there are other ways that are important. for example, the mail-order pharmacies. the pharmacies have for the third year in a row won an award for pharmacies. what it did, it freed up the pharmacists that got them from out behind the counter to out in the clinics, and doing medicine reconciliations, adherence to the regimens which in the end improves the outcome. there was talk about competition. competition these days in health care is choice. if we're not the health care agency, if we're not the delivery system that veterans choose, then we will have lost. and coordination care is important. and in talking about a big idea, one of the things we have learned is that to relentlessly

drive an organization in performance measures, that are processed measures, will not get us where we need to be. we want to drive this organization on value. value is quality over cost. quality is in the eye of the beholder so there's multi-dimensions to it. it's the opportunity cost, the emotional cost of getting care. but we need to make that equation right for the veteran. for you all as our oversight board. and for the american public. because if we are not a value to all of you, again, we will not have met our mission. so thank you, sir. again, thank you for the first panel. i thought it was excellent. and i'm prepared to have a further discussion. >> thank you very much for being here, dr. jesse. my staff asked the office -- and i know this is not under your purview -- but what i asked for is, asked the office of congressional and legislative affairs to provide an organizational chart for va's office of mental health services

to include accompanying names and titles on the 18th of april. on may 7th, my staff was informed that this deliverable request would require either a letter from me, as the chairman, or to go through -- now, get this, members -- a freedom of information act request. i sent a letter that same day. however, i still don't have it. so either a chart doesn't exist, or va doesn't want to share it with the committee. what do you think about that? >> well, i -- first of all, i apologize. there's no reason why you nor anybody else shouldn't have an organizational chart. i'm actually surprised they're not available on the web. but i apologize you're being put through that amount of effort to get it, and i will get it to you. >> by close of business tom will be appreciated.

can i have your perm assurances it will be? >> i'll certainly try. >> i heard you put "try" in there, but there's no reason we should not have it tomorrow. or if it doesn't exist, you're correct. during a recent visit to the columbus mississippi seabok, i understand that many prefer to use the tuscaloosa medical center because it's a closer proximity. it was mentioned that there's a memorandum of understanding in place to allow this choice for veterans. so i guess my question is, in a supposedly integrated system, why is there a need for this type of bureaucracy in order to cross a vision line? >> i don't know the answer to that. i don't -- particularly if there's a memorandum of understanding that people can go back and forth. i think since the days of dr.

kaiser, we've said it's one va. veterans should be able to choose which va he goes to. so i don't have the explanation for that. >> if you could, also, for the record, gather that. >> yes. >> the other thing is, why are veterans who cross lines c categorized as new rather than an established patient? >> that, i know they're not supposed to. i looked into it a little while back. i had been at the clinic up in south dakota, and i was walking past a waiting room and there was a gentleman sitting there. and a guy says, guys in suits, they must be from washington, get in here. so i went and talked to them. and their comment was that they love the care they were getting in south dakota, but nobody, retired people tended to go to warmer places in the winter, and their only complaint was they went somewhere else, that they were not recognized. even though they were going to

the same place over and over again. i came back and looked into that. there is a process that people are supposed to follow to do that. and apparently we don't have that methodology as clearly as it needs to be. it should not happen. if you're in the va, you can be found. but i'll also say that there is a -- an initiative to not only do that avos vha, but across all va. if you change an address in benefit side, that gets pulled over into a master index. so that the entire agency sees each individual as one person. and not having multiple -- we need to do that to make this seamless. >> when vha issues a policy letter or a directive, how does that instruction flow from the central office to the field? >> the technical process is that, as the directives get

signed off, by the undersecretary, then the distribution route goes through the networks. so it goes through network operations, down to the network directors, and then from there it tiers down to the facilities, into the field. at the same time, the bottom -- the last line of virtually every director, at least the ones -- the clinical ones i've been involved with, will have who your point of contact is, if there's questions. so there's ways to move -- you know, clarity and technical expertise, back to the folks who are trying to implement that directive. >> and my final question, and i'm running out of time, but the committee's been told repeatedly that the va central office, policy is often transmitted outside of any authority chain, and often viewed by many va medical centers as voluntary. is that true? >> i certainly hope not. a directive -- you know, a directive it is a directive.

they're very explicit statements about what's required. if there are -- if there are options and opt-outs, they would be placed in that directive. i think the key principle needs to be that directives are not ambiguous, that their intent is clearly defined, that the metrics by which they're going to be measured are clearly articulated. and that there is a solid and defined methodology for ensuring that they are in fact being met. and the intent of the director has been met. >> thank you. mr. michaud, you're recognized. >> thank you very much, mr. chairman. thank you very much, dr. jesse, for being here. my question is, you heard earlier dr. mccoy, and for the record, i mean, dr. mccoy is not a medical doctor. raised a number of concerns with the choice card provision in the sanders/mccain bill. do you see any bills with va's

ability to provide veterans with eligibility, verification, such as choice cards, to see non-va doctors? >> you know, i don't know explicitly, but we've been doing this -- there are several different methodologies for non-purchase, non-va care, the term seems to be used all encompassing. when we give someone a fee card, it is the authorization for you to go out and get your care. and there are some limits around that. it's not a preauthorization, but there are bounds about what care can be provided. if it has to exceed that, they get authorization. i believe that's the way it works. it should not be an inhibiting factor. and i think you heard from fill lip makulsky the other night that if that were the type of case, it would not be a call to

a random number somewhere. we would have the health resource centers run by the business office managing that. i would presume. so until we have the regulations around it, it's a little bit difficult to speculate. but we have the capability to do that. >> when the va does it today, do you have any problems with verification? >> well, i'm not going to say it's perfect. but i think, you know, for most cases, it's effective. you know, we've been looking at better ways to do it. project hero and project arch were set up for that, to see if there's a better way to get the distributed care out there. >> the project is in maine, veterans -- they love the way that's been working. >> yeah. >> the vision structure has been under scrutiny for a few years now. i understand that vha has reduced the number of headquarters staff through the -- through the realignment

effort. is that process finished? >> well, i'd rather think of it as a work in progress. so there was a task force, a group that looked at this, and clearly there was wide variation in the size of each of the visions that could not be explained on the size themselves, meaning the total number of veterans, or their purpose. because their purpose is inherently the same. what this group did is they came back and clearly defined the core roles that needed to be in each vision office. and some limited amount of flexibility around that, which was fundamentally driven around the size of the vision. so we went from a variation of, i think at the low end just under 40 people in the office to a high end of 160. they're all now between, i think, about 55 and 65. clearly defined roles. this is what you must have in there. a little bit of flexibility.

but there is not an ability to continue to flex up that staffing without coming in for further review. it's a work in progress, because it's been pushed out this year. we'll see how it works. we're constantly looking at it. if it needs to be smaller, we'll make it smaller, or if it needs to be bigger, we'll make it bigger. that's what we did. so we tried to standardize at the vision level. >> thank you. just to follow up on the chairman's comments about getting a directive from central office, and having the visions carry through with that directive, and these are -- you know, i've heard comments that the folks are more concerned about the directors' interest in how things are run versus the secretary's, because the secretary comes and goes. and i've also heard on the vba

side as well, when the american legion went out to do their system worth saving, brought note to the fact -- to the va employees, that's not what central office said you should be doing. in response, this is the baltimore, maryland, vba. we're doing it the baltimore way. so i think there really is a problem in some of the areas, and i would encourage you to make sure that when the directive does come, that it's followed through. and the other note i want to say since my time's running out, you look at the department of defense, they have the world divided up in seven different regions. and i question whether or not we need 21 visions throughout the country. and on that note, i yield back, mr. chairman. >> thank you very much. >> thank you, mr. chairman.

dr. jesse, welcome. i'm looking at the organizational chart of the va. i guess this is the veterans health administration. and i'm wondering, if a physician within the va wants to lodge a complaint or make a suggestion, where on this chart does that occur? i don't see a place that has physicians. >> there are two places, actually. on that chart, there is a doctor who is the deputy undersecretary for policy and programs. and in that is patient care services. and rolled up under patient care services are much of the physician based -- and other clinical services. >> i guess the reason i'm bringing this up is i worked at the va. and i talked to many va physicians and they complain

they have very little recourse when they have suggestions for changes or complaints within the system. i notice here on the chart here that the office of nursing is right here under the -- reports directly to the undersecretary. >> yes, sir. >> why isn't there a similar place for doctors? >> so, the physicians work through programs. so the office of -- >> what i'm trying to get to, it seems the nurses have more input to leadership than the doctors do. the doctors often have suggestions that make -- that improve the quality of patient care. the physicians i talked to, i just talked to a group of va physicians yesterday, and they're, frankly, telling me that they get reprimanded. and they had this retribution if they try to change the system. have you ever heard about that? i've had physicians say they've not been allowed to talk to me by their superiors, they're not

supposed to talk to me. >> let me -- >> is the policy of the va to not allow physicians not to speak to members of congress. >> absolutely not. >> i'm glad to hear that. >> and remember, that if i -- >> if i -- >> as a clinician -- >> why would it be that physicians have been told not to speak to me? >> i have no idea, sir. it's not right. physicians have the right to speak to anybody. >> that's what i would think. >> there is a mechanism through -- surgeons have the office of surgery, dr. gunner has been a stellar leader in that. emergency medicine has the -- >> this is occurring now, today. yesterday. this pattern of veteran -- or physicians within the va being told not to speak to congress, being told not to rock the boat, because if you try to make productive, it will make somebody else look bad.

this is a direct quote from physicians that work within your system. >> sir, i also work with those physicians. and, you know, much of the improvement occurs at the local level. we identify best practices at those levels. we use our -- leverage our network capability to distribute them. there is no reason that physicians should not and cannot communicate freely. how can we have improvement if people don't feel they can exercise -- >> that's the situation. that's today. i was at a meeting, where there was perhaps 50 va physicians, and the common theme of the discussion was that they were afraid to talk to me, and what can be done -- i'm afraid to tell you what's going on at the va, doctor, because doctor, because everyone has told us they will be punished and they will be put through onerous peer review situations that were obviously punitive so they were afraid they wouldn't be able to practice outside the va. i'm just telling you what's

occurring. >> that's inexcusable, and i will -- >> can you pledge to me if i speak to a va physician and he complains to me he was reprim d reprimanded you will help me make sure this whistle-blower guy doesn't get punished? >> well, we don't tolerate punishment of whistle-blowers. we absolutely do not -- >> but i'm saying it's occurring today, dr. jesse. if i have a physician who talks to me -- because they were asking me yesterday, doctor, how can you assure me if i tell you what's going on that you can stop me from getting fired? and i had a little bit of trouble telling him that i could promise him that he couldn't get fired. do you understand what i'm saying? what i'm asking you if somebody comes to me with that complaint, can you promise me they won't get fired? >> sir, i will promise you that they won't get fired for complaining to you. i can do that much. i can't speak to individual situations. all right. sorry. >> but also understand that if we do find that somebody has

directed people not to talk to members of congress, it is a crime. >> it's inexcusable. we don't accept that. >> it is criminal. >> yeah. i think the voice of the veteran who we serve, the voice of the line people working with veterans every day is crucial if we're going to improve this organization. we have to be listening. >> you're recognized for five minutes. >> thank you. sir, in florida we serve almost 600,000 veterans. we are the third largest population of veterans in the country, and my question goes to i personally think the va system is an eight or a ten, but when i -- first year i was teaching, the principal said if you're an eight or a ten, where is your room for improvement? so i'm starting out saying i think the system is very good.

what are the recommendations you would have for some improvement because i don't think the entire system is damaged as i hear, and i do think there are things that we could do. i remember when secretary brown, jesse brown, when the veterans from the northeast came to florida, we serviced them, and we didn't get reimbursement. the reimbursement stayed in the north. so i know a lot about the institution, probably more than anybody on the committee. >> so how can we improve? well, the first thing we can do, as you heard earlier today, there are many va facilities that are top achievers, incredible performance, but not everybody is there, and the first thing we need to prove is to get everybody up to that same level. second is, we say we are a quality organization, but i constantly remind our staff that there are multiple domains to

quality. one of them is access and one of them is timeliness. so if you can't have access, you can't even have quality. so fixing this access problem and doing it immediately is key. third is equity. you know, if there are inequities in the delivery system, we've got to identify them, we've got to figure them out, and we've got to make them go away quickly. so as we improve the standards of all hospitals, raising all boats up to what we know we can achieve but also ensuring that access, quality, equity are uniform principles of how we do that work. >> we had a hearing, the florida delegati delegation, on the va this morning and one of the recommendations at one time the va could just, i guess, hire a doctor, and now they have to go through a different system. >> i'm not sure what you mean. we have a process for kre den shalling and privileging

physicians. it's not unique to the va. every hospital in this country will do the same thing. our process is actually -- the credentialing process is pretty good but we're working with dod because they have one, too, but it's different from ours and trying to establish a credentialing process. in the conversations around tell health where you have people practicing across state lines, you can have a uniform set of credentialing. that takes time. the one thing that is unique to va is that physicians especially but i think almost all employees have to go through security and background checks, and that takes some time. what we're trying to do and, in fact, we learned a lot of lessons if you remember last year when we had the hiring initiative to plus up the mental health workforce, we learned a lot about the speed of hiring and the challenge but simple solution is don't wait for step

"a" to fix before you start step "b," before you start step "c." parallel process, you can cut down that time. if we don't do that, we lose people while they're waiting to get their job. >> nursing is another example that it takes so long for us to process a nurse. and how do we advertise? do we advertise just in the va system or how do we do it? >> there's a requirement, i believe, that all federal jobs have to be posted in ---ed a a feder -- at a federal website but i know when i'm reading the richmond paper there's always ads for the va looking for nurses there. everything goes into a website, but, in fact, you use local resources. we also have executive and physician recruiters as part of workforce services that go out and reach out and try to find these people. we leverage them