Commission on Care Final Report June 30, 2016 Final Report of the Commission on Care June 30, 2016 Commission on Care 1575 I Street, NW Washington, DC 20005 commissiononcare.sites.usa.gov 1575 I Street, NW ▪ Washington, DC 20005 June 30, 2016 We are honored to submit to the President, through the Secretary of Veterans Affairs, in accordance with the Veterans Access, Choice, and Accountability Act of 2014 (VACAA), the enclosed recommendations for transforming veterans’ health care. We believe these recommendations are essential to ensure that our nation’s veterans receive the health care they need and deserve, both now and in the future. We worked with an absolute commitment to putting veterans at the heart of our deliberations, and believe our recommendations will create an integrated, community- based health care system for veterans that will be sustainable for the long term. During the term of the Commission on Care, we evaluated the 4,000-page Independent Assessment Report; held public meetings; listened to a broad range of stakeholders, including veterans and leaders of veterans service organizations; made site visits to Veterans Health Administration (VHA) facilities; and exchanged ideas with individual veterans, VA and VHA leaders, VHA employees and health care providers, members of Congress, economists, and health care experts. Overall, the Commissioners agree with the findings of the Independent Assessment Report, which are consistent with the expansive body of other evidence the Commissioners have reviewed. This evidence shows that although care delivered by VA is in many ways comparable or better in clinical quality to that generally available in the private sector, it is inconsistent from facility to facility, and can be substantially compromised by problems with access, service, and poorly functioning operational systems and processes. The Commissioners also agree that America’s veterans deserve much better, that many profound deficiencies in VHA operations require urgent reform, and that America’s veterans deserve a better organized, high-performing health care system. The most public and glaring deficiency was access problems. Congress attempted to solve this problem through a provision in VACAA that directed VHA to implement a temporary program allowing for greater choice. The Commission finds, however, that the design and execution of the Choice Program are flawed. In its place, we offer specific recommendations for standing up integrated veteran-centric, community-based delivery networks that will optimize the balance of access, quality, and cost- effectiveness. The Commission also finds that the long-term viability of VHA care is threatened by problems with staffing, facilities, capital needs, information systems, health care disparities and procurement. Fixing these problems requires deliberate, concurrent, and sequential actions. It also requires fundamental changes in governance and leadership of VHA to guide the organization during the next two decades through the rapid changes coming in demographics, technology, and in the structure of the overall U.S. health care system. VHA has many excellent clinical programs, as well as research and educational programs, that provide a firm foundation on which to build. As the transformation process takes place, VHA must ensure that the current quality of care is not compromised, and that all care is on a trajectory of improvement. VHA has begun to make some of the most urgently needed changes outlined in the Independent Assessment Report, and we support this important work. Implementing the recommendations in this report will greatly enhance VHA’s ongoing reform efforts by providing both a systems-oriented framework and vitally needed changes in organizational structure. Foundational among these changes is forming a governing board to set long-term strategy and oversee the implementation of the transformation process, and building a strong, competency-based leadership system. The remaining recommendations work in harmony to ensure veterans receive timely access to care, have options for where and how they receive care, are cared for in an environment that embraces diversity and inclusion, and are supported in making informed decisions about their own health and well-being. These recommendations are not small-scale fixes to finite problems. Instead, they constitute a bold transformation of a complex system that will take years to fully realize, but that our country must undertake to provide our veterans with the high-quality health care they richly deserve. Respectfully Submitted, Nancy M. Schlichting Delos M. Cosgrove, MD Chairperson Vice Chairperson David P. Blom David W. Gorman Commissioner Commissioner The Hon. Thomas E. Harvey, Esq. Rear Adm. Joyce M. Johnson, DO, USPHS (ret.) Commissioner Commissioner The Hon. Ikram U. Khan, MD Phillip J. Longman Commissioner Commissioner Col. Lucretia M. McClenney, USA (ret.) Lt. Gen. Martin R. Steele, USMC (ret.) Commissioner Commissioner Charlene M. Taylor Marshall W. Webster, MD Commissioner Commissioner TABLE OF CONTENTS TABLE OF CONTENTS ................................................................................................. VII LIST OF FIGURES .......................................................................................................... X LIST OF TABLES ........................................................................................................... XI EXECUTIVE SUMMARY ................................................................................................. 1 INTRODUCTION .......................................................................................................... 21 COMMISSION RECOMMENDATIONS ...................................................................... 23 Redesigning the Veterans’ Health Care Delivery System .............................................. 23 The VHA Care System .......................................................................................................... 23 Recommendation #1: Across the United States, with local input and knowledge, VHA should establish high-performing, integrated community-based health care networks, to be known as the VHA Care System, from which veterans will access high-quality health care services. ............................................................. 23 Clinical Operations ................................................................................................................ 37 Recommendation #2: Enhance clinical operations through more effective use of providers and other health professionals, and improved data collection and management. .............................................................................................................. 37 Recommendation #3: Develop a process for appealing clinical decisions that provides veterans protections at least comparable to those afforded patients under other federally-supported programs. ................................................................ 40 Recommendation #4: Adopt a continuous improvement methodology to support VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center. ................... 43 Health Care Equity ................................................................................................................ 47 Recommendation #5: Eliminate health care disparities among veterans treated in the VHA Care System by committing adequate personnel and monetary resources to address the causes of the problem and ensuring the VHA Health Equity Action Plan is fully implemented. .................................................................. 47 Facility and Capital Assets ................................................................................................... 55 Recommendation #6: Develop and implement a robust strategy for meeting and managing VHA’s facility and capital-asset needs. .................................................... 55 Information Technology ....................................................................................................... 66 Recommendation #7: Modernize VA’s IT systems and infrastructure to improve veterans’ health and well-being and provide the foundation needed to transform VHA’s clinical and business processes. .................................................... 66 vii COMMISSION ON CARE FINAL REPORT Supply Chain .......................................................................................................................... 81 Recommendation #8: Transform the management of the supply chain in VHA. ............ 81 Governance, Leadership, and Workforce ......................................................................... 94 Board of Directors .................................................................................................................. 94 Recommendation #9: Establish a board of directors to provide overall VHA Care System governance, set long-term strategy, and direct and oversee the transformation process. .............................................................................................. 94 Leadership ............................................................................................................................ 101 Recommendation #10: Require leaders at all levels of the organization to champion a focused, clear, benchmarked strategy to transform VHA culture and sustain staff engagement. .................................................................................