 It's really my pleasure to introduce a very special guest, the Honorable Dr. David Shulkin. Dr. Shulkin has served as the Undersecretary for Health for the Department of Veterans Affairs since June 2015. In this position, he acts as the Chief Executive of the nation's largest integrated healthcare system. Dr. Shulkin has an esteemed professional resume which includes serving as President and CEO of Beth Israel Medical Center in New York City and Chief Medical Officer of Three Hospitals and the University of Pennsylvania Health System. As an entrepreneur, he founded and served as the Chairman and CEO of Dr. Quality, one of the first consumer-oriented resources of information for quality and safety in healthcare. Dr. Shulkin has been named one of the top 100 physician leaders of hospitals and healthcare systems by Becker's Hospital Review and as one of the 50 most influential physician executives in the country. I've had the pleasure to work with Dr. Shulkin over the last several months since he's been here and I'm telling you, he is a breath of fresh air and we're so pleased that he took his time today. I know he's traveling coming straight from another trip but I thought it was so important for you to hear directly from VA his vision as the Undersecretary for Health, what they're doing, what progress has been made. I'm honored from Mr. Gibson this morning. I think this will round out our presentation really well and what we're going to be talking about. So Dr. Shulkin, please join us. Give him a warm welcome. Well, thank you very much. I'm really pleased to be here today and so glad that all of you came this morning. I can't tell you how important it is that you're doing the work that you're doing and that you're here to advocate on behalf of veterans coming into VA at this time with so many people targeting us and so much attention that is often not positive knowing that you're there understanding the work that we're doing advocating on behalf of veterans. I can't tell you how important that is and so I just really want to not only recognize but congratulate and thank all of you at DAV for the work that you're doing and giving you a chance to sort of update you on what's going on in VA I think it's going to be important. I'm going to move through this very quickly because it's very hard to tell you all the things that are happening in VA in a short period of time but as Joey said, I had the privilege to join VA about seven months ago. I had not really been in the VA healthcare system for about 25 or maybe even 30 years when I first did my residency in VA. This is the day that Secretary Gibson actually signed me in in July of last year and it's been a very different experience for me coming from the private sector into VA. In fact, the irony is I used to joke when I would run hospitals as the CEO around the country. I used to say what's it going to take to get this done in the hospital and act a congress and it actually turns out that now I say that a lot because almost everything that we do really literally takes an act a congress. But one of the unique things that I have that may be passed under secretaries haven't had is that I do get to compare the difference between what the VA healthcare system does compared to the private sector and quite frankly when I came into the system not knowing as much about the VA haven't had really worked there in 25, 30 years, I guess I did wonder, well shouldn't we just privatize the VA? I sort of had an open mind but I will tell you after being here now over seven months and actually practicing in the VA taking care of veterans, that's where I was coming from on my trip. I was seeing patients, I can tell you that what we do in the VA healthcare system is very different than what happens in the private sector and cannot be easily replicated and would be a big disaster for veterans and for the country to simply throw this system out. So what I have begun to speak about and actually writing about in national journals are the things that happen in the VA healthcare system that are completely different than what happens in the private sector and so you can see on this chart here you know the private sector doesn't provide and I know what DAV does in terms of this transportation it doesn't provide support for caregivers if you don't have a home no one in the private sector is going to go out and work to find you a home. The integration of behavioral health with primary care completely different. The single EMR platform that we have completely different than what you find in the private sector. So it's very important to remind the country about this and in fact particularly for veterans if we were just to send people out into the community you can see from these studies that very few practitioners out in the community actually understand what people who have served this country have gone through just one in five having any type of cultural competency about military service only 13% of those in the mental health field in the community really can speak about military or deployment issues or use the types of therapies that work so much and so the more that I've gotten to know the VA understanding not only how we treat veterans differently clinically but the fact that we train 70% of the doctors in this country through the VA healthcare system the fact that we are doing research the only organizations doing research to specifically help and improve veteran health this is an organization that quite frankly I don't think can or should be replaced by the private sector. The other thing that you don't really get a sense about until you join the VA and have a chance to visit places around the country like I do as the undersecretary you get to see the way that our culture and traditions get carried on that I think is so important it makes it so special. This is actually a picture from a trip that I took to the North Chicago site where it's called the final salute I don't know how many of you have ever seen this but in hospitals again where I've spent my career when a patient passes away they typically as you see on TV will drape a white sheet over them and wheel them in a stretcher down the hall to the morgue which is always at the far end of the hospital in the basement and watching a patient with a white sheet draped over their sheet just being wheeled down the hall can be pretty depressing for other patients who are in the hospital so what they do in the VA now is instead of using a white sheet they drape the stretcher with a US flag and people line up you can see here to give what's the final salute as the veteran gets to be wheeled down so it's turned into a respect and honor tradition rather than one that is depressing and I just think it really speaks to how the VA is different how it treats veterans different I think many of you who have been involved with DAV for years understands that the VA actually provides some extraordinary care this is Phil Longman's book where you know his story where he was hired by one of the national magazines to go out and to do a featured story on find the very best healthcare system in the country and we want to feature them on the front cover of our magazine so he went out to do his research he came back to the editors and said I found the best healthcare system they said that's great where is it he said it's the VA healthcare system they said you're an idiot you're fired and they literally fired him so he went out and wrote a book about this and actually documented years and years ago because I think the book's been out almost a decade now about the very best outcomes in the country what's interesting is is that these same findings are being shown as we speak today this was from the Journal of the American Medical Association two weeks ago their featured study that basically showed that the mortality rates in VA hospitals for conditions like acute myocardial infarction and congestive heart failure are superior to those in the private sector so really the same exact findings that Philip Longman wrote about in his book have been replicated time and time again and last to this day that we just simply are doing a better job than many of the private sector hospitals are doing one of the reasons why we do we are we have the best analytics we can study what we're doing better than almost any healthcare system in the country and again this is a field I've been in a long time this is what we call our sale performance where you can actually see how we're doing in every metric and we're pretty transparent we publish this data you can see that the VA healthcare system overall is improving dramatically year to year we're getting better that's what you would hope our organization would do focusing on things that we can do better and actually implementing performance improvement and you can see everything on the right side in the blue the yellow the green is better the red it means that that's the opportunity that we have to continue to improve on and get better on so we're not we're not where we need to be but this is an organization that every day is getting stronger and better and we have a lot of people helping us to the last count that I had 137 external groups giving us reports and recommendations every single thing that we do is under the microscope and people telling us about about how we can do a better job so when I came into the organization knowing that there's so much public scrutiny obviously knowing the reason I'm here is because there was a crisis in the VA healthcare system primarily started with our wait time crisis I established five priorities for the health system that we're focused on the first is to fix the access issues I'm going to tell you a little bit about that the second is to fix our employee issues to make sure that this is a place that people want to come to work and feel supported and we can fill our key positions the third is to implement best practices the fourth is is to develop what I call a high performance network which I know DAV has some very very good ideas on and the last and probably most important is to restore the trust among veterans in the VA healthcare system and the American public to have confidence in what we're doing so I know we have some work to do there so I just want to tell you a little bit about the progress we've been making and then have you make up your mind whether we're headed in the right direction of course the wait time crisis the access issue starting in Phoenix in April 2014 really put the VA into its current state of crisis but this was not a access crisis that happened in 2014 this had been building for years and years and years and in fact I can go back and find reports from 15 years ago that predicted that this was going to happen and all these events were going on because no one had taken the appropriate steps to make the systematic impacts or improvements that you need to to make sure that we're taking care of veterans in a timely fashion this is actually just data showing that if we just asked veterans themselves these are our patient satisfaction scores you can see the veterans themselves were telling us that there was a problem going on well before the crisis in Phoenix having said that we do have a issue and I will show you how we're fixing it but I do want to remind people so does the rest of healthcare I mean all of you know if you try to go out to your community doctors and again this has been my business for 30 years people in the community have a tough time getting in to see the doctors they need when they want to get them and so if you ask veterans and you ask non-veterans whether they have trouble getting care you can see veterans actually think they have better access to healthcare than most non-veterans this is highly geographic as we know but most of the country is struggling with these same issues when I first got to VA and I began to start asking some questions about the wait time issues it amazed me that no one had actually separated out veterans who were waiting for urgent care things that couldn't wait I have a tumor in my chest versus routine care which is I'm going back to see my primary care doctor for my six month checkup VA had not ever separated that we kept every veteran waiting in a single large list and so the first thing that I did was which I thought was just really basic healthcare management I separated veterans into those that needed care urgently from routine care and as soon as I got my list of 57,000 veterans waiting for urgent care consults we held within two weeks what we called a national stand down we opened up every medical center across the country on a Saturday and we said we're not going to stop until we take care of every one of those 57,000 patients waiting for urgent care whether it means bring them in that day to the emergency room whether it means get them to see a doctor in the community that day and by the end of the day we had taken the list of 57,000 down to 55,000 and today that list is less than a couple hundred veterans the reason why it still is a couple hundred veterans we had wrong phone numbers, people moved, people died reasons that we can't get in touch with those veterans and you can see that we kept sustainability on the number of patients that have urgent care needs being seen right away after that stand down down to a low level so today we're never going to get back to the 55,000 this is a much much smaller number of sustainable impacts on consults now this doesn't mean the wait list for veterans go away you may have to wait a longer time to get eyeglasses, audiograms, non-urgent issues but our first priority is to take care of people who are sick who can't afford to wait and that's where the VA is now focused we are implementing this year in 2016 same day access across the country for primary care and for mental health issues so this is not for every issue that you'll have same day access but if you need to get in to see a primary care doctor and you're having an urgent issue that day by the end of 2016 every medical center in the country is committing to having same day access we have about 50 medical centers out of 150 today that have same day access I can tell you where I was practicing this weekend they have same day access I was there in walk-in clinic any veteran who needed to be seen in Manhattan could be seen that day we need to get that across the country and we will do that by the end of the year we are implementing what we call seamless access which means if you normally get your care in St. Louis but you're traveling and you're in Florida or you're in another part of the country you should be able to walk in and get your care at any VA medical center not hear oh well your home clinic is in St. Louis you have to contact them so by the end of the year we will have implemented a seamless system not only for prescriptions but for all medical care across the country so you can feel safe wherever you travel that you have the VA healthcare system behind you for those who say well what's VA been doing since the crisis we really have been working hard to get more appointments available you can see by measuring the workload of every VA doctor and clinician we are up 10% since the crisis happened so we've just been improving productivity of the average doctor having them see more patients and having more hours this is equated to 20 million additional provider hours of care throughout the system we are growing our telehealth capabilities particularly for veterans who have to travel a lot you can see we now have the largest telehealth system in the country and that's something that we're continuing to invest in and to grow we are learning from one another now across the system believe it or not we had not been doing a lot of sharing about what worked in California with what's working on the east coast now we are implementing sharing of best practices we've actually held our first Shark Tank do all of you watch Shark Tank on ABC? I'm not doing a plug for them but it's one of my favorite shows so we actually held a Shark Tank where we got every VA to submit their best practices, their best ideas we actually had sharks bidding on them and now we have a number of best practices that were committing to spread out consistently across the country so that we are learning from one another and making sure when we learn something's working that we're implementing it consistently throughout the VA healthcare system and we're bringing new innovations to not only VA in the country we just had an announcement two weeks ago that one of our researchers has developed a non-addictive medication for pain that hopefully can replace opioids and everyone knows about the real issues that we have in this country about people being addicted to their prescription medications and this really taking over their life so this would be a major advance something that we're really working on on pain management we're also using new technology you can see this is one of the new kiosks that we're looking to put in certain areas across the country particularly rural areas where you could just walk into a shopping mall or some area where we don't have a facility walk in and using telehealth be able to get your physical exam right in that kiosk so you can see how using new technology new ideas we can bring VA care closer to where people live not have to have them travel hours and hours and be able to get the type of care they need we're developing new ways of identifying veterans who are at risk for suicide using large data sets and predictive analytics being able to identify who's at risk so we don't have to consistently just wait and hear about terrible things that have happened and this is data that's coming out of the VA healthcare system osteo-integration we performed our first in the country osteo-integration surgery at Salt Lake Cities VA about three weeks ago this is where if you need an amputation we actually build the device right into your bone and your skin so that you can actually get a much better feel when you walk and you use the device and it's much easier to switch devices in and out you can see that that's the metal bar being put right into there so it's like a Lego piece where you can actually put your prosthetic right into it snap it off, snap it on and this is the first time this has been done in the country but we think it will become a standard of care in the years to come and finally what I want to just talk about a little bit is about where the VA healthcare system is going it's what I call a high performance network and this is really how do we work with the VA healthcare system and doctors and hospitals in the community to serve veterans best I think it would be a huge mistake to say that VA needs to trim down its services that VA needs to begin to withdraw providing services to veterans I think that if anything we need to make sure the things that we're doing in the VA are world-class and we need to begin to put more resources into them but when we work with the community particularly in our choice program right now we are not making sure that veterans are going to the very best doctors we're essentially sending veterans out to whatever doctors are signing up in the system and that's not the way I believe that we should be doing this so what a high performance network is is actually monitoring the quality and the outcomes of veterans within the VA system which we're doing great but now expanding that to be able to monitor the outcomes and the quality when veterans go outside the VA healthcare system and actually having a command center that's able to track the outcomes of veterans much like NASA tracks the rockets when they send them up in the space because we now have the ability to do that and what it ends up resulting in is our ability to make sure veterans are getting the best care anywhere so they have to leave a VA in Birmingham, Alabama we now have data that suggests that on this if you can see the small print this says that the very best place to go in Birmingham would be Walker Baptist Medical Center and the very worst place to go would be right below it the Baptist Medical Center in Princeton and so what a high performance network begins to do it allows us at VA to use our large data sets to tell veterans where they can get the very best outcomes of high quality care when they should be using VA for that high quality care when there's actually better outcomes outside the VA how they could use it and our role becomes to coordinate the care for veterans no matter where they're getting that care within the VA healthcare system or when they have to go out of the VA healthcare system but that's a very different message than saying that we need to trim back on the VA or we need to privatize the VA duty to make sure that when a veteran does have to go outside of the VA healthcare system we know that they're getting the very best care and we can make sure that their care is coordinated with the doctors who are within the VA healthcare system I did want to just end on these last two slides the most important thing our currency is not to make money in the VA healthcare system our currency is to earn the trust and confidence of veterans in the VA healthcare system and the way that we need to do that is to be open and transparent about everything we're doing the things we're doing well I hope I've shared some of those with you today but also the things that we're not doing well and that we need to get better in and I'm a pretty strong advocate for telling it like it is if there are areas that we're not serving veterans well I certainly want to hear about it and I am not at all ambivalent in the position that we have to do better we have to staff our critical positions with the right people today I have 34 medical centers without a director without a medical center director I don't know how you can restore confidence and trust if you don't have the right people leading your organization so that's one of the things which I'll mention on my last slide that we could use your help with we also need stability for our leadership positions so that's one thing that loses a veteran's trust is when their doctor leaves the VA healthcare system or when there's constant turnover veterans want these long relationships with the people caring for them and we have to do things to keep our doctors and our leaders making sure that VA is a great place to deliver care and we have to make sure that we're empathetic too often I'm hearing stories about the inconsistency in the way it's their healthcare providers and so we have to reemphasize this is a system that is here to serve we have to embrace servant leadership and empathy in what we do so lastly just asking for your help as you go out to speak to members of Congress and I know Deputy Secretary Gibson talked to you about this this morning from my perspective in the health system the things that we really need to help for is we need Congress to allow us to be able to spend money for veterans for care in the community with more flexibility we have money but they're in these very very rigid pockets of money like checking accounts and I can't use one in one account to help spend in the other account and it makes the system complex to use difficult to understand and doesn't benefit veterans so we're asking for that funding and we've given them some proposals provider agreements allows us to go out and contract with doctors and hospitals in the community or nursing homes that are the highest quality nursing homes or doctors or hospitals and we need the ability to contract with them with what's called provider agreements to get the job done we don't have that today lastly the last two the physicians we are only allowed to pay a doctor 40 hours a week in current federal laws many doctors now are becoming what are called hospitalists or they work in emergency rooms that have shifts that work more than 40 hours a week so we're becoming non-competitive as an employer because the private sector can allow them to work 60 hours one week and 10 hours the next week we can't do that so we need the ability to work outside the 40 hour work week for doctors and lastly to be able to get the job done all our spots our leadership spots in medical centers there's 34 medical centers that today I don't have anybody running them we need what's called title 38 funding it allows us to be more market competitive for these positions like the private sector and I can tell you I'm having a tough time finding people to want to take these jobs because the private sector is hiring them away from us so we need that type of flexibility I much appreciate your support and advocacy on our behalf and thank you for everything you're doing on behalf of veterans