 Good afternoon. I want to welcome everyone to DAV's Service and Legislative Seminar. I'm Jim Marslack, DAV's National Service Director, and I'm joined by Joey Elam, DAV's National Legislative Director as co-host for today's seminar. As we have done for the past several years, we'll be having a candid conversation with senior leaders at the Department of Veterans Affairs about some of the most critical challenges and policies affecting veterans, including burn pits and toxic exposures, VA healthcare and benefits, family caregiver support, suicide prevention, survivor benefits, and many other topics. But before we begin, we want to introduce our special guest. I'm pleased to introduce the Honorable Matthew T. Quinn, Under Secretary for Memorial Affairs. In this position, he has responsibility for 155 VA national cemeteries and 120 VA grant-funded state and tribal veteran cemeteries that provide dignified burials for veterans and eligible family members. He has a retired Major General, having served nearly 37 years in the Army and Army National Guard, culminating in his selection as a 27th Adjutant General for the State of Montana. His service included commanding the A Company 34th Signal Battalion and Operation Desert Storm in 1991 and the 495th Transportation Battalion in Operation Iraqi Freedom. He is a recipient of numerous military awards, including the Distinguished Service Medal, the Bronze Star with one bronze oak leaf cluster, and the Meritorious Service Medal with three bronze oak leaf clusters. Under Secretary Quinn earned a Bachelor's Degree in Electrical Engineering from Montana State University, a Master in Business Administration from the University of Montana, and a Master of Strategic Studies from the U.S. Army War College. Please join me in a warm welcome for Under Secretary Matt Quinn. We also are pleased to have with us today Dr. Sharif El Nahal, VA's new Under Secretary for Health, who was sworn in just a couple of weeks ago after having been nominated by President Biden and confirmed by the United States Senate. Dr. El Nahal is a physician leader who has a range of experience working in both the public and private sector, including two stints at VA. Most recently, he served as President and Chief Executive Officer of University Hospital in Newark, New Jersey. He previously served as New Jersey's 21st Health Commissioner. Dr. El Nahal's federal service includes two years as Assistant Deputy Under Secretary for Health, Quality, Safety, and Value, and a year as a White House Fellow in the VA. During that time, he co-founded the VHA Innovation Ecosystem, a program that continues to foster the spread of innovation and best practices to improve Veteran care across the nation. Dr. El Nahal holds an MD from Harvard Medical School and an MBA with distinction from Harvard Business School. Please join me in extending a warm welcome to new VA Under Secretary for Health, Dr. Sharif El Nahal. Very pleased that we are joined by the Acting Head of VBA, Joshua Jacobs, who also assumed his position within the last two weeks. Josh Jacobs serves as a Senior Advisor for policy performing the Delegable Duties of the Under Secretary for Benefits. In this role, he leads more than 25,000 VBA employees and 56 regional offices to deliver nearly 135 billion in VA benefits to almost 6 million Veterans and their survivors. Josh previously served two stints as a Senior Advisor in the Office of the Secretary, most recently focused on the designing and implementing new structure and processes for enterprise governance and policy development. In 2016, he was awarded the Secretary's Meritorious Service Award. Prior to joining VA in 2021, Josh was a Senior Associate at Booz Allen Hamilton. Josh also served nine years in the U.S. Senate, including two years as a Deputy Staff Director for the Senate Veterans Affairs Committee, where he often worked closely with Joy and other members of our legislative team to develop and act and oversee legislation to strengthen Veterans health care and benefit programs. Please join me in warming a warm welcome to the new Acting Head of VBA, but an old friend of DAV, Josh Jacobs. Before we get to questions, we wanted to give each of our guests the opportunity to share some opening thoughts, what is happening in their respective administrations and their plans for the future. Let's begin with the most senior member of our Distinguished Trio, NCA's Under Secretary, Matt Quinn. Thank you. Well, what was left off of the bio is lifetime member of DAV. I want to make sure. Listen, I've been on the position just over a year. I came into this, as was mentioned, from the Montana National Guard, really not knowing the mission of National Cemetery Administration, not knowing the breadth of what the teammates that I have the honor to serve with do. But they are committed to the veterans so that we honor the service of our veterans, but likewise committed to the family members as we recognize the sacrifice that those family members gave. I like to tell our teammates within NCA, we are that final benefit. We have that final opportunity to thank that veteran for their service and to thank that family member for that veteran service. That's the last time we as a nation will be able to provide the true honors that that veteran deserves for her or his service. So it's so critically important that we work with you all to make sure that our team members know that mission, what we can do better and how we can better support you all. We have a great goal within NCA. 95 percent of veterans should have a national or a state tribal territorial grant cemetery within 75 miles. That's our mission. That's our goal. We are right now at about 93.7 percent and I think probably some of the questions will hit on this. But we need your all support in ensuring veterans know that this is a benefit that they have received to their service and that family members know that when it's time to provide that final honor to the veteran that they should at least consider the National Cemetery Administration. So thanks for joining us here today. Super proud to be with you and thanks for your all service and your all sacrifice. Thank you. Next some opening comments from Dr. El-Nahal. Thank you so much Joy and I want to thank Commander Marshall and DAV leadership for the gracious invitation and I want to thank all of you most importantly for the daily work you do for your colleagues, veterans, people who've served this country honorably. The way I view my job in this role is to do the work for them in every way that I can. I have not served myself under unlike under Secretary Quinn but let me just go through a couple things in my life in my history that brought me close to people who served this country and to veterans. Among my first clinical experiences in medical school was in the West Roxbury VA in fact it was I think my first emergency room rotation and I met a veteran from Connecticut who drove over an hour with crushing chest pain just to get to that emergency room and so of course after we stabilized him we knew he was having a heart attack he knew he was having a heart attack we asked him you know why did you drive all this way here instead of going to that emergency room five minutes away from where you live and he said I would not trust my care with anybody else this is my hospital there are veterans like me here and these are the folks who know what I need every single day and so I knew that I would try to work for organizations for the rest of my life that did that for people and had a mission that was that important. Fast forward through my education the 2014 access crisis happened and I decided to try to raise my hand and volunteer what I knew in medicine what I knew in access to health care to try and help and so I applied to the White House Fellowship joined the VA team and spent what I didn't know ultimately would be almost three years working my hardest to serve the folks at medical centers clinics across the country serving veterans every day. I learned in other words how to be a leader in VA right after my medical training that was my most formative experience in learning what I could do for people at that level. Fast forward even more to my experience running a level one trauma center in Newark New Jersey served a town of 300,000 people including EMS services and then a global pandemic happened less than six months after I started at that hospital. We were struggling our staff was out due to COVID themselves almost every bed in my hospital was filled with somebody with this deadly disease and at that time we were desperate for help and then who and other than the US Army reservists a group of folks from across the country came to my hospital side-by-side with my clinicians integrated with our team to serve our patients. They not only came once but they came twice in the most recent Omicron surge this past January this time active-duty Army clinicians and so of course I always had an appreciation for what folks who wear the uniform do for us but no longer was that appreciation abstract or theoretical I was seeing these heroes side-by-side with us dealing again with the worst public health crisis we had ever seen. And so my appreciation isn't just because you all sacrificed for us it's personal when the president nominated me for this position that was my way of helping to pay back folks that I knew came to my need when our community needed it and I got to appreciate what folks like you have done across the entire world to keep us safe. I couldn't be more honoured to be here thank you so much for the invitation. Opening comments from VBA's acting undersecretary. Great thanks very much Jim thank you Joy and thank you everyone for the warm welcome I have to say having sat and listened to this morning session I feel incredibly energized. The scope and the breadth of the services and the support that you provide to veterans and families is is really tremendous and it's also a reminder of the obligation that each of us has along with our colleagues to deliver on the promises of a grateful nation. I know that we haven't always lived up to that promise but I know that there is a commitment and a will to do so and I know together we can do that successfully. I know that each and every one of you as well as your colleagues and friends who aren't here with us today do tremendous work day in and day out supporting the veterans, families, caregivers and survivors who've contributed to the greatness of this nation and I know that your team in DC, Jim, Joy, Randy have done an incredible job leading the charge to make improvements to the policies and the support and the funding that we need to do our job on behalf of each and every one of you and it's with that collective effort that we are on Wednesday going to be able to go celebrate the passage and the implementation with the signature of the President for the PACT Act. So I want to say a big thanks to each and every one of you for doing that. Now the hard part we may we may all realize is not what it took to get to this point and that was hard. The hard part is going to be in actually implementing the bill and delivering on that promise and I know that we need to work hand in hand with each of you to provide transparent communications about what we're doing to work collaboratively when we're off track and I know Randy, Jim, Joy, I've known Joy since 2007. I know she doesn't mince words she doesn't hold back and she tells us when we're doing something right and I know each and every one of you will tell us when we're not doing what we need to be doing. I can promise you we are going to do our best. We're going to step up to the challenge because we're excited for the opportunity to provide more access and improve outcomes for everyone this this bill will benefit but it's not going to be easy and while much of the attention that we're going to face is going to be focused on the bill. We have a whole host of other business lines that we need to deliver on whether it's insurance, our GI Bill and education programs, our home loans and many other things and so I am really looking forward two weeks in to continuing to work with each and every one of you as we work to fulfill the mission of this great nation and so I very much appreciate the opportunity to be here and looking forward to the discussion. Thank you. All right so we'll get the conversation started and we first want to talk about the continuing impact of COVID-19 the pandemic and how it's affected every part of VA and we'll start with Mr. Quinn. It's been two and a half years since the onset of the pandemic there's certainly been many improvements and obstacles that have been overcome but COVID still continues to impact VA in some degree. What were your biggest COVID impacts that NCA had to overcome during the past couple years? Are there still any COVID restrictions remaining for national cemeteries and burials and what COVID related issues remain for NCA going forward? Yeah I listen great question so like most of the nation when COVID hit we weren't sure the impact that it was going to have on our national cemeteries so there was a three month period in which we weren't doing direct internment services for our veterans that bothered our crew greatly but we had to be sure that when we brought veterans or family members to our cemeteries to do an internment that we were doing that safely and so we did stop direct internment services and ask families if they would like to do an honor ceremony at a further date when we knew more than we would we would open that up to them. We are starting to see the impact we believe from COVID in terms of our internment rates so 2021 one of the largest years for the number of internments we've done in our national cemeteries 2022 is on pace to at least meet if not exceed the number of internments at our national cemeteries across this nation and so we continue to watch that closely. We've seen the type of internments change from coffin casket based internments to more cremations as we look across and those there are different pockets where we're seeing more cremations in some areas two-thirds of our internments are cremations and one-third cascaded in other areas I was up in Jacksonville yesterday there's still about 50 percent casket 50 percent cremation and so we continue to watch those trends as we look at new cemeteries or as we expand existing cemeteries on how to continue to best serve veterans. We did have two of our national cemeteries which kind of ran into a bind where services were taken longer roughly about six weeks longer than than what we want them to take we added additional staffing at those two cemeteries and brought in some extra services to some temporary committal shelters so we could get that back on track. Our goal is two weeks from the time a family calls and a lot of that is dependent upon the family scheduling when the family's looking to do it some families may want to wait until they can gather the family together we'll certainly take that into account so I think NCA is back on track where we need to be with our families and our veterans and hopefully you all as you are out at our national cemeteries or at any one of the state grant cemeteries are seeing NCA back in the fold serving veterans serving family members as you all expect and as we expect we should do. Excellent. Do you guys have any plans to further reduce wait times and one of the questions we get from our membership quite often is would NCA consider allowing weekend burials to reduce those wait times? Yes. That's something to be and talked about. So we have we actually did a model before I came on board looking at a Saturday internment and we did that for about 18 months there was some uptake on it but but not a lot of demand that would justify us having so we would have to shift our workers into a maybe Tuesday through Saturday as opposed to Monday through Friday so as we evaluated those sites that did a Saturday internment it really came back to families wanted that Monday through Friday for the most part we will do a special occasion if there needs to be if we have a KIA return that asked for a Saturday internment for religious purposes or other needs will adjust a schedule but for the most part I think what's working best for the veterans and families and if that's not true I need to hear it but it continues to be a Monday through Friday schedule. All right. Excellent. Thank you very much. Let's turn to VA Joy. Dr. Ellen Hall we know that VA spring into action especially on the health care side as soon as covid began and even before we were getting some you know word and information from VHA clearly you know you should be commended for the way VA reacted making sure that veterans I mean there were lots of restrictions but keeping veterans informed about what they needed to do to be able to get medications how they could be seen in mental health how they could you know get what they needed to get vaccines when that was available. So are there any you know things are sort of starting to turn return to somewhat of a normal what restrictions are remaining in VA facilities and given you know the new variants that are circulating I'm sure everyone's concerned again you know where we're going with this and then what is the status of any backlog of medical appointments that were created because we know you know a lot of people just now are being able to go back in and kind of take care of some things they needed to do in person. Yeah thanks Joy really important questions and it's really been a journey not only for VA but really for the entire American health care system since the pandemic started and so always in my mind will be the balance of number one keeping our veterans families caregivers and survivors if they're in our facilities safe our employees who serve them safe but also maximizing to the extent that it's safe the ability for you to interact with your veterans when they're in our facilities and especially that tension comes with nursing homes and community living centers we still do hear a lot of complaints about accessibility in certain parts of the country knowing that a lot of these restrictions are in place that the among the most vulnerable veterans don't get sick with this disease and while the variants have come and gone it is still a very severe virus when it comes to folks especially in nursing homes and so that balance is never going to be perfect but know that we have excellent people on the infectious disease side geriatrics and extended care and really national experts and what they do deciding where we go on restrictions versus not knowing that the compassion that all of you want to see when you're in and when you have family members and loved ones and it's something that we're considering every day I will say that the overall trajectory of the pandemic is still uncertain we don't know what's going to happen after the dominant variant now which is be a five there's already a new variant that's starting to take hold it's a subset of be a four we're going to see how that goes but we're in a situation now where the vaccines that initially came out are becoming less and less effective as the virus mutates and changes and so there are vaccines on the horizon that will help protect against this virus better and hopefully in the coming months so we're excited to see that we're going to offer that to our employees and veterans across the country I think moving forward again we are going to make sure that every single new therapy and innovation is available to our veterans that'll be my job to fight for stockpiles for example of new vaccines new therapeutics and make sure that that's available to you so that when you're advocating in your parts of the country for your veterans you make sure they're getting what they need what they need and so that feedback to us will be extremely important what do you think the long-term impact will be of the on the pandemic and flu scene just the future models of care I mean we know there was a lot of use of telehealth which was just a godsend to be able to at least communicate face-to-face but what do you are you seeing any trends you know at this point where now there's going to be this major change in how health care is delivered just across the country yeah so we were doing the majority of health care in person we were doing more telehealth than the private sector for example before the pandemic started but we were still doing the vast majority of appointments in person then the pandemic started and all the investments VA has made in telehealth over the years kicked in and almost every clinic appointment was done via telehealth for quite some time and so that was an explosion and the use of that technology which I think not only benefited our employees and being more facile with it our doctors or nurses the folks who see veterans every day but it I think made veterans more and more comfortable using the technology because frankly there was no other choice for a little while now we're in the situation where we have to figure out what the role of telehealth is versus in person appointments and I think the answer number one is a mix so no one's going to tell you that we're going to go full bore on one and then never do the other that's that's the wrong move but also just to view telehealth as yet another tool in your doctors and nurses tool belts to deliver the care you need so for most veterans it's going to be a mix and that mix is going to depend exactly on what that veteran is facing the diseases that they have the problems that they're facing and even for mental health where you can do a lot of appointments safely and effectively through telehealth our mental health clinicians say there's often information you can get in person one on one with that veteran that may not be as possible if you're beaming into their home with other people around etc so I think that all has to be personalized and tailored to what that veteran needs and it's our job to design our programs and equip our frontline docs and nurses and care teams with that technology and so I think you're going to see a leveling off of telehealth much more than we were doing before the pandemic but still less than the peak of the pandemic when in person appointments weren't as available one last question on that you know early on there were a lot of challenges with for everyone you know supply chain issues which still linger linger on but what were the lessons learned for VHA you know you know fear again a bit of a different thing where you know is VA gonna do something specific with regard to that making sure that they have the supplies that they need directly without having to rely on you know things coming from across the world so our again frontline folks who are seeing veterans in very very desperate situations during the pandemic that situation came close to not having what the PPE that they needed to safely do their jobs based on all of the problems with the supply chain that were happening globally but for the most part VA kept up way better than the civilian sector in terms of health care in getting the supplies they needed to the field and to medical centers and clinics what I can tell you is that since the begin the pandemic began a lot of new programming was put in place to reduce that risk going forward number one the stockpiles of PPE in every hospital and clinic there's now 90 to 120 days worth of anything someone might need to serve a veteran safely that did not exist before we were in this quote-unquote just-in-time system for these critical medical supplies no longer so that's one piece of reassurance the second is the development of these things called regional readiness centers where we actually have backup stockpiles of PPE that can be used by our employees and veterans in strategic locations across the country so that if this or that ended up being close to running out we can deliver those supplies safely and effectively to those hospitals I think this is being done and this is before I got here by the way so it's not a pat on my own back better in VA than almost anywhere else that said you can never be too lax about this because you don't know what that next medical supply is there was a chance that we would run out of liquid oxygen at certain points testing supplies really critical things so we're always thinking about this our supply chain folks are constantly working to make sure that that does not happen thank you great news Jim I'll turn it back to you thanks Joy this question's for acting under Secretary Jacobs VBA was also significantly impacted during the COVID pandemic and particularly by the need to maintain social distancing early on that disrupted the ability of veterans to receive disability compensation exams in addition to disruption to operations at the National Personnel Record Center and St. Louis significantly delayed VA's ability to develop claims and thus extended wait times for veterans has VBA overcome these and other COVID related challenges and what actions are being taken or need to be taken to overcome continuing disruptions and impacts from the pandemic yeah I think VBA like our partners and VHA and NCA were significantly impacted by the pandemic you mentioned the National Personnel Record Center they they effectively had to shut down for some time or in unable to obtain the records that we need to use as part of the claims process what we were able to do with the help of VHA was to vaccinate a number of those employees and we also put our VBA staff on the ground to help get records moved out so whether we needed it for a claim for a burial we were able to help do that we've also been working to scan a lot of those records so we don't have the same reliance on the paper based system so that as we look to a potential future scenarios we have a backup plan that increases the optimization of the process I would say the other major impact was the medical examination process and certainly when we're trying to social distance and maintain safety doesn't feel right to send a veteran to go get a physical exam if it's not critical and so in some cases we're able to eliminate the need for that by finding evidence that existed in the file in other cases we just delayed the decision and so what we've been having to do is work through those claims I would say we recently had a milestone our backlog went below 170,000 for the first time in two years which is which is a big deal and it's thanks to a lot of hard work but it's still too high and so what we're doing is really a workload management issue it's trying to balance the need for getting the oldest claims first while also managing to tackle those that are ready so we can get and we can optimize the speed at which a veteran can get their high quality claim. So prior to the pandemic VBA a good portion of the workforce did telework prior to the pandemic what lessons did VBA learn during the pandemic about remote work the past two and a half years and what do you foresee as the future balance of remote and in-person work for VBA yeah I would say with big thanks to Tom Murphy who is my predecessor and is now a is back in his full-time job as the as a district director for the northeastern section we were able to navigate quite well and I think the major lesson that we learned is we can do a good job in a remote posture and so we were able to kind of manage notwithstanding the challenges that I just mentioned and and I think that the major lesson for us as we look forward is there has to be a right balance and so right now we are bringing people back to the office and as part of the broader OPM policy that requires staff to be in the office two days per pay period but we're trying to navigate a balance of meeting employees where they are some want to be back full-time some don't want to come back to the office at all and really what we need to do is to look at the numbers to understand what are our production numbers what are our quality numbers and then what is that due to the culture and I think we're still working that out we're working through a couple of a virtual regional office pilots where we're going to be testing fully virtual capabilities and very focused areas and so I think as we're moving forward we're going to take an evidence-based approach to assess how we might explore kind of optimizing more virtual work but all the while maintaining a public facing presence because we need to have people boots on the ground who can engage with veterans who want to come in who need help we also know that DAV and our other VSO partners are on the ground in our regional office buildings and we want to make sure that there are people there as well and so we're still working through all of this like much of the rest of the world and so I would say there's more to come I mean that's great news to hear that all of your public contact offices are open and operational for five days a week Monday through Friday correct that's my understanding yep outstanding thank you very much joy so Dr. El-Nahal before I ask some tough questions about VHA vacancies I think I could speak for our membership here that we all really appreciate all of the for the all the clinical staff in VHA how hard they work the stress that they were under during the pandemic for the last several years many of them you know really coming putting veterans first before their families in some cases and at great risk at great risk their personal health so we do we do really appreciate that but we know that there were staffing shortages you know even before the the pandemic and we can only imagine the the pressure on staff you know to retire perhaps to leave and we we're worrying about these vacancies can you talk about how VHA's workforce has been impacted by that what you are doing to recruit retain and you know attract new high qualified you know clinical people to work at VHA so if there's an issue that keeps me up at night the most on week two it's this one I part of my job is to come to these conventions and be totally honest and as transparent as I can be about these issues that said the entire American health care system is facing worker shortages now and my job is to make that problem less and less impacting the care that our veterans get every day I will say that our staff know better than anybody else the folks in the field the medical centers clinics the vet centers know that we have the best patients in the world and they did not leave at rates that other health care workers left in different parts of the health care system because they know that especially during the worst parts of the pandemic toward the beginning people got tired though I mean this was something that required the a and hospitals across the country to make people work multiple shifts in a row dealing with a virus that we didn't know at that much about putting their own selves and lives at risk and so because of those dynamics there's a lot of folks who are near retirement even mid-career who decided to say listen you know the worst part of this is over I have to retire so that's one dynamic that we're seeing and in fact these are the folks with the most experience and are onboarding new nurses clinicians every day to lose them at the rates that we did was really tough on top of that with all the dynamics of the economy the pressures on pay went up through the roof for VA to be competitive to be able to pay these extremely talented hard working people competitive rates compared to our colleagues in the private sector that got harder and harder and so the secretary took note of this and worked with all of you worked with the SO's worked with his partners in Congress to pass the raise act which helped bump wages up significantly for clinicians across the field so that has helped in addition to that with the passage of the packed act that is giving us even more authorities to be able to bring on staff of all different kinds not just clinicians but environmental service workers folks who keep hospitals and clinics moving extremely important folks that make sure at the end of the day the veteran gets what they need we will have even more tools in our tool belt to be able to do that better there's a lot of really great things in the packed act that aren't as public but will help the gears of VA work better and better and that's one of them what I pledge to do is make sure that VA and by the way our amazing staff across the country are already trying to do this it's my job to make it even easier and amplify those efforts needs to be at every recruiting event in the country for health care needs to be in front of every professional society in the country that has anything to do with hospitals clinics and health care and mental health we have to be there and prove to folks that we are a great place to work and even more importantly we have to focus on retaining the incredible people we already have so that has everything to do with managing this concept called burnout again folks getting tired folks getting stressed in the field throughout the pandemic and we do that not only by providing spaces and time for people to be whole which is what we encourage all of our employees to do spend time with your loved ones do the things that make you human make sure that when you're not at work you're doing everything you need to do to refresh yourself so that you can give it all for your veterans when you come back but what can I do from my perch and what can every leader do in VA to break down the barriers for them to be able to do their job faster and better just one example our schedulers right now when they're at the network level with a bunch of hospitals have to have four or five different scheduling grids up on the same computer screen to be able to navigate the same question that a veteran calls and asks when can I get the soonest appointment for mental health or GI appointment or whatever it might be the number of clicks they have to do the number of steps they have to take to do something so simple unless I'm actually understanding what that experience is like and unless I am obsessed with how long it's taking for them to do the right thing by our veterans the longer it will take to solve these problems and so that's how I've approached leadership my whole career go to the front line understand what these folks need to do to serve that's better and then rework everything we can and fix the systems around them to do that better and that's gonna be my pledge to all of you thank you well I think our members will definitely appreciate that and one of the internal things we constantly hear is also about the HR issues that you know people that want to serve come into VA and work for VA you know that there's still this big leg time and you know they can't wait for all the you know leg time that occurs through HR so hopefully you'll be working on HR issues as well to kind of clear the path for those folks that you're trying to bring into VA we'll turn now to what's become one of the biggest issues for veterans VA and Congress no no doubt burn pit toxic exposures and the PACT Act so Jim I think you're gonna start with some questions for VBA yep thanks Joy what a week for the passage huge win for veterans or families and survivors with the president signs into law hopefully on Wednesday all the responsibilities ships from Congress now to VA yeah so we want to really hear from VBA on how you've been preparing how do you how do you think you're gonna be able to implement the PACT Act whether you will need additional funding resources staffing legal authorities in order to manage a new workload while continuing to reduce the backlog yeah we just talked about the backlog and now you're gonna have this huge influx yeah new claims yeah it's great great question and it's one we've been working on for for some time so when the president came into office secretary McDonough came into office there was a very concerted effort to more proactively intentionally and collaboratively tackle issues related to toxic exposures and so part of the way that we did that it was by elevating this you mentioned my work on the governance structure so being intentional about bringing the whole of VA putting forward questions and then driving implementation and holding people accountable we work to expand the type of research that we consider as we as we explore issues related to exposures and we also came out with 12 new presumptive service connections so asthma rhinitis sinusitis as well as nine rare respiratory cancers so there's been a lot of work improving the collaboration between the folks who are experts in the claims process in VBA and the experts on military environmental exposures that work in VHA with Dr. Elnohal I would say with respect to the PACT Act specifically there has been a lot of internal planning going on you know the organization you know VA is you know 400,000 plus people it's a big ship to turn it takes a lot and so we've been working very intentionally to close the gaps and break down the silos so that we understand as we project the number of claims the types of claims we're going to get what that means for VHA and working to try to get that as granular as possible so that he can plan for and resource appropriately the medical centers that are going to realize an increased utilization or new enrollments in VBA specifically we've been working on a whole series of people process and technology efforts so we've been working to hire 2000 plus new claims processors to tackle the new the expected increased inventory and we're working to hire more the challenge with that of course is that many of the hires that we make are internal promotion so we have people working in our contact centers and then they interview and get hired to be a VSR so that creates a different opening that we then need to feel but we're working to do both that as well as the important training so our staff need to understand what the new requirements are so that they can do the right work and we don't have to redo it on the on the process piece we're looking at ways that we can optimize the process so looking at you know unnecessary additional evidence gathering and ways to cut down the amount of time that it takes for the evidence portion of the evidence cycle or for you know ready for rating cycles we've got a whole team working through all of that and then our own Rob Reynolds is doing really incredible work on automation so looking as we now have I think 20 conditions that have gone through development and we're working to to rate those claims through a new automated process that still preserves a person reviewing and making the ultimate decision but really optimizing the technology and the data that we have to drive a much more efficient process that brings about benefits more quickly for the veteran and then finally what I would add is communication this is a very big bill with a lot of different parts to it and as written it includes different implementation timelines so we talked about the different implementation timelines on VHA for eligibility there are also different implementation timelines for the various conditions that will soon become presumptively service-connected and so working to communicate what all that means to reduce the confusion and also to preemptively understand that there are going to be predatory actors out there who don't have the same altruistic approach that DAV does to do what's right for the veteran family member on the survivor but view this as a paycheck and so trying to make sure that we're partnering with DAV we're partnering with the states we're partnering with other VSOs and finding those people who aren't affiliated so that they know how to go about getting that information we have a website va.gov slash packed where we have a lot of the information and questions available for anyone who wants to know we also are going to be pushing people to go to 1-800-MY-VA-411 and so I think it's going to be incumbent upon all of us as we move forward to be very diligent very disciplined about pushing out a proactive message finding veterans and family members where they are and making sure that they know we want them to apply for benefits we want them to come in for health care and to let them know how to do that the communication piece you talked about it's great news to hear for us and our members I mean I think for those that have previous denied claims for some of these issues things like that the more information that can be provided to them the better I also appreciate you mentioning the predatory claims companies I'm sure a lot of our members have seen commercials and getting emails about Camp Lejeune toxic water and you have to be very very careful when you get those and make sure you're talking to your advocate your DAV NSO to make sure that's the best route for you to take versus found a claim at VA because any benefits you get from those you're going to be responsible to pay those back if you're getting VA benefits as well so you have to be very careful in those scenarios I appreciate you mentioning that I know you've been very involved in VA's work to develop its own internal model and decision-making process for adding new presumptive conditions as well related to burn pit and toxic exposures can you provide an update on the model and talk about what impact the enactment of the pact act will have on it yeah well thank you one of the things that we've been doing since coming in in February of January of 2021 is working to develop a new approach to evaluating and considering when and how to establish new presumptive service connected disabilities I think it's been fraught it's been a challenge over over many many years and so we're working to try to lower the threshold by which we have to establish evidence necessary to make that connection we have developed a model that is was used to help drive the decision for some of the earlier presumptive service connections I mentioned and it's being evaluated at the moment by the office of science science and technology policy within the White House but as part of the pact act there is a requirement that we have this new approach reviewed and validated by NASA the National Association of Science Engineering and Medicine and so by law we will once the bill is signed we'll have to work with them to evaluate whether the model we have developed is is sufficient before that point though we're gonna have to work to collaborate with DAV with other VSOs to make sure that you understand the approach we get the feedback and that we make adjustments where and when appropriate one of the benefits of the pact act is among many other things is we had a number of conditions we were proactively working on so constrictive bronchiolitis working on lung cancers on brain cancers we were working to try to drive those through the process well those are going to be part of the pact act so what's going to happen next as part of this new model is we're going to need to develop a list of conditions that we need to run through it so we're going to have to work through the substance of what the model is and how it makes decisions and then we're going to need to develop the list of conditions that we then run through that model and there's a requirement within the law that we need to push that through the federal register we need to publish it we need to solicit public comment and so we'll be coming back as part of that process and having the conversation with with you with Randy with others to make sure that we're looking at the right conditions and and explain in the logic for why we are or are not looking at those conditions. We're excited about the collaboration for sure so thank you. Turning to the health care provision of the pact act I know Joy has a few questions for VHA. Yep Dr. Eleanor Hall back to you. The pact act will expand health care eligibility over the coming years for millions of veterans exposed to burn pits and other toxic substances including age and orange. Could you talk a little bit about how VHA is preparing to deliver that care to newly eligible veterans and do you think this is going to really be a big impact on you know staffing? Are you going to need additional resources to meet the needs of these veterans? So I'll start Joy by just expressing how much of a privilege it is to be entering the organization right when the biggest expansion of veterans benefits is going to take place in a generation. That in of itself is such an incredible thing and so you know it's going to be my job and concert with my colleagues on stage to implement that and VHA is doing what it can but I'll also say that the collaboration that we're going to need very close collaboration with VBA in the preparation but also the execution is extremely extremely important. So first of all the law requires us to screen start screening folks within that 90 day period after it goes into effect for toxic exposures. So that's going to be something our doctors and clinicians have to do at the point of care and it's a requirement by law so we have to execute it and the way we're going to approach that is basically through clinical alerts. Now this is not going to be perfect in the beginning but I can tell you so much planning again well before I got here has been in place to try to get that going so that veterans are being asked the question proactively. We're not going to wait for your members to call us and say I had this exposure I might be eligible for benefits. We should be getting that from you when you enter our clinics and hospitals. That was congressional intent that's the president's intent we're going to be reaching out and trying to get as many folks in when they're eligible as possible so that's one way of doing it. The second is this concept that we're talking about now of no wrong door right so nothing's more demoralizing when you call someone for service and say no that's the wrong part of the organization click right you know that should never happen especially while we're again about to do something incredible for hundreds of thousands of veterans newly eligible but folks who already come into our walls who are now going to increase their reliance on us for care. And so that has everything to do with the mechanics of things like phone trees when folks call the number they know to get VA and they're curious about this is there an easy way for them to route up to you know the benefits organization folks to understand what they're eligible for all of that is being built in right now to the different ways that we interact with veterans and the veteran experience office is really helping with that too because they again they they really do nothing but try to understand what the experience of veterans are at the end of the chain with what we're doing so that's another thing that we're trying to do importantly we're also we also need to make sure that as we continue to try to improve access and as we continue to try to get more appointments available more services available to the vets that we already have there's gonna be a lot more vets who need us after this legislation and so I have to do everything I can with our data modelers the modelers and mr. Jacobs organization DOD other parts of the government that have all the data that we might need for where these vets are and their likelihood of calling us to get service that we give all that information we can to our medical center directors and clinic directors on the ground so that they can start planning for what's needed into the future who do I need to hire what services do I need to build what community partners do we need to engage now to say hey we're gonna get these folks with these conditions coming in what do they need so all that planning is happening and we're gonna have to implement very soon so you know again oversight on this and my focus on this will really be important thank you well we certainly hope that you'll continue the tradition of being a good partner with DAV and the other veterans service organizations and making sure that we're informed right up front so that we can share that information through our different pathways you know we have a DAV magazine that reaches over a million you know plus veterans social media channels and all other ways and we want to make sure we help get the word out and pass the message along so veterans know what they're eligible for and how they can access their benefits under Secretary Quinn although the PACT act doesn't have you know it's such a direct impact on NCA nonetheless it will increase the number of veterans eligible for burial benefits has NCA considered what the impact of the PACT act will have on its operations in your workload and do you foresee a need for any additional resources or legislative authorities that might be necessary yeah I enjoyed great question again and I'll tell you we have been a part of that entire planning process within BA as we've looked at the PACT act coming on board and final passage frankly as we look at it it's very clear that the the heft of the work will be within VHA and VBA truly our hope would be that our workload goes down due to our veterans who have been exposed to toxins and and burn pits actually are getting the care that they should get so we'll continue to watch this more eligible veterans certainly we'll play out over time for NCA we'll plan for that we'll watch Jim's previous question about the wait times for internment services but again I think the two gentlemen on my left and right are the ones who will be carrying the load for BA on the PACT act passage great I know you mentioned in your opening comments that NCA has established the goal of providing 95 percent of veterans with access a burial option within the 75 miles of their home and I know you talked a little bit about you know where you are on that but I just want to re-emphasize you know for those really rural and remote areas what are the challenges that you have doing that and what are what are your you know initiatives that you might have in place yeah so I'll tell you you know 93.7 percent that last 6 percent will be a that would be the tough mile to get because of of rural areas but here last week I was up in Alaska we opened a tribal veteran cemetery Metlacatla cemetery up there that that will provide access to tribal veterans in that area previously in Oklahoma where Oklahoma opened their first state grant cemetery that'll give a great access to veterans in the Oklahoma area that that are in that region so we continue to work with our partners both at the tribal as city state area as well as territories through our grant program and the grant program we will provide the grant for them to construct the cemetery they're responsible for the O&M but that's how we're going to reach the bulk of our veterans we've got two programs within NCA both our urban initiative and our rural initiative a rural initiative is ongoing and it will be establishing of national cemeteries and states in which there is not currently a national cemetery the urban initiative is to provide a columbarium option where land is tough to get it'd be very difficult to do a national cemetery with with full cascaded burial options but our urban initiative is to provide a columbarium in an area where veterans have maybe a closed cemetery here a couple weeks back I was in Indianapolis and the cemetery that we had closed 63 years ago we were able to work with the local cemetery there where we have a veteran cemetery as well and open a columbarium only option there and so that gave veterans of the Indianapolis area again a burial option for those who are willing to do the columbarium option so all of those programs are how we will continue to provide that access to our veterans but I can't stress enough how important the partnership with the states and with the tribal governments will be to reach those areas where the federal government is just not able to reach specifically and so we'll continue to work for those options with states tribes and territories out there to to reach all veterans and again get to that cemetery within 75 miles for a national shrine that the veteran deserves thank you Jim thanks Joy acting under Secretary Jacobs we talked about the backlog and it's great that you it's below 170 for the first time in two years I believe it was but does VBA anticipate increasing overtime or contracting out any part of the claims process to help bring down that backlog yeah we're currently we've taken a pause in mandatory overtime for a couple of months but we are expecting to resume that very soon here I believe at the end of the month beginning of September I think mandatory overtime has certainly been essential in our ability to tackle the inventory and I think what you've seen is a significant increase in the number of claims decided but we keep getting more and more claims which is a good thing and so we want to encourage that but I do anticipate you know mandatory overtime resuming but I think again it gets back to a lot of the people process technology we need that we need more overtime we need to hire more people we need to optimize the process so that we eliminate inefficiencies that are unnecessary to reduce the time and then we need the benefit of automation so that we can do so as well I do want to talk about automation but before that I mean when should veterans expect to see significant progress in reducing the time it takes to process their claims and I and just for the audience a backlog claim is a claim that's been pending for over 125 days that's how that's characterized so just curious if you have any thoughts on you know when veterans should expect to see some increase and I know that's a tough question especially with the PACDAC and we we realize there's gonna be an influx of claims coming in yeah what I would say is the average days pending for a claim are right around that 125 number but what you'll see is the average days to complete are a little bit longer and with the number of potential claims that we're anticipating coming as a result of the PACDAC I anticipate the inventory and the backlog will increase and I think what we're doing is we've got our our foot on on the gas trying to get ready so you know between now and January we're writing all the regulations we're working more on the additional conditions to include through automation we're changing the internal processes the IT system changes the flashes so that our staff are ready on January 1 to start processing claims associated with the PACDAC but I think one of the the challenges we're going to face is getting to the point of communication is we will likely see challenges with timeliness because of the just the sheer size of the volume and so what we're going to do is we're going to work to prioritize the claims that are kind of most timely so based on you know whether you know we've got claims from someone who's homeless someone who's experiencing financial hardship someone you know who's over 85 you know a variety of different categories and so the the timeline is still we're working through the calculations but I think it's probably going to take several years for us to try to get back to normal once we expect all of these claims coming in and again we we haven't talked about hypertension but you know hypertension we're expecting quite a few claims and so as we look at the timeline associated with implementation for the PACDAC there are some process implications for for following that timeline so we're working internally to try to figure out how we can how we can explore the the potential to optimize how we get claims as quickly as possible well that's great news I mean and we're a big supporter of submitting electronic claims and we want to be able to do those as quickly as possible and get them to you as quickly as possible with all the all the accurate information as well in regards to automation can you tell us a little bit about what that means what automation really is that that Rob Reynolds is working on and how much of an impact do you anticipate that helping with the claims process yeah so big thanks to Rob here who's been doing just an incredible job what we're we're looking at doing is figuring out how to take the information we have pull it into the system so that it makes it easy for the the raider to then have everything he or she needs to make a decision so rather than going through all of the files and and trying to trying to find the sufficient evidence and the records that they need it's pulling it's extracting all of that so we pull it in from from the claims input from the dbq from other sources and then we have it very simply and concisely available so that you can then go and just say do you meet all the requirements yes okay we're going to grant it if not what we then do is we don't deny it as we move it to a secondary review so that there is an ability to to take a closer look and make sure we're not missing something and so we're still in the early stages i'm optimistic about the potential but i'm also pessimistic and that i want to see it proven before we start telling you uh what the impact is i will tell you that uh were it not for the progress we made with vbms and moving from an entirely paper-based system to an electronic one we would not have been able to manage through the last two years of the pandemic and i anticipate as rob and his team continue to get more conditions in uh through the automation development process we're going to see similar benefits both those that were anticipating in terms of lifting the total number of claims we can produce and the time in which to do that but i would say probably some additional benefits that we're not anticipating as well yeah i think a lot of people assume that when we're talking about automation the decisions can be made by a computer and no one's looking at it and so it's great for everyone to understand that there will always be a person reviewing that decision especially when it's a denied decision someone has to physically look at it to make sure it is accurate in the words with the law yeah the the other thing i would add is that sometimes when you talk about automation people who are working in that field think that means their job is going away and nothing could be further from the truth we need more people i mean the number of potential claims we're estimating from the PACT Act alone is gonna it's gonna keep us very very busy for a very long time and people are excited about that but we want to make sure we can do more for more people and so this is one way that we're attempting to do so so talking more about it monetization when we talk about automation that's obviously a key element of managing the the significant workload vba has and preventing future backlogs um what are vba's plans for sunsetting and replacing older IT systems such as vbmes and scp and does vba have sufficient resources to modern modernize its critical IT systems yeah well i'll tell you we have a fantastic cio and kurt del bene kurt came to us from microsoft where he was a senior leader there and i actually met him back in 2015 i believe he had left microsoft at the time to go help save healthcare.gov and i was working as a senior advisor in the office of the secretary and went up with uh then under secretary for benefits alison hickey because we were working to launch bbms at the time and we were dealing with a number of outages and so we had a team go up with us and we met with kurt who is uh architecting the save the saving of healthcare.gov to talk about how he approached saving and dealing with the operational issues of that's IT system and then applying it to vbms and so he is now uh in va and helping us think through what does the future of vbms look like as well as our other IT system so we can rationalize um the investments uh to optimize outcomes for veterans so that there is an ongoing review um and uh i don't have an exact date of when that will be done but what i can tell you is we're taking a hard look at what the system should look like and and what the next phase of it will be. i know one of the big enhancements that was made recently to bbms was the bbms notification queue which essentially provides copies of notifications to the representatives electronically you know right away so that's been a significant enhancement so i want to thank you for that it's been a big help to our national service officers to be able to have that information electronically because it was a paper-based system essentially so now we have it electronic it's it's been fantastic so thank you for that absolutely and and my hope is that as we're continuing to look at this next phase that you're a partner with us as we as we consider what changes are are warranted um because at the end of the day we need to optimize the process so it works for the people who use it and that ultimately it increases productivity and it increases quality well we love to hear about more collaboration as you know we talked about that earlier today the more we can collaborate the more we can do together and the and the better we're all going to be able to serve veterans and their families and survivors so thank you yeah under secretary quinn um i'm sure you agree with that that modern updated it systems are equally important for nca uh does nca have any major it modernization projects underway and will there be a need for additional resources to fund those yeah i it's something i'm looking hard at and i'll tell you i look at what vba is able to do with automated claims and and frankly we're not there yet within nca i i uh you know one of the things that that we should probably talk about is uh we have a process for pre-need eligibility so for veterans out there who are looking to make a determination or family members whether that veteran is eligible for interment at a national cemetery we have a pre-need application i know there's forums out on the table out here at at the nca desk but that process is a slow process i i submitted my uh file here uh the other the other month and uh submitted by dd 214 which i had on hand and three months later i got a note back from nca that said congratulations you are eligible for interment at a national cemetery and i just that's too long uh there should be an automated method if vba can make a determination on on a claim eligibility uh within days nca should not take three months to to make a determination so we're going to change that process a little bit we're going to look at how we can automate that process i think hand in hand with vba because there are benefits that individuals may put in for that mirror the eligibility for interment at national cemetery and so i'm in good discussions with vba on how we can partner up not have two silos but have a partnership in which determination for eligibility for interment at national cemetery now i will say at the same time uh that's on the pre-need basis but on the time of need basis when a family or a funeral home calls our call center uh they will put that effort at the front to ensure that we have a determination on eligibility instantaneously near instantaneously so that that family knows and that funeral home knows that veteran is eligible but but the the pre-need is where i think we really need to work scheduling i think we should do a better job scheduling vha does a good job scheduling i think and um we need to to be as easy to schedule an internment service at one of our national cemeteries as well so there are those things that i'm looking hard at i'm bringing on a senior advisor to help me work through the process work through the business process that we currently use do we need to collect the same forms that vba has already may be collected and we're going to get through that and and we're going to make it easier for veterans one to know that they're eligible and two for family members to know that that is an option doesn't obligate them to be interred in national cemetery but that the option is there so i think there are things absolutely that nca needs to be doing and we're getting after it we're getting after it with the help of vba and my friends over at vha all right outstanding and if you ever need any help from dave with support for congress for additional funding or anything please let us know yeah appreciate it thanks you joy dr helen hall the modernization of the electronic health record system is central to the future of vha health care i'm sure you you know that um but the ongoing rollout of the oracle serner e hr system has had some problems documented by both gao and the va's office of the inspector general so i just wanted to give you an opportunity to perhaps talk to our membership a little bit about that um what was in those reports what vha is going to be doing vha to make you know sure safety remains the number one priority um as that system rolls out well joy i like how you pose the question uh both from the standpoint of the need to modernize our electronic health record because there is a need that example i brought up earlier where you know your veterans are calling to get an appointment trying to find out where they can go for the quickest and best one and then having to bring up four or five medical record scheduling systems to do that has everything to do with the fact that even though our current one vista cprs which is still in most places clinicians love it it's designed for them um and it's a system that they're used to a lot of reasons that it's just not sustainable into the future and so the decision to modernize the hrs is absolutely necessary and so the question is what's happening with this decision and how are we executing it um you also framed it well from the standpoint of safety what is inexcusable absolutely inexcusable as if the electronic health record and the way it's deployed leads ultimately to veteran harm and we've seen an inspector general report with a list thankfully most of these cases were minor harmed and missed things but there were a couple of cases where the electronic health record was a component of something that should not have happened to a veteran the moves that dr terria dirham has made the deputy secretary and the secretary on delaying the rollout in certain medical centers across the country has everything to do with the safety story we have to make sure that our clinicians are not pressured and are not facing a system that ultimately makes their care unsafe and so you will not find a bigger advocate for our frontline folks who use the system than me because i know what it's like to go through an electronic health record rollout as a clinician as a doctor and as somebody who's tried to make changes to these types of systems as a healthcare healthcare leader and so what are we going to do to address the safety risk well number one we're making sure that we are plusing up the number of folks at the point of care where your veterans are to come to the assistance of people who are trying to use that system when they're making care decisions putting in orders and making sure those medical orders get to the right place so that your veteran gets the lab your imaging study that next appointment right so making sure that support system is important another word for that is change management you don't just expect people to take on a completely different way of working and expect everything will go right no you have to support folks especially on the front line through that process the second thing we're trying to do is make sure that the avenues for those folks to raise awareness about the problems that they're facing are maximized who can they call how quickly will they get a response these are the things that i have to be obsessed with as vha is the customer of this effort on behalf of veterans we need to make sure they have every avenue of raising those issues up to the top levels if needed so that we can call cernar and say this is not working right you need to change this now i will tell you holding oracle cernar accountable for making sure that the system does not go down as often it is and it still is going down to a certain level frequency to the frustration of a lot of us is going to be huge on this and we will take every legal avenue that we can to make sure the basic blocking and tackling of this system literally just staying on for our clinicians that that improves over time and i will be the loudest voice in the room if i need to if that basic downtime issue is not fixed but more importantly we need to also make sure that we are doing everything we can to prepare before that next deployment happens i joined dr adiram again the leader of the initiative with network 10 serving the upper midwest you had leaders from across that network to say listen we are here for you we're working as a team and we are a resource to make sure this goes well and we will do everything we can to make sure that you're ready before you start and i think if you look back with man grand staff and spoke hand the selection of that particular medical center and preparation of that medical center was not where it needed to be before they had that new system deployed and so the point is that we are learning over time with each of these deployments and where we you all need to hold us accountable is if the the next deployments don't go as well and your veterans most importantly feel that your veterans should never ever feel the impact of electronic health record change that should just should not happen we need to make sure that our systems and our people are supported and trained so that the care that your veterans are getting is not impacted and that's my commitment to try my hardest to do that in concert with that electronic health record team we're glad to hear that because this issue has been ongoing for decades as far as you know this we know that a modernization needs to occur there's been failures over time a lot of money has been provided by congress they want to do the oversight people are getting frustrated and you know again the last thing that we want to happen is for our veterans not to be safe so we appreciate your commitment to that and we were we will certainly be holding you accountable and saying you know we want to make sure that that that you said like you said that harm does not come to any veteran as a result of the the modernization effort but we appreciate that and I see we're just about out of time here you know but I wanted to give each of you a chance to make some final comments as we close and just be able to talk a little bit about you know again anything that you maybe we haven't covered this afternoon we could go on for for hours I know we have lots of questions but giving you that chance so I think first we'll do maybe undersecretary Quinn let you have a few comments well listen it's been a good discussion I think I just want to remind each of you that have stuck with us here I am you and I am you working within the VA I came from the field not having worked for federal government in the past other than my military service and I can assure each of you that from Secretary McDonough to Deputy Secretary Remi to my partners here on stage with me I can't remember serving in an organization to include the U.S. Army and Army National Guard that is more dedicated and know the customers that they serve you really do have the right team in the right place doing the right thing for veterans within the VA I get my health care through VHA I get my benefits and have total confidence through VBA I've not used NCA yet thank you but I have confidence in what they will do I got to tell you NCA and there is a survey that comes out every three years we just did it again this year the results are pending but NCA is number one for customer satisfaction in the United States both private entities private corporations as well as federal government your NCA within the VA is the number one for customer satisfaction our employees out across our 155 national cemeteries understand their mission is a non-fail mission their mission is to provide those final honors to that veteran who has served our nation honor boy or to that family member who has sacrificed so that their veteran can serve again our goal is to get a national cemetery or a state tribal territorial grant cemetery to within 75 miles of every veteran out there we're close but we got a ways to go and it's partners like great state of florida hammer Hartzell who's sitting here in the front row that we're going to get that done and we'll continue to strive to get a cemetery a national shrine within 75 miles of every veteran so again i am you i am you working within the VA and a partnership with DAV is how we will continue to best serve our veterans so again thanks for your time today and and uh appreciate the questions acting under Secretary Jacobs any final thoughts for VBA um thanks very much Jim and and joy and and thank you everyone i guess what i would say is we have a once in a generation opportunity to increase our support for veterans and their family members it's going to be a lot of hard work and what i would say to each one of you is what i would say what i said to all of the vba employees my first week which is i operate under three core principles one is full transparency so telling you what's happening with a priority on collaboration on working together and third doing everything with the veteran at the center and so as we move forward with implementation of the pact act and fulfill our mission across the organization i look forward to doing all three of those with you and i'm sure there'll be plenty more to come it's going to be a really momentous opportunity and the opportunity is is really limitless so thank you very much for a really productive conversation for including us and look forward to many more thank you and dr ellen hall asked you to go last but also asked just as a point of privilege we talked a little bit behind before we came on just about women veterans and your vision for women veterans and didn't get a chance to ask a question about that but i know you have some thoughts about that and i think our women we have a lot of women veterans in the audience today and um sharing how you can make sure that um they feel comfortable and welcomed at our vas and that they know the you know for all veterans um can count on v8 to serve them and to the best of your ability if you have a few comments thanks thank you joy and um that is an extremely important priority in addition to other things that we didn't get to talk about today on this panel equity more generally giving as much as we can in terms of inclusivity of the care that we provide to veterans of all stripes across the country mental health and suicide prevention the among the most important clinical priorities in addition to the care that we give to disabled vets and our spinal cord injury centers and so many other services that all of your members and your veterans depend on um and also just working with folks who know veterans better than anybody else what i'd like to say is that the competitive advantage that va has compared to the rest of health care is number one knowledge and trust of the veteran there isn't a single health care system that has the trust scores that va does for its customers but also the scope and the scale and the size of our incredible organization a shout out to our incredible clinical employees vha employees across the country who do this work for all of you every day without them there's nothing i could do to be a partner with you and helping them uh but ultimately uh i think this will be the honor of my professional life uh in this role i was asked by folks who interviewed me for this job including somebody in this room who will remain name nameless who will you work for if you are selected and my answer was veterans that's my primary boss and my only request to you uh it's as josh said and others uh and under secretary quinn and others on this panel let me know if we're not doing that what we need to do to serve your members to serve your veterans we can't do this without you i can't do this without you and i hope that this was an opportunity uh for me to introduce myself to you but also commit that we will be very close partners and doing everything we can for veterans thank you so much on behalf of jim myself and all of us here at dav you want to thank our three guests this afternoon for joining us and we really look forward to continuing to work with you to strengthen the health care benefits nca for all veterans their families and survivors so we really appreciate you taking the time spending it here today with with dav members and let's give them a great round of applause thank you