Dr. Carolyn Clancy (00:04):

So the coach said to the veteran, “Take out your iPhone. Okay. What do you got on your screensaver?” And the veteran showed them a picture of his wife or family and said, “Well, that’s what we’re talking about. That’s part of your mission, what matters to you.” And I think that’s going to be an ultimate game changer.

Speaker 2 (00:28):

Welcome to Hospitals in Focus from the Federation of American hospitals. Here’s your host, Chip Kahn.

Chip Kahn (00:38):

Most of us are patients at one point or another, whether it’s for a routine doctor visits or an unexpected trip to the hospital ER. Ideally, whatever it is, our patient experience should be seamless. However, despite caregivers’ best intentions, they often fall short. We usually don’t have an opportunity to share our immediate feedback in a way that can impact our real-time patient experience. And we can only hope that our responses to post-care questionnaires have value for the next patient.

(01:12):

One agency, the Department of Veterans Affairs or VA, is taking on this issue of patient experience directly. In January 2015, the VA developed a new office, the Veterans Experience Office, to take the department to the next level for the entire experience of veterans, whether for healthcare services or how to navigate life after military discharge. Through qualitative and quantitative veteran customer service data, they have transformed the continuum of care.

(01:47):

As a leader of the VA’s transformation, my friend, Dr. Carolyn Clancy, who is joining us today, is here to tell us that story of the VA’s efforts to improve the patient experience and how their initiative could have broader applications and be scalable beyond the walls of the VA system. Carolyn is the assistant undersecretary for health, for discovery, education, and affiliate networks at the Department of Veterans of Affairs. I have had the pleasure of working with her for many years in multiple capacities, including her time as the director of the Agency for Healthcare Research and Quality. Carolyn, thanks so much for being here today.

Dr. Carolyn Clancy (02:31):

Well, thank you. I am really honored to be part of this. I really appreciate you including me.

Chip Kahn (02:37):

Carolyn, before we get started with our specific topic, could you give us a broader overview to set the context for this in terms of the evolution of the VA’s approach to healthcare, particularly being such a large system?

Dr. Carolyn Clancy (02:53):

I’d be delighted. So a few things to know about the VA system. It’s huge. We have about nine million plus veterans enrolled. That’s a little over half of the living veteran population. We have hospitals and clinics across the 50 states as well as some of the Pacific territories like Guam, Samoa, and also a clinic in Manila and Puerto Rico, of course. So we serve veterans where they are. We’re not thinking in terms of is there a market, but we’re thinking of is in terms of how do we serve these veterans.

(03:26):

Originally a hospital-based system until the mid ’90s, very little outpatient care. And then the system was transformed to include clinics and the hospitals were arranged into what are now 18 regional networks. So it’s a huge system. I want to stress that a lot of our medical center directors, as we call them, are almost like mayors. Because in addition to overseeing a hospital, they are overseeing a campus which may be pretty large depending on where they’re located so that’s grounds and upkeep, and they all have police forces and many other functions which we don’t outsource. Those are all federal employees. So we have close to 400,000 people who work in this system, including in outpatient settings.

(04:15):

And one other key feature, which I think position does very well for the pandemic was VA got into telehealth pretty early, early 2000s. It was not seamlessly integrated into the system, but nonetheless, we had the capacity. When everyone went into lockdown, we had the pipes. What we had to do was expand them, which is very different than starting up from scratch. This is by definition an academic system. Every last one of our 170 medical centers has some trainees there. And it may surprise people to know that about 70% of US docs got some training in a VA. So we’ve got a big impact on the future footprint of the healthcare workforce. And it’s not just docs, it’s nurses, it’s pharmacists, it’s physical therapists, occupational therapists, all adding up to a total of about 60 different disciplines, multiple mental health disciplines, for example. Very, very dedicated. About a hundred of our facilities actually conduct research themselves. And really an amazing place. And it would be very hard for me to overstate the dedication of this workforce. So I’ll stop there. Except to note that our best estimate is that about a third of our people live in rural areas. And I don’t really mean lovely exurbia, I mean really rural.

Chip Kahn (05:40):

So with that Carolyn, and going back to my best of intentions in such a large system, I assume over time it has been easy for some patients to get lost, to not know how to navigate it. So obviously the patient experience across this continuum of care is I’m sure an issue. And I know a number of years ago, as I mentioned, a former Secretary Bob McDonald, started an initiative to try to affect the entire veterans experience. Not just healthcare, but all the experiences. And I know you were involved from the ground floor of this and have been part of the effort to take whatever lessons or guidance or reports came from here and figure out how to make those work at the ground level for the patient. Can you give us a sense of how that initiative evolved and how you took it from data to individual patients?

Dr. Carolyn Clancy (06:42):

What a great, great question. I’d have to say that like many changes, I can’t say this was instantly embraced by people in the VA healthcare system. We were doing CAHPS surveys, inpatient and outpatient, and weren’t sure that we necessarily needed to be part of a veteran experience office that encompassed all aspects of a veteran’s journey. And it turned out to be an absolutely brilliant thing that Secretary McDonald did.

(07:10):

He actually brought in someone to lead it. A fabulous individual who had worked in the food industry a lot. And when I heard that, I was a little tiny bit worried. But he went on to say that one of his prior jobs had been to bring McDonald’s to France. And he described the difference in cultural expectations. Everything that Americans like about at McDonald’s, it’s fast, you’re in and out and so on really was not a very much appeal to people in France. So they had to adjust. And just even listening to that story started to make me realize there was something really, really important here.

(07:50):

Your opening comments when you talk about we’ll have to look at the results of our questionnaires and figure out if we can make this better, really brought it home to me. A lot of what people now refer to as service recovery, you need to have almost real-time information. So as a result of the efforts, not only have we seen our CAHPS scores go up quite a bit, we’ve also seen Trust scores, which we considered the pinnacle achievement. I think we were struggling to believe that the veterans Trust in our system was about 70% when Bob McDonald was here. And this took a little bit of statistical squinting, if you know what I mean. And now it’s well into the 90s, which to me is completely amazing because it is a big system.

(08:41):

Do some people get lost, as you mentioned? Sometimes, yes. In addition, we have the interesting challenge … A lot of veterans are pretty mobile. Now that might be snowbirds who migrate from climates to Florida or other warmer climates when it gets very cold. It could just be people out on the road. But we have figured out a lot of ways to adjust to that. And our overarching theme is meeting veterans where they are. Our aspiration is that you don’t fit our rules, we use our capacity to meet your needs. Now, do we hit it out of the park every time? Not yet. But that is our very, very clear aspiration.

Chip Kahn (09:27):

Carolyn, can you give me some examples of how this plays out for an individual patient in the clinic going through the hospital or going through a cancer experience where they’ve got a lot of doctors, a lot of tests, a lot of interaction with facilities, whether they be clinics or inpatient hospital. For the individual patient. What does this mean, the reforms that you put in place?

Dr. Carolyn Clancy (09:52):

Yeah. A couple of points. One is we have heard from our veterans repeatedly that their primary care clinician is hugely important. We heard that in terms of who do you trust to get information about vaccines from? We hear that in many, many different areas. We also heard from veterans, particularly during the pandemic, that they thought visits should be more proactive than reactive. And what’s fascinating about that is that really meshes nicely with the notion that many of our people have been leading here in something called Whole Health, which ultimately strives to meet the goals of an individual rather than us telling you what the goals should be.

(10:40):

Now, reactive medicine is an important part. You’ve got chest pain, you want people to react like right now. But there’s a lot of areas where the patient needs to be in the driver’s seat, but we need to set the context and the stage that makes that easy for them. So by talking to veterans directly, we were able to learn a lot about that. And an innovator from Madison, Wisconsin tried something very interesting called My Life, My Story. He would send in volunteers to meet with veterans. I’m talking sitting down with them for a couple of hours and interviewing them about their lives, what impact medical care and medical problems that had on their life and so forth. They would take it home and transcribe it and turn it into a more narrative document and bring it back to the veteran who would say yes or no, or can you emphasize this point a little bit more. And that’s embedded in their electronic record. The first time I heard about this, I was just blown away.

(11:41):

Now, this was separate from the Veteran Experience Office, but I think very, very much in the spirit of we are here to serve you. We need to meet you where you are. You don’t need to move to be closer to us or to adhere to all these rules. Our job and our goal is to help you live the best, healthiest life that you can.

Chip Kahn (12:03):

My Life, My Story has really impacted the patient-physician, the relationship. Can you talk about that a bit? How the caregivers, I guess, from physicians to physician assistants, the others that are guiding the patient through the system, how is this information in the record impacting that experience, that direct patient care?

Dr. Carolyn Clancy (12:30):

So first, let me just say I’m an internist. And the person who’s thought of as the patron saint or founder of internal medicine, a man named Sir William Osler, who came out of Hopkins, used to say that a good physician treats a disease and a great physician treats the person with the disease. And that’s really very similar to the aspiration of My Life, My Story. Veterans vary as any individuals within a group would in terms of how reflective they are, but it is hugely, hugely helpful because really only the individual can provide the context in which they’re experiencing, for example, difficult medical problems like cancer treatment or having a lung transplant or something serious or even struggling with a chronic illness.

(13:19):

So being able to hear this story actually provides cues for their caregivers to be able to present information to that veteran in a way that they can grasp, and that makes sense in the context of their whole life. This is why we sometimes refer to it as Whole Health. One of our major facilities in Boston, they actually use this with medical students. They tell them about the program, and then they ask them to go find a patient and go through the whole exercise themselves. And it is wildly popular because this is what people imagined. And in days of old, this is not exactly how you learned about clinical medicine and taking care of people.

Chip Kahn (14:02):

Build on that a little bit. You’ve found these new ways to impact the patient experience. And from our work, particularly when you were at HHS a number of years ago, obviously your focus, there was so much on quality, safety, innovation in those areas, measurement of facilities and providers and caregivers on those areas. How do you think your initiatives to get closer to the patient to help the patient through this continuum of care has impacted those larger systems issues of quality and of care itself and safety in the facilities and in the clinics and in the system?

Dr. Carolyn Clancy (14:48):

It’s a really wonderful question. We still use a lot of data to track this. So we’re very, very pleased that a higher proportion of VA hospitals did well in HCAHPS, a higher proportion got four or five stars than the private sector. So we think that’s wonderful. What I think is personally wonderful is it’s not very long ago that there was exactly one seriously academic hospital in our system, this was Madison, as it turns out, that actually did extremely well in HCAHPS. And when I called the director to say, “What are you doing that’s right?”, he couldn’t tell me. Now, he went back and spoke with his team and so on and so forth. But I think what came out of the Veteran Experience Office was that clinical excellence and innovation has to be combined with the patient’s context. And that is hugely important. That is really the holy grail.

(15:45):

So it’s not that we’re not measuring these things, it’s more that we have reframed the proposition as opposed to we’re going to kill this HCAHPS score or we’re going to nail this particular metric. It really changes much more to be about the story of the veteran themselves, which frankly has far, far broader appeal than saying, “Wow. Our scores improved by 3.6%.” If you’re a quantitative type, you might say, “Whoa. That’s really big. That’s bigger than the standard deviation.” But most people don’t react to that. They’re thinking about the veteran in room 322 and the person we saw this morning who’s been struggling, and finally now is getting a handle on managing his or her illnesses.

Chip Kahn (16:29):

So Carolyn, the HCAHPS, this survey of patients is clearly being affected by all the work you’re doing. In a sense that at the VA what’s next? With instituting these initiatives, you’ve made a lot of progress with patients. In terms of the continuous quality improvement for the patients what do you see as the next challenge, the next matter you’re going to take on to make sure that the patient is treated as a whole person?

Dr. Carolyn Clancy (17:02):

A couple of different things. One is that this is a system that prides itself on innovation. Some of which comes out of research. We recently had a celebration of the fact that we had, after a number of years enrolled our millionth veteran and what we call the Million Veteran Program. These are veterans who’ve donated their genetic information because it could help other veterans. And we have that link to their clinical electronic data for the care that they get in our system. It’s amazing, and no one else has a system quite like this.

(17:36):

One area that we’re very, very interested in is age-friendly healthcare, which is amazing. This is the kind of thing I used to hear about on the radio, and I’d be thinking, oh, well that makes sense. So what does that mean? It’s actually an idea that focuses on four M’s. What medications does the patient take? What is their mentation? What is their mobility? Are they at high risk of falls and so forth? And very importantly, what matters? Now, some people you ask them what matters to you? What are your goals and they’ve got it right away. They immediately have answers for you. And others have to reflect more.

(18:20):

I heard a terrific story from one of our coaches who when he first started, he wasn’t really sure he was in the right job. This all sounded good, but being here. And then he heard one of his colleagues talk to a veteran who when asked about his mission, looked blankly. And so the coach said to the veteran, “Take out your iPhone. Okay. What do you got on your screensaver?” And the veteran showed them a picture of his wife or family and said, “Well, that’s what we’re talking about. That’s part of your mission, what matters to you.” And I think that’s going to be an ultimate game changer. There’s lots of other technological innovations as well, but actually figuring out what matters to that individual I think is frankly what most people hope for, even if they sometimes don’t expect it anymore from healthcare.

Chip Kahn (19:10):

Carolyn, let’s take this to the next level beyond the VA. And let me ask, going back to this idea that came from Bob McDonald and you and others disseminated from the work of the Veterans Experience Office into the system itself or the patient’s experience. What’s applicable more broadly from that? What lessons did you learn that you think could be taken into the private sector, be taken into other healthcare systems, be taken for other physicians, dealing with patients who are not part of the VA, who are just other Americans who are experiencing whatever that calls them to go through this continuum of care that we have on the private side?

Dr. Carolyn Clancy (19:59):

I think obviously what is your mission in a system where about a third of our employees are veterans themselves has a particular resonance. But I think in healthcare broadly, people want care that is responsive to their needs and frankly helps them do a better job of managing their own care. Although we often hear about consumer demands, by and large, I’ve never heard anyone describe a medical encounter, whether that’s a doctor visit or visit to the ER as something they’d been planning for recreation or for a lot of fun. And in general, it’s not that much fun. So I think trying to be very, very attentive to the individual context is really important. And I think we’re starting to see that in the private sector.

(20:49):

So the last time I went in for a primary care visit, I got a questionnaire about depression symptoms. I’d never had that before. This was not looking at me, but this is more just saying, this is a problem that we know that some people have, and if you’re struggling, we’d like to hear about it. Obviously a lot of systems are trying to do this through a variety of digital means, and I think the real trick there is going to be how do you balance the need for human to human interaction with what can be done purely digitally?

(21:24):

I heard a terrific story recently from one of our alumni who’s now working at WashU and said that during the pandemic, when they sent people home who were still ill and they had oximeters and temperatures and so forth, they sent them a questionnaire every day, which was really quick and about their symptoms and so forth. And being sensitive to the fact that not everyone might have the technology and how to use it, you could use a phone call as well, and they figured the worst case would be 50% would want to do this by phone and 50% would want just to do it online only. And about 80% wanted to talk to someone. A unique context there with many people being isolated, but it made me appreciate that we still haven’t figured out that right balance. So I think there’s a lot of interesting experimentation going on here, but also across the private sector, and we’re anxious to learn from that as well.

Chip Kahn (22:21):

Carolyn, this has just been so helpful, and I appreciate this. I really appreciate what you’ve accomplished at the VA. I can’t get over this notion of the patient is the center of things and the care is then for the patient, and it’s so important in all the systems across healthcare that provide care.

Dr. Carolyn Clancy (22:43):

Well, I can’t say it works perfectly every single time, but that is our aspiration and the difference is palpable. Again, I can’t overstate the dedication that people, the vast majority of our colleagues have to serving veterans, but providing a path and a different strategy for getting there is really, really important.

Chip Kahn (23:06):

Carolyn, thank you so much for joining us this afternoon, and I’m sure that our audience will really appreciate hearing from you.

Dr. Carolyn Clancy (23:15):

Thank you very much for having me.

Speaker 2 (23:21):

Thanks for listening to Hospitals in Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media at FAH hospitals and follow Chip at Chip Kahn. Please rate, review, and subscribe to Hospitals in Focus. Join us next time for more in-depth conversations with healthcare leaders.

Speaker 4 (23:43):

Voxtopica.

Dr. Clancy serves as the Assistant Under Secretary for Health (AUSH) for Discovery, Education & Affiliate Networks (DEAN), Veterans Health Administration (VHA), effective July 22, 2018. The Office of the DEAN fosters collaboration and knowledge transfer with facility-based educators, researchers, and clinicians within VA, and between VA and its affiliates.  

Prior to her current position, she served as the Acting Deputy Secretary of the Department of Veterans Affairs, the second-largest Cabinet department, with a $246 billion budget and over 424,000 employees serving in VA medical centers, clinics, benefit offices, and national cemeteries, overseeing the development and implementation of enterprise-wide policies, programs, activities and special interests. She also served as the VHA Executive in Charge, with the authority to perform the functions and duties of the Under Secretary of Health, directing a health care system with a $68 billion annual budget, overseeing the delivery of care to more than 9 million enrolled Veterans. Previously, she served as the Interim Under Secretary for Health from 2014-2015. Dr. Clancy also served as the VHA AUSH for Organizational Excellence, overseeing VHA’s performance, quality, safety, risk management, systems engineering, auditing, oversight, ethics and accreditation programs, as well as ten years as the Director, Agency for Healthcare Research and Quality.