Non-Clinical Topics

Despite Shulkin ouster, VA continues with VISN restructuring plans

by Sandra Basu

July 12, 2018

WASHINGTON — Despite changes in leadership, VA is planning to move forward with restructuring efforts, including redesigning its VISN system.

“Our goal is to streamline business processes, ensure clearly defined roles, responsibilities and authorities among all levels in VHA, so that we are functioning in a way that is more efficient and, most importantly, produces better results and accountability,” VHA Executive in Charge Carolyn Clancy, MD, recently told lawmakers of the Veterans Integrated Services Networks system.

Clancy made her remarks at a recent hearing on VA’s governance structure held by the House Committee on Veterans’ Affairs. At the hearing, Committee Chairman Rep. Phil Roe (R-TN) said he “wholeheartedly agrees that the VISNs are due for an overhaul.”

“They should be in the fail-safe mechanism when a medical center goes off course. Unfortunately, too many of them seem to be inflicted with a case of learned bureaucratic helplessness,” Roe pointed out.

He also warned that, “if VA does not articulate a definition of success with measured outcomes, then we have no guarantee that veterans will be better off with this restructuring.”

The hearing follows the announcement in March by former VA Secretary David Shulkin, MD, that an agency restructuring effort would include redesigning the VISNs. Shulkin was responding to findings of a VA Office of Inspector General (OIG) report on problems at the Washington, D.C., VAMC, which he said demonstrated failures at all levels of the VA system.

He indicated that he did not believe the issues were isolated to that one facility, adding, “I’ve directed that we begin to start doing changes at every level of our organization, at the facility, at the network level and the central office level.”

At the time, Shulkin noted that “the VISN model was put in place 20 years ago” and that “the times change, the needs change.” He also announced “a significant restructuring effort involving VISN’s 1, 5 and 22,” which have faced management and leadership challenges.

At the recent hearing, Clancy told lawmakers that W. Bryan Gamble, MD, a VA executive who is a retired brigadier general, would .lead the review of the three VISNs and provide recommendations about the redesign process.

“The findings from this review will be combined with ongoing feedback from network directors and our ongoing modernization effort to formulate the final plan for the redesign of the VISNs,” she said.

Need for VISNs?

At the hearing, Roe questioned whether VISNs are even needed, saying, “I can’t figure out what the VISN does.”

Clancy responded that VISNs “have a vital role” and that the VA is using this opportunity to learn from other industries.

She said she consulted with Hospital Corporation of America Chief Medical Officer Jonathan Perlin, MD, PhD, who said that accountable regional leadership is needed for consistency across a large system.

“That is what we are trying to build,” Clancy said, adding that the goal of the redesign effort is to have “one mission” statement for all of the VISNs.

Rep. Julia Brownley (D-CA) questioned Clancy about the responsibilities of VISN network directors and how some of the problems cited in the OIG report were able to occur.

“Why did some of these disasters happen in some of these VISNs?” Brownley asked.

Clancy said the problem was that the VA “did not have a consistent job description for network directors in concrete specific terms.”

“It is fair to say that some of our previous network directors had a much more hands-off approach for a variety of reasons,” Clancy explained. “I think it is also fair to say that, in 2018, that is simply not going to be the path by which we assure that all veterans get great care.”

VA Inspector General Michael Missal, who also testified, agreed with that assessment, noting, “I think there is great confusion out there about what the VISN director is supposed to be doing.”

When asked by Brownley whether VISNs are still needed, Missal answered that, “in certain situations they have been very helpful, but it all goes down to the people involved.”

Brownley further questioned whether the roles and responsibilities of VISNs should be narrowed. Missal said the roles should be “clarified” and that he and others “look forward to what VA comes up with in terms of their study of the VISN system.”

Also testifying was Roscoe Butler, deputy director for healthcare for the American Legion’s National Veterans Affairs and Rehabilitation. Butler told lawmakers that his organization “applauds former Secretary David Shulkin for proposing to look into reorganizing the VISN and VA Central Office.”

“The VISN’s primary function was to be the basic budgetary and planning unit of the veterans’ health care system. However, as we all know, the VISN structure has morphed into an expansive operation, consuming more staff, resources, funding, and physical space,” he said.

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