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6 Findings, Conclusions, and Recommendations The Institute of Medicine was asked to form a committee to evaluate the merger of a Navy military treatment facility (MTF) and a Department of Veterans Affairs (VA) medical center in North Chicago into a federal health care center (FHCC) in terms of its benefit to the Department of De- fense (DoD) and the VA compared with maintaining separate VA and DoD facilities. Specifically, the sponsor asked the committee to undertake—but not be limited to—six tasks (Box 6-1). In addition to addressing each of the tasks outlined by the sponsor, the committee developed six recommendations regarding the Lovell FHCC merger. STUDY TASKS Task 1: Assessment Criteria The committee recommends (see Recommendation 3) that the DoD and the VA conduct a comprehensive evaluation of the Lovell FHCC dem- onstration designed to provide the basis for determining at the end of the 5-year demonstration period whether the FHCC model has been a success and whether it should be adopted in other locations where the VA and the DoD share health care markets. Appendix B contains the framework for such an evaluation that could be adopted by the VA and the DoD. The purpose of the evaluation is to understand how the FHCC demon- stration functioned and the factors that explain its evolution and outcomes, 165

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166 LOVELL FEDERAL HEALTH CARE CENTER MERGER BOX 6-1 Substantive Study Tasks* 1. Establish criteria for near-term and longer-term assessment of the suc- cess of facility integration that can be used in follow-on assessments. Determine if success criteria would be different if the partner DoD health care facility was supporting operational units instead of basic/ advanced training units, such as the Navy Health Center Great Lakes. 2. Evaluate whether performance benchmarks that DoD and VA have established in their executive agreement have been achieved. 3. Examine the lessons learned from similar mergers elsewhere in the federal and private health sectors that may be applicable to DoD/VA mergers. 4. Evaluate the most pressing concerns of the stakeholders and recom- mend ways to mitigate or eliminate these concerns. 5. Evaluate the specific impact of the merger on the level and quality of training received by active duty medical personnel and VA providers. * The sixth task was to prepare a written report with findings, conclusions, and recommen- dations for the DoD and the VA that will be available to the general public. which would provide lessons for designing more effective FHCCs in the future. Thus the evaluation framework looks at a much broader range of explanatory variables than internal processes (called implementation initiatives in the evaluation framework in Appendix B) that might affect outcomes, such as a single chain of command or integrated clinics. The broader framework includes the influence of the national and local contexts and of organizational capabilities and readiness. This approach makes it possible to understand not only if it is a successful demonstration (or not) but also which factors made it successful (or not). Task 1 asks for criteria for assessing the “success” of the FHCC dem- onstration in the short term and the longer term. The framework in Ap- pendix B considers short-term outcomes to be those observed in the first year or 2 and long-term outcomes to be those that emerge after 3–5 years. The Lovell FHCC is a difficult case because the phenomenon being dem- onstrated—an integrated health care center—was not fully in place the day it became operational and, in terms of having an electronic health record and other information management systems in place to support integrated operations, may not be fully in place within the 5-year time frame of the demonstration. Nevertheless, there will be lessons to learn, as Chapter 3 demonstrates, and some outcomes can be measured, although it might take several years to discern effects.

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FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS 167 The executive agreement (EA) for the Lovell FHCC identifies the de- sired outcomes. To recapitulate from Chapter 5, they are (compared with operating separate VA and DoD health care centers in the same health care market): more accessible health care, higher-quality health care (e.g., more preventive services and continuity and coordination of care), cost savings or cost avoidance, increased market share among eligible beneficiaries, greater patient satisfaction, greater provider satisfaction, improved clinical proficiency of active duty providers, improved training programs, and bet- ter research opportunities. Operational measures for each of these outcomes need to be identified and adopted. Chapter 4 indicates that, first, data on some but not all of these outcomes are being collected monthly as part of the 15 integration benchmarks and that, second, it is difficult to discern trends in the short term. The outcome criteria of most importance are financial, such as the net reduction in costs per episode of care or procedures; clinical, such as the numbers of preventable drug-drug interactions and allergic reactions to drugs; patient-focused, such as time to third appointment and standardized patient satisfaction survey results; and, in the case of the Lovell FHCC, military operational readiness-focused, such as the percentage of recruits unable to graduate on time for medical reasons. The evaluation framework in Appendix B suggests some intermediate-term outcomes that correspond to some of the outcomes expected of the Lovell FHCC listed above, such as higher patient volume and quality of care measures. Other metrics take longer to collect and analyze and are listed as long-term outcomes, such as cost per patient, increased market share, and health status of patients. As part of this task, the committee was also asked to consider the differences in assessment criteria for FHCCs serving training units (such as the Recruit Training Command [RTC] at Great Lakes) and those serv- ing operational units. Operational units are more varied and have more complex mission-related medical issues than training units. They require medical personnel with knowledge of military medicine, which VA medical personnel do not routinely have, and who respect the unique cultural iden- tity of servicemembers in operational units. There are also service-specific differences in medical needs and the relationship between the medical and line units (e.g., Air Force medical units report to the local operational com- mander, while the Army and Navy medical commands are centralized). Ad- ministrative business functions would be similar for medical units serving training and operational units. Despite these differences between training and operational units, however, the criteria for success in an operational versus a training unit will be similar, although the benchmarks might be set at different levels.

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168 LOVELL FEDERAL HEALTH CARE CENTER MERGER Task 2: Performance Benchmarks The departments specified 15 “integration benchmarks” that incor- porate 37 measures of the degree of integration success. Most of the in- tegration benchmark results are updated monthly (some are updated less often, such as the annual audit reports and facility inspection results). Each measure is reported on a 5-point scale from highly unsuccessful to highly successful, according to a 117-page technical manual. The resulting Integration Scorecard is reviewed monthly by the FHCC leadership and the departments. The committee has a mostly positive evaluation of whether perfor- mance benchmarks that the DoD and the VA have established in their EA have been achieved. As of June 2012, there were 23 fives (highly successful), 5 fours (very successful), 6 threes (successful), 1 two (unsuccessful), 1 one (highly unsuccessful), and 1 unrated measure. The scores for some measures have varied, but rarely more than one point up or down or for more than 1 or 2 months since ratings began. Further details are in Chapter 4. One measure that is critical to integration—that is, the implemen- tation of joint information management/information technology (IM/IT) capabilities—has not been successful, as noted in Chapter 3. It is unlikely to improve further until parts of the new electronic health record (EHR) being developed jointly by the DoD and the VA become available, beginning with a joint pharmacy program scheduled to be operational in 2014. The committee notes that most of the performance measures are spe- cific to the VA or to the DoD rather than to the integrated performance of the FHCC, which is why the committee concluded that these alone do not constitute the basis for an adequate evaluation of the Lovell FHCC’s success at achieving integration. The main purpose of the performance benchmarks was to address the concerns of the respective departments that the Lovell FHCC experiment might fail badly before the end of the 5-year demonstration period. The Government Accountability Office (GAO) issued reports in 2011 and 2012 on the Lovell FHCC’s progress toward implementing the 12 in- tegration areas covered in the April 2010 EA. In its June 2012 report, the GAO found that 6 of the 12 were fully implemented (governance structure, patient priority system, contracting, research, quality assurance, and con- tingency planning), compared with 4 in 2011. Integration benchmarks was one of the five areas “in progress” (the others were reporting requirements, workforce management, property, and fiscal authority). The GAO found that one area—IM/IT—was delayed, requiring workarounds that were re- sulting in additional costs for the Lovell FHCC in terms of reduced provider productivity and increased administrative burden. The GAO found, as did this committee, that the FHCC has not quantified the extra costs but indi-

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FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS 169 cated that the FHCC has engaged the Center for Naval Analyses to assess costs and document any savings from integrated patient care (GAO, 2012). Task 3: Lessons Learned from Other Federal and Private-Sector Health Care Mergers The committee addressed the third task by commissioning a compre- hensive overview of the private-sector health care merger literature and analyzing the lessons learned reported by the nine VA/DoD joint venture sites. The review of the private-sector merger literature appears in Appendix D, “Collaboration Among Health Care Organizations: A Review of Out- comes and Best Practices for Effective Performance,” and is summarized in Chapter 5. The lessons learned from the VA/DoD joint ventures reported at the annual joint venture conferences are also summarized in Chapter 5, and short profiles of each joint venture and the lessons learned they have reported are in Appendix C, “Department of Veterans Affairs/Department of Defense Joint Ventures: Brief Histories and Lessons Learned.” Task 4: Stakeholder Concerns The committee was not able to conduct a statistically valid survey of the most important stakeholders, the patients. However, the committee heard from stakeholders, including several veteran and retired military enrollees, at the Lovell FHCC at its third meeting, held in North Chicago. The commanding officer of the RTC, who receives daily reports on recruits being seen at the west campus emergency room or admitted to the hospital, said that the FHCC was performing as well as the Naval Hospital/ Health Clinic Great Lakes had been, for example, in the percentage of re- cruits unable to go to their next assignment for medical reasons. The president of the affiliated medical school, the Rosalind Franklin University of Medicine and Science, had a positive view of the effect of the Lovell FHCC merger on medical education and training. He and senior fac- ulty and deans told staff who visited the university earlier that the merger created additional training and research opportunities because of the larger and more varied patient base. Additionally, the performance benchmark score for trainee satisfaction, as measured by the Lerner Perception Survey each July, was 5 in July 2011, compared with the baseline score of 4. The amount of research funding, as measured quarterly, has scored 5s, com- pared with the baseline score of 3. The veterans testified that they were satisfied with the care they were re- ceiving at the Lovell FHCC. They said initially there were concerns among the veterans enrolled at the FHCC that they would not receive the same level of attention as before when the Navy started using the center but that

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170 LOVELL FEDERAL HEALTH CARE CENTER MERGER those fears were not realized. Veterans appreciate the new facilities and mingling with active duty servicemembers and their families. The retirees appreciated the easier access to services at the west campus than when the Navy clinic was still on the naval base. The veterans had two major concerns, however (which were consistent with earlier interviews of several veterans and retirees by committee staff). One concern was that the time it takes to fill prescriptions was much lon- ger than before the merger, averaging at least an hour for veterans (active duty servicemembers have first priority and go to the head of the line). Although the wait times had shortened significantly more recently, they were still unacceptable. As documented in Chapter 3, the pharmacy, which is located in the ambulatory care center (ACC), was sized with the expec- tation that refills would be available through the VA’s Consolidated Mail Order Pharmacy (CMOP) program, but the DoD did not approve of having its beneficiaries use it. At the time this report was drafted, the FHCC was preparing another executive decision memorandum requesting the use of the CMOP program to ease congestion in the pharmacy. The other concern was the location of the mental health clinic on the third floor of the ACC, which is accessed through a balcony over the atrium between the ACC and the hospital building. The veterans said that some patients, many of them with posttraumatic stress disorder or generalized anxiety disorder, were deterred from using the service because of a fear of heights. They also feared that someone would be able to commit suicide by jumping from that location. There was a similar fear about the new four- story parking garage. This was a concern during the building of the ACC and the garage although they were considered to exceed applicable building standards. Subsequently, a veteran did commit suicide by jumping from the third story of the atrium, although not from near the mental health clinic. Consequently, steps are being taken to retrofit the atrium and the top level of the parking garage with fall protection barriers. Task 5: Staff Training The committee did not find that staff training was affected by the merger except in one area, which was of special concern to the Navy in agreeing to merge clinical operations with the VA in the FHCC. The concern was whether independent duty corpsmen (IDCs) and active duty advanced practice nurses (APNs) would be able to practice their skills in the merged FHCC, especially in the inpatient setting. One issue is that the Navy privileges APNs even though they are not licensed as such, while the VA requires nurses to be licensed for independent practice. Another issue is that IDCs must be ready to be deployed to locations where they are not under the direct supervision of a physician or a nurse and, therefore, must

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FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS 171 be able to perform procedures that would not be allowed in the civilian sector, including in the VA health system. As described in Chapter 3, special training of VA staff on the duties of corpsmen was provided, and several compromises were reached to allow APNs and IDCs to maintain needed clinical proficiencies at the Lovell FHCC. RECOMMENDATIONS Develop Uniform Policies, Procedures, and Business Practices for Federal Health Care Centers Findings The Lovell FHCC model is distinguished from other VA/DoD collabor- ative initiatives primarily by being a single organization rather than a part- nership. The concept is that a health center that is operationally unified will be more cost effective and better positioned to provide high-quality health care. The implementation of the Lovell FHCC highlights the difficulty of achieving unified policies and procedures when each parent department has its own planning, operating, and reporting procedures for the same health care center functions. Some of the differences stem from different missions (e.g., the military’s need to ensure and document individual medical readi- ness to deploy), but many others are just two ways of accomplishing the same thing (e.g., clinical credentialing). The dilemma is that the departments operate multiple health care de- livery centers—59 DoD military treatment facilities and 153 VA medical centers—to which they each want to apply common standards, business rules, administrative systems, and reporting requirements. Health system administrators are responsible for the overall performance of their health care systems and are naturally reluctant to exempt any one facility from their system’s rules. The history of the Lovell FHCC implementation is replete with instances in which the FHCC was unable to obtain consensus on using a single approach to a particular function and therefore has had to carry out both. Having to operate two EHR systems is a prime example, because it affects patient care, but there are many other examples of dual systems that reduce efficiency and inhibit integrated clinical and adminis- trative services. The bottom-up consensus process used in implementing the Lovell FHCC accounted in part for the outcome of incomplete integration. That approach was very useful for bringing to the surface differences in depart- ment procedures and statutory authorizations that had to be addressed in implementing the Lovell FHCC and any future FHCCs, but it also made it harder to reach agreement on a single way of doing things. The process

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172 LOVELL FEDERAL HEALTH CARE CENTER MERGER of vetting solutions up the department administrative chains was not only time-consuming, it also provided many opportunities to agree to disagree on integrated approaches. Some issues could be appealed to the Health Executive Council (HEC) or to the Joint Executive Council (JEC), but the HEC and the JEC are interdepartmental committees, not authoritative decision-making bodies. The FHCC leadership consistently pushed for uni- fied policies and procedures but was not always successful. Recently, the VA and the DoD agreed to develop a unified approach at the enterprise level in some cases rather than to try to facilitate local solu- tions. Prime examples of joint enterprise-level solutions include the efforts to develop a joint EHR system (the integrated EHR, or iEHR) and a joint disability examination process for wounded, ill, or injured servicemembers (the Integrated Disability Evaluation System, or IDES). These agreements resulted from top-down directives from the DoD and VA secretaries, who are personally monitoring progress through regular meetings. Conclusions Additional opportunities remain to develop enterprise-level solutions to differing department requirements and business practices. This would enable more cost-effective joint health care delivery collaborations, whether they are DoD/VA joint ventures or FHCCs. An example of an opportunity to work out a common approach would be a unified process for creden- tialing health care providers. Other opportunities include uniform cost accounting, civilian workforce policies, performance and quality measures, access to care standards, drug formularies, and mail-order drug refill pro- grams. The more that common policies and processes are adopted, the more integrated FHCCs can be, which in turn should increase opportunities to achieve more accessible and cost-effective patient care. RECOMMENDATION 1. Before establishing additional federal health care centers, the Department of Veterans Affairs and the Department of Defense should agree on a governance plan and common policies and procedures for joint health care delivery functions. Achieving additional enterprise-level agreement on single policies and processes is a critical first step in planning additional future FHCCs and would also assist the Lovell FHCC in reaching its full potential. The VA and the DoD may also have to obtain statutory authority from Congress to integrate authority, employees, and funding, and to allow the transfer of property between the two departments.

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FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS 173 Complete Development of a Jointly Usable Electronic Health Record System Before Establishing Additional Federal Health Care Centers Findings The IM/IT goal for the Lovell FHCC is to “safely interface VA and DoD legacy systems to support an integrated DoD/VA facility with multiple care locations” (Filippi, 2011). The Lovell FHCC expected the software capabilities that its clinicians and other subject matter experts had identified in early 2009 as the minimum needed for integrated use of the VA and the DoD EHR systems to be in place when the FHCC opened on October 1, 2010, but they were significantly delayed. These included single registration and single sign-on (implemented in December 2010), orders portability for radiology (implemented in June 2010), and orders portability for labora- tory (implemented in March 2011). Two capabilities are still not ready for implementation, namely, orders portability for pharmacy and for consults, and are not expected to be ready for several years. Conclusions The lack of EHR system interoperability, despite the development of workarounds (such as hiring five pharmacists to manually check both EHR systems for possible drug allergies and interactions), significantly reduced the efficiency of health care delivery for at least the first year of Lovell FHCC operations. The lack of single-entry access to both EHR systems has hindered the ability of the Lovell FHCC to deliver higher-quality or more efficient, cost-effective health care and to provide better research opportuni- ties. The ability to seamlessly deliver electronic health information from the veteran, military beneficiary, and health care provider perspectives should be the hallmark of an FHCC. RECOMMENDATION 2. Additional federal health care centers should not be implemented until an interoperable or joint Department of Defense/Department of Veterans Affairs electronic health record system becomes available. The level of interoperability should be what the Center for Information Technology Leadership calls Level 4, the highest level, which is when struc- tured electronic data in each system can be computed by the other system. At Level 3, for example, structured data in one EHR system can be viewed but not computed by the other EHR system. The DoD and VA secretaries have committed their departments to developing such a system together—a new joint EHR system (the iEHR)—

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174 LOVELL FEDERAL HEALTH CARE CENTER MERGER rather than upgrading their current (now legacy) EHR systems and trying to develop interoperability software. The iEHR will be developed in phases with some modules, such as pharmacy, scheduled to be completed in 2014; the final modules are due for completion in 2017. It would be helpful for the iEHR system to have the capabilities identified by the FHCC clinical task group as the initial set of core IT capabilities required by the Lovell FHCC earlier rather than later in the development process if establishing additional FHCCs is a priority. Develop Criteria for Selecting Future Federal Health Care Center Sites Findings The VA and the DoD have developed criteria for identifying “joint mar- ket areas” for increased health care sharing. They are health care markets with large DoD and VA beneficiary populations where shared facilities and services would provide access to services or infrastructure not available in one or the other organization; improve efficiency through economies of scale; reduce duplication of services, infrastructure, or both; and mitigate the impact of deployment on access. The Joint Facility Utilization Resource Sharing Working Group under the VA/DoD HEC has identified more than a dozen joint market areas and has worked with them to develop additional sharing agreements. The VA and the DoD have adopted a definition of joint ventures. They are local alliances or partnerships formed to facilitate comprehensive cooperation, shared risk, and mutual benefit, and they are expected to last at least 5 years. To qualify as a joint venture, the departments look for regular ongoing interactions in at least several of the following areas: staffing, clinical workload, business processes, management, information technology, logistics, education and training, and research capabilities. One of the joint market areas—Charleston, South Carolina—graduated to being a joint venture in early 2011. The VA and the DoD have not defined FHCCs and do not have criteria for choosing their locations. The Lovell FHCC is considered to be unique and is no longer a joint venture. Conclusions To a large extent, the criteria should address the juncture at which FHCC lower operating costs or greater effectiveness are shown to outweigh the associated significant implementation costs (i.e., a single organizational structure and integrated administrative and clinical processes) enough for the FHCC structure to be regarded as preferable to a joint venture sharing

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FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS 175 arrangement and its comparative cost effectiveness. At the time that infor- mation gathering for this report was completed (June 2012), the costs of implementing the Lovell FHCC had been substantial, while efficiencies and cost savings that might be expected had only had a limited time to transpire. The VA and the DoD should base a decision to establish another FHCC on evidence that it would provide higher performance in quality, access, or cost effectiveness compared with other arrangements, including a joint ven- ture agreement. An important source of evidence on the costs and benefits will be the comprehensive evaluation of the Lovell FHCC recommended below. RECOMMENDATION 3. The Department of Veterans Affairs and the Department of Defense should develop criteria for selecting future federal health care center (FHCC) sites. The criteria should address the costs and benefits of establishing a fully integrated organization compared with the costs and benefits of other collaborative arrange- ments, such as joint ventures, taking into account local health care market trends, institutional capabilities and readiness, unique local circumstances, and departmental limiting factors. Only when firm cri- teria based on cost savings and the expectation of enhanced health care service delivery are met should the concept of a future FHCC be considered. Analyze and Promulgate Lessons Learned from the Lovell Federal Health Care Center Experience Findings The leadership of the Lovell FHCC encountered numerous issues that had to be resolved to achieve an integrated organization and uniform poli- cies and procedures. Many of the issues resulted from conflicting policies and procedures of the VA, the DoD, and the Navy. Some were the result of statutory requirements and the lack of statutory authority. Many of the issues have been resolved by adopting the policy or pro- cedure of one department with the agreement of the other department. In some cases, agreement on a single policy or procedure could not be reached and workarounds had to be developed to meet the requirements of the two departments. Some issues could not be resolved because of irreconcilable policy differences, such as an integrated police force including active duty masters-at-arms on the west campus. Ultimately, four critically necessary actions had to be authorized by legislation: (1) the authority to transfer civilian employees from one department to the other; (2) the authority to transfer the ACC and other Navy-built facilities and related personal prop-

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176 LOVELL FEDERAL HEALTH CARE CENTER MERGER erty and equipment from the DoD to the VA; (3) the authority for the DoD to transfer funds to a joint Department of the Treasury account under the VA; and (4) the authority for DoD beneficiaries to be treated by the Lovell FHCC as they would be at an MTF. However, the legislation authorized these only as part of a 5-year demonstration in North Chicago. Every difference between VA and DoD policies and procedures had to be addressed at multiple regional- and headquarters-level decision points. This often took months, and sometimes years, to resolve through numer- ous drafts and meetings. The extra burden of this process was very heavy, especially at the local level where planning the integration was an extra duty for most staff members. Conclusions The implementation of the Lovell FHCC provides a road map to issues that will be encountered in any future attempts to establish FHCCs and of- fers many examples of ways to overcome or bypass those impediments. It would be extremely beneficial for planners of future FHCCs, and in many cases for existing and future joint ventures, to adopt solutions developed and already approved by the VA and the DoD without having to undertake the long negotiation process that the FHCC had to go through. An impor- tant, groundbreaking contribution would be made by the FHCC staff if they developed joint DoD/VA guidance materials, including a best-practices document or guidebook to disseminate local solutions or “fixes” arrived at to solve problems that arose in the implementation of the merger. RECOMMENDATION 4. The Department of Veterans Affairs and the Department of Defense should systematically compile and analyze the lessons learned from the Captain James A. Lovell Federal Health Care Center merger experience, including both what and what not to do, and disseminate them through onsite consultation, webinars, technical assistance, and other means to other federal health care center sites considering joint ventures and related collaborative arrangements. Conduct a Comprehensive Evaluation of the Lovell Federal Health Care Center Demonstration Findings The Lovell FHCC has been in operation for less than 2 years and is still implementing parts of the integration plan. It is too early to tell how successful the overall integration effort has been or will be when the dem- onstration period ends in 2015. That there have been substantial one-time

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FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS 177 costs is clear, but whether these have led or will lead to lasting efficiencies or can be adopted by future FHCCs to avoid unnecessary costs is not yet known. The Lovell FHCC is tracking certain performance indicators designed to inform about the relative degree of success or failure, for example, if the facility is providing poor, less, or more expensive care; hurting operational readiness; reducing patient satisfaction and staff morale; or providing fewer education and research opportunities. However, the VA and the DoD have not adopted a comprehensive evaluation plan to judge objectively the suc- cess of the Lovell FHCC at the end of the 5-year demonstration period and to help them to decide whether the Lovell FHCC would be applicable in other locations. Conclusions Without a formal evaluation plan, the success of the integration effort will be more difficult to determine after the 5-year demonstration period than it should be because not all the data needed for such an evaluation are being collected prospectively. RECOMMENDATION 5. In considering the Captain James A. Lovell Federal Health Care Center merger and future collaborative arrange- ments, the Department of Veterans Affairs and the Department of Defense should develop a comprehensive evaluation framework with defined and measurable criteria for assessing performance that take into account local and national contexts, organizational capabilities and readiness, implementation plans, intermediate outcomes, and likely long-term impact. The committee offers a comprehensive evaluation framework in Ap- pendix B. Expand the Knowledge Base on Federal Health Care Collaborations Findings The DoD and the VA have not systematically analyzed the experience of the Lovell FHCC and the lessons that may be learned from it in consid- ering if and where to establish additional integrated VA/DoD health care centers modeled after the Lovell FHCC merger.

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178 LOVELL FEDERAL HEALTH CARE CENTER MERGER Conclusions The Lovell FHCC offers a number of lessons learned about what works well—and what does not—that would be useful to future FHCC decision makers and planners. The mergers of private-sector health care organiza- tions do not provide adequate models for integration of federal health care organizations because they are narrowly based on increasing market share and revenue and usually do not involve clinical integration, only adminis- trative consolidation. Published studies demonstrate substantial variation in performance after private-sector collaborative ventures. Nonetheless, lessons learned from private-sector mergers and pertinent data would be useful for both the Lovell FHCC and future endeavors (Appendix D con- tains a paper commissioned by the committee on the experiences of joint ventures and private-scector health care mergers). RECOMMENDATION 6. The Department of Veterans Affairs (VA) and the Department of Defense (DoD) should fund studies to address the key findings and questions raised by the experiences of the Captain James A. Lovell Federal Health Care Center merger and other VA/ DoD collaborative arrangements. These studies should address the implementation issues involved in establishing collaborative arrange- ments, including leadership, governance, communication, organiza- tional culture, coordination, incentives, and related factors associated with improved access, quality, slowing of the increase in the cost of care, and military readiness. REFERENCES Filippi, D. 2011. James A. Lovell Federal Health Care Center IT informational brief. Presenta- tion by the director of the DoD/VA Interagency Program Office to the IOM Committee on Evaluation of the Lovell Federal Health Care Center Merger at its first meeting, Washington, DC, February 25. GAO (Government Accountability Office). 2012. VA/DoD Federal Health Care Center: Costly information technology delays continue and evaluation plan lacking. GAO-12-669. Washington, DC: GAO. http://www.gao.gov/products/GAO-12-669 (accessed September 21, 2012).