Appendix B

Framework for Evaluating Department of Veterans Affairs/Department of Defense Health Care Collaborations

In the process of its deliberations, the committee created a framework (Table B-1) to guide its evaluation of the Lovell Federal Health Care Center (FHCC) merger that may prove useful to assess future collaborations between the Departments of Defense (DoD) and Veterans Affairs (VA), whether these take the form of shared service arrangements, joint ventures, or partial or full mergers. The five major categories for consideration include (1) national and local contexts, (2) organizational capabilities and readiness, (3) implementation initiatives, (4) intermediate outcomes, and (5) long-term impact. Each of these is discussed in turn.

NATIONAL AND LOCAL CONTEXTS

Whether various forms of continued or expanded collaboration between DoD and VA medical facilities make sense will depend to a large degree on the national and local contexts within which such collaborations might be realized. Among the most important of these are the current DoD and VA departmental policies, goals, and objectives. The Lovell FHCC “integration,” for example, was inherently constrained by the need to conform to many divergent DoD and VA policies. In some respects, the degree of success of the integration was achieved through major “workarounds” of current national VA and DoD policies and business processes. In the extreme, one could imagine a fully merged “Federal Health Service” that would totally absorb and integrate current DoD and VA health care policies and institutions. For a variety of reasons, this may not be feasible in the near future. In the meantime, any future collaborations must recog-



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Appendix B Framework for Evaluating Department of Veterans Affairs/Department of Defense Health Care Collaborations In the process of its deliberations, the committee created a framework (Table B-1) to guide its evaluation of the Lovell Federal Health Care Cen- ter (FHCC) merger that may prove useful to assess future collaborations between the Departments of Defense (DoD) and Veterans Affairs (VA), whether these take the form of shared service arrangements, joint ventures, or partial or full mergers. The five major categories for consideration in- clude (1) national and local contexts, (2) organizational capabilities and readiness, (3) implementation initiatives, (4) intermediate outcomes, and (5) long-term impact. Each of these is discussed in turn. NATIONAL AND LOCAL CONTEXTS Whether various forms of continued or expanded collaboration be- tween DoD and VA medical facilities make sense will depend to a large degree on the national and local contexts within which such collabora- tions might be realized. Among the most important of these are the cur- rent DoD and VA departmental policies, goals, and objectives. The Lovell FHCC “integration,” for example, was inherently constrained by the need to conform to many divergent DoD and VA policies. In some respects, the degree of success of the integration was achieved through major “work- arounds” of current national VA and DoD policies and business processes. In the extreme, one could imagine a fully merged “Federal Health Service” that would totally absorb and integrate current DoD and VA health care policies and institutions. For a variety of reasons, this may not be feasible in the near future. In the meantime, any future collaborations must recog- 193

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TABLE B-1  Framework for Evaluating Department of Veterans Affairs and Department of Defense Health Care 194 Collaborations* Organizational Intermediate National and Local Capabilities and Implementation Outcomes Long-Term Impact Contexts Readiness Initiatives First 2 Years 3–5 Years • Department of • Shared vision • Combining • Increased operational • Operating efficiencies Veterans Affairs • History of working departments and readiness for recruits • Costs per patient and Department together services • Expanding patient • Patient functional health of Defense (DoD) • Culture • Transferring volume to critical status measures policies, goals, • Leadership personnel mass to maintain • Increased market share objectives • Information • Orienting competency in local area • Number and technology employees • More in-house • Other location of facilities capabilities • Communication/ surgery—added • Size and number of • Care management education posttraumatic stress people served • Care improvement • Developing disorder unit • Local health care • Performance policies • Increased professional market—public and measurement • Developing shared opportunities for staff private sectors • Training and electronic health • Residency • Local labor market human resources records opportunities • Other development • Other • Healthcare • Financial reserves Effectiveness Data • Other and Information Set, DoD, Joint Commission benchmark measures • Employee satisfaction • Patient experience measures • Other * It is important to evaluate shared services, joint ventures, and partial and full mergers, etc., against their own stated goals and objectives in addi- tion to those expected by external parties, including accreditation bodies, payers, and others.

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APPENDIX B 195 nize the constraints imposed by the existence of separate executive branch departments with differing missions, statutory requirements, departmental policies, administrative procedures, organizational cultures, performance standards, and reporting requirements. Other important contextual factors include the current degree of in- terdependence among DoD and VA facilities relative to collocation, cur- rent sharing of services, various informal arrangements, opportunities for medical and health professional education and research, and related factors. Other additional factors include the number of people served by the enti- ties involved, their demographic characteristics and health needs, and the characteristics of the local private-sector health care marketplace. Further considerations include the strength of the local economy, the availability of workforce, and related resources. Relationships with medical and affiliated health professions schools are also an important consideration. Despite the national policy challenges, the local context was quite fa- vorable for the Lovell FHCC integration. For instance, the Navy and the VA facilities were located very close together, allowing the VA to accom- modate Navy beneficiaries and improve the capacity of its medical facility and the Navy to save money by not having to replace its obsolete inpatient facility. In addition, the VA patient population offered a more varied and complex health care treatment mix to allow Navy clinical personnel to keep up their skills, while the overall increase in the number of patients created some economies of scale and staffing efficiencies. For the VA, in addition to increasing use, the larger and more varied patient base, including women and children, provided increased training and potential research opportuni- ties for medical students and residents. Into the future, changes in demand for both DoD and VA facilities will be an important consideration for the success of collaborative activities. The veteran population enrollment for VA health care services is projected to decline over the next decade, and immediate indicators suggest a reduced future demand. Another factor to be considered is the difference between the requirements of more standard health care operations as opposed to recruit training sites, such as that found in the Lovell FHCC merger. The country’s slow economic recovery, the burden of debt, and related factors may also affect how the nation chooses to provide health care to its military personnel and veterans. ORGANIZATIONAL CAPABILITIES AND READINESS The second key component in considering future collaborations is a rigorous realistic assessment of the capabilities and readiness of the in- volved parties. While there are many important factors to consider, among the most critical are the governance and the stability of leadership of the

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196 LOVELL FEDERAL HEALTH CARE CENTER MERGER involved entities; the budget authorities and restrictions; the electronic health record (EHR) system and information technology infrastructure capabilities; the human resource systems, capabilities, and personnel re- sources; and the care processes and management/improvement/performance measurement systems (including outcomes that can be compared against external benchmarks). The single biggest barrier for the more complete clinical implementa- tion of the Lovell FHCC was the incompatibility of the DoD and the VA EHR systems and the resultant technical challenges and barriers. The time necessary to integrate various features of the two systems was seriously un- derestimated, resulting in delays and incremental “one-off” workarounds. The problem of having to reconcile two different human resources systems was solved by the decision to move all the Navy civilians into the VA personnel system, although the active duty servicemembers could not be moved. A great deal of time and energy had to be spent addressing cultural differences between the Navy and the VA, which would also be expected from potential mergers between the VA and other branches of the services that have their own distinct cultures. Chapter 2 of this report provides the history of the Lovell FHCC merger and Chapter 3 gives a more detailed description of the implementation process. DoD and VA entities considering further collaborative opportunities also need to assess their current care management and quality improve- ment processes, and their ability to generate performance measures. To their credit, the Lovell FHCC leaders developed a set of standardized per- formance measures in the areas of patient access, quality of care, patient satisfaction, provider satisfaction, and mission readiness that are tracked on a regular basis. Finally, the financial resources available to implement further collab- orations must be assessed relative to the challenges of implementation. Because of its status as the first demonstration of an integrated VA/DoD health care facility, the Lovell FHCC received substantial resources from the departments that might not be available to future integration efforts and, if provided, would significantly increase the cost side of the cost-benefit equation. IMPLEMENTATION INITIATIVES An accurate documentation of the actual changes made at the Lovell FHCC is critical to evaluating the successes and failures in North Chicago to inform other collaborations between DoD and VA facilities. The central question involves change. Specifically, what changes are made by whom, with whom, and with what results? Examples include the acculturation of shared mission and vision through the establishment of joint governance

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APPENDIX B 197 and leadership structures (see Organizational Capabilities and Readiness), joint business offices and a joint strategic planning process, development of multidisciplinary teams and ongoing and continuous communication mechanisms, the combining of departments and services, the transferring of personnel, staff orientation, shared EHR system implementation, and many other such changes. INTERMEDIATE OUTCOMES Intermediate outcomes can be categorized in terms of cost and effi- ciency, clinical processes and outcomes, patient experience, and education and research. Cost and efficiency measures include various measures of productivity as well as cost per patient. Clinical process measures would include the Healthcare Effectiveness Data and Information Set, the DoD, and the Joint Commission benchmark measures. They might also include patient and staff satisfaction measures. Research and education measures could include the amount of research funding generated but also the num- ber of articles published in peer-reviewed journals, particularly articles jointly authored by DoD and VA researchers. Each potential collaboration should also be evaluated on intermediate outcomes based on its unique organizational mission, strategic goals, and objectives. Some examples at the Lovell FHCC included developing in- house surgical capacity, upgrading the emergency department, extending the range of specialty services provided onsite, increasing professional op- portunities for staff, improving the operational readiness of the recruits and other active duty servicemembers, and increasing the clinical competence of Navy providers. LONG-TERM IMPACT While intermediate outcomes can usually be observed within a year or 2 of implementing an expanded collaboration, it is also important to examine the longer-term impact that emerges over a 3- to 5-year period. The impact can be measured by responses to key questions. For example, are the initial positive outcomes sustained over time (e.g., in the areas of health care value and efficiency, access, patient clinical outcomes, patient functional health status outcomes, patient experience measures, and re- lated metrics)? Is there growth in the patient population served, admis- sions, and other indicators of service use? These data should be compared with comparable data available from private-sector institutions to better examine the overall nature of a DoD/VA health service impact in a given geographic area. Finally, it should be asked what additional innovations in

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198 LOVELL FEDERAL HEALTH CARE CENTER MERGER new program development have taken place as a result of the collaborative activity established several years earlier. While the committee’s framework can be used retrospectively to as- sess the Lovell FHCC experience, its greater potential is as a template for evaluating and learning from future collaborations between the DoD and the VA. It can be used both by an external entity to provide an independent assessment of collaborative activity as well as by the collaborating institu- tions themselves to assess their ongoing progress.