Q&A with VA's New Hospital Chief, an Outsider

Private sector hospital and health system turnaround specialist David Shulkin, MD, takes on his biggest career challenge—turning around the troubled healthcare system of the Department of Veterans Affairs.

Almost 15 months following the embarrassing and deadly wait time scandal at several Veterans Administration hospitals, the agency has a new leader who is a physician, who cut his teeth in private healthcare administration, and who has entrepreneurial experience.

With those three boxes checked, the hope of the selection committee that recommended him to the President is that he'll bring new thinking into an agency that sorely needs it. They hope he'll be a leader who can break through entrenched practice patterns and bureaucratic snafus to build an organization that serves veterans as efficiently and selflessly as many of them have served their country.

His name is David Shulkin, MD, and he took the oath of office July 6.

Until he accepted the undersecretary role, Shulkin had been president of Morristown Medical Center, Goryeb Children's Hospital and the Atlantic Rehabilitation Institute (part of New Jersey's Atlantic Health System). Prior to that, he led a high-profile financial turnaround for New York's Beth Israel Medical Center from 2005–2009.

He also has entrepreneurial chops, as founder of Doctor Quality Inc., one of the first consumer-focused healthcare quality information web sites, which was acquired by Quantros Inc., in the early 2000s.

Shulkin says he didn't seek the VA job, but when approached, felt a duty to try to serve. He cites his father's role as a as an Army psychiatrist—the younger Shulkin is an internist—and his grandfather's role as a VA pharmacist as reasons he would like to take a crack at helping reform the organization.

Although Shulkin is not a veteran himself, many veterans groups supported his confirmation. He says their support will be critical as he tries to reform the organization. That support may become stronger if he commits to concrete reforms. A recent editorial urged him to focus on specialty care within the VA, while farming more routine care out to private providers. That specific recommendation is only one example of the scope of structural change that many veterans, taxpayers, and congressional leaders are counting on him to deliver.

Following is a conversation between myself and Dr. Shulkin shortly after he took the oath of office, edited for clarity and brevity.

HealthLeaders Media: I'm sure there's a good story behind your desire, and your selection for this job. Why did you want it?

Shulkin: Well, the issue about what's been happening at the department has been a very public story over the past 15 or 16 months. Certainly when I read about the wait crisis, I had the reaction of so many people, which was that I was really disappointed that our veterans weren't getting the type of care they should be getting.

After that sort of sunk in for a while, I began to ask myself if there was anything I could do to be helpful. Then, when I was approached… to be part of the solution, it was something that I really thought long and hard about: First whether I could be helpful, and second, whether I thought that I had the duty.

I decided that I just couldn't walk away from this opportunity—that it is too important for the country and that I personally have a mission to help be part of the solution.

HealthLeaders: How did the offer materialize?

Shulkin: First, I was approached by the administration on whether I would have an interest in exploring this. The process takes quite a while, starting with a commission appointed to identify the skill sets and competencies of the right leader of the VA.

As you know, one of the things I bring to the table is the private sector perspective. I have not worked in the VA system in quite a long time. In fact, the last time was when I was a resident rotating through medical centers.

So one of the issues that I considered was whether it was important [to the search committee] to bring someone from the outside who would bring this perspective and sort of challenge the status quo, or [whether there] was an interest in maintaining and possibly bringing someone from the inside who knew how to change things.

So that was part of the discussions we had. There is a recognition that within VA that we do have to relook at our practices and be willing to make some hard decisions and some major changes going forward.

HealthLeaders: What is your top priority as you take over at the VA?

Shulkin: My top priority, the overarching priority, is to restore the trust and confidence of the veterans' health system in the minds of the people we care for: the veterans. That's my most important mission.

What we've experienced and seen over the past 16 months is really a break in the trust between the people who rely on us and the system.

Now, how you get there, that really breaks down into a number of different strategic priorities for me, but overwhelmingly, we're not going to be successful if we don't have that confidence back in the system.

The absolute priority right now is to fix the access issue. We can't provide high quality care if people aren't able to get appointments to get the services they need.

HealthLeaders: Many of the recently exposed failings of the VA are, at some level, both a failure of basic customer service and lack of accountability. What are your views on how you instill a culture of customer service not only in healthcare, but in government healthcare?

Shulkin: When you talk about this issue of customer service, I think it's important to differentiate. Largely, my assessment is that this is not a people issue. The VA has about 350,000 employees, and for the most part my assessment is they are extremely committed people who are committed to the mission and who want to do the right thing.

There were a few, a relatively small number of people, who had lost their way around the values and mission and we've worked hard to remove them from the system. But this is really a systems failure, not a people failure.

The systems we have become so cumbersome and bureaucratic that it really has let the veteran down. So my goal is to help the people who work in the system become empowered to really be able do what they came to work to do which is to serve veterans. Everything I'm doing is to refine the way we do business to help our people do a better job serving veterans.

HealthLeaders: Who do you view as your top "internal" constituents? What among your strategic plans requires their cooperation?

Shulkin: When you operate in a public system like we do, there are large numbers of constituents. Clearly our number one constituent is the veteran. Everything we do needs to put veterans at the center of what we focus on. So establishing—as we're doing our planning—making sure there is feedback and input from veterans themselves is the number one internal priority.

We're fortunate in that we have veterans' service organizations that represent millions of veterans that are very effective at being able to help us get a correct assessment of the voice of the customer, so those relationships with veterans service organizations are absolutely key.

I've never been involved in a change effort that doesn't involve your internal staff that has been successful, so it's very important that there be buy-in not only from the people we serve but also our staff and physicians.

HealthLeaders: How do you think your experience running private sector hospitals will help you as you take over the VA?

Shulkin: I think that one of the root causes of what led to some of the issues in VA was a sense that the VA system was different, and that the VA system was in many ways not comparable to what was going on in the rest of healthcare.

Frankly, my perspective is that the same market forces that are impacting private hospitals and private physician groups are impacting VA. That is, a strong drive to reexamine what you're doing, a drive to create better value, to be more customer focused and to improve your outcomes.

I think my experience in the private sector in having to sit down and really relook at business models is going to allow me to come in and to challenge some of the issues in VA that frankly probably need to be challenged. Bringing those best practices from the private sector into the VA will help me in being effective in achieving the outcomes we're looking for, which is better care for veterans.

HealthLeaders: What's the biggest difference/similarity between running a thousand hospitals and clinics versus one?

Shulkin: The biggest difference is the size and the scale. Implementing change efforts on this large a level is clearly something that is very different than when you do it on a smaller and geographically restricted group of hospitals.

But the similarity is that the leadership principles do translate in running either a small or large group of hospitals. As a leader, you need to effectively articulate a vision that is communicated with consistency and with clarity, and feedback to the organization on whether we are achieving the goals or not is extremely important when you get to the size of an organization we're talking about in the veterans' health system.

One of the differences for me is that creating an effective team so that there is consistency and clarity around what the goals are is going to be extremely important because no one person can have an impact on a system this big.

HealthLeaders: How do you plan to instill a culture of accountability throughout the organization?

Shulkin: The way you do that is by really adhering to the principles of transparency. [It is] setting goals, having data that is reliable, and having those measures essentially understood and available to your leaders in the system and to the frontline staff.

Feeding back the progress or the lack of progress with those goals and measures, I think, is the way you hold people accountable. The data that's available in the VA system makes this extremely possible to do if you adhere to the principles of transparency and regular communication.

HealthLeaders: How much difference do you think one person can make in any bureaucratic institution the size of the VA?

Shulkin: Well, I guess we're going to find out. That's the best I can say. I'm a realist about this, but I am going to approach every day as an opportunity to make a difference and improve. That is the way I've thought about coming into this job. This is a very big task. It is a very big system and, as you said, the impact of any individual is really unknown.

But the way I am approaching this is that it is not only a critical mission but this is also a huge privilege to be given the opportunity to lead this system, so I will take advantage of every minute that I have in this role, give every effort, [and draw on] all my past experience to help me work within the system to make a difference.