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Interview: Dr. Robert Petzel

Under secretary for Health, Department of Veterans Affairs

Dr. Robert Petzel was appointed under secretary for health in the Department of Veterans Affairs (VA) on Feb. 18, 2010. Prior to this appointment, Petzel had served as VA’s acting principal deputy under secretary for health since May 2009.

As under secretary for health, Petzel oversees the health care needs of millions of veterans enrolled in the Veterans Health Administration (VHA), the nation’s largest integrated health care system. With a medical care appropriation of more than $48 billion, VHA employs more than 262,000 staff at over 1,400 sites, including hospitals, clinics, nursing homes, domiciliaries, and Readjustment Counseling Centers. In addition, VHA is the nation’s largest provider of graduate medical education and a major contributor to medical research. More than 8 million veterans are enrolled in the VA’s health care system, which is growing in the wake of its eligibility expansion. This year, VA expects to treat nearly 6 million patients during 78 million outpatient visits and 906,000 inpatient admissions.

Previously, Petzel served as network director of the VA Midwest Health Care Network (VISN 23) based in Minneapolis, Minn. In that position, Petzel was responsible for the executive leadership, strategic planning, and budget for eight medical centers and 42 community-based outpatient clinics serving veterans in Iowa, Minnesota, Nebraska, North Dakota, South Dakota, western Illinois, and western Wisconsin.

Petzel was appointed director of Network 23 (the merger of Networks 13 and 14) in October 2002. From October 1995 to September 2002, he served as the director of Network 13. Prior to that position, he served as chief of staff at the Minneapolis VA Medical Center.

Petzel is particularly interested in data-based performance management, organization by care lines, and empowering employees to continuously improve the way we serve our veterans. He is involved in a collaborative partnership with the British National Health Services Strategic Health Authority. In addition, he co-chairs the National VHA Strategic Planning Committee and the VHA System Redesign Steering Committee.

Petzel graduated from St. Olaf College, Northfield, Minn., in 1965 and from Northwestern University Medical School in 1969. He is board certified in internal medicine and on the faculty of the University of Minnesota Medical School. Petzel was kind enough to sit down with Faircount senior writer John D. Gresham recently and discuss the VHA, particular programs and initiatives, and the Department of Veterans Affairs in general.

The Year in Veterans Affairs & Military Medicine: What did you do before you came here (the Department of Veterans Affairs – VA) to go ahead and run the day-to-day operations of this place?

Dr. Robert Petzel: Well, first of all, I’m phenomenally fortunate to be given this opportunity. This has been a dream of mine for a considerable period of time. Tracing my career all the way back, I started as a staff physician in the Minneapolis VA facility. I was the chief of staff for the chief medical officer in that facility for about 18 years, and then in 1995, I was selected as one of the original network directors when Ken Kizer reorganized the VA into those 22 networks. In 2002, we merged two networks, the one I was in and the network below us, to form a bigger network called Network 23, where I served for a number of years as the network director. In May 2009, I was asked to come in to be the VA’s acting principal deputy secretary. This was after Dr. [Michael] Kussman had left, and Dr. [Gerald] Cross was made the acting under secretary. The announcement came out shortly thereafter for the under secretary’s job. I applied and was fortunate enough to be chosen and eventually confirmed by the Senate, and actually sworn in to the under secretary’s job on Feb. 12, 2010.

What is your medical specialty?

I’m an internist. I at one time had specialty training in nephrology, but I haven’t done any nephrology for a long, long time. I would basically be a general internist.

What is your basic portfolio of responsibilities here at VA?

Well, if I could, John, maybe I could talk about what I visualize the Veterans Health Administration [VHA] needing to do as a start, and we’ll lead into some of that other stuff. When I applied for this job, I spent a considerable amount of time thinking about my experiences in VHA and basically came to the conclusion that there were three things that I would want, in a general sense, to work on if I were to become the under secretary here at VA. One of them was to create a mission statement for VHA. I think it’s very important for an organization to have a clear understanding of where they want to go so that each employee can look at the work that they’re doing and relate it to what the organization wants to become, or relate it to what the organization is trying to be. So I wanted to create a mission and a vision statement.

Secondly, I thought that we needed to align all the elements of VHA. We have this incredible array of programs, whether it’s geriatrics, telehome health, a hospital-based home care, a variety of different programs in geriatrics, in mental health, it just goes on and on. Nobody on this planet has the … depth and breadth of programs that VA has, but they’re not well integrated and they’re not all aligned to accomplish the same thing. Nor is our performance management system, nor is our reimbursement system, the VERA [Veterans Equitable Resource Allocation] model, etc. I felt that all of these things needed to be aligned and integrated to accomplish this vision that we’ve described.

Then the third general area had to do with variation. There’s tremendous variation within the Veterans Health Administration; variation in our organizational structures around the country, variation in our business practices – at every single medical center, they’re different – and variation in the way we organize medical care and the kind of medical care that we practice. That variation is not always compatible with good quality practices, and it’s costly. So my third general issue with VA was to reduce the variation in the system. We’re a national integrated delivery system and we should be doing things in a more standardized way, not a centralized but a standardized way. Those are the three general areas I felt that we needed to address. The first of those that has been addressed is the mission and vision statement that we have developed through the help of many people in the organization, a new mission statement that I would be delighted to read to you, if you like.

Please do, sir.

“VHA will continue to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are both patient-centered and evidence-based. This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery, and continuous improvement. It will emphasize prevention and population health and contribute to the nation’s well-being through education and research and in service in national emergencies.”

So, our transformational delivery system will be patient-centered, continuously improving itself based on team care, data-driven and evidence-based, emphasize population health, and will provide value. Those are the six fundamental pieces of the kind of delivery system that we want to develop, or that we‘re visualizing that VHA needs.

Sounds like the kind of business foundation that a large corporation could use to start turning a profit.

Well, certainly any health care organization could, absolutely. This is particularly, I think, consistent with the themes that Secretary [of Veterans Affairs Eric K.] Shinseki has identified, that we’ll be veterans- and people-centric, that we will be results-oriented, and that we will be forward-looking. This vision statement is very forward-looking.

What was the process like to create both the mission and the vision statements when you began? Because, as you say, there had not been a new one in a very long time, if at all. How hard is it to go ahead and change that direction?

Well, what we did when I came into the job, we actually created six work groups, and I’ll talk later about the other five. One of the work groups was what we could call a vision work group: That was a group put together to help create a new vision for the Veterans Health Administration. It was co-chaired by two individuals, representative members from around the country at various levels in the organization. They began the work of involving other people as well, trying to craft a new vision statement with some guidance from myself and others. Now, it went through a number of iterations. We went back and forth with drafts, etc. Finally, using that group of people from our field and people in the central office here, we arrived at a common understanding of what we wanted for a vision statement. We then included the deputy secretary, our Office of Public Affairs people, our people in OCLA – Office of Congressional and Legislative Affairs. So, we engaged the entire organization eventually in vetting, if you will, this new vision statement and finally came to an agreement that this is what we wanted, and this is what everybody approved. You see now that we are just in the process of getting to roll this out. I have the advantage, personally, of having worked in this organization a very long time – 40 years. In terms of understanding it and knowing it, its nooks and crannies, etc., I have a tremendous advantage, I think, over other people.

You bring up the point that this process involves not so much standardization or centralization, but trying to improve the whole range of organizations and processes and ideas through use of modern data and performance-based processes, correct?

It’s definitely not centralization, but it is standardization. We are a national integrated delivery system and should be more standardized. If a patient goes to a clinic in Muskogee, Miami, or Minneapolis, they ought to see the same basic organization of the clinic and the way it functions. They ought to receive the same kind of medical care for a particular problem. That’s one of the things that I’m trying to accomplish, is to ensure that people get the same kind of experience wherever they might be.

So a “little old lady” veteran in Texas is going to get the same basic processes and care that she might get down the road in Baton Rouge?

For the same problems. Correct. This shouldn’t be unique to the VA. This is the way the health care system in this country ought to look and ought to function.

How do you see the use of data-based performance management techniques helping you do this?

The crucial thing is that people, first of all, need to have data at the point where the work is being done – about the cost of their work, the quality of their work, people’s satisfaction with their work, and the access to that work. Those are the four terms or basic domains of what we call “health care value.” If people have that data, then what we expect in our delivery system now is that they will have a process by which they sit down periodically and they look at their data. They will say, “What needs to be improved?” They decide what needs to be improved, they decide on the changes, and they make those changes in their work group. Let’s say it’s time in a primary-care clinic. Then they look at their data subsequently to see if the changes have the effect that they indeed wanted to have. The data is absolutely fundamentally important. You cannot manage, you cannot improve the work you’re doing, unless you’re able to measure the work you’re doing.

Metrics are important?

Absolutely, fundamentally important.

Part of this of course is the development of electronic health records –

The electronic health record that we have helps tremendously in accumulating this data. It also is a tremendous – on a different level, it is a tremendous tool for managing patients. It’s just an incredibly important tool for both the individual patients and populations of patients.

As we all know, nothing’s perfect and there are more than enough challenges for you and your fellow VA executives to work on. The big one everyone talks about is the question of access. There’s been a recent announcement by the president on several of your initiatives. What are you doing in your capacity to help improve the qualification and access process for veterans who are, if you will, for the first time trying to either gain access to their benefits or gain access to new benefits for emerging conditions?

That’s an excellent question. I believe that the choice that people are going to have for a health care system and the choice they make is going to be based on two things. One is the accessibility of the system that provides good geographic and chronologic access. Two is how satisfactory is the experience? How are they treated as an individual and as a patient?

You’re not just talking about the veterans system, but all health systems?

For any system, but it’s particularly important for us. That’s one. Now, two is that access means a lot of different things. I’d like to explore just a little bit what that’s about. It means, in the standard sort of ways, are the VHA system’s clinics geographically accessible, and can you get an appointment in a timely fashion? Those are two elements. But access also means do they have all the services that you need? Do they provide an experience that literally draws you into that clinic? Is it available to me? Will it meet my needs? Does it have the kinds of things that I want? We have 8 million enrollees and we have 6 million approximate users. We need to attract and we want the system “accessible” to those 2 million people who aren’t using us now, but who are enrolled with us. That’s number one.

Number two is that we want to make our system more geographically and chronologically available to us. We used to have a standard where we wanted 95 percent of our patients to receive their appointments within 30 days. We’ve now moved that standard down to 14 days. Beginning next year, we’re going to be measuring access to our clinics based on a 14-day standard. We’re expanding our access geographically by adding community-based outpatient clinics, doubling the number of people that we have on tele-home health, increasing our home-based primary care programs so that we bring more care into the homes. When you’re talking about people who live in rural areas particularly, this is a tremendous way to improve their accessibility. They may be 400 miles away from a medical center, but they can be monitored at home – their EKG, their heart rate, their blood pressure, their weight – all of these things can be measured just like you would do in a clinic visit from the home. The nurse practitioner, the nurse, or the doctor can manage that patient in their home without having to have them come into a clinic, which is sometimes some distance from where they live. It’s a tremendous advance in terms of accessibility. The fourth element of that is that we’ll be buying more care in communities. We’ll be using our non-VA fee-basis program to provide better access in many communities. Access is very complex, but incredibly important as a foundational part of a health care system.

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John D. Gresham lives in Fairfax, Va. He is an author, researcher, game designer, photographer,...

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    Edward F. Purcell

    All the heads of VA medicine should ask us everyday vets about our opinion of the VA health services. Our area here in the Gainesville, Fl is one of the worst according to a VA doctor of my acquaintance as well as my own personnel experience. I know that the staff can not get fired because they are government protected and the employees let us know that by their horrible service. Not all but a good majority of the ones I have been in contact with could care less about servicing the vet then in paying more attention to the sandwich they are eating or to their nails and retouching up the polish on them. Even in such places as the cafeteria the absolute waste and uncaring attitude is eveident. In the Gainesville hospital cafeteria there is one person whose only job is to make sure that the condiments, napkins and plastic ware is kept full and that the little surface area is wiped clean. They do this hours upon hours never moving from that spot except to talk to the cashier, when one is there. The VA help staff in our area, Ocala, FL , will not return phone calls so any questions that one might have goes unanswered and we are left floundering without answers leaving ourselves open to make mistakes when filling out forms. When they do answer the phone they do not have the answers and shuffle us off to another person who does not have the answers. I can not afford my medication any longer and since I can not pay for it with any regularity they arbitrarily take it out of my disability. Living on the little bit of SSI and the little bit of disability makes it a choice of what bills to pay, food or medicine is on of my latest choices. This is the thanks I, as a veteran of eight years active service get for my honorable service. If I had known how this country was going to treat me as a VN era vet what this country has become, (more socialist then a republic) perhaps I would have been better off being a hippie and demonstrating. I probably would be treated better by welfare than I am now. I am so damn disappointed that this is what I face after living an hones and hard working life. I lost everything while those who caused it gained everything. To bring it full circle i can not afford my VA medicine, the VA staffing here locally is horrendous and nobody disciplines them for their inactions and self serving attitudes. This is not a one time occurance as it happens over and over again.