system. >> well, i thank you for that. i think i echo you, this physician leadership piece i really have buy-in on that. i'm somewhat biased that mayo clinic plucks their leadership from their physicians and that rotates through. that's proven to be a successful model. i yield back. >> thank you. i would like to take the -- thank the entire team that has worked on this. it was not just you too. obviously our goal was to provide care to those in need, for our veterans. one of the things that i've seen that assures our veteran patients as much as anything else is having a primary care doctor they call their own. that's one of the successes that i see. what i do not like is the stigma sometimes that any doctor that's not within those walls is a non-veteran doctor. think we need to change that stigma. there are va doctors just as much as anyone else, that this he are part of a system. when it comes to choice, i think we need to embrace greater choice because the decisions on referrals and choices should come between the primary care doctor and the patient. we don't need another layer of bureaucracy of people that don't know the doctor or the patient that decide who you get to go to, where and when. because as you know, making a referral is based on many things in knowing your patient. it has to do with personality sometimes. it has to do with the level of expertise. it has to do with co-morbidities and the severity of those quo morbidities and there is no panel that can embrace that. only the primary doctor and the patient. that's the kind of system i think we need. because if i was a patient in that system i would be saying, doctor, are you referring me to this person because you have to, or because it is the best fit for me? that's what we have to open our minds to is having that capability. we've got to know the cost and efficiencies of what's taking take -- taking place. i've said since the day i got here almost four years ago, how much are you spending per unit are you producing? we did have one independent survey here. they said that for a primary care visit, it was between $400 and you can make a pretty good $600. living on the outside $400 to $600 per patient visit. obviously we have to have that type of data to make our decisions. certainly use the example of an organ transplant team. not every va should have or can have an organ transplant team. you have to have within the va a system that people can refer to because that's the most efficient, the most effective and that is the best care. i'm getting to a question. and that is, where do we need to go as far as next moves? i think we all kind of agree that the electronic record is a first move. and along with that, the decision on how we go about handling a board of directors constitutionally or otherwise. so beyond those two, what would you say would be the next move where we can weigh in and have some impact on the next move in better in our situation? >> we may have different points of view on this. i would i would say the personnel system itself. one of the critical elements is attracting talent. there is still a lot of openings within the va system in all types of jobs, whether it's leadership or front line or positions -- physicians. and i think that looking at how to create a more organized system that ensures that in all positions there is an ability to attract that talent. i actually think that with that, va would do a much better job attracting talent across the country, because there are many people, including some at henry ford, that have gone to work for the va because they want to help veterans. i think that if they felt that this system were more efficient and effective, they'd be there. >> i think you clearly need that. but i think ultimately at the end of the day cloe, it is about the people that make it work. it is not about bricks and it is not about bricks and mortar changing the culture. that's going to require sustainability at the leadership and a sustained push at changing the culture of the organization. the focus clearly has to be on the patient, the veteran, and how you are going to do the best thing for the veteran. everything will flow from that. that is your northstar. and everybody in the organization needs to understand that from the get-go. >> >> every ship the comments. i yield back. >> did the commission look at all about the difficulty that the va being able to hire military doctors and the da? other any obligations or issues with that? you may not have the answer. i just want to oppose it. mention, i think my colleague, mr. o'rourke for , bringing up residencies that we've increased them. my my understanding is the va has not been able to assign all of is them, only 300 out of the i just want to take a moment to 1500. make an appeal to my republican doctor colleagues to address the medicare cap and the time extensions. i would hate to lose those because of the clock is running out. one issue that's come up over and over again is the way that in our bso tomorrow, from are concernsony, there are regarding private sector metrics. the va has testified many times that the private sector does not measure things that are important to veterans health care. how did the commission envision the va adopting private sector measures if the private sector does not measure them? does not measure them? health factors that in combat experience affect people. i think there is a way to work toward that set of metrics that could be very comparable. >> we're looking at the same sort of things. here is the thing. are they truly comparable? i know you do these metrics. >> being in detroit, we live in a world of trying to always have reasons why our data looks worse. and we try not to have those excuses. that we clearly believe that are strategies to improve care even when we have a tough socioeconomic group of people with poor health conditions. we serve as many many organizations do a lot of veterans that don't seek care within the v.a.. so i think we've got to really drive toward those kinds of metrics that push us in a direction of much higher performance. >> as you know, comparing the va to private sector care is not always a fair comparison. for instance, the va must secure to federal hiring and firing practices that allow for fair treatment of due process. you heard you areengage with one of the other members. i was delighted to hear that you believe a central problem is leadership training and follow-through, making sure there is progressive discipline. and that a lot of these personnel procedures exist in private sector care as well. and i might have you elaborate more on what you said before because accountability is one of the things that you're struggling with. >> it is very easy in a health care environment to find reasons why people don't perform. it just is. often there is a pattern of making excuses for people. and it is critical that we push on that level of accountability in performance in all positions. front line staff, physicians, nurses, leaders. and i and i think that's part of the culture that toby and i have talked about today, is creating that sense that you have to perform at a high level and that in fact you're going to follow through on making sure that if people aren't doing that, that there is consequences. >> >> i would just add to that, any time i found a problem, regardless on a nursing floor or on a hospital, goes right back to leadership. change the leadership, you put a better leader in, you get better performance. i can't stress too much the importance of leadership. >> and investing in the training. caller: >> absolutely. >>-- >> absolutely. >> and you believe it is possible for there to be accountability that we can improve accountability at the v.a.. >> there has to be accountability. do you not have accountability when you get voted on every year? >> but in other words, we don't do it with due process. the due process has to be a part of that accountability system. but leadership has to work with that due process. >> let me make a comment though. i do think human resources as a division within va is undervalued and underinvested in from my vantage point in terms of the quality and the experience of hr leadership. because it really takes strong leadership on the hr side to really put those processes, systems, in place to make sure that people are following them. and when we talked with some of the hr leaders, we did not get the sense that that was the tradition of the va system to have that level of leadership. >> i would completely second that. it was embarrassing to hear that the level of hr activities at the v.a.. >> so perhaps rather than focusing in on the due process procedures and all of that, there is some value in that. but focusing on the investment in hr would be a worth while thing for this community to look at. >> yes. >> thank you. >> just a quick comment. phenomenal work -- work and you bring to this committee that we as the committee expect and the taxpayers expect and that's credibility. the way i understand the math, you guys command $13 billion of revenue between both clinics be with and that's done successful. so you are the experts in the room on managing health care. on the choice, certainly we are all fortunate on the committee here to have thousands of veterans in our districts and we realize how important we are to represent them and how fortunate we are. i'm a big advocate of choice. and the argumentative's heard against it as far as expanding the distance or taking away the obstacles is that two weaken the va system simply because you could possibly have a migration of patients. in my opinion i think it would actually strengthening va system. it did make some more competitive things get better with competition. doc, back to your comment, i've worked with the emr as well as the three physicians on my right have. you said the cleveland clinic reports up to 100 quality metrics. you and i both know those metrics should be reported just like that with an emr because they are entered into the database. so that answers the question of quality metric measurement right there. so it's a huge thing to get emrs in place. they work. and again, we need to do it commercially. the way you eat a whale is one bite at a time. of those four things you highlighted in your testimony, the emrs, and the supply chain. hopefully the va is leveraging their volume of catheters, name whatever -- trache tubes. but if they're not, i think you said you guys save $274 million over a period of time. if if the va's not doing that, then, wow, shame on them for not getting in the game long ago. because they order millions of quantities of supplies probably on a quarterly basis. do do you have any comment on that? >> yes. i think one of the other things i emphasized is that particularly for physician choice issues, like pacemakers or the artificial knees or hips or that, to get the physicians involved. then you can drive down to a couple of choices, and then you can drive the price down with the providers of those pieces of equipment. >> it's just good business. >> interestingly, the va does a terrific job on drug purchases. >> yes, they do. >> why >> i yield back. >> thank you, mr. chairman. i want to welcome you both and thank you for your leadership and service. district, over 60% of the veterans have to travel off i went at a minimum of five hours by air for medical appointment. in the commission's final report as part of the commissioner's site visit observations, the report cites poor access to va care for rural veterans as one of the major weaknesses of the v.a.. for instance, in american samoa, the hospital is in such need of upgrades to facilities and equipment, as well as being short staffed, that the va drastically limits the use of the hospital for va health care. will the u.s. insular areas included in this evaluation as part of the underserved and/or rural areas? and, would you please highlight which of the commission's recommendations aim to address these underserved areas, especially those you think would apply to be u.s. insular territories? >> you know, to be candid, we have not spent time on the specific issues that your place of origin really has. but but on the other hand, we did pay a lot of attention to the issues of rural access and really thinking about how to provide improved access. this was one of the reasons we thought it was so critical to really look at a more integrated model of care. because in many parts of our country and beyond, we have situations where veterans simply cannot get the access they need locally through the va, but in fact are using in some cases private health care. but perhaps not organizing it as well. and the organization is actually very critical to the outcomes of care, care coordination, making sure people have the kind of providers that they need. so what we recommended was this integrated model of creating one system so that in every part of where veterans live and work, that they have access to what they need in a way that really enhances their outcomes. but we did not look at that specifically. >> thank you, mr. chairman. i yield back. >> thank you very much. any other questions? >> i have no questions. >> i have one other quick question. it kind of piggybacks on what mr. chacon it was asking about. my question is, we all agree that due process is very important. my question is, should it take a year or longer to discipline an employee or to fire them? >> well, the way i look at that is it depends on the situation that they're dealing with. in most cases, due process is much more efficient than that. but if someone has a serious issue that has appeals built in, sometimes time has a way of increasing. but i think the key is measuring, is the process sufficiently operating. and those are things that should be evaluated to really determine whether that timing makes sense or not. >> i agree. for example, as a physician, we do annual reviews of everybody at the cleveland clinic, including positions. we do not just fire someone unless it is something terribly egregious without having gone through the due process over a period of time. sometimes sometimes that's more than a year of collecting a physician's information. but depending upon the -- we have fired some people on the spot for egregious things that have occurred. >> all right. thank you very much. also, i would like to again thank the ten veteran service organizations that did in fact provide written testimony for today. it is a very important part of the record, as is the written testimony that va provided as well. again, i think you heard from every member of this committee a great appreciation of the time and the effort that tu and all -- that you and all commission members did provide. the document is very important for us, for transforming a department that is in need of serious transformation into the 21st century. and i would say that all members would have five legislative days with which to revise and extend or add any extraneous material regarding this hearing. without objection, so ordered. with that, this hearing is adjourned. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] [captions copyright national cable satellite corp. 2016] ks at the health care system for veterans, and later, a panel of law professors on the state of free speech on college campuses. u.s. diplomats update members of congress on the violence and humanitarian situation in the south sudanese civil war. they look at actions the international community can take to address the crisis, including a potential arms embargo and the deployment of a regional protection force. this hearing of the house foreign affairs subcommittee on africa is about two hours.

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