'We are your colleagues': VA's Dr. Shereef Elnahal looks to expand partnerships

When Shereef Elnahal, MD, U.S. undersecretary of health for veterans affairs, speaks about efforts to improve the Veterans Health Administration, his words likely sound familiar. That is because Dr. Elnahal's priorities, as head of the nation's largest integrated healthcare system, are practically the same goals as those of private hospital leaders.

His team is working to hire more people to work in the system's 1,298 healthcare facilities, 171 of which are acute care hospitals. They focus on efforts to ensure services provided to more than 9 million veterans is the safest and highest-quality care. And they continue to double down on efforts to accelerate the VA's journey to becoming a high reliability organization.

Dr. Elnahal is marking his first anniversary in his position, a role that went unstaffed for several years before he was confirmed July 21, 2022. He spoke with Becker's about his inaugural year as undersecretary and the strides his team has made in advancing key objectives, including making sure all veterans with suicidal ideations get care they need at VA facilities and private sector hospitals. The VA will cover the costs of non-VHA provided care in these circumstances.

Dr. Elnahal also said he is focused on working with private sector healthcare leaders to ensure that the proverbial "rising tide," which in this case is an across-the-industry focus on safety, quality and patient experience, does indeed lift all "boats."

Editor's note: These responses have been edited for clarity and brevity.

Question: Hospitals across the country are trying to attract and hire quality employees in all departments. How is the VHA doing when it comes to workforce recruitment?

Dr. Shereef Elnahal: We are pleased to have unprecedented demand to work in our healthcare system. We're getting a record number of applications across the country. Part of that is our aggressive recruitment efforts and advertising of available positions. I've made this my most important foundational priority for this fiscal year because we know what that demand curve looks like. Our veterans are demanding more care for us. 

Additionally, out of the debt ceiling negotiation, VA medical care did extraordinarily well as a bipartisan part of the agenda. As a result, we have the funding to hire more people, and that's going to be absolutely necessary to make sure that care is accessible to veterans. We've hired more than 40,000 people externally into our system since Oct. 1, growing our workforce by 4.9 percent. We may surpass 5 percent. 

Q: What is the most important thing you want hospital leaders in the private sector to know about the VHA?

SE: Hospital CEOs should be aware that, chances are, you have a VA [hospital] in your community or near your community. VA hospital leaders are your colleagues. I was an academic medical center CEO, so I was on your side of the fence. I always felt it was very important to learn from my peers. I looked to have healthy, collaborative relationships with other hospitals and health systems. 

The reality is, we're colleagues by default. About one-third of our care is purchased from the communities where veterans don't have access to VA services. By necessity, we have to purchase that care and coordinate that care with all of you. For the benefit of veterans, we should be working closer together. 

Q. How can academic medical facilities partner with the VHA? 

SE: Section 704 of the PACT Act is a great piece of legislation because it allows us to work independently with our academic affiliates. It allows us to create infrastructure with the most modern technology that will provide the best, most innovative care. 

We already have two really exciting partnerships in discussions with the University of Pennsylvania and Stanford University to expand healthcare to veterans. Very importantly, it will also make the training and research infrastructures even more robust on these campuses. 

I encourage any of our academic affiliates who are reading this to reach out to us with any project that you're thinking about. And chances are if you're thinking about expansion in your regions, we're thinking about the same thing for veteran populations who are there. These partnerships will strengthen the VA and allow for the robust training of a pipeline to grow our workforce.

Q: Like so many of your private sector colleagues, the VHA is on a journey to high reliability. How are you applying high reliability principles — and achieving results — in such a vast healthcare system?

SE: High-reliability efforts began at the VA right before the pandemic started. If this was a less mission-driven organization or an organization that didn't place the care and well-being of its patients — veterans — at the top of its priority list, it would have been easy for the pandemic to have distracted us from that initiative. 

But, actually, the opposite happened. The VA's focus on the principles of high reliability like sensitivity to operations, deference to expertise and assessing vulnerabilities and areas of possible harm has been excellent. The first phase of additional training of clinical staff across the system has been completed. We are now training new employees and onboarding new folks, which is our most important priority for this year.

On top of that, we've set up the systems and processes that allow us to execute on high reliability efforts like peer huddling, safety huddles before procedures and having leaders of hospitals get together and talk about the vulnerabilities per day and the assistance they need to create safer systems of care. These are the principles that we're combining with really important cultural work and we're already starting to see the dividends of these efforts.

Q: Have you seen any improved metrics since focusing on the VA's HRO efforts?

SE: Our safety incident reports have gone up, which is a good thing. We know that nowhere near all of the safety vulnerabilities that exist are reported in any healthcare system. So the fact that those reports are going up is a very good sign.

The other reassuring data element is that near misses are now a much greater share of incidents reported than actual harm, which is also what you want to see with a healthy and evolving safety culture. So the total reports are going up, but the share of near misses and proactive reporting for things that didn't ultimately reach the veteran, still allows us to learn and improve the system.

Q: What can be done to encourage hospital staff to report these safety-related incidents?

SE: Folks who don't feel like there is a supportive safety culture, who do not feel psychologically safe, won't report the vulnerabilities that they know. With high reliability training on high reliability principles led by our leaders across the country, it helps to surface what folks know is wrong with the system of care.

You really can't fix a problem if you don't know about it. Leaders across the system benefit from hearing about these problems, and it's their responsibility to make sure that there is an environment of psychological safety that lends itself to reporting. That's a really big feature of our work on high reliability.

Q: Is there anything else you want Becker's readers to know about the VHA and the care you provide?

Suicide prevention is our most important clinical priority. It is a public health crisis that we've seen for many years now and it was worsened by the post-9/11 veterans coming home with significant trauma, posttraumatic stress and mental health conditions. This is not just a clinical care mission, which it is, it's also a public health mission to understand what we can do to better detect suicidal ideation, the existence of mental health conditions, but also to be there for veterans in the community.

I think it's telling that about half of veterans who die by suicide have never presented with the need for mental healthcare.

We want to make sure our community partners know that the VA will pay claims for care performed when a veteran presents with an emergency suicide risk.

(Editor's note: "Veterans in acute suicidal crisis will be able to go to any VA or non-VA healthcare facility for emergency health care at no cost — including inpatient or crisis residential care for up to 30 days and outpatient care for up to 90 days. Veterans do not need to be enrolled in the VA system to use this benefit," according to a Jan. 17 VA news release.)

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