Bali because we go back a ways as a change agent experienced in leading change in complex Health Care Systems and networks. He is committed to improving the Patient Experience and drives initiatives focused on clinical care, Quality Improvement and systems redesigned mouth at Johns Hopkins medicine. Fda, led the department in the transformational journey to provide veterans with easier access to both the va care in private or cared that he oversaw the vas community of care network, which includes about half a million providers, academics and Community Networks and expanded telehealth across our vast system of care, treating about 1. 5 million patients annually. A significant improvement that was done in terms of providing access to care and increasing access to care for veterans. He is a nationally recognized expert in hiv medicine and health equality. He has published over 150 abstract chapters in leading journals. He has made important contributions to the understanding of Patient Engagement and health care individual environmental factors , influencing access and participation in care. He is Board Certified in internal medicine and Infectious Diseases. He received his bachelor and medical degree right here at the university of florida. Hes also completed internal medicine residency at Johns HopkinsInfectious Disease fellowship at the hospital of the university of pennsylvania. He also holds a masters in Public Policy from Princeton University in masters of science in Health Policy researcher in the university of pennsylvania. Please join me in welcoming dr. Dr. Rihiyah. [applause] can you hear me all right . Its a pleasure to be here bringing together my undergrad in medical School Training here at the university of florida, my work at the va, so its a bit of a homecoming to be here. Thank you for inviting me and for having me. Im looking forward to our conversations today. I really wanted to share a couple of thoughts about how Health Health care is changing in America Today and really draw on lessons from veteran affairs and how other Health Care Systems and experts can use those lessons to continue to drive forward positive change for patients and for providers and the population atlarge, which is really the title of our top today, how you take ideas and put them in implement them into this and the change in health care. I just want to for set this up tonight and really talk about what is changing in health care and how you think about that as really the context for conversation today on how to lead change in Health Care Systems and networks. The first is to think about our population is changing. Many of you know our population is aging and part of that, more for patients who take care of house multiple chronic conditions. We are seeing multiple chronic conditions are on the rise. We also know, over time, to be able to manage those individuals, we have to rely on more than one provider, and more than one specialist. In the primary care world and the specialty world, the number of referrals, the likelihood that that patient would leave and office with a referral to see another dr. Has been rising. You can see this means there are multiple providers involved in the delivery of healthcare, not just one primary care provider or one specialist. We also know that healthcare is now delivered in multiple settings. You can watch to a Grocery Store or pharmacy and you might be able to receive a flu shot. Thats very different than what was occurring ten, 15, 20 years ago. Telehealth or how you actually communicate through a smart phone to deliver healthcare wasnt around before. The venues where you can actually receive healthcare has also changed. Whats that mean . I wanted to give one example thinking about opioids which is in a lot of our clinicians mind these days. Weve seen the number of opioid prescriptions, and this is data from medicare that are prescribed by more than one provider has been on the rise. In 2010, only about 40 of medicare beneficiaries, and this was about 1 Million People they looked at, had a prescription from one provider. That means 60 have prescriptions from more than one provider. When you look at those that had four providers prescribing , the likelihood that their prescriptions overlap for about 70 of the time. You can imagine thats a problem if you have a to prescription, and those medicines are very dangerous and can result in bad Health Outcomes. Thats exactly what happened. The more subscribers, the more likely you are to get admitted because of use of those opioid prescriptions for the starts to highlight a case in point more providers, more settings, more chronic conditions that might have pain and this is one example of how we want to make sure we avoid and prevent changes in healthcare. One thing thats been around for a long time that hasnt really receive the attention it deserves is really thinking about the social determinants of health. If you look at the graph, healthcare, if someone comes to see me, the overall contribution to their health is only about 10 . Their genetics, the behavior, the environment and social and economic and legal situations, all of that has a bigger impact on their health and wellbeing than a prescription i might write my office. That means we dont just need better medicine and better treatment, we need to think about how we can get out there and address what we call the social determinants of health. One way of doing that is the Health Policy which means every policy that we pass, whether its the local level or the National Level will have some impact on Health Whether its transportation and how quickly you can get between your home and a doctors appointment, whether its agriculture or environment to policy, all of that impacts the health of our community. The cdc and others have been promoting policies. Think about the Health Impact of the various policies that local through National Government might be working on. This goes without saying, the cost of healthcare in treating these multiple chronic conditions is deftly on the rise. You can compare and contrast between 2006 and 2010, the cost of treating patients with five or more chronic conditions is on the rise. Its very interesting. They overwhelmingly take up the burden of cost. Ill give you an example. For those individuals with five or more chronic illnesses, they only represent a small portion of the population but they make up 35 of the health care costs. What we have to do is focus on how we can better coordinate that care and manage those conditions and it will help start than the cost curve. The last couple. I wanted to make before we get into the meat of the conversation is the rapid pace of change in healthcare. We talked about multiple settings and multiple providers and chronic conditions and the cost of those, healthcare has been changing very rapidly. This is not just something that has been happening over decades. Heres a perfect example. The movement from what we call volumes of value. Right now, many Healthcare Providers in the country get rewarded by what we call feeforservice. They get paid for their time and appointment, but they dont necessarily get paid for the outcomes they are delivering. The Health Outcomes we want to see in our patients. The diabetes is under control. They have good blood pressure. You can see in 2016 the medicare and Medicaid Services , 30 of those payments to doctors in that year were based on value which is a very large increase in only going to grow over time. One of the ways they can deliver that Value Proposition is through something called Accountable Care organizations. These Accountable Care organizations have been growing have about 923 acos across the country that cover about 32000 americans. That is a huge increase in the number. You can think about not only the change thats occurring, but how fast that change is occurring. Ill give it to other examples. One is on fda drugs that are put approved. You can see the sharp line over the last decade, the number of new drugs approved for the treatment of healthcare has been rising. Interestingly, there they are consolidating. You might see hospitals merging more rapidly and it might even have occurred here in gainesville. Healthcare is becoming more and more networked unless the last individuals are going at it alone. Lets think about that and how the pace of change thats occurring today and how as leaders in healthcare, how can you adapt to that environment. How can you create positive impacts for patients, their families in your communities . What i wanted to do is use my experience at the da. I left about two weeks ago and i was the deputy under secretary and we focused a lot on the veterans Choice Program. I was going to give you, use that as an example of how various leaders in healthcare can provide change. In 2014, the va was experiencing a lot of each each each access issues and that was all over and veterans were able to access the care they needed. As a result of that crisis, the issue, Congress Passed what we call the choice act for the veterans choice and accountability act. This act really provided the department of Veterans Affairs with 15 billion. 5billion to support i internal structure to hire doctors and nurses and 10 billion to partner with outside providers to provide healthcare. From the very beginning, that program had a number of challenges. One is that it a 90 day implementation. , its a very short time. I almost compared that to the experience of tricare which is another military type program but it took three years to get that program up and running. Its very, very constrained timeframe. Thinking about the department, the department of Veterans Affairs has about 1700 types of care. There is a lot of Different Health professionals across the country, all the way from hawaii, alaska, florida and new york. How do you communicate with all those different providers. How do you get them on the same page to move them forward. The law that was passed, the choice will have a lot of different requirements. It required the department to behave in a different way than it ever behave before and very different than other programs that it had. There were issues there in that it differed so things had to be different we need to be able to adapt to that. Next was medication. There was about 22 million veterans that live in the united states. About 9 million are enrolled in the va. Those 9 million that support the law have to get a card. It looks like a Health Insurance card, but not everyone was eligible to receive that benefit. That created a lot of confusion. When you get something in the mail that says you can get this benefit but you really couldnt, it you had a meet certain criteria that were stipulated. How do you communicate with patients across the country and let them understand what those benefits are, especially, how do you communicate when the criteria that are used change from daytoday or are very hard to understand. Lastly, infrastructure. Really the movement with the Choice Program is how do you start to leverage some of the principles that Health Insurance companies have for many years, but as a Healthcare Company they didnt really have these left. There in issues with infrastructure. Thats really a little bit of a challenge that the va faces. When i walked in, i came to the apartment three years ago and started working as the assistant deputy in the deputy under secretary two years ago, these were some of the headlines that i was faced with about the federal Trace Program being all smoke and mirrors and having problems, it leaves veterans frustrated and clinics waiting for payment. Again, all these headlines on issues that have existed with the program. We will talk a little bit about the process that we went through to create positive change, but i will tell you up front, all the stories are not rosy today either. I think theres been a lot of Forward Momentum and positive movement, but we still have a way to go to get the program and really the concept of internal and external working well. Im one of those people that likes to simplify things so when i was reflecting on how we went about creating change, i thought about what were the things that our team did that really started to move the ball. They can really be summed up by active, continuous transformation. I will go over each one of those different words today, and that might be, hopefully as we leave this conversation this evening, hopefully it will be a framework that you might be able to use in your own circumstances on how to create change in healthcare. First is active. Its really active engaging the right stakeholders in developing the future state. This was critical. Its very common for someone to come in and say i have all the answers, heres what we need to do. Typically that is a way to create a failing program. You really need to listen to your customers and your stakeholders and your patience in the community about what they need. The first thing we did was we started to think about how we can make improvements in the choice Community Care and actively engage our stakeholders. I know they do this in their own right at the department, kind of across the board. The first thing we can do is identify who we should talk too. They are our customer and the patient and the center of everyone we do. The schedulers, we need to think need to ask what worked for you and supply those to the process. We actively engaged and learned from all the stakeholders and we need to listen. We need to take that feedback and put it to use. They were in those geographies and set up ways to walk through the process. This was very important and we conducted the datagathering exercises to form what the future state was. That was key so we didnt come in preconceived, we actually gathered information along the way. What we heard throughout the process was heres our issue and we group them into six categories. Eligibility. At that time it enough they were eligible for the program or not. Theres just a lot of confusion about to i have this benefit or do i not. The referral process is really confusing. Thats when you go from point a to point b. Youre going from one hospital or clinic to another. Every one of these programs had a different way of doing that. Maybe one way you walked in with piece of paper. Another way it was electronic portal or a phone call, it was very confusing for people to manage. Which way my supposed to use it. Care coordination was very challenging. We talked at the beginning of our time about multiple providers. This is the perfect example of multiple providers. Not only are we making sure we coordinate within ourselves but how do you work with other providers. Community care networks, one of the things we learned early on was how important it was to be good partners for your Community Providers. That means making sure they have all the information they need and for veterans, making sure they had providers that meet their needs and their community. Provider payment, this is key. If you dont pay well and you dont pay on time, no one wants to work with you. We heard a lot of frustration as we did this, listening to different immunity providers and groups saying hey, were not able to get our accounts receivable or our bills paid on time. Lastly, customer service, all these different programs created confusion. How do you provide a service to not only veterans but to physicians and staff and Community Providers to get their questions answered. We kind of laid it all out there. Here are the challenges we are hearing today, and what we did is again, when i walked in, where do you start . How do you start to tackle that . Theres so much that you can do. We are going to focus on the things that are important and work on those things first. We used a process called journey mapping remap a patients journey through a specific experience. We looked at all of the important touch points as they went to the Community Doctor and back. We look to eligibility and the referral process and care coordination. The work that we are going to do has touched veterans. We wanted to make sure everything aligned to the important touch points that told us was valuable to them. The next was thinking about continuous evolved capabilities of the entities to achieve desired outcomes. What does that really mean . Change is not a oneonone thing. You dont just in fermented new program or new technology. You have to constantly evolve. The healthcare marketplace is constantly changing the needs of patients and providers are counseling changing. What you want to do is make sure you are constantly evolving and building capabilities. Capabilities will allow you to succeed in the future. They dont all come together for the greater good. So, what we did is we really thought about how can we use capabilities to link vision and action. Then, when you think about all the stuff to do, ill work on this, ill work on that, if its not coordinated we wont see that impact. We thought about we needed to start where we want to get to. The touch points that are important, thats the journey. Capabilities will feed into those and projects will be used to build those capabilities. It might sound simple, it actually takes a lot of effort to really focus the Organization Im working on projects and initiatives to build capability to drive toward those important touch points that your patient told you are key. This is really our Capability Framework that was developed at va Community Care when i was there. Theres touch points at the top and three or four capabilities the department has to develop to make sure that touch point was successful and satisfactory your customers. I will use the example of eligibility. Really what we need to do is have three capabilities. We have to be able to determine if someone was eligible, with the communicate, it might be through a selfservice portal through the phone or through information and then we have to be able to track it. Again, very simple but we are working on projects to build each of those different capabilities. Another example of Customer Experience which is that we really want to provide education to everyone knows about the program. We want to respond to increase in a timely fashion and be able to capture it so we can it improve on it. Its not overly complicated or Rocket Science but its focusing the energy so all the different projects of the team worked on a line to a touch point and capability and if it didnt, then we need to work on it. At the bottom are really how we create transformative programming. How do you create change. This is one of our pilot programs. How do we apply them to other states and make them work. We need to take that knowledge to be able to deployed across the country. Lastly is transformed. How do you transform operations to standardize processes . What does that mean . When you think about these different projects and capabilities, not all of them might work in everything will circumstance so the balance that a lot of healthcare leaders and any industry have to balance is between standardization and customization. I would use this graphic, theres 14 competing standards. 14, thats ridiculous. We need to develop one standard that covers everyone. Lets do that. Then what happens is another standard. Its very common that everyone recognizes theres an issue and so they think will just do all this way. Then you realize it doesnt work with this population and so whats really important is how you create that balance. What we used was something called guide rails and best practices. You want to be able to create guide rails but you dont want to be overly prescriptive. You want to say heres the outcome we want to deliver and heres your sandbox that you can play them. We want to inform not by best practices and say heres five best best practices that weve identified that you might want. Over time we can actually shrink those guide rails even further as some of those best practices become more common. Its a very deliberate process because if you try to overly standardize as a department when the care is very different than the care here, you might not get it right. You want to provide a little bit of that flexibility in wiggle room and informed not by best practices that over time start to kind of standardize more and more. What we did, initially to support that is to create a platform. What we realize is we couldnt push out changes to the system if not everyone was using the same language or same platform. Over the past year or so, weve been rolling out what we call our local operating model and what that really looked like is how can a local facility organize themselves to succeed. Too do that they have to have the guide rails, consistent processes, active partnerships. A standard way to do care coordination and very responsive customer service. We started to lay the foundation for what that model looks like. Want to get that place. Then it makes it easier to iterate, if you have the same platform across country, over time as new developments or new processes get improved, you can make those changes much easier. So think about it as, theres a couple industries today that we dont even think about that are standardize so theres a lot of cameras and lights in the room. While they are plugging into a standard electrical port. You can plug in many things into that electrical port. That serves as a platform. The same thing probably with a lot of you and your different devices. There is a common usb type platform that you can connect different places. There is a common framework that you can use over time. There used to be an era in america where all the railroads run Different Levels and they couldnt really cross from one to the other until there was an effort to standardize that platform and actually connect all the different systems. The same thing with the cable industry. There used to be different types of plugins for cable and now theres a standard cable outlet you can use any service for any product you want. Having that platform is very important because it it allows you to iterate over time and that something that is we talked about how it goes from being just a Healthcare System to healthcare network, there needed to be some platforms that were there before. I just wanted to share a little bit of the outcome on what happened. The last couple years. We are going to leave this now and take you live capitol hill outside the office of minnesota senator al franken. He will have remarks about Sexual Misconduct allegations. You can find the program we just left online and search for healthcare policy. One. [inaudible conversations] ,. [inaudible conversations] , one. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] again, waiting just outside the office of minnesota democrat al franken on capitol hill. He is expected to make remarks about Sexual Misconduct allegations. We had work that he was approaching the doorway and may have decided there was Something Else going on in his office. He has not come out yet to make remarks in the Office Building before the reporters are stationed outside. Also the Ranking Judiciary Committee member resigned for his committee post after it came out that he used money to settle allegations, Sexual Misconduct allegations against him as well. We will wait here for senator al franken returning to the senate in washington d. C. At 230 eastern we will take you to the white house as well for the White House Briefing with press secretary sarah sanders. She will be answering questions about tax reform negotiations as one of the big topics in the senate this week. Also the president s visit is expected on capitol hill during the weekly party lunches. I am sure we will hear about a number of other issues from the white house as well. Congress returning from thanksgiving recess in the senate will be in at 4 00 p. M. Eastern. They will be voting later today on judicial nominations and the rest of the week is focused on tax reform. The full senate is expected to work on the tax reform bill i midweek. On the other side of capitol hill, they would return to capitol hill tomorrow. They will require anti harassment and discrimination training for all house members as well as staff. You can watch the house live on cspan. Were just waiting for al franken who is making remarks outside his office on capitol hill. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] waiting outside the office of senator al franken, democrat of minnesota to talk about Sexual Misconduct allegations. Again, one of his fellow senators Ranking Judiciary Committee member also resigning from his committee post after it came to light he abused money in a taxpayerfunded to settle allegations against him. We will bring you back here as soon as senator franken comes outside of his office to make remarks about the allegations against him. Also to let you know we will take you live to the white house at 230 eastern here on cspan2. Currently live under way over on cspan, a conversation about private Sector Development in afghanistan hosted by the center for strategic and international studies. Thats live under way on cspan. While we are waiting for senator franken to arrive, we will take a look at a segment we had yesterday on washington journal. It talks about work place Sexual Harassment. Welcome back to the program. From new york, columnist for the nation good morning to you. The morning. In the round of politics, the media and other fronts, including entertainment, Sexual Harassment, is at the forefront of our National Discussion . What you think about the conversation were having, and do you think any changes could come from that. I think its an amazing conversation. Its the sort of thing you could have never imagined happening until it happened. The Harvey Weinstein extravaganza just set off this incredible outpouring from wome women, the me to movement, and instead of it being a one off with some horrible powerful creeps who were ushered off the stage forever and everything goes back to normal, women are coming out with their own stories. Some of these stories are pretty terrible, and many famous men are being implicated in the scandal, but also, i just want to say, i think its such a mistake, and this is where i wonder about the conversation we are having. Its focused on individual, powerful, famous men whereas Sexual Harassment is such a broad phenomenon of ordinary people, especially workingclass women who work in the Hotel Industry where the restaurant industry. You know, for example, i was so shocked by this. Almost half of all female Hotel Workers have been greeted at the door of a room by a man showing him his. I mean really. Did you have any idea there were so many weird over entitled frat boy man in the world . I think, we dont really know where this is going to go. I think theyre going to be powerful tendencies trying to push it all back and close that door, but then there are people pushing to have the door opened even wider. Will be at the forefront of pushing that back . Well, i think donald trump has a big interest in doing that, he is the pussy grabber in the white house. 15 or 16 women have accused him, very credibly, of sexually harassing them and more, and yet, he won. He won the election. I would say that the people who voted for him have a powerful interest in shutting this whole thing down because they obviously dont care about it. As far as capitalizing on the current conversation, and making changes on the workforce and other areas, what do you think has happened in order to see those changes go from a conversation to actual change . Thats the big question. I think law is not going to be enough. The workplace has a loss that protect women supposedly, although in reality, they frequently dont because the structures are there in the actual work place to enforce them, but i think beyond that, we really need to start raising boys and men a little differently. Somehow an extraordinary number of men are growing up with the idea that this kind of behavior is perfectly okay. Yeah yeah, people say shouldnt do it, but in real life its fun and why not. So, i think we need to have a broader conversation. Do you see this is a generational thing . You see changes as far as the attitudes coming up from the younger men changing their older counterparts . You know, thats what people my age, thats what Harvey Weinstein said i grew up in a different generation. Oh yeah. He grew up in a generation where it was okay to rape people who wanted to work for you . Please. The things here accused of doing a were never okay. He just got away with them because he was powerful and women werent terminated and would lose work. I would say theres been a little bit of social change around this, some boys in some parts of our culture are being raised more carefully, but i dont know that its changed all that much. If you look at the situation on College Campuses where many young men seem to be going too far and the whole fraternity scene, those are young people. I think if you were to ask a 20yearold waitress what her situation is in the diner, i dont think its all that different than it wouldve been 40, 50 or a hundred years ago. If you want to ask questions, you can call one of two lines. Menu can call in at 202, 7,488,000. Women 202 7488001. You can also tweet us or post on our facebook page. You can do that as we have our conversation. Talk about the conversation you are having specifically with men about this topic. What are you hearing from them . Im sorry, the producer was talking to me. Can you repeat that i was looking in the wrong direction. Is perfectly okay. As far as specifically what you are hearing from men on this topic, what are they telling you . Men are all saying i would never do this, this is so terrible, but on the other hand, is it so terrible. I think theres kind of a Movement Among men to disassociate themselves from this kind of behavior and to make very clear distinctions between what i did is okay and what he did is not okay. Thats pretty natural. Nobody likes to think there a bad person. I think the par point of this shouldnt be that youre a bad person, the point should be now we are going to change. We are going to be different