Civilian career and making that transition into the government world can be jarring. What wanted you to take up the world of government quick. During my twenties i didnt have a chance to serve the way that you did. I spent my time in medical institutions building my medical training. That was one of the real regrets that i had with this amazing country that i was not able to give back. Later in my career i was the ceo of a hospital and i had the opportunity to get a call from the white house for cho this was right at the time in 2014 when it was very public crisis in the v. A. That veterans were dying waiting for care. I was sitting there as a citizen to say i feel terrible about this. If anybody deserves the best care possible it is our veterans i wish there is something i could do to help. As sometimes happens i get a call from the white house to say would you consider coming to help lead the v. A. Healthcare system because were looking for somebody how they understand how healthcare works. I did but everybody tends to do. To make a list of pros and cons and con side was much larger but how could i say no . This is my duty as an american citizen to give back. So i really didnt think much and i said yes. Im prepared to come help teeseven that was during the Obama Administration initially and then to get into that but i would love to read a brief quot quote. Early on you right its important america understands what it is and how it works and why it exists. As mentioned a lot of people dont understand the scope and what they are responsible for. Maybe you had an elevator pitch because it goes well beyond health care. There so much more. I wrote the book im not sure the American Public understands why the v. A. Exist. But its a part of the National Security system. When we rely on the voluntary military that is less than 1 percent of americans serving but they raise their hand and are willing to sacrifice themselves, when they go there is a commitment that they will take care of them and there is no other organization that is focused on that. The v. A. Provides healthcare for 9 million a minute veterans. So it has a large effort directed toward education, g. I. Bill, benefits for those who require assistance if they are disabled, and through the time to make sure every veteran when the time comes is buried with dignity and respect was 114 v. A. Cemeteries so this is the second largest in Us Government with 370,000 people who are they are many veterans themselves to have that support and understanding of the american people. With the second largest budget and from civic standpoint. Thats right and also just about the healthcare aspect. And then with the private sector in the government i have never worked in government before. And reading these Horror Stories that i would go there and find this system is so broken and to say the best thing i can do for veterans is aluminate the v. A. Healthcare system and move everybody into private hospitals. And after i got to the v. A. To see what it does and then put on my white coat as a doctor to take care of veterans and visited hospitals across the country and went to see places like where we bring paralyzed veterans. And then i began to understand what the v. A. Does is very different than what the private sector does. And that the private sector doesnt do that the v. A. Healthcare does. For example the Behavioral Health care system it is expensive and large it is struggling to get access with these 9 million veterans that already is struggling we know the veterans do not come out on the right side of that so ive been a very strong advocate that this is a system that works well so it will be a sustainable system. I do want to come back to privatization which is a large part of your book. We will get to that but i want to continue with this setting because it reminded me of a common thing in the veteran community that if youve been to one youve been to them all the mention especially you have done a lot to visit different ones why do you think that is cracks even though talking about an agency that has oversight you get so many different stories . But you hear how the membership says they love the care that they get they would just like to have access faster but why is there such a variety of level of care . It is under public scrutiny that no other system in the country. So Little Things that happened in the v. A. Would never come to the attention turns out to be the subject of congressional hearings. So there are lots of things that are happening in v. A. Hospitals that dont happen in the Public Sector but using that comparison will what is the best hospital for me to go to . Interestingly there is no such thing and they may not be good of those other areas. To have the largest system in the country you will have some that are excellent and thats what you will find in healthcare but it has that complexity so therefore we have a large number of veterans that live in rural areas and especially the specialists its a challenge for the private sector as well. With a tremendous variation between what works from one place to another and of course i work very hard on to stander night one standardize these practices. And from your first confirmation hearing you need to come to alaska because they are circumstances here and you need to understand that sweat just to let people know about that journey many people dont understand the Senate Confirmation process. Actually in order to go quickly through a senate process and not require an entire floor vote you have to have unanimous consent and the white house that you have unanimous consent you will be confirmed in the next couple of minutes and write does that vote was happening senator sullivan said not so quick i need to have a conversation with the nominee. He said im standing on the senate floor and about to cast my vote. But i want you to commit to me in the first 30 days if confirmed that you will come to alaska with me. Because its very different than other states and i said senator we are going to alaska. I imagine that was your intention anyways because there is a lot of variability geographically speaking to those rural areas. Alaska is one of the few states New Hampshire and hawaii are the others that dont have their own hospital. Meeting the healthcare needs of those states is extraordinarily challenging. We actually partner with the air force. But i was delighted to travel with the senator as i was to other rural states like maine as well. Thats the way you really get to understand how to fix the problems that are out there like talking to veterans what they are experiencing. And you continue to see patients i wouldnt say you had the time to do it because you were working very hard seven days a week but that was something that you felt was necessary to your understanding. Every leader could do their job more effectively if they understood the impact of their decisions. If i would be making a decision on which electronic record how could i make that decision if i never use the electronic record cracks in working with patients and doctors and how they enter one interact so i would put on my white cut my white coat nobody knew i was secretary. But it helped me to understand what was working and how they experience the decisions and that made me a better and more effective leader. That there is a funny anecdote. In your doctor capacity. You god a startling response from the veterans. I would see patients to ways. I would see them in person in the exam room and then in telehealth from my office in washington from a rural part of the country so i got to experience both urban and rural. But i was in the new york manhattan v. A. When i saw a patient he said i need a physician to fill out this form and i said what is it more cracks he said i am suing the secretary. I asked him what that was about. He was a homeless veteran trying to get additional benefits to get himself out of the situation and back on track i needed a physician certification of his issues. I said first of all i will help you get you the form that you need but i dont think im the person to do it and he said why they said because im the secretary. But we got him on his way and another physician helped him. [laughter] you mentioned five priorities you had when you came in can you talk about those and how you arrived and to achieve those goals quick. When i first came to the v. A. I had never worked in government before Better Organization i was going to have to learn and it was so large that if i had waited until i truly understood everything we would be waiting a long time but veterans were literally waiting for care i felt like i didnt have the time so i came in and studied from the outside as best i could and said we will have priorities right now but single is to address the wait time crisis there were hundreds of thousands of veterans waiting more than 30 days for care. But most critical to me but there are 57000 waiting for urgent consultation. Waiting more than 30 days for urgent and that was totally unacceptable to me and that set the bounds of what i thought was reasonable so i immediately called for every Medical Center to be open the following weekend and we contacted the 50000 veterans and then we had that list down to less than a thousand by monday morning. So once we got that backlog taken care of i want to make sure we never got into that situation again. So i did a couple things. First it was to publicly post wait times today v. A. Is the only system ive aware of that publishes wait times so that people can see the second that i did was to establish Sameday Services throughout the entire country so by december 2016 i could tell secretary mcdonald president obama every v. A. Medical center had the capability to see everybody on the same day basis so that somebody with a urgent issue could not be taken care of. There was an article of the jama after he put all these things in place compared to the private sector for the wait time and the v. A. Is better now that we have made tremendous progress to address that issue with that commitment of employees and the staff that work there on establishing improving employee morale because there were 45000 vacancies in the v. A. And that is a significant challenge. Probably one of the most important priorities is to regain the trust of the veterans that we serve. We dont have a stock price if we are doing better with stock price but we can track regaining the trust that we lost in that began to climb is continuing today which is very good news. We had established another priority to create best practices learning from one to another. To decrease that variation that was successful thats how we established our priorities. And these things you brought from the pie private sector and does other things. Interestingly not only with the ways of government with the wait time issues but to start to think if i was a government employee. And with the private sector to government. And for many of those practices. And to modernize the way it is thinking. But the private sector could benefit from. This is a twoway learning between the private sector and government. Thats interesting there is an ongoing continued debate about the future of healthcare and i dont think that is the perspective that is brought into the conversation about what we can learn from the government side people say we can learn from the government. People dont understand looking at outcomes of care through the population which is very popular the v. A. Outperforms the most every other Major Health Care system. Not saying it is the best there are some great Healthcare Systems out there that this country provides Terrific Care but if you look on average the v. A. Performs better than most of the private sector so look at some of the things we did for example i made the declaration i wanted to eliminate hepatitis see from the entire veteran population of 163,000 veterans and now fortunately we have a federal drug that can eliminate the virus at 95 percent or higher cure rate. So now any veteran shouldnt have hepatitis so Congress Gave us one. 5 billion. We proactively contacted every veteran now we have treated over 100,000 of those veterans and are on the way to eliminating hepatitis c. We need to do that in the general population. Not Many Health Systems think that we proactively. But these are the lessons we can learn from the vat seven. Veterans show that our membership generally there is things they went for improvement but you didnt mention those priorities but you address in the book another area in which the v. A. Gets around military veteran suicide. As a complicated issue Mental Health is complicated but even we as a country are struggling to understand or figure out how to solve du have any insights how we can begin to address thi this . The highest clinical priority that i established was to reduce veteran suicide. Twenty veterans a day it is a staggering figure that i used to sit there and say if another day goes by then there goes another 140 veterans. There is still so much work to do but thats why im pleased secretary wilkie has continued to make veteran suicide a priority for the v. A. Taking a look at this of those 20 veterans a day, only six are getting care from the v. A. System. Fourteen are out in the community my biggest worry is they are getting help at all. So one of the first initiatives was to start outreach for Community PartnersCommunity Groups and churches and religious organizations and groups like the united way and local and state governments Work Together to identify veterans at risk. Every v. A. Medical center has a Suicide Prevention coordinator and their job is to be out there looking for veterans at risk in identifying ways to help them. That is one practice i think the v. A. Has that the private sector should have. This is an American Public health issue not just veterans. But we need to do a lot more for go the underlying reason why people take their lives as in because they wake up one day and say i feel like doing this but they are suffering. It could be depression, pts depression, ptsd, chronic pain, substance abuse, we have to look at the ways to get to the underlying reason to find that diagnosis and treatment and to make sure we are proactively identifying how we can help and theres so much more work to do. Lots of promising opportunities to do that with predicted analytics and therapies. But much work to be done. This is a number one priority as well. Especially that the situation is not improving from both military to show were not getting at the problem. And we shouldnt be looking at it as a an Emergency Response issue but chronic pain or homelessness, Financial Issues so much could be reaching into that. But clearly there has to be a whole government and whole Society Approach to this but the v. A. As the leader for the Veterans Community should be spearheading that. Yes. And im proud of the work the v. A. Is doing. But like many tough problems that americans face, we have to do more and push through some of those barriers that prevented us from making progress. You are right the recent Suicide Prevention report reports the data differently so it looks like a different one a smaller number. Actually went up a little bit but this is not about a scorecard. Its about making progress. Im not sure we are there yet. Im not sure we are there yet. To begin to change this culture throughout the country that doesnt recognize the service of Women Veterans as we do male veterans. The Fastest Growing demographic in the military is and then in the military. About 14 of our military service play extremely important roles and not to recognize and respect their service is simply wrong and something that cant be tolerated by the va or any other part of our society but i do think you are right this is a reflection of issues we see in the broader society. What theyve decided to do and something that ive supported a rather than waiting for the culture to change is to make sure we are providing the care everyone deserves so we have created Womens Centers that often have separate entrances but create a secure and comfortable environment where women get to go get their care and dont have to worry about any of the issues we talked about and in some ways it is a shame we have to create separate places for people that we were not willing to wait and say we are going to try to change attitudes that the same tim bute we are providing these centers we do need to begin to change the attitudes. There was a recent public issue at the washington, d. C. Va where a woman that her and was harassed just walking through the halls and had the courage to come out and talk about that experience, and i know that i certainly went out publicly and supported her as many of the organization stated to say this is unacceptable. We need people to this brave woman to be able to speak out on behalf of her fellow veterans, and we need to begin to start changing these attitudes. As you mentioned we need male veterans to speak up for them as well. Its not something the burden should be completely placed on the Women Veterans. One of the ways in which we are trying to begin this process and drive a topdown understanding that there really does need to be and should be a cultural change is to change the motto of many people dont know the motto of the va is an Abraham Lincoln quote for he who has borne that out over his widowed aunt for his orphan. Weve been pushing and there is legislation to change it to something that is more embracing of the changing nature of our military and our veteran community. Its something that frankly has received pushback in a lot of the quarters. Did this come up when you were within the va . Guest it was one of the disappointments i had. The military is the place in our society where differences and diversity hav