Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Tue, 3 Apr 2018 15:11:14 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001Is4ME-tyfXEfwi0k0wC0fl24gOvRKRYYE1JicYsNKf7xcWSTehCuA5Q3SuL6bnSw3MpXxZsC7FLuptcXOjc9JFBasqEeD4ql8huLnVqaYiON4U_ci31JOkQomew_UF-NoTCuDLTMa4dYf3sRdFqSUolvpqP6dikYo4lFtW2s6g2NL9tpoW5C-3ENTFaTTisQ&c=sjleRohzbb8W24Si2TIK8ZSkNFwOAdXc_F0glEnggB2HnyL4tOQ1Rg==&ch=yxmoOIDYcSZOXETwekw-Ag1iHhAIJd59DRt1EkZUyIclb2bnawgS7w==]
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The Fickenscher Files, Vol. 6, Issue 6
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001Is4ME-tyfXEfwi0k0wC0fl24gOvRKRYYE1JicYsNKf7xcWSTehCuAxD90cmBIQLy97qG1yxz6dScfoPqpPg2tgig1EcIja0bMRieRT-0uIctDocLco2exlTJYRe9wbXlmeUkNbtBWFTuPTGmgNhSRUUe0vKHEThuogkCyViidF5a6BJLMmkpTm0O3_5mVije0U0lRV-evQRn9dbEcYMW0A==&c=sjleRohzbb8W24Si2TIK8ZSkNFwOAdXc_F0glEnggB2HnyL4tOQ1Rg==&ch=yxmoOIDYcSZOXETwekw-Ag1iHhAIJd59DRt1EkZUyIclb2bnawgS7w==],
MD, CPE, FACPE, FAAFP
@MDKev
A compilation of information, thoughts, and perspectives on the issues of the day
related to healthcare, technology, and beyond - including the latest culinary explorations.
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Quote(s) Of The Week
"I came to run the Department of Veterans Affairs because I'm committed to veterans,
and I'm committed to fighting for them," Shulkin told CNN's Jake Tapper on "State
of the Union" Sunday. "And I would not resign, because I'm committed to making sure
this job was seen through to the very end."
David Shulkin, MD - Former Secretary for US Department of Veterans Affairs on his
Tweet firing by President Donald Trump over the past weekend
{Chief of Staff John Kelly] "...called Shulkin and gave him the opportunity to resign,"
Schlapp said. "Obviously, the key here is that the president has made a decision.
He wanted a change in the Department of Veterans Affairs. He wanted more results
 coming out of that particular department. ... That is why he moved to make this
 change."
Mercedes Schlapp - White House Director of Strategic Communications in comments 
on Fox & Friends where she backed away from the original contention that Shulkin
 has resigned his position as VA Secretary
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Consulo Indicium
Information for your Consideration...
The Pace Of Blogging - For many of us - who are news junkies - one of the first 
things we do in the morning is turn on the news. Over coffee and breakfast, we ponder
all of the changes that have occurred overnight and the Tweet storms on the horizon
to gain a better view on the lay of the land. But, it's difficult. The change of
 direction, the requirements for fact-checking on many items, the incomprehensible
blizzard of changes in staffing are all distractors to the many issues facing America.
As my readers know, "health care" is at the top of my list as an issue that needs
resolution. It also needs consistency of policy over time. It needs leadership with
integrity. It needs bipartisan solutions. And, for these reasons - I'm sending a
 "special" blog because of the recent changes at the Veterans Administration. As
 always, your thoughts and perspectives are valued. Send them to [email-masked]
[mailto:[email-masked]]. They will be read, reviewed and appreciated.
Now...on to the reason for the special blog...
The Discontinuity Of Continuity - At the outset, let me say that this note is out-of-character
for me. In fact, it's a first! I don't usually comment on people changing positions
or moving from or to various roles. I view those types of changes as the inevitable
outcome of what happens in modern day corporations. However, the decision by President
Trump to fire US Veterans Affairs Secretary David Shulkin, MD deserves some commentary.
There are a couple of items you should be aware of before reading my thoughts. First,
I've known David for nearly 25 years. We "grew up" together in the world of health
care systems as Chief Medical Officers for various care delivery organizations. 
As part of that club, we got to see one another's warts, scars and traumas as we
 all moved from working as clinicians to becoming administrators and then, working
diligently to become leaders - a process that most of us continue to work on to 
this day.
Second, David is a person who is driven by facts and data. One of the reasons the
VA has turned the corner in recent years is because of the measured philosophy he
has brought to the agency. When push comes to shove, an approach to solving problems
where "just the facts, Ma'am" is the dominant model creates an environment of accountability
- and, transparency - that is difficult to argue against.
Third, on a good day, taking on the challenge of remodeling the VA is a gargantuan
task. On a bad day, it can seem impossible. Change is difficult but in an organization
like the VA - it requires a degree of perseverance that is inestimable. Yet, David
has slowly but surely moved the chess pieces forward in an effort to provide veterans
with the health care they deserve.
Finally, any person looking at the capabilities of the VA and those of other health
care systems would easily come to the conclusion that forming some type of alliance
between this large, cumbersome bureaucracy and local health care delivery organizations
would make sense. But, there is clearly not a cookie cutter model and anyone that
goes down that road will likely be doomed to failure. The potential integration 
and/or collaboration with local providers is a move that requires the careful consideration
of the types of services available locally to support not just the run-of-the-mill
medical problems of veterans but also the unique veteran disabilities whether physical
or mental. It also makes sense to have some defined proof points recognizing that
the initial models will likely be variable and not deployed on a uniform basis across
the entire nation. Such was the approach of Dr. Shulkin...
While Dr. Shulkin's departure will no doubt be absorbed - just as the departure 
of most leaders in government or private industry - his methodical movement toward
"solving the problem" will likely result in a backward slide within the VA. It is
unfortunate. When one considers the data, it's obvious that progress was once again
occurring within the VA after a 10+ year hiatus. Efforts were being made to enhance
quality; initiatives, to enhance service; and, projects, to increase access. And,
at the end of the day - increasing the quality/service/access triad is one of the
important requirements for "making health care better" (my personal mantra for why
I get up in the morning for nearly 40 years).
So, what should be done about the VA? Here are a couple of steps that require serious
consideration and which the next Secretary should put on the table as part of the
requirement for taking the job. It's probably not a complete list and - more importantly
- is a list that is devised as an "observer" of the VA rather than as "consultant"
or "employee" or "advisor" to the VA. These are purely my high-level thoughts in
 considering how our nation can best honor its commitments to veterans and also 
drive efficiency and effectiveness in a large, bureaucratic organization. The thoughts
include:

1. Initiate a Revised Structure for the VA - Congress should seriously consider 
re-establishing the VA as a separate "Public-Private Partnership" (P3) corporation.
One of the issues that Dr. Shulkin mentioned in his departure interviews was for
 Congress to address how the problem of the "revolving door of leaders" at the VA
can be resolved. Political appointees to leadership positions is the last thing 
that is needed to solve the problems. In a large organization that is complex and
spans the entire nation - consistent, focused and reliable leadership is essential.
It will require a strong, diverse team that moves in concert philosophically and
 managerially to solve problems. Large, diverse corporations require such leadership
to be successful. There are good examples that serve our nation well. Two examples
come immediately to mind. In the shipping industry, our nation's ports are mostly
managed by P3 arrangements - and, quite successfully. Having open, high quality 
operations at the ports has been a cornerstone of our successful economy for many
years. A second example is the increasing use of P3 approaches for managing our 
nation's transportation infrastructure. Whether it is roads, bridges or interstate
highways - such an approach has been successful. It's not easy and the approach 
of shipping is different than transportation so, again, there are no cookie cutter
models. On the international level, we've seen the use of P3 arrangements for managing
"public" health care systems and organizations in the United Kingdom, for example.
So, the idea has merit, it is being used internationally and, it should be considered.
2. Establish a Functional Governance Model - While the P3 model is a potential solution,
the requirements for making it work - in my estimation - will never be met if Congress
serves as the "Board of Directors." I don't care whether it is a Democrat or Republican
Board that is in control. Congressional governance will only continue to exacerbate
the ongoing problems of the VA. Rather, appropriate "oversight" should be put in
 place that represents true governance - like a large health care system. The delivery
of quality, reliable, cost-effective health care for veterans is not a political
 process. It requires a governance oversight that can resolve the very significant
problems faced in providing care to veterans. If I were a Czar and able to make 
the changes, the Board of Directors would be something like: 3 veterans, 3 health
system leaders, 3 "open" positions; and, 3 Congressional appointees. The positions
would be staggered and be for 6 - 9 years in duration. They would be required to
 provide a report to Congress every year. I'm sure there are other parameters but
this is a good starter kit.
3. Deploy Tele-Technology - The VA has actually been one of the leaders in exploring
the use of tele-technologies for enhancing the ability of the agency to delivery
 services. In particular, the use of VA systems has been shown to be very effective
in delivering care to rural areas and to those veterans with mental health issues
such as PTSD. What's needed; however, is for Congress to support a national infrastructure
plan for enhancing the digital capacity of all geographic areas across the USA on
a ubiquitous basis. The fact of the matter is that many rural areas - which are 
large swaths of the nation - have inadequate digital capacity for supporting the
 types of communication required for effective telecare.
4. Continue the Focus on Service - One of the areas Dr. Shulkin emphasized was enhancing
the service capability of the VA. This is a cultural phenomenon and does not simply
occur because of declarations. The efforts that he initiated should be continued
 and expanded. And, in my experience, culture starts at the very top with leaders.
So, continuing that focus from the Office of the Secretary will be crucial or it
 will hit the dustbin of talked about strategies that never become reality.
5. Continue the Drive for Transparency - When problems are hidden or covered over,
they are unseen. Dr. Shulkin has really pushed the "transparency" agenda which has
been very good for the VA. The ideas and efforts need to be continued. Continued
 use of metrics and comparisons to private health care providers should also be 
expanded. Let's hope that this effort does not slide into oblivion with the passing
to a new leadership team...
Let me offer a final comment on Rear Admiral Ronny Jackson, MD [http://r20.rs6.net/tn.jsp?f=001Is4ME-tyfXEfwi0k0wC0fl24gOvRKRYYE1JicYsNKf7xcWSTehCuA3XCTrVNJR4imHgLdEA74OgcPcdlIkIJOwksLNa3v6QIfb4JI4vZIDX0GoPvT66VM-VprqWtfIXbfVuc3aRfMQk9ApLtsSG9TqncmOCfwBzNuXI8QKTN8tlLBppYUF6qOFcl8OkNPPa-QjQLt_dvlEk=&c=sjleRohzbb8W24Si2TIK8ZSkNFwOAdXc_F0glEnggB2HnyL4tOQ1Rg==&ch=yxmoOIDYcSZOXETwekw-Ag1iHhAIJd59DRt1EkZUyIclb2bnawgS7w==]
who has been named by President Trump to replace Former Secretary Shulkin. Dr. Jackson
has a strong medical pedigree. He is a graduate of the Uniformed Services University
of the Health Sciences, a graduate of an Emergency Medicine program and a Fellow
 with the Beth Israel Deaconess Medical Center Disaster Medicine program. Plus...he
has lots of military medals and awards. But, does that prepare him for the role?
 While there is every indication that Dr. Jackson is an outstanding clinician - 
that does not necessarily provide the grounding for leading large, complex organizations
- despite the support he is receiving [http://r20.rs6.net/tn.jsp?f=001Is4ME-tyfXEfwi0k0wC0fl24gOvRKRYYE1JicYsNKf7xcWSTehCuA3XCTrVNJR4i_C2vpaqfZizWLECRBVyhr9qR61bnhd40FumDrLREgiwxtpd31xe0KEdpqUpYluWeELdaLxReYFDsenS4tLd9l97a2VZDiDJA67ZhbXe-TEc2hXGdndK7anx06fxAiejexWlZ3rlyoaEm5GSTedGdKGGToHGcjNcUi6w5BCZaTdhH89DrH8XEBVYi5jg5ErVgWZsPurS9mkqz0GAtEd82Ew==&c=sjleRohzbb8W24Si2TIK8ZSkNFwOAdXc_F0glEnggB2HnyL4tOQ1Rg==&ch=yxmoOIDYcSZOXETwekw-Ag1iHhAIJd59DRt1EkZUyIclb2bnawgS7w==]
from various sectors.
I will never forget when I took on my first role as a Senior Vice President and 
Chief Medical Officer. This was after nearly 10 years of some managerial experience
in leading smaller groups of 10 - 20 people. Early in the experience, I remember
 an issue coming forward where I decided I needed to take action. I reached for 
the metaphorical handle on the decision lever and pulled it with bravado and action.
Nothing happened. This is what happens in large, complex organizations. Change does
not happen by pulling on the metaphorical handle. Rather it comes through providing
a vision, through being the type of leader you want others to be and, by setting
 a direction and encouraging your followers to step up and refine the ideas. I question
whether Dr. Jackson is ready for the challenges of the VA. All the training and 
skills of an outstanding clinician do not solve the problems of management and leadership.
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The Weekly Whisk
Musings from a foodie...
McDonald's is still McDonald's [*] If you haven't tried it, try it once. If you 
have tried it, try to stay away (except for the fries, of course J ) And, Coke is
Coke regardless of where you get it. The burgers are the same world over so there
is some comfort in that part of the McDonald's equation. But, it's small comfort.
Enjoy.
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - The support shown to our nation's veterans by Dr. David Shulkin during
his term of office within the VA and in his statements to the public on what needs
to occur for the important societal obligation.
The Good - The integrity exhibited by Former Secretary Shulkin.
The Bad - The lack of consistent leadership from what most of us still consider 
to be the most important office in the world - The White House.
The Ugly - Tweet terminations.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001Is4ME-tyfXEfwi0k0wC0fl24gOvRKRYYE1JicYsNKf7xcWSTehCuA5Q3SuL6bnSw3MpXxZsC7FLuptcXOjc9JFBasqEeD4ql8huLnVqaYiON4U_ci31JOkQomew_UF-NoTCuDLTMa4dYf3sRdFqSUolvpqP6dikYo4lFtW2s6g2NL9tpoW5C-3ENTFaTTisQ&c=sjleRohzbb8W24Si2TIK8ZSkNFwOAdXc_F0glEnggB2HnyL4tOQ1Rg==&ch=yxmoOIDYcSZOXETwekw-Ag1iHhAIJd59DRt1EkZUyIclb2bnawgS7w==]
are the personal views of Kevin Fickenscher, MD and do not reflect the views or 
policies of any organization with which he is affiliated.
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