The 128th Interagency Institute for Federal Health Care Executives was a significant occasion for us as it was the first time that the Institute has been held as a formal entity of the Uniformed Services University of the Health Sciences. The sessions were held on the university campus and most of the participants stayed at the close by Navy Gateway Inn. I am especially grateful to Dr. Charles Rice, President; Dr. Arthur Kellermann, Dean of the F. Edward Hébert School of Medicine; and COL (Ret) Bob Thompson, Chief of Staff, for their strong support in making everything go as smoothly as possible. I also want to express our appreciation to CAPT Marvin Jones, MSC, USN, Commander of the Naval Support Activity Bethesda, and his staff for their support and assistance. In addition, there are many other USU faculty and staff, and numerous NSAB staff members who worked very hard to help us launch the IAI at the university.

For some years I have considered that the logical ‘academic home’ for the Institute should be the Uniformed Services University. Now that this is in place, I feel very confident that the long-term future of the Institute is assured. I hope that the Institute will be a strong partner to the many other professional development programs at USU.

I would also like to take this opportunity to thank the Honorable Jonathan Woodson, MD, who has recently retired from the position of Assistant Secretary of Defense for Health Affairs. From the very start of his appointment, Dr. Woodson has been a wonderful supporter of and participant in almost every Institute during his tenure. He has always set the tone for our discussions and challenged the participants to be effective innovators as they move into positions of increasing responsibility in the military health system, the U.S. Public Health Service and the Department of Veterans Affairs. We hope that Dr. Woodson will be able to remain as a faculty member for the Institute and we wish him all the best for his future activities.

The reports from the Small Group activities are published in this newsletter. I congratulate our participants for their thoughtful and constructive reports and I commend all the reports to you.

We were once again honored to have a Canadian participant in the Institute. It was a special pleasure to welcome Colonel Scott McLeod, Deputy Surgeon General, Canadian Forces Health Services Group. Scott was an active participant and made many contributions to the discussions. Brigadier General Colin MacKay, Surgeon General, Canadian Forces Health Services Group, and an Institute graduate, came to Washington especially for the ‘Lessons From Other Countries’ day which we were privileged once again to hold at the Embassy of Canada. We sincerely appreciate the hospitality of the embassy and Commander Ian Torrie, RCMS, Health Services Attaché, Canadian Defence Liaison Staff, also an Institute alumnus, for his strong support.

With best wishes,

‘Richard F. Southby, Ph.D. (Med), F.F.P.H. Director

Interagency Institute for Federal Health Care Executives

Spring 2016

Volume 29, Issue 1

From the Director…

THE RECORD Interagency Institute for Federal Health Care Executives

FHCEIAA Members, Meet Your President

Page 2

COMMANDER AARON P. MIDDLEKAUFF, USPHS

CDR Aaron Middlekauff serves as Chief Pharmacist and Consultant of the US Coast Guard (CG) Pharmacy Program providing technical and operational pharmacy oversight support for all CG pharmacy assets. He also serves as the CG Health Information Privacy & Accountability Act (HIPAA)/Privacy Officer Service representative.

Prior to his current duties, Aaron served as the CG Senior Health Services Officer and Regional Pharmacy Executive (RPE) at the USCG Headquarters Clinic, CG AIRSTA Miami Clinic; a senior outpatient pharmacy officer with the Indian Health Service at the Alaska Native Medical Center; nine years with the Air Force as the Chief of Inpatient and Outpatient Pharmacies at Elemendorf Air Force Base; Chief of Peterson Air Force Base Pharmacy while stationed at the US Air Force Academy; and three years serving in enlisted capacity in Misawa, Japan and Texas.

Aaron graduated from Drake University with a Doctor of Pharmacy in 2001 and completed his Masters of Business Administration from Trident University in 2012.

He resides in Virginia and enjoys golfing, bowling, camping, fishing, and spending time with his family.

Letter from the President, FHCEIAA

Congratulations to the alumni of the 128th Interagency Institute from the Federal Health Care Executives Institute Alumni Association! It is a tremendous privilege and we are ecstatic you have joined our team.

There are certainly many challenges we face daily in our respective professions, duty sections and offices. I am confident that these challenges provide opportunities to demonstrate the brilliance and unparalleled resourcefulness of this amazing group of leaders in federal healthcare.

I encourage each of you to maintain essential connectivity, connections and collaborative wisdom to maximize our resourcefulness and effectiveness. We are looking to the energy and enthusiasm of our highly respected alumni as well as welcoming our new graduates as any new ideas on how to advance the Institute are absolutely welcomed. There is currently a proposed initiative to tap in and harness a social media presence. This will be an exceptionally useful venue for maintaining a vital presence, connection and sharing of current events and dialog in a central repository. Stay tuned as our goal is to have this implemented by the end of summer.

I will make myself readily available and am eager to serve as a responsive resource. Know that I am truly honored and humbled to be serving as your president this year.

I look forward to achieving extraordinary accomplishments together!

Aaron Middlekauff CDR, US Public Health Service Pharmacy Force Manager, US Coast Guard Health Manager Quality and Performance Improvement Division COMDT, USCG HQ (CG-1122) 2703 Martin Luther King Jr. Ave SE, Office #9Y21-22, STOP 7907 Washington, DC 20593-7907 (202) 475-5181 Aaron.P.Middlekauff@uscg.mil

Visit the website: FHCEIAA.net

Page 3

Everyone enjoyed celebrating the USAF 67th birthday

on September 18th!

An Australian Outlook on International Engagement

A summary of remarks by Brigadier David A. Creagh, AM, CSC, Australian Army, at the Participants and Alumni Dinner, April 27, 2016

This is my third year in this assignment as the Australian Military Office attaché to North America. My key role is to act as the Australian Chief of Army’s ‘diplomat’ to the U.S. Army and U.S. Marine Corps. This is part of a larger Defence team focusing on science and technology, acquisition, and policy. Many Australian personnel, military and civilian, are embedded in North America.

Outlook

My outlook, the Australian outlook on international engagement is, I suspect, no different than yours, your senior leaders or POTUS for that matter. Our relationships are built on shared values, trust, mateship, a shared outlook on life, freedom, liberty, and international order. This is not a free good and it can never be taken for granted. The U.S. has many special relationships. The one with us is one of many but its special and it is one that is based on ninety-eight years of fighting together.

Like you, we were a colony of the United Kingdom and until it looked as if Japan was going to invade Australia in WWII, it was our most important relationship. Since WWII though, our relationship with the U.S. has been a huge influence. The preeminent collective security agreement that binds us together is the ANZUS Treaty. When signed in 1951, it committed us to cooperating on military matters in the Pacific Ocean region, but, today it is taken to relate to conflicts worldwide. It has been enacted only once by Prime Minister John Howard following the 9/11 attack on the U.S. I take it that this highlights why Australia remains the largest non-NATO contributor to current operations in Iraq and Afghanistan.

It is not only a treaty that binds us together but also the many years of fighting together. I am often asked by fellow attachés about our special relationships bilaterally and as a key partner. More often than not, I point to our shared history – the genuine affection and deep respect for each other can all be traced back some ninety-eight years.

History

I just want to recount a couple of highlights about the American Civil War for historical purposes. There were 140 Australian and New Zealanders who fought in the war. Most were veterans who immigrated to Australia during our gold rush but 40 Australians were enlisted by the Confederacy in 1865 when the CSS Shenandoah pulled into Melbourne for repairs.

We actually commemorate the Battle of the Le Hamel in July 1918 as the first time that American Doughboys and Australian Diggers fought together. There are stories about how General John ‘Black Jack’ Pershing viewed this collaboration, recounted by men from the 33rd Infantry Division. Corporal Thomas Pope, an American infantryman, joined an Australian company in a successful counterattack on German forces on July 4, 1918. He earned the Medal of Honor, the Croix de Guerre and the Distinguished Conduct Medal. He died at age 94, the last living WWI veteran who had been decorated with the Medal of Honor.

In 1942, General Douglas MacArthur was appointed Supreme Commander of Allied Forces in the Southwest Pacific Area. His headquarters was initially based in Melbourne, then Brisbane. At one point, he commanded more Australians than Americans. He welded a huge influence over Prime Minister John Curtain as fighting continued in the Papuan (1942), New Guinea (1943), and the Philippines Campaigns (1944-45).

Following the six-month Battle of Guadalcanal, the 1st U.S. Marine Division was sent to Melbourne to rest, retrain and prepare for subsequent operations in the Pacific Theater. To this day, the division’s patch includes the Southern Cross constellation and the folk song, Waltzing Matilda, is played whenever they ship out.

Corporal Bill Allan was a 26 year old medic with the 2/5th Australian Infantry Battalion fighting in New Guinea in 1943. On July 30, during an attack by American troops on Japanese positions up Mount Tambu, (continued on page 14)

Page 4

Group I Report:

Challenging the Status Quo: Lessons in Unconventional Leadership from and Unconventional Leader

Group Members: CAPT Elizabeth Adriano, USN; CAPT Janine Allen, USN; COL Kimberlie Biever, USA; Mr. Daniel Devine, VHA; Dr. DeAnn Farr, VHA; Brig Gen Christopher Lentz, USAFR; Col Scott McLeod, RCMS; COL Eric Newland, USA; Col Todd Osgood, USAF; Col Zindell Richardson, USAF; CDR Thad Sharp, USN; COL John Stang, USA

Assignment: Outline the major components of ‘Unconventional Leadership’ as presented by Nancy Schlichting in her book. How do these differ from other approaches to leadership? What do you consider are the positive and negative aspects of Schlichting’s proposals? Can her recommenda-tions be applied to the challenges confronting our five federal health agencies and, if so, how?

Response: When entering a leadership position, in a relatively successful organiza-tion, it’s easy to become complacent. This behavior stems from the adage “Why fix something that is not broken?” Unfortunately, this concept of “status quo leadership” has no momentum and incapable of any significant innovation. It stems from a miscon-ception that taking risks exposes their self and threatens their position. Although some may think this is a successful strategy, it is a self-centered approach that does not move the enterprise forward. It shuts down contradictory opinion, forces everyone to agree to everything and does not encourage progressive thinking. In the face of a changing environment, this leadership style impairs the organization ability to adapt. Successful leadership that can respond instead of react to change must take risks and shatter the status quo.

Health care has become the most expensive commodity in America. It makes up 18% of the Gross National Product with no evidence of plateauing. It has become a critical focus of the government and the health delivery industry. This expensive system, with meager evidence of quality, may be in part due to “status quo” leadership over the past several decades.

The passionate CEO of the Henry Ford Health Care System, Nancy Schlichting was able to revolutionize a failing health care system with financial crisis in a bankrupt and corrupt city. Inspired by the industrialist Henry Ford, she was able to improve quality and efficiency within this health care system by taking risks, facilitating innovation and investing in diversity of its people. This unconventional leader outlined her strategy in “Unconventional Leadership” which led this health care team to achieve the Malcom Baldridge National Quality Award.

The Department of Defense has had a stigma of being resistant to change with a perception that it maintains the sta-tus quo. However, the current military prides itself on diversity that mirrors that of the country. Not only is there var-ied culture and ethnicity. The military has service cultures that contribute to its diversity. It is also diverse in branch of service. It has also been to source of much medical innovation after engaging in ongoing conflict for 15 years.

The establishment of the Defense Health Agency, under the leadership of Dr. Woodson, is a significant transition from the conventional medical health structure that has been present for decades. Also, Vice Admiral Rachel Bono has been entrusted with the creation of 10 joint initiatives to improve efficiency and eliminate expensive redundancy such as the establishment of a joint pharmacy and a unified electronic health record.

Also, during the Ebola outbreak in West Africa, the nation called upon the Department of Defense for assistance since it exceeded civilian capability and it is poised for rapid deployment. In addition to establishing evacuation guidelines, Air Mobility Command, in less than 6 months, developed the capability of transporting infected patients that was nev-er part of Air Force doctrine.

Despite these examples of embracing diversity and innovation, our leaders in health care can sometimes be cautious about taking risks. There can be fear that the next promotion or assignment can be affected by standing out. The principles of Nancy Schlichting’s unconventional leadership should continue to inspire the national health care leaders. In the words of President Kennedy “Conformity is the jailor of freedom and the enemy of growth.”

Page 5 THE RECORD

Left to right: Brigadier-General H. Colin MacKay, Surgeon General, Canadian Forces Health Services Group,

and Lieutenant General Mark A. Ediger, Surgeon General, U.S. Air Force, address the 128th Interagency

Institute regarding military health systems in Canada and the United States at the Embassy of Canada,

Washington DC, on April 22, 2016.

Page 6

Group II Report: The Refugee Crisis

Group Members: Dr. Debbie Hettler, VHA; Dr. Bill Nylander, VHA; CAPT Reg Ewing, USN; Col Scott McKim, USAF; Col Christopher Paige, USAF; COL Chuck Unruh, USA; CDR Tara Cozzarelli, USPHS; CDR Jeff Draude, USN; LTC Jody Dugai, USA; Lt Col Tess Goodman, USAF; CDR John Kendrick, USN

Assignment: The ongoing refugee crisis impacting many nations has been described as the most significant and pressing issue of its kind since World War II. How adequate have the responses of been from the international community, including individual countries and international organizations? What are the short and long term consequences of this situation and recommend other appropriate responses which should be considered.

Response: The current growing diaspora, stemming from violence in Afghanistan, Iraq, Eritrea, and most substan-tially from the Syrian conflict, has exposed a lack of legal, political, and economic collaboration in the areas most impacted by the exodus—neighboring countries and Europe. Civil war in Syria has caused half of its population to be displaced internally or externally, or killed. While the majority of refugees are living in Jordan and Lebanon, the prospects of returning to Syria are waning, causing many to seek asylum farther from home. More than one million refugees have made the treacherous trip across the Mediterranean and entered Europe in 2015 alone.

The recognition of refugees and the obligations of the receiving states go beyond moral imperatives and have a basis in international law. The Convention relating to the Status of Refugees, also known as the 1951 Refugee Convention, is a United Nations multilateral treaty approved at a special United Nations conference on 28 July 1951, defines criteria for refugee status, and sets out the rights of individuals who are granted asylum and the responsibilities of nations that grant asylum. While a “right” to asylum has not been established by law, “States may not return a refugee, in any manner whatsoever, to the frontiers of territories where his/her life or freedom would be threatened because of his/her race, religion, nationality, membership of a particular social group or political opinion (the principle of non-refoulement).”

The World Health Organization (WHO) definition of “health” is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. In a perfect world, this definition would provide a template of the ideal state of an international response in cases of refugees suffering from lack of safety or well-being in their daily living situation. This aid may consist of resettlement, protection, medical assistance, food or immigration to a safer country. However, when the reality of national self-interests and the role of a country or the associated mission of their military is considered, all necessary aid for humanitarian efforts may not be feasible to offer to those in need. There may not be available infrastructure to allow the incorporation and addition of refugees in need of relocation into another country.

In order to discuss potential appropriate responses to the ongoing Syrian refugee crisis, the instruments of national power to include diplomacy, military, and economic intervention by the international community, individual countries, and international communities must be considered. Each nation’s unique factors, proximity to the conflict, ethnic and religious make-up of its indigenous population, and it’s economic and political strategy all influence their refugee response.

The variations of outreach and degrees of support thus far include humanitarian aid, financial backing, assimilation, resettlement, or asylum. By 2017 it is expected that Germany will have invested 50 billion euros to shelter, feed, and integrate their refugees into functioning members of society. Jordan continues to provide security and asylum via enormous, isolated refugee camps despite the tremendous strain on their national systems and infrastructure. The United States, with humanitarian aid totaling $5.1B since 2011, is the leading donor to the biggest humanitarian emergency in our era.

The Regional Refugee and Resilience Plan (3RP) is the coordinated plan of support to countries in the region (Iraq, Egypt, Jordan, Lebanon and Turkey), and appeals to governmental, inter-governmental, and non-governmental agencies to provide targeted responses to the refugee crisis within several critical sectors such as shelter, education, health, and recovery. In 2015, the plan identified $4.3B (USD) in requirements, $2.67B of which was funded.

Page 7 THE RECORD

Continued conflict, exacerbated by nefarious internal and external interventions guided by self-interests, will increase the flow of refugees. The worsening condition of the physical and economic infrastructure of the region will also cause refugees to lose hope and look beyond to a more secure (Europe) asylum. These pressures may lead to increased xenophobia, populism, disenfranchised elements and could force governments to restrict the flow of asylum seekers. From a health standpoint, crowded camps, poor access to healthcare, including immunizations and other public health basics may lead to a decline in the health and well-being of Syrian refugees, and an increase in communi-cable disease. Economically, migrant flow generally brings (i) highly skilled / professional (ii) persons willing to take on jobs the existing population generally does not want. The International Monetary Fund estimates that EU refugees will add approximately 0.19% of EU GDP to public expenditure in 2016, which will add to public debt and possibly temporarily increase unemployment. Over time, with workforce integration, the refugees are estimated to boost annual output by 0.1% for EU as a whole. The European Commission estimates the refugee contribution to increase the collective EU GDP between 0.2 % to 0.3% by 2020. Countries with more efficient access to work tend to experi-ence positive contributions and the impact on growth relies heavily on the labor market performance of the migrants.

A long term consequence of this population migration may result in further violence, either by extremist operatives or even civil war beginning with geographically closer and resource stressed countries like Jordan and Turkey. There are concerns among EU intelligence agencies that militants utilize refugee routes to infiltrate vulnerable countries with insufficient vetting processes. The Norwegian Intelligence Service estimates 5-10/1000 quota refugees have ties to militant groups.

Refugees can be categorized into three groups, those actively seeking asylum and assimilation, those not currently motivated to return, but not assimilating, and those who are actively returning. A multi-faceted, system approach which addresses this spectrum of refugee cate-gories is required to address the current crisis. First, the flow of refugees must be reduced through the establishment of safe zones in south-ern and northern Syria, enforced by US, NATO/EU members and with the support of the United Nations High Commissioner for Refugees, NGOs, and other Middle Eastern countries. NATO and EU navies must stem the flow of seaborne refugees especially in light of the potentially fatal voyage.

Next, with support from NGOs, neighboring countries housing refugees, and refugee camps, must increase access to education, healthcare and other social programs. The 3RP appeal for 2016 is $5.78B, with the sectors of Education, Livelihoods and Social Cohesion seeing increases, while the requirement for the Shelter sector has declined.

Careful screening is necessary to ensure migrant eligibility for asylum, but also to reduce the likelihood that members of terrorist organizations can enter the host country.

Finally, there must be more diplomatic, financial, and, if necessary, military efforts to resolve the Syrian civil war. The degree of destruction and chaos that Syria has sustained is overwhelming. In looking at a recent model of rebuilding a nation, the coalition in Iraq, for example, provided security, assistance with standing up a new government and public systems that were destroyed during the conflict. Support of this type must be considered if the people of Syria are ever to return to their homes.

Page 8

Group III Report: Outcomes Measures in Healthcare: Now and Beyond

Group Members: CAPT Joe Molinaro, USN; CAPT Michael Johnson, USPHS; LTC Hope Williamson-Younce, USA; COL Edward Michaud, USA; Col Timothy Paulding, USAF; CDR Carol Burroughs, USN; Col John Mammano, USAF; Ms Connie Lee, VHA; CDR Amy Smith, USN; Lt Col Jason Lennen, USAF; Dr. Marsden McGuire, VHA

Assignment: During the past five years increasing attention has been focused on ‘Outcomes Measurement’ in health care as the most appropriate approach to assess effectiveness and efficiency in health policies and the use of resources – people, technologies and finances. Are the best measures and mechanisms being used? What modifications or different approaches do you recommend, and why?

Background: The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.¹

Across all military treatment facilities and the Department of Veterans Health Affairs (VHA), “outcome measures” have been defined generally in one of the following categories: quality, safety, efficiency, patient/provider satisfaction, readiness and health. The Centers for Medicaid and Medicare Services (CMS) defines the importance of quality outcome measures under three general fundamental principles: structural, process and outcome measures:

Structural measures of quality: We can assess the adequacy of the “inputs” to care, such as the care setting, the qualifications of care providers, and the equipment and technical devices used. This is the structural perspective of quality, and the specific measures used to assess quality from this perspective (such as percentage of RNs with bachelor's degrees at a given home care agency) are termed structural measures of quality.²

Process measures of quality: We can examine the “throughputs” to care such as specific interventions, comprehensive-ness of assessment, and adequacy of care planning. This is the process perspective of quality, and the specific measures used to assess quality from this perspective, such as the whether a depression assessment is conducted at admission, are termed process measures of quality.³

Outcome measures of quality: We can assess “outputs” of care by examining what happens to the health status of patients as a result of care. This is the outcome perspective of quality. Influencing outcomes is the fundamental reason we provide health care. The specific measures used to assess quality from this perspective, such as whether a surgical wound healed during the care interval, are termed outcome measures. The rationale for using outcome measures for quality improvement rests with the aforementioned fact that safe and effective outcomes are what drives our delivery of quality health care.⁴

Table 1: Critique of Current Outcome Measures

Outcome Measure Effective/Useful Needs Improvement Not Effective/Useful

Outpatient Quality

(HEDIS, Harm events—

delayed diagnosis, etc.)

Provides comparative data

Provides baseline safety

standards/benchmarks

Limited to just assessing a process interoper-

ability for electronic health records

Lacks assessment of outpatient patient

experience

Inpatient Quality

(Partnership for Patients,

Patient Quality Index—PQI,

ORYX)

CAUTI, SSI, CLABSI, falls

Provides information on safe-

ty-related performance

Would be helpful to have aggregate data for

inpatient/outpatient measures (utilizing

modeling capability to determine and

predict potential health outcomes)

Readmission rates

Access to Care Metrics

(3rd Next Avail, Leakage,

Enrollment)

Provides baseline data for

clinic availability

Needs to assess patient’s preference (i.e.

moving towards a “convenience care” model

similar to the one the Navy is moving

towards)

Doesn’t fully measure capacity (limited

to information entered)

Doesn’t assess secure messaging/other

access points for patients

Cost

(PMPM, RVU’s/Productivity)

Easy data to access; provides

baseline visibility into a

provider’s workload/

performance

Need to assess aggregate data over time

Limited to a fee-for-service measure

Doesn’t measure medical necessity/

efficiency

Medical Readiness

(Dental Class 4, PHA)

Good indicator for preventive

medicine/readiness to be

deployed

Military focused; expansion needed to entire

beneficiary population and other health care

systems

Needs to mature and become a more

efficient process

Staff Readiness Good indicator for readiness

to be deployed

Military focused; how can other systems be

integrated?

Lacks benchmarks

Doesn’t currently evaluate excess

capacity/availability across medical

facilities to assist

Page 9 THE RECORD

Table 1 critiques current outcome measures which include, but not limited to: Outpatient quality, Inpatient quality, Access to care, cost, Medical readiness, and Staff readiness. Effectiveness/usefulness aspects of these outcome measures are identified while pointing out their limitations and areas for improvement. ⁵

Recommendations: Outcomes measures are tough to develop and implement which will require continued leadership engagement

for success. Need for interoperability to accurately track medical issues across systems to evaluate interventions and their

effectiveness. Current measures are imperfect and will require continuous adjustments to broaden the intended focus which

include the family. Standardize measures across private and public sectors. A combination of targeted process as well as outcomes measures will be required. Priority target measures may include Patient Reporting Outcomes Measures, Skills/CPG Verification, and

aggressive population health (like dental now).

Conclusion: Currently the various federal organizations use a combination of outcome and process measures to evaluate the effectiveness and efficiency of care provided. Outcomes are most closely linked to patients and therefore serve as important guides for strategic evaluation of how an organization is doing. Senior leaders should select the most relevant outcomes for display on a dashboard that gives them a view of how well the organization is performing. Process measures remain necessary to track performance of evidence-based activities that feed outcomes. These are most helpful to intermediate leaders that more directly monitor and influence the processes occurring at the point of care. It is valuable to have a mechanism in place to monitor the vast array of measures to highlight deviations for evaluation and focused improvement. It is necessary to have a standard process in place in order to study process adjustments and determine the impact on outcomes of interest. As we understand more about the various drivers of outcomes we can and should adjust the processes and their measurement to accommodate for what we have learned. So while it is appropriate to focus on outcomes as a strategic direction, we are not able to impact these directly apart from effective processes, which in turn need to be monitored for effective performance.

References: ¹World Health Organization (WHO), Preamble to the Constitution of the World Health Organization as adopted by the International Health Confer-ence, New York, 19-22 June, 1946, http://www.who.int/about/definition/en/print.html (Accessed April 20, 2016). ²Centers for Medicare and Medicaid Services. Outcome-Based Quality Improvement (OBQI) Manual. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/downloads/HHQIOBQIManual.pdf, (accessed April 20, 2016). ³Ibid. ⁴Ibid. ⁵Thomas, Valuck. Interagency Institute for Federal Health Care Executives May 2016. Pathway to Improvement: How Quality Measurement and Incentives are Driving Change.

Health: The Ultimate Outcome

HEALTH

QALY

Mortality

DALYMorbidityStructural Measures

Process Measures

Intermediate Outcomes

Socioeconomics

Environment

Genetics / Genomics

Behaviors

HEA

LTH

CA

RE

T I M ETypes of Measurement that Correspond to the Level of Health Engagement

Page 10 THE RECORD

Group IV Report: The Whole of Government Approach

Group Members: Col Therese Bohusch, USAF; CAPT James Chalker, USN; LTC Nicole Chevalier, USA; LTC Casey Geaney, USA; CAPT David Lau, USPHS; COL Tawanna McGhee-Thondique, USA; Mr. Russell Peal, VHA; CAPT Fred Schmitz, USN; CAPT Jonathan Stahl, USN; Col Brenda Waters, USAF; Col Lee Williames, USAF

Assignment: The ‘Whole of Government’ framework has received much attention and been the subject of conferences and discussions in recent times as a necessary and practical construct for tackling major societal challenges. What does this approach entail and what are the advantages and limitations in adopting this broader perspective? Does it make practical sense in terms of developing better policies and programs to the challenges confronting the provision of federal health services, especially those provided by the five agencies represented in our Institute?

Response: The National Defense Authorization Act (NDAA) is the Congressional mandate identifying the primary objectives for the Military Health System (MHS). The 2014 NDAA language directed the MHS to take immediate action to improve underperformance, standardize metrics, hold the Services accountable for improvement, and to make accurate data driven decisions. This language was echoed in the 2016 NDAA with mandates to increase access to care, increase transparency, and manage the rising costs of Department of Defense (DoD) healthcare. Over the past decade, the MHS has not been able to make enough improvements to satisfy the Congressional Military Oversight Committee, leading to a stark edict for immediate action. The DoD was directed to establish a governing body to ensure MHS compliance with Congressional mandates.

The Whole of Government Approach is a practical construct for tackling major national and governmental challenges. This approach requires that the sum of all resources be brought to bear in pursuit of strategic objectives. This concept is reflected in the organization, policy, and mission of the Defense Health Agency (DHA). Diplomacy, Information, Military, Economics and Culture (DIME-C), is a framework used to apply these instruments of power in the whole of government approach to the MHS and DHA strategy.

Diplomacy. The Defense Health Agency (DHA) was established as the oversight agency and Congressional liaison for the MHS. DHA’s primary objective is to demonstrate and communicate MHS effectiveness and relevancy, maximize efficiencies, and control rising healthcare costs. Diplomacy is the principal means of establishing strategic partners, establishing shared lines of effort and gaining buy-in from stakeholders and the community. DHA uses diplomacy to engage and collaborate with Congress, Sister Services, the Veteran’s Health Administration (VHA), civilian health centers and organizations, TRICARE, host nations and DoD-eligible beneficiaries. MHS working groups continue to identify variance and redundancy within the organization and develop action plans to eliminate under-performance and non-compliance, resulting in improved access to care, shared services and cost savings.

Information. The DHA agreed with Congress that increased transparency is a critical enabler in demonstrating value and communicating MHS relevancy to stakeholders. The commercial off-the-shelf electronic health record will provide 24-hour worldwide access to secured medical information. DHA adopted a core set of access, quality, and patient safety metrics from the civilian sector. MHS dashboards of system-wide performance measures allow oversight and accountability with internal and external stakeholders, with the ability for comparison against civilian healthcare systems. Regular monitoring provides actionable information for training, staffing, and appropriate resourcing to further improve access, quality and safety. Electronic health records and system improvements will provide patients improved access to their records, appointment scheduling, and communication with providers; they will also have access to hospital and provider statistics. Transparency improves patient experience.

Military. The MHS is the only U.S. health system with a military mission and is the best combat casualty care platform in the world. We are an innovative, learning organization unified around the mission with demonstrated 97% battlefield injury survival rate. The MHS readiness platform delivers a medically ready force and ready medics while providing a comprehensive home-station health benefit.

Economics. National healthcare costs are increasing due to innovations in technology, demand for expanded coverage and redundant examinations. Congress continues to mandate that MHS rein in the rising DoD healthcare budget. The DHA achieved a FY2014 net savings of $3.482 billion by establishing 10 shared service initiatives.

Page 11

Culture. To ensure a strategic vision, the DHA champions the Quadruple Aim lines of effort: 1) Improving Readiness, 2) Improving Population Health, 3) Improving the Patient Experience and 4) Reducing the Cost of Healthcare. As part of implementing this cultural shift, the DHA is improving leadership engagements, validating and improving the culture of quality and safety through robust process improvements, regularly reviewing performance, adopting industry best practices, and minimizing undesirable variations across the system. Institutionalization of these Congressional mandates will advance the organizational desire to become a high-reliability organization and the preferred center for care.

Successes. In 2015, DHA integrated 10 Tri-Service shared services that demonstrated the MHS ability to standardize processes and practices, becoming more efficient and operating as a joint entity. More than 1,700 employees were integrated across the Army, Navy, Air Force, and the former TRICARE Management Activity (TMA) into the DHA at 40 sites around the globe. DHA monitors MHS activity and provides needed support.

Challenges. While the DHA shared services reported initial success, difficult communication amongst Congress and the Services continue to present challenges to the whole of government approach to move the MHS forward. VA Choice and the TRICARE Urgent Care extension programs are both designed to improve access to care. However, many military bases and VA facilities are located in small communities with already limited resources. A concern is that the influence of Congressional constituencies may override the potential opportunity for the whole of government to assess the TRICARE and VA network capacities to target these programs where they can be successful. The federal agencies, Congress included, must embrace a shared evidence-based azimuth to realize the expected efficiency and effectiveness.

The Way Ahead. The Whole of Government approach to the MHS has realized significant achievements, but unique opportunities remain for DHA and the MHS to lead cultural shifts resulting in sustainable improvements in health. First, DHA must collaborate with the Services to establish common, executable goals while respecting the Services’ individual cultures. DHA should continue to identify and incorporate best practices from civilian and federal healthcare organizations to standardize and improve MHS processes. The Quadruple Aim presents the federal health services and Congress the opportunity to develop a system that targets prevention, incentivizes healthy behaviors, limits access to unhealthy exposures, and optimizes readiness.

FHCEIAA presents a Distinguished Service Award each year to an accomplished Federal Health Care Executive who:

Has made outstanding contributions in the field of Health Care Administration of the Federal Medical Service, or

Has been a strong contributor to the Interagency Institute for Federal Health Care Executives, or

Has been a staunch supporter of the Alumni Association for many years.

The 2015 Distinguished Service Award was presented to Dr. Boris Lushniak, MD, RADM, USPHS Ret, by COL Mark Harris, MC, USA, Immediate Past President, FHCEIAA, on May 2, 2016.

Dr. Lushniak, former Acting Surgeon General of the United States, has joined the faculty of the Uniformed Services University of the Health Sciences as Chairman, Department of Preventive Medicine and Biostatistics.

Page 12

Group V Report: Perspectives on Resolving Conflict in the Middle East

Group Members: Col Michael Foutch, USAF; Col Jim Lasswell, USAF; Col Mark Weiskircher, USAF; Col Kathryn Weiss, USAF; COL Gary Wheeler, USA; CDR Liza Lindenberg, USPHS; LTC Russ Methvin, USA; CDR Ethel O'Neal, USN; LTC Aatif Sheikh, USA; CDR Barbara Whiteside, USN; Dr Caitlin Thompson, VHA

Assignment: Like poverty, the continuing conflicts and crises in the Middle East seem to be intractable and without sustainable, long term resolution. What are the fundamental issues that appear to be impossible to resolve by all parties involved? What are the reasons for the continuance of these conflicts? What could, and should be done by the international community to decrease conflict and bring real stability to this region?

Introduction: The Middle East has a long history of conquest, violence, and instability with the earliest records going back to 1250 BC. Although there is no likely panacea that will bring stability to the region, a critical look at issues and possible solutions can provide decision makers a fresh perspective. The instability in Iraq and the inability of the populace to increase socioeconomic status have increased the complexity of the already difficult operational environment due to religion and the actions of traditional major powers. The disenfranchisement of the local populations, lack of cooperation among State and non-State actors, and the increasing extremism on all sides has further exacerbated conflicts and decreased stability within the region. Any progress in resolving these issues will require enhancing cultural/religious intelligence, balancing stability with national interests, and engaging power systems that are currently in place.

Fundamental Issues: Any discussion, must review the fundamental issues that appear to be impossible to resolve. These include religious conflicts, actions of traditional powers, and an inability to increase socioeconomic status.

Regional state actors thwart stabilization of the Middle Eastern region. Internally, countries like Iraq continue to battle over leadership based on sectarian control. The primary rift is between Sunni and Shia Muslims, but also includes other groups such as the Kurds, Yazidis, and Mandaeians. This presents significant problems for national cohesiveness, government infrastructure and effective security forces.

Actions of traditional powers also threaten destabilization of the region. First, Saudi Arabia, traditionally Sunni, and Iran, predominantly Shia, fuel sectarian divisions within the region. Next, beginning centuries ago, there have been numerous influences and actions of outside powers, from the Crusades through the present. Perhaps the best example is when state lines were arbitrarily redrawn post-World War I by outside state actors which were not based on internal cultural alignments.

A fundamental problem for the lack of a thriving, stable economy is the fact that oil is the predominant natural resource in the region. With the drop in oil prices, countries are putting less money back into their national economy. This is compounded by widespread government corruption that creates socioeconomic destabilization. Civil war and the Arab Spring allowed the growth of ISIS.

Causes of Continuing Conflict: Popular opinion and mainstream media have bemoaned the recent rise in Islamist extremism plaguing the Middle East and North Africa. However, nascent modern-day terrorism was witnessed as early as 1968. Increasing ease of transportation and more open international borders combined with modern communication have enabled the globalization of extremism and terrorism.

Extremist groups have capitalized on a large and disillusioned young population. With 60% of the region’s population under 25 and youth unemployment increasing to 30%, upward mobility is an unachievable hope for most. Combined with governments that disenfranchise modest, moderate groups this results in increasing polarization. Additionally, the historical marginalization of minority groups contributes to inherent distrust of democracy that prevents meaningful change.

Another factor impeding stability is the emergence of non-state sponsored terrorism. Recent disruption of the status quo created a power vacuum that was rapidly filled by fundamentalist Islamist groups. Benefitting from dispersed training sites and funding sources, these groups have expanded dramatically in influence and geographic control.

Additionally, current fundamentalist groups exhibit profound sophistication in their utilization of modern communication tools. Employment of social media has propelled the Islamic State onto the world stage. In fact, ISIS’s use of social media has out-performed the West through a combination of professionally produced content mirroring Hollywood-style videos and through unprecedented segmentation of their products tailored to specific geographic regions and native languages.

Options to Create Stability:

Cultural/Religious Intelligence: The Western powers and Russia’s understanding of the cultural and religious issues in the Middle East is inadequate. It will be important to network with key leaders across the region and religions to determine appropriate solutions. They must broker understanding amongst the affect parties while accepting that New World solutions may exacerbate the problems instead of resolving them.

Stability vs National Interests: Historically, oil has been of strategic and economic import throughout the World. However, this has created competing interests and lead to instability and colonialism in the region. Diversifying the economic outlook of the entire population, not just the few, will decouple wealth from one resource and alleviate the geographic and economic pressures for conflict. World powers must focus on the stability gained from this diversification instead of the potential political impact or national interests.

Current Power Systems: The West must also reevaluate their alliances and determine if they are contributing to the problem instead of the solution. Traditional allies such as Saudi Arabia and Israel may no longer provide the same strategic advantage as in the past. In 2008, the US provided Israel with $2.4 billion in direct aid and $1.4 billion to Saudi Arabia in 2012. Assistance should be leveraged to incentivize these partners to support lasting solutions.

Conclusion: Building a better Middle East will decrease enmity, promote broad prosperity, and help establish universal civil rights. In the last 70 years, the conflict has expanded from Israel/Palestine to regional players. As technology continues its rapid pace, there is increasing potential that this conflict could spill onto the world stage. In the contemporary environment, unless world leaders begin to focus on establishing real stability in the Middle East, the world risks perpetuating an additional 3,000 years of conflict.

References: http://news.bbc.co.uk/2/shared/spl/hi/middle_east/03/v3_ip_timeline/html/history.stm www.pbs.org/wgbh/pages/frontline/shows/target/etc/modern.html www.economist.com/news/middle-east-and-africa/21685503-five-years-after-wave-uprisings-arab-world-worse-ever www.aljazeera.com/indepth/features/2013/07/2013729182834978685.html www.pbs.org/wgbh/pages/frontline/shows/target/etc/modern.html www.brookings.edu/blogs/techtank/posts/2015/11/19-isis-social-media-power-lesaca www.brookings.edu/blogs/techtank/posts/2015/09/24-isis-social-media-engagement http://www.thestrategybridge.com/the-bridge/2016/1/14/a-new-5-point-plan-for-stability-in-the-middle-east http://www.wrmea.org/2008-november/congress-watch-a-conservative-estimate-of-total-direct-u.s.-aid-to-israel-almost-$114-billion.html http://us-foreign-aid.insidegov.com/q/150/1590/How-much-money-does the-U-S-give-to-Saudi-Arabia http://www.thestrategybridge.com/the-bridge/2016/1/14/a-new-5-point-plan-for-stability-in-the-middle-east

THE RECORD Page 13

THE RECORD Page 14

An Australian Outlook on International Engagement (continued from page 3)

Allen carried twelve wounded Americans to safety under fire. For this he was awarded the Silver Star.

Australia’s Regional Perspective

Given our shared values and similar perspectives, it should come as no surprise that our countries also share common concerns about Australia’s part of the world: North and south Asia The rise of China to super power status North Korea Traditional rivalries A move from bilateral to multilateral agreements Friction points such as the South China Sea A more outwardly focused and regionally engaged Japan Papua New Guinea and Fiji (closer to home for Australia) A region which will eventually become an economic power house Huge defence spending The largest Muslin country in the world – Indonesia Radicalism – Bombing in Bali and the Australian Embassy in Jakarta With these considerations, there is little wonder that the U.S. is ‘pivoting’ back towards the Pacific.

Clearly, the 2011 Foreign Policy Initiative is part of the strategy. Notwithstanding, we are a small country in comparison to you and Asia, in particular Southeast Asia. The Southwest Pacific is our home and, like you, we take on responsibilities in encouraging emerging democracies to grow and we expect Nation states to conduct themselves in accordance with international norms. We take our role as a small middle weight power and a responsible international citizen very seriously.

Defence White Paper 2016

This Defence White Paper is good news for Australia as and good news for the U.S., our most important strategic partner. Like you, the defence of Australia and its interests remains our raison d'etre.

Some of the objectives in the document include a commitment to spend 2% the Gross Domestic Product for defence, greater independence and self-sufficiency militarily, and the retention of an all-volunteer professional force that is well-trained, well led and well equipped. The outcome being an interoperable, expeditionary-focused joint force capable of taking a leading role in our region but also capable of contributing in larger scale conflicts as part of a coalition.

But, none of this worth anything if we don’t have the right relationships, if we don’t fight to ensure our values and

perspectives remain shared ones.

Photo: Ms. Nancy Schlichting signed her book,

Unconventional Leadership, for Colonel Scott McLeod,

RCMS, Deputy Surgeon General, Canadian Forces

Health Services Group, on April 25, 2016, following

her presentation at the 128th Interagency Institute.

See the group report on page 4 for further details.

Page 15

Embassy of Canada, Washington DC, April 22, 2916

Above: Surgeon Captain Stephen Bree, RN

Below: Mr. Jonathan Davidson, JD, Chief of Staff,

Senator Michael Bennet

On right: 128th Interagency Institute participants and faculty

THE INTERAGENCY INSTITUTE FOR FEDERAL HEALTH CARE EXECUTIVES

Dr. Richard F. Southby Director Distinguished Professor of Global Health & Executive Dean Emeritus, GWU 5325 MacArthur Blvd NW Washington DC 20016

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