Annual 2008 VA/DoD Joint Venture Conference David Grant Medical Center VA Northern California Health Care System WILDER: Intro myself…..Thanks for inviting us and giving us the last presentation of the conference…. I am pleased to be presenting with my counterparts at the VA, KC and Sandy. KC: Lt Col Doreen Wilder David Grant Medical Center KC Carlson and Sandy Robison VA Northern California Health Care System

Agenda Brief overview of sharing relationship Staff Integration Other Best Practices Lessons Learned Contact Information WILDER: Today, we will briefly talk about our sharing relationship; I know many of you heard our presentation at the MHS conference this past Jan so we won’t go into too much detail. Sandy will then highlight our best practice – staff integration. KC: Lt Col Wilder and I will then wrap up with the key principles that we believe guide our overall success, and wrap up with those ever present opportunities for improvement as we look at new Oceans of Opportunity

Brief Overview of Sharing Relationship Sharing agreement between 60 MDG and VANCHCS established in 1994 Veterans utilize DGMC for ER, inpatient care, radiation therapy, neurosurgery, and specified diagnostic services VA Fairfield Clinic (adjacent to DGMC) includes joint neurosurgery clinic and DoD contract chiropractic clinic Agreement incorporates Pre-Sep Program, a consolidated DoD Pre-Separation and VA Comprehensive and Pension physical (25-50 per month) 60 MDG Satellite Clinic located at VA’s north Sacramento site 6 PCMs for 60 MDG enrollees located at Sacramento site Includes active duty Coast Guard and dependents VA provides lab, x-ray, pharmacy services to DoD beneficiaries 60 MDG pays VANCHCS for this service; therefore, no patient copay required (acts a TRICARE provider) KC: Sharing agreement between DGMC and VANCHCS was formally established in 1994. Initial sharing in the MSA included 24 hour Emergency room services, inpatient, select outpatient specialty care, and hyperbaric medicine. Two DoD satellite clinics activated in Sacramento VA facilities in 1999 and 2000 to support Tricare beneficiaries following the BRAC closure of the 77th MDG at McClellan and Mather. In 2000, the 35,000 sf VA Fairfield OPC (adjacent to DGMC) activated. Shortly thereafter, DGMC’s neurosurgery clinic and a chiropractic contract clinic relocated from DGMC. The agreement continued to expand to include a BDD program for Travis personnel, robust radiation oncology and JIF programs which we will mention later. Today the Master Sharing Agreement consists of over 40 shared services.

Best Practice: Staff Integration “The staff is seamless. We have a completely integrated staff, working and growing together.” WILDER: Not having segregated wards has improved our operation and partnership. Attitude of leadership makes or breaks the integration Integrated staff are found in our Operating Rooms, ICUs, Neurosurgical service, Social Work, and Hemodialysis unit. We also have a full time Nurse Manager for the VA on site. Patients are not assigned to a VA or DOD beds. I’ll now turn the brief over to Sandy, who will talk specifically about our nurse integration. Our Chief Nurse was scheduled to attend with us today, but she is back at Travis having a good time with the Unit Compliance Inspection.

Best Practice: Staff Integration Hiring Advertising Application review process Interview processes Recognize expertise Emphasize integration from the start Electronic vs. paper record I don't have critical care experience; important to have the Critical care NM to talk about the types of patients that are admitted to their units. Tour the unit with the candidate. Emphasize the program – integrating VA staff with DoD staff Address VA nurses transitioning from a computer based medical records to a paper chart. Did lose one VA nurse over this.

Best Practice: Staff Integration Education/Staff Development Requirement comparisons—one folder Contains both agencies’ requirements Orientation to VA and to DGMC Consider variations of accepted standards “They (VA nurses) are highly motivated and are important assets to our unit. I was fortunate enough to be oriented to the unit by Sally.” Maj. Lowry, Nurse Manager Education requirements Met with SDO and compared the VA annual requirements and the annual requirements for DGMC. -They accepted VA training as equivalent to theirs on the same topic ex: Infection control, HIPPA, privacy, cyber security. -Trimmed down the Health Stream requirements to less than 10. -Kept topics that were unique to military and/or DGMC. May have to look a little longer to find some things, but everything is there We knew we had made progress when one of VA RNs was selected to orient the new AF nurse manager. Access to VA computers has been issue. Need to allow time for VA staff to do annual training.

Best Practice: Staff Integration D/C Planning & Case Mgmt. Joint morning rounds Promotes collaboration Improves communication VA nurses help to facilitate D/C planning “It's Friday – Don't Expect Miracles” Capt Lydon, DGMC, UM Nurse Identified as a need to improve communication regarding discharge planning with VA patients admitted under the sharing agreement. Result: VA nurse and social worker now go to morning rounds with the inpatient teams.

Best Practice: Staff Integration Leadership Role of the VA Nurse Manager VA nurses in supervisory positions Maintenance of VA identity Performance discussions “Maria was right to be concerned. I actually find her concern reassuring because it tells me that she is thinking the problem through and is asking the right questions. She handled it well last night.” DGMC Critical Care Medical Director For the ICU meetings, I sit with the AF nurse manager and the message is there. Attend unit staff meetings VA Nurses do have all the same opportunities as their DoD colleagues. They work in roles such as charge nurse, preceptors, shift leaders. Need to provide opportunities for the nurses new to the VA to establish their "VA Identity" 19 nurses working at DGMC; one of the RNs was appointed to NPSB. Have to have good communication with your AF counterpart. When there are performance issues, both the AF manager and VA manager need to address the issues with the nurse.

Other Best Practices at the Joint Venture Trust and integrity between VA and DoD We understand and support each other’s mission Fisher House and Air Force Inn Support Engaged and supportive leadership Regular Meetings/Ongoing Communication Monthly Joint Initiatives Working Group Quarterly Executive Management Team meetings Reversible Reimbursement Methodology…Keep it simple User Review of MSA Always looking for ways to strengthen each other Annual strategic planning off sites are critical We look for the right solution for both parties WILDER: Our success is at so many levels: Trust and integrity between VA and DoD … we are friends and colleagues We “get” each other. Dr O’Neill understanding our readiness currency needs is invaluable!! Making him our Honoree MDG Commander has continued to strengthen this mission. Fisher House is on campus and does allow for Veterans use on a space available basis. We have entered into an agreement with the VA to offer a priority of reservations at the AF Inn which was not in place in the past but now allows for improved pricing and availability for veterans. Engaged and supportive leadership KC: Regular meetings/on-going communications…we jointly chair these meetings and take turns hosting Simplify your reimbursement (we do 75% of CMAC) and our staff are actively involved in updating/reviewing the MSA. Always looking for ways to help each other out…by doing that we strengthen each other’s programs It’s a marriage…never 50/50…always a little give and take

Lessons Learned Address issues early on Keep the personalities “in-check” Patient-centered focus WILDER: Whatever you do….keep the lines of communication open and address the issues early on. If you can remember this is business and keep the personalities in check – you can go a long way. Talk about the Night Hawk issue KC: Whatever we you do – if you keep the patient needs at the forefront – you won’t go wrong. All of our patients have served – they deserve our best efforts