My second year as chief of staff.

Could it really be? It was April 2004 and I had survived the ups and downs of the first year as chief of staff. I was expecting to settle into what I had thought was the normalcy of the job. I imagined I had crested most of the waves that had come my way. But my challenges had just begun ...

Staffing and more staffing

My second year started with two service chiefs and my administrative assistant leaving. After sorting through more than a dozen resumes and applications for chief of surgery, I determined to wait until someone who shared my vision for our surgical program came along. The position was too important to compromise on who would be selected.

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Opportunity knocked one day with a phone call from a surgeon in Georgia who was interested in relocation. Having learned from previous experience that personal involvement is key in recruiting, I became more proactive and maintained frequent phone and e-mail dialog with this candidate.

During his interview, I clarified my vision and the challenges that lay ahead, offering him nothing less than total honesty and openness. I also served as an intermediary to facilitate some of the less customer friendly aspects of our bureaucratic organization. This approach worked; in August we were on board with a new chief of the surgical service. He has become a tremendous asset to our staff. This drove home to me the importance of servant leadership in recruiting qualified staff.

Unfortunately, this approach did not work for another service chief. Again I was contacted by an individual making a confidential inquiry about a position at one of our two campuses. I continued phone calls and regular e-mail, and was hopeful when he narrowed his job search down to two possibilities.

In the end, he chose the option that required less vision and offered more money. One lesson was that money talks, but we did not have enough of it to talk loud. So, almost two years into the vacancy of this position I remain poised and alert for the right person to head this group.

Lesson: Even when you think you did everything right, things don't always work out your way.

A national search for an administrative assistant netted two top candidates, both superbly qualified. Human resources did an excellent job. All of the senior executive leadership interviewed the candidates. Reaching a consensus was not easy, yet I was determined to do so.

The candidate who was selected arrived here in September. Again, he was a talented addition to our staff. For me, it was an exercise in flexibility and timing.

Lesson: Be patient in making major staffing decisions, and allow the right people to surface. Faith in people sometimes works wonders.

Growth of opportunity--research, surgery

Implementing vision required baby-sized steps. I came with a vision to recreate a clinical research program, having participated in clinical research myself in the past. I knew I was walking into a highly bureaucratic realm: the Veterans Administration (VA) had completed a stand-down for research in 2003. So to make it happen, I would need the assistance of a lot of people.

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My first contact was with the research administrative officer at another VA facility at our network. She was my mentor as I worked out the details of how this program would function. She introduced me to important officials at the national office who would be required to concur with our application, and she asked for their guidance on how best to proceed.

She enlisted the assistance of the internal review board (IRB) chairs at the university and they agreed to add us to their review. A memorandum of understanding was the next thing needed, and this involved networking with the directors at the university-affiliated VA and my own, as well as the staff at our network office.

We completed our application for our federal-wide assurance, the document that certifies our ability to perform research, ensuring compliance with all the standards under federal law to conduct human research.

It was a great day when, after a year of effort and networking, we received this three-year approval on October 27, 2004. We were one step closer to doing clinical research!

The next challenge was navigating the logistics of doing research. We are still working on staffing this and hope to get the first protocol through the IRB six months after receiving federal-wide assurance. I am committed, though, to doing the process correctly, because our credibility, the NCQA accreditation of our network VA, rides on this.

Hiring a chief of the surgical service presented a whole new set of opportunities. Having had a surgical program that was staffed by unmotivated surgeons prior to his arrival, I concluded that one of the first challenges was coping with the ever-growing demand for surgery.

As the new chief's enthusiasm has begun to carry the day, we are challenged to find the money to acquire the equipment and supplies that he needs to carry on. When all of this came to light, our director asked us to take a step back and come up with a surgical business plan.

This was a wise request. It forced us to prioritize where we wanted the service to go and identify possible risks and benefits for each decision that we were making. The resulting document served as a blueprint for the service, as well as a communication tool with those stakeholders who wanted to know where we were going (and not going) and why, so that they could justify providing the assets that would be required to see it enacted.

Lesson: Using a group of people to employ systems thinking is one of the most effective ways to come up with a master plan.

Budget woes, budget wars

The dictum of living within your means has always been as true of the VA as everywhere else. However, in order not to overspend our budget we were required to pay current operating expenses with money allocated to capital investment. Since this was happening at a network level, the network was able to maintain a bailout fund that could be tapped by each hospital at the end of the year. But we were spending away our capital reserves to pay operating expenses, something that has definite negative long-term consequences.

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Funding in this manner leads to the long-term consequence of having obsolete capital equipment, and no budget to replace it. That is why we went to the system of having a budget allocation during the year, and living within it. This freed us to make necessary operational and capital decisions during the year, forcing us to tradeoff for what programs and projects would be funded.

If it was only so easy! First there was the modeling to address. Admittedly some costs are, as best one can tell, truly fixed, including the salaries of the physicians who treat the patients. Others, in a managed care system such as our own, are only approximations. Included in this category are pharmacy costs for patients (covered by the VA), and costs for referrals to sub-specialist providers outside our own system.

The modeling is further complicated by how the system plans to provide services to its enrollees. At one end of the spectrum, you can simply close your own doors and contract for all services with other groups. A review of costs associated with outsourcing care to the private sector showed this is not the best business decision and should be avoided when possible.

At the other end of the spectrum, you attempt to bring those services back in house so that you do not have to outsource any of them (which is an expansion of services within your own organization, but not in the spectrum of clinical care overall.)

Yet these models look very different, and there may be start-up costs associated with bringing services back in house that were previously purchased outside the system. That is where we found ourselves when it came to bringing the majority of surgical services for our patients back under our own roof.

Each manager was asked to come up with a list of cost savings measures in an attempt to shift away as much as possible of the deficit. We were directed:

* Not to increase or decrease any staff overall

* Not to start or stop any programs and services

What was left after these restrictions was an attempt to shift as much of the contracted services back to the sub-specialist providers elsewhere in the VA, as well as generate a list of medications in our formulary that could be substituted for higher cost ones.

While HMOs may have economic incentives and disincentives for consultations, we were not allowed to employ them. Instead, we had to generate our own service agreements with the sub-specialists, as well as an oversight mechanism to be sure that they were being complied with.

Even now, my one hand holds the throttle called "cost containment" and my other is on the throttle called "performance goals," in a constant balancing act to bring these in alignment in a fixed budget scenario where no profitability incentives exist to make the figurative airplane stay aloft.

In addition, there are constant tradeoffs between services offered by the hospital, as well as the impact that budget cuts make in every aspect of patient care. Who is to say which is more important--engineering or psychiatry? Housekeeping or pharmacy? Nursing or medical staff?

Lesson: I realize again how hard it is to make decisions that inevitably affect individual patients' lives. The only answers lie in true systems thinking by people who are able to consider the greater system as a whole in order to make these tradeoffs, keeping patient care our top priority.

More inspections

Having passed our Joint Commission on Accreditation of Healthcare Organization's (JCAHO) survey, we were in relatively good stead. However, 2004 was the year when JCAHO was converting to continuous survey readiness.

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In addition, we also found out in May that the U.S. Inspector General would pay us a formal visit in June. Whose knees were shaking just a little bit?

Once again we scurried to make sure that our operation was shipshape. The IG was to focus on our policies more than JCAHO had done. Having updated all of our policies in the previous year, I knew we were in good shape. As it turned out, the inspector team gave us a clean bill of health after reviewing our patient care.

We were cited for not documenting training for moderate sedation for contractor personnel, a small oversight that we have fixed. Overall, it was an encouraging visit.

Lesson: Have a written policy for everything.

What this taught me, though, in addition to the small inspections any facility will face is that one never stops getting ready for inspections. This, in fact, is the mandate behind JCAHO's continuous survey readiness.

Be ready to show your stuff at any time, any place. It is important to make sure that you are doing the right things by the patients you serve 24/7/365 so that it doesn't matter when the next group of inspectors arrives.

We depended heavily on a highly qualified performance improvement staff, and their guidance did not let us down. I learned not to be afraid to ask questions, even when it's clear that full compliance with the standards does not exist. So, we did our preparation for our mid-cycle evaluation and continue to be vigilant for our weaknesses and vulnerabilities, seeking to correct those processes in order to provide only first-quality health care to our patients.

The media

The Capital Asset Realignment for Enhanced Services (CARES) decision was announced by the Secretary of Veterans Affairs in a well-orchestrated forum on May 7, 2004.

This decision was based on a review of all of the VA facilities in the country, including plans for consolidation of services and facilities in certain areas where projections for demand showed decreased utilization in the future.

We lived in the suspense of suspecting that the secretary would endorse the recommendation of the CARES commission, which would affect one of our two facilities more than the other, yet the announcement from Washington was repeatedly delayed. Not surprisingly, once the decision was announced, we were surrounded by a media blitz that focused on the recommendation that the inpatient services of one of our two facilities would be closed.

Unfortunately, local media reported that the entire VA hospital was targeted for closure. Evidently, the reports had not been able to discern between closing an inpatient unit and closing the entire facility.

Even after the decision had been announced, no timetable was immediately given for implementation of the plan (and still is not for our facility). But soon there were untold numbers of phone calls questioning the decision, as if the local administrators had made it.

Overnight I became the visible representative of the VA to many people I had never met, mostly in the community. As soon as people find out that I work for the VA, they asked, "Is it true that they are going to close the VA hospital?"

Thankfully, I had worked out a well-scripted response that emphasized that the secretary's decision would only affect inpatient services, and that these services would be acquired through community hospitalization according to the projected need for inpatient beds in 2012.

Talking to everyday people about the issues ultimately became the greater challenge for me, more so than learning how to talk with the media itself. Being chief of staff means that I embody the values of the organization to the community.

Lesson: Proper communication with the community is a priority.

EEO and me

Equal opportunity is the law, and for good reasons. I have never knowingly engaged in a violation of this law, but this did not prevent an employee from alleging that I had.

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The grievance, then the fact-finding, then cooperating with human resources to coordinate a response were followed by a series of affidavits to the Equal Employment Opportunity hearing official. Since a resolution was not obtained, the next step was the request by the employee for a hearing before a judge.

This began the cascade of depositions and the final hearing. In short, I got a baptism into health law that I wasn't expecting.

It has been a long road to justice. It was my first formal encounter with the legal system, never before having been accused of medical malpractice. I discovered that telling the truth, even in a medical malpractice case, can be convoluted by the other side to attempt to show bad faith. Yet there is no choice other than to stand up for what you did, for what you were sure was right at the time that you did it.

Again, this was an experience in representing the agency as much as myself. (I learned that you also want to hire trustworthy people, because you will end up depending on their wisdom and insight to get through the hard times.) Again, the importance of documentation was driven home, as document after document was scrutinized and rescrutinized for what it might have said or not said.

While it has been hard to maintain humility in the face of what I see as an unfair accusation rather than becoming defensive, I constantly remind myself of the need to be humble and honest nonetheless, since my character is on the line.

Lesson: In medical administration, as in medical practice, documentation of actions is the key to defending oneself against claims.

Good-bye boss

The coup-de-grace came on December 20, with the announcement of my director's resignation to take a position in another state. He made the proclamation with great aplomb, and caught most of us by surprise.

Although I was happy for him, I struggled with my feelings. Here was the person who hired me, believed in me and mentored me. I had accepted the position as chief of staff from him, based on his vision and mine. Less than two years after I arrived, my boss was going to leave. It was a personal tsunami.

It's not that people don't move on, of course. The usual moves, retirements and resignations affect us all. The reasons are as diverse as the people who move, and the personal reasons involved in my director's decision certainly were noteworthy. But none of that assuages the sense of sadness and loss, knowing a friend and mentor was moving on.

We are in a transition period while we wait for a new director to be appointed. The search committee has formed. My duties have expanded again, as I exercise a watchful eye on all areas of the operation and arrange a coordinated response with my co-administrators to the issues and problems that face us. Soon we will start a new era in our history with a new director.

Lesson: Change calls for increased flexibility and leading by example.

Epilogue 

April 2005. Two years have now passed since I first became chief of staff, yet only a fraction of the challenges facing me when I came have been addressed.

New challenges include helping people learn to cooperate with each other in an unfamiliar department. Another is learning better how to focus time and energy in the right direction to get things done, while becoming more proactive rather than reactive in setting my agenda.

I am beginning my mission of mentoring staff here. What lessons will I have to share with them? Will that grow into something else? Only time will tell. Most of all, I am continuing my quest to exhibit humility and kindness to my fellow workers. And, more than ever, I rely on the scaffolding of people who are here to help and cheer me on.

Marc Wooten, MD, CPE, FACP, FACR CPE, is chief of staff of VA Northern Indiana Health Care System and volunteer clinical associate professor of medicine at Indiana University School of Medicine in Fort Wayne, Indiana. He can be reached at [e-mail]. The views expressed in this article are not those of the Department of Veterans Affairs or of the United States.

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By Marc Wooten, MD, CPE, FACP, FACR