Context of the Intervention

Speaker A So my name is Steve Zanakis, and I'm a retired army brigadier general and a psychiatrist who had been involved with Steve Clement for many years. But particularly in the early 1990s, you and I were asked by the new surgeon general at that time, General Al Siddlanu, to come in and do a comprehensive review and analysis of the Army Medical Department and recommend to him and to the senior army leadership some plans for reorganizing it. We were introduced I was introduced to many of the writings and teachings of Dr. Jakes early on in the project, and there was an immediate appeal that we were able to grab onto and use for our project here, and particularly an appeal in such a large organization as the Army Medical Department.

Speaker B Why don't you talk a little bit about the size? Because we'll take the context of this is a pretty significant case study of intervention in the medical field.

Speaker A You have an active duty force. First of all, it's a diverse organization so that it has many missions. It provides direct care to soldiers and other combatants in the combat theater. It has to prepare and train medical people, professionals at all levels, from frontline medics to thoracic surgeons. It does research in very basic, important areas, particularly infectious disease. It has a complex schoolhouse, and there are, at least over at that time, 50,000 people, military, active duty and civilians, who were assigned to the Army Medical Department at eight medical centers worldwide. Span and control large, complex organization. A budget of $15 billion spent for.

Speaker B All sorts of and if I recall, at the time, we were exploring radically new ideas of telemedicine cutting edge technology, being able to deliver top quality care worldwide via telemedicine issues at the time.

Speaker A And just many areas of basic research that even now have come out that we realize and even preparing for this new avian flu epidemic. It's been the army that has been able to decode some of the old viruses from the 1918 epidemic. So there's a lot that is done in army medicine.

Speaker B But at the time, we were really it was post Gulf War. We knew we were going to be downsizing. And so that really brought together a convergence of ideas to how do we do this in a smart way.

Speaker A And we were lucky that our surgeon general said, we're going to approach this in a very systematic, thoughtful way, and we're going to do it based on analyzing the system and looking at what we think are going to be the trends that are going to influence it in the coming years and be able to reorganize ourselves to meet the kinds of responsibilities and missions that the organization is going to have. And it was a very interesting time for us because in the early 1990s, we had by that this was 1992, it was three years after the fall of the Berlin Wall. Our relationship with the Soviet Union was changing, which meant that the whole army was going to have to change and think about what was going to be its combat mission in the coming years. We just come out of the Gulf War and again wondering what were going to be our responsibilities to the Middle East and other areas across the globe. In medicine, we were going into a real effort to establish managed care plans. A new president was coming in with some ideas about how health care should be reorganized. And there was still again a proliferation of all sorts of new treatments and technology.

Speaker B And if I recall, we were under tremendous pressure to outsource through submained contracts a certain amount of the healthcare to a local community, which caused us to have to take a look at the structure that we have needed to put in place to be able to affect that kind of change.

Speaker A Well, the thought of the National Command was that we're going to have a smaller military in any way. Many of these functions can be done by contract because it's more efficient and we don't have to do it, quote, in house we can do them by bringing other people on.

Speaker B So one of the issues was that Elliot talks about this concept of getting people to work, do the right work at the right level, at the right time. And so one of the issues was to start at the right location, where is the real nub of the delivery system? And that was interesting because we had our series of military treatment facilities all linked together to tertiary care med center. But when we started the analysis, we had to pick the right spot to start at and we didn't have regions at the time.

Speaker A Well, the question that we were facing was, and again, reflecting many of the trends, was, is there a smarter way to organize our delivery system to understand that it's much more integrated than up until this time it seemed to be, and technology was enabling us to do that. And we could now communicate much better than we had ever before. And so we could have truly an integrated healthcare system and be able to look at what were the front lines, where primary care was in fact the largest responsibility, where we had to do secondary and third level layers of care as well as much more subspecialized treatment. So we took a look at the work. What was the clinical responsibility, who was doing it, what were the kinds of patients, what were the problems that they were presenting and what was the smartest and most effective way to deliver to them, where they in fact was a point of care.

Speaker B And in fact, what we eventually ended up was that we established regions where the medical center was dual headed as the regional commander because he or she had to make a decision as to what was the proper trade off. Was it more cost effective to deliver the care internally in our own facilities? Or was it more cost effective to buy that care in the commercial sector? And at the time, we were also just beginning to do joint ventures with the local VA because there were some things they were doing that were more cost effective than we could do them ourselves.

Speaker A There were a lot of trends that we really mapped into our process. I think what we did was you had introduced to general anew the idea that there was a very logical way to look at how an organization should operate by very systematically identifying the work was being done, the complexity of the work and for the leadership over the timelines they had to plan and think out. And so that it was for us the right time to review all the different responsibilities we had, use this method which was really kind of empirically based, and take that information and to systematically be able to reflect it to our leadership and say, from this comes some recommendations of how we should operate in a much more effective way.