1. 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

2. 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

3. 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 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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

10. 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