Leading the Defense Health Agency: Interview with Lt. Gen. (Dr.) Douglas Robb, director, Defense Health Agency

Across the country healthcare systems are focused on ways to reduce variation in care, improve patient safety and more effectively use health information technology to improve clinical decision-making and outcomes.

The Military Health System isn’t immune to such changes. In fact, within the military, there are additional imperatives for designing an integrated health system which includes more joint operations as a way to meet its aims of readiness, improving the health and care of people it serves, and doing this while managing costs.

With the creation of the Defense Health Agency, DoD has taken a step in this direction. DHA is the starting point for comprehensive enterprise-wide reform. It is a leading example for how DoD will seek to modernize and integrate its system of care -- creating a stronger, better and more resilient military health system for the future.

•  How is the Defense Health Agency changing the way DoD delivers healthcare?
•  What are some of the key challenges faced in restructuring such a complex system?·        
• How is DHA transforming its health information technology portfolio?

Lt. Gen. (Dr.) Douglas Robb, Director, Defense Health Agency joined me on The Business of Government Hour to explore these questions and so much more. The following is an edited excerpt of my conversation with General Robb.

General Robb, would you provide us with the mission and vision of the recently established Defense Health Agency? What’s the impetus for the creation of DHA and the overall organizational redesign of the Military Health System?

I could give you the formal mission statement, but I’d like to put this more plainly. The Defense Health Agency (DHA) is a Combat Support Agency supporting the Military Services.  Simply put – the Combat Commanders and the Services are my customers.  Our job in the DHA is to help ensure the warfighter gets what they need from us.  In return, we took on a host of responsibilities in the form of “shared services.”  We need to deliver common services to the Army, Navy and Air Force  -- health IT, medical logistics, hospital and clinic construction and maintenance, public health, the TRICARE benefit.  I could go on.   There are ten shared services in all. 

The DHA also is responsible for health care delivery in the National Capital Region – at Walter Reed National Military Medical Center, and Fort Belvoir Community hospital, and we serve as the marker manager for the entire region. 

The impetus was straightforward.  In the combat theater, we were operating as a joint team in every phase of operations – and coordinating the delivery of care in a more effective way. The idea behind the DHA is that we needed to bring this same joint approach to our peacetime operations.  There are far more similarities than differences, and we need to take advantage of this commonality.  And the fact is, this is about a lot more than just efficiency.  It supports readiness, it supports maintaining health, and it supports health care delivery.

General Robb pursues his agency’s mission with approximately 4,000 full-time employees – military and civilian -- spread globally; and, with a budget over $15 billion per year.  DHA manages the TRICARE contracts, pharmacy contracts, Health IT services, medical research and development, the construction budgets for military hospitals and clinics along with a number of other services.  

Now that you’ve provided us with a sense of the larger organization and the mission of your office, perhaps you could tell us more about your specific responsibilities and duties as the director of the DHA? How do your efforts support the department’s overall mission?

There is a saying inscribed on the wall as you walk into my office.  It says “Medically ready forces….Ready medical forces.”  That’s the mission of the Military Health System overall, and its our responsibility in the Defense Health Agency.  And it’s what I come to work every day and focus on and talk about. 

Let’s take an example of how that plays out. The Army, Navy and Air Force and our hospitals in the National Capital Region all need, say, an anesthesia machine.  They can go out and purchase about 8 different machines.  But, what we need to do on a regular basis – and what we have done – is sit down with the anesthesiologists from all of the services; make sure we have their requirements for what THEY need; and then get them to agree that we will buy a SINGLE machine.  There are several benefits to that.  One – we leverage our joint buying power and get a good price. Two – we get a product that all of our providers agree is what’s needed.  Three – when people move from hospital to hospital…overseas and back…to deployed location and back…they are working with the same machine.  That's good for clinical care, that’s good for readiness, and that’s good for cost control.

My team and I spend every working day on what common clinical and business needs we have – and try to figure out how we get the customers – the Services – what they need in a timely way. 

Regarding your responsibilities and duties, what are the top three management challenges that you face in your position and how have you addressed those challenges?

1. Building the plane as we’re flying it – the DHA as an agency is still in IOC - initial operating capability. That means that while most of the basics are up and running, we’re still implementing pieces of the agency to get it fully operational. Managing an agency while simultaneously building and shaping what it will look like requires everyone to come together in a coordinated fashion. 
2. Standardization and integration – one of the main goals of the DHA was to standardize and reduce variation across the Services to provide more joint, integrated care and support to our warfighters and our beneficiaries. For me, that means often taking three different ways of doing things and bringing everyone to the table to agree on one way to do things in the future. As you can imagine, that’s not always the easiest conclusion to reach – but it is what makes the DHA’s role so critical in the future of the MHS.
3. Challenging budget environment – finally, there’s no real way around it – we’re in a tough budgeting environment. Between sequestration and budget cuts, everyone in the Department has to refocus and revaluate how we spend our resources. Now, I’m proud to say that we at the DHA are leading the charge, delivering XX dollars more in savings than we were expected to in the first year. We will deliver a total of XX dollars over our first five years. This requires some hard choices. But, they are necessary choices and they are choices we are making together.

Along with the challenges you’ve encountered, leading the effort under your charge can also be fraught with unanticipated or unexpected surprises. To that end, what has surprised you most since taking on current role?

 I’ll give you a couple of nice surprises or pleasant facts. I wouldn't call this a surprise, but what makes my job easy is the people. I can’t tell you what talented people we have – military and civilian.  And, to a person, they tell me – “we should have been doing this ten years ago. This makes all the sense in the world. This is a motivated workforce.  They want to make this work, and they are.

Second – I was deeply involved in the Task Force that led to this Agency being established…and we thought through many options. Thought we had it right…but it was surprised, again pleasantly, by the response from other government agencies and from industry. They have told me how much this has made their job easier and more effective.  They love having a single belly button, a single point of contact to negotiate with –  whether its DISA, or the Defense Logistics Agency, or private contractors who are trying to understand and respond to government requirements, we have streamlined the interface for them with the Military Health System. It’s been very gratifying.

Recognizing that DHA is in its infancy, I would like to get a sense of your key strategic priorities going forward. Would you elaborate on your strategic priorities for reshaping your organization and the way MHS operates and delivers care? To what extent do these priorities dovetail with Secretary Hagel’s six strategic priorities for reshaping forces and institutions for a different future?

My boss, Dr. Woodson, worked with all the Surgeons General and with me to iron out the six strategic priorities for the MHS in the coming year – and there is complete alignment with the Secretary’s priorities.

The Defense Health Agency is establishing a “shared services” model for managing and overseeing the operational work for a host of functional areas? What is a “shared services” model and why have you adopted such an approach? What specific benefits and realized successes derived from pursuing this new path?

There are 10 shared services aligned under the DHA. Five of these shared services were implemented on 1 October 2013. The other five shared services will be implemented no later than 1 October 2015, the date for DHA Full Operating Capability (FOC).

Facility Planning
Medical Logistics
Health Information Technology
TRICARE Health Plan
Pharmacy
Public Health (Summer 2014)
Contracting
Budget & Resource Management
Medical Education & Training Medical (Summer 2014)
Research & Development (Summer 2014)

DoD’s EHR modernization project can be viewed as three separate, but related events. Would you tell us more about your efforts to implement a new Electronic Health Record and elaborate on each of these phrases? What are the biggest challenges to deploying this system and what are the top criteria for its success?

If war is the dark side of human experience, military medicine is the hope and the light. The past 12 years have been the longest period of war the US has ever experienced, but they have also seen incredible developments in medical care. Would you elaborate on recent medical innovations (i.e., blood-clotting bandages and advances in regenerative medicine) derive from the battlefield? To what extent has military medical advances translates to the civilian world?

Lt. General Douglas Robb underscores that it is mission first, people always. “I'm a firm believer that if you take care of your people, they'll take care of the mission. There's only two states of being; either you're ready or you're not. There's no in between.”

 I invite you to listen and download a complete version of my interview with Lt. General (Dr.) Douglas Robb on The Business of Government Hour.