Wild Blue Yonder on the Air - Ep. 21 - Lt. General Ronald Place on the DHA and Military Medicine Published Nov. 29, 2022 By Lt. Colonel Joshua Miller & Lt. General Ronald Place Wild Blue Yonder on the Air -- Opinions, conclusions, and recommendations expressed or implied within are solely those of the author(s) and do not necessarily represent the views of the Air University, the United States Air Force, the Department of Defense, or any other US government agency. Speaker 1: And weather remaining go. Lt. General Ronald Place: So that's not all systems are currently go. S1: Three, two, one. Lt. Colonel Joshua Miller: Wild Blue Yonder on the Air is the podcast of the Air University peer-reviewed online journal and forum focused on military-related thought and dialogue. I'm Lieutenant Colonel Joshua Miller, a Medical Service Corps officer, an Air War College student, and host for today's podcast. Today we have the opportunity to speak with the DHA Director, Lieutenant General Ronald Place about a series of issues surrounding the DHA transition and readiness of the force. Thank you for listening. Today we had the pleasure of having the DHA Director give a brief to the Air War College on the DHA and the roles and responsibilities, strategy, direction, and where we are now. Now we have the privilege of having Lieutenant General Ronald Place join us for this podcast. Sir, thanks for taking the time today. We greatly appreciate it. Place: Yeah, thanks, Colonel Miller. It's my pleasure to be here and really appreciate what you're doing to show everyone just how important the critical aspects of military medicine really are. Miller: Appreciate that, sir. All right, so today we're going to go over some questions regarding several issues around the DHA and really look forward to the discussion that will generate. So starting off, the DHA is relatively new. We're in year nine of the DHA transition. And you're the third DHA Director. So how is that transition going in your opinion? And furthermore, has it changed for the DHA in terms of direction or strategy over those 10 years? Place: Yeah, that's a great question. As you mentioned, relatively young organization. So the challenge of the first director really was how do you bring all these pieces and parts together? Department of Defense plan to bring shared services, the Tricare activity, as well as the national capital region altogether into a single organization. So first director, his responsibility was to do that, bring it all together. As that happened, the second director was maturing all that, but then was given additional direction by the department. But more importantly, by the Congress to say, hey, this thing called the Defense Health Agency, that's a great thing. We see it as a good joint medical operation. We believe more should be put into that joint organization to include all fixed facility healthcare delivery, right? All the brick-and-mortar clinics, dental clinics, medical clinics, hospitals, medical centers. And oh, by the way, develop a plan for that. So the second director was really given the responsibility to grow more things into it. But more importantly, to plan how to transition all those things in. My responsibility as the third director was actually to do the transformation, the physical transition of hospitals and clinics and medical centers, etc., into the agency. Plans for a smooth transition of Department of the Air Force, the Department of Navy, Department of the Army civilians to becoming Department of Defense civilians. So transferring the property books that were on service property books for all the contracts that were service contracts. So all the technical details of doing that transition and oh, by the way, while I've been the director, the completion of the transition to a commercial off-the-shelf electronic health record and all aspects of that. Maybe you've heard of this, a national pandemic or a global pandemic also happened. But then all by the way, the Congress also decided, hey, this is a good idea. We think we should put more things into that bucket. So the research development acquisition across the military health system in the process of being transitioned almost done into the DHA and the global public health community across all three of the services, not operational public health, but installation, public health and everything is associated with it. So my responsibility has been truly bringing all those pieces and parts together into one organization. And as I handed off to the next director, the next director's responsibility will be say, okay, we've come from a new organization, small organization to a not so new but huge organization. How do we mature this organization? What's the right process? What's the right policies? And how do we make it such that all this work leads to better outcomes that matter to us? And my guess is we're going to spend a little time talking about some of those outcomes. Miller: Yeah, absolutely. So as it's maturing and you're assuming more of the responsibility as a third director here and going on to the fourth director, do you think that a combat support agency was the right thing to call the DHA? Because it seems to be a very robust organization and enterprise compared to say, DLA. They did not absorb every logistics person in all three services and say, we're going to be the force provider for logistics. Place: Yeah, that's a great question. Thanks for asking. And in particular, the way you framed it with DLA. So from a uniformed medical team, about half of the uniform medical team works inside of our military treatment facilities. So in hospitals, clinics, et cetera, about half don't. Now, in the Air Force, that's not true. The huge majority of medical Airmen work inside of MTFs. The majority in the Army do not. And it's maybe 50-50. I don't remember the exact numbers, maybe 60-40 for the for the Navy. So across the total joint force, half of us work inside the MTFs and about half of us don't. So this isn't where we've taken we DHA, we've been given responsibility or authority for all uniformed medical personnel. We've given responsibility for healthcare delivery inside of MTFs and because of shared services, and I'll give you an example, health IT. So rather than having several different health information technology systems, it's a single system. Well, in order to do that, it has to be able to flow functionally between the operational space and the fixed facility space. So combat support agency responsibilities for health IT mean that. Combat support agency responsibilities include the Armed Services Blood Program. So the collection of blood and distribution, not just to our fixed facilities across the world, but into the operational environment. It means for medical education and training campus that for the majority of the specialties, Blab and CEO or a respiratory therapist or an OR tech, et cetera. That skill set is the same skill set. So how do you increase the effectiveness by bringing it all together in a consolidated fashion? Effectiveness, meaning that we get as good of outcomes or better spending less resources to do it. So you're not going to hear the word efficiency out of me. You're going to hear the word effectiveness out of me, which is how do we optimize the use of resources? So the whole goal of a combat support agency isn't to ignore the special requirements of the individual services. They should be there. But for those that are not unique to a particular service, how do we increase the effectiveness of whatever that is? By bringing it together in a joint organization that can do it more effectively and then support the COCOMs across the world with that joint solution. And that's why whether it's the DHA or any other organization, combat support agencies goal is to do just that. Miller: Oh, that's good stuff. I appreciate that, sir. It's different for the Air Force as our operational force presentation resides in our MTF compared to a large portion of our sister services, but framing it that way helps out. I appreciate that. So getting back to the transition and how things have the direction of strategy has remained the same and changed over the years. Do you think there's any part of it that's stagnated that we really must kind of kick it in the rear end to get it going here? Place: Well, stagnated is a pejorative word, so I'm not going to use that particular word. But the Department of Defense is a complex organization and the military health system within it is a really complex organization. And because of that, when it comes to change, you can say, well, it's easy, you just need to do this. But there's so many interrelated pieces and parts that there is some hesitancy to change any one part of it, not really knowing necessarily what the second and third order effect on the rest of the system, the rest of the medical part of the system, let alone the rest of the Department of Defense that we support. So I think some hesitation is an okay thing, from a quality perspective, we measure twice, cut once, except in medicine, it's more like measure 13 or 14 times and then cut once. So I wouldn't use the word stagnation. I'd say that in our really complicated, complex environment that's heightened by this global pandemic and really challenging resource environment, that being deliberate on how we do our decision-making is probably an appropriate thing. All that said, could we be more flexible, could be more agile, could be faster in that decision-making architecture? I think the answer is undoubtedly yes. But for an organization that's nine years old, trying to live up to the legacy of Army medicine and Navy medicine and Air Force medicine and a really high bar has been set, I think deliberate work across that is probably the right answer. So in general, I think we're doing okay speed-wise. But I agree with everybody who thinks that we likely should be going somewhat faster. Miller: So as the director, kind of one of the senior medical personnel having the DOD, we've spent a lot of time talking about in their war college best military advice. So as the senior uniform medical representative to SecDef, DepSecDef, Chairman of Joint Chiefs, along with the Joint Chiefs surgeon, what lessons have you learned about framing best medical advice in terms of risk that is actionable by senior leaders? Place: So risk really, in my opinion, means that you have to know the outcomes that you're looking for and the variables that may impact that outcome that you're looking for. So as opposed to gambling, where you just make a change and you hope for the best, risk really means understanding all those variables. And then what are the potentially negative impacts on that outcome that you're looking for? And from a risk strategy then, what are the resources, perhaps small amounts of resources and by resource, I mean money, certainly, but people, time, space, what are the resources that I can apply against those variables such that the risk to the mission that we're trying to achieve or the risk to the people who are doing the work to try to achieve that is lessened? So when it comes to best military advice, that's the way that I try to have everybody else understand that as well. Risk isn't just about hoping for the best, risk is looking at all those different factors and showing the senior decision maker, here are the resources that you have that you may be able to apply against those variables such that the outcome that you want is more likely to happen. The negative outcomes that you don't want to happen are less likely to happen by applying these different things. That's the way I look at best military advice. Miller: That's good. And I appreciate that you use the term outcomes too much. We focus on a positive result or accomplishing something, but an outcome lets it be up for interpretation on how that's going to be. We like it to be positive a lot of times, but a lot of times we don't have control of that in a support capacity. So I appreciate the term outcome. So when you talk about variables and you talk about risk to mission and risk to force, how do you mesh your advice with the service surgeons? Place: Well, the services are the force providers, which means that they're the responsible agents to recruit, train, organize, equip the forces that will then be made available to the COCOMs to include NORTHCOM if there's a Homeland Defense mission or humanitarian assistance mission here in the United States that for which there's an appropriate lawful activation. But in order to do all those things, that means that my responsibility on our installations and inside of our MTFs and in the medical education and training campuses to take that guidance from the service surgeons when it comes to the medical education and training camps. What is it that you want them to learn and make sure that at the end of the time that they're in our medical education and training campus, we've met the requirements of the services to train them in whatever it is that they want them trained. Similarly, when they're working in the MTFs, now it's sustainment. Are we still getting the right sets, the right reps so that I can sustain the skills that each of those services want me to have individually or want us to have collectively as a team to be successful in operational environment? So everything has to be collaborative between the service senior medical advisors and what they're saying to their service chiefs and service secretaries and what we're trying to do in the Defense Health Agency to meet those requirements. And then collectively, all of us, come together with the auspices of the joint staff surgeon to make sure we're meeting the requirements that COCOMs for the DHA is twofold. First, are we really giving them the current competent service members individually in teams? And then second, for those combat support agency functions that I mentioned before, are we providing those specifically to the COCOMs on those unique capabilities? Miller: So as tactical and operational leaders, the FGO level, the MTF director level, what advice do you have for those leaders to provide best medical, military advice to installation commanders or senior mission commanders? Place: Well, the first part is we think about different things. We use different words. We see the world differently than those who don't work in the medical community. So the first advice I have really is to make sure you understand the problem, the leader that you're trying to give advice to is looking at. And often, based on our experiences that are largely confined to medical things, we don't have as good of ability to understand the problem as they're describing as we think we do. So the first part is truly work to understand the problem set. And then the second part is we tend to have our own language, our own vocabulary, our own way of communicating with each other that people outside of medicine don't understand. And in many cases, whether we're patients or line leaders or community partners or whatever, we don't want to embarrass ourselves by saying, I don't understand that. And so the way that we're describing it often isn't understood by the people that we're talking to. So the advice that I have is first, make sure you understand the problem set and you have to embarrass yourself a little bit to admit that you don't understand a particular word or a phrase or a thing that's happening, start with that. And then second, make sure that in our communication back after we've understood the problem set and we're describing what our advice is and why we're using phrases, language, et cetera, that are understood by those that we're trying to give our advice to. The major problem that I see is a failure to communicate. And it's because we're using different language. We don't understand them and they don't understand us. And if that's the case, then we're likely not to give good advice. But it's only by having a shared understanding of the problem and a shared understanding what the solution set is that we can get to a reasonable solution. Miller: It's easy to lose connectedness to what our operational mission is. As we're sitting in an MTF and we see eight plus million beneficiaries over here and we see a million plus beneficiaries over here that actually generate the operational mission, it's easy to shift focus and then get that mile away medic moniker that falls too often on us. Place: That's right. And we need to challenge our assumption as well. We're so used to looking inwardly at only the problems that we see inside of our MTF that we don't broaden our vision, broaden our horizons to see where is it that we fit in this bigger enterprise locally even? And are we effective at saying, when we need help? And are we effective at saying when we can provide help? Because it's a mutually supported supporting relationship always between the healthcare community and those that we serve. We support everything that they do from a medical perspective, but we're supported by the idea that there are people in uniform who are working inside of our MTFs. So it's a mutually supported supporting organization. And only if we understand that relationship can we be successful. Miller: Absolutely. So it brings us to our next topic here. We talked about jointness. It's not a new military concept. We've seen it with SOCOM. We've seen it with TRANSCOM where we've consolidated resources. But this transition is unique as we've talked about other combat support agencies. So the DHA is at the center of an organizational experiment where we've combined Army, Navy and Air Force medical personnel and specifically the cultures that have been absorbed by the DHA. So as we look at that, what are the positives and what are some of the challenges of the different cultures that you've seen? Place: Yeah, well, the cultures exist inside the services. And I'm going to say service culture, not military department, meaning that there's a different culture in the Marines than there is in the Navy. There's a different culture in the in the Space Force than there is in the Air Force, knowing that the Space Force is a nascent organization, but taking its roots out of space command. So it came from something. But those cultures have been part of why those organizations are successful. So I'm quite frankly not interested in changing the culture. The culture that I'm most interested in and the historical culture behind the DHA is actually TMA, the Tri-Care Management Activity. A significant part of the DHA headquarters is based on the Tri-Care Management Activity. Now, the general organizational culture of TMA is one of it has to be right with the idea that when a beneficiary, so a service member or family member, retiree, et cetera, when they have a question about their Tri-Care benefit or they have a question about this bill being paid, then the Tri-Care team, they're not as interested or at least in the past, they weren't as interested in how fast we were answering the question. They're interested in having a perfect answer. But if you think about the uniform force, the enemy of good is perfect. If we wait for a perfect answer, we've often waited too long to have any sort of effect from the decision that we're having. And so the culture inside the agency is how do you recognize the service culture that has made them successful and bring that into the agency and have it be understood by the agency while transforming the historical legacy TMA culture from one of perfection of accuracy to speed of support? So not that we want the answer to be wrong. We want the answer to be right. But how perfectly right does it have to be, in which case it's too late? So how do we have it just right enough to have it fast so it's within the realm of useful for the service member, useful for the family member, useful for the commander? Who's wondering what the heck is TRICARE doing or what's the DHA headquarters doing? So changing from we have to be perfect to we have to be working at the speed of relevance. And it has to meet the threshold of minimum good enough and hopefully close to perfect. It has to be in a minimal threshold. But the faster that we can meet that minimal threshold and get answers to people, we become a relevant military organization. So it's not about changing the service cultures. It's about changing our internal culture, bringing in those service cultures often which involves speed and being relevant to those that we support. Miller: That speed of relevance is huge. And that enables change at the rate of relevance and enables trust with our with our partners, our mission partners and our beneficiaries. Place: Yeah, I'm glad you brought up the concept of trust. One of the challenges that we have is that in general, trust has to be earned. And so then for us in the agency, what do we have to do to become trustworthy? And it's a natural thing for a new organization, for a new company, for a new thing, I mean, just think about it when you're shopping. Do you automatically trust this car dealer? Do you automatically trust the food in this restaurant is going to be great? Or do you automatically trust that what you're getting out of this store is going to be a great product? No. That commercial enterprise has to earn it. Why are we any different? We shouldn't be. The way that we'll achieve trust from the COCOMs, the way that we'll achieve trust from the services, the way that we'll achieve trust from the American people is by being trustworthy, which requires action on our part, not requiring somebody else to change, requiring us to make sure that we meet that mark of being trustworthy. Miller: Yeah, absolutely. There's a difference in the cultures between the services, but there's also a difference in the way our services trust us. We are very much embedded into our line counterparts. And so as an Airman and a medic, how do we keep service culture intact and still make a culture within the DHA that is agile and effective? Place: Yeah, well, I think what that means is that we have to continue to be. So whatever uniform we wear, we do have to continue to be embedded within our organization. So as an Airman, it's appropriate for you to be in Air Force and Air Force only organizations for some period of your career so that they see you and you see them. And there's this understanding that a medical Airman is always going to be there. But by the same token, once you get past echelon one and in some cases echelon two, but even echelon two is often joint. But once you get back to echelon three, echelon four, it's all joint. So it's not one or the other. It's how do we optimize both. As I mentioned to a group just a little while ago today, in fact, it shouldn't be an us versus them. It should be how do we understand how Airmen support the Air Force and medical Airmen support the Space Force and similarly for the other services. But how can we not lose that trust within our own services by when you get back to echelon three, echelon four, back to the United States. There's a there's an understanding that no matter who is there, it's going to be okay. But in the operational environment, do I feel more comfortable with someone who wears the same uniform with me for this particular thing? If the answer is yes, great. And if the answer is, well, maybe not. And I'll give you an example. When it comes to resuscitated surgical teams, they're just not enough. And so as an Army surgeon, there was never a case where an Airman or a Marine came into a place that I was the surgeon of record and they said, no, no, no, no, you're wearing the wrong uniform. I'm only going to be operated on by an Air Force surgeon or by a Navy surgeon. That never happens. And so how do we figure out what are the things that are no kidding service specific and we're always going to be there for them? And how do we get everybody comfortable with at echelon where jointness is okay and we're all comfortable with it? And part of that is, are we good emissaries as a uniform medical team across the joint force? And if we are, that means that we're saying that except on Army Air Force Day or Army, Navy Day or Navy Air Force Day, when we can give each other a hard time about the other uniform that we're wearing, every other day than that, depending on... It doesn't matter what uniform we wear; we are in support of the other services and the uniforms that they wear and the value that they're providing to the organization. And it's only by being free with our information. And oh, by the way, holding ourselves accountable where we're not achieving the outcomes that we believe that we should be achieving. We admit to that and we find ways to make improvements to it and we drive continuous process improvement in our organization. Miller: That's a difficult thing because it's not about pushing back against a DHA culture, establishing a really joint team, a joint medical team. That's going to be every place I've ever deployed. I've deployed six times in my career, every place I've ever deployed, it's been a joint deployment. And so I get that that is our future. But it's when we're in garrison and we're sitting there with our line installation commander and telling them that we're part of the team and that we're going to support them. And it's getting stuck in this dichotomy that we're still fighting through, which I think is a little bit tough, maybe more for the Air Force. And this is speaking from an Air Force lens because of how embedded we've been with our line and that our line leadership has been our chain of command. Place: Yeah. I think you've described it effectively, that it is a bigger mindset. It is a bigger change on Air Force installations. It's not good or bad. It's just a bigger change. My point in all this is I have no desire to change the level of support that's happening on Air Force installations. I'm open to the idea that the manning might be better, which may require it to be different or maybe not, or the equipment may require it to be changed. I don't know. Or the times that we do it. So, again, this isn't about how do we take things away from any particular installation. It's how do we optimize the support we give to every installation across the entire total joint force? Miller: And that'll go a long ways to build and trust during the previous engagement when you're speaking at Air War College, you used the analogy of a bank. And I found that very much appropriate to what we do. We say we're going to serve you, but only on our terms when we're here in a support team role for the operational mission. Place: We just have to think it through. And then how do we use technology? So I didn't bring that up in that conversation earlier, but is there ways for us to use distributed technologies to meet the Airmen or to meet the Guardian where they are? Now, sometimes, as I did mention, sometimes you do have to come into the clinic, you do have to come in the hospital. It's hard to operate when you're in your house. It just is. But there's so many things that we require people to come to us for that, do we really get a whole lot of value out of it? Miller: Yeah, absolutely. Place: It's a big time investment. And so is there ways to get a similar outcome at much less of investment of time? And I think the answer to that is yes. Miller: Yeah, probably. We are very much archaic in how we deliver medicine still to this day. So I agree with you there, sir. So balancing culture of all the three services is hard enough. But on top of that, as the DHA director and all the MTS that you've accrued during that transformation piece, faced some pretty significant challenges. I think it was last year you put out a memo based on our fiscal landscape saying we lost $6.4 billion in our budget. So how do we balance congressional expectations to be cheap and efficient? The promise to provide healthcare, the business of health care and readiness. What does that look like for you? Place: Well, I'm going to use a different word. To me, it's never about efficiency. There are some people who talk about efficiency wedges and taking things out of the budget to force organizations to become more efficient. So I recognize why the word is being used considerably. But I'm more about effectiveness, which means to means these are the outcomes that you want. These are the resources you can put against it. How do you optimize the most important outcomes using the resources that you have? If you look against the last decade, we've been relatively stable with the resources, despite some inflationary pressure year over year over year, the last year, of course, has been considerable inflation pressure, but there's inflationary pressures every year. And yet we've been able to provide essentially the same level of access year over year, improving quality and improving safety, which implies that we probably were over resourced for some time. It's becoming more and more apparent that the efficiencies that we've so far gained are likely at the edge of how much more efficiency we can gain without either significant changes in innovation or significant changes in process. So within the agency, we don't really have a whole lot of control over technological innovation. We have some research development acquisition monies, but not a whole lot. So there is some ability for us to innovate our way out of it. But there is significant ability for us to think through process. Are we really using the resources that we have? So in particular, people, are we using the people to their maximum capabilities. And my belief is that we still have some room to grow in that. How much? I don't know, but that's our challenge internally while I describe what we're doing to the resources. So I do have conversations with the House and Senate appropriations committees on this is what's happening with the money that you invested with us. Here's the challenges as we see them. Here's where we're making increases in our efficiency that, as I describe it, leads to increases in our effectiveness, et cetera. But that's a dialogue between the Department of Defense and the congressional appropriators to make sure that at least to the minimum necessary that the department says and that the Congress agrees with that we're always funded at those levels. And then it's responsibility for all of us then to turn that resourcing into the outcomes that we're looking for. Miller: Are there specific programs or processes or training that the DHA is prioritizing to improve medical readiness and ready medics in preparation for the next major conflict as we're going through these kind of turbulent fiscal times? Place: Yeah, I think that all of us are working on at least one of them. That's the knowledge, skills and abilities. And by that, I mean, do we do a good job of recognizing what are the skills, what are the cognitive decision making skills, what are the technical skills, what are the attributes or characteristics that we want of our medical team so that they'll be able to be successful in an operational environment with good clinical outcomes? So KSA, as we call them, Knowledge, Skills and Abilities or Attributes. So to me, we have half a dozen or so of them in at least an initial version of it, which means that as I'm a general surgeon by training, am I getting the right numbers of surgical cases? I'm getting the right types of surgical cases such that I'll be prepared to be a general surgeon in an operational environment. Similarly for ICU nurses or emergency physicians, orthopedic surgeons, anesthesia providers, etc. Well, we've started into that, but our operational team is way bigger than just the trauma teams. And so how do we use what we've learned so far in that KSA program for every single medical specialty against every AFSC, every NEC, every MOS, every AOC. Each of the services describe them just a little bit differently. How do we do that individually and then secondarily, knowing that we're almost never an individual, we're almost always a team? What is the team interaction? And do we have the right people on the right teams with the right capabilities such that there's some synergy involved with all of that skill such that by bringing multiple people together, we have a better outcome. So we've gone into that with some ability to understand what that looks like, but we are nowhere near finished for where that needs to go. So I think that's an important point. I think we have just about finished the transition of the implementation of our new electronic health record. We haven't come close to leveraging all the capability that comes from that electronic health record. There's so much data. There's so much analytics that's out there that's been incompletely leveraged so far in large part because we continue to use the analytics associated with our legacy electronic health records. We've not turned the corner yet. Further, we've been in this global pandemic for almost three years. We've learned an awful lot from it. But in many respects, we haven't turned what we've learned into process plans, et cetera, for future CBRN type elements. I'm not suggesting this is a CBRN element, I'm saying that it's an opportunity for us to learn to be prepared for a CBRN element. How fast do we respond? How fast do we learn once we are responding to it? Have we failed fast and change our mind? How much have we integrated the decision making with logistics with command functions? Have we moved the right things around? So there's all kinds of opportunities for us to utilize the incredible experiences that we've had from COVID and turn it into operational preparedness plans from a medical perspective to all kinds of different potential scenarios. So I see those three big things that we still have ahead of us for work that we can do. Miller: Yeah, it's interesting in the Air Force specifically, we've historically in my career have focused on ability to survive and operate as a CBRN environment, specifically nuclear biological. And so it's Kim suits. It's things like that. But it hasn't been really, do we have the ability to survive and operate in a pandemic response? Were we able to carry on the mission and still remain operational effectiveness when that came about? And so it's great that we're taking those lessons learned and making them truly lessons learned, not just lessons observed into our next biological response plans as we move forward. Place: Yeah, we'll see how effective we are. That's how you know it was in a lesson observed or lesson learned. It's only as you stress it for the next time. Did you do better? So right now there are still lessons observed. And until we can demonstrate that we can do it better, it always will be. Miller: That is a tough thing to measure. Effectiveness on an operational level. Your enemy always has a choice in that one. Alright, sir. So as we kind of move on here, military medicine has historically been viewed as inefficient and inexpensive when compared to civilian health care. That generates, I think, a non-apples to apples comparison. That's really not a fair comparison, but that's what we get compared to when it comes to our congressional counterparts. Excuse me. Nonetheless, effectiveness and efficiency, I know you don't like the term, but we hear it a lot in the MTS are critical focal points. How do you characterize the DHS balance of effective efficiency for health care delivery? Specifically, what differences are there, if any, based on the populations we serve? Take, for instance, retirees versus our active duty force to balance that currency versus that readiness in our forces. Place: Yeah. One of the unique aspects of the military health system, it's a combination of a ready-to-go-to-war function meshed with a congressional entitlement. And by congressional entitlement, I mean care for our family members, care for retirees, care for retiree family member. That's all an entitlement as opposed to care for the service member on the installation, care for the service member wherever she or he is anywhere across the world and be prepared to do it. So what I just said, I think we all see that as the readiness function. Are we assuring the readiness of the force being there medically ready for anything? And are we assuring the readiness of the medical force being the medical team is prepared to not just provide installation health care, but the whole gamut of health care in an operational environment. And an overlay against this requirement for a health care benefit that comes from service, right? Benefit to our families. And should we stay in long enough to have earned a retirement that that benefit that goes with it? My personal belief is this was a really good idea. And I say it that way in that if done well, we can provide health care benefit type functions that augment or sustain the currency and competency, the readiness of our medical team, in which case we're spending one dollar for two things. If you look at the rest of the Department of Defense, there's no... Other than readiness value, driving a tank around and shooting at a range or flying a fighter around and shooting at a range or steaming an aircraft or aircraft carrier around and flying sorties off and shooting at a range, none of those provide real value other than readiness. Whereas we we're providing the readiness value of are we ready to do our job? But we're also delivering on that health care delivery entitlement requirement. So if done well, we're remarkably effective with the use of those resources. So our job is where there is an overlay anyway of overlaying both of those functions so we can be, in this case, efficient with the use of that money. But that isn't to say that they're not two completely different mission sets that we're required to do. So to me, our responsibility is to understand the difference between them, understand where they do overlap, make sure that we're great at where they overlap, but not lose sight of the factors where they don't overlap and our requirement to still do them. Miller: The readiness piece tends to slow us down and is hard to articulate. And we don't have a consistent narrative as to what readiness is, at least from an Air Force perspective. I think we lose that string when we start pulling it down and saying this is how we measure it. This is how we qualify it. And it gets lost. Place: Sure. And I think the major reason for that is if you look at the healthcare delivery side of it, we have very good ways to measure how much work we do. We have very good ways to measure how good it was, what was the quality of it, that sort of thing. And because we're so comfortable with all these other things, we believe that on the readiness side, if we can't do that, then we're not measuring it. I don't think that's true. I think if you look at the rest of the Department of Defense, they don't have nearly the very solid metrics that we have when it comes to healthcare delivery. So rather than trying to hold ourselves to the standard that we do for the healthcare delivery side, how do we compare ourselves against the other readiness of the rest of the Department of Defense? And can we utilize the similar measures to show we are or we're not? And if not, how do we fill that gap and achieve that readiness? Or what resources would it take for just-in-time training, equipment, whatever it is to be able to achieve that readiness, just like the rest of the Department of Defense because they do it very well. Miller: Defining that requirement, codifying that requirement more clearly, I think is the difficult part because I believe at the MTF level, a lot of them believe that our primary purpose is to deploy, take care of uniformed bodies. And so there isn't a lot of effort being done to say I can maintain taking care of these other 12,000 beneficiaries that are coming to my facility. Or if they do go down that route, our hiring process is not agile enough, our contracting process is not agile enough to be able to effectively pull in those resources if we immediately deploy. Place: That's a great point. I'll give a good example for it. So the Army's process of hiring is different than the Navy's process of hiring, is different than the Air Force's process of hiring, which is different than the Department of Defense's process. So as an OSD, Office of the Secretary of Defense Agency, we use the Department of Defense methodology. But it's still pretty slow. And so how do we think through every step of the way, see which steps provide value, which steps don't provide value, and for each of those steps, how long should it take? As we've looked through it, what we've noticed is that first, there's an awful lot of steps. And second, because there's an awful lot of steps and each step doesn't really take that long, the person who's involved and responsible for that step says, well, look, it's going to take whatever the days are, and I'm not going to say it, but it's a lot of them. It's going to take a lot of days. It doesn't matter if I take three days or five days. It's only two days differently. What difference does it make? But if 50 people are handling it, and that's an exaggeration, but I'm doing it for effect, if 50 people are handling it and every single one of them adds two days to it, it's 100 days and it's 100 work days, right? Not weekends. It's 100 work days. So if that's the case, now we just made a process 20 weeks longer, four and a half months longer. Why? Because every single person along the way said, yeah, it doesn't really matter if it takes a couple of extra days. Miller: I feel that pain, sir. Place: Yeah. So now it gets down to understanding the system. And if we're all part of the relay team and you have the baton, then I have the baton, and the next person has the baton, the next person has the baton, and we only win if collectively we're fast and we understand how that works, then collectively we can make the process better. Same goes for contracting. Who has all the steps? Where does the money come from? Where does the authority come from? How much time really is necessary to put it out as a request for proposals? How long does it really take to evaluate those proposals? It's a multi-step process in contracting as well. And the same sorts of things. Again, we're noticing it. If anything, that's a multi-step process that a particular person or a particular part of the organization has a very small piece of it, we tend to think, it doesn't matter how fast I go. It's the wrong way to think. You're part of a team. Teams win. How do we get everybody on a shared understanding of why that matters? Miller: No, absolutely. 100% correct. So as we talk about teams and we talk about the Air Force medics being part of the DHA team and being part of our line team, continuing to support that, what advice would you give our operational and tactical leaders on communicating what support they're going to be able to give? I'll give you an example before I go on. I came from a base where nearly 70% of my population and my MTF was active duty. To train them to Air Force level requirements took 177,000 hours a year to train them. That means wing exercises, but that also means I'm not producing value under DHA standards and metrics. So communicating that effectively to both sides and being able to carry out my mission was very difficult. Do you have advice that you can give our operational and tactical leaders as we move forward in that? Place: Yeah. First advice I'll give, at least on the MTF level, we have a system of record called Dimmer's Eye that if done appropriately is going to show all 177,000 of those hours were appropriately used. But what we also find, my guess is that you saw it at this last space to viewers, that that's not what happened, that we didn't code our time against those readiness requirements. Instead, we said we were doing clinical work when we weren't. So it isn't about do we do the work that's required by the services? I say, yes, we do. If it's a requirement, then we do it. But that also means that we are using the systems of record to document what's most important. And if the service says this is an important thing that must be done by every Airman, then by gosh, it should be. But it also means we have to document it that way. Otherwise, what it means is we're using defense health programming money because you said that, I'm using you euphemistically here, but you said that you were working in the outpatient clinic, but really, you were doing this other task. So we're using defense health programming money to do a non-defense health program task, which makes everybody look at us and say, you're inefficient military health system. Miller: Right. Place: You spend all this money on healthcare delivery stuff, and yet you didn't produce that healthcare delivery volume, quality, et cetera. So I'm absolutely in favor of it. The services set the requirements and we deliver on those requirements. But it also means that we appropriately and effectively use the systems of record for documenting it. Miller: That's fair. So I ask from a previous kind of operational leader here, are we doing anything investing in technology to make that a less cumbersome process? Place: Yeah. Well, the short answer right now is no. I believe that there may be other systems, commercial off-the-shelf systems that are compatible with our new electronic health record that may allow us to do it. Now, I'm not promising unicorns and rainbows that are there's this thing, there's this software program that's out there. And if only we had that, then all this is going to go away. I'm not saying that. But I am saying that one of the advantages of having a commercial off-the-shelf electronic health record, it becomes compatible with all kinds of things that are available in the commercial sector. And your product doesn't get purchased if it isn't really helpful in the commercial sector, as opposed to the things that we do internally. We have good people trying to develop things. They don't have to sell it to anybody. Right? Miller: Right. Place: So that's one of the huge differences. So I do believe that that based on where our health IT acquisition team is, that there are solutions that are out there that will allow us to do it more effectively, that then give us better information about what we're doing and how we're doing it with what then will show to your point before is it more expensive or less expensive inside of our organizations, inside of our MTFs? One of the reasons it looks more expensive is because we say that we're spending a whole lot more time doing healthcare than we really are. Miller: Yes, we do. Place: And so if a system really shows where we are and it's easy and intuitive to use, the data will be more accurate showing just what those differences are. And I do think that's out there and I do think it's coming. In the short term, no promises from me, but I just fundamentally believe that there is opportunities out there for us to make that better for our staff. Miller: Is our process within the DHA agile and expedient enough to be able to implement one of these things without taking years to go about it? We've seen multiple iterations of Alton, people trying to tag in an AHLTA, make something happen. We've seen Genesis take years to implement. And granted, it is a huge project, so I'm not discrediting the timeframe there. But we've also seen within our respective services, the six and especially with IT vulnerabilities, it takes a long time to get something approved. Place: Yeah, the beauty of the MHS Genesis system and has likely been largely invisible to the staff is we have day over day, month over month, iterative improvements of the MHS Genesis program. And as opposed to the old days where you'd put in your change request for AHLTA, your change request for CHS and months later, maybe something will happen. This can literally be done overnight. And so the configuration changes are so much faster in Genesis. So once we have the programs, the agility of those who are managing the program to make iterative improvements is just huge. So eventually, yes, but when it comes to whether it's Dimmer's Eye as the program or whatever the next generation or the next commercial off-the-shelf product is, the initial implementation will probably take some time, not as long as MHS Genesis, which is that enormous record. But it will take some time to implement it across the force. But once implemented, iterative improvements in it, our PEO, our Program Executive Office team is showing that they can be very agile and responsive for upgrades in our system. Miller: That's great. It's good to hear. It's refreshing to hear coming from an MTF level that we have the ability to be more agile and change at the speed of relevance, as we spoke earlier. So ask on Genesis, Genesis has become a four-letter word and some of our MTF a little bit as we roll this out, the workload processes that it increased just the training requirements, getting up to it and just slowing down patient care overall. Are we seeing improvements to that as we get further into our waves? Place: Yeah. So lots of things that were blamed on Genesis, some of which really was a Genesis problem. Some of it was the local area network. The land just couldn't handle it. Some of it was reducing the wrong workflows. Some of us were mapped from the wrong computer to the wrong printer to the wrong location and figuring out how that worked. That's not a Genesis problem. That's a problem. Miller: Sure. Place: Just the work to set up the system. And I say that right all systems deliver what they're designed to deliver. Okay, so ours did. And the way that we designed it, the way that we worked it through, even though we went through all kinds of different planning elements in the initial phase zero in the Pacific Northwest. And even in the first couple of waves, it really wasn't nearly as agile, fast, et cetera, as we wanted it to be. But in the current waves, we are achieving pre go live productivity in a matter of days to weeks now, as opposed to months to in the Pacific Northwest, even longer than a year to be able to get back to what the productivity was. So we're also finding some safety or particular quality and safety improvements. So the duplication of imaging is down considerably, not that there isn't still some duplication. Again, we're selling some legacy science and Genesis science. Do they talk to each other or not as well as we'd like them to? But Genesis across the whole organization, the duplication of radioactive imaging should essentially become zero unless there's a clinical need for it. If you look at the loss of laboratory specimens and the results of it markedly down, if you look at the global trigger tool and our safety investigations and our safety evaluations up, but patient safety elements of harm are down. So productivity is one measure of the effectiveness of an organization. But quality and safety are other measurements of effectiveness for an organization. Productivity also has to do with access. Without access, it's hard to get quality outcomes and the safety that goes with it. So I acknowledge the challenges with access that leads to those outcomes that we want. But I'd caution everyone to be careful about only measuring one thing, access, productivity being one of them. But how does it fit into the global scheme of all of those things of access, quality, safety, productivity, et cetera? Therefore, cost that comes with that productivity. And iteratively, we're getting better and better and better and better at it across all four of those elements, not just at the at each of the successive waves, but even as the waves as we come further away from them. The people inside of them are getting more effective with the use of the resources, better at the quality of the care that we're getting, better at the access to care, as long as we continue to staff them that way, staffing a different issue, seen at many locations. And I don't mean to minimize that because it's a real challenge in some locations. But Genesis is not the problem most of the time now. Genesis is part of the solution now. And as we get through the final waves here in the East Coast and then overseas in calendar year 23 and everybody's on the same program and everybody can see everything, we see continuing improvements in quality and safety. Then driving increases productivity and then improvements in access across the entire enterprise. Miller: Well, that's great. And it all helps that epicenter of what we do is that patient encounter. Place: It is. Miller: And so access, everything else is kind of superficial to that. But we have to focus on that. And a new medical record is definitely the right way to go. I've had all to my entire career and never once to liked it. [laughter] Place: Well, I hope you when you next get to Genesis, I hope you like it. Miller: I'm sure I will, sir. So we brushed on the topic of COVID. So we'll dive into that a little bit. It's consumed a very large part of your tenure as DHA director, but seems to be fading into the background. Do you think that's a mistake just to kind of let it go as just something in the past? Place: I wouldn't describe it as letting go. I'd say changing priorities when that was a huge risk to mission and risk to force, then significant resourcing being placed against COVID, I think was the right thing. There is not currently significant risk to mission or risk to force. And so Department of Defense leaders, service leaders are saying, I have other things that are higher priority for me to put my resources against to include time, my resources against right now. But there's not anyone that I know of in a senior leader position across the Department of Defense who says we're done with it. Nothing to think about. Nothing to worry about. That's not the way it's looked at. It is looked at, though, as how do we take those, as we discussed early or earlier, the observances that we have and change them from lessons observed to lessons learned? How do we use the DOTMLPF-P process to consider this was a challenge. Here's how it fits. What is the doctrine that needs to change or what's the training that needs to change? Are we structured the way that we need to be able to respond to some pandemic event or even across the entire CBRN event? How can we how can we be better organized to respond to it? So that's where the services are. That's where the department is now. So I wouldn't characterize it is it's over. It's done with it's now. And how do we continue to learn from it while we have other priorities that we're focusing on right now? Miller: Makes sense. So as we've dealt with COVID during your time, is there anything that you're most proud of that you've seen the military health system respond to effectively. Place: Yeah, all kinds of different things. I've said it several times in public and I'll say it here on your podcast, if there hadn't been a DHA, the requirements that came, the pressure that came from senior leaders in the Department of Defense, we would have made one. We would organize one because we didn't have a medical common operating picture. We didn't have a view of what our inpatient status was across the enterprise. We didn't have a consolidated view of how to do other than the clinical practice guidelines within the DOD and VA, but we didn't have a rapid methodology of taking here's a clinical problem set. How do we rapidly say here's how you evaluate it, here's how you treat it, here's all these sorts of things that we did with COVID. So we didn't have a rapid methodology of saying here's a problem set. We think we can do it with COVID convalescent plasma. Let's across the entire enterprise collect 10,000 units of it. And we did. We didn't have a methodology of a single plan to rapidly organize and distribute vaccines. We didn't have that. But we did with COVID. So all these things from a joint environment, not taking anything away from the COCOMs did great work, not taking anything away with the services did great work. But when you needed a consolidated joint response, we didn't have a methodology. And to be fair, the DHA wasn't mature in that space either. But we have become significantly more mature because of it. So I see huge value to the agency. My hope is the department sees it as huge value to the department. The maturation of the agency that happened because of COVID was it horrific yes. Thousands, tens of thousands of American lives lost in every state, hundreds of thousands across the entire country. Horrific. Yes. But thank God we're able to figure some things out and make the military health system better because of it. Miller: Yeah, absolutely. Sir, it's been a great discussion so far. I'm going to ask you one more question. As a strategic leader, as a senior leader of our military health system, what keeps you up at night as we progress through our transition? Place: Well, the thing that worries me is are we going fast enough? We talked a little about it earlier that we are generally slow at our maturational changes and there's good reasons behind it. But do we become more comfortable as a medical community knowing when good enough is achieved? And again, I don't mean setting the bar lower. Set the bar high enough that good enough really is good enough, but when we achieve good enough, are we ready to execute? Our line brothers and sisters, they understand that very, very well and they become comfortable with it, knowing that you're not going to get it perfect. But if you wait too long for perfect, then there's other downsides that happen from it. So for me, I worry, are we understanding that agility and relevance go hand in hand? Second, do we communicate well, not internally with our own medical language, but are we able to translate what we think about, what we worry about to senior leaders who don't think like us from a medical perspective and don't talk like us? And can we help ourselves by collectively doing a better job of communicating where we really see challenges and risks associated with those challenges to those who don't think like us, don't work like us, don't talk like us, et cetera. And then finally, there is really significant improvements in the jointness of our organization. But are we going far enough or have we gone too far? What's the right balance between this is unique enough for a particular service that it must be maintained in the service versus there's incredible value from jointness and interoperability and consolidation of equipment and training, et cetera? What's the right balance between that? And I don't know where it is. I think there's something to be said for some things probably we've gone too far in jointness and there's some service things that we don't want to lose. And in many other things, we haven't come nearly far enough in the jointness and there's still significant work to be done. So depending on what the topic is, we still have a long way to go to figure out what belongs in the joint space, what belongs in the in the service space and how we can make those mutually supported so that we don't lose or we don't lose either one of them. Those are the big picture things that I'm concerned. Miller: Yeah, those are big challenges for us as we move forward. But General Place, I appreciate your time. That's all the time we have for today. So it's been a pleasure getting to chat with you, asking you some questions and getting your insights. Want to offer you congratulations on retirement here in a couple of months. And so it's been a pleasure to serve with you under the DHA. Thank you. Place: Yeah, you're welcome. It's been my pleasure to be here with you and talking about things that I think are important to our teammates, but also important to the line leaders that we serve, the COCOMs that we serve and the beneficiaries that we serve. So thanks for having me on. Miller: It's a pleasure.