Rachel Foster says being the chief innovation officer for the Defense Health Agency is the perfect capstone of a long career spent acquiring a wide variety of experiences and skills that perfectly serve her current focus. And that focus is on mining the operational layers of the Military Health System for great ideas on how to improve health care outcomes, streamline processes, and cut costs and then clearing away the bureaucratic hurdles that typically trip up such ideas before they can even get tried out.
And if those ideas prove on a small scale to be best practices, she works hard to diffuse them throughout the enterprise. In doing so, Foster has developed a fascinating approach for shepherding such projects around the middle bureaucratic layers that often prove fatal for fresh innovative ideas.
Foster discussed her approach with Federal Times Editor Steve Watkins. Following are edited excerpts:
How has your innovation role within Health Affairs evolved?
Dr. Woodson [Dr. Jonathan Woodson, assistant secretary of Defense for health affairs] showed up about three years ago. At the time, I had been the acting deputy assistant secretary of Defense for health budgets and financial policy for two years. I told him I would really like to focus on innovation. One of the things he said was that we really need to understand the culture of innovation and what it takes to create a culture of innovation across the enterprise. And then he said he wanted to focus our efforts on starting small. In other words, if we know some place thatís doing something thatís a best practice, we need to be able to replicate it. Or if we have somebody that has a good idea, we should be willing to assume the risk. If you are just going to pilot it at a small place, thatís a small risk, itís not a big risk, right? So we sat down with Dr. Woodson and developed a template for what the innovation program would be.
And so in year one, we asked Dr. Woodson, Ďwhat are your priorities?í He said he wanted to focus on recapture of specialty care into the direct care system. Another was reduction in tobacco use. The third thing was to look at the issue of obesity, not just in the active duty, but with family members, because that has an impact not only on their lives, but certainly on healthcare costs in the long run.
In trying to flesh out the template for the program we started doing what we call deep dives and developed a series of innovative initiatives in those three things that he had selected.
Whatís your approach to moving these innovation initiatives forward in such a large, lumbering organization?
There are the people who have the ideas, their immediate supervisors, there is that middle management, and senior leadership. But this is such a large enterprise. Itís not like I can reach everybody in the enterprise. Itís really an interesting challenge. The way that I have approached the challenge ó and the way that Iíve approached the challenge of human capital activation ó is to decide what am I going to tackle to get the highest return on investment?
And then this is my ocean vision ó itís a bad analogy, but itís the only one I can come up with: On the bottom layer of the ocean are the MTFs [Military Treatment Facilities] and they are operational. If you are in the military, there is a command and control layering. The MTFs are out there delivering health care. Then thereís the middle of the ocean, which is all of these fish, big and little, some of them are in functional lanes, some of them are in command lanes, like the regional commands, some of them are multiservice markets. There are many different layers in the middle, each service has its layer and then we have a layer. And Iím sure if I looked at IBM, it would be the same thing. I think large organizations have large middle layers.
Then thereís that upper crust, the senior leaders, people wearing the stars and the stripes. They are kind of floating on the top. I feel that if I can work on these components for the top layer and the bottom layer that I can get the ocean moving in one direction. I feel that first of all, by definition middle management is in the middle. So if a senior leader makes a decision the middle management will follow them. They might not like it, right?
Itís only when someone lower pushes the decision up through the middle management that they may or may not want to do it for their own particular reasons. They just kind of like, you know, put it in the desk drawer or a circular file and it goes away. The trial balloons that never make it to the top are numerous.
My strategy is to connect the top to the bottom for this process. I feel like I can feel the energy and leverage because I can move each one of those. I can work on the top: We have a Medical Business Operations Group, the Medical Deputies Action Group, and thereís still the SMMAC, the Senior Military Medical Advisory Council. Each of them has a place. They are all at least one star, that is a two star and thatís a three star council. Depending on the kind of decision I am looking for, thatís where I would start the process.
Whatís an example of how you would apply this approach?
Weíre always looking to recapture care. There is never, since the beginning of time, a situation where weíre not looking to see as many people in the system as possible, both for readiness and for cost efficiency. Why send [patients] downtown and pay for it when we have doctors in our medical treatment facilities? We had something called MHSSI in our process: Military Health Systems Support Initiative. It has been around for at least 10 years, maybe more. There were hardly any initiatives under the MHSSI process.
Letís say you are a physical therapy function at Camp Lejeune. Letís say you have PT specialists but you are referring $1 million of PT care downtown because you are just overwhelmed. You know that, if you could hire one more PT guy and two more assistants and buy for $10,000 some of that equipment like beds and stuff like that, you could recapture $750,000 in care. And you know it would only cost you $200,000 to pay for all of that each year. So thatís a huge ROI, right? How do you get the money? Itís not in your budget, right? The process was developed so that you could request doing a business case and then get the money approved and we would pay it from private-sector care [accounts] because you are recapturing private-sector care.
The only problem was they built this huge bureaucracy around it. So you are looking at a single MTF with a small initiative and it would take them 12 to 18 months for their initiative, if it ever did bubble up all the way through their service. It has to go their commander, to their regional command, to their OTSG [Office of the Surgeon General] ó everybody questioned the business case. Everybody was redoing the business case. Then it might finally get over to the Tricare regional office who would look at it and redo the business case. Then eventually it might get up here approved for us to spend the money. Well, by the time you got the money, you didnít care anymore. Especially if you were in uniform, you were gone or you were practically ready to rotate out.
People donít hang on to good ideas for that long. I knew right away that if I wanted to activate the local level I had to find a way to put money in their hot little hands for good ideas that were reasonable. And I had to get a single business case done. Something for $200,000 doesnít deserve 10 people and four business cases, right? It really only needs a single business case by someone who is well-qualified to do the business case, right? And frankly, itís not the person with the idea. If youíre a doctor or a PT therapist, you donít do business cases for a living. Even I donít do business cases for a living, right?
I took that process and I rewrote it. Granted, it took me a long time. But I didnít have the staff. I have a staff now. That is the most wonderful thing about all this. I really actually have a staff. So my bandwidth is much bigger than it was a year ago when I was working on this. I rewrote the whole process and I went to the medical operations group and I said to the clinicians, would you like us to fund your good clinical ideas within 60 days? And they said yes. Thatís all I needed to know. What I did is have new guidance all written up and posted. Basically, it has a list of like 12 people who are qualified to do the business cases. So if you are an MTF and youíre not in a multiservice market, you go to a Tricare Regional Office [TRO]. And if youíre in a multiservice market, there is a person designated in your market to go to.
If it doesnít have a positive ROI, they tell you that. And thatís OK. Come and play again later if you have another idea or whatever. But you have instant feedback, and we actually post that on our community of interest, which we set up on milSuite [a protected social media enclave for the military community]. Thatís why Iíve been using LinkedIn to pilot communities of interest. Iím getting ready to launch, by the way, an innovation hunterís request on there in about a week. Iím really excited about it. We created a mailbox ó DHA innovations, DHA.mil ó and weíre going to target patient experience. And I am going to tell people that I donít want vendors trying to sell me products, but I really want peopleís ideas for what would improve the patient experience with military medicine. Iím going to try it with the LinkedIn group Ė weíre actually up to 3,700 now.
So we have a community of interest internally on milSuite. I have about 120 people signed up. Letís say a mid-size facility proposed an initiative in X, but it didn't have a positive ROI because of so-and-so. So people can learn from that. Part of knowledge sharing and management is gaining wisdom and knowledge. We're trying to get the community to talk to each other about what they are doing and weíre going to share information with them about what is working, and ask if there are other facilities that want to try initiatives.
Because at the end of the day you have to have an idea, you have to pilot it, but, as Dr. Woodson says, you have to diffuse them throughout the enterprise. When something works, itís a standard best practice, do it everywhere. Donít make everybody get on their hands and knees and beg you for money. Thatís what weíre trying to do with the MHSSI program. Weíre trying to get initiatives, and when we have enough evidence that they work, weíre going to create them into program issues to send them in for the program review so that theyíll diffuse them.
What Iím saying is, from a governance/system performance perspective, I can figure out how to create a fast process. And when it gets up here, the MOG [the Medical Operations Group, which consists of the senior health care operations directors of the service medical departments, the Defense Health Agency director of health care operations, and a Joint Staff surgeon representative] has 30 days to approve it. And they donít have to discuss it. They are the Medical Operations Group. Itís a one-star clinical group that is headed by the services. So when we get a MHSSI initiative that has gotten positive ROI, they send it to me and I put it on the agenda for the Medical Operations Group. But they donít have to discuss it. What it is is it requires service coordination. That is their notification that they have 30 days to say yes or no. If they say nothing itís approved and the money moves. The goal is [a final decision] in 60 days.
The reason I put it up at the MOG is so that, not only will we be tracking it, but it is about transparency, right? Action officers have a lot of knowledge, but the senior leaders don't often have the same type of knowledge translated to them in a way that they can take action. But they're the ones that are supposed to be leading. If you don't provide them with the knowledge that they need to lead, then you're not really serving them well. There are a lot of people in the organization doing good things, but they never know about it. They don't get to make a diffusion decision. Our goal is to get these initiatives approved, get the money to them, track them, report to them and then ask the MOG questions. So quarterly we will get on their calendar and actually discuss with them how well they are doing. We will say, 'Listen, we have got three orthopedic whatever and they were all looking very good. Do you want us to seek out another few facilities to try this so-and-so?' If they say yes, then we'll do that, we'll get a couple of more signed up. If we got six and they're all positive, we'll say we think this is ready for enterprise-wide diffusion. We are going to create for them the decision point that allows them to make enterprise-wide decisions because they don't normally get handed enterprise-wide decisions, right? That's creating motion up here and it is connecting the bottom to the top.
With the MHSSI initiatives, do you have broad goals or is this just kind of catch as catch can, and then expand as it makes sense?
My goal is to get a lot of activity started at the medical treatment facilities as a human capital activation and let them know that if they have ideas to recapture healthcare that they can help themselves. That way, all I have to do is reach out, the process is easy, easy to understand, easy to go through, that we are creating communities where they can talk to other people that are trying to do the same thing so they can learn from each other. We are really practicing the human capital activation with that. So while it is limited in target it does build a lot of good will. I am using it as kind of the hinge pin for an MTF innovation program.
I want to replicate this at each of the medical treatment facility (MTF) levels. This is the real way for me to impact the middle because you know how people get to the middle, right? They come from the bottom and they work their way up into the middle. So people in the middle are responsive to the most senior leaders if they want to get promoted. But if they come from the operational level and theyíre used to this sort of thing, when they get to the middle, then they actually become innovation hunters and promoters of it themselves. Iím trying to develop a fully fledged program that an MTF can pick up and implement. We are literally writing position descriptions for a chief innovation experience officer and Camp Lejeune is the facility we are working with first because David Lane is such a great partner. He already has got the lady he wants to designate as that. We are looking at their instructions because we are going to come up with activities and awards and rewards that they can do. We already developed a tool kit. Just a generic tool kit, so if you have an innovative idea how to do whatever ó it lists what questions you should ask, how you should do an ROI.
Commanders have a lot more power than they leverage. We want to give them the tool set to actually create innovation in their own MTFs. I'm going to work with the MTF on how to find money, I want to teach them everything I know, all my dirty little financial secrets about how to find money. The biggest secret is that he or she who is ready to execute on the last day of the fiscal year will always get the money. Because there is always Ė itís like the game of musical chairs, you know, where they take away a chair no one wants to be seated and fall to the floor. So everybody starts throwing their money back at the comptroller as the year gets closer to the end because they don't want to be sitting on unobligated O&M dollars. So if youíre the smart kid on the block and youíve got a contract and a mod and a friendly contracting officer and it's all ready to go, it has to be an awarded contract obviously, but the mod is written up and it needs a little green stuff, you're in.
So Iíve got MHSSI down to 60 days. I think thatís pretty damn good. It used to take 12 to 18 months [for a decision]. And thatís assuming you ever got heard. We only had something like eight [MHSSI initiatives] that were active. Can you imagine in an enterprise this size ó Iím hoping that by next year we have 50 or 60 active initiatives. I already have about 10 submitted. Now theyíre starting to come in in bunches. Itís like flowers, you know?
So your strategy with these is, in essence, cutting out the middle. So how do you coordinate that?
Iím making the Army, the Navy and the Air Force responsible for coordinating with their middle. Iím not. And it makes my life easier. I gave them 30 days to do it. They are on a ticking time clock and if they fail to get an answer it's done, itís a yes.
So coordination is still happening, but itís just happening in 30 days. And itís coming from the top down so you know they get an answer. When things bubble from the bottom up, people donít feel like they have to answer. You canít task someone above you to answer you in 30 days. Someone above you can task you to answer in 30 days. I have just kind of flipped it around a little bit, rewrote the script.
What is happening with the ROI you are getting back from those initiatives? Is that being used as operational funds or is it just being put into your savings goals or something else?
We call it trade space. Thatís sort of our corporate term with the budget. Let's say you have an idea and the ROI was two to one. I give you $100,000 but you save $200,000 from private sector care. The budget people go in there and they subtract from private sector care $100,000 and give it to you forever. They realign $100,000 but they know that their healthcare costs are going to be reduced by $200,000. So now thereís another $100,000 that private sector care would have spent that they can put in what we call the trade space. They can use that to pay bills. So if there are additional bills in the enterprise part of the program review, they can use it there. Or if the comptroller or someone is taking a hit on the program they can use it to pay that kind of a bill. In other words, instead of paying a bill by hurting yourself you are paying a bill from money that you freed up because you did something more efficiently. And everybody is happy. The hospital is happy because they are seeing more patients, we are happy because we are saving money and we can pay our bills either to the department or a bill that is in the enterprise. Thatís kind of how we look at the movement of money.
How well do you think your role and experience in driving innovation translates outside of the Defense Department and across the federal sector?
First of all, I am the first chief innovation officer ó and Iím pretty sure Iím not going to be the last ó for military medicine. I can't tell you how important I think this is.
Every agency not only should be looking at how it can be more efficient and effective, but how can it actually be delivering the products and services to whoever its customer is in a way that delights them. I think thereís a sweet spot in there, itís not one or the other, itís not efficiency over pleasing your customers.
I really am looking for other chief innovation officers. I know that the White House has kind of an innovation office, but I donít know that they have any kind of way of pulling us together. Iíd even be willing to host it if I could find out who they were, whatever theyíre called. I donít know if they would be called innovation officer. I think that we have a lot to learn from each other. Things that I figured out how to do, they havenít. And things that they may have already learned ó maybe they figured out how to write MOUs and get some kind of activity to take place with the private sector that I havenít figured out, right? And if they figured it out, the one thing we have in common is that we are federal entities, so weíre appropriated dollars, we are spending the taxpayers money, we have oversight by Congress. So working together, we can really, I think, make it even bigger. It would be more of an institutional impact than something like the [Clinton-Gore era] Reinvention Labs. It was kind of like what I did before. It was cherry picking.
So cherry pickingís not bad. I learned a lot from my cherry picking. But this approach is much more invasive. Itís grassroots. And thatís what youíve got to do. Itís odd to say that someone has to lead the grassroots, but you have to fix the processes so the people who actually have to run the programs and implement the ideas have access to the senior leaders so that they have a voice. And actually give the senior leaders the respect that they deserve, give them an opportunity to make decisions where they don't normally get the opportunity to make decisions.
I am hoping that some other agency reads this and says I really want to set up an innovation program and I definitely would be willing to go help them and talk to them, I really would. I feel just so strongly about it. Because Iím very much a public servant and I like the government to be as good as it can.
Do you think the governance model that youíve employed at DHA to leverage innovation toward improved cost and mission performance can be applied at other federal agencies or other mission disciplines?
Yes, yes, yes. I think it would be such a legacy for this administration.
This is a skill set. [Take, for example, information technology.] Itís about moving information, itís about security, itís about, when it goes down, how you fix it, itís about user error, right? Same thing [with innovation]. I really feel that this is coming. It would be wonderful if the federal government, instead of being the last to recognize it, recognized it right now when thereís really no better time. Is there ever going to be a better time? The government needs to reform. It needs to reduce its cost so the taxpayer is satisfied with what they were getting from the government and is happy with their Congress. Is there ever going to be a better time to try to build this skillset and to set up innovation offices and work together to have that be a cross-functional thing where they learn from each other and we support each other so that we can steal liberally? We are all the government, right? Anybody can steal my program. I didn't build it to sell it. I built it to share it. Thatís what itís all about.