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Balancing Mission and Margin (05:17)

“No money, no mission” is commonly heard in reference to mission-driven organizations. How do health care organizations that may not have much margin, such as VA centers and safety-net hospitals, balance their mission and margin so that they can manage resources effectively? Kimberlydawn Wisdom, Chief Wellness and Diversity Officer and Senior Vice President for Community Health and Equity at Henry Ford Health System, asks Sanjay Saint, Chief of Medicine for the VA Ann Arbor Healthcare System, for examples at the VA.

For a lot of academically affiliated VA centers, one of their key resources of excellence is the university, explains Saint. The University of Michigan, for example, provides the physicians, medical students, residents, and additional resources that the Ann Arbor VA otherwise would not have access to.

“But I think that this is a broader point, and that’s how do you keep people who want to come to the VA?” Saint adds. “We don’t pay that well. Most of my physicians can make more money working somewhere else.”

Saint points to Daniel Pink’s book Drive, which Stephen Swensen had brought up, summarizing three key points of motivation: mastery, autonomy, and purpose. To promote mastery, VA Ann Arbor invests in mentoring. And at most VAs, there is more autonomy, for example for learners. VA Ann Arbor instituted a Fellow of the Month award — many of the people who do consults there are fellows —which includes a signed paper award and a $25 gift certificate. “I’ve had some section chiefs, in cardiology for example, where if the fellow does not win, the section chief will speak to him or her and ask why they don’t,” says Saint. As for a sense of purpose, “that’s what we have,” he says, “and I would say to a greater extent than even a fantastic place like the University of Michigan. Our goal is to treat every single veteran like they are a family member.” A large percentage of people who work at the VA are also veterans and receive care there.

Continuing the thread of keeping people engaged, Wisdom asks about the final salute for veterans that Saint described in his talk. “I don’t know whether or how much that occurs across health systems in general that are not part of VAs, but other health systems can do that, correct?”

They can. Frederick Cerise, President and CEO for safety-net Parkland Health and Hospital System, notes that Parkland has a veterans resource group that recently instituted that practice. “[It’s] just a wonderful thing to do,” he says.

Saint describes a comparable end-of-life practice at hospitals in Japan. A few days after a person dies and their body lies in the morgue, the body is taken away. The physicians and nurses who cared for the patient are called to join the patient’s family, and as the hearse drives off, the family and doctors and nurses bow to each other as a sign of respect — the doctors thanking the family for the privilege of caring for their loved one and perhaps apologizing for not being able to do more, and the family thanking the doctors and nurses for that care. “The final salute is the VA’s way of also thanking a soldier for what they’ve done and what they’ve sacrificed for this country,” Saint says.

“The way we respect and regard a person even at the end of life or upon their transition is so important,” adds Wisdom. “Oftentimes, that’s what the family remembers.” She mentions how some faith traditions want the body to lay in state in the room they expired in for about 8 hours. “Being very mindful of how we regard and respect people during those end-of-life times is really key.”

From the NEJM Catalyst event Essentials of High-Performing Organizations, held at the University of Michigan’s Institute for Healthcare Policy and Innovation, July 25, 2018.

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