Mission Driven: Point of Care to Final Salute (10:28)

“Shortly after I turned 18, I received a letter requiring me to sign up for the Selective Service. This is a requirement for all men in the United States in case a draft is needed. I refused,” says Sanjay Saint, Chief of Medicine for the VA Ann Arbor Healthcare System.

He recalls his parents’ response: “Sanjay, this is your decision, but we came to this country from Kenya and brought you and your sister with us because we thought that America would be the ideal place to raise our family.” His father had lived in four countries on four continents and had never felt as free as while living in the United States — other places did not welcome his race or religion. The source of that freedom, his parents said, came from the people willing to sacrifice everything for their country. Because of them, others could immigrate and thrive.

Saint changed his mind and signed up. While he has not been drafted, he says he has never forgotten that conversation and the duty he feels for those who serve. “It’s one key reason I work for a mission-driven health care system like the VA.”

He notes the special things that VA medical centers do that are rarely talked about, in particular the final salute for veterans who die at the hospital. After a patient is pronounced dead, their family is called in to see them. The body is placed on a gurney and draped with the American flag. Taps plays in the hallway as the body and family are led toward the exit, signaling health care workers and fellow soldiers to pay tribute — civilians stand with hands on their hearts while veterans give the military salute, standing if they are able.

“For me, as a civilian, I’m reminded of how lucky others and I are that we get to care for these men and women who all too often are forgotten and may be struggling mightily,” says Saint.

Other mission-driven health systems have their own means of respecting patients. Saint recalls caring for patients with AIDS as a medical student at San Francisco General Hospital — a mission-based organization committed to the underserved. “The care provided to patients on ward 5B, as it was known at the time, served as a model for high-quality, compassionate care for those with AIDS, as the New York Times reported in 1985,” he says.

Faith-based systems are similarly mission driven. “The Catholic-based system Ascension Health refers to their 150-plus facilities as ‘health ministries’ rather than hospitals, thereby emphasizing a holistic approach to patients that also focuses on their spiritual needs.”

Saint notes how the VA is the largest integrated health care system in the U.S., with about 160 hospitals and nearly 1,000 other facilities such as outpatient clinics. Approximately 9 million veterans receive care at the VA every year. The VA is also the largest provider of health care training in the country; nearly two-thirds of all U.S. doctors receive some of their training at a VA hospital. The VA’s electronic medical record system was a trailblazer when first introduced in 1995 and is still considered a top system in the country.

Studies consistently show that the VA does well compared with non-VA care. For example, a recent General Internal Medicine study found that VA hospitals performed the same as or significantly better than non-VA hospitals on most safety, mortality, and effectiveness measures.

However, the study also found high variation across VA facilities. “While the VA is better than people likely think, it’s far from perfect,” says Saint. “Much work remains to be done to further improve the VA.” He calls out improving access and timeliness of care, reducing bureaucratic hurdles, and paying more attention to what frontline clinicians need to perform well. Returning to the issue of variability, he says we need to figure out how to ensure consistent, high-quality care across the VA’s thousand facilities. “Many VA hospitals, perhaps most, provide terrific care. However, there are too many that provide inadequate care for various reasons.”

“Despite its problems, the most remarkable aspect of VA hospitals is the patient population, the men and women who have sacrificed for this country,” says Saint. “I didn’t sit in the foxhole with them or parachute into jungles, but I still have a duty to provide America’s veterans high-quality care, delivered humanely.”

Saint learned this from watching colleagues at various VA hospitals. “They have a special attitude toward their patients,” he says. “It takes the form of respect, gratitude, empathy, and a level of caring that is nothing short of love. You can see it in the extra services provided for patients who are often alone in the world, too far from home to be visited.” Comparing University of Michigan patients to VA Ann Arbor patients, Saint found that while 70% of university patients had visitors, only 10% had visitors at the VA. Partly for this reason, it’s common for VA Ann Arbor nurses to refer to their patients as “our veterans.”

Saint once cared for a middle-aged veteran who was diagnosed with cancer that had metastasized widely. Saint’s team offered chemotherapy to give the patient an extra few months to live, but instead he chose hospice so that he could be home with his wife and play guitar. Before the patient left, he shook a medical student’s hand and said, “Thanks for being a warrior for me.”

“He’s going home to die, and he’s thanking us. That’s the special kind of patient who shows up at a VA hospital,” says Saint. “Every single one of them should have the special kind of care they deserve and we must ensure that that care is superb from the moment they leave the service to the time of their final salute.”

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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