there was a high demand for primary care throughout the VA system. Research showed that many VA facilities believed that 55 percent of patients would choose to receive primary care at the VA facility if a primary care system was fully implemented in 1993. The study also showed that the VA facilities believed that 83 percent of veterans would choose to receive primary care at the VA if fully implemented by 1998. These results made it clear to the administration that it was time for a reform. As a result, the VA issued a directive in 1994, that required all VA healthcare facilities to have primary care teams by year 1996. As a result, percentage of patients receiving primary care at the VA increased from 38 percent to 45 percent to 95 percent, during 1993, 1996, and 1999. This mandate served as the foundation for the VA reorganization under Dr. Kenneth W. Kizer. Dr. Kizer, a physician trained in emergency medicine and Public Health, was appointed by President Bill Clinton as Director of U.S. Veterans Health Administration in 1994. He was hired to update and modernize the VA health system in order to eliminate negative perception and to align the system with current market trends. Core issues included advancements in technology and biomedical knowledge, aging and socioeconomically disadvantaged Medicare patients, coordinating care, and rising healthcare costs. There was much opposition to a major reform. Many legislators preferred an incremental change over a wide-scale reform. However, Kizer was known as being very innovative. To publicize his vision he expressed his mission and vision of the "new VHA" and outlined seven key principles to guide change. His ultimate goal was to provide coordinated, high quality care at a low cost. He launched his reorganization plan in 1995 by decentralizing the VA system. He organized all VA operating units into 22 geographic based networks known as Veterans Integrated Service Networks (VISNs). This allowed networks to manage themselves and adapt to the demographics of their location. Patients were then assigned to a group of doctors who would provide coordinated care. One director was hired for each VISN network. Instead of hiring all directors internally, a third of the newly hired VISN directors were hired outside of the VA system. The directors were responsible for meeting performance goals and improving upon measurable key efficiency and quality indicators. Directors monitored performances and reports were generated to