OP-ED

Will the Shinseki Resignation Turn around the VA?

ShinsekiAs I wrote  on LinkedIn, instead of blaming “bad managers” or a “lack of integrity” at local VA sites, like Phoenix, we have to look at the system.

Dr. W. Edwards Deming always said that senior management is responsible for the system. We need to ask who designed, set in place (or tolerated) things like:

  • Unrealistic” 14-day waiting time goals (says the VA Inspector General)
  • Bonuses and financial incentives driven by hitting these targets
  • A culture where people can’t ask for help (“don’t make things look bad”)
  • An environment that tolerates not having enough capacity to meet demand

In circumstances like that, being pressured by distant leaders to hit an unrealistic target… I would GUARANTEE that there would be some level of cheating. And, more than 40 VA sites are under investigation by the Inspector General. This is systemic. It’s too simplistic to label people as “bad” and to then fire them. “Gaming the numbers” is very predictable human behavior (and it happens in other countries’ healthcare systems too).

In his statement, Shinseki did point fingers at himself on one level:

At the end of a speech to an annual conference of the National Coalition for Homeless Veterans in Washington, Shinseki addressed a new interim report on the VA health-care system’s problems. He said he now knows that the problems are “systemic,” rather than isolated as he thought in the past.

“That breach of integrity is irresponsible,” he told the largely supportive audience. “It is indefensible and unacceptable to me.” He said he was “too trusting” of some top officials and “accepted as accurate reports that I now know to have been misleading with regard to patient wait times.”

President Reagan famously quoted an old Russian maxim, “Trust, but verify.” That’s good advice for leaders anywhere.

Toyota’s Taiichi Ohno also famously said:

“Data is of course important in manufacturing, but I place the greatest emphasis on facts.”

“Data” might include spreadsheets and reports on the web. Data are too easily gamed, faked, and fudged. People can manipulate data in many ways and leaders need to be aware of that.

“Facts” are things you can see with your own eyes. Lean leaders “go to the Gemba” (or the actual workplace) to see first hand and to talk to the people who are doing the work. A Lean VA leader would visit locations (or send people) to help verify that data is not being manipulated and that processes are being followed. You’d talk to veterans to see if they have complaints about long waits that aren’t showing up in the data.

Accepting Shinseki’s resignation won’t, in and of itself, fix the VA. I’ve recommended that the VA do the following:

A good start would be to remove the arbitrary target and focus on actually improving capacity and reducing waiting times. Keep measuring waiting times, but use the data for collaborative improvement instead of rewards and punishment. Keep the focus on the important mission – patient care. Instead of just hitting a 14-day target, let’s get waiting times even lower than that.

We can’t just scapegoat Shinseki or any other local leaders. It’s good, in my mind, that Shinseki accepted responsibility… but the government has to fix things.

I quite strongly believe the reports that Shinseki is a good and honorable man. He served our country and retired as a four-star general. We owe him a debt of thanks. He just wasn’t able to get this fixed. He said:

“… the “lack of integrity” is something he has “rarely encountered.”

and:

Shinseki acknowledged that he had been too trusting of the information he received from VA hospital employees, and he said that during his 38-year military career he always thought he could trust reports from the field.

He also said:

“I can’t explain the lack of integrity among some of the leaders of our health-care facilities,” he said. “And so I will not defend it, because it is indefensible. But I can take responsibility for it, and I do.”He added: “So given the facts I now know, I apologize as the senior leader of the Department of Veterans Affairs. . . . But I also know this: that leadership and integrity problems can and must be fixed — and now.”

Vowing to fire people won’t fix the VA. If there are “bad people” here, how did the VA end up with bad leaders in 40+ sites? That’s another systemic problem.

Maybe he made one systemic change on his way out:

Shinseki said he issued directives that no senior VA executive will receive any performance award this year and that patient wait times be deleted from officials’ performance reviews as a measure of their success. 

Maybe that dysfunction is now gone, but we still have the dysfunction of LONG waiting times. That problem needs to be addressed… since that’s the ultimate problem and the real scandal.

Mark Graban (@MarkGraban) is a consultantauthor, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen. His latest, The Executive Guide to Healthcare Kaizenis now available. He is also the VP of Innovation and Improvement Services for KaiNexus. Mark blogs most weekdays at www.LeanBlog.org.

Livongo’s Post Ad Banner 728*90
Spread the love

28 replies »

  1. If the patient has capacity and competence the family is irrelevant.

    Give the vet the money and let him choose how to spend it. He gets to keep it if he does not spend it.

    Then and only then will the system be reformed.

  2. If private hospitals look the same it is because they have been remolded by the feds to look like a federal operation.

    In government the drivers of the dysfunction are different.
    In government it is corruption that covers the incompetence. The best and brightest has never worked in government. But corruption flourishes in government.

    The VA and all government services direct to the voter need to be eliminated.

    They ALL are corrupt.

  3. Then you completely reject your earlier statement and recognize the patient’s right to control his own destiny. Your former statement seemed to be advocating death panels that you blamed on the extreme right.

  4. allan

    If the patient is of sound mind his/her wishes MUST be respected first- but to include professional assisted relief from unbearable sufferring

  5. You really believe a board not the individual of sound mind is entitled to provide the answer?

    Doctor, at the bedside your responsibility is to the competent patient.

  6. Sorry about the duplicate post- But thanks for your interet

    allan- here is my answer to your question

    ANS- a board of ethical professionals including family members- if the individual is of sound mind the individual should be included of course- The extreme right calls these “death panels” – I call them quality if life and quality and dignity of death panels

  7. I seem to remember this question asked one blog later so I will post the same response I posted on the other blog.

    This is a rhetorical response not meant to be answered, rather meant to be silently thought about.

    Who determines the quality of life of an individual? The individual or a third party?

  8. Here is an agressive #4 point plan to begin to fix VA Health Care

    – it begins with improved recruiting health standards- many (1 in 5) current recruits are unhealthy long before they are recruited

    – improved medical triage on the battlefield .Stop saving lives that have zero chance of any quality of life

    – convince ALL Vets that more is not always better in medicine – it isn’t – often treatments actually harm

    – all above said have zero tolerance for excessive delays and fraud but don ‘t over promise what you can’t deliver

    Dr. Rick Lippin
    Southampton,Pa

  9. How can the firing of one man lead to a change in the VA? It is the culture of the VA that needs to be changed. The VA has to realize that its existence is to help veterans that sustained war injuries, not to maintain jobs for union employees

  10. “The VA scandal, to me, is about management and leadership, not politics. These same dysfunctions occur in private businesses, as well.”

    Yes, General Motors still is not fixed. China sales covers its U.S. dysfunction.

  11. Interesting how so far in the above comments, no one touched on how the entrenched bureaucracy of the VA system and its incredible shortcomings that most Obamacare supporters neglected to mention in touting this new monstrosity for the public, these consequences will be felt among most Americans as Obamacare policies just mirror those of the VA.

    Bonuses are examples of profit agenda, and as I will continue to say until I die, you can’t have a profit agenda AND provide sound responsible care simultaneously. But, the profit mongerers who parade here at THCB will find the usual primitive defenses to refute my position.

    And most who naively read here will just reflexively nod and sigh in acceptance, as the lies win on.

    Pathetic how the physicians here who practice daily clinical care really don’t speak out in unison to reject this assault on health care. But, managed care’s front line incursion 20 years has decimated the caring and invested providers, eh? When in Rome…well, prepare to burn!

  12. Jack Welch used to tell investors shortly after he became CEO that he divided managers into four groups as follows: (1) those who make the numbers and share our values, (2) those who don’t make the numbers and don’t share our values, (3) those who don’t make the numbers but do share our values and (4) those who make the numbers but don’t share our values.

    He wanted managers who were either already in the first group or could adapt to the new culture of teamwork and collaboration and breaking down boundaries among divisions and functions that he was trying to create so they could move into the first group. Those who were having trouble making their numbers were offered help and many were able to improve. The toughest group he had to deal with was those who made their numbers, usually through fear and intimidation, but didn’t share the company’s values as Welch articulated them. If they couldn’t adapt, he pushed them out but made sure they got help in finding another job in an organization where they would be a better fit.

    It’s hard to imagine VA managers getting the authority to make personnel changes the way Welch did and, even if they got such authority, it’s probable that they wouldn’t use it anywhere near as much as they should. If people perceive that they can’t or won’t be fired, there isn’t much incentive for them to change the way they do their jobs.

    Perhaps we should try opening some new VA clinics that are the equivalent of charter schools meaning publicly financed but privately operated without unions and rigid civil service rules around salaries and promotions and see if they can outperform nearby VA clinics. Alternatively, under certain circumstances, veterans could be given vouchers to seek care in the private healthcare system. I think it’s unlikely that the current system is fixable from within because of both cultural rigidity and the difficulty of getting necessary changes through the political process.

  13. Metrics end up being used as a bludgeon, rather than enabling development or evolution. Long wait times mean hire up and grow, or resolve inefficiencies. At the VA, it meant:hide. Collecting data to bury is at least wasteful, perhaps criminal.

  14. 🙂

    Try getting away with “data is” in JAMA or NEJM or onay of a host of scientific journals.

    I could not be more “in touch.” My data are clear on that. And, the Victorians didn’t get everything wrong.

  15. “Will the Shinseki resignation turn around the VA?”

    NO

    On another blog that I participate in there are multiple “war stories” from physicians – many of whom trained (partially) in the VA system. These stories date back many years.

    I remember in the late ’70’s at the Baltimore VA that the patient’s TPR’s (Temperature, Pulse, Respiration) were always the same. That was because the nurses never checked them. The joke was that a Vet’s TPRs stayed normal for hours after he died!

  16. @BobbyG

    Ha!

    And yet, talk of Big Data is everywhere we turn …

    And Big Data “are everywhere” sounds Victorian and completely out of touch

    I’m from the Usage school.

    Oh and insufferable is probably the wrong adjective .. : )

  17. “Will the Shinseki Resignation turn around the VA?”
    __

    No. Not one whit. It had to be done for political purposes, but that’s all.

    Pile on the now-retiring Vietnam war era vets atop the now-dying-off WWII and Korean war vets, and also pile on the Afghanistan and Iraq war vets (many of whom would have been KIA in prior conflicts), add in a good dose of GOP purely vindictive anti-Obama VA funding obstruction, there’s no way they can scale up. If you are a vet with a service-connected war injury/condition, you should be able to present your VA card at ANY medical facility and get treatment. The mainstream pols are finally starting to advocate this. Finally.

    Outsource the VA to ThedaCare (and pay them adequately). They’ll stand and deliver.

  18. hey guys, all you need to do is look at the inefficiencies created by the electronic ordering components and css of the Vista EHR. Doctors and others on the health care team front lines are slowed by 30%-40% by these devices, although the libraries of records may be helpful.

    Thus, the combination of more demand for care with the inefficiencies of the EHR slowing down the care team created an impossible situation. The cover-up was on, because no one would stick their neck out to tell the truth from the front lines.

    Go fix the problem rather than point fingers.

  19. Lying about data happens everywhere in which people are measured by specific metrics. It is equivalent to “teaching to the test” at its worst, when teachers don’t just teach to the test but give the students answers to the tests to make the pass rate numbers look good. Or discourage kids from taking the SATs or applying to their first-choice colleges to make college acceptance look good.

    The difference is that this isn’t about scores — people are allegedly dying. Not just “people” but vets who served our country in wartime. The blame is highly sharable. There isn’t enough money (blame Congress) and it’s not being spent well (blame the executive branch).

    But there is a solution for measurement. Not a perfect solution, but a partial one. Measure outcomes, not inputs. What is the age-adjusted death rate of vets served by the VA in a region, vs. other regions. When people did die, when was the last time they interacted with the system? Was the death “managed” or “unmanaged.” (This can be defined but these alleged deaths were all in the unmanaged category.)

    I don’t know what the exact categories are, but it’s much harder to game outcomes than process measures — we’ve learned that in wellness, where vendors get accredited by NCQA no matter how much they make up their outcomes, if they do a few processes right.

  20. The VA already uses metrics of wait times and patient safety. And having worked in private and academic hospitals, I agree that the issues listed above are general management problems.

    But given the sheer size of the VA, these issues present a larger problem and are more woven into the culture. And as any business school Organizational Behavior student knows, changing the culture of an organization, especially a large one, requires significant leadership at the top with consistency at all levels below, as well as systemic infrastructure changes and process redesign.

    There will be all kinds of finger pointing and discussions of throwing more money at the clinical staff vs privatizing parts of the system. It’s a fair debate. But no amount of money will compensate for poor leadership, and I’m not sure if the iron will exists to do the kind of house cleaning needed and to weather the transition period of righting the ship. Even Jack Welch and Lee Iaccoca faced criticism, but they were fortunate to be right in their choice of actions and had the ability to stick to their choices. Importantly, they were also able to navigate their organizations by private sector rules that I highly doubt the VA will ever be able to engage.

  21. This exact same paragraph could be written about some private hospitals, non-profit or for-profit, non-union or unionized:

    “Incredibly inbred and ego driven middle management (both nurses and doctors), a promotion system based on friendships and loyalties rather than competence, a level of politics I ddin’t know was capable at an organization that has relatively little financial incentive, a unionized organization where poor performers could not be removed but only shuttled off to another division and even then only after 2 years of write up/performance plans/ and multiple reviews, and all of the classic tales of how data can be obfuscated to hide actual facts.”

    These are general management problems, not just government problems.

    You don’t think you can use waiting time metrics or patient safety metrics like private hospitals do?

    You’re right, nobody from the Joint Commission ever sees the reality of how things are in hospitals. It’s fraudulent. As they say in England, “The Queen thinks the whole world smells like fresh paint.”

    Management problems.

    The good news is that it’s fixable, if we wanted to.

  22. If this wasn’t such a tragedy and a colossal example of mismanagement, I would be laughing.

    I have worked as a physician in two separate VA hospitals, in very different parts of the countries. The issues I saw were similar – incredibly inbred and ego driven middle management (both nurses and doctors), a promotion system based on friendships and loyalties rather than competence, a level of politics I ddin’t know was capable at an organization that has relatively little financial incentive, a unionized organization where poor performers could not be removed but only shuttled off to another division and even then only after 2 years of write up/performance plans/ and multiple reviews, and all of the classic tales of how data can be obfuscated to hide actual facts.

    The unfortunate issue is that the VA can’t clean house with their existing staff. Shinseki is just the top. I’m not sure that going to each facility and trying to get information honestly from the underlings would work (Have you even been at a hospital before a JCAHO inspection? It’s like people shoving toys under their bed before Mom and Dad come to check if your room is clean. No one is honest and everyone is afraid of getting called out as the whistleblower. And no whistleblower laws don’t help – you just get tagged as the trouble maker by the administration and eventually are tortured till you leave).

    And you can’t impose the metrics of private hospitals where you often have better resources and support, not to mention a non-governmental mindset. The last of the two hospitals I mentioned brought in a physician from the private sector to lead the department – he was highly efficient, result driven and follows metrics that he believed would make the organization as effective as his last one. But all he’s really done is to alienate everyone with unrealistic rules, he’s shifted around schedules to make it look like something has improved though it hasn’t, and has filled out a lot of reports that give the appearance that much has changed and that he has been responsible for it.

    The VA is a great organization for the genuine love of taking care of people that have served our country. The staff take real pleasure in looking after the veterans that have looked after us. But there is a level of house cleaning required to make it work effectively that I am not sure is practical or possible.

  23. Yes, “data are political” or “data are apolitical” would be correct.

    I think the core issue of reducing waiting times should be a non-partisan issue we can all rally around.

    The bureaucracy (which is non-partisan) should be freed from bad management practices, like targets and incentives. Dr. Deming was calling for this in government over 30 years ago.

    The VA scandal, to me, is about management and leadership, not politics. These same dysfunctions occur in private businesses, as well.

  24. I think a lot of people fail to get that the VA scandal isn’t about politics, it’s about data and how data is handled.

    Data is political, like everything else.

    Or should that be data “are” political. ; )

  25. I’d hope that even the most Libertarian minded small-government folks out there would want government to perform well at the things they do, especially involving our military and our vets.

    Republicans shouldn’t take any glee in this VA problem, because it was around during the George W. Bush administration.

    The dictum about “making the trains run on time” unfortunately refers to the Italian fascists… and it wasn’t even true about making the trains run on time:

    http://www.snopes.com/history/govern/trains.asp

    Japan, though, does amazingly well at this.

  26. Great post, Mark. At the end of it all, this is what matters: “but the government has to fix things.”

    Both parties and both ideologies have taken leave of their senses and there is no longer apparently even a modest inclination towards making continuous incremental improvements, be it in wait times or any one of hundreds of other issues because the drive for high expectations might annoy one constituency or another. No one expects the government to perform miracles, but most of us do expect some kind of operational and fiscal competence, the kind that functionaries and bureaucrats around the world have become famous for.

    Whatever happened to the dictum to make the trains run on time?

Leave a Reply

Your email address will not be published. Required fields are marked *