The Veterans Affairs (VA) hospital scandal has policymakers calling for VA Secretary Eric Shinseki’s head, and this week they got it, when President Obama accepted the Secretary’s resignation.
Some policymakers are also calling for privatizing VA hospitals, allowing them to be owned and operated by the same entities that own and operate the hospitals the rest of us use. This idea assumes the hospital community as a whole performs better than the VA, and the sad truth is we don’t have any evidence of that.
We know that on average, other hospitals are not doing a great job. Upwards of 500 people each day die from preventable errors in American hospitals, one in 20 admitted patients will get an infection, and one in four inpatients suffer some form of harm unrelated to the reason they went to the hospital in the first place.
Evidence suggests waiting lists like the VA’s may be common, as well.
So how does the VA compare? We don’t know. We don’t have much data publicly available to begin with, and we have virtually nothing that compares VA hospitals with other American hospitals.
To be clear, data is being collected—it’s just not typically available to humble souls like you and me and the rest of the American citizenry. Hospitals get accredited to receive Medicare and Medicaid payments, but accreditation reports are not made public by hospital. Health plans collect claims data, but most of that is never released to the public. The Centers for Disease Control, the Centers for Medicare and Medicaid Services, and other federal agencies collect reams of data, but much of it is not made public, either.
This dearth of information is why employers and other purchasers of health care formed my organization (The Leapfrog Group), to ask hospitals to report on data they can’t get anywhere else. Their support means it’s free for hospitals to publicly report and free for consumers to access information about hospitals in their community. But only about a third of hospitals participate.
As 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.Continue reading…
In a post on the New York Times’ Economix blog not long ago, Princeton economics professor Uwe E. Reinhardt addresses the common characterization of the British health care system as “socialized medicine.” The label is most often used pejoratively in the United States to suggest that if anything resembling Great Britain’s National Health System (NHS) were adopted in the U.S., it would invariably deliver low-quality health care and produce poor health outcomes.
Ironically, Reinhardt notes, the U.S. already has a close cousin to the NHS within our borders. It’s the national network of VA Hospitals, clinics and skilled nursing facilities operated by our Veterans Healthcare Administration, part of the Department of Veterans Affairs. By almost every measure, the VA is recognized as delivering consistently high-quality care to its patients.
Among the evidence Reinhardt cites is an “eye-opening” (his words) 2004 RAND study from in the Annals of Internal Medicine that examined the quality of VA care, comparing the medical records of VA patients with a national sample and evaluating how effectively health care is delivered to each group (see a summary of that study).
RAND’s study, led by Dr. Steven Asch, found that the VA system delivered higher-quality care than the national sample of private hospitals on all measures except acute care (on which the two samples performed comparably). In nearly every other respect, VA patients received consistently better care across the board, including screening, diagnosis, treatment, and access to follow-up.
Last Wednesday, President Obama called the much-publicized problems in the Veterans Affairs health system “disgraceful” as delays in care in at least 26 facilities grabbed media attention. In testimony before Senate and House Congressional committees, VA officials disclosed systemic misrepresentations about the timeliness of treatments in VA primary care clinics: rather than getting care within 14 days of request, many veterans appear to have waited 6-12 months to see a doctor, and some are alleged to have died while waiting.
In referencing a special report due this week that assesses the scope of the problem in the Department of Veterans Affairs, the President’s commitment to fix the problem was unequivocal: “I want to see what the results of these reports are and there is going to be accountability.”
As I have watched the VA storyline play out over the course of the past few weeks, I found myself asking questions the reporters weren’t:
Why do we need to operate a separate system of 820 clinics and 151 hospitals for Veterans?
Might the system of care for the 21 million it currently serves not be better coordinated through the U.S. health care system of 5200 public and private hospitals, 820,000 physicians, 1200 federally qualified health centers, 2000 community mental health clinics, 56,000 pharmacies and 1700 retail clinics? In most communities, there’s a surplus of beds.
In most communities, those with insurance can get doctors’ appointments and receive treatment. Veterans who lack private coverage, like those who are uninsured, have fewer choices. It is not a capacity issue: it is an economic issue.
And common sense suggests we might redeploy some the VA health administration’s $60.3B budget for better coordination with the private systems that already operate in our communities while reducing duplication of services and their associated costs.
Why don’t we get serious and fix the problem of access to primary care shortage once and for all? It’s not just a veterans’ problem. Those who live in poorer neighborhoods lack access.
Public trust matters. It’s hard to build and easy to lose.
Of late, subpar performance has drawn public attention to a wide variety of industry notables:
- General Motors agreed to a fine for malfunctions resulting in 24 recalls in recent years including 2.6M most recently with faulty ignition switches.
- Security breaches in customer information at Target, Michaels and other retailers hurt sales and cost at least one CEO his job.
- The Department of Veterans’ Affairs has been exposed to questions about its safety record, notably delays in treating veterans in its hospitals in 9 states.
Entire industries have seen their public trust erode as a result of misdeeds or self-inflicted wounds—the investment banking industry’s mortgage loan debacle, venerable news organizations from lack of objectivity, industrial food manufacturers from unhealthy supply chain management and so on. And industries like higher education and others face tough questions about their value proposition, as if decades of good will no longer matter.
In most cases, leaders of the most prominent organizations in these industries accept responsibility, appoint task forces to investigate and address their issues with the media and investors head-on. Their trade groups, likewise, announce new initiatives to restore public confidence. They hire professionals to bolster their influence. and in some cases, rebuild their reputation.
Public trust in industries matters as much as confidence in the individual companies and organizations themselves. An industry’s reputation and good will is always buoyed by the reputation of the companies that are its marque market leaders, and always at risk as a result of the misdeeds of any member, known or unknown.
By and large, excepting occasional drug manufacturing scares or recent well-publicized safety issues in a few of the 3000U.S. compounding pharmacies, our industry has remained virtually unscathed from the ever-more-skeptical public’s thirst for muckraking. The U.S. health system enjoys the confidence of the majority, especially older adults for whom it is always top of mind.
But the reality is this: the US health industry is susceptible to erosion of its public trust, not as a result of the Affordable Care Act nor political in fighting in Congress.
As your correspondent understands it, dozens of veterans died while waiting for outpatient appointments at the Phoenix Veterans Administration (VA) Hospital. Approximately 1500 vets were assigned to an “off-the-books” waiting list that made the clinics’ official waiting times appear shorter than they really were.
Because waiting times are an important feature of health care quality, the VA was probably holding its local administrators responsible for routinely measuring and reporting them up the chain of command. If reports are true, instead of using their increased budgetary resources to provide more care, the Phoenix bureaucrats allegedly responded by gaming the system.
And the scandal is flourishing. Investigations suggest other VA hospitals may have also adopted the same wait-list legerdemain. A senior D.C. official resigned fast-tracked his already scheduled retirement. The VA Inspector General’sinvestigation prejudgment is that none of the deaths can be attributed to delays in care. You can’t make this stuff up.
“Good grief!” says your correspondent. Numerous articles like this, this and this had convinced lay writers, impressive policy wonks and countless physicians that this version of government run health care was not only the greatest thing since the invention of Medicare, but a model for U.S. health care reform.
Not any more.