Now that Washington has acknowledged cultural malaise and a broad failure to provide timely access to health care at the Department of Veterans Affairs, Congress and the executive branch are competing frantically to show the public how hard they are working to fix that failure.
It’s ugly. Congress is throwing money at the problem and improvising short-term Rube Goldberg “solutions” certain to have unintended negative consequences that will fuel future failures. The office of the inspector general, which napped through a decade of evidence that demonstrated the quality problem at the VA, has responded by subpoenaing whistleblowers who brought their complaints to outside advocates—a surefire way to stifle critics.
Timely access to care is not the only problem. The June 23, 2014 letter from Special Counsel Carolyn Lerner to President Obama makes it clear that appropriateness of care is also a huge issue at the VA because the agency has been using such a low standard for quality determinations—essentially imminent threat to human life. The administration’s own Nabors report, released last Friday, recognizes that the operational issues result from a cultural breakdown.
A significant cause of quality problems at the VA is a basic management mistake that dates from the Clinton administration. Consistent with trendy theories of the time, the VA relied primarily on a decentralized quality control operation embedded deep into the organization, although the VA also placed too much faith in its inspector general and its accrediting organizations. What that model meant is that the employees who should be the watchdogs of operations reported to the very officials whose performance they were supposed to be monitoring. You don’t need a fancy-pants MBA to understand what was inevitable: managers had a means and motive to suppress internal criticism of their operations, and they did so.
When I ran the Social Security Administration, I always had a chief quality officer who reported directly to me. It was an unpopular office, but I would not have had it any other way. My chief quality officer validated data definitions and techniques, ran studies, and did not hesitate to challenge assertions of the deputy commissioners who were running field operations and the world’s largest system of justice. Many operational improvements resulted from this work.
Left unchallenged, any large organization—public sector or private sector—will tend to present only “happy talk” about its achievements to the chief executive. That type of forced consensus minimizes friction at the senior level until failure mounts and crisis disrupts the artificial bliss, just as it did for former Secretary Shinseki at the VA and Mary Barra at General Motors. It also creates exactly the kind of dysfunctional culture identified by Rob Nabors.
On the VA website the organizational chart for the office of the secretary is cluttered with small offices located there as political statements; these well-intentioned organizational blunders distract the secretary from strategic issues. What is even more meaningful is that there is no senior official reporting directly to the secretary whose primary responsibility is quality. When I asked the VA press office if the agency had designated a chief quality officer, the person indignantly responded, “I don’t have the slightest idea”—as if I had asked about the win-loss record of the secretary’s softball team over a ten-year period. She later sent me the email address of an employee in New Mexico who did not respond to emails.
It appears that in practice the agency has conceptualized its top quality person in headquarters to be either the deputy undersecretary for clinical practice or the deputy undersecretary for operations and management, two positions with significant operational responsibilities. The occupants of these positions have been neither incompetent nor timid. Deputy Undersecretary for Operations William Schoenhard sent a detailed April 2010 memo to regional directors insisting that they take “immediate action” to end practices that distorted waiting-time data.
No “immediate action” occurred. Schoenhard’s supervisor has acknowledged that he saw that April 2010 memo, but he did not clamp down on hundreds of decentralized and resistant fiefdoms. In other words, a self-interested senior official thwarted the person who understood the problem and tried to do the right thing—a highly predictable outcome given the agency’s organizational structure. An agency head cannot count on managers running major operations to be transparent about their management problems; President Reagan’s “trust but verify” should be embraced by the head of any large organization.
On Monday President Obama announced the nomination of Robert McDonald, a veteran and a former CEO of one of the world’s largest corporations, to be the new secretary of Veterans Affairs. It’s a good choice. The new secretary should streamline his bloated front office until it has no more than five direct reports; Congress needs to support him when special interest groups complain that components dedicated to their special interests are “demoted.” One of those five direct reports should be a chief quality officer—independent of the operational components—with line control over the employees in charge of quality in the field. The healthy tension created by this reorganization and a commitment to a culture of quality would give the VA a chance to heal.
Michael Astrue served as commissioner of Social Security from 2007-2013.