As I wrote about 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.”
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.
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.