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Secretary Shinseki Has Resigned; Will Things Change at the VA?

va secretary shinseki attends labormanagement relations forum with national va council 150x150 Secretary Shinseki Has Resigned; Will Things Change at the VA? leanFollowing up on posts from Monday and Wednesday, we see this headline today: “Shinseki resigns after VA scandal.”

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.”

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 lean blog Secretary Shinseki Has Resigned; Will Things Change at the VA? leanAbout 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.

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5 Comments on "Secretary Shinseki Has Resigned; Will Things Change at the VA?"

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  1. Mark Graban
    Twitter:
    says:

    I got this comment via email and it mirrors what’s in news reports:

    Have you ever been in or worked in a VA Hospital? The productivity is so low it is laughable.

    The Albuquerque report showed the 8 person cardiology dept was seen a total of 32 patients a week! Hello!

    If no one is seeing any patients, of course the wait times will be long.

    How do we fix the capacity and throughput problems? Let’s not just throw money at it – fix the systemic factors!
    Mark Graban recently posted..Podcast #200 – Paul Spiegelman, “Patients Come Second”My Profile

  2. Mark Graban
    Twitter:
    says:

    I saw this comment in a different story:

    “He’s a very good man,” Obama said of Shinseki. “He’s deeply disappointed in the fact that bad news didn’t get to him.”

    Actually, the Inspector General had been raising this as an issue for years… the unreliable data and the gaming. How did Shinseki not know? That’s not believable.

    Shinseki is, I’m sure, a very good man. But, it’s the role of leaders to ensure that bad news flows upward. When local VA sites say that they, basically, got in trouble for reporting long waiting times or bad data… well, bad news and bad data isn’t going to flow upward.

    This isn’t just a “big government” problem. This is a big problem in the private sector, in big companies (and sometimes small). Alan Mulally famously had to address this at Ford where nobody ever reported the status of anything as “red.”
    Mark Graban recently posted..WSJ Video on Gaming the VA Wait List System & TargetsMy Profile

    • Dale Savage says:

      From the news reports this morning, this is also part of the problem at GM with the ignition switch issue. Silos in an organization could be part of the problem. Everyone works within their silo and fail to see the need to report anything outside of it, whether the direction is horizontal or vertical.

  3. Dan Stoelb says:

    Being a veteran myself I have seen the good side and bad side of the VA system. There are many dedicated individuals who care and provide outstanding customer service ( doctors, nurses, administrative, support). Unfortunately in this instance as in the private sector, when you:

    - Lose sight of why you are in business.
    - Fail to remember that your job is providing customer service and not just getting a check.
    - Fail to stay focused on the basics
    - have ineffective leadership

    The system will fail to deliver what it promises it will.

    The culture of the VA will not change with Shinseki’s resignation. Culture can only be achieved through practicing and making decisions based on stated values and principles, accountability for results and individual and organizational performance results, and effective leadership.

    Start getting rid of non- performers; fire those who violated rules, laws and regulations is a good start to getting people to understand what is important in an organization and what they will be evaluated on. People will then start to change their behavior which will change the culture over time.

    But Beuaracracy will not allow that to happen, because it creates institutions that eventually evolve to focus on procedures, policies and lack of incentive due to no competition instead of working everyday to further the needs of its customers or change.

    • Mark Graban
      Twitter:
      says:

      Thanks for your service and thanks for your comment, Dan.

      The thing I have trouble with is who to fire… there were certainly ethical lapses by those who fudged or falsified data. But, what happens when (as I assume happened here) the gaming was implicitly or explicitly encouraged by senior leaders? I wouldn’t fire people who were just “following orders.” I wouldn’t even fire those who were gaming the system to get a better bonus. They didn’t create the system… they were doing what’s completely rational and expected in a system that set unrealistic targets and didn’t give them proper support.

      I don’t expect people to speak up and take actions that will get them fired… that’s why whistleblowers are really brave… because they don’t always get the protection they are promised or entitled too.

      Somebody needs to shake up the bureaucracy. That will require a lot of leadership…
      Mark Graban recently posted..Debate about Lean at SF General Hospital – Hire a Consultant or More RNs?My Profile

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