Look at the System, Not the Individuals
I've been wanting to blog about the “VA Scandal,” but have avoided it because
- it is somewhat politicized (as tends to happen),
- the allegations and story are moving quickly, and
- the whole thing just makes me sad, so I stop writing.
Building on Monday's post… when the news first broke about scandals at the VA (the Veterans Health Administration), a lot of the focus was on “secret waiting lists” and individuals in Phoenix “gaming the system” (or fudging the numbers):
“A fatal wait: Veterans languish and die on a VA hospital's secret list“
Right away, commentators and politicians were calling for people's heads. I thought, “Wait, this seems like it's a really systemic problem… let's not rush to blame people in Phoenix or elsewhere.”
The allegation, from internal whistleblowers, was that appointment waiting times were made to look shorter than they were through the use of off-the-books “secret waiting lists.”
“The VA requires its hospitals to provide care to patients in a timely manner, typically within 14 to 30 days, [Dr.] Foote said.”
One problem with goals and targets (targets set by upper management, especially from headquarters) is that they are arbitrary. Why is the target 14 days? Why not 10 or why not 20?
Update: The target was 30 days until 2011, when it was reduced to 14 days.
The goal can be skewed because it doesn't mean “14 days of waiting from the call requesting an appointment,” it means providing an appointment “within 14 days of the date requested by the patient,” which opens things up to shenanigans.
Another problem occurs when the target isn't achievable without cheating… this inevitably leads to cheating, “fudging the numbers” or “gaming the system.” It's rational behavior and I don't blame and doctors or managers who did this, given their circumstances. A VA undersecretary called the 14 day goal “unrealistic” a few years back… so the trouble that resulted isn't the least bit surprising to me.
Look Good or Actually Be Good?
This WSJ video explains the four “scheduling schemes” or ways of cheating the system:
If it's easier to “look good” than it is to “actually be good,” local leaders will make things look good, especially when faced with the loss of bonuses or other consequences from NOT hitting the targets. $8.8 million in bonuses were paid out to leaders at seven VA facilities accused of cheating because they hit their numbers (even though the numbers were false.
“According to Foote, the elaborate scheme in Phoenix involved shredding evidence to hide the long list of veterans waiting for appointments and care. Officials at the VA, Foote says, instructed their staff to not actually make doctor's appointments for veterans within the computer system.
Instead, Foote says, when a veteran comes in seeking an appointment, “they enter information into the computer and do a screen capture hard copy printout. They then do not save what was put into the computer so there's no record that you were ever here,” he said.”
Read more about this at CNN.com if you're not aware of it. New reports today say the “secret waiting lists” aren't just an accusation, but a reality. And, the Inspector General says it's “systemic.”
Bad Systems, Not Bad Apples
Many people react by wanting to punish those who cheated the system.
I reacted differently — thinking about the leaders who created the targets, the bonuses, and the fear.
This, from the beginning, smelled like a systemic problem and it's not solved by punishing individuals who acted quite rationally… their bosses wanted things to look good (I'm guessing), so the local leaders made things look good. The VA in Phoenix reports “fictitious” numbers to DC and everybody is happy… except for the veterans who are waiting for care.
More evidence of this “gaming” being a systemic problem are the allegations of different types of cheating at different VA sites and cities across the country. There isn't just a “bad apple” or two in Phoenix.
Other cases and allegations keep piling up (there might be more, it's hard to keep up – at least 26 sites are under investigation):
- Doctor says Temple (Texas) VA manipulated waiting lists
- Exclusive: VA Scandal Hits New Hospital (Albuquerque)
- VA clinic employee on leave after e-mail about manipulating appointments (Wyoming)
- Exclusive: Texas VA Run Like a ‘Crime Syndicate,' Whistleblower Says
The fact that the same “gaming” behavior is taking place in multiple cities. We have secret off-the-books waiting lists. We have patients being intentionally guided toward appointment dates that are available instead of what was truly requested (artificially pushing back the patient's “requested” date to what's actually available) making the numbers look better – closing the gap between “requested” and “scheduled” to within 14 days.
The gaming taking place in MULTIPLE locations only emphasizes how systemic the problem is. We don't have uniquely ruthless or horrible managers in these different cities. Again, they are acting rationally by cheating in the face of pressure to hit unachievable targets. I've seen people “game the numbers” in different businesses (including GM)… the people doing this usually realize it's wrong, but they rationalize it in some way (including saying, “well, that's what the boss wants”).
The Core Scandal is the Long Waiting Times
To me, the real scandal is that it takes so long for vets to get the care they need… and these delays can be deadly (for one man and at least 23, in total). 1,700 patients in Phoenix were waiting up to 115 days instead of getting treatment within 14 days (the usual target / goal). There are real human costs to this and that shouldn't be forgotten.
This whole thing shouldn't be a partisan issue. I was complaining about systematic VA delays back in 2007, under the George W. Bush administration. Then-candidate Barack Obama complained about it too.
Therefore, it's not a new issue. The current leadership, including VA Secretary Eric Shinseki has known about this problem (of long wait times) for years. What has been done? Not enough, apparently. Do you blame Secretary Eric Shinseki? Do you blame President Obama? Do you blame the Republican Congress?
Again, long VA waiting times of various sorts are NOT a new problem, as I've blogged about before, including these posts:
- We STILL Need to Reduce Waiting Times for Veterans
- These Wounded Soldiers Need Lean To Get Their Benefits?
- Honoring Our Troops with Better Service through Lean
The Obama-Biden transition team was specifically warned NOT to trust the VA waiting time data:
Veterans Affairs officials warned the Obama-Biden transition team in the weeks after the 2008 presidential election that the department shouldn't trust the wait times that its facilities were reporting.
“This is not only a data integrity issue in which [Veterans Health Administration] reports unreliable performance data; it affects quality of care by delaying — and potentially denying — deserving veterans timely care,” the officials wrote…
In particular, the 2008 transition report referred to a VA inspector general recommendation to test the accuracy of reported waiting times…
“Audits of outpatient scheduling and patient waiting times completed since 2005 have identified noncompliance with the policies and procedures for scheduling, inaccurate reporting of patient waiting times and errors in [electronic waiting lists],” the briefing papers state…
The briefing materials do not reveal any concerns about outright fraud in manipulating waiting times, but they make repeated references in summarizing past audits and reviews about data accuracy.
Well, I guess it has turned out to be fraud.
Choices to Make When Demand Exceeds Capacity
As a hospital leader, you're given a target of “14 days” for waiting times. You're told that your annual bonus and future promotions depend on hitting those targets. What do you do?
It's important to keep in mind that demand for VA treatment has increased dramatically in the past decade.
From 2002 to 2012, the VA handled a steady increase in outpatient visits, from 46.5 million annually to 83.6 million. The number of veterans receiving mental health treatment grew from less than 900,000 in 2006 to more than 1.2 million in 2012. The 1 million new disability claims filed in 2009 were an all-time high, until 2010 and 2011, when new records were set.
Spending up “using 2011 dollars, America spent $88.8 billion on the VA in 2007, and $125.3 billion on the VA in 2012.”
But has it been enough?
If spending would have to increase proportionally to volume/demand (probably not a good assumption), we had a 44% increase in outpatient visits and a 29% increase in spending. Was that enough to keep up? Was the VA already under capacity before these wars started?
Update (from the previous VA Secretary):
The VA's budget has more than tripled, to $154 billion in 2014 from $49 billion in 2001, the year I became secretary. In that time, the veteran population has declined to 21.9 million from 25.5 million.
So maybe “lack of spending” isn't the problem and wouldn't be the solution?
If you're a manager of a VA facility and you see that the number of appointment requests is greater than your capacity, you have some choices and you can:
- Figure out how to increase capacity and throughput (perhaps, using Lean) without spending more: Possible, but moderately difficult?
- Ask for additional spending: Unlikely and pretty impossible?
- Cheat the system and make things LOOK better: Possible, and fairly easy?
Too many local leaders chose to fudge the numbers by creating secret waiting lists and the like.
As Brian Joiner wrote in his outstanding book Fourth Generation Management: The New Business Consciousness, there are three things that can happen when you have a quota or a target:
- Distort the system
- Distort the numbers
- Improve the system
It seems like there was too much focus on #1 and #2 at VA locations.
When top leadership sets up measures and just accepts what's reported at face value… inviting and REWARDING gaming of the system, that's the fault of top leadership for being naive and for not helping fix the real problems (the lack of capacity and long waiting times).
It would have been a better countermeasure to speak up and ask for help, since the VA is allowed by law to pay for private healthcare for veterans (and spends 9 to 10% of its budget on this). That's been one “short-term countermeasure” recently – putting more focus on outside resources – but it's a shame that it took a national embarrassment for this to occur.
Who Do We “Hold Accountable?”
When there's anger and top leaders are “mad as hell,” people want “accountability.” It's a good start (but not enough) for leaders to be mad about bad performance… this anger can lead to improvement. But, if the anger just leads to scapegoating and punishment (such as throwing individuals “under the bus”) then, that's not as good. I put the term “accountability” in quotes because it's a very loaded to term. In this day and age (and this is true in many private hospitals), accountability means blame and punishment. Punishing individuals doesn't address the underlying systemic issue.
As Dr. Lucian Leape, one of the fathers of the modern patient safety movement says:
We need to quit blaming and punishing people when they make mistakes and recognize that errors are symptoms of a system that's not working right, and go figure that out and change the system so no one will make that error again, hopefully. We have to change the culture, so everyone feels safety is his or her responsibility, and identifies hazards before someone gets hurt.
I think that applies to more than safety – it applies to nearly every other performance management issue.
Earlier in the investigation, President Obama said:
“I know that people are angry and want swift reckoning. I sympathize with that. But we have to let the investigators do their job and get to the bottom of what happened. Our veterans deserve to know the facts. Their families deserve to know the facts. Once we know the facts, I assure you if there is misconduct it will be punished,” the president said.
So who do you punish? People at individual VA locations? I'd argue that if you're going to punish anybody, it's those responsible for the design of the system. Who set the targets and who set up the bonus incentives? Who didn't create an environment where local leaders could speak up? This probably goes up pretty high to the top, close to if not to Secretary Shinseki. That's why there are bi-partisan calls for Shinseki to resign. I'd call for that too, if anybody cared.
Today, President Obama doubled down on accountability, saying:
Anybody found to have manipulated or falsified Veterans Affairs records “will be held accountable,” President Obama said Wednesday…
Speaking about reports of long wait times — and efforts to cover up the delays — Obama said that if they're proven true, the behavior is “dishonorable” and “disgraceful.”
“I will not stand for it,” Obama said. “None of us should.”
This means punishment of lower level people:
“…he also noted that some employees had already been put on administrative leave.”
Again, I think that's not the right approach. Gaming the numbers might not have been a high-integrity move or was it the bravest thing to do… but when people's bonuses and paychecks are at stake, I understand why most of the local leaders and doctors went along with the ruse.
It's tempting for Shinseki to deflect responsibility by blaming those below him in the chain of command:
“Earlier this month, Shinseki told NPR's Robert Siegel that he would “take swift and appropriate action” if reports that the Phoenix Veterans Affairs Health Care system kept two lists of veterans waiting for care – one for sharing with Washington and another showing wait times that sometimes reached beyond a year — were substantiated.”
He's pointing to a problem in PHOENIX, when it's more broader and more systemic than that.
So What Now?
What do you think of the government's problem solving and corrective action plans so far? Are you optimistic that things will be truly fixed or will we just see more “naming, blaming, and shaming” that doesn't get to any root causes?
Will a scapegoat be named? Will it be Shinseki? Will it matter?
I think the more important questions with longer-lasting impact are:
- How will we increase capacity and throughput to get REAL waiting times down, providing better care?
- What sort of systemic changes will be made regarding targets, performance evaluation, bonuses, and the such?
How do we REALLY fix this?
Note: As new information comes in, I'll post comments instead of editing the post…
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Comment from a military medicine leader via LinkedIn:
My response:
Maybe we take that VA care for granted… But progress is made by focusing on problems and fixing them. Hang in there, veterans who are waiting for care… I’m on your side.
But, again, I’m not blaming or disparaging individuals at the front-lines of the VA… it’s a leadership problem.
From Linkedin:
My response:
Agreed… remove the 14-day target, remove the performance-based incentives, and allow people to focus on 1) patient care and 2) real system improvement. We should be measuring the tracking the waiting times… but use that data for improvement, not for rewards and punishment.
Completely agree. First focus on the system, the systemic problem, protect the customer, and improve the outcome and value to the customer. Short-term that may be leveraging other private facilities, which are now also under unprecedented demand due to a combination of millions more with insurance (a good thing) and a rapid rise in doc retirements.
But there does need to be accountability, and as you said with a couple exceptions the rhetoric seems to unfortunately point to lower level folks who are simply responding to the leadership paradigm they operate in. Yes the system system is the problem, but leaders are expected to lead, to recognize problems, and to improve. Recognizing problems isn’t a hard task when others are already telling you, in 2008 in this case, that a problem exists.
As much as I respect Shinseki for his other accomplishments, he should have grabbed onto that nugget of information, recognized its potential impact on his customers, dug into it, and raised holy hell to fix it. That was his job. Not doing so by him, and his senior staff and even his own bosses, is a failure of leadership. Expecting a different leadership outcome by the same leader in the future just because more scrutiny is applied from the outside is not realistic (I dare say it meets the definition of insanity), and that’s why senior leaders should sometimes “leave” – even when the problem is with the system.
This is an unbelievably sad story. The VA was once held up as a model of government-run single payer healthcare. Whether there’s a lesson in that is a story for another day. Let’s protect the customer first.
Amen. That was Shinseki’s job… come in with fresh eyes (and a new President) and be “mad as hell” publicly to help get things fixed. Being “mad as hell” now… that’s too little, too late.
If the problem is “the system,” Deming said that responsibility for the system lies with senior leadership — those who set targets, set up bonus systems, make decisions on pay increases and promotion, etc. They are the ones who created this very predictable mess.
Again from LinkedIn:
My response:
There are a few problems:
1) Demand for care exceeding supply and capacity. That must be fixed.
2) The targets/incentives/bonus structure…
New leadership (a new boss) and the same system will just lead to more clever forms of cheating and gaming the numbers.
Again from LinkedIn:
My response:
It’s hard to ask people to “do the right thing” when their paycheck (or pay increase or bonus or promotion) is at stake. I bet most of the employees and local managers knew this cheating was bad, but they were pressured to do it. What was their alternative? Quit?
This is an excellent overview. If you get a chance, watch the opening scenes of the Robert Redford movie “Brubaker” where Redford as the incoming Warden concealed his identity to view his facility as a prisoner in order to obtain a direct view of the chaos and corruption. VA should randomly select patients and employees to provide first-hand testimonials of “day-in-the-life” events which would counteract the effects of administrative and reporting fraud.
I’ll have to check that movie out. There’s no substitute for going to see for yourself. Even if the data look good, it’s worth going to confirm the process and HOW those results are being achieved…
I believe Medicare has “mystery shoppers” who try to look for fraud and abuse. I wonder if something similar would help…
In Lean jargon, this could be categorized as “going to the Gemba”. The response by VA leadership of astonishment and indignation is really pathetic. I am reminded of another classic movie, Casablanca, where the Police Captain expresses that he is “shocked, SHOCKED, to find there is gambling on the premises” immediately before he collects his roulette winnings.
Some quotes from Dr. W. Edwards Deming that are still relevant today:
Quotes from Out of the Crisis
and
and
The real tragedy is that, much like the GM scandal, they knew about the flaws over ten years ago. Here is a sample news release from February 7, 2000. Without the date, it would be difficult to realize that it is not a current press release.
http://www.va.gov/opa/pressrel/pressrelease.cfm?id=181
Why do we think making more scapegoats or giving them more money would make any difference in the long run?
Thanks for sharing that. The “gaming” has been known about for a long time… maybe not as far back as 2000.
The issue of always asking for more money. I’d be the first to argue that “more money” is not always the answer (nor the best answer) to most problems. But, I’d expect that, with a 44% increase in demand for appointments, that spending would have to increase and that “record” budgets might very well be necessarily.
As is true in the private sector, the cost of healthcare goes up constantly (and goes up too much, due to the waste and bad processes). And, the number of vets goes up.
More money might create more capacity (more doctors, more space, more equipment), but the government and the VA should first use Lean to make the best use of the resources they already have.
Creating scapegoats, even Secretary Shinseki, won’t really help too much without changing the way the system works.
I’m going to try to read the Inspector General report (Summary and full report PDF link), but this snippet is from CNN;
It’s more clearly said in the IG summary:
How bad do you have to be for allegations like that to be coming in DAILY about Phoenix?
Here is a chart I made from the Inspector General Report showing the impact of the “gaming” and data falsification:
I heard a commentator on NPR ask a basic question: Isn’t it wasteful for the VA to have a duplicate, separate healthcare infrastructure? He mentioned that vets can obtain civilian healthcare through Tricare, a DoD program. Plus if they are old enough, they can choose Medicare.
So why are we investing in a separate, duplicate VA healthcare infrastructure (hospitals, staff, processes, bureaucracy) rather than offering vets benefits through the existing healthcare industry?
The same commentator mentioned that that’s the model typically used in Europe for their vets (not verified by me, and I don’t know if that’s working any better).
I don’t know the answers, but I’ve heard two similar questions about overlap and necessity:
1) Why are there separate problems for active duty military and for vets? They’ve had trouble coordinating care and medical records.
2) Should VA care be limited only to specialized care that relates specification to injuries (and not every health condition)? Here in San Antonio, there is very specialized and advanced care for soldiers who have lost limb(s) and/or have suffered severe burns. I can see the argument for keeping specialized research and care, but understand the questions about why somebody can get a hearing aid from the VA instead of a voucher and privately-contracted care… or even something more like a Medicare model for vets?
I have a more fundamental question; why are public employees paid bonuses? Bonuses come from profit, when you are an expense [ a necessary one perhaps ] you don’t get a bonus.
It’s easy to us all to point fingers as to who to blame at the VA, suggest how to punish them, or to offer opinions how to resolve a bureaucracy that doesn’t want to be and cannot be fixed.
Sure you may think you did something by voicing your brilliant ideas, but at the end of the day it does nothing and the Veterans still go on suffering, needlessly.
So as usual we’ll all move on with our busy lives and soon forget that there ever was a problem.
Isn’t that the American way?
But let us not forget, that we are not just talking about fellow human beings, but rather fellow Americans who sacrificed their lives, lost their limbs and in many cases a whole lot more, just so you and I can enjoy the freedom we have today.
There is a simple solution that will help the Veterans, but I doubt that one single person out there will take me up on it!
It’s easy… Now is the time for us “ALL” to give back to our solders!
Everyone here is in a professional field, and many are in medical professions.
Here’s a novel idea…
People helping people. That’s people (You) to help people (Veterans).
It starts with one (me) then two (you), four (others) eight and so on.
It is limitless!
I propose that we in the medical profession offer complimentary services to our vets.
Myself, I have been in the hearing aid business for over 37 years. I am willing to provide a complimentary service to all South Florida vets, and welcome them here for services on their hearing aids that have been provided by the V.A. rather than wait six months for an appointment.
This won’t cost me a penny, just time. And yes, I am willing to work longer hours without being compensated in order to do something about the problem other than just talking about it.
So the question is, who else is willing to join in?
Or are you all just talk?!
Contact me, let’s get something started and keep the ball rolling.
Roy Binder
earman@bellsouth.net
More evidence that “gaming the numbers” is a broad management problem, we have these reports from the UK:
Police officers despise fiddling crime statistics, says expert
Criminologist says many officers in England and Wales scandalised by widespread manipulation of figures
[…] can lead to all sorts of problems. See the examples of the NHS emergency departments and the VA waiting time scandals for examples of people “fudging the numbers” or “gaming the system” instead […]
[…] The Real #VAscandal is the Long Waiting Times & Bad Management, Not Gaming by Bad Apples […]
[…] The Real #VAscandal is the Long Waiting Times & Bad Management, Not Gaming by Bad Apples […]
[…] of 14 days waiting time for appointments that the Office of the Inspector General called “unrealistic.” Hence, the cheating and gaming […]