At the end of May, after a series of exposés and congressional hearings, General Eric Shinseki, was pressured to resign as Secretary of the Department of Veterans’ Affairs. The major reason for his departure was that the department, including up to 1,700 potential sites of care, couldn’t see Veterans in a timely manner. These problems have been known to the VA, including some misreporting of wait times, since at least 2005 (OIG Report of 5/28/2014). At some time a program was instituted to incentivize the CEOs of individual VA facilities to create a culture of rapid response to a request for an appointment. If appointments were reported to be available, the CEO and staffs could receive a financial incentive. It should not come as a surprise then that intelligent people who were trained in a business model were able to find a way to “hide” the fact that many veterans (1,700 in Phoenix alone) were not getting appointments within 2-3 weeks of a request. A “ghost” waiting list was kept at in least two hospitals (Phoenix, Arizona, and Hines, IL – interestingly one common thread between those hospitals is that the CEO was the same person – first at Hines (Feb. 2010-2012) & then at Phoenix (2012-2014)). This CEO is reported to have received at least one significant financial reward for what appears to be misreporting results of her administration. This is almost a perverted application of the concept “you get what you pay for or what you measure”.
If Gen. Shinseki’s transgression was that patients were not being seen promptly, it might be that he believed what he was being told. General Shinseki certainly understood leadership. He had participated in writing a book (Be, Know, Do: Leadership the Army way). He certainly was aware that more junior military officers were supervised and mentored to ensure that they understood ethics, how to adjust to stress and how to adjust to try to achieve commander’s intent. There are multiple data/opinions (from the lay press, but buttressed by data from at least the Harvard Business School and Northwestern’s Kellogg School of Management among others) suggesting that, in many business settings, CEOs with Military Experience tend to be highly ethical and generally able to lead civilian organizations to success. The bureaucratic leaders that Shinseki inherited in the DVA didn’t seem to embrace this ethical culture. He observed, “I can’t explain the lack of integrity among some (italics are mine) of the leaders of our healthcare facilities. This is something I rarely encountered in 38 years in uniform.” In addition one might question whether the employees that staff the VA system understand/understood the overall mission and goals of the VA system – VA is committed to developing a culture that is advanced, forward-thinking and completely Veteran-focused.
We might take as a lesson that in large organizations new leaders might entertain a healthy degree of skepticism relating to the ongoing conduct of the staff. General Shinseki certainly knew about leading by walking about – being visible to his subordinates and reinforcing the message of the mission. If he had been aware of the problem of having veterans seen promptly, could he have been able to convince his superiors (congressional committees) to increase funding for the VA for more providers? About 3 years ago, I volunteered to help in the clinics at a local VA hospital outpatient department. I was told that there was no need for more physician coverage. In retrospect, I doubt that. There may have been no budget for more physician coverage, but they might have accepted volunteer physician help.
Dealing with a civilian bureaucracy, with trade unions representing much of the workforce was certainly something that military training may not have prepared a CEO to handle. This structure would have made it more difficult to reprimand recalcitrant staff than it would have been in the army. However, I would hope that a military leader could emulate General Marshall who is reputed to have taken ineffective commanders out of their role, and then give them a second chance to acquire the skills to subsequently become a real leader. This would seem to be a better way to help a subordinate grow than simply removing or firing someone. Those working within the framework of a second chance may be more motivated to embrace and encourage a culture that we are looking toward. There are suggestions that ongoing culture and competence training of VA intake or appointment staff wasn’t continued. Many effective organizations (Mayo clinic for example) have ongoing culture classes for all levels of the organization. In addition, a very clear, but simple set of values and expected behaviors that is promulgated prominently throughout the organization should help improve honesty (Dan Ariely in “Predictably Irrational” (2008) showed that this type of nudge can influence behavior)
Could the VA scandal have been prevented? – In all likelihood yes. Would it have been easy to prevent? – No. How did it happen in an organization that was thought to be amongst the best in the late 1990’s? The most likely answer to that question is that someone took her/his foot off the gas that had kept ongoing training and culture intact and allowed the system to sink back into mediocrity. The new leadership didn’t go back to the beginning to ensure that meritocracy resurfaced.