Despite a growing number of public officials calling for his resignation in light of a new Inspector General’s report on the dramatically longer wait times in a Phoenix hospital than what they were reporting, General Eric Shinseki is not the problem at the Veteran’s Administration (VA). The calls for him to be fired seem to be from those want a quick and simple solution to what is a much deeper problem. Firing someone, anyone, appears to be “doing something,” whether or not it will help or hurt the search for a solution.
Given the general’s history and capability, he has actually made many things much better at the VA during his term of office. Forcing him out now is likely to make the situation at the VA worse — not better — as there will be no one in place for some time to actually take charge to fix the problem. A new secretary, even after the staggeringly long time it would take for nomination and confirmation, will take months more to learn who is who in the department: who is trustworthy, who is or is not competent, and which systems are the root cause of the problems. No one gets four stars without being extraordinarily capable; thus Shinseki may actually be the best person to identify the sources of the problems and to get them fixed.
The fundamental problems at the VA are systemic and not individual, though some individuals undoubtedly did very bad things. In large organizations, it is systems that drive behavior. No one individual, even a cabinet secretary, can dictate systemic behavior to such a degree.
In the case of the disinformation about waiting times at VA hospitals, there was a system in place that set a standard that no wait time should be longer than 14 days. There was also an individual performance review system that would be affected positively with more money or promotions for meeting the standard, and negatively for missing the standard.
There were other systems in place regarding resources – personnel, facilities, financial, and computing systems – that apparently made it impossible to meet this lofty wait time standard. If you don’t have enough psychologists to treat veterans with PTSD, for example, it is impossible to make an appointment for them when no service is available. There may also have been sheer incompetence at some facilities, but it is important to eliminate the systemic problems before assuming incompetence or malfeasance.
When individuals work within a system where there is no possibility of meeting the standard due to circumstances beyond their control, they have essentially three options: Work to improve or fix the system, distort the system, or distort the data.
The VA systems are undoubtedly created at headquarters, and many may have simply evolved over time rather than being carefully designed. The incompatibility of the military records system and the VA records system is a well-known problem that has yet to be fixed. Some of the wait times are clearly based on the problem of incompatible paper work, which should be electronic, not paper.
For people in the VA hospitals, there would be little or no opportunity to fix the system. Thus they distorted the system through various gaming devices, for example, setting up fake appointments and never telling the patient, so it look like they met the time frame. Then the appointment would be “cancelled” and could be set up again to appear as if it were timely. Others were kept out of the computerized wait-list altogether.
The AP reports that the VA headquarters has been aware of the problem for a number of years, though the extent of the problem may have been kept from the Secretary. A 2010 memo from William Schoenhard, then the VA’s deputy under-secretary for health operations and management, reported on some of ways the system was being gamed. Shoenhard ordered the practices to be stopped and instructed managers on how to detect them. In the memo he stated, “Please be cautioned . . . additional new or modified gaming strategies may have emerged, so do not consider this list a full description of all current possibilities of . . . practices that need to be addressed.”
Given that people in the system were unable to meet the standards, the underlying cause of the gaming, this memo was worse than useless. It did not address the underlying problem of why this gaming was occurring. What were the real problems that made the wait times so long? Why were people afraid to come forward and expose the problems? No Secretary or chief executive can fix a problem they don’t know exists.
In addition, there apparently was inadequate knowledge of how to design effective systems including the key components that must be in place if the organization is to operate effectively. Systems design is a more complex process than is commonly recognized, but the three main components are.
The system should have had a clear purpose, a statement of what the system is supposed to achieve. Clear statements of authority let those who must operate the system know who has the authority to do what. Authority within a system is a statement of what an individual may do, within what limits and carries with it the accountability for exercising proper judgment in doing it.
The system should have controls in place. These may be created from data streams that are checked automatically with anomalies noted for further check by a manager or designated person. More often a person’s manager checks for critical information on how the system is functioning and how people are exercising judgment and accomplishing (or failing to accomplish) their work. For example, checking on the wait times to get medical care should have been monitored to verify the system is being used correctly, to identify problems as they arose and to check on the quality of the decisions of the authorized person who is working within the system.
Putting an audit system in place, or a check by a manager above the level of the manager who is responsible for the control function. The audit is to check that the system is being used, that the controls are in place and being used correctly and to identify whether or not the system is doing what it was intended to do in the most effective and efficient way feasible. (Others, such as accountants, may carry out the mechanics of the audit, but the decision on audit is made by the manager above the manager responsible for control, or in government at an even higher authority.)
Most often the audit function is omitted when designing a system, thus inadequate or even harmful systems are allowed to continue hurting not only agency clients but also the employees who struggle with inadequate direction, authorities, resources, etc.
The Schoenhard memo apparently did not clarify the authorities and limits on those authorities in order to achieve the purpose – wait times that met the required standard. He did tell managers to check on potential gaming of the system, but with no sense that there were (and are) problems with the system itself. From spending time with some VA employees, I am sure most of them would like to do their jobs well and serve the veterans who are their clients to the best of their ability. Gaming a system is a clear indicator of a flawed system.
Most importantly, there was no audit function in place, nor was there any indication the Schoenhard recognized the need for one. With the information we have today, it is clear the system to reduce wait times was not working. In addition, it appears that managers were not acting as controls. Finally, there was no audit that would have demonstrated quickly that the system was not achieving its purpose and that the controls were not functioning.
Given the perceived need to distort and lie about the system, it is likely that managers and higher level administrators were encouraging this practice. Their performance reviews depended upon it, and they did not want to alert Congress to the real problems they were facing. It is likely there was extreme pressure not to reveal problems, and real or implied threats of punishment for those who did. The hospital administrators who allowed, or encouraged such practices should be removed as they lacked the integrity and courage to confront the real problems and to notify those above them as to why they could not meet the standards.
Now that the problems are visible, let Shinseki and others investigate the real causes of the wait times and fix what is clearly a broken system.
Catherine G. Burke is an associate professor emerita of public administration at the University of Southern California’s Price School of Public Policy. She is the co-author of Systems Leadership: Creating Positive Organizations.
