“Who’s right?” “What’s wrong?” These questions reflect a constructive approach to problem solving. “Who’s right?” suggests that instead of finding someone to blame, you identify people who have taken steps to make things better.
“What’s wrong?” puts the focus on analyzing the problem. A chief executive officer of a very successful company became a multimillionaire with these questions as a key part of his management approach.
In looking for “Who’s right?” with Veterans Affairs, two people come to my mind: Eric Shinseki and Dr. Chip Taylor.
Mr. Shinseki, former VA secretary, gave a phenomenal gift to the nation’s veterans when he changed the rules for qualifying for post-traumatic stress disorder disability income. He declared that proving one was in a war zone was an adequate prerequisite to consider that one might have PTSD from military service.
For many years before this change in policy, I saw veterans denied a service-connected disability for PTSD because good paperwork was not kept in the midst of the chaos of war.
Dr. Taylor, chief of staff at the Roseburg VA, came to find me late one afternoon, because he was taking great care to handle a sensitive situation involving a veteran in my care in the best possible way.
It was after 4:30 p.m., so the Mental Health Clinic where I work was closed. I was not in my office because I was leading a group. Dr. Taylor had to go to a lot of trouble to find me. In my 20-plus years in the VA, I never had a person in the top leadership of a hospital personally seek me out to be sure a decision was made that would provide the best possible outcome for a veteran!
Dr. Taylor is one of those persons who is making a very positive impact.
“Who’s right?” makes me also think about the report, “Results of Access Audit Conducted May 12, 2014, through June 3, 2014” (www.va.gov/health/docs/VAAccessAuditFindingsReport.pdf). It represents a scientifically respectable piece of research that was done to get at the truth about the extent of deceit in VA wait time statistics. Amazingly, it was completed in 21 days.
It was a Herculean task to visit over 700 facilities that included 140 medical centers and more than 550 large community-based outpatient clinics. Face-to-face interviews were done with scheduling clerks at each facility. Each interview was about 45 minutes long. The people were randomly selected and their names were not revealed until the audit team had arrived at the local VA. In total, 3,772 interviews were conducted.
Overall, 13 percent of scheduling staff interviewed indicated they received instruction from supervisors or others to do things that would make the access data look better than it was. At least one instance of such practices was identified in 76 percent of VA facilities.
I found two of the major conclusions reached by the audit to be especially noteworthy. I have translated these into common language:
1. VA leadership really screwed up when it put money into the pockets of administrators if new patients were seen within two weeks, and it was obvious that there were not enough primary care providers to do this.
2. There is a serious problem with the VA’s moral compass, and we must figure out how to cure the widespread assumption that cheating is OK.
The Access Audit report demonstrates that there are still good people in VA Central Office who choose to act with impressive integrity to expose VA shortcomings.
“What’s wrong?” turns my attention to the organizational structure of the VA. What we have now is a psychotic bureaucracy: Leaders are too often out of touch with the daily realities of providing good care. When inaccurate assumptions replace reality, you have insanity. VACO personnel use literally several hundred statistics to measure the quality of service throughout the VA system. This seemingly good idea can go very wrong.
When managers and clinicians take care to meet various standards, there is not enough time to listen to all of the patient’s concerns and respond to them.
A perfect example of this kind of craziness is that VACO improved access to care in mental health by reducing the quality of care. Before the current crisis of integrity, VACO ordered that the first appointment with patients be reduced from 90 minutes to 60 minutes.
Time to adequately assess a patient’s mental health problems was taken away. Instead of adding more clinicians to reduce wait lists, patients’ time with providers was diminished.
If veterans and Congress are really serious about fixing the VA, they will demand that decades of research on healthy organizations be used to radically restructure the VA. The nature of an institution is like garden soil. If it is healthy it will grow great things.
If the soil is poor, the harvest will be very disappointing.
John R. “Jack” Finney, Ph.D., of Roseburg is a clinical psychologist who has worked for the Roseburg Veterans Affairs Medical Center for more than 20 years. He’s also an ordained Presbyterian minister.