The current Department of Veterans Affairs crisis at its core is about corruption and malfeasance that has obstructed the health care of veterans. The crisis has illuminated critical issues including access to initial care, administrative bonuses, and harsh, reactive punishment for those who try to speak up for patient care.
The crisis actually involves the entire structure of VA health care. Recent Congressional hearings reveal systemic lack of accountability, no functional oversight, no transparency, and seeming “diplomatic immunity” for management misconduct.
The VA and Congress have long track records of responding to crises with action plans, and millions of dollars, before gaining credible understanding of the problem. A 2011 study in the Annals of Internal Medicine found that the culture of an organization is the greatest determinant of patient care outcomes. And VA culture is precisely where the new secretary should focus attention. Responsibility for wrongdoing lies in the hearts and minds of individual VA managers, and in a pathologic organizational culture.
The VA has witnessed the institutionalization of a criminogenic culture characterized by:
1. Increasingly flexible ethics (public abuse of employees, threats, and intimidation by leadership as accepted practice).
2. Rewards for those who go along and don’t identify problems.
3. Hostility and or punishment toward those who identify problems, driving individuals out of the organization through intimidation, threats, humiliation, professional isolation and withdrawal of organizational support.
Four years ago, in 2010, having concerns of patient safety, unethical leadership practices and problems with delay and access to care, I contacted the Office of the Inspector General (OIG) asserting that the VA had become a “criminogenic organization.” My concerns were simply dismissed.
Many exceptional employees work for the VA Roseburg Healthcare System. Yet more than 50 providers, seven chiefs of staff and two mental health chiefs have left in the past few years. These facts alone adversely affect patient care.
In healthy organizations, those who voice concerns are valued as “early warning systems” for emerging patient care problems. In the VA, those who step forward have nowhere to go. Many have tried to speak up, go up the chain of command, contact congressmen, and, in final desperation, as it is a career death knoll, contact the OIG. Avenues of reporting have been rabbit trails to nowhere.
An independent forensic organizational investigation is needed to reveal the complexity of problems within the VA. For veterans, getting the first appointment is but a single barrier in the labyrinth-like system of care.
Despite warnings last week from the Office of Special Counsel, the VA continues to investigate itself. Congress is tacitly supporting this self-monitoring poised with billions more to be administered by individuals responsible for current wrongdoings.
Those directly responsible for orchestrating existing problems are still in charge at the facilities and regional sites — still exacting fear and suppression. Unless administrators involved in manipulations of resources, safety, quality or barriers to patient care are removed, there will be no substantive change in culture.
The VA is not alone in its administrative criminogenic behavior, but there is something particularly shameful about exacting unnecessary misery and death on our veterans. I would like to believe we are a better country than demonstrated by what the VA currently affords to our veterans.
General Motors and NASA’s space shuttle disaster similarly provide sentinel organizational lessons to heed. Paraphrasing recent congressional hearings on General Motors’ faulty ignition systems: “GM has demonstrated lack of accountability, lack of urgency, and lack of safety to do the job ... and if you haven’t changed the people — you haven’t changed the culture.” Might Congress also extend this analysis to the VA? And do we remember the NASA experience? Numerous middle managers were silenced or ignored as they actively raised concerns of impending disaster — then the astronauts died. The same has occurred in the VA.
We now know hundreds of thousands of veterans have not received timely care — in some cases no care. Did employees know about these manipulations? Yes, we knew something. We knew we had no forum to discuss critical clinical care issues; we knew clinical structures of the system had been hijacked to lie, distort, deny and destroy records and reports “to meet performance measures” linked to senior leadership bonuses; and we knew that patient care has been adversely affected in recent years.
Do veterans die in the VA because of this? Yes. Do veterans suffer needlessly? Yes. Did those who speak up and try to unveil the wrongdoing pay a price? You bet they did, and still do.
To stay focused on providing veterans health care will require acknowledging the systemic mismanagement of problems within the VA, holding those accountable for egregious behavior and including veterans as key stakeholders in all decisions for comprehensive change. Veteran trust will only come through collaboration, inclusion and transparency. The goal must be functional health care for veterans.
Marcia Hall of Umpqua is a 17-year employee of the Department of Veterans Affairs in Roseburg. She has worked in both direct patient care and middle management. She can be reached at firstname.lastname@example.org.