A single silver lining in the Department of Veterans Affairs' health-care scandal may be the teaching moment the disclosure of the agency's failures has provided. Thoughtful public managers at all levels of government are pausing to reflect and consider how -- or if -- such a pattern of poor performance, cover-up and mistreatment of whistleblowers could happen in their agencies. My experience suggests that under the wrong conditions, any public agency can slide into habits that treat those it serves with indifference and find ways to falsely claim competence and success.
The appointment of a new veterans' affairs secretary from a corporation with a textbook reputation for inculcating a culture of high performance, competence and customer service is a good first step. Yet Proctor & Gamble's disciplined corporate culture was built over decades and is sustained by selecting, mentoring and promoting leaders at all levels who have internalized that culture.
VA reformers face a much more complex problem. Few would dispute that the huge agency is rife with resistance to change, and even veterans' service organizations disagree on solutions, with some focusing on fixing the problems within VA-operated systems and others advocating greater reliance on private-sector health services. But if the reform effort allows itself to be drawn into an ideological fight between public and private service models, reform will stall out. A lesson in point is the education-reform movement, in which charter-school competition has generally failed to stimulate overall public-school improvement. The risk for the VA is that the fight will be over who delivers services, not what quality of service veterans receive.
For eight years, my public-management responsibilities included two statewide care-delivery systems, for people with behavioral health challenges and for those with developmental disabilities. Both systems provided institutional and community-based care. Both provided our executive team with unwanted teaching moments -- when individuals died in our care, staff practices fell far below contemporary standards of care, and resistance to change jeopardized the progress of individuals who deserved much better than we were offering. In addressing these acute instances of system failure, we learned what chronic conditions underlay them and what strategies were likely to succeed in changing our systems.
Among the chronic, underlying circumstances of big institutions or systems is that they tend to be opaque to outsiders. Absent a strong leadership focused on mission, that opacity leaves ample opportunity for the institution to be run for the convenience and benefit of its employees. (A staff person at one developmental center explained to me that they turned out the center's Christmas lights at 5:30 "because that's when the staff leave.") The VA story illustrates that top-down metrics, with strong incentives for good results but little validation, are a recipe for disaster.
A second chronic, reflexive characteristic is the unwillingness of leadership in many institutions to be honest about compounding problems and limited resources. Similar to the VA system, our developmental centers once primarily served people with moderate disabilities, because so few survived infancy. When the centers and the care system saw rising numbers of individuals with complex, challenging disabilities, care quality fell because few wanted to acknowledge the need for staffing and competencies to care for them until, as an executive who led the expansion of community-based care remarked, "the institutions blew up."
The pivotal starting point for change must be a recognition and affirmation of mission. Many other challenged institutions have learned that "person-centered" orientation is key -- that is, evaluating performance from the perspective of the consumer/patient. If one measures process but doesn't ask about patient experiences, the metrics are incomplete. Had every vet who contacted the VA for an appointment been asked to describe his or her experience in securing an appointment, seeing a doctor promptly as promised, and receiving follow-up care, can we imagine the VA routinely falsifying records to cover up reality?
If the mission of the VA is to provide timely, convenient, quality care to veterans, why did it take a scandal for it to be noticed that only 2 percent of veterans living full-time on Nantucket were using VA services? Operating the system trumped guaranteeing care for vets, so an alternative delivery vehicle (the local hospital) wasn't seen as an efficient way to reach them.
Sadly, the Nantucket story is not an isolated one for the VA. Reforming the agency -- or any similarly troubled public institution -- will require clarifying the mission, building metrics around those goals and finding leaders capable of adapting to new challenges. Courage, disruption and steel nerves will be needed. Remember that if there is not a lot of screaming, nothing is really changing.