By Rose O. Sherman, EdD, RN, FAAN
Knowing that I spent 25 years in nursing leadership with the Department of Veterans Affairs, many of my colleagues are interested in my thoughts about the current scandals involving wait times, cover-ups and performance bonuses. For a number of years now, I have heard my former colleagues talk about the challenges in meeting the growing demand for patient services with reduced or flat budgets, aging facilities and the addition of 6.8 veterans from Iraq and Afghanistan who are eligible for care. The problems were compounded by flaws in leadership and trust that were recently well documented in a New England Journal of Medicine Perspectives piece written by Dr. Ken Kizer (a former Undersecretary for VA Healthcare) and Dr. Ashish Jha, a Boston VA staff physician. Kizer’s views are extremely relevant because he is credited with having transformed the VHA system between 1995-1999 from a centralized health care system with uneven quality and inefficiencies to one of the most efficient, effective, and equitable health care delivery systems in the US.
The saddest part of the story is the toll that this is taking on the excellent frontline clinical staff nationwide that veteran groups have been quick to defend in every hearing that has been held. An irony is that a recent audit of VA wait times system-wide found that 96 percent of the 6,004,350 appointments currently scheduled have wait times of 30 days or less. Only 4 percent of appointments have wait times of more than 30 days – better than the private sector according to PNHP backgrounder on the VA – June 2014
When an unachievable performance measure (appointments within 14 days) was coupled with performance bonuses to executive staff, the stage was set and some leaders failed miserably in their responsibility to be ethical and model the way for staff…..a key element of leadership according to Kouzes and Posner authors of The Leadership Challenge. What has followed is one of the most visible examples of leadership failure to occur in the healthcare system.
Leaders Should Model the Way by Living the Mission and Values
Every organization has a unique mission, vision and values. Kouzes and Posner contend that it is the role of the leader to clarify and affirm those values for staff. Consider the following mission and core values of the Department of Veterans Affairs:
Mission Statement
To fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.
Core Values
VA’s five core values underscore the obligations inherent in VA’s mission: Integrity, Commitment, Advocacy, Respect, and Excellence. The core values define “who we are,” our culture, and how we care for Veterans and eligible beneficiaries. Our values are more than just words – they affect outcomes in our daily interactions with Veterans and eligible beneficiaries and with each other. Taking the first letter of each word—Integrity, Commitment, Advocacy, Respect, Excellence—creates a powerful acronym, “I CARE,” that reminds each VA employee of the importance of their role in this Department. These core values come together as five promises we make as individuals and as an organization to those we serve.
Integrity: Act with high moral principle. Adhere to the highest professional standards. Maintain the trust and confidence of all with whom I engage.
Commitment: Work diligently to serve Veterans and other beneficiaries. Be driven by an earnest belief in VA’s mission. Fulfill my individual responsibilities and organizational responsibilities.
Advocacy: Be truly Veteran-centric by identifying, fully considering, and appropriately advancing the interests of Veterans and other beneficiaries.
Respect: Treat all those I serve and with whom I work with dignity and respect. Show respect to earn it.
Excellence: Strive for the highest quality and continuous improvement. Be thoughtful and decisive in leadership, accountable for my actions, willing to admit mistakes, and rigorous in correcting them.
Staff look to leaders to show by their actions that they live by the values that they profess. You can imagine the discouragement that frontline staff in the VAs involved in this scandal must have felt when they knew that the timeliness of appointments were being falsified. Kizer and Jha offer some important guidance about what needs to happen in the VA moving forward in their New England Journal article. These include 1) establish a few key metrics to measure to get things back on track; 2) reconsider the whole idea of performance bonuses as hiring additional providers is where the money should probably be spent; 3) begin publicly reporting performance measures in the same forums now required for other healthcare organizations by the Centers for Medicare and Medicaid. What is deeply sad about this situation is that the remarkable progress that the VA has made in the past twenty years in improving care often being at the forefront of innovation such as with Electronic Medical Records is easily forgotten in the face of scandal. Leadership in VA has a steep climb ahead to rebuild the trust of veterans, the public and their own staff.
References
Kizer, K.W.& Jha, A.K. (June 4th, 2014). Restoring trust in VA Health Care. New England Journal of Medicine, Available at http://www.nejm.org/doi/full/10.1056/NEJMp1406852
PHNP, (June 18th, 2014). PNHP backgrounder on the VA – June 2014
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