Until he resigned in May, VA Secretary Eric Shinseki led his department of more than 350,000 employees for five years by setting “bold goals” that looked impossible to achieve but that he knew, from his Army years, could inspire better performance and, from Congress, bigger budgets.
But did a goal to cut wait times in half for patients seeking care finally put VA administrators under such pressure that many chose to manipulate performance data, compromise their integrity and even put patients at risk?
A VA physician described for me his reaction, and that of colleagues, when word reached them in 2011 that veterans seeking a primary care appointment, or specialty care consults, were to be seen within 14 days rather than 30 days, the goal VA health care had used since 1995.
“That statement that we had to see patients within 14 days was so unbelievably unrealistic that people laughed at it,” the doctor recalled. He spoke frankly on condition that I not reveal his name or where he works.
“When I first started with VA I was told that when they put in a consult to [my specialty] -- and it’s all computerized so you can see exactly the time it was placed -- the goal was to see that patient within 30 days. If we were seeing 80 to 85 percent within 30 days, [bosses] were happy,” he said.
“That became very difficult because the volume of patients was just overwhelming. Then, all of a sudden, we heard that 30 days had become 14 days. It wasn’t any kind of an official announcement. And I’ve got to be honest: nobody made a big deal about it. In fact they didn’t pay any attention to it at all. It was just so stupid they might as well have told me I had to see the patient within 14 seconds. It wasn’t going to happen.”
Not everyone inside VA health care, however, could ignore the new goal as nonsense. Administrators responsible for hitting appointment timeliness marks suddenly had higher hurdles to clear, or to scoot around.
Who set the new goal and for what reason?
A senior VA official made available to discuss this the 14-day goal has been removed from all supervisor performance plans. He also said he didn’t know who made the original decision or whether it was individual or a group.
When it was set, he explained, apparently there was concern about ensuring that patients who needed critical care be given “same-day access.” So someone suggested that lowering the 30-day goal, he said, would somehow incentivize staff to deliver more same-day care to critical patients.
“I think the mistake we made was to use as an average measure” a 14-day goal set per appointment, as though using it would signal “we had same-day access for people who critically required it,” this official said. “I think we just saw 30, we wanted to get closer to same day access, and so they adjusted the performance measure from 30 to 14.”
That was as clear as he could explain what occurred. In retrospect, he added, another mistake was “we didn’t change the resourcing levels with the [new] resource requirement.”
In other words, the 14-day goal was set but not funded. VA health budgets still grew for identified purposes and programs, but no dollars were committed specifically to shortening patient wait times. That would have meant hiring more physicians, nurses and support staff, buying more equipment and setting up more examining rooms and operating rooms.
“That was a mistake,” this official conceded. Why no funding?
“At the time, it would have just been people thinking that setting bold goals was a good thing for an agency,” he said.
That sounded familiar. Bold had characterized Shinseki’s leadership style. He was the secretary who promised to end veteran homelessness by 2015. He also promised by that year to end the compensation claims backlog, which he conceded he had aggravated with another bold move. Shinseki added heart disease, Parkinson’s and B-cell leukemia to the list of conditions VA would compensate for and treat as service-connected ailments if veteran had stepped foot in Vietnam. Scientists had found an association between these ailments and defoliants like Agent Orange used in the war.
Last summer, while Shinseki was visiting a VA claims processing site in Newark, N.J., I interviewed him about his ambitious goals.
“There’s a fine line between being bold and foolish,” the retired four-star general and wounded warrior said. “I think for the most part, over all the things I’ve ever done in life, [I’ve mostly been] bold and a few times foolish. I think I’m bold here.”
He said he didn’t regret setting bold objectives.
“I’ve been writing plans all my life. I never wrote a tentative plan. That’s not what you expect from a guy you want to solve a problem.”
Debra A. Draper, director for health care at the Government Accountability Office, said VA officials told GAO that they had lowered the wait time goal to 14 days because performance data by 2011 showed VA was meeting the old goal for more than 95 percent of veterans seeking care.
The trouble with that decision, Draper said, was that VA appointment data had been unreliable for years, as both by GAO and the VA’s Inspector General often reported. Yet meeting wait time goals had been an element of VA performance contracts for administrators since at least 2000, she said.
Factors that made the data unreliable included a scheduling policy that was unclear and open to local interpretation; antiquated scheduling software; inadequate staff training and, effectively, no oversight of data reports.
Was the shift to 14 days a factor in the current scandal?
“You don’t know people’s motivations,” Draper advised. “But, yeah, going from 30 days to 14, for someone who was planning to do something nefarious or manipulative, it’s more pressure to do that.”
But Draper believes the scandal would have occurred even if VA had left the 30-day goal in place because so many veterans were complaining to Congress and to veteran groups about long waits to access care, she said.
“Whether it’s 14 or 30 days, data need to be reliable so they can really measure [and manage] to whatever the benchmark is,” Draper said.