“My VA”

Mike-Peg VeteransToday (as I write this) is Veteran’s Day.  I’m a veteran.  My wife is a veteran.  My dad was a veteran.  My father-in-law is a veteran.  Most of my uncles are, or were, veterans.  Some of my best friends are veterans.

There are some (including some in Congress) who feel that changing the bureaucracy is not enough.  For instance, Representative Jeff Miller, Florida Republican and Chairman of the House Veterans’ Affairs Committee, said “A bureaucratic reshuffle isn’t a substitute for firing employees who were responsible for the wait lists, ignored whistleblowers, or otherwise put the department’s needs ahead of veterans.”

Why am I skeptical?  Renaming the VA program will not change the system.  Firing employees will not change the system.  The employees are only acting rationally to the system they are in.  As Brian Joiner pointed out years ago, people have three choices when it comes to getting better results:  1) distort the numbers, 2) distort the system, or 3) improve the system.  Any day in any healthcare system (including, but not limited to the VA) you will find examples of options 1 & 2.  Employees (including management) are acting rationally to the system that has been put in place.  Fortunately, there are some instances where choice #3 is being pursued.  This is what we are trying to encourage at the ThedaCare Center For Healthcare Value.  But choice #3 will only happen when top management takes the right action.

The systems that are in place in the VA healthcare systems have been in place for years and years.  Simply working on the surface will not suffice.  Similar systems are in place in many non-VA healthcare systems.  Only top management can change a system, but this will require new knowledge and new skills.  It will also require courage and a willingness to unlearn a lot of what we think is true and to learn different principles.  Top management needs to change the way they think.  This is tremendously difficult and anyone who thinks otherwise is fooling himself or herself.

Top management needs to understand different principles for enterprise excellence.  You don’t adopt these principles, they adopt you.  What I mean is that these principles affect everyone and every organization.  They apply whether you are aware of them or not, and there are consequences when you don’t understand these principles.  The Veterans’ Administration is feeling the effect of these consequences.

Here are three of these principles that focus on engaging and enabling everyone to help to improve the systems:

  1. Lead with Humility:  Top management must admit that they do not know it all.  This will be difficult for all, impossible for most.  Trying to manage from the office, boardroom or the conference room will not work.  Management by fear, exhortation, or proclamation will not work.  This includes renaming the program, i.e. “My VA.”   What does “leading with humility,” look like?  Get out of your office.  Go see what’s really going on at the real front-line (where value is provided to the patient).  Ask questions about what’s going on (not on the numbers).  Reflect on what you discover.  Take action to improve the systems in which these people work.  Do you even know what a system is?  Are you willing to learn?  Stop relying on (and stop rewarding) heroic efforts, hard work, and firefighting.  What are the consequences of not leading with humility? One consequence is that you will never know the truth about what is going on in your organization.
  2. Learn Continuously:  Admitting we do not know it all is only the first step.  Action must be taken to unlearn a lot of what we have been taught and to learn new principles.  Learning does not end at graduation.  The prevailing style of management came about because management developed what Dr. W. Edwards Deming called the “mythology of management.” For instance, we learned to divide an organization into parts and to try to manage the parts – holding managers accountable for the productivity of their individual departments.  We hold these productivity standards to be sacred.   We mistakenly think that holding individuals accountable for their part will add up to an efficient and quality organization.  In fact, this approach produces the exact opposite, and we are then surprised when silos develop and people do not collaborate.  That is a consequence.
  3. Respect for Every Individual:  Everyone is born with intrinsic motivation and they enter the workforce with best intentions to work with others and to make a contribution.  The systems of reward and punishment (starting with school) affect everyone, and drive their behaviors.  The problem starts in first grade and only gets worse from there.  People will act rationally in response to the systems they are in.  When we see actions and behaviors of anyone (including management), our first question should be “What systems might be causing that behavior?”  Our next question should be, “What can we (management) do to change those systems?”  If people hide the truth about wait lists, or try to silence whistle-blowers, they are most likely acting rationally to the systems they are in.  Firing these people will not fix the system.  Respect for every individual means understanding why people are acting the way they are, and working with them to design better systems.  One consequence of not respecting every individual is that the only people you will have left working for you are those who could not find a job somewhere else.

Only top management can take the action necessary to truly create a system that views every veteran (and patient) as the center of focus.  The good news is that there are managers in some organizations that are taking the necessary actions.  They exhibit the courage to lead with humility, learn continuously, and respect every individual.  They exhibit the kind of courage than many veterans demonstrated when they sacrificed to serve their country and countrymen.

I’ll reserve my warm hug for those managers.

4 Responses to “My VA”

Dave Goode says: 11/17/2014 at 6:50 pm

First, as one veteran to another, my respects to you and Peg.

Your blog points are very well made. I don’t think the average manager has the constitutional wherewithal to take the road you have mapped out. As the mud slides down the hill insulation becomes the tact of preference. This can only be counteracted by credible continuing leadership from the top that gives people assurance that doing the right thing is OK. As I reflect my career in my retirement I come back to those points and decisions where I could have done better. You saw some of those. I don’t think I’m continuing that track with the organizations I am now with on a voluntary basis. But I keep coming back to “I could have done better” in some work situations. Keep up the good work you are doing. You are certainly mapping the right road, particularly with the VA situation. My best to you and Peg. Dave

Mike says: 03/11/2015 at 5:48 pm

I am a manager at the VA. I lead a service line. The bureaucracy has gotten so complex that it is impossible for anyone to easily make any changes. Wrongful actions by a few untrustworthy individuals that get splashed across the headlines end up leading to layers upon layers of rules that prevent anything bad from happening but also it prevents good things from happening too. The system trusts NO ONE. And because no one has any autonomy to act, nothing can get done.

The only way to make VA work, is to actually GET RID of an entire layer of rules so people have authority to act. At the same time, those people must be held accountable for their own actions and the rest of the organization should be allowed to act with freedom.

Michael Stoecklein says: 03/11/2015 at 6:04 pm


Thanks for providing your input on this post. If we traced the problem back to it’s roots, I think one of the causes would likely be a misunderstanding of variation. The example you provide is an illustration of what goes wrong when management reacts incorrectly to variation. In this situation, it is possible that there were some rare (special cause) instances (untrustworthy individuals) that management reacted to. Rather than deal with the special cause(s), they changed the entire system (added rules and bureaucracy). I see it all the time, and the problem is not isolated to the VA. I recently wrote a paper on this topic. The knowledge about understanding variation and the correct management action goes back to before 1940, yet management in healthcare has not been exposed to this knowledge. This is one of the foundational pieces of knowledge that Dr. Deming introduced to the world in the 1940s and beyond, and which became a critical component of the Toyota management system, but top management in healthcare by and large has no idea of this concept. Ignorance is not an excuse. Those who don’t understand this principle still suffer the consequences of taking the wrong action.

Mike S.


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