The Wall Street Journal reported that "the Senate recently whisked through with only three dissenting votes a bill cobbled together by Bernie Sanders and John McCain that authorizes $500 million to hire additional VA providers, over $200 million to lease 26 medical facilities, and an unspecified amount to contract private care for veterans who live more than 40 miles from the nearest VA or experience treatment delays."
What is the problem Congress is trying to solve? Dedicating resources to the problem may or may not be the answer. In fact, in studying over 135 health care systems in 13 countries in the last six years, we have found that lack of capacity is rarely the problem. The problem is actually most health care delivery systems are full of waste. Waste in any process is manifested by excessive waiting, defects, unnecessary movement, and too much inventory to name a few. Health care is besieged by these wastes. Instead of throwing more resources at the problem, we should reexamine each step in care delivery. Removing the waste in the processes is the answer, not $50 billion a year in new spending.
But, sadly, very few in health care are looking at it this way. And, frankly, the private sector is no better than the VA in this regard. Last year an important article published in the Journal of Patient Safety concluded that between 240,000 and 400,000 patients die each year in the U.S. due to medical error. Those appalling numbers suggest a patient dies unnecessarily in this country every 79 seconds. Most of those deaths are in the private sector, not the VA. Giving veterans vouchers to use the private health care system doesn't seem to be the right solution either.
Suffice it to say, the VA has a lot to consider and it needs to come up with workable answers soon. The growing scandal is already taking a huge toll in lives lost and lack of confidence in the institutions that created the scandal in the first place. And, changing the leader of the VA will not solve the problems they face unless they change the way they deliver health care, period.
Two Fundamental Problems
Though seemingly complicated at first glance, the issues they face can actually be boiled down to just two fundamental problems.
First is perverse incentives. It's been proven over and over again that financial incentives are rarely helpful for improving health care quality. Most of these incentives defeat the purpose for which they were designed. In this case, the conflict is clear: If leaders are incentivized for shorter wait times but have no tools or ability to change the result, it is not surprising the data collected might not reflect actual performance.
The second problem and perhaps the most important is dysfunctional government oversight. I have worked with hundreds of VA leaders over the last few years. All of them are dedicated professionals. But each one describes the blaming and onerous conditions the government (meaning Congress) has shackled them with as suffocating and demoralizing. VA leaders have been deeply committed to improving care for veterans for decades.
Part of the stated improvement process is to make visual and public the problems as they surface. In theory, this would allow everyone on the VA team to understand the problems they all face and would give them enough information to work toward practical solutions with continuous improvement. But, in the current system, every time they try to follow this blueprint and address problems in a transparent way, there is a politician ready to publicly demean them for political gain.
So, it would appear that the problems in both the VA and private health care are pervasive and very similar. If that is true, then perhaps the VA mess might lead to some good for everyone, especially if the crisis serves to shine a spotlight on the safety problem prevalent in all of American health care.
And, if it does, what can be done to fix it? There are plenty of naysayers and blamers who will immediately jump on the exposed problems and find someone (most likely someone in the other party, not theirs) to blame. But few will have real answers.
And, there are answers. And, they are working.
Some health care organizations have been learning a new method that is leading to markedly better safety and quality. Borrowing from the best ideas used in great manufacturing companies, organizations such as Palo Alto Medical Foundation, Lehigh Valley Health System, and New York Hospital and Health Corporation have dramatically improved wait times for patients, raised the quality of health care, and lowered the cost.
What these organizations and others are learning is the Lean method, introduced by Toyota Motor Company many years ago to improve quality and efficiency. The fundamental purpose of the method is to improve customer value, primarily by removing waste from processes.
One of the key wastes in health care is waiting, and Lean attacks the waiting problem by understanding the reasons for waiting and then rapidly and rigorously redesigns processes to reduce it. I think it's important to note that nurses and physicians are key to this redesign. Unlike most health care management systems the decisions for change in the Lean system are actually made by the frontline workers, rather than having it foisted upon them by managers who may be out of touch with the real issues these dedicated folks face every day in their jobs This is where value is created for the patient and it is where the organizational knowledge is to change care.
The blame game may be the prevailing standard in politics but it doesn't work in health care. If congress would allow the dedicated professionals at the VA to apply the principles of continuous improvement through Lean, and allow transparency to be unfettered by politics, most of the recently identified problems would never have occurred in the first place.
It's well past time for a cure. The best medicine for America's veterans is to remove politics from their care, and redesign the way it's delivered going forward.