Push accountability on Capitol Hill to fix problems with the VA
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Since the news first broke three years ago this month that as many as 40 veterans died while waiting for access to medical care at the U.S. Department of Veterans Affairs (VA), one of the first, and most consistently, uttered words from lawmakers has been the need for accountability.

In direct response to this scandal, in August 2014, Congress passed the Veterans Access, Choice, and Accountability Act of 2014, which aimed to do just that — inject accountability into the VA by providing the Secretary with additional tools to fire non-performing employees.


However, the law that ultimately passed was significantly watered-down from an earlier version that passed the House, The Department of Veterans Affairs Management Accountability Act of 2014, which gave the VA Secretary ultimate firing authority, similar to that of a CEO at a large company.


Unfortunately, three years later, little has been seen in the way of progress. So little that, newly-appointed Secretary David Shulkin noted that he was unable to fire a Houston-based VA employee who was caught watching pornography while with a patient. In response to the situation, Shulkin himself issued a statement saying “this is an example of why we need accountability legislation as soon as possible.”

Shulkin’s pleading with lawmakers for changes in the law to quickly remove poor-performing employees is a far cry from his predecessor, Bob McDonald who simply stated “you can’t fire your way to excellence.”

Despite Shulkin’s embracement of accountability and all the finger-pointing by Congress, demanding accountability alone won’t solve the VA’s problems. Although tools to terminate poor-performing employees are a good start, for example, the vitality curve served companies like General Electric well for decades, what VA needs more than hollow cries for accountability is a change in organizational culture. It’s difficult, if not impossible, to legislate culture, so VA needs to change its habits just as much as it needs Congress to change the law.

In his book “The Power of Habit,” Charles Duhigg tells the story of Paul O’Neill, a former government bureaucrat, ironically from the VA, who transformed Alcoa by focusing on the issue of employee safety, rather than buzzwords such as synergy, rightsizing, profit-margins, or in the case of the current VA — accountability.

When asked how he did it, O’Neill stated “I knew I had to transform Alcoa. But you can’t order people to change. That’s not how the brain works. So I decided I was going to start by focusing on one thing. If I could start disrupting the habits around one thing, it would spread throughout the entire company.”

In other words, organizational change begins by attacking a keystone habit, and allowing organizational change to ripple through the organization. As Duhigg continues in The Power of Habit, “keystone habits start a process that, over time, transforms everything.” As an example, Duhigg cites to the fact that regular exercise goes hand-in-hand with better eating habits and effective weight loss than attempts at either of these things alone.

To use another example, in Medicaid, this is known as “the bus pass problem.” As explained by Cardinal Innovations Healthcare CEO Richard Topping, “Medicaid isn’t about successfully managing patients medical costs, it’s about managing the conditions that drive their health.” In other words, no amount of expensive care will improve the health of a patient who doesn’t have transportation, and can’t get to a doctor in the first place.

Turning back to the VA specifically, O’Neill and Duhigg discuss government spending on healthcare, observing that, rather than being guided by sound principles of logic and deliberate priorities, the government was “instead driven by bizarre institutional processes that, in many ways, operated like habits.”

In the example of Alcoa, employee safety wasn’t just a sound principle, but also something that both unions and executives could agree upon as a priority. Thus far, the American Federation of Government Employees (AFGE), has been viewed by many, mainly Republican, lawmakers as enemy number one of accountability reform via termination of poor performing employees.

So, the million dollar question then is: What is the keystone habit that VA can change, that unions, veterans service-organizations and lawmakers can all agree on, that can truly reform the Department? VA already proclaims to be a mission-driven organization that focuses on veterans and, as Duhigg notes, identifying keystone habits is tricky, and one must know where to look.

Perhaps if lawmakers were willing to switch gears from accountability alone to discovering keystone habits that promote accountability through new structures and chain reactions that turn old, bad habits into good ones, we’d start to see more meaningful reform take hold.

Without such meaningful reform, changes in the law won’t matter, particularly to individual veterans trapped at the hands of bureaucrats, if the organizational culture remains powerless to do anything against those who choose not to follow the law. Although the pornography-watching employee is perhaps the most glaring example, inability to follow the law, unfortunately, trickles down through every VA business-line.

Take, for example, a veteran’s widow who has an appeal pending at the Philadelphia Regional Office. That office is run by Diana Rubens, VA’s poster-child for why employee accountability is an important part of the organizational change process. When attorney Katrina Eagle notified Ms. Rubens that her staff were incorrectly applying a law stating that veterans may still be entitled to disability compensation for disabilities other than those that the Institute or Medicine has determined are presumptively due to Agent Orange, Rubens’s response was, according to Eagle, “callous, offensively patronizing, and professionally disappointing.”

Similarly, although legislators have been spending almost as much time talking about appeals reform as they have about accountability, little will change with a new law if VA employees aren’t following the law in the first place.

Obviously, changing habits can be arduous, and the process takes time. But, once we are able to better understand the VA’s habits and how they operate, we are better able to gain power over them and, in turn, achieve what has thus far proven elusive: accountability.

 has dedicated her career to ensuring accountability within the Department of Veterans Affairs (VA) to care for our nation’s veterans. She is the principal at Riley-Topping Consulting and has served in a legal capacity for the U.S. House of Representatives Committee on Veterans’ Affairs, the National Veterans Legal Services Program, the U.S. Court of Appeals for Veterans Claims, and the Department of Veterans Affairs. You can find her on Twitter: @RileyTopping.

The views expressed by contributors are their own and are not the views of The Hill.