Originally published in PM Times on May 23, 2016.
How would you solve this problem?
The US VA has unacceptable wait times for veterans seeking medical assistance. The VA medical centers around the country are overbooked and understaffed. Some veterans have to wait months for appointments and treatment. There has been negative media attention on this growing problem, especially when it came to light that VA administrators covered up the delays by fabricating reports. Other branches of government, like the Congress as well as the public, are up in arms.
What do you do to solve this? Well, the US Congress solved it by allocating $10B USD to allow vets to seek care at private medical providers through a new program called Veterans Choice. On the surface, this seemed like a reasonable solution since it quickly expanded the potential providers who could serve the vets. Oh, did we mention that Congress gave the VA 90 days to pull this program together?
That sounds like a recipe for disaster. Can you imagine any project you might work on that has a $10B budget in the first place? Let alone 90 days to conceive, plan, and implement it? Most things in the government take 90 days just for the conception part, much less the whole thing.
Well, as you can probably guess, the program is having trouble. Billions have been spent, and the problem has gotten worse. According to NPR, the wait times for veterans has actually increased with the privatization plan. See NPR’s article for details on how the level of service has gotten worse instead of better. Obviously, organizations want projects and programs to meet their goals and objectives and improve their KPIs (Key Performance Indicators) and not make them worse.
There are several reasons for this colossal failure, and we invite you to read the story to hear about them, if interested. What we’d like to explore here are some lessons learned (or at least observed from afar) about this whole affair.
- Jumping to solutions. Resist the temptation to jump to solutions. Most problems will have multiple solutions that can fix the problem. However, some are almost always more practical, will cost less, and cause less disruption than others. Picking one solution without analyzing the problem for root causes, without looking at the feasibility of implementing each, and without understanding both the costs and benefits of the solution will more than likely result in wasting money and a great deal of rework. For example, the use of private physicians meant that some veterans would have to travel much further to receive care under the new solution. Over 28,000 of them were affected in this way, a significant number.
- Politics. Remove politics from your initiatives if possible. With the VA and the US Congress, that is like asking a cat to remove its whiskers. It is simply not going to happen. But in business, surely we can work as neutral facilitators to reduce the political and the biased views of stakeholders when addressing the problem at hand.
- Resources. The Veterans Administration was tasked with creating this new program when they were already underfunded, understaffed, and overly extended. So they had to outsource the program’s creation. Out of 57 potential vendors, only four were willing to attempt the near-impossible task of building a major infrastructure so quickly. Then two of the companies backed out when they learned it had to be finished in 90 days. On our projects at work, we need to be sure that we have a plan to implement the changes and that we have some idea of the resources (people, time, and money) to complete the work.
- Ah, the problem. How many of you think the trouble started when Congress ignored the real problem? Raise your hand, please. If anyone involved with this initiative had done any root cause analysis, they may have discovered what it would take to really fix the problem. If the urgency had been less, perhaps they would have realized that delays in scheduling appointments were in large part caused by the VA’s reliance on paper files. The proposed solution of privatizing the care did nothing to solve the paperwork problem. Here, as in our organizations, it often seems like we have a solution chasing a problem, in this the case reducing federal programs in favor of outsourcing. Analyzing both the problem and the solution would have led to better outcomes.
- Cobbling a Solution. Because of the tight time constraints and few vendors, the solution was built on top of an existing vendor system. That may have been OK if the existing system was effective, but it had a special-purpose focus and had several flaws in it. Adding a “quick-and-dirty” extension onto an already faulty system is obviously never a good idea.
- Scope. We can all applaud the allocation of the $10B to address a major problem. The difficulty with rushing something so large in so small a time-frame is that it never works.
- Chunking the effort, say by piloting it in a few VA Centers, might have quickly uncovered issues that could have been fixed before rolling it out system-wide. It may have also revealed that the solution was unworkable before further money was wasted.
- Allocating some of the appropriation to increasing staff at existing VA centers would most certainly have helped. (Full disclosure: our son is a physician at the Portland VA. We have heard firsthand that his Center needs more staff at all levels, so we assume every VA may be in the same boat).
- Some of the funding could have been devoted to converting the VA’s antiquated paper records to electronic medical records. It’s not hard to see that would have helped in reducing delays.
- Business Transformation. A huge new program like Veterans Choice represents a major shift for all stakeholders, especially the veterans and the medical providers. Rushing a major change in so short a time minimizes the need to transition stakeholders to the new solution. NPR mentions “many veterans were confused” by the new procedures, caused in part because the Choice program had to interface with the overall VA medical system. The interface was resolved by adding a 3rd party administrator between VA doctors and the outside physicians. The result complicated scheduling and made it worse. With so little time to adopt the new program, training, communication, and publicity were drastically abbreviated.
In summary, the way the Veterans Choice program was handled left much room for improvement. The VA is reconsidering how much of the administrative outsourcing they should have done. Congress may not allow them to do that. The problem first came to light because of scandals in covering up the delays and Congress is considering expanding the Choice program to take more control out of the hands of the VA. Meanwhile, the rework and delays continue.