AN ENCOUNTER WITH VA POLITICS ILLUSTRATES THE NEED FOR CULTURE CHANGE WITH VA CENTRAL OFFICE
By Ali Parand, a general internist and former VA ISP physician
In May 2019, the Department of Veterans Affairs terminated a 10-year-old program that sent healthcare providers to fill temporary staffing needs at VA medical clinics throughout the country. An innovative business model, the VA Interim Staffing Program (ISP) was designed to save the agency money and to recruit highly-skilled providers who would otherwise not have worked for the VA. In the years prior to its dissolution, the ISP received accolades for efficiency, cost savings, and teamwork and leadership. The program had begun to scale to a greater number of providers and a broader range of specialties, and President Trump’s first VA Secretary—a physician executive who recognized the value of the program—directed the ISP to expand even further.
News of the ISP’s dissolution came as a surprise considering the agency’s persistent staff vacancies and responsibility for managing the most-complex patient population of any healthcare system in the US. The VA Administrators’ rationale—that the decision was part of VA “Modernization efforts,” that the ISP did not serve agency needs and that a new telehealth initiative would suffice to replace it—was vague, confusing, and inconsistent with realities in the field. This left VA employees familiar with the program perplexed and questioning why VACO (VA Central Office) would eliminate a useful and critically-needed enterprise.
The manner of the ISP’s dissolution was even more confounding—providers were removed from the field with minimal advance notice. This effectively pulled the rug from under VA facilities that had scheduled providers to staff their clinics in the summer and fall of 2019, leaving them flailing in their attempts to find alternatives to care for their Veteran patients.
Since the justification for the ISP’s shuttering did not make sense, a group of ISP employees set out to discover what was really going on. What the group found was typical of patterns increasingly alleged within federal agencies over the past few years—a disregard for truth, an emphasis on optics over substance, and the sidelining of administrative competence in favor of “yes men.”
The ISP group’s investigations and subsequent efforts to reinstate the program included meetings with VA administrators and with legislative staffers on Capitol Hill. VA administrators justified the dissolution of the ISP by referencing misinformation—falsehoods about the ISP’s efficiency and utility and misrepresentations of the capabilities of a new telehealth-based initiative intended to supplant the ISP. Administrators even used disinformation to mislead Congress about their decision during a congressional briefing on the ISP’s dissolution in October 2019.
The ISP was a tested-and-proven model that delivered both in-person and virtual care through providers on-site at VA facilities worldwide. The program was also designed to assist with on-site staffing needs during emergencies and crises, such as the current COVID-19 pandemic. The still-conceptual and untested telehealth-based model touted as an alternative to the ISP provides only minimal direct patient care on-site—providers mostly “telework” (long-distance) from their homes. Despite the new telehealth initiative being in the developing stages—it wasn’t even up-and-running in much of the country when the ISP was terminated—it had become a PR tool and politically valuable (even pre-pandemic). Aggressive attempts were being made to promote this new temporary-staffing model, and it was repeatedly peddled to Congress.
Although the new, alternative telehealth initiative has been able to support some VA facilities with staffing shortages, its complexity, cost, and administrative burden have dissuaded many facilities from using it. More importantly, the experimental telehealth model is mostly limited to remote staffing. (Most of its providers spend less than 10% of their time on-site.) This framework may serve the needs of some locations that have the most difficulty attracting providers, but nearly all VA clinics prefer having the option of an on-site temporary-staffing provider which the ISP offered. Additionally, the ISP had a 10-year track record of demonstrated versatility and efficiency upon which many facilities had come to rely.
While all ISP providers were encouraged to transition into the newly-created telehealth initiative, only a handful ended up doing so. Upon the ISP’s termination, most of the program’s providers did not seek re-employment with the VA, and many have indicated that they would only pursue continued VA employment if the ISP is reinstated.
Because there was no sound reason that the ISP could not have continued to function along-side the new telehealth model (the ISP cost a small fraction of the new model and was much more administratively efficient), dozens of frontline providers and VA facility leaders joined in an effort to reinstate the Interim Staffing Program. This is likely one of the most concerted frontline grassroots attempts to engage agency executives in the VA’s recent history.
After being repeatedly stonewalled by VA administrators, 30 ISP providers appealed to the Secretary of the VA. The group’s second letter to the Secretary implored him to demand accountability within VA administration as resolutely as it is demanded on the front lines. The letter concluded with the following entreaty:
“As current and former VA physicians, NPs and PAs, it is our belief that, in order for the VHA [Veterans Health Administration] to successfully become a High Reliability Organization, HRO principles need to be adhered to within VHACO [VHA Central Office] just as much as on the front lines. Hence, it is concerning that the dissolution of ISP has involved a lack of transparency, communication, deference to expertise (the experts here being primary care service and section chiefs), situational awareness, and ultimately, accountability.
Because employee morale is contingent upon trust in our leaders and because a just culture should apply to VHACO just as much as it applies to the front lines, we are currently trying to “raise our hands and stop the line” by asking that ISP’s mistaken dissolution be addressed.”
The group’s letters to the Secretary were never answered. But 9 days after the second letter was sent, during testimony to Congress, the Secretary added insult to injury by saying:
“I have made it clear that the VA is a bottom-up organization, where people at every end of the strata have a say in how their work is performed; they have a say in how their leaders perform their work. And, I think that has gone a long way to improving morale amongst our staff. And, if morale amongst our staff is high, the care for Veterans is much better.”
The type of organization that the Secretary describes is not consistent with the ISP group’s experience. Rather, its experience was of an executive leadership more interested in optics than truth, in “yes men” than competence, and in the agenda of DC administrators over concerns of frontline providers. Even the VA’s Inspector General seems to have acquiesced to this new culture—the IG having repeatedly declined to investigate ISP-related concerns, evidence, and findings despite multiple submitted complaints.
Based on evidence, interviews, and correspondence, ISP employees who spent the most time investigating the dissolution of the program concluded that the administrators’ perplexing decision was based on a limited and inaccurate understanding of the ISP’s design, capabilities, and function. Moreover, the decision-makers’ zeal to generate publicity for the new telehealth initiative seems to have resulted in the perception that the ISP presented unwanted competition.
The VA has more than enough need for multiple temporary-staffing models in light of the agency’s significant clinical vacancies, and competition among business models would allow local VA facilities to choose the best, most cost-effective option. Rather than empowering these facilities and the Veterans they serve to “vote with their feet” and choose the option that best suits their needs, the administrators that shuttered the ISP were ensuring that there was only one game in town. The decision-makers were effectively picking the winner that best suited their own needs.
As for the abrupt withdrawal of ISP providers from VA clinics, multiple longtime Central Office employees have said that this reflected a level of mismanagement rarely, if ever, seen within the agency. The only tenable explanations that the ISP group could come up with for this roughshod action are that it was the result of administrative incompetence (due to a limited understanding of and unwillingness to learn about ISP-provider roles in the field) and/or administrative malfeasance (due to an attempt to rush the process and make the ISP’s termination irreversible before anyone would have time to discover what was going on).
Of course, either of these explanations is reckless and inexcusable—because the rushed provider withdrawal needlessly restricted patient access to care and VA facilities’ abilities to serve Veterans. What’s more, had the administrators listened to concerns from the field and taken a little more time to think through the implications of their actions, the ISP would have ended up serving even more critical staffing needs during the current COVID-19 pandemic (which began just months after the program’s hurried dissolution).
Another hypothetical: Had the previous VA Secretary not been ousted for his attempts to counter privatization, the ISP group’s petition would surely have been acknowledged and the program’s dissolution would almost certainly not have occurred. More than likely, the dissolution-decision would not have even been made since the decision-makers (had they been appointed to begin with) would have known that they could not have gotten away with it.
In a presentation to VHA executive leadership last year, the VA’s Assistant Secretary for Congressional and Legislative Affairs—who allegedly participated in the previous Secretary’s ouster—gave his audience the following advice:
“Sometimes, the facts really don’t matter: even when we do everything right, someone, somewhere, can say we did something wrong; life isn’t fair; Sometimes, the facts really do matter: but only when we have a coherent and coordinated response, and accept accountability and responsibility with professional grace, firmness, and some street smarts; life is tough.”
If VA privatization is the tacit agenda—often felt by VA employees to have been the elephant in the room over the past 4 years—facts can sometimes be an inconvenience and messaging is made paramount over truth. However, if the VA’s goal is sustainable, high-quality, cost-effective care for our nation’s Veterans, full stop—using the combination of public agency and private enterprise that works best—then transparency, competence and accountability are essential to achieving this.
VA administrators and legislators cannot get us all to this goal without doing a better job of listening to and engaging those in the field. Hopefully, a new administration (and conscientious Veterans congressional committees) may bring a renewed dedication to the VA’s mission and take more seriously our responsibility “to care for him who shall have borne the battle.”