VA Greatest Enemy is Hiding in Plain Sight: Accountability

No service member leaves the military typically hoping that their livelihood will hinge entirely on the integrity of a public servant's work ethic. Or that the quality measures of VA healthcare will depend on whether the medical facility is under pressure to report favorable numbers. But that's exactly what's been happening for years at VA medical facilities across the country.

Even after the Phoenix scandal of 2014, and the exposure of Tomah VA's "Candyman," drug-stealing hospital employees, and a VA provider caught watching porn while with a patient made headlines, we still find ourselves ensnared in a circular, fruitless conversation on the need for greater accountability in VA. Hopefully, that will change as the U.S. House of Representatives soon decides whether the VA Accountability and Whistleblower Protection Act of 2017, following the Senate's passage of its own accountability bill, is the answer.

The VA Accountability and Whistleblower Protection Act of 2017 will grant VA Secretary David Shulkin the authority to quickly fire unethical and negligent VA employees while protecting whistleblowers who assume the risks associated with speaking truth to power about wrongdoing. The challenge Shulkin faces is bigger than his authority, however, should the bill pass.

The VA's entrenched and self-serving culture will inevitably come at odds with his enhanced authority — an immovable object against an irresistible force — except, in this case, one side will have to give. The question is how do stakeholders ensure that accountability has a fighting chance against a ubiquitous, powerful enemy with a near-perfect record of victories. The answer is to turn that enemy against itself.

"[C]ulture precedes politics, "said American businessman Foster Friess, "and I think the attempts to try and legislate people's behavior isn't going to be productive until the culture decides what they want to achieve." Lying at the core of VA's cultural identity are the true power brokers in the agency, the middle-senior managers, who wield the most authority with the least accountability, at least in the eyes of the public.

These are the high paid VA executives with highfalutin titles who work at the Veteran Integrated Service Network (VISN) offices and VA Central Office and rarely, if ever, have to interact with veterans. Their comfortable distance from a myriad of problems in VA, many of which are within their domain of control and authority to confront and resolve, is the problem. Also, they are rarely implicated when VA scandals are uncovered (Remind me of who was the VISN Director for the Phoenix VA in 2014?) even though their poor decisions or dereliction of duty can often be directly linked to problems at the facility level.

Worse yet, too many have spotty work histories of their own as former VA facility directors who were "punished" by receiving a promotion and transfer to a VISN office. Some spend more time positioning themselves for contracts and consultant positions in their post-VA life than visiting the VA hospitals under their auspices. Under the present VA healthcare framework, these same individuals are paid to manage the budgets, oversee the staff, and enforce the policies at every single VA medical facility in the country, which drives their collective influence in VA.

Realistically, it will be up to them, not the Secretary, to decide whether the agency is ready for a new era of heightened accountability, free of the moral hazard and recidivist behaviors that many come to expect of VA. It will be up to the VA Secretary, however, to decide whether these VISN "oligarchies," as many view them, should continue to wield that kind of power along with the anonymity that has shielded most of them from accountability.

On balance, numerous senior managers are shielded because of the good works of many VA employees and the capabilities the agency performs very well. No other large healthcare system rivals VA's competence to deliver specialized services at a national level, such as spinal cord injury and disease and polytrauma care or synthesizes access to healthcare, benefits, support, and peer mentorship better than VA. But what VA needs most right now is the one "ability" it presently lacks and can no longer be taken for granted — accountability.

Whether that means better protecting whistleblowers, shortening the reprimand process, or recouping ill-gotten bonuses and relocation expenses, achieving a state of being answerable to the public, the Congress, and most importantly, veterans will be dictated by the worst behavior the VA Secretary is willing to tolerate. This starts with examining the role and influence of the senior middle managers, who have the most at stake once the showdown between accountability and culture begins.