What is Wrong with the Department of Veterans’ Affairs?

(A Quality Assurance Perspective)


Wallace M. Ward, QE
30 October 2008

Judging an organization’s structure is usually the first activity in a Government procurement cycle. As a quality assurance professional, I have performed this task for tens of billions of dollars worth of procurements. Relying on my experience, I have decided to tackle one of the largest quality assurance questions that remain unanswered.

We all have seen the headlines about the problems within the Department of Veterans’ Affairs this past year. These problems vary from improper care of facilities where patients are treated to destruction and mishandling of veteran documents.

So, exactly where do you begin to find answers to what is really wrong with the Department of Veterans’ Affairs? When the recent problems arose concerning the shredding of documents and mishandling of mail at Regional Offices levels, James Peake, current Secretary of the Department of Veterans’ Affairs belittled the problems by stating that it was just a handful of records.

Stop! Think! What kind of records? These records are usually communications concerning a veteran’s claim for compensation and benefits. They may be medical files, documented service duty and locations, requests for appeals and important data for a veteran’s claim. With a claim processes averaging more than 180 days and additional claims coming in the door each day which may cause this wait time to increase, this could very well be a veteran’s life or death situation, cause un-needed severe financial hardship or both.

Let’s just try to solve this record handling problem first. What causes it? How do you stop it? Most importantly, how do you keep it from re-occurring?

The first answer you will likely hear is that it is caused by a disgruntled, lazy, untrained, uncaring or some such employee. That gives rise to questions about supervision and the chain of blame can travel upwards until someone finally proclaims the problem is solved when the root cause has not been determined and surface has not even been scratched.

A thorough quality audit performed by external professionals is what is really needed to find problems like this. Big picture quality assurance requires experience and a well founded understanding of the principles of Juran and Demming. The first thing that will be evaluated will be documentation. This will entail a top to bottom exercise to see how processes are done. What are the rules and regulations of the organization and are they reflected in the flow processes and their performance documentation? The audit must be sure to cover unwritten rules and regulations. Careful attention must be given to morale and work performance. Look at internal department “stake holding” and determine if it is justified. This is often associated with “managerial turf” where lines are drawn regarding specific responsibilities and who gets blamed or praised for some action. This is especially true of Regional Offices.

Next on the agenda is the Pareto Analysis. Better known as the Critical Few/Trivial Many tool, that solves 20% of the critical problems which in turn solve the remaining 80% trivial problems automatically.

Many private industry organizations and some Government agencies have relied on automation to make a difference. A properly designed artificial intelligence system can reduce mistakes, increase output and reduce costs. How do you automate, you ask? By making use of an analytical tool. As you performed your quality assurance audit you collected data which will allow you to make a Fishbone Diagram. Also known as a cause and effect diagram or an Ishikawa diagram, this is a tool for the study of processes. It shows possible causes of an effect on the "bones" branching out from a line representing the process which produces the effect. Its primary limitation is that it has no means for adequately showing the possible inter-relationships of the various causes.

Kaoru Ishikawa intended the "fishbone" as an analytical tool and not a means to track issues.

Hint! The relationship of issue to fishbone is many while one fishbone can point to a root cause, that if corrected can solve many issues!

So, looking at the Department of Veterans’ Affairs, just what is the problem? My first guess would be one that is sure to shock you; fraud prevention! How did I determine this? From top to bottom, the Department of Veterans’ Affairs demonstrates an adversarial nature toward the veteran. Management keeping an eye on costs, lower level staff decisions, claims reviewers, document handlers, have all been subjected to the “adversarial” mentality. The fraud guidelines should be reviewed carefully in a Fish Diagram. The adversarial mentality allows the employee to exploit their client, the veteran. And so, they reason, it allows them to let some of that antagonism be focused back on the system. The result is a lack of respect toward material things in the office in addition to the lack of respect toward the clients themselves.

These adversarial guidelines will have to change if an automated system is put in place. The Department of Veterans’ Affairs has demonstrated the need for an automated system by the mere presence of its current backlog. Another Government agency has more than a 20 year history of using automation. A good example of a properly working automation system is the United States Postal Service, which has used automation to stem growing personnel needs, enhance delivery speed and handle ever increasing workloads while reducing cost of investment.

It is time for the Department of Veterans’ Affairs to solve some problems instead of creating them! And it is time for an outside entity to step in to help map out the critical processes within the VA system in order to identify the key issues in the breakdown of this system.


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