Following in the Errant Footsteps of the VA

The recent revelation of the crisis—and failure–of caregiving in the VA health system raises grave concerns for American health care in general and should motivate physician leaders to re-evaluate their approach to ethical health care.

Until recently, the VA health system was a recognized leader in health care quality, patient safety and ethics, outperforming most American hospitals in these areas. It had also established an award-winning program entitled “Integrated Ethics” designed to tackle “a recognized ethics quality gap.” This program addressed ethical issues on three levels of organizational activity in the VA system of health care: clinical decisions and actions, organizational systems and processes, and environmental and cultural factors. It was a program that was to “ensure that our systems and processes are designed to make it easy for people to do the right thing.” Yet despite this acclaimed and award-winning program, the “VA scandal” was a crisis of ethics. How does this happen?

Some have maintained that it was inadequate leadership: “the perceptions of leadership define the culture—not only what the leaders do themselves but also the behaviors they encourage, support, and don’t tolerate in others.” Others have pointed to a vast and rigid organization that valued documentation over action and reduced ethics to compliance and risk management. Still others have pointed to the focus on quantifiable performance measures that perceived ethics as an impediment to quality care, since “one cannot manage what one cannot measure.” Rob Nabors, President Obama’s deputy chief of staff, in his White House review of the Veterans Health Administration characterized the institutional culture as “corrosive” and concluded, “The VHA leadership structure is marked by a lack of responsiveness and an inability to effectively manage or communicate to employees or veterans.”

In reading through the VA documents on “Integrated Ethics” one notes the striking shift in ethical focus. “Leaders” are no longer physicians, but administrators. The locus of ethics as well as accountability is no longer the individual or the physician-patient relationship but the system. This, I would maintain, is the most lethal change, for once again, the physician-patient relationship, so crucial to medical care, has been severed and the physician is now tethered, instead, to the organization.

What should give us pause is the fact that our new government-leveraged health care system, the Affordable Care Act, is undoubtedly modeled on this once highly successful government-run VA system. Why would the government not use a system that has been highly successful one venue as a template for an even greater venue? And so the same processes that gave rise to the VA scandal are likely to be repeated on a greater level in the Affordable Care Act. The underlying fallacy is that systems and processes that are designed to optimize coding and maximize billing will be able to make it easy for “people to do the right thing.” Form-filling and box-checking cannot substitute for meaningful dialog. And metrics, no matter how good, cannot measure “care,” especially when those performance measures are tied to reimbursement dollars–for dollars dictate. In the end, one ends up serving “mammon”–and as we know, “one cannot serve both God—or ethics–or patients—and mammon.”

Organizational processes increasingly marginalize and eliminate ethical concerns because those concerns fail to accommodate themselves to the efficient and pragmatic processes of organizational health care systems–they don’t fit into “utilitarian boxes.” The implementation of processes has eliminated what really matters—the physician-patient relationship. And so as we follow in the footsteps of our big brother, the VA, and attempt to incorporate the same system processes into our even larger health care system, we may be faced with an even greater fall–unless we can take back the reigns and restore the relationships…

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