VA scandal: How to fix a broken system

Mr. Robert McDonald:

We admire your courage. In accepting this nomination, you are about to confront one of the most daunting challenges in all of federal governance: reforming the VA hospital system.

You face three great challenges.

The first is size. With 6.5 million patients, 300,000 employees and more than 150 hospitals and 850 clinics, the system is too large to adequately perform its core mission of providing lifesaving and recuperative care to veterans of war.

You must make the VA health-care system smaller. This will be your greatest challenge.

By returning to the VA's roots and treating only war and service-related injuries, you will enhance care for all veterans. Congress is working to find private-sector alternatives. Help them find answers for those whose needs are unrelated to their service. It does no favors to vets to make this organization bigger.

The second challenge is the corrosive culture you inherit.

Imagine how daunting your job leading Procter & Gamble would have been if you could not trust your subordinates. Imagine what kind of company P&G would be if your down-line directors believed they could mislead you and get away with it. Your chances of accomplishing real reform would be next to nil.

The VA has many great, duty-minded, veteran-centric employees. It also has too many employees, in too many important positions, who have demonstrated they will lie. They must go.

The third of your challenges is time. Bureaucracies as large and dysfunctional as the VA will resist change by waiting you out. You have no more than 31 months — realistically, less — to enact reforms before President Barack Obama leaves office and the next wave of political appointees moves in. You must act quickly.

There are steps you can take that will improve your chances of ensuring quality health care for vets. None will be easy. Some are dramatic.

Advocating for these changes will not win many friends. But you will re-construct a VA health-care system that is what it should be: an effective provider of the specialized health care earned by those wounded in service to their country.

President Obama departed from tradition by turning VA leadership over to a successful private-sector executive. You know why as well as we do. He expects results, and you have a track record of getting them.

An executive gets results by identifying challenges and attacking them with sound, achievable solutions. We believe the solutions we offer will make the biggest difference in the lives of veterans.

As for how to address these challenges, read on. And good luck.

Resolution 1: Downsize.

It is a clear disservice to veterans when the VA makes promises it cannot keep. Vets with war wounds, including often-hidden ailments like post-traumatic stress disorder and concussions, have always been the VA's top priority. They should be the system's only priority. Or nearly so.

By focusing on those injured in service to their country, the VA can ensure they get the best care possible. We owe it to them.

This mission — the VA's historic mission — also will improve care for all other veterans in the system. They are more likely to see a doctor quickly in the private sector, and they will not be an afterthought in an overwhelmed system.

The VA performance audit ordered by the White House and released last month showed wide discrepancies in quality of care among facilities. Seeing the doctor shouldn't be a roll of the dice.

Quality is more effectively monitored in the private sector. Make use of it. Whether through vouchers or an expansion of TriCare, the system serving uniformed military personnel, you must consider options in the private health-care market.

Reflect on how you got here. The VA health system's evolution over the years — from an agency narrowly constructed to address the unique health-care needs of returned war vets to a shadow Medicare system — caused profound mission bloat.

Seeking to be an all-purpose health-care system for all veterans turned out to be an act of bureaucratic "compassion" that locked at least 65,000 sick veterans out of an appointment with a VA doctor.

That is not just evidence of an overwhelmed system. It is evidence of a system frozen in pathological stagnation. In mortal stasis. There is no effective way to "fix" a system this big, with this many divergent priorities. Building more hospitals and adding to the bloat, as a Senate bill would do, will not help.

Bigger is the enemy of better. A trimmer VA, undistracted by other demands, can better treat war veterans. The private sector, where quality is more effectively monitored, is better equipped to treat the rest.

This is not a reform the VA can accomplish overnight, especially when the private sector is adding millions of non-veteran patients through the federal Affordable Care Act. But, in time, the VA system can and should find the means to place the vast majority of its patients in a system that can provide them with quality care promptly.

That is the approach recommended by Dr. Gail R. Wilensky, one of the nation's foremost authorities on reforming public-health systems. "Over time," she told us, the VA "should allow the private sector to take on veterans' other medical needs," while focusing on "those conditions that require complex interventions that are directly related to war injuries."

Resolution 2: Focus on those "complex interventions" the VA does well.

VA medical researchers have led the world in developing new treatments for patients suffering the wounds of war, including PTSD and concussions. A veritable revolution in the design of artificial limbs and other prosthetics have served to make horribly wounded service veterans nearly whole again.

The VA has developed other areas of expertise. It has a world-class reputation for its breakthroughs in post-stroke care and rehabilitation. It should continue — and enhance — that which it does best.

At its best, the VA has been a lifeline for wounded vets who could not have found civilian medical care that understood their unique needs. That was the fundamental premise behind President Abraham Lincoln's order establishing the National Home for Disabled Volunteer Soldiers in 1865. And it was the driving force behind the creation of the modern VA following World War I.

That original mission is the job the VA does as well as anyone in the world. It must return to it.

Celebrities like Larry Fitzgerald support vets. Do you? The above photos were culled from the #standwithvets social-media campaign.

Resolution 3: Enact a zero-tolerance policy for lying to the boss. This would include zero tolerance for the boss lying to himself.

The VA has been doling out $400 million in performance bonuses per year. Directors of the Phoenix VA hospital received $10 million in bonuses the past three years.

All of this lucre has been doled out despite at least 30 audits, reports and investigations by federal oversight agencies between 1999 and 2013 that found serious, pervasive and chronic problems with patient wait times.

A CEO should be able to add two plus two. If your directors are reporting flawless patient care while everyone outside the organization is reporting a serious, chronic problem with patients waiting for care, that means you are not getting accurate information. In the private sector, heads would roll for that kind of discrepancy. They should be made to roll at the VA, too.

This is not a comprehensive list of the challenges you face, or the resolutions you may propose. But you're a CEO. You deal with the big stuff.

If you address the challenges cited above, you have a real chance to effect the kind of reform America's service veterans deserve. Which is to say, profound reform.

Anything less would be just kicking the can forward. We assume you didn't take on this huge task for that.