Culture, Cover-ups
Plague VA Health System

Appointment delays, inaccurate reporting and varied quality of care found

Last fall, Thomas Breen, a 71-year-old U.S. Navy veteran noticed blood in his urine. With a history of bladder cancer, Breen called his Veterans Affairs (VA) hospital in Phoenix for a follow-up appointment. He had to wait months to get in. In the meantime, his family took him to a private hospital where he was diagnosed with bladder cancer. As Breen’s daughter-in-law told the Los Angeles Times, when the VA called in early December to schedule an appointment, she informed the scheduler it was too late—Breen had died on Nov. 30.1

At another VA health facility, just a few weeks into his new job as a scheduling clerk at a VA clinic in Austin, TX, Brian Turner was instructed to "cook the books."

"They said, ‘You gotta zero out the date. The wait time has to be zeroed out,’" Turner told the Washington Post.2

"Zeroing out" was a workaround for the VA’s accountability system, which was monitored by supervisors in Washington, D.C., to ensure patients weren’t waiting too long for appointments. When a patient would ask for an appointment on a specific day, Turner would search for the next available time—which was usually several days later. When the patient agreed to the later date, Turner would type that the patient requested the later day. Suddenly, a wait time that may have been much longer was reported as zero days.3

Occurrences like these are why an investigation was launched into allegations that VA healthcare facilities were manipulating patient waiting lists to hide long delays in access to care. The Phoenix VA healthcare system is at the center of the scandal—managers there are being accused of falsifying records to make it appear patients were being seen within the VA’s standard for a timely appointment, which is about 14 days. In actuality, patients in Phoenix waited an average of 115 days for an appointment, and secret waiting lists were kept to hide the true wait times.4

A nearly month-long internal audit completed in early June shows these problems are systemic across the wider VA healthcare network. The audit of 731 VA facilities and nearly 4,000 employees found nearly 60,000 veterans were waiting for appointments at VA health facilities, and 70% of VA facilities have used alternative scheduling methods so wait times appear shorter. More than 10% of scheduling staff reported they were instructed to alter patient appointment scheduling.5

Backtracking on progress

The VA Health Administration (VHA) is the largest integrated healthcare network in the United States with 1,700 hospitals, clinics, counseling centers and nursing homes throughout the country.6

In the past, the VA healthcare system has been viewed as a leader in medical advances, especially when it comes to gathering and releasing performance data. In 2011, it began publishing hospital medical complication and surgical death rates based on a national surgery quality improvement program. An internal database called Strategic Analytics for Improvement and Learning (SAIL) tracks procedure outcomes and ranks VA hospitals on various safety measures for benchmarking.7

The VA healthcare system’s patient satisfaction scores are high—a 2013 survey by VA found 93% of patients said they had a good experience when they received care. A 2005 comparison of VA patient medical records with a national sample found better quality of care at the VA, especially for depression, diabetes, high cholesterol and hypertension.8

So, how did access to care become a problem?

Part of the cause has been attributed to a shortage of doctors—particularly primary care physicians—coupled with an increased demand for VA healthcare. The American Federation of Government Employees reports some VA doctors carry workloads of more than 2,000 patients. The goal set in the VHA handbook is 1,200.9

Preliminary audit results sent to President Barack Obama pointed to an "overarching environment and culture which allowed this state of practice to take root."10

Consider the accountability reporting system that was supposed to make officials in Washington, D.C., aware of problems in the field through data. Instead, a culture of manipulating data to hide deficiencies developed, and employees risked backlash for pointing out patient care issues.11

Even when officials learned this was happening, as they did in 2005, and attempted to address the issue, honest reporting wasn’t enforced.

"Because of the fact that the gaming [manipulating the system] is so prevalent, as soon as something is put out, it is torn apart to look to see what the workaround is," said William Schoenhard, who was working as the deputy undersecretary for health for operations and management in 2005. "There’s no feedback loop."12

Furthermore, while the criticism and investigation of the VA healthcare system has revolved around patient wait times for appointments, SAIL data show there is another serious problem within the VA healthcare system—widely varying patient care results among VA facilities and what experts call "a slippage of quality" at some facilities.13

Next steps

On May 30, Eric Shinseki, the Department of VA secretary, resigned. Shinseki said he was unaware of the access to care and reporting issues engulfed in the system. Following the results of the internal audit, an external, independent audit of scheduling practices will take place.14

As the VA healthcare system looks to fix its systemic issues related to access to and quality of care, refining its performance-metric reporting system will be key.

According to William E. Duncan, who supervised the publication of medical outcomes until 2012, "The goal was not for hospitals to be average performers. The goal was to be in the top 10%. Our patients have little recourse, and they rely on our staff to tell them the truth. We can’t forget that medical quality is not just access to care."15

—Compiled by Amanda Hankel, assistant editor


  1. David Zucchino, Cindy Carcamo and Alan Zarembo, "Growing Evidence Points to Systemic Troubles in VA Healthcare System," Los Angeles Times, May 18, 2014, www.latimes.com/nation/la-na-va-delays-20140518-story.html#page=1.
  2. David A. Fahrenthold, "How the VA Developed Its Culture of Coverups," Washington Post, May 30, 2014, www.washingtonpost.com/sf/national/2014/05/30/how-the-va-developed-its-culture-of-coverups.
  3. Ibid.
  4. Sandhya Somashekhar, "Some of the Internal Problems That Led to VA Health System Scandal," Washington Post, May 30, 2014, www.washingtonpost.com/national/health-science/some-of-the-internal-problems-that-led-to-va-health-system-scandal/2014/05/30/399095b4-e81e-11e3-8f90-73e071f3d637_story.html.
  5. Ben Kesling, "Nearly 60,000 Veterans Face Delays Receiving Health Care—VA Audit," Wall Street Journal, June 9, 2014, http://online.wsj.com/articles/over-100-000-veterans-face-delays-receiving-health-careva-audit-1402339138.
  6. Somashekhar, "Some of the Internal Problems That Led to VA Health System Scandal," see reference 4.
  7. Thomas M. Burton and Damian Paletta, "Veterans Affairs Hospitals Vary Widely in Patient Care," Wall Street Journal, June 3, 2014, http://online.wsj.com/articles/veterans-affairs-hospitals-vary-widely-in-patient-care-1401753437.
  8. Somashekhar, "Some of the Internal Problems That Led to VA Health System Scandal," see reference 4.
  9. Ibid.
  10. Michael D. Shear and Richard A Oppel Jr., "V.A. Chief Resigns in Face of Furor on Delayed Care," New York Times, May 30, 2014, www.nytimes.com/2014/05/31/us/politics/eric-shinseki-resigns-as-veterans-affairs-head.html.
  11. Zucchino, "Growing Evidence Points to Systemic Troubles in VA Healthcare System," see reference 1.
  12. Fahrenthold, "How the VA Developed Its Culture of Coverups," see reference 2.
  13. Burton, "Veterans Affairs Hospitals Vary Widely in Patient Care," see reference 7.
  14. Kesling, "Nearly 60,000 Veterans Face Delays Receiving Health Care—VA Audit," see reference 5.
  15. Burton, "Veterans Affairs Hospitals Vary Widely in Patient Care," see reference 7.


ISO 9001 Draft Available
For Public Comment

ISO 9001—Quality management systems—Requirements, the most widely used International Organization for Standardization (ISO) standard, has been made available as a draft international standard (DIS), a key milestone in its revision process.

As all ISO standards, ISO 9001 is reviewed every five years and is now being revised to ensure it is relevant and updated. At the DIS stage, all interested parties can submit feedback that will be considered before the final draft is published by the end of 2015. In addition, the draft version now can be purchased, giving organizations the opportunity to get a taste of the new standard before the final publication date.

Comments will be accepted until July 15. For more details, visit http://asq.org/standards-draft-iso-9001-2015.html. Only U.S. stakeholders can provide public comments. Other stakeholders can purchase the standard or contact their National Standardization Bodies to learn how they can contribute.


Baldrige Singled Out in Report to President Obama on Healthcare

A recent report sent to President Barack Obama called out the Malcolm Baldrige National Quality Award as an opportunity "for raising awareness of performance excellence" in the U.S. healthcare system.

In the 66-page report released in late May, the President’s Council of Advisors on Science and Technology (PCAST) offered seven recommendations to Obama, "all of which support and reinforce each other as components of a strategy to improve the quality of delivery of healthcare and the health of Americans through systems engineering," the report said.

The Malcolm Baldrige National Quality Award was specifically mentioned in the sixth recommendation: "Establish awards, challenges and prizes to promote the use of systems methods and tools in healthcare."

The report continued: "Health and Human Services and the Department of Commerce should build on the Baldrige award to recognize healthcare providers successfully applying system engineering approaches."

 The report, titled "Better Healthcare and Lower Costs: Accelerating Improvement Through Systems Engineering," can be accessed at http://tinyurl.com/pk23tq9.


Two Teams Reach Gold
Status At ASQ Competition

United Arab Emirates’ Dubai Aluminium and Argentina’s Tgestiona were awarded gold-level status at ASQ’s International Team Excellence Awards after showcasing how they increased quality and financial savings at their respective organizations.

ASQ announced the gold-level winners—along with silver and bronze—at its recent World Conference on Quality and Improvement, which was attended by nearly 2,800 people. In the awards’ 29th year, 39 teams from 14 countries competed.

Dubai Aluminium’s stub repair reduction team used lean Six Sigma and the define, measure, analyze, improve and control method to slash repair costs by reducing product damage from 6% to 3%, resulting in $1.3 million in annual savings.

Tgestiona’s matter of time team used Six Sigma to address the process for handling customer access to the company’s systems, which affects more than 20,000 users of 256 systems. The results included reducing the error rate from 10% to 0.05%, and reducing processing time from 26 days to fewer than three days.

For more information about the award recipients and the team excellence award process, visit http://asq.org/wcqi/team-award.

Short Runs

THE INTERNATIONAL CONFERENCE on Quality 2014—Tokyo will be held Oct. 19-22. The conference takes place every three years and is sponsored by ASQ, the European Organization for Quality and the Union of Japanese Scientists and Engineers. Visit www.juse.or.jp/e/conventions/202.

THE SOCIETY OF Automotive Engineers (SAE) Foundation received a $75,000 grant from the Chrysler Foundation to continue providing science, technology, engineering and math education programming to K-8 students. An SAE program called "A World in Motion" gives younger students opportunities to learn about math and science concepts. For more details, visit www.sae.org/news.

ASQ News

ASQ RECEIVES AWARD  ASQ achieved the excellence level of achievement from Wisconsin Forward Award Inc., the state award’s top recognition. The award is modeled on the Malcolm Baldrige National Quality Award framework, process and criteria. ASQ will join other Wisconsin-based organizations receiving the award at ceremonies in December. For more information about the award, visit www.wisquality.org/wfa/wfa.

SCHOLARSHIP RECIPIENT  ASQ’s Healthcare Division awarded its annual $2,000 Nightingale Scholarship to Ellen Martin, a doctoral student in the school of nursing at the University of Texas-Austin. Martin was recognized for demonstrating an outstanding commitment to pursuing quality improvement in the healthcare field. For more information about Martin and the award, visit www.asq.org/media-room/press-releases/2014/20140512-nightingale-scholarship-winner.html.

NEW CASE STUDY ASQ’s Knowledge Center released a new case study about India-based Max Life Insurance and how it improved customer retention through Six Sigma and quality tools. The improvement project nearly tripled Max Life’s customer retention rate and generated more than $8.6 million in revenue. Read more at http://asq.org/knowledge-center/case-studies-max-life-improves-customer-retention.html.

LSS TRAINING OFFERED Redesigned lean Six Sigma Green Belt and Black Belt courses are being offered by ASQ. The courses will teach participants to use lean and Six Sigma tools to improve workflow and reduce inefficiency. The peer-reviewed courses, created and taught by Master Black Belt industry experts, include instructor-led classroom training and one-on-one coaching. For more information or to register, visit www.asq.org/sixsigma-elite.

NEW ISO/IEC TRAINING ANAB unveiled new training on ISO/IEC 17021, Conformity assessment—Requirements for bodies providing auditing and certification of management systems. The training will provide an understanding of the requirements of ISO/IEC 17021 and its relationship with other certification scheme standards and International Accreditation Forum documents. The course also includes information about potential developments related to the revision of ISO/IEC 17021, scheduled for release in late 2014. For more information, visit www.anab.org/resources/anab-training.

Who’s Who in Q

NAME: Bryan T. Blunt.


EDUCATION: MBA from Western International University in Tempe, AZ.

INTRODUCTION TO QUALITY: While Blunt considered product quality to be a top priority throughout his working career, the light really came on regarding process quality when he was a manufacturing engineer at AlliedSignal.

PREVIOUS JOBS: Director of quality for Textron Systems Inc., director of quality for Lycoming Engines and director of supply chain quality for Cessna Aircraft Co.

CURRENT JOB: President, Quality Works Consulting LLC.

ASQ ACTIVITIES: Past section chair of two ASQ sections and immediate past nominating chair of ASQ Phoenix Section.

ACTIVITIES/ACHIEVEMENTS: One of the earliest Black Belts certified at AlliedSignal, where the first large-scale deployment of Six Sigma took place after its initial development. Received Textron Six Sigma’s prestigious "Top Gun" award. Currently a doctoral student in organizational leadership at Grand Canyon University in Phoenix. Involved in several areas of church ministry.

PUBLISHED WORKS: Author of Turnaround: The Quality Path to Saving the Business (QW Press LLC, 2011).

RECENT HONORS: Blunt was part of the 2013 class of ASQ fellows.

PERSONAL: Married, three sons and eight grandchildren.

FAVORITE WAYS TO RELAX: Reading, playing the guitar and spending time with his wife and their pet labradoodle.

QUALITY QUOTE: "There are no great businesses that are not excellent in terms of quality."

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