Learning from the VA Mess

 As I am sure everyone knows, Eric Shinseki resigned his position as Secretary of the Veteran’s Administration. That is appropriate if only because that is how Washington should work. As I was told many years ago, once ‘you’ become the lead part of the story, you need to go. This of course pertains mainly to senior appointees, but the point is simple: Shinseki isn’t supposed to be in that job for his own good; he is there – as is every appointee in every administration – to further the platform of the president who appointed him. So, once you are more news then the organization or the platform the odds are you are taking away from the platform. Thus, time to go.

All that being said, what can we learn from what has happened and what is happening with the VA?

I had an opportunity to talk with a very experienced Washington lawyer this past week about much of this. I made the statement that we don’t even know what is going on at the VA, in a fundamental sense: we don’t have a comprehensive inspection system, and the VA – like all the other departments in the government – has never been independently audited. (The VA, like every other department and agency in the Executive Branch has an Inspector General and a Comptroller – but they do not attempt top to bottom audits, the federal government uses its own accounting system [one that is so far removed from the accounting procedures used by private and commercial sectors that use of it would land you in the hoosegow] and there is no formal process of inspection, reporting and grading in most of the departments, the uniformed services being an exception in that specific regard.)

As my friend said, right now you probably couldn’t complete an audit – a true audit – of the VA. They have operated within the rules of the federal fantasy world that – like DOD – no one really thinks a true audit is possible. (In the mid 1990sDOD was ordered by Congress to switch something approaching ‘common accounting practices’ but has failed to do so. In 2010 Congress ordered DOD to be ready for a ‘full audit’ by 2016; just several weeks ago the comptroller for DOD told Congress that the DOD was not going to be able to meet that deadline – 7 years isn’t enough to prepare for an audit.)

So, the first lesson we need to learn is this: you can’t know what is right and wrong if you can’t know anything. Said differently, you need to keep orderly books. That sounds pretty mundane, and pretty obvious. And while it is for corporate America, there are many small businesses, and even more charities, non-profits, and state and local government agencies that simply don’t have squared away books. And if you can’t put your finger on your assets and liabilities – all of them – then you have no starting point. So, get your books straight.

The second point is this, and this pertains to any organization of more than two people, you need to have standards and you need to inspect to those standards. In the early days of any organization everyone knows ‘where you are going,’ and everyone is working just as hard as they can. But that knowledge and passion can fade quickly.  With it will also fade your excellence. So you need standards. And you need to have some sort of inspection and grading process. Recommendation: set really high standards, ones that look impossible to meet. And establish a yearly (at a minimum) inspection regime for your major elements – whatever they are.

Now, this doesn’t need to be onerous, dramatically formal, or terrifying; it doesn’t need to be a form of punishment. But there does need to be some process to ensure high standards are set and met. Inspections can be used to identify problem areas where you need to commit more training assets or any other type of assets, to include leadership attention. In fact, done properly, inspections can become a key tool for constant improvement of the organization and the people in it.

Third, your organization – the formal organization – will very rapidly grow into its own ‘persona,’ and as such, it will consume energy to protect itself, not help your mission.

As a result, performance can be misleading; you need to regularly dig into the actual workings and understand what is going on. For example, there was certainly some good, and in some cases ex exceptional medical treatment in Russian hospitals at the peak of the Soviet Union; but that's not because the system worked, it's because there is a common thread of decency in most people and the bulk of the people who end up as doctors and nurses - anywhere, any time - want to help. So, they do. The question that needed to be asked then (assuming the leadership in the USSR cared – which they didn’t) and which needs to be asked and answered now with regard to the VA is whether the system is helping, neutral or hurting the practice of doctors and nurses helping patients.

As an old friend used to say (3 decades ago), whenever you debrief any operation, and your decisions in that operation, you need to know what decisions worked and why, which ones didn't work and why not, and which ones were irrelevant and why.

How many times have you heard (said for that matter) something to the effect 'well, the director (CEO, President, etc.) was all hosed up and the directions were a mess, but we figured out a way around the road block and made it work.' (That is nearly the motto of some organizations.) Every time someone says that they are saying the system - the organization - isn't part of the solution. At best it is not helping and not hurting. But, in all likelihood, it is hurting.

You need to take the time to understand precisely how your organization is helping – or hindering – your people in the performance of their tasks. And you also need to understand if and when you are having no impact on the organization, when your ‘decisions’ have no meaningful impact on operations.  But, if your people are constantly commenting on ‘finding a solution’ outside the system, you have a serious problem.

Lessons Learned

When people talk about leadership they love to talk about vision, and mission statements and ‘motivating the troops,’ and all the other pieces that can make being a leader – at any level – both challenging and exciting. But there is another piece to leadership, and it is as necessary a part of leadership as are the fundamentals of vision, intellect, communication and the rest. That piece is the process of learning from mistakes.

In the military, particularly in certain high performance communities such as fighter aviation and Special Forces, there is a process that is known colloquially as ‘the debrief.’ In fact, there are a broad range of ‘debriefs,’ from the intense, 20 minute long, pointed tactical debriefs that take place immediately after every flight or every special warfare ‘problem’ – whether operational  (real) or exercise, all the way up through theater-wide collection of ‘lessons learned’ that take weeks or months to assemble and are analyzed by the various war colleges and such offices as the ‘Center for Naval Analysis.’

All of these various efforts have as their goal improving the performance of all those involved and all those that will follow. Properly done, this process will improve both the planning and execution of any effort, unit level training, and the equipment used, and most importantly, will improve the decision-making ability of those involved.

There are three major cognitive categories of every de-brief or lesson learned:

- What worked and Why?

- What didn’t work and Why not?

- What worked in spite of your actions?

There are more possible ways to parse this, but when done properly, these three major subdivisions will in fact encapsulate all the other possible categories.

This is nothing more than an effort to learn from experience, so that all benefit from the mistakes of others. To do it well requires several characteristics, including the ability to accurately collect information on what has taken place, the ability to accurately relate and analyze that information, and the ability to coldly and clinically analyze and evaluate the results.  This last item, the ability to understand what happened and reach an accurate conclusion, is the most important part of the entire process. Without it the process is meaningless. And without it, it is impossible to become a top decision-maker.

Good ‘debriefers’ become such because they practice the art for years, continually honing what can only be described as an art. To watch a top fighter pilot or SEAL debrief an operation is to understand the full scope of a real professional. It requires dedication to excellence, discipline and a critical eye; and years of practice.

Of course, one of the real problems with Lessons Learned is that if you keep at it long enough you will eventually arrive at a problem in which the next step is ‘start over with a completely different concept.’

This is perhaps the hardest decision that any organization can face – though to give the ‘devil his due,’ DOD has made this decision from time to time. Examples mainly can be found in procurement decisions in which certain classes of weapon systems have been terminated. For example, in the 1960s DOD and the Air Force ended the B-70 high altitude, supersonic bomber when it became clear that the technology trend for future weapons made the survivability of such an aircraft unlikely. Businesses have the advantage that they can attach profit and loss figures to many concepts, making the decision to stop easier in some – but certainly not all – cases.

But, in the end, the key is that the experiences of the past need to be continually analyzed and assessed and good leaders will evaluate those assessments and decide when it is time to say ‘enough.’

It is worth noting that this is what is not happening in the federal government; we have several echelons of leadership that are seemingly incapable of recognizing that they are incapable of controlling what is happening in the ever expanding and increasingly complex departments and agencies. Large businesses have the advantage of clearly understood returns on investment/profit and loss statements to ‘keep them honest’ – hard data points that allow them to ‘fall back’ onto more or less objective material; governments do not. Healthcare can be measured either at the very personnel level – between you and your doctor, or it can be measured in profit and loss statements among the various businesses that make up the health care industry. But the efforts to control large and sprawling operations such as government health care are showing an organization that has already unraveled. But the leadership refuses to see that the only reasonable step at this point is to reduce the size of the effort and their own span of control.