A key aspect of Tiger Teams is their ability to stress test, beta test, and routinely check how operations are performing and recommend changes from the position of the customer. Recently the Department of Veterans Affairs (VA) – Office of Inspector General (VA_OIG) investigated a critical piece of the Mission Act of 2018, the health information exchanges. While the VA-OIG received useful and valuable information from the VA and the community provider side, the customer/patient side was not included. From experience, I can affirm this is broken!
Recently, a veteran needed emergency care and received that care through the community providers under the Mission Act of 2018. The records from the community care provider never transferred to the VA, the billing has been a mess of letters and notifications, and the patient’s issues were never followed up with the VA provider until the patient called and made it an issue. One of the main selling points for community providers was to share electronic health information easily with the VA, which included notifying the primary care providers when a patient was seen in the community. This aspect remains a “pie-crust promise” as well as a frustrating issue for patients and VA providers alike.
Before the Mission Act of 2018, if the veteran patient was sent to a community provider, the patient transferred manually all records to and from the VA and the community provider. Allowing for lost records, duplicated records, and a host of problems in bureaucracy. One of the issues the veteran experienced in seeking community care was the historicity of medical records to reduce costs and not duplicate tests; however, the community provider was never able to obtain that historicity and the emergency room costs were greater for the VA.
Thus, the need to operationally check the system, processes, and patient experiences using Tiger Teams. A Tiger Team is a group of experienced people who interact with the business as customers, who have been granted the authority to make changes and see those changes implemented. These are a selected group who work from a central office and are dedicated to improving business performance. While I applaud the progress made with conforming to the Mission Act of 2018, there remains significant work in the patient experience to be completed and currently, the situation is not the roses and rainbows the VA-OIG is portraying.
Tiger Teams are also helpful in another way, that of “bird-dogging,” or acting as the researchers, and developers of ideas towards making improvements. The VA-OIG recently brought to light that the VA needs to expand retail pharmacy drug discounts. With the number of prescriptions filled by the VA hourly, the fact that the VA does not have volume discounts was surprising, but unfortunately, not unexpected. The VA-OIG estimated that of the $181 million spent on retail drugs in fiscal year (FY) 2018, $69 Million would have been saved. From the VA-OIG report:
“VA is one of four federal agencies eligible by law to receive at least a 24 percent discount for prescription drugs purchased for its facilities and dispensed directly to patients. However, for prescription drugs purchased through retail pharmacies for beneficiaries, VA pays the higher average contracted wholesale price because it does not have the authority to require drug manufacturers to provide the drugs at discounted prices.” [Emphasis Mine]
Unfortunately, the program inspected for savings on retail pharmacy prescription was but one of several VA drug programs lacking statutory authority to save the taxpayers from being gouged on prescription drugs dispensed through retail programs at the hands of the VA. Hence, the findings are surprising, but not unexpected. How long before the VA secretary will collaborate with the Office of Regulatory and Administrative Affairs to pursue whatever changes are required to give VA the appropriate legal authority to purchase all prescription drugs through retail pharmacies at discounted prices? At the tune of one program saving $69 Million a year, the benefits add up in a hurry.
How would Tiger Teams help in this situation; by doing the legal leg work, establishing relationships, initiating inquiries, and discovering all the other programs where the statutory authority is missing to close a gap and save money. While the VA Secretary is responsible, delegating this authority to a Tiger Team saves time and improves the patient and taxpayer experiences. This is why the Tiger Team must work from the VA Secretary’s Office, endowed with the power of the secretary, to make and affect change for the good of VA.
Finally, the power of Tiger Teams is also manifested to the VA in another way, returning to a situation after the VA-OIG has made recommendations to ensure compliance occurs. Another recent VA-OIG report shows that after a scathing VA-OIG inspection, the Department of Veterans Affairs – Veterans Benefits Administration (VBA), was still out of compliance in their internal quality control procedures, systems, and processes. While some improvement had been made to spot errors, the procedures and processes that allowed those errors to occur were receiving zero attention by the internal quality inspectors. Which is akin to noticing the horse is out of the barn, but not shutting and locking the door to keep the horse in the barn. There is no valid excuse for the VBA quality controllers to not have been doing their jobs since the last VA-OIG Inspection.
The Tiger Team, with sufficient and specific authority, has the power to cut through the excuses, the red tape, and the intransigence of federal employees to root out the why, and establish a path to correction. Yet, the VA Secretary is not using the Tiger Team concept as a tool to effect change, power compliance, and intervene to improve the veteran experience with the VA, the VBA, the VHA, and the National Cemetery.
Suggestions for improving the processes at the VA continue to include:
- Establish forthwith a roving Tiger Team, provide these employees with proper authority, and set them to work fixing the VA. Allow the Tiger Team to establish flying squads inside the agency, hospital, medical center, etc. to report back on compliance issues, and any pushback they receive in correcting errors.
- Cut the bureaucracy that intransigent employees are using as a tool to stop or slow down change. The VA’s internal bureaucracy is the tail that wags the dog and since it is out of control, it requires an external force to regain control and proper order.
- Imbue the Tiger Team with an active mission statement, purpose, and organizational design. The Tiger Team is an active, not passive, tool that requires people dedicated to making change and seeing results.
Never has the axiom, “If it ain’t broke don’t fix it,” been less true. The VA is broken and desperately needs fixing. With the help of those dedicated VA Employees, the proper leadership, and a Tiger Team to aid, the VA can be fixed and fixed quickly!
© Copyright 2020 – M. Dave Salisbury
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