Eric Shinseki set a positive tone at the top of the VA system, but he evidently had misplaced faith in his employees. (Chip Somodevilla/Getty Images)

by Melinda Henneberger

Janet Nickolaus, who took early retirement from her job as a psych nurse in a Veterans Affairs health clinic in Port Angeles, Wash., a year ago, used to fantasize that Secretary of Veterans Affairs Eric K. Shinseki would visit their waiting room incognito “and see how people were being treated and find out what was going on.”

What he would have seen, she said, is receptionists effectively making “medical, clinical decisions” by deciding who would be seen when — and sometimes telling veterans to call back in 30 days.

“That’s what bothered me the most, but when I complained,” she said, a supervisor disputed her direct observations. She finally left in frustration.

A current employee at the clinic, who spoke on the condition of anonymity out of fear of retribution, said that “horrendous” situation had improved recently after two receptionists retired.

Veterans Affairs Secretary Eric Shinseki apologized to veterans and their families, to members of congress and to the American people Friday morning, saying the recently revealed issues at the VA are "indefensible" and announcing changes within the system. (Associated Press)

“But vets still can’t get in for three or four months, even in our brand-new clinic. We burn our doctors out because there’s no support, and to try to change anything is impossible because it doesn’t even get past our manager. It’s like they don’t want to deal with the issues.” The clinic manager did not return a call seeking comment Friday.

To many in the trenches of the vast and decentralized VA system, Shinseki was seen as “the good guy everybody knew was trying to help,’’ Nickolaus said.

But of course, that undercover drop-by she hoped for never happened. And so much bad news was covered up that Shinseki resigned Friday over a widespread conspiracy to hide long wait times for military veterans seeking care.

It’s often said that an organization’s tone is set at the top — and that person sends employees a message of either fear or safety about speaking up to voice concerns. Yet just the opposite seems to have occurred at the VA, as Shinseki traveled the country urging bureaucrats not to be afraid to bring problems to light.

“It’s never just one leader who creates a culture’’ or changes it, said Palo Alto, Calif.-based organizational change consultant Lisa Friedman, co-author with her husband, Herman Gyr, of “The Dynamic Enterprise: Tools for Turning Chaos into Strategy and Strategy into Action.’’ In her work all over the world, she has frequently seen “competing messages” within organizations — and sometimes, a competing message can drown out the voice of the nominal leader, or even change him or her. Shinseki may not have been changed by the apparently swamped bureaucracy underneath him, but with 2 million more patients entering the system in just the last five years, neither was he apparently able to reform it.

When he put new guidelines in place requiring that veterans be seen quickly, the response was to fake the paperwork to make it look as though wait times had disappeared.

But with nothing less than the lives of our veterans at stake, how could employees do that, and why would they lie?

Nickolaus’s answer to that question is that after years of being “told to shut up or retire,” most people eventually do one or the other. “You see the dead wood and get exasperated.”Overwhelmed, she said, you despair of actually changing anything, in other words, and give up.

Two other former VA employees dispute speculation that financial incentives for some managers in facilities that cut wait times might have been a motivator for those who falsified paperwork; they question whether low-level employees would really band together to break the law in hopes of winning a bonus for a boss’s boss’s boss.

But if that wasn’t the motivation, why resort to trickery instead of sounding the alarm that the guidelines weren’t realistic?

Army vet Alex Horton, a blogger from Texas who served in Iraq and worked in the VA’s public-affairs operation for three years under Shinseki, suspects that “most of it is keeping your supervisor off your back.”

He sees Shinseki’s only real failings as, first, trusting that his own dedication to the mission of getting veterans the care they deserve was widely shared in a bureaucracy full of what he saw as “dead-enders who don’t care who’s on top.” And then, too, Horton said, Shinseki “did things the Army way; you don’t fire junior soldiers, you retrain them.”

It’s difficult to fire anyone in the VA system, said another former employee, and an issue no one wants to talk about is that some subpar workers are veterans themselves.

The VA’s ancient IT system was also a problem. A May 2010 report from the U.S. Government Accountability Office said the care of more than 5 million vets in some 1,500 facilities “relies on an outpatient scheduling system that is over 25 years old.” In 2000, the report noted, a major overhaul was planned, but in 2009, the VA finally “terminated a key contract supporting the project.”

For good reason, apparently, since “after spending an estimated $127 million over 9 years on its outpatient scheduling system project, VA has not implemented any of the planned system’s capabilities.”As a result, the report said, the VA was cutting its losses and “essentially starting over.”

Nickolaus, who worked for the VA in Port Angeles and before that in Portland, Ore., said she wasn’t too surprised by the dreadful news out of the Phoenix VA Health Care System, where dozens of veterans allegedly died waiting for care. That’s because a former colleague of hers from Portland had gone to work in Phoenix, then almost immediately moved back to Oregon.

When a psych nurse in the Northwest hears whispers of dysfunction in Phoenix before Arizona Sen. John McCain (R), whose dedication to the military no one doubts,something is seriously wrong.

Watchdog reports as far back as 2000 document some of the current problems, so why hadn’t members of Congress from around the country heard complaints of long waits at facilities in their home areas? Why hadn’t the heads of the veteran service organizations, with whom Shinseki had breakfast every month? And for that matter, why hadn’t reporters in every city and town where there’s a VA facility?

A decorated Vietnam veteran who lost part of his right foot when he stepped on a landmine, Shinseki was awarded three Bronze Stars and a Purple Heart. As Army chief of staff during the George W. Bush administration, he dared to publicly disagree with Secretary of Defense Donald Rumsfeld over how many troops would need to stay on in Iraq after an initial invasion.

If the four-star general thought his own underlings at the VA would be that stand-up, however, he seems to have wildly overestimated them.