"We now know there is a leadership and integrity problem among some of the leaders of our health care facilities, which can and must be fixed.  That breach of integrity is indefensible," said then acting Veterans Administration Secretary, Sloan Gibson in June, 2014. The VA experienced long waiting lists and kept double sets of books as well as secret lists of unseen veterans. Veterans may even have died while waiting to be seen.

Measurements seemed more important than mission in many parts of the VA. A White House audit revealed that 13%of schedulers reported that supervisors told them to falsify wait times to make them appear shorter than they were. In fact, The inspector general had issued numerous reports in recent years that identified scheduling deficiencies, resulting in lengthy wait times and negative impact on patient care. 

The VA is in crisis. From 2002 to 2012, health care enrollees increased by one-third to 9 million. Outpatient visits doubled to 83 million per year. In the last three years, primary care visits have increased by 50%, but health care providers by only 9%.  It is abundantly clear that the VA needs to undergo a culture change. Its mission involves serving and honoring the men and women who are America's veterans.  While the VA's values acronym is "I CARE" standing for "Integrity, Commitment, Advocacy, Respect and Excellence," mission and values appear to have been overlooked.