While receiving a call from the local VA to schedule an appointment, where the VA initiated the call, I discovered a genuinely despicable practice had spread at my local VA. I have a name, that name is not “Honey,” “Darling,” “Sweetie,” or other terms of endearment. If you employ a term of endearment in professional exchanges, you are practicing the height of disrespect. I expect to be called “Darling” when I visit independent truck stops in the Southeastern US and Texas. My wife does not use these terms, my friends use my name; why is the VA, specifically in New Mexico, allowed to employ such disrespect? My name is on the computer in front of you, why are you choosing to not use my name? Where is quality control? Where is the leadership team in preventing problems from becoming a VA-OIG inspection issue?
Quality control is powered by actively engaged leadership and includes call monitoring, training materials, risk control, attitudes, behaviors, and so much more. When there is no quality control, the business experiences a phenomenon comparable to a herd of dairy cows, fresh from milking. Each cow will head off in different directions, the adventurous cows will run to the farthest fence and push against the boundaries, finding a definite boundary, they return to the middle of the field and graze. Finding weak limits, or no boundaries, the cows will wander all over the place and never eat properly. The less adventurous cows will plop themselves down, and be intransigent until they discover the boundaries are gone, and then the crazy in cows comes out. Some of the cows will bawl incessantly, some will stop eating, others think they can be adventurous and get tangled in fences or eat the wrong food and become sick, and so much more. Fences protect the cows, durable fences are required to promote a healthy herd; quality controls are the boundaries that protect the worker, promote sound action, and prevent some of the behaviors that create the roots of the Department of Veterans Affairs Office of the Inspector General (VA-OIG) reports that keep crossing my desk.
As previously stated, several times, in fact, the complicated organizational structure of the Department of Veterans Affairs (VA) is a root cause as to why the veterans suffer so much at the hands of bureaucrats. The VA is geographically broken into Veterans Integrated Service Networks (VISN), these VISN’s oversee geographically grouped, generally by state, Veteran Health Care organizations (VA Hospitals and clinics). In theory, how the VISN acts is supposed to trickle down to the hospital and clinics improving performance and generalizing operations across a broad geographical area. Unfortunately, what is passed down to hospitals and clinics in the VISN is often the dregs, the poor practices, and the insanity of a complicated bureaucracy. When one hospital in a VISN is in trouble, look to the VISN, and see replication. Happens everytime; thus, change the organizational structure, simplify the hierarchy, and clean out the drones.
For example, the Chief of Staff in VISN 10, hired an ophthalmological surgeon who was not credentialed, not properly certified, and inadequately trained, and then repeated their mistake at the end of the probationary period by hiring the surgeon on full-time. From the VA-OIG report, we find the following description of the surgeon, “… the surgeon lacked adequate training to perform cataract and laser surgery as the surgeon did not satisfactorily complete an approved residency training program, was ineligible for board certification in ophthalmology, and did not meet the facility’s ophthalmologist hiring requirements. Several credentialing and privileging activities did not comply with Veterans Health Administration requirements and included inadequate primary source verification from foreign educational institutions and insufficient references attesting to the surgeon’s suitability to perform cataract surgeries.” The VA-OIG report then proceeds to discuss “multiple leadership deficiencies” that led to this surgeon being hired and allowed to practice. The Chief of Staff caused a problem for veterans, but the language is “leadership deficiencies.” Where is the accountability? Where is the demand for replacing the leader? While the surgeon was eventually terminated, what about recompense for the malpractice committed? The VA-OIG report documents, “… the surgeon’s productivity, competency, and [deficient] technical skills began within months of hire. The surgeon did not consistently demonstrate the skills to assure good outcomes, was unable to meet surgical productivity expectations, and surgery times exceeded norms.” Where is the Chief of Staff’s culpability in this dangerous affair?
Speaking of leadership culpability, there remains a recurring theme in several recent VA-OIG reports, failing quality ratings, but the leadership team is new. I understand that new leaders will require time to positively influence organizational attitudes and behaviors, what I do not understand is why time is used as an excuse and nowhere in the VA-OIG report is a list of leadership tenure to justify the time excuse, nor is a reinspection time identified. When I audited business for performance, these factors are always in the report, time on station, efforts to change since appointment, when the next inspection will occur, and recommendations to improve between the end of the examination and the reinspection. More needs declared in these inspections, as the VA-OIG just does not appear to inspect an entire health care system without cause.
Regarding leadership and quality controls, here is an example of a construction project where leadership and quality controls were desperately needed, yet remain missing. The Ralph H. Johnson VA Medical Center approved a series of construction projects by awarding contracts. Instead of construction beginning within 150-days, construction began around day 743 on average. Instead of blueprints costing $74,000, the final cost was $441,000. While other claims of misappropriation were alleged, the VA-OIG did not investigate or could not validate those claims. Where is the leadership of the VISN to proactively ask tough questions of the local hospital leadership to determine where problems are occurring? Where are the quality control officers, the risk control officers, and other leaders in demanding compliance with VA regulations? Construction was averaged at 743-days after contract award, which is a minimum of 593-days out of compliance, and there are costs associated with delaying construction contracts; what were those penalty costs, and why are they not included in the VA-OIG report? Where is the discussion on why the delays occurred? Where are the leadership and quality controls?
As the home shopping channel is always proclaiming, “But wait, there’s more!” The VA has six fiduciary hubs to look after the resources of those veterans deemed unable to manage their own finances. The Salt Lake Fiduciary Hub got behind in their workload and leadership, and quality control were the reasons why the workload backlogged, add in staff churn, and the fiduciary hub fell significantly in arrears in their work. The VA-OIG documented a need for workload management plans, training on how to prioritize work action items, a process for weeding out duplicate tasks, and how to measure production to ensure goals are met. The recommendations from the VA-OIG reads like the primary duties a director must already possess to meet the demands of the job they fill; yet, this director is not documented as being replaced for failure to do their job. Basic leadership skills require a knowledge of how to help schedule work, balance workloads, train on prioritization of tasks, communicating, and building a team. Where is the leadership and quality controls to ensure productive work is performed, and leadership is doing their jobs? The VA-OIG is not the solution to these leadership deficiencies!
The Hampton VA Medical Center in Virginia is reported to have had $1.8 million in improperly marked, inventoried, or accounted for inventory in forgotten rooms of the hospital. The supplies had been sitting for “an indeterminate amount of time.” Stock supplies had been improperly ordered, and the staff was inadequately supervised to protect the medical center and the taxpayer from fraud, waste, and abuse. The facility in May 2017, and again in May 2018, had identified the same deficiencies the VA-OIG documented and did nothing to rectify the situation. While the VA-OIG has made “several recommendations” the problem remains, the leadership failed to act in 2017, and 2018, what steps were put into place to ensure action finally occurs in 2019? Audits are part of an integrated quality control process; where is the rest of the quality control program? Where was the hospital leadership in 2017 and 2018? Quality control audits cost money and not correctly responding to an audit should have penalties; where is the accountability for design incompetence that has allowed this problem to survive two audits and an OIG inspection?
Some of the VA-OIG reports crossing my desk discuss what the VA-OIG terms, “Comprehensive Healthcare Inspections.” Unfortunately, too many of these reports include the verbiage to this effect, “The OIG issued 22 recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Infection control and general cleanliness • Mental health unit panic alarm testing response times • Mental health unit seclusion room flooring • Emergency generator testing (3) Controlled Substances Inspections • Reconciliation of dispensing and return of stock • Controlled substances order verifications • Routine inspections by controlled substances coordinators (4) Military Sexual Trauma (MST) Follow-up and Staff Training • Providers’ training (5) Antidepressant Use among the Elderly • Patient/caregiver education on medications (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership (7) Emergency Departments and Urgent Care Centers • Waiver for 24-hour operations • Staffing and call schedules • Use of required tracking program • Directional signage • Equipment/supply availability.” The root cause of many of these VA-OIG recommendations is leadership and quality control; yet, never is quality controls mentioned, even though the inspection, and the SAIL and CLC metrics are quality control programs. Congressional representatives where is your leadership in insisting upon full implementation of a quality control program, follow-through on the program’s application, and demands for quality improvement? The elected representatives of the American Republic must be held to task for failing to act to improve the bureaucratic nightmare they created through inaction and legislative fiat.
Another recurring theme, where leadership and quality control are non-existent, and which happens to profoundly impact the quality of life for patients, are those issues emanating from long-term care facilities and the veterans living in those facilities. 55 patients in San Juan, Puerto Rico were impacted by, “… staff inadequately monitoring the patient. Documentation was insufficient, and there were no care coordination agreements between the care facility and other service providers. Licensed practical nurses did not add registered nurses as co-signers to notes to alert them of changes in the patient’s status, and the patient’s care plan had not been modified to include the initiation of chemotherapy.” Mainly, the staff failed the patients, the patients suffered harm, and the injury was caused because of a lack of leadership and quality control.
I want to conclude this article with a major thank you to the officers and staff in the Milwaukee VA who saved the life of a non-veteran. From the story, “Instantaneous response by Milwaukee VA police, followed by immediate action from emergency room personnel, saved the life of a non-veteran who was within minutes of dying of a heroin overdose.” Having worked at a VA medical center where veterans committed suicide in the parking lot of the VA, it is good to see that the measures being implemented by the Federal Police are having a positive effect on veterans and visitors alike. To all involved in this incredible story, “Thank you!”
© 2019 M. Dave Salisbury
All Rights Reserved
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