As a new decade and year begin, the Department of Veterans Affairs Office of Inspector General (VA-OIG) reports continue many of the same themes from 2019 and earlier, specifically the failure of leadership. There is an axiom in the US Military, applicable to the Department of Veterans Affairs (VA), “When leadership fails, soldiers die!” Well, leadership at the VA faile,d and veterans are dying and this is an inexcusable trend requiring immediate rectification. Leadership at the Minneapolis VAHCS, Minnesota failed to communicate, and a veteran struggling with suicide ended their life while admitted to the VA Hospital. While the VA-OIG brought several issues to bear on the leadership team, I noticed a blatant irregularity, from the report comes the following:
“The internal review team identified many lessons learned for which the Veterans Health Administration (VHA) does not require action items. VHA does not provide written guidance on the identification of lessons learned, related action expectations, and how to distinguish lessons learned from root causes.”
Why perform an after-action review (AAR) and not require action items to be identified, actions to be taken, and methods to measure change? Why does the Veterans Health Administration (VHA) not provide guidance on how to conduct an AAR? Leadership communication is a root cause in many of the blunders the VA generally, and the VHA and Veterans Benefits Administration (VBA) specifically, suffer on a regular basis in VA-OIG reports, yet the oversight teams in Washington D.C. cannot be bothered to provide written guidance; this is a perfect example of designed incompetence, and the veteran continues to be abused by the bureaucracy.
Designed incompetence is the term for establishing a bureaucracy where excuses can be automatically made, problems never addressed, and people not held accountable as a system benefit, not a system flaw. The VA-OIG report held another gem, “During an internal review, the facility’s root cause analysis team did not interview staff members involved in the patient’s care.” Designed incompetence protected the leaders, allowing for excuses to lead to a dead veteran, and the bureaucracy protected their own by not properly investigating. At my local VA Hospital in Albuquerque, NM., not talking to staff members directly involved in an issue is a well-worn game, where employees have been arbitrarily dismissed and the leadership protected, veterans have died, staff and patients have attacked patients and staff alike, and more, all because the investigations are conducted without ever talking to people involved in the issues.
The VA-OIG raises a final issue, “The Patient Safety Committee and the Quality Management Council meeting minutes did not document deliberations and track actions to resolution.” Leading to the final question, why conduct an AAR if you are not going to act to rectify a problem? Failure to change means the veteran who died in a hospital is disrespected more in death than in life, and this is utterly and completely reprehensible conduct by the VA.
The VA-OIG conducts Comprehensive Healthcare Inspection (CHIP) of various VA Medical Centers, I remain fascinated at the trends that continually and regularly are commented upon, and I would ask the VA-OIG, do you have trend lines for certain occurrences of issues in CHIP inspections? For example, in doing a rudimentary review of the VA-OIG reports in my email box, I find a total of eighteen (18) CHIP reports from the VA-OIG from 12/01/2019 through 01/15/2020 and not surprisingly there is a regular problem arising in every single report, “Implementation of corrective actions from root cause analyses.” Thus, not only is the CHIP regularly citing problems with conducting and implementing action items from root cause analysis, the same issue is killing veterans, and the designed incompetence was displayed in the comments from the VA-OIG, “… the Executive Leadership Board was not following actions until completion.”
Department of Veterans Affairs Office of Inspector General, when regular comments are found, who tracks and works on the nationwide issues? Where does your data go once collated into trend lines? Are you receiving support from the elected officials to which you report performance?
Elected officials in the House of Representatives and the Senate, you and your staff have access to these same reports, what are you doing to hold the VA leadership accountable? What are you doing to support change in the VA Bureaucracy to stop the veterans from dying at the hands of designed incompetence? When will you be as ambitious about veterans as you are about getting re-elected? You were elected to do a job, you are part of the leadership problem at the VA, when will you act?
© 2020 M. Dave Salisbury
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