For Memorial Day (2020), the National Cemetery, through the directive of the Department of Veterans Affairs (VA), restricted the placing of flags at several national cemeteries, upsetting the plans of Boy Scouts, and angering countless veterans, survivors, dependents, and extended families. However, the intransigence of the VA on this matter is but a symptom of a larger problem.
The Department of Veterans Affairs – Office of Inspector General (VA-OIG) recently released two additional reports on behavior unbecoming at the VA. The first report concerns the delays in diagnosis and treatment in dialysis patients, as well as patient transport at the Fayetteville VA Medical Center in North Carolina. The second is another death of a patient, as well as deficiencies in domiciliary safety and security at the Northeast Ohio Healthcare System in Cleveland.
The VA report from North Carolina includes significant patient issues, especially since two veterans died while in the care of the VA. Significant issues are generally code words for incredibly lax processes, and procedures that are easily avoided, provided people care enough to do their jobs correctly, succinctly, and thoroughly. Where patients are concerned a dead patient is pretty significant. Two dead patients are beyond the comprehension of a reasonable person to not ask, “Who lost their jobs over these incidents?”
Patient A, has leukemia, and from the VA-OIG’s report we find the following responsible parties:
“… A primary care provider failed to act on Patient A’s abnormal laboratory results and pathologists’ recommendations for follow-up testing and hematology consultation. Community Care staff did not process a consult and schedule Patient A’s appointment.”
Patient A died from a gastrointestinal bleed while waiting for transport to a hospital from a (VA Contracted) [long-term] care facility. Patient A’s delays in care led to death in hospital, and the failure of a hospitalist to initiate emergency procedures contributed to the veteran’s passing. Patient A’s death is a tragical farce of bureaucratic inaction, compounded by the same symptoms as that allowed for Memorial Day (2020) to come and go without the honored dead of America being remembered. Symptoms not cause.
Patient B, was also in a (VA Contracted) [long-term] care facility, in need of transport back to the hospital, and the administrative staff’s delays had Patient B arrive at the hospital in cardiac failure, where the patient subsequently died. In the case of both patient’s facility leaders did not initiate comprehensive analyses of events surrounding the patients’ deaths or related processes. But, this is excusable behavior at the VA due to frequent executive leadership changes impeding the resolution of systemic issues. I have been covering the VA-OIG reports for the better part of a decade and this excuse is always an acceptable excuse for bureaucratic inaction. Hence, the first question in this madness is to the VA-OIG and it needs to answer, “Why is this an allowable excuse?” Don’t the people remaining know their positions sufficiently to carry on when the executive team is in flux? Again, symptoms not cause.
The patient death in Northeast Ohio, started with the domiciliary, on a VA Contract care facility. Essentially, the patient died because of methadone being provided without first gaining an electrocardiogram. Oversight of the contracted domiciliary did not include accuracy checks on paperwork, but the VA-OIG found that for the most part, the contracted domiciliary was following VA Contracting guidelines. From the report, no gross negligence led to the veterans passing, and for the most part risk analysis and other post mortem analysis were conducted properly. Why is this case mentioned; symptoms not cause.
When I worked at the New Mexico VA Medical Center (NMVAMC) I diagnosed a problem and was told, repeatedly, to not mention the problem as the director would be furious. The problem is bureaucratic inertia. Bureaucratic inertia is commonly defined as, “the supposed inevitable tendency of bureaucratic organizations to perpetuate the established procedures and modes, even if they are counterproductive and/or diametrically opposed to established organizational goals.” Except, the bureaucratic inertia I witnessed daily was not “supposedly inevitable,” it was a real and cogent variable in every single action from most of the employees.
I spent 12 months without proper access to systems, but the process to gain access was convoluted, unknown, ever-changing, and so twisted that unraveling the proper methods to complete the process and gain access was never corrected, and this was a major issue for patient care in an Emergency Department. Why was the process so bad; bureaucratic inertia. Obtaining information about the problem took two different assistant directors, two different directors, a senior leader, and the problem was identified that licensing requirements were the sticking point in the problem.
Bureaucratic inertia is the cause of too many issues, problems, and dead veterans, at the Department of Veterans Affairs. The symptoms include delays in administrative tasks that lead to patients dying for lack of transport to a hospital. The symptoms include cost overrun on every construction project the VA commences. The symptoms include abuse of employees, creating a revolving door in human resources where good people come in with enthusiasm, and leave with anger and contempt, generally at the insistence of a leader who refuses to change. The symptoms include a bureaucrat making a decision that has no logical sense, costs too much and is never held accountable for the harm because the decision-maker can prove they met the byzantine labyrinth of rules, regulations, and policies of the VA.
Veterans are dying at the VA regularly because of bureaucratic inertia. Hence, as bureaucratic inertia is the problem, and the symptoms are prevalent, it must needs be that a solution is found to eradicate bureaucratic inertia. While not a full solution, the following will help curb most of the problem, and begin the process for the eradication of bureaucratic inertia.
- Give the VA-OIG power to enact change when cause and effect analysis shows a person is “the” problem in that chain of events. Right now, the office of inspector general has the power to make recommendations, that are generally, sometimes, potentially, considered, and possible remediations adopted, provided a different course of action is discovered.
- Give the executive committee, of which the head is Secretary Wilkie, legislative power to fire and hold people accountable for not doing the jobs they were hired, and vetted at $110,000+ per employee, to perform. Background checks on new employees cost the taxpayer $110,000+, and the revolving door in human resources is unacceptable. But worse is when the leaders refuse to perform their jobs and remain employed.
- Implement ISO as a quality control system where processes, procedures, and policies are written down. The ability for management to change the rules on a whim costs money, time, patient confidence, trust in leadership and organization, and is a nuisance that permeates the VA absolutely. The lack of written policies and procedures is the second most common excuse for bureaucratic inertia. The first being, the ability to blame changing leadership for dead patients!
- Eliminate labor union protection. Government employees have negotiated plentiful benefits, conditions, and pay without union representation and the ability for the union to get criminal complaints dropped, and worthless people their jobs back is an ultimate disgrace upon the Magna Charta of the United States of America generally, and upon the seal of the Department of Veterans Affairs specifically.
Secretary Wilkie, until you can overcome the bureaucratic inertia prevalent in the ranks of the leadership between the front-line veteran facing employee and your office, lasting change remains improbable. Real people are dying from bureaucratic inertia. Real veterans are spending their entire lives in the appeal process for benefits and dying without proper treatment. Real families are being torn asunder from the stress of untreated veterans because the bureaucratic inertia cannot be overcome from the outside. I know you need legislative assistance to enact real change and improve the VA. By way of petition, I write this missive to the American citizen asking for your help in providing Sec. Wilkie the tools he needs to fix the VA.
The VA can be fixed, but the solution will require fundamental change.
Change is possible with proper legislative support!
© Copyright 2020 – M. Dave Salisbury
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