To the Honorable Secretary Robert Wilkie
Department of Veterans Affairs
For almost a decade, I have read and studied the Department of Veterans Affairs (VA) from the position of patient, employee, concerned citizen, and now as an organizational psychologist. During this time, I have read many Department of Veterans Affairs – Office of Inspector General (VA-OIG) investigation reports, and yearned to be of fundamental assistance in improving the VA. I have an idea with potential for your consideration, “Tiger Teams.”
In the US Navy, we used “Tiger Teams” as “flying squads” of people, dedicated to a specific task, and able to complete work quickly. The teams included parts people, technicians, specialists, and carried the authority of competence and dedication to quickly fixing whatever had gone wrong during an evolution, an inspection, or even in regular operation. It is my belief that if your office employed a “Tiger Team” approach for speedy response, your job in fixing core problems the VA is experiencing would be easier. Please allow me to explain.
The VA-OIG recently released a report regarding deficiencies in nursing care and management in the Community Living Center (CLC) at the Coatesville VA Medical Center, Pennsylvania. The inspection team validated some complaints and were unable to validate all complaints because of poor complainant documentation. Having a Tiger Team able to dispatch from your office, carrying your authority, would provide expert guidance in rectifying the situation, monitoring the CLC, and updating you with knowledge needed to answer the legislator’s questions regarding what is happening. The VA-OIG found other issues in their investigation that were not covered under the scope of the investigation, leaving the VA-OIG in a difficult position. Hence, another reason for a Tiger Team being created, to back stop and support the VA-OIG in correcting issues found outside their investigatory scope.
For a decade now, I have been reading how the VA-OIG makes recommendations, but where is the follow-up from the VA-OIG to determine if those recommendations are being followed and applied? Too often there is no return and report feature built into the VA-OIG investigation, as these investigators just do not have the time. Again, this is what a Tiger Team can be doing. Taking action, training leaders, building a better VA, monitoring and reporting, building holistic solutions, and being an extension of your office on the front lines. Essentially using the tools from your office to improve the operations locally, which builds trust between the patients and the care providers, building trust between the families and the VA, and delivering upon the Congressional mandate and VA Mission.
Another recent VA-OIG report also supports the need for a fast response Tiger Team. Coordination of care and employee satisfaction concerns at the Community Living Center (CLC), Loch Raven VA Medical Center, in Baltimore, Maryland. In geographic terms, this incident is in your backyard. While the VA-OIG inspection was rather inconclusive, and recommendations were made, it appears some things are working in this CLC and other things are not working as well as they should. By using a Tiger Team as a flying squad, intermittent and unannounced inspections by the Tiger Team can aid in discovering more than the VA-OIG could investigate, monitoring the situation, and reporting on progress made in improving performance.
As an employee, too often the director of HAS would claim, “That problem is too hard to fix because it requires too many people to come together and agree on the solution.” Or, “The solution is feasible, but not worth the effort to implement because it would require coordination.” Getting the doctors and nurses talking to and working with administration is a leadership role, providing support to leaders is one of the best tools a Tiger Team possesses one authority is delegated. The Tiger Team presents the data, presents different potential solutions, and the aids the leadership locally in implementation. As an employee I never found a problem in the VA that could not be resolved with a little attention, getting people to work together, and opening lines of communication. Thus, I know the VA can be fixed.
The Tiger Teams need to be led by an organizational psychologist possessing a Ph.D. and a personal stake in seeing the VA improve. The organizational psychologist can build a team of like-minded people to be on the flying squad, and these team members should be subject matter experts in VA policies, procedures, and methods of operation, and should change from time to time. I have met many people from the VA who not only possess the passion, but are endowed with the knowledge of how to help the VA, and I would see the VA succeed. Yet, I am concerned that the VA is not changing, not growing, and not developing the processes and procedures needed to survive, and this is damaging the VA, which leads to wasted money and dead veterans.
Why not have a flying squad for each VISN, who can meet to benchmark, compare notes, and best practices. Who work from home and visit the local offices in the VISN, reporting directly to your office with a copy to the VISN leadership. Whose job is to build the Tiger teams needed to oversee, provide expert support, and practical analysis. The idea is to help you gather real time data, improve implementation of VA-OIG recommendations, and meet the demands of Congress. If a Tiger Team, with the functioning Flying Squad, can save one VA-OIG inspection in each VISN, by improving that VISN, medical center, CLC, etc. before it becomes a major problem on the sSix O’clock News, then the Tiger Teams have paid for themselves.
All veterans know of the Phoenix VA Medical Center debacle, where veterans died while waiting for appointments. I fully believe that had the VA Secretary had a Tiger Team in place, the root causes of that incident would have triggered the necessary flags to save lives and avoid or mitigate the catastrophe. Flying squads are the Tiger Team in action, and action should be the keyword for every member of the team. The mission of the Tiger Team should be to find and fix root causes, repair trust, and implement change needed to improve VA operations at the Veterans Benefits Administration (VBA), the Veterans Health Administration (VHA), and the National Cemeteries.
The VBA is especially vulnerable, and in need of outside resources to support change. Recently the VBA was involved in another scandal involving improper processing of claims for veterans in hospital over 21-days, resulting in millions of dollars either overpaid or underpaid to the veterans. Training, managerial oversight, and proper performance of tasks was reportedly the excuse the VBA used, again, to shirk responsibility. Tiger Teams can provide the support needed to monitor for, and encourage the adoption of, rectifying measures and VA-OIG recommendations, not just at the VBA, but across the full VA spectrum of operations.
Please, consider implementing Tiger Teams, from your office, assigned to a specific VISN, possessing the authority delegated to run the needed analysis, build support in local offices, and iron out the inefficiencies that keep killing veterans, wasting money, and creating problems. I firmly believe the VA can be saved and improved, built to become more flexible, while at the same time delivering on the promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.”
Thank you for your time and consideration.
© Copyright 2020 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the pictures.
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