Long have I written about the Department of Veterans Affairs (VA) and the Office of Inspector General (VA-OIG) reports which cross my inbox. Long have I been utterly disgusted with the waste, fraudulent behavior, and the utter disregard for the patient witnessed in the VA Medical Centers across America. As a veteran and taxpayer, it is past time to begin to see action to rectify these types of issues.
The VA-OIG conducted an inspection to evaluate concerns related to a Virtual Pharmacy Services (VPS) pharmacist’s discontinuation of antidepressant medication for a patient of the Minneapolis VA Health Care System, which resulted in the patient not having prescribed antidepressant medication for approximately six weeks before dying by suicide. The VA-OIG found that the pharmacist never notified the psychologist, never checked the patient’s record, simply discontinued the medication. While the VA-OIG found process and procedure issue, the fact that a medication could be arbitrarily discontinued without a “Red Flag” being raised with the provider and the patient is deeply troubling. Worse, the quality control processes in the pharmacy did not trigger a problem when a medication was discontinued without a provider order; why?
There is a dead veteran, and a pharmacist who claimed they did not know they could access a patient file; and the excuses do not hold water! This incident is a tragedy of epic proportion and I must ask, how many more veterans will die because medications are arbitrarily turned off?
The next VA-OIG inspection is a bit of a pretzel, there is another dead veteran by suicide, and processes and procedures were recommended by the VA-OIG to correct some small issues in bariatric surgery patients. Reading this report, it appears that this veterans’ suicide was not directly connected to preoperative counseling for bariatric surgery which was essentially the scope of the VA-OIG investigation. If there is a connection between the bariatric surgery and the suicide, it was beyond the VA-OIG investigatory scope. Hence, the VA might not be at fault for the suicide, but the VA-OIG recommendations indicate more can and should be done in the future to decrease the risks postoperatively.
Let me be clear, room for improvement to decrease risk does not assign or negate blame in this situation. The death of a veteran through suicide remains a tragedy and the VA can and should be doing more to help reduce veterans committing suicide. With the convoluted processes and the contradictory bureaucracies inside the VA, much more can be done as an organization to streamline and bring efficiency, transparency, and responsibility to the employees making patient decisions.
Another VA-OIG report does clearly reflect the responsibility and lack of care a patient received at the VA. The Tennessee Valley Healthcare System in Nashville is responsible for test results still not being properly communicated to the veteran in a timely manner, which delays treatment and care. Fall 2018, a patient went undiagnosed and untreated for pancreatic cancer due to failures in communicating test results, collaborating with the primary care providers, and for the electronic health records not containing a system of alerting providers that an adverse test result occurred. Hence, this patient’s problems have three root causes:
- Failure to notify the patient.
- Failure to collaborate between different hospital units for patient care and safety.
- Failure of the electronic health records programming to include alerts.
From personal experience, I must wonder if any patient notification would have made a difference. The patient notifications are simply the results, not definitions, no descriptions, just ranges, and results. Hence, the patient notification process must include clarity of the results so non-medical people can understand what was found and the implications.
While I applaud the VA-OIG for insisting that an internal review is conducted and problems rectified, I have significant doubts that change will occur. It appears that unless the VA-OIG is following up on their recommendations; which is outside the VA-OIG’s authority, the change will not occur. A truly unfortunate series of events occurred in this patient’s life and the bureaucracy of the VA will prevent anyone from being held accountable for the failures, nor will change occur to protect another veteran.
The W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina, was recently inspected for concerns regarding anesthesia provider’s practice. While no issues were found under the VA-OIG scope regarding the provider’s practices, other issues were discovered. The problems found were all administrative in nature and included the usual training, timely record keeping, following the policies established by VHA, etc. Juran’s Rule states that “When there is a problem, 90% of the time the problem lies with policies and procedures, not people.” How, and when, a person does their job is more often the root of the problem and is evidenced again with this VA-OIG investigation report. The fact that this problem continues at all VA Medical Centers (VAMC) across America is indicative of a systematic issue in poor organizational design, then in the individual employee. The VA must address these organizational issues that breed complacency in employee adherence!
With confirmed cases of nepotism still occurring in the VA, this time in Miami. With continued issues regarding ethics violations and the proper use of time and materials for teleworking employees. With the continued employee obstruction witnessed in so many cases of records not being readily available to VA-OIG inspectors. The VA desperately needs to have a deep cleaning and reorganization. Why has the VA not adopted ISO-9001 for Hospitals? Why hasn’t the VA adopted ISO-9001 for the VBA or National Cemetery as a coherent process for organizational change and improvement?
Consider that there remains a dearth of written processes, procedures, and policies in the VA. So much so that more than one VA Hospital operates on “Gentlemen’s Agreements” between departments, instead of official policy statements and procedural plans. This lack of written policies and procedures is the excuse and the general recommendation of so many VA-OIG inspection reports that I am shocked Congress has not begun asking about this single issue. The first rule I learned as an EMT was, “If it is not written down, it never happened.” I was told this is the first rule of medicine; yet, somehow the VA can escape without writing down how to perform work. Doesn’t that seem strange to anyone else?
Where the lack of written procedures is most noticeable, is at the Veterans Benefits Administration (VBA), where the quality control people missed 35% of the errors routinely, never checked each other’s work, never learned lessons to improve performance, and were not properly supervised. Yet, training, communication, and written procedures are routinely used as excuses, and corrective action is outside the VA-OIG investigatory scope. So, while the problems are being identified, the leaders are refusing to do their jobs! From the VA-OIG report comes the following details:
“The VA-OIG estimated that during the review period, regional office managers inappropriately overturned errors in 430 of 870 quality reviews (about 50 percent) where claims processors requested a reconsideration from a quality review specialist- identified errors. The VBA has not established adequate oversight or accountability to ensure the timeliness of error corrections. The OIG estimated that during the review period 2,000 of 4,400 identified errors (45 percent) were not corrected in a timely manner and 810 of 4,400 identified errors (18 percent) were not corrected at all.” [Emphasis Mine]
Again, I ask, where are the written procedures that form the standards of work which are used to hold employees accountable? With an 18% error rate never being addressed by quality control, this means that veterans are being underpaid or overpaid for their benefits, and the VBA does not care that these issues are killing veterans.
Personally, I experienced a VA overpayment that took more than 3-years to payoff. Three years where my benefits were docked for an administrative mistake that was not found until the next decision was made on my claim several years after the original mistake was made. What is worse, the mistake I paid for, was not a mistake at all, and the funds were later returned as another quality person found the error and corrected the documents accordingly, but the discovery took another VBA claim decision to catch, from beginning to end this issue of overpayment took three different decisions by the VBA and more than 8 calendar years from beginning to end.
Every single taxpayer in America has a personal stake in seeing the VBA do their jobs timely, efficiently, and correctly. Every single veteran in America has a vested interest in seeing the VBA perform their roles with fewer rates of error than those reported by the VA-OIG. Every elected official in America benefits in some way from the decisions of the VBA and should be able to demand higher quality decisions, better performance, and more transparency from the VBA. Consider, if the problems of performance are this bad for a spot check analysis by the VA-OIG, how bad are the real numbers?
The VBA was also investigated for improper payments to schools through the Vocational Rehabilitation and Employment Program (VR&E) to the tune of $554,998. Most of the errors were in transcribing numbers and the electronic program did not raise any alerts or attempt to rectify the problems, and no quality control system is in place to protect against human error. The VA-OIG investigatory scope included 1.8 million payment transactions from 01 Jan 2014 to 30 Dec 2019. While this is a much better error rate; the fact that the technology and the work processes were not catching these errors timelier, which means more billing issues, more wasted resources, and more problems for the VA, the VBA, the VR&E program, the taxpayer, the colleges and universities, and the impact goes on and on.
The VBA was also recently inspected for failing to accurately decide service-connected heart diseases. The root cause was the questionnaire developed to ascertain what and when regarding the heart diseases experienced. Six months, 01 Nov 2018 through 30 Apr 2019, were selected and 12% of the claims were improperly decided which totals $5.6 Million in improper payments where a veteran either received too much or too little for their claim. Necessitating repayments or backdated payments once new and material evidence was procured to force the VBA to make a new determination. Inaccurate decisions on claims involve a lengthy appeals process, expenses for testing, and the veteran is always responsible for the mistakes made on their claim. Thus, the exasperation of these mistakes on the families, friends, and communities of the veteran involved in a VBA mistake.
When the VA-OIG finds errors made by the VBA the veterans affected are not notified that the VBA made an error in their determinations. The VBA does not form a task force to evaluate these errors and correct them internally unless money is owed and then the collections department is left to muddle through the decision, not the VBA. Thus, when veterans ask for transparency in the VBA processes, we are asking for the VBA to own their mistakes, fix the problems they are creating, and correct the errors in a timely fashion. It should not require new and material evidence to trigger the VBA to make a new determination when the VBA made the original mistake in determining eligibility in the first place!
All because the quality controllers do not have written procedures to measure standards of performance against. All these errors are due to improper organizational design and old computer systems, which are ready-made excuses for not performing work in a timely and efficient manner. All because the leadership fails to delegate, monitor, observe, and function. Why are the leaders missing, because they are all in meetings, all day, every day, and not at their desks!
Just like the labor union provided bumper sticker proclaims, “SAVE the VA!” [Emphasis in original], it is time to “SAVE the VA!”
© Copyright 2020 – M. Dave Salisbury
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