Due to personal issues with the Department of Veterans Affairs (VA), specifically the Carl T. Hayden VA Medical Center (VAMC) in Phoenix, AZ I fell a little behind in June/July/August of 2020. As I work to clear the backlog of completed Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports from August, please keep in mind solutions to these problems are available. The failure of leadership to be held accountable, by the elected officials is staggering, and the lack of accountability and responsibility boggles the mind. Without exception, I know the VA can be improved, developed, and saved.
August 2020 begins with an individual employee making a decision regarding healthcare decisions for a veteran at the Robley Rex VAMC in Louisville, Kentucky. The VA has a process where individuals can be allowed to be surrogate decision-makers for a veteran who needs additional assistance. This process works is legal and is a great tool for family and friends of veterans to play a significant role in the healthcare process of the veteran. In this instance, the process failed, not because the process was bad, but because people did not do their jobs properly.
The VA-OIG assessed an allegation that providers permitted an individual with no legal authority to make medical decisions on behalf of a patient, and a host of other patient rights were trampled as documented. “The patient experienced a three-week medical and mental health hospitalization with repeated episodes of confusion, agitation, and combative behavior. The patient was transferred to hospice care and died five days later. The VA-OIG found that facility staff did not take the required appropriate steps to identify and confirm the eligibility of this surrogate. The VA-OIG determined records did not contain sufficient documentation of physicians’ clinical assessments to support diagnoses and treatment decisions. Clinical communication and collaboration were inconsistent, insufficient, and negatively impacted the patient’s continuity and quality of care. Providers did not consistently document medication monitoring and oversight activities to ensure safe patient care. The patient’s transfer to hospice was completed without fully pursuing other diagnoses and treatment options and staff did not ensure the patient’s rights were upheld regarding involuntary admission and behavioral restraints. Facility leaders did not complete a thorough quality of care review to understand the reasons for the patient’s atypical hospital course and outcome” [Emphasis Mine].
Many times, the VA-OIG reports do not clarify all root causes due to employee privacy; however, from the report, the employees who repeatedly allowed the neighbor to make healthcare decisions were exceeding their legal bounds and made decisions that harmed the patient. This veteran died and from the report, it is clear the veteran died confused, possibly due to medication changes, and the family was not notified in a timely manner because the neighbor, without legal and written authority, was allowed to make healthcare decisions for the veteran, even though there was written healthcare directives on file for a family member to make these decisions. Utterly shameful behavior!
The Veteran Integrated Service Network (VISN), is a geographical grouping of VA Healthcare Systems, e.g. hospitals and clinics, under a combined leadership plan. One of the tools the VA-OIG uses to monitor the quality of patient care inside VISN’s is called a “Comprehensive Healthcare Inspection Program (CHIP). CHIP covers selected clinical and administrative processes all of which are deemed consistent with promoting quality patient care. The CHIP occurs on a rotational 3-year periodicity and the focus is shifted slightly each 3-year cycle to, theoretically, encompass all administrative processes over time. The VA reports the following are the specific areas that lead to quality patient care through administrative practices:
- Quality, safety, and value;
- Medical staff privileging;
- The environment of care;
- Medication management (specifically the controlled substances inspection program);
- Mental health (focusing on military sexual trauma follow-up and staff training);
- Geriatric care (spotlighting antidepressant use for elderly veterans);
- Women’s health (particularly abnormal cervical pathology result notification and follow-up); and
- High-risk processes (specifically the emergency department and urgent care center operations and management).
All of which is mentioned as an explanation providing details for the following VA-OIG inspection reports of CHIP received in August 2020. A total of seven CHIP reports were received in August recording performance from inspections carried out. These reports, while somewhat individualized for the specific VAHCS, reads like a carbon copy. Repeatedly written procedures for standard operation are missing, staff training is inadequate or antiquated, risk analysis is not able to be competently and correctly conducted, patient safety issues abound, and the proper utilization of management processes remains glaring!
The CHIP reports are so repetitive in nature, the VA-OIG recommendations are grouped, conveniently, into the eight administrative areas listed above. According to proper management techniques, the VA-OIG then “encourages” the leadership team to select one or two areas for improvement and focus their efforts on leading change in those areas. For example, if the VAHCS wants to improve in risk analysis, the leaders can begin by promoting training on properly conducting risk analysis online, hold meetings to review risk analysis procedures and begin to train and develop staff on improving n this area.
However, here is where reality meets theory, without written standard operating procedures risk analysis cannot be completed properly. The bureaucracy protects itself and will thwart the implementation of written standard operating procedures as this removes designed incompetence that keeps the bureaucrat in power at the VA. Thus, the root cause of improving root cause analysis is the lack of written procedures that measure performance against a single written standard.
CHIP Report after CHIP Report the same issues arise, are noted, recommendations from the VA-OIG are documented, and the same response is supplied; this represents the epitome of designed incompetence and the root of the problem the VA is facing. Recommendations for improvement have been repeatedly provided and change can occur; but, not without dedicated leadership, not management, to thwart the bureaucratic quagmire that the VA has fallen into.
Another regular entry on the CHIP reports is the following: “Employee satisfaction scores revealed opportunities for the Associate Director for Patient Care Services to improve employee attitudes towards senior leaders.” Here is the problem, how many of the “senior leaders” are less than managers, promoted beyond their maximum level of incompetence, solely because they were the next warm body in line; too many! When staff training is a repeated issue on CHIP reports, one must ask how employees are being measured? Where are the written scorecards that reflect a process that was used to measure employee performance fairly and equitably? Was the employee trained on how to perform their role according to the standards published? Do the scorecards reflect that all employees have been trained, measured, and reported equally?
Guess what, since staff training remains a consistent problem, the staff leaders are the problem! A major part of “Quality, Safety, and Value” is “Leadership and Organizational Risks.” A lack of training in properly, timely, and correctly performing one’s role as hired is both a leadership and an organizational risk. Failing to train employees is the absolute worst comment a leader should be informed of by a third-party inspection team. Yet, the training of staff is consistently the root cause after a lack of standardized operating procedures. Every mid-level supervisor, trainer, manager, director, etc. titled individual at the VA should be embarrassed when told their staff is untrained; but, it appears these same leaders do not care!
How can a person draw the conclusions that the VA appears to not care about improvement, or that the lack of caring is rampant across the entire VA structure; look no further than the site visit VA-OIG inspection report of the Department of Veterans Affairs – Veterans Benefits Administration (VBA). The deputy undersecretary for field operations expected regional office managers to be aware of issues raised in other regional office site visit reports, but there was no written policy for addressing frequently identified errors. So, the mid-level regional office managers must be told to investigate internal websites to gather lessons learned and apply those lessons in their regional offices. What an incredibly inept excuse; shameful conduct by a senior leader, and how much worse does this attitude become as it filters down to the troops? The behavior that claims a new policy is needed to improve performance is utterly bereft of logic and demonstrates the lackadaisical attitude being discussed. Then these same leaders wonder why their staff is disengaged, disconnected, and distrusting of leadership; unbelievable!
One of the first lessons I learned in becoming a business professional was, “If you have to write your ethics down, you have already lost.” The VA policies on ethics, ethical conduct, and ethical behavior are voluminous, trying to cover every detail, every loophole, every issue, and mostly the VA-OIG reports on ethical breaches reflect individual poor judgment at best, and designed incompetence at worst. Yet, still, the VA tries to implement ethics without a source, moral behavior without a purpose, and the individual employee is left with plenty of excuses for not behaving in a properly ethical manner. This is the topic of another article; but it must be made clear here and now, ethical lapses continue to abound at the VA. From the nurse not giving drugs to patients and selling the drugs on the street, to hospital directors not disclosing what appears to be a conflict of interest, the VA remains afloat on a sea of ethical violations.
The remaining reports in August reflected an investigation that the VA-OIG was unable to substantiate due to a lack of reports filed in a timely and proper manner. More designed incompetence on the part of the VA. Also included in these final reports were more repetitions of issues discussed where staff training was the root cause for ethical violations, failure to properly perform duties as hired, and staff training was the problem with adherence and compliance issues.
The disconnect is obvious, and the direction forward is clear. Hospital Directors, write the standard operating procedures, using the resources of how the work is performed currently as the baseline. Then begin correcting and amending the written procedures over the following year to improve performance to a written standard. Once the written standard is completed, e.g. the baseline, begin training of staff. You cannot measure individual performance without standards, and standards cannot be followed without written operating procedures for conducting business.
© Copyright 2020 – M. Dave Salisbury
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