July Updates: OIG Reports That Should SHAME the VA!

Survived the VALate last week, I received a call from the Chief of police at the Phoenix VA Medical Center.  In July, I had been arrested for not wearing a mask.  By late August, I had figured the Phoenix VA Medical Center Director was going to just “forget me” and hope I go away, then the call comes in.  The Chief of police begins by stating, “I do not know why I am calling you, but I was requested to call and see what I can do to help.”

This response of the chiefs can be viewed two ways, he honestly does not know and needs to be updated, or he is using this as a conversation starter and does know.  I choose to see the best in people and gave the chief the benefit of the doubt.  I explained the situation, the multiple different stories regarding “VA Policy on Mask Wearing,” my multiple visits where I was not hassled about not wearing a mask, the confusion with the face shield, and the behavior of his officers in trying to implement poor policy.  To which the chief replied, I cannot help here and will return this issue to the director’s office where I had initially filed the complaint.

I do not blame the VA Police for arresting me.  They are tools of policy, as I have discussed previously and you can review here.  The police in my situation are stuck in the middle between a ridiculously inept hospital director, and the need to enforce the policies which issue forth.  At the beginning of COVID-19 hysteria, the director received a memo from the Department of Veterans Affairs (VA) regarding how to handle COVID-19.  The director did not adapt the policy to the local hospital, placing patients at risk who wears a mask in Phoenix summer conditions; nor, did the director include the ability for individual adaptation to individual patient health concerns, SAIL Metrics.  Thus, the VA Police are stuck, they cannot allow exceptions, they cannot allow for individual accommodations, and this places more burden upon the veterans seeking and requiring care at the Phoenix VA Medical Center and clinics.

The VA provides the rating of VA’s and the following website: Why not the best VA which will easily explain in a numeric format the indicators of problems with each VA.  What I find interesting is how many times the worst VA hospitals find themselves on the Department of Veterans Affairs – Office of Inspector General (VA-OIG) for egregious breaches of common sense, customer service, and common decency.  The Phoenix VA Medical Center is in VISN 22, and knowing the various hospitals intimately in VISN 22, the only conclusion possible in reviewing the data is that the 8 different hospitals in VISN 22 are in a dead heat race to the bottom, and the Albuquerque NM VA Medical Center is the best of the worst.

Carl T. HaydenThe VA-OIG conducted a healthcare inspection at the Atlanta VA Health Care System (VAHCS) in Decatur, Georgia, and found they had a backlog of open community care consults, and the OIG found deficiencies in processing, scheduling, and timeliness of these consults. Important to note, the contributory factors included but were not limited to, inconsistent scheduling processes, inconsistent oversight, and deficiencies with third-party administrator scheduling oversight, shortages of scheduling staff, and lack of training and supervision for scheduling staff. The facility did not consistently meet facility process requirements for scheduling audits and lacked a process to identify consults that were missing documentation after administrative closure.  While the Decatur VAHCS should be praised for not having any critical patient concerns due to the scheduling failures, this appears to be more luck on the patient’s part, than efficiency on the scheduling staff part.

The VA-OIG conducted a healthcare inspection at the Nashville VA Medical Center in Tennessee to evaluate alleged deficiencies in cardiac telemetry monitoring services including policies, staffing, and communication.  The facility should be praised for its progress in fixing deficiencies without the recommendations of the VA-OIG investigatory team.  The facility leaders also deserve praise for their attention to details, improvements in communication, and other facility improvements made since Feb 2019.  The last time this facility made the VA-OIG inspection report, the investigation was not pretty and their improvement needs to be praised; while more progress is needed, congratulations on the progress made.

Speaking of providing praise where praise is due, the VA-OIG conducted a comprehensive healthcare inspection of the Kansas City VA Medical Center (VAMC) and multiple outpatient clinics in Kansas and Missouri.  While this VAMC and outpatient clinics still have significant growth in improving SAIL metrics, they have progressed and growth is happening.  I send my regards, and sincere congratulations on the progress made.  I also wish them the best in continuing to improve.  This VAMC has a long road to recovering, but I know with patience, improved organizational design, and better staff training, they can get where they need to be.

ProblemsImagine you’re a patient, or worse a family member escorting the patient, with suicidal ideation, and you hear the doctor say, “the patient can go shoot themselves. I do not care,”  How would you feel about the 12-hour stay in the Emergency Room, after seeing seven different providers who did not read the notes, complete adequate patient handoff between the ER and outpatient mental health, which also includes deficiencies in the hand-off processes, and providers’ failure to read the outpatient psychiatrist’s notes, which led to a compromised understanding of the patient’s medical needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan.  Completing six-days later in the veteran taking their life.  This exact scenario should NEVER have occurred but did at the Washington DC VA Medical Center.  Now, the physician making that detestable comment had previously made similar comments about other patients; crickets from leadership.  The ER physician making this incredibly obtuse statement has a history of making “inappropriate comments” about patients in the ER, and this has been known to leadership since Feb 2019.  No action, no investigation, no remediation, and now we have a dead veteran because the representative of the VA had the gall to say, “the patient can go shoot themselves. I do not care.”

I-CareWhen any veteran dies by their own hand, it is a tragedy.  But, when the VA has any responsibility in that veteran committing suicide, heads should roll, individual people should be held accountable, and in this case, especially, criminal proceedings should commence!  I worked in the VA ER, I know what the providers, nurses, and other staff providing patient interactions say.  I have reported several inappropriate comments that the patients heard to no avail, no recourse, and no action by hospital leadership.  I know, intimately, the political chicanery that occurs at the VA, and I can tell you, this IS a pet issue with me, and I am unapologetic in calling for criminal charges on these providers who are abusing veterans and their families!

Leadership CartoonThe VA-OIG inspected the VA Illiana Health Care System (VAHCS) and multiple outpatient clinics in Illinois.  The VA-OIG also inspected the William S. Middleton Memorial Veterans Hospital and multiple outpatient clinics in Illinois and Wisconsin.  I have been in both and I can say unequivocally, more progress is needed and the leadership desperately needs to improve professionalism among staff, improve patient safety from the bureaucrats not providing care, staff competencies, and staff training.  All of which were among deficiencies mentioned by the VA-OIG.  There is great potential in these VAHCS’ for achieving greatness, but the bureaucrats need deep cleaned, and removed!

What continues to astound me is the replication of excuses and issues between VAMC’s and VAHCS’ when these comprehensive healthcare inspections are conducted.  On average, I can expect 3-5 comprehensive healthcare inspection results from VA-OIG per week in my email box.  Yet, the same exact issues and excuses are used time after time, location after location.  Those VAMC’s and VAHCS’ who are failing know they are failing, and the lack of care witnessed by the inaction of the hospital leadership infuriates this veteran.  Leaving me asking, “Who will care enough to demand change and cease allowing these tepid and weak excuses to be allowed?”  Are the elected officials even looking at the repetitive nature of the issues and asking follow-up questions, demanding answers, or even bothered by failures in comprehensive healthcare inspections?

I have not personally visited or been a patient in the following VAMC; however, the stories I hear from my friends and colleagues tell me the VA-OIG might have missed a few indicators of problems in this inspection and bought the excuses for designed incompetence.  The VA-OIG conducted a review at the Ioannis A. Lougaris VA Medical Center in Reno, Nevada. The review proactively identified and evaluated declining performance metrics that could affect the quality of care and patient safety.  The staff blamed the falling metrics on “losing focus, staff pay, other change initiatives, inefficient processes, which all contributed to performance deficits.  These are standard excuses for designed incompetence and I refuse to accept these conclusions by the VA-OIG.  Will the Ioannis A. Lougaris VA Medical Center in Reno, Nevada be the next Phoenix, AZ VAMC to kill a couple hundred veterans before these excuses are no longer accepted?

VA SealThe behavior of the VA as recorded in these VA-OIG investigations and inspections continues to reveal significant problems with staff, where the staff has designed processes and procedures to allow a ready excuse for any problems that arise and continues to prove that a veteran takes their life in their hands when visiting the VA.  These actions must cease forthwith.  There is no excuse for the behavior investigated and reported.

© 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.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

https://www.linkedin.com/in/davesalisbury/

Published by

msalis1

Dual service military veteran. Possess an MBA in Global Management and a Masters degree in Adult Education and Training. Pursuing a PhD in Industrial and Organizational Psychology. Business professional with depth of experience in logistics, supply chain management, and call centers.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s