In reading the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports, it never ceases to amaze me the designed incompetence the leaders will stoop to use to thwart criticism. For example, the length of time a leadership team has served together is an acceptable excuse for not making changes. Yet, this same excuse is employed year-over-year, and location after location. It was reported on one inspection summary that the leadership team had been together for 10-years, but recent changes in roles was to blame for the continued lack of compliance. These are the Department of Veterans Affairs (VA) employees who would rearrange the deck chairs on the Titanic to obstruct passenger evacuation and blame the passengers for failing to get out of the way of the chair!
In recent reports from the VA-OIG, leaders have been apprised of problems, admitted they were “engaged in finding solutions,” and the VA-OIG gave the leaders a pass along with several additional recommendations to consider. Yet, given the height and breadth of malfeasance at the VAMC’s where health problems occur, can anyone trust that the leadership team is actually working to resolve the problems? If the VA-OIG returned unannounced in 3-6 months after the initial complaint, would progress have been made?
The problem with designed incompetence is that these excuses do not just evaporate, the excuses either survive long enough to become organizational design errors, or they are purposefully addressed until resolved. There is no magic wand, potion, or witches brew that erases designed incompetence; but that is exactly what a person is led to believe when reading the VA-OIG reports.
The VA-OIG performs comprehensive healthcare inspections as a regular inspection for the medical treatment facilities of the Department of Veterans Affairs – Veterans Health Administration (VHA). I have personally reviewed hundreds of these reports over the last 10-years of monitoring the VA. The regular nature of the inspection report indicates some VA healthcare facilities can perform like trained seals for their inspections. Always, I am left to wonder what the reality in those same facilities looks like.
Albuquerque is a great VAMC to exemplify this point. One ER room, on the inside of the door, held a blood spot for more than 18-months. The spot was there and noticed, and reported to the doctor and nurse, when I was in that treatment room in the spring of 2016, and the same spot was still there in the spring of 2019 when chance had me in the same room for another exam. But cleanliness was never a problem for this VHA facility in the VA-OIG inspection reports.
At the Albuquerque Hospital, in the Emergency Department, it was common to witness homeless veterans be abused by the staff. The staff justified their actions, beliefs, and biases, where never censured, and physical harm was delivered to the veterans. No one on the ED leadership team, or on the hospital leadership team, when notified of the problems, ever acted to remedy the situation. When reported to the OIG, the OIG found no basis for the complaints, but the abuse continues.
The VA-OIG has published an end of year survey of COVID preparation and response to the COVID pandemic by the VHA. 68 separate facilities responded to the invitation. These same facilities who brag about how quickly they adapted processes and procedures, are the same facilities bemoaning a considerable increase in cancelled appointments and severe reductions in patients served. Not a single respondent mentioned the draconian measures taken to keep veterans from accessing care or the zealous employees who are enforcing those draconian measures. No single respondent is discussing the failure to follow EMTALA when patients seeking care are turned away for not wearing a mask. There is a correlation between patients not being served by the VA and how many are using non-VA facilities, but that is a data point outside the COVID survey, and that data point might not support the hand clapping and cheering by the providers and administrators of VHA facilities.
I cannot see any reason to cheer and clap over the COVID response by the VHA. When I have accessed the VA Hospitals from Feb to present, the empty halls are a testament to the absurdity of the government response to a viral disease. Being turned away by a provider for not wearing a mask, after waiting for 45-minutes is a testament to the futility of mask mandates and the uselessness and ineffectiveness of the draconian operating procedures for a virus. Watching patients coughing their lungs out sitting beside a patient bleeding, and another patient throwing up does not cause me to celebrate the “COVID Response” by the emergency room administrators. Watching empty treatment rooms sit empty while the waiting room is packed full of people waiting to be seen in an ER is not a cause to celebrate employee retention plans and patient treatment options.
The Carl T. Hayden facility in Phoenix, has had every one of the same issues in care as any other VHA facility in America, and frankly, the leadership team should be ashamed, disbarred, and unemployed! Since 1996, I have crisscrossed the continental United States. I have observed nurses drawing blood or giving shots without gloves, or with fingers ripped off the gloves. I have witnessed patients with broken bones forced to wait for hours on end because they were homeless, and the nursing staff didn’t want to see that homeless patient one more time. I have watched dependents turned away from receiving treatment which under EMTALA is illegal. I have been turned away from treatment multiple times, still illegal under EMTALA. I have made countless suggestions on how to improve, I have written letters to hospital administrators, VISN leaders, and the Federal VA Leadership all to no avail. Yet, the VA has the audacity to cheer and congratulate each other on the “fine response to COVID the VA has made.” Worse, the complaints fell on deaf ears, attached to plastic lips, and hiding vindictive hearts.
Before the VA’s cheers again for their great job fighting a flu virus, remember this, there is nothing to cheer about! No activity made by the VA from Feb 2020 to present is worthy of cheering, clapping, or congratulations. No business process has been laudable. No daily operating procedure is worthy of acclaim. Not a single event is worth even an honorable mention or a participation trophy. Your job is to serve the veterans, spouses, and dependents and you are failing your first and only mission!
Shame! Shame! Shame! Shame on the elected officials, Republican, Independent, and Democrat, who have allowed this problem to grow and done nothing! Shame on the myriad of presidents who have done nothing but throw good money after bad, without demanding progress and holding real people responsible for real results! Shame on every single VA employee who shirks their job for easiness to the detriment, pain, and suffering of a veteran, dependent, or spouse!
© 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 images.
All rights reserved. For copies, reprints, or sharing, please contact through LinkedIn: