The Department of Veterans Affairs (VA) is in trouble due primarily to the employees’ lack of written directions, procedures, and processes to complete work. Of the poor Veterans Health Administration (VHA), there is none worse than the Carl T. Hayden VA Hospital system in Phoenix, AZ. I support this conclusion with both personal observations and through comparative analysis. Much research has gone into this conclusion, and while there are other VHA’s that compete for the bottom, the clear winner remains the Phoenix VA Medical Center (VAMC).
What is bureaucratic fiat?
Bureaucratic fiat is government employees who make decisions in their positions who rigidly adhere to any rule not to perform their job, inconvenience the customer, or thwart responsibility, accountability, and maintain their positions. Bureaucratic fiat survives sections from the Office of Inspector General (VA-OIG) through designed incompetence, lack of training, confusing processes, unwritten rules and guidelines, and simple negligence.
Veteran Suicide!
Outside of first responders and active military, the suicide rates of veterans are too high and rising. The suicide rate is disgusting to behold and tragic beyond words. Of all the topics I discuss, veteran suicide remains my pet topic. When veterans or military members (Reserve, National Guard, or Active) commit suicide, this rips a hole in communities, families, and the guilt the family and friends carry is so intense, they struggle not to commit suicide themselves.
Scrutinizing the Government!
The VA-OIG reported on a veteran who committed suicide, with ties to the Carl T. Hayden VA Medical Center in Phoenix. The veteran reported to the hospital, asking for help. The VA-OIG found that processes were intentionally not followed. Help was not forthcoming, and the veteran committed suicide before the VA got their thumbs out and offered this veteran help. The VA-OIG found the following:
-
-
- “While the patient awaited the testing, facility staff failed to offer mental health treatment.
- The social worker did not complete a suicide risk assessment and relied on another social worker’s suicide risk assessment completed eight months prior.
- A family member called and left a voicemail message for the social worker. However, the social worker’s documentation did not include essential information, specifically that the patient died by suicide.
- Upon learning of the patient’s death by suicide, a Suicide Prevention Coordinator failed to complete timely documentation of outreach to the patient’s family… the mental health delegate did not approve the community care psychology consult within three business days, as required by VHA.
- The third-party administrator scheduled the patient for therapy rather than psychodiagnostics testing.
- The facility scheduling staff did not complete required outreach efforts when the patient missed a primary care appointment one day before the patient’s death by suicide.
- The Suicide Prevention Coordinator did not complete the patient’s behavioral health autopsy within 30 days, as required.”
-
One incident, one VAMC, one veteran, and nothing from the VA will protect veterans and improve the adherence to the policies and procedures moving forward; why even investigate by the VA-OIG?. I weep with this family who lost their loved one to suicide. I scream in frustration that the VA can continue to kill veterans struggling with suicide with impunity.
Do not be deceived; this is not the only incident in Phoenix or all of the VA Healthcare System. A veteran reaches out for help with suicide ideation, receives bureaucratic nonsense instead of support, and is treated to the red tape that becomes the noose in the suicide of that veteran. One event a year is a tragedy of epic proportions. The list never seems to end, nor do the bureaucrats ever get held accountable for their inactivity, contributing to veteran suicide.
12 November 2020, The Military Times reported that from 22005 through 2018, veterans committing suicide had risen dramatically, to a high in 2014 of 6,587. Is the epicness of this tragedy more apparent? Presuming that each of these veterans had two parents who came together and invested time to create the child that became the veteran, 13,174 parents now weep to lose their son or daughter who committed suicide. According to the US Census, families in America had 1.9 children per couple (2014), rounding up to 26,348 is the potential parents and grandparents affected by suicide, and 52,696 is the pool when siblings are added. If each of these suicides had a significant other, with two parents and two siblings, the potential affected by suicide is now approximately 105,392. Add employers, friends from employment, communities, and educational or academic acquaintances, and the number of people affected by suicide can quickly reach a million people. I used 2014 as the year to base the numbers upon as this was the highest number currently available, but 2020 saw a dramatic increase in suicide among all age groups and those with the Census delays; I doubt America will learn the full impact from COVID government madness any time soon.
Now, consider the following, each of those veterans who committed suicide in 2014 (6,587) had a suicide prevention team in place at the VA who failed to act. 6,587 people who deserved better treatment at the hands of the government employees, who have pledged to fulfill President Lincoln’s 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. Failed the veteran and played a role in the suicide of the veteran. Rarely do the veterans who commit suicide, in VA parking spots, on Federal property receive the attention they deserve. I am intimately aware of one such issue with the VA Medical Center in Albuquerque. The veteran could not get help, became frustrated, walked to his car, and killed himself.
2019, The Washington Times, who proudly continues to declare that “Democracy Dies in Darkness,” ran a story about veterans who take their lives on VA Campuses, is a “form of protest” against the VA Healthcare system. No, this is not generally the case; the veteran is not protesting; they are fed up with the fight to be respected, noticed, and receive assistance from people who have pledged to fulfill the Department of Veterans Affairs Mission Statement. To fulfill President Lincoln’s 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.”
I demand to know where are the legislative branches of government in scrutinizing the operations at the VA? Why are suicide rates allowed to climb without significant input from the legislative branch? Why are veterans, directly after an encounter with the VA bureaucracy, committing suicide without in-depth investigations where heads roll for failing to perform the most basic customer service in fulfilling the VA’s Mission Statement?
While an employee of the VA, to get to the directors of the hospital’s offices, I had to walk past this mission statement that hung on brass letters, and all my attempts to aid in change fell on brass ears and plastic lips! Every time the VA-OIG reports another death by suicide, death by negligence, with ties directly to VA employees not performing their jobs, I want to scream in frustration! Veteran suicide rates are egregiously high, and for veterans to commit suicide within 96 hours of a visit to the VA is 100% unacceptable! Why 96 hours; because to date, this is the longest time between actions by the VAMC and the death by suicide the VA-OIG has reported where VA employees should have been held accountable for their refusals to act in a manner to prevent a veteran from committing suicide.
After over a decade of reading and reporting VA-OIG reports and investigations, the deaths by suicide and negligence are the ones that raise my ire the most! I would see the VA improve, but until the VA admits, or is forced by elected representatives to admit, they have a problem, nothing will change. But the horror in that sentence is that veterans will continue to commit suicide and die through VA Employee negligence, and their deaths are as unremarked as if these heroes were common criminals who died in a prison brawl. This remains an abysmal testimony to the incompetence and uncaring bureaucrat found in the VA’s vaunted halls!
© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.
DNC-Consulting 