In physics, for every action, there is an equal and opposite reaction. I am not a fan of the word reaction, for a reaction places all the control of the action into the control of the original actor, and nature does not work like that. But, to reason, we sometimes must use language common to all to understand each other; thus, it is sufficient to my purposes to use the term reaction in this discussion. A similar law applies to psychology; a human chooses to act, natural consequences follow. The ability to as, agency, and the person being acted upon, the actor, play a significant role in how and why businesses succeed and fail.
Societies, cultures, governments, and countries all rise and fall on the moral agency of the individuals in power, the common citizen, and the collective leaders of those groups of people. I have always liked the movie “The Fiddler on the Roof,” Tevye makes a statement about how without tradition, they would be as shaky as a fiddler on the roof. Bringing a mental image of a fiddler, balancing upon a roof, and having two options, climb down and resume playing, or learn to balance on the roof while playing. Both choices offer natural consequences that are easily understood, especially if you have ever worked on a roof.
I have consistently written about VA Leadership failures for several weeks, rightly calling out the administrators at the local VAHCS and VAMC, the VISN, and the Federal levels. Hospital leadership is not so different than leadership in any other industry, even though the VA has tried to make hospital leadership distinct. Herein lay the problem, an employee, a nursing assistant, has just been sentenced to 7 consecutive life sentences for second-degree murder.
“Mays was employed as a nursing assistant at the VAMC, working the night shift during the same period of time that the veterans in her care died of hypoglycemia while being treated at the hospital. Nursing assistants at the VAMC are not qualified or authorized to administer any medication to patients, including insulin. Mays would sit one-on-one with patients. She admitted to administering insulin to several patients with the intent to cause their deaths” [emphasis mine].
We have an affect, but what was the cause?
“While responsibility for these heinous criminal acts lies with Reta Mays, an extensive healthcare inspection by our office found the facility had serious and pervasive clinical and administrative failures that contributed to them going undetected,” said VA Inspector General Michael J. Missal” [emphasis mine].
Regardless of her intention, an employee was allowed to commit murder because of the “pervasive clinical and administrative failures” of the VAMC leadership. Now, two days prior to receiving the results of Reta Mays’ court proceedings, I received the Department of Veterans Affairs – Office of Inspector General report on the clinical leadership failures. I have not witnessed a more despicable and damnable report of leadership failures in the decade-plus; I have been following and writing about the Department of Veterans Affairs or any other government agency!
“In June 2018, facility leaders identified nine patients with profound and concerning hypoglycemic events dating from November 2017 to June 2018” [emphasis mine].
The scope of the administrative investigation is as follows. Staff from the VA-OIG’s Office of Healthcare Inspections (OHI) assessed the following areas, in parentheses is who owns the problem raised in the investigation:
- Mays’s hiring and performance (Human Resources)
- Medication management and security (Pharmacy and Security)
- Clinical evaluations of unexplained hypoglycemic events (Nursing and Doctoral Staff)
- Reporting of and responding to the events (Facility Leadership)
- Quality programs and oversight activities (Facility Leadership)
- Facility, Veterans Integrated Service Network (VISN), and VHA leaders’ responses and corrective actions (Local and area-wide administrators)
- During the course of this review (investigation), the OIG also noted areas of concern regarding hospice and palliative care practices and nursing policies and practices (Nursing, Patient Care and Safety, and Hospital Administrators)
Just as logic tells the fiddler on the roof that he has two choices to live a long and musically fruitful life, the investigation reveals that the VAMC leadership had choices and made both poor and potentially criminal choices in this investigation of Mays’ conduct.
“Ultimately, quality health care is dependent on leaders who promote a culture of safety that reduces or eliminates those risks whenever possible. Providing high-quality health care to a diverse and complex patient population demands the support of, and adherence to, an organization-wide culture of safety. When this occurs, a patient-centric environment becomes the “norm.” Conversely, systemic weaknesses in a facility’s culture of safety can have devastating consequences. The OIG found that the facility had serious, pervasive, and deep-rooted clinical and administrative failures that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier. The failures occurred in virtually all the critical functions and areas required to promote patient safety and prevent avoidable adverse events at the facility” (pg ii) [emphasis mine].
Before we go further into the report, it must be made clear; the investigation team found the leadership, the hospital administrators responsible for allowing Mays to kill seven patients. Attack another patient with the intent to kill and a potential additional hypoglycemic patient who died under her care but could not be directly linked to Mays. A question arises, how did Mays gain employment with the VA; the answer, a former HR employee, failed to do their job in conducting “… background investigation file and determining her suitability for employment!” In a previous article, I wrote about the hazards the VA was purposefully opening themselves to by using “COVID” as an excuse to delay proper investigations into backgrounds when hiring. Here is a classic case where “COVID” is not related, and failing to investigate a background led to people dying!
The VA-OIG last year reported that hiring practices had been relaxed due to COVID and background checks delayed for employees being hired during a pandemic. Yet, when will those background checks be completed? If someone is found unfit due to background checks, will they be forced to return all their wages for lying on a government form? If there is a testament to the need for comprehensive background checks on employees, the seven (7) dead patients who died at the hands of Reta Mays! How many times will this story replicate because the hiring managers are not doing their jobs?
Let us reason together, is the VA administrators the problem with the VA? Does the VA leadership require immediate and total removal? How would you resolve the issues without breaking the system and further endangering the lives of veterans? Please let me know in the comments section.
VA Secretary Denis McDonough signed onto the “I-Care” principles as core values in care for veterans in the VAHCS. When can we, the veterans, see that these core principles have been onboarded and are correcting behavior?
“VA Core Values describe how VA will accomplish its mission and inform every interaction with our customers. These Core Values are Integrity, Commitment, Advocacy, Respect, and Excellence — better known as “I CARE.” VA’s Core Values will continue to serve as the right guide for all our interactions and remind us and others that “I CARE.”
- I care about those who have served.
- I care about my fellow VA employees.
- I care about choosing “the harder right instead of the easier wrong.”
- I care about performing my duties to the very best of my abilities.
Mr. Secretary… The veterans are dying now! We are waiting!
© 2021 M. Dave Salisbury
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