Communication: The Devil is in the details – Shifting the VA Paradigm

I-Care23 January 2020, I wrote about how a medical support assistant (MSA) was negatively influencing communication between my primary care provider and myself.  Today, I discovered the Department of Veterans Affairs – Office of the Inspector General (VA-OIG) is reporting the same problems in several other VA Medical Centers across the country.  One veteran waited 36-calendar days for a positive test result notification; yet, because there were no “adverse patient events as a result,” the lack of communication is not considered an issue.  Another example involves a patient and do not resuscitate (DNR) orders, along with family concerns and end-of-life home hospice care.  The VA physician/hospitalist in charge had four incidents raising concerns the VA-OIG investigated, where the need to improve communication is the problem with no solution, support, or quality controls.

I guarantee, if there is a 36-day lag in a positive test result notification to me, there would be an adverse patient reaction.  While the VA-OIG made communication recommendations, I would bet dollars to doughnuts that the problems in communicating remain a significant customer service issue.  Why, because the majority of comprehensive inspections the VA-OIG conducts include failures in communication, and the amount of communications issues resemble bunny rabbits in a field with no predators.

The “I-Care” customer service program at the VA reports the following in every I-Care class:

“How we treat veterans today determines if the veterans choose the VA tomorrow.”

On the I-Care Patient Experience Map, how communication is used influences how the veteran feels about choosing the VA for their needs.  Yet, the VA continues to communicate like the veteran has no choice, no options, and does not matter.  Here are some communication tips, tailored specifically to the VA; may they find application quickly in VA customer operations.

  1. The VA claims that the primary care provider, the nurse, the MSA, and the patient are a healthcare team.  If this is the case, then the first step in improving communication is a technical fix opening as many channels of two-directional communication as possible.  Including email, voicemail, text messaging, telephone, fax, and instant messaging.  If the patient has all these channels, and they do; why can’t the nurse, the doctor, and the MSA use all the same technology to communicate?
  2. The VA has improved on this issue, but there is considerable improvement still to make; when test results come out, copy the patient on the results, automatically. But, where the patient’s results are concerned, explain the results.  Have the nurse or a physician assistant write some comments about the results, before sending them onto the patient.  Currently, I receive bloodwork results and have to Google/Bing my way through the results and guess when discussing the results with my spouse.  I received bloodwork results from UNM, the results came in digitally to my email box, with hyperlinks to explanations by doctors in the UNM system.  I received X-Ray and MRI results that claimed “all normal;” this does not tell me anything and increases the problems in understanding what was observed in the X-Ray and MRI.
  3. Face-to-face customer service is a skill that requires training, quality assurance, and monitoring. Yet, the MSA’s at the VA, who do the most customer influencing communication, are not trained, monitored, or quality assured.  The result, patients are treated horribly or are treated amazingly well, based solely upon the individual.  Unfortunately, the leadership in charge of customer service are often the worst offenders for poor customer service.  This must change; implementing a quality assurance program is not difficult, or expensive, and provided the quality assurance does not become the stick to beat people into submission, will provide positive fruit.  But, everyone who communicates with a veteran needs training and needs methods for improvement.
  4. Stop active listening as the standard for communication. In a hospital environment, especially, the standard should be reflective listening to achieve mutual understanding.  Active listening skills can be faked, thus inhibiting proper communication.  As an example, review the physician hospitalist who was able to fake care for patients sufficiently to fool the VA-OIG, but the patients and their families were left without feeling they had communicated sufficiently to act with confidence.
  5. “I-Care” is a good program; why has it not become the standard for all customer interactions? There is no reason for this program to not be a mandatory baseline standard of employee behavior from Secretary Wilkie to the newest new hire.  Yet, hospital directors can dismiss “I-Care,” refuse to implement “I-Care,” and disregard “I-Care.”  To grow the “I-Care” culture, every employee needs to onboard and commit; where is this being insisted upon?

Too often, the root cause analysis is either poor communication as the issue, or a substantial sub-issue; yet, even with the insistence of the VA-OIG, communication failures remain.  No more!  The VA must implement “I-Care” for every employee, implement a quality assurance program for communication, hold communication training, and design communication goals for every classification of employee.  Most importantly, every single leader must exemplify the customer standards they want to see in their employees.  There are no valid excuses for failing to communicate!

 

© 2020 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.

The Department of Veterans Affairs: The Liars and Thieves Edition

In December 2019, I witnessed an employee of the Department of Veterans Affairs, Hospital Administration, create rules to inconvenience a veteran, lie to a veteran, obfuscate, and generally mock a veteran.  The incident included the employee threatening the veteran with throwing away documentation, the primary care provider needed because the veteran was not mailing the forms to the doctor as the employee demanded of the veteran.  The veteran must travel and thought dropping off the forms would be acceptable; until he met this employee.  23 January 2020, I was the veteran being lied to, and my “cherub-like demeanor” evaporated faster than dew in a July sun.  For the December incident, I signed my name to a letter going to the Hospital Director Andrew M. Welch, written by the abused veteran, and testified that I witnessed the treatment this veteran received.  To the best of my knowledge, no action was taken by the hospital leadership where this employee is concerned, I asked.  A copy of this article will be sent to hospital leadership.  If any additional information comes available on this issue, I will write an addendum and update this article.

23 January 2020, 1505-1510, I went to my primary care provider’s clinic at the Albuquerque, New Mexico VA Hospital.  I had another appointment, was early, and went to ask why I am receiving letters claiming the primary care clinic is “having difficulty” contacting me.  The employee is titled “Advanced MSA,” which means they are a Medical Support Assistant who has been promoted.  For my other appointment, I have received two text messages, one automated call, and three appointment emails.  For my next appointment, 24 January 2020, I have received two text messages, one automated call, and three emails.  For my appointment in December 2019, I received two text messages, one automated call, and three emails.  I regularly receive calls from other clinics in the VA Hospital.  My cellphone has voicemail, and the voicemail is regularly checked and responses made.  Yet, the MSA claims, “I have tried calling you, and you do not have voicemail.”  I checked my recent calls, and showed the MSA where I had not received any calls from the VA on the days indicated, and asked why I can receive all these other calls from the VA, including the text messages, but only his calls are not showing up.  The MSA then became intransigent, resolute, and adamant, raised his voice, and told me our conversation was done.  After observing the ways and means of this VA employee over the course of many months previously, I wonder, “how many other veterans are not being contacted in a timely manner, while this person lies, cheats, and steals?”

Unfortunately, this is the standard, not the exception for the MSA’s in the HAS (Hospital Administration Services) Department, led by Maritza Pittore, at the Albuquerque VA Hospital.  I have witnessed multiple MSA’s committing HIPAA violations through record diving, gossiping about veteran patients, acting rudely, ignoring veteran patients and their families to complete conversations, and refusing to do their jobs.  As a point of fact, one assistant director one told me, “if what the VA does was replicated by a non-government hospital, they would be closed down and sued.”  While employed from June 2018 thru June 2019, I brought this to the attention of the leadership, including multiple emails and voice conversations with Maritza Pittore, Sonja Brown, and several other high-ranking leaders and their assistants, all to no avail.  I have had nursing staff tell me confidentially that they cannot do anything where the MSA’s are concerned because “it’s none of their business and outside their job duties.”  Yet, the VA continues to proclaim the MSA, the Nurse, and the doctor, along with the patient, are a “healthcare team.”  Upon being discharged, without cause, reason, or justification, I brought this information to the OIG, my congressional and senate representatives, among many others, all to no avail.  The level of customer service, especially at this VA Hospital, is far below the pale because the leadership refuses to engage and set standards for customer service, with enforced penalties.  More to the point, the employees mimic the customer service they receive from the leadership team.  Thus, even though the Federal VA Office has launched “I-Care” as a customer service improvement initiative, the customer service in this hospital continues to fall and will continue to fail until the leadership exemplifies the standards of customer service expected.

As a dedicated customer service professional, I have offered multiple solutions to the continuing problems veteran patients experience in the Albuquerque VA Hospital at the hands of the MSA’s and other front-line customer-facing staff; but the suggestions all continue to fall upon deaf ears.  I do not paint all the MSA’s and staff as liars, thieves, and cheaters, because there are some great people working at this VA Hospital.  Unfortunately, the rotten apples far exceed the good workers by multiple factors and powers, to the shame of the leadership team who continues to ignore the problem, deleting emails, and generally lying when placed on the spot about the problems.

An example of this occurred recently where a member of the staff of a congressional representative asked about communications sent from an employee to the Director of VISN 18, with carbon copies being sent to Maritza Pittore HAS Director, Ruben Foster MSA Supervisor, and Sonja Brown Associate Director of the Hospital.  None of those emails “magically” exist when asked for, and the verbal conversation included outright lies, misdirection, and complete fallacies.

Since the VA-Office of Inspector General (VA-OIG) continues to appear disinterested, I can only ask, “what does a person do to see action taken to correct the problems, right the abuses, and bring responsibility and accountability to the employees of the Federal Government?”  President Trump is providing great leadership, VA Secretary Wilkie is doing a good job and needs more help, but the elected officials in the House and Senate refuse to do their job, and the middle management of the VA is entrenched, obtuse, and inflexible.  The US Media treats veterans’ issues as a punchline to a bad joke.  Still, the problem worsens; still, the abusers maliciously treat people abhorrently; and still, those placed in leadership positions stall, obfuscate, and hinder.

My treatment at the VA Hospital in Albuquerque includes being physically assaulted by an employee, my medical records perused by, and then gossiped across at least four separate clinics, and still that MSA remains employed.  In fact, this employee was promoted for her “good work and dedication to helping veterans.”  I am sick and tired of the poor treatment, the harassment, and the vindictiveness served to veterans of all types, sizes, and colors, at the hands of petty bureaucrats as they visit the Department of Veterans Affairs.  The Albuquerque VA Hospital is one of the most egregious examples of bad behavior and nepotism in the country and it is past time the leadership was replaced and the assaults and crimes brought into the sunshine for some “sunshine disinfectant.”

© 2020 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.

Leadership and the Department of Veterans Affairs – Shifting the Paradigm on Killing Veterans (Part 2)

I-CareAs a new decade and year begin, the Department of Veterans Affairs Office of Inspector General (VA-OIG) reports continue many of the same themes from 2019 and earlier, specifically the failure of leadership.  There is an axiom in the US Military, applicable to the Department of Veterans Affairs (VA), “When leadership fails, soldiers die!”  Well, leadership at the VA faile,d and veterans are dying and this is an inexcusable trend requiring immediate rectification.  Leadership at the Minneapolis VAHCS, Minnesota failed to communicate, and a veteran struggling with suicide ended their life while admitted to the VA Hospital.  While the VA-OIG brought several issues to bear on the leadership team, I noticed a blatant irregularity, from the report comes the following:

The internal review team identified many lessons learned for which the Veterans Health Administration (VHA) does not require action items. VHA does not provide written guidance on the identification of lessons learned, related action expectations, and how to distinguish lessons learned from root causes.”

Why perform an after-action review (AAR) and not require action items to be identified, actions to be taken, and methods to measure change?  Why does the Veterans Health Administration (VHA) not provide guidance on how to conduct an AAR?  Leadership communication is a root cause in many of the blunders the VA generally, and the VHA and Veterans Benefits Administration (VBA) specifically, suffer on a regular basis in VA-OIG reports, yet the oversight teams in Washington D.C. cannot be bothered to provide written guidance; this is a perfect example of designed incompetence, and the veteran continues to be abused by the bureaucracy.

Designed incompetence is the term for establishing a bureaucracy where excuses can be automatically made, problems never addressed, and people not held accountable as a system benefit, not a system flaw.  The VA-OIG report held another gem, “During an internal review, the facility’s root cause analysis team did not interview staff members involved in the patient’s care.”  Designed incompetence protected the leaders, allowing for excuses to lead to a dead veteran, and the bureaucracy protected their own by not properly investigating.  At my local VA Hospital in Albuquerque, NM., not talking to staff members directly involved in an issue is a well-worn game, where employees have been arbitrarily dismissed and the leadership protected, veterans have died, staff and patients have attacked patients and staff alike, and more, all because the investigations are conducted without ever talking to people involved in the issues.

The VA-OIG raises a final issue, “The Patient Safety Committee and the Quality Management Council meeting minutes did not document deliberations and track actions to resolution.”  Leading to the final question, why conduct an AAR if you are not going to act to rectify a problem?  Failure to change means the veteran who died in a hospital is disrespected more in death than in life, and this is utterly and completely reprehensible conduct by the VA.

The VA-OIG conducts Comprehensive Healthcare Inspection (CHIP) of various VA Medical Centers, I remain fascinated at the trends that continually and regularly are commented upon, and I would ask the VA-OIG, do you have trend lines for certain occurrences of issues in CHIP inspections?  For example, in doing a rudimentary review of the VA-OIG reports in my email box, I find a total of eighteen (18) CHIP reports from the VA-OIG from 12/01/2019 through 01/15/2020 and not surprisingly there is a regular problem arising in every single report, “Implementation of corrective actions from root cause analyses.”  Thus, not only is the CHIP regularly citing problems with conducting and implementing action items from root cause analysis, the same issue is killing veterans, and the designed incompetence was displayed in the comments from the VA-OIG, “… the Executive Leadership Board was not following actions until completion.”

Department of Veterans Affairs Office of Inspector General, when regular comments are found, who tracks and works on the nationwide issues?  Where does your data go once collated into trend lines?  Are you receiving support from the elected officials to which you report performance?

Elected officials in the House of Representatives and the Senate, you and your staff have access to these same reports, what are you doing to hold the VA leadership accountable?  What are you doing to support change in the VA Bureaucracy to stop the veterans from dying at the hands of designed incompetence?  When will you be as ambitious about veterans as you are about getting re-elected?  You were elected to do a job, you are part of the leadership problem at the VA, when will you act?

© 2020 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.

Desperate Changes Need at the VA – A Letter to the President

President of the United States
Attn: The Honorable Donald Trump
1600 Pennsylvania Ave NW
Washington, DC 20500

12 December 2019

Dave Salisbury
1947 Edith Blvd SE
Albuquerque, NM 87102

Subject: The Department of Veterans Affairs

Dear Mr. President,

Please forgive my presumptuousness in writing to you directly.  I have made several attempts at raising the issues contained herein at lower levels, to no avail.  As the Chief Executive Officer of the United States of America, I come to you as the person of last resort.  The Department of Veterans Affairs (VA), especially Healthcare and Benefits departments are sick, and in desperate need of urgent corrective action.

  1. The VA-OIG has documented multiple times when claims have been improperly been decided, where training was lacking, leadership failed, and the veteran suffered.  Yet, never in the VA-OIG report is a discussion on correcting the past decisions.  The process for a veteran to have a previous decision, more often than not improperly decided by the VA, is to produce new material evidence, and wait interminably for the VA to decide they need to act.  This single issue is a leadership failure of enormous proportions, that Congress refuses to act upon; thus, the leadership failure begins and ends with the House of Representatives and the Senate refusing to do the jobs they were elected to complete.
  2. While the following is specific to the New Mexico VA Healthcare System (NMVAHCS), the problem is rampant throughout the entire VA healthcare system. I witnessed, 11 December 2019, a VA employee tell a veteran that they would not submit paperwork for the veteran, to the doctor, in the clinic unless the paperwork was “processed correctly.”  Meaning that the veteran took an envelope, placed the VA forms inside the envelope, and then mailed that paperwork to the VA Hospital.  The veteran lives a significant distance to the hospital and was trying to do in person what had failed through the USPS.  The employee went as far as to claim, “If that form is placed on my desk, I will throw it away because it is not being presented to the doctor in a manner acceptable to the employee.”  Never have I witnessed such blatantly disrespectful behavior by a bureaucrat.  In true bureaucrat fashion, he created rules to thwart, obfuscate, and dodge work; unfortunately, this is standard practice with the majority of employees in customer-facing positions in the VA.  The leadership failure, the protected status of termed (beyond first-year) employees at the VA, and the dearth of customer service skills are all aspects to the core problem the VA is terminally suffering from, bureaucratism.
  3. From June 2018 to June 2019 (5-days short of completing my first year) I was an employee of the NMVAHCS, working in the Emergency Room as a Medical Support Assistant (MSA). I was discharged through lies, deceit, and under the auspices of Quid Pro Quo, where my termination was required for two others to be promoted.  While employed, I regularly reported to the leadership team my supervisor, the HAS director, the hospital director, the VISN 21 director, and the VA-OIG problems like HIPAA violations, a physical attack by a senior MSA on my person, fraud, waste, and abuse, as well as potential solutions to improve the ER operations.  All to silence and platitudes from the leadership team.  Did you know there is a loophole in the whistleblower protections if you are under term employment, (1, 2, or 3 years term) you have no whistle-blower protections, and if your job is lost, you have no whistle-blower protections?  The abusers have worked out many angles to protect the dregs of society while allowing malfeasance and misfeasance to proliferate in government employment.  Please allow me to elaborate upon the specific issues witnessed:
  • A 14-year old is being treated in the ER. A 16-year old is turned away.  The difference, the triage nurse who decided who gets seen and who gets bumped because the NMVAHCS cannot treat children.  When asked what age is considered a “child” under the hospital policy, no answer in 12-months of regularly asking.  I saw several times when this repeated, the most egregious was a new military spouse, 17 years old, denied treatment at the ER that services the Air Force Base next door due to being “too young” per the triage nurse.  By the way, under Federal Law, this is illegal for an ER to do; yet, this was regular practice while employed.
  • A health technician supporting ER patient care comes out of the ER and begins to harangue a patient currently being seen, expressing comments that made clear the health technician knew intimate details of that patients’ chart and past care and treatment received. Under HIPAA this behavior is illegal, as well as being immoral, unethical, and plain wrong.  Yet, HIPAA is regularly broken by MSA’s, Health Technicians, and other care providers in this VA Hospital.  Every time these HIPAA violations were brought to the attention of the HAS Director, excuses, platitudes, and professional brush-off occurred.  On more than one occasion, the HIPAA violator was promoted to “treat” the problem.  When these issues were brought to the attention of the VISN 21 Director, the problem was pushed back onto the assistant hospital director in NM for further consideration.  When complained of to Congressional Representatives, lame excuses were generated by the Assistant Hospital Director and the HAS Director and accepted by the Congressional Representatives staff.  HIPAA Abuse continues unabated!
  • Homeless veterans regularly received substandard treatment when compared to other veterans. I saw nurses bad-mouth, scream, and yell at homeless patients.  I saw a homeless patient with a broken leg, get delayed treatment for more than four hours because the duty nurse was tired of treating this particular patient and didn’t believe the veteran had broken his leg after a fall.  I saw nurses put patients into treatment rooms and left for anywhere between 45-120 minutes because the shift was changing and the nursing staff did not want to treat another patient before their shifts ended.  The nurses stood outside the patient’s door, joking, carrying on, and gossiping while the patient listened and waited to be seen.  Every time these issues were raised the lamest excuses came from leadership, platitudes, and pie-crust promises that were delivered.  I reported these issues and more via both verbal and email, to no avail; yet, when a member of Congress’ staff contacted the hospital, there is no email proof that the leadership was ever made aware of these problems.  If these are examples of “World-Class Care” being delivered to veterans, I shudder to consider what poor service would include.
  • The NMVAHCS has a reputation for killing the employment of term employees all the way up to their last day under the term. For example, a housecleaner employee, a good worker, well-liked by the staff where she cleaned, got into a disagreement with her supervisor and was terminated at lunch on her 364th day of employment in a 365-day term.  Her supervisor did not need a reason to discharge her and used this to end her employment.  An MSA male employee, hard worker, came in on his 361st day of term and was terminated, no reason, no excuse, no justification, simply told to scrape his employment parking sticker and leave.  This pattern has repeated so often, that the veteran employment counselor at workforce connections warned me to not accept employment with the VA due to the NMVAHCS’ reputation for ruining people.

The NMVAHCS is one dead veteran from becoming the next Phoenix VA Hospital incident.  I am not without hope, but it will take the House and the Senate to enact the type of change needed in the VA to truly see significant and lasting change.  Towards this end, I suggest the following:

  1. Draft legislation, one a single sheet of paper canceling the collective bargaining agreement (CBA) of all Federal Government Labor Unions immediately, and forever sundering the death grip the labor unions have on policies and procedures that protect the criminal and steal valuable resources from government coffers through direct and indirect means and methods. The cost of labor unions in government is astronomical and removing this single cost will open funds in Federal Budgets that are desperately needed.  I know this is a political hot potato, and I know the impeachment farce continues to be a mental and physical drain.  But, as the German Philosopher has said, “The hard is good.”
  2. Draft on a separate sheet of paper, new legislation giving the Secretary of the VA plenipotentiary power, the likes enjoyed by every CEO in the private sector, to enact change. You have a good VA Secretary, but the staff is a hodgepodge of weak-kneed political cronies that should have been retired years ago!  This legislation also would allow for a cleaning of house at the VA, realigning the entire organization, placing the power to positively affect veteran lives into the hands of the PACT team and out of the hands of the bureaucrats.
  3. Place power into the hands of a roving IG team to have benefit claims immediately reviewed after a lapse in the procedure is discovered. Meaning that the veteran’s claim affected by bad decision-making by the VA is immediately checked by the VA-OIG instead of waiting around in record purgatory for new and material evidence.  Another VA-OIG team should be put to work reviewing past claims where the VA was caught, and getting this backlog cleared out.  The appeals process for benefits claims needs a complete overhaul.  While this legislation and action might require more than a single sheet of paper to enact, it is the right thing to do.
  4. The Mission Act was a good first step, but the entrenched bureaucrats are hindering and hampering the roll-out for personal gain, e.g. retirement. Encourage Congress to take up the legislation proposed, insisting that nothing else is added to these bills to protect the veracity and simplify the approval process.

I appreciate the work you do.  I especially appreciate your classy wife, your well-behaved and intelligent children, and the gains made in “Making America Great Again.”  I know the proposals are difficult; but I also know if we do not attempt the impossible, we can never know the realization of the legacy left to each American by those who have sacrificed before and leave a legacy of hope for our children’s children.  Thank you for your sacrifice and service.

 

Sincerely,

M. Dave Salisbury

Questions, Suggestions, More Uncomfortable Truths – Shifting the VA Paradigm

I-CareWhile receiving a call from the local VA to schedule an appointment, where the VA initiated the call, I discovered a genuinely despicable practice had spread at my local VA.  I have a name, that name is not “Honey,” “Darling,” “Sweetie,” or other terms of endearment.  If you employ a term of endearment in professional exchanges, you are practicing the height of disrespect.  I expect to be called “Darling” when I visit independent truck stops in the Southeastern US and Texas.  My wife does not use these terms, my friends use my name; why is the VA, specifically in New Mexico, allowed to employ such disrespect?  My name is on the computer in front of you, why are you choosing to not use my name?  Where is quality control?  Where is the leadership team in preventing problems from becoming a VA-OIG inspection issue?

People ProcessesQuality control is powered by actively engaged leadership and includes call monitoring, training materials, risk control, attitudes, behaviors, and so much more.  When there is no quality control, the business experiences a phenomenon comparable to a herd of dairy cows, fresh from milking.  Each cow will head off in different directions, the adventurous cows will run to the farthest fence and push against the boundaries, finding a definite boundary, they return to the middle of the field and graze.  Finding weak limits, or no boundaries, the cows will wander all over the place and never eat properly.  The less adventurous cows will plop themselves down, and be intransigent until they discover the boundaries are gone, and then the crazy in cows comes out.  Some of the cows will bawl incessantly, some will stop eating, others think they can be adventurous and get tangled in fences or eat the wrong food and become sick, and so much more.  Fences protect the cows, durable fences are required to promote a healthy herd; quality controls are the boundaries that protect the worker, promote sound action, and prevent some of the behaviors that create the roots of the Department of Veterans Affairs Office of the Inspector General (VA-OIG) reports that keep crossing my desk.

As previously stated, several times, in fact, the complicated organizational structure of the Department of Veterans Affairs (VA) is a root cause as to why the veterans suffer so much at the hands of bureaucrats.  The VA is geographically broken into Veterans Integrated Service Networks (VISN), these VISN’s oversee geographically grouped, generally by state, Veteran Health Care organizations (VA Hospitals and clinics).  In theory, how the VISN acts is supposed to trickle down to the hospital and clinics improving performance and generalizing operations across a broad geographical area.  Unfortunately, what is passed down to hospitals and clinics in the VISN is often the dregs, the poor practices, and the insanity of a complicated bureaucracy.  When one hospital in a VISN is in trouble, look to the VISN, and see replication.  Happens everytime; thus, change the organizational structure, simplify the hierarchy, and clean out the drones.

For example, the Chief of Staff in VISN 10, hired an ophthalmological surgeon who was not credentialed, not properly certified, and inadequately trained, and then repeated their mistake at the end of the probationary period by hiring the surgeon on full-time.  From the VA-OIG report, we find the following description of the surgeon, “… the surgeon lacked adequate training to perform cataract and laser surgery as the surgeon did not satisfactorily complete an approved residency training program, was ineligible for board certification in ophthalmology, and did not meet the facility’s ophthalmologist hiring requirements. Several credentialing and privileging activities did not comply with Veterans Health Administration requirements and included inadequate primary source verification from foreign educational institutions and insufficient references attesting to the surgeon’s suitability to perform cataract surgeries.”  The VA-OIG report then proceeds to discuss “multiple leadership deficiencies” that led to this surgeon being hired and allowed to practice.  The Chief of Staff caused a problem for veterans, but the language is “leadership deficiencies.”  Where is the accountability?  Where is the demand for replacing the leader?  While the surgeon was eventually terminated, what about recompense for the malpractice committed?  The VA-OIG report documents, “… the surgeon’s productivity, competency, and [deficient] technical skills began within months of hire. The surgeon did not consistently demonstrate the skills to assure good outcomes, was unable to meet surgical productivity expectations, and surgery times exceeded norms.”  Where is the Chief of Staff’s culpability in this dangerous affair?

Speaking of leadership culpability, there remains a recurring theme in several recent VA-OIG reports, failing quality ratings, but the leadership team is new.  I understand that new leaders will require time to positively influence organizational attitudes and behaviors, what I do not understand is why time is used as an excuse and nowhere in the VA-OIG report is a list of leadership tenure to justify the time excuse, nor is a reinspection time identified.  When I audited business for performance, these factors are always in the report, time on station, efforts to change since appointment, when the next inspection will occur, and recommendations to improve between the end of the examination and the reinspection.  More needs declared in these inspections, as the VA-OIG just does not appear to inspect an entire health care system without cause.

Regarding leadership and quality controls, here is an example of a construction project where leadership and quality controls were desperately needed, yet remain missing.  The Ralph H. Johnson VA Medical Center approved a series of construction projects by awarding contracts.  Instead of construction beginning within 150-days, construction began around day 743 on average.  Instead of blueprints costing $74,000, the final cost was $441,000.  While other claims of misappropriation were alleged, the VA-OIG did not investigate or could not validate those claims.  Where is the leadership of the VISN to proactively ask tough questions of the local hospital leadership to determine where problems are occurring?  Where are the quality control officers, the risk control officers, and other leaders in demanding compliance with VA regulations?  Construction was averaged at 743-days after contract award, which is a minimum of 593-days out of compliance, and there are costs associated with delaying construction contracts; what were those penalty costs, and why are they not included in the VA-OIG report?  Where is the discussion on why the delays occurred?  Where are the leadership and quality controls?

As the home shopping channel is always proclaiming, “But wait, there’s more!”  The VA has six fiduciary hubs to look after the resources of those veterans deemed unable to manage their own finances.  The Salt Lake Fiduciary Hub got behind in their workload and leadership, and quality control were the reasons why the workload backlogged, add in staff churn, and the fiduciary hub fell significantly in arrears in their work.  The VA-OIG documented a need for workload management plans, training on how to prioritize work action items, a process for weeding out duplicate tasks, and how to measure production to ensure goals are met.  The recommendations from the VA-OIG reads like the primary duties a director must already possess to meet the demands of the job they fill; yet, this director is not documented as being replaced for failure to do their job.  Basic leadership skills require a knowledge of how to help schedule work, balance workloads, train on prioritization of tasks, communicating, and building a team.  Where is the leadership and quality controls to ensure productive work is performed, and leadership is doing their jobs?  The VA-OIG is not the solution to these leadership deficiencies!

The Hampton VA Medical Center in Virginia is reported to have had $1.8 million in improperly marked, inventoried, or accounted for inventory in forgotten rooms of the hospital.  The supplies had been sitting for “an indeterminate amount of time.”  Stock supplies had been improperly ordered, and the staff was inadequately supervised to protect the medical center and the taxpayer from fraud, waste, and abuse.  The facility in May 2017, and again in May 2018, had identified the same deficiencies the VA-OIG documented and did nothing to rectify the situation.  While the VA-OIG has made “several recommendations” the problem remains, the leadership failed to act in 2017, and 2018, what steps were put into place to ensure action finally occurs in 2019?  Audits are part of an integrated quality control process; where is the rest of the quality control program?  Where was the hospital leadership in 2017 and 2018?  Quality control audits cost money and not correctly responding to an audit should have penalties; where is the accountability for design incompetence that has allowed this problem to survive two audits and an OIG inspection?

NetworkingSome of the VA-OIG reports crossing my desk discuss what the VA-OIG terms, “Comprehensive Healthcare Inspections.”  Unfortunately, too many of these reports include the verbiage to this effect, “The OIG issued 22 recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Infection control and general cleanliness • Mental health unit panic alarm testing response times • Mental health unit seclusion room flooring • Emergency generator testing (3) Controlled Substances Inspections • Reconciliation of dispensing and return of stock • Controlled substances order verifications • Routine inspections by controlled substances coordinators (4) Military Sexual Trauma (MST) Follow-up and Staff Training • Providers’ training (5) Antidepressant Use among the Elderly • Patient/caregiver education on medications (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership (7) Emergency Departments and Urgent Care Centers • Waiver for 24-hour operations • Staffing and call schedules • Use of required tracking program • Directional signage • Equipment/supply availability.”  The root cause of many of these VA-OIG recommendations is leadership and quality control; yet, never is quality controls mentioned, even though the inspection, and the SAIL and CLC metrics are quality control programs.  Congressional representatives where is your leadership in insisting upon full implementation of a quality control program, follow-through on the program’s application, and demands for quality improvement?  The elected representatives of the American Republic must be held to task for failing to act to improve the bureaucratic nightmare they created through inaction and legislative fiat.

Another recurring theme, where leadership and quality control are non-existent, and which happens to profoundly impact the quality of life for patients, are those issues emanating from long-term care facilities and the veterans living in those facilities.  55 patients in San Juan, Puerto Rico were impacted by, “… staff inadequately monitoring the patient.  Documentation was insufficient, and there were no care coordination agreements between the care facility and other service providers.  Licensed practical nurses did not add registered nurses as co-signers to notes to alert them of changes in the patient’s status, and the patient’s care plan had not been modified to include the initiation of chemotherapy.” Mainly, the staff failed the patients, the patients suffered harm, and the injury was caused because of a lack of leadership and quality control.

Thank you!I want to conclude this article with a major thank you to the officers and staff in the Milwaukee VA who saved the life of a non-veteran.  From the story, “Instantaneous response by Milwaukee VA police, followed by immediate action from emergency room personnel, saved the life of a non-veteran who was within minutes of dying of a heroin overdose.”  Having worked at a VA medical center where veterans committed suicide in the parking lot of the VA, it is good to see that the measures being implemented by the Federal Police are having a positive effect on veterans and visitors alike.  To all involved in this incredible story, “Thank you!”

© 2019 M. Dave Salisbury

All Rights Reserved

Any images used herein were obtained in the public domain, this author holds no copyright to the photos displayed.

 

 

Uncomfortable Truths: Department of Veterans Affairs, are you listening?

It was surprising that the Department of Veterans Affairs will automatically share health information with third parties without the veterans written consent unless the veteran opts-out in writing or submit a revocation in writing submitted in person or by US mail.  Especially surprising is that the official form for opting-out is not legally active until October 2019, and the deadline for opting-out, in writing, is 30 September 2019.  While this news if significantly troubling, let us define the full problem, courtesy of the Department of Veterans Office of Inspector General (VA-OIG).

I-CareOn 12 September 2019, the VA-OIG completed their investigation into the Beneficiary Fiduciary Field system (BFFS), who handle benefits payments for veterans and other beneficiaries who, due to injury, disease, or age, are unable to manage their financial affairs and are thus vulnerable to fraud or abuse.  The veterans affected are those who are the most susceptible in the veteran population, and the government agency charged with protecting, helping, and supporting these veterans is vulnerable to fraud and misuse.  In fact, the VA-OIG found that the BFFS, “… lacked sufficient controls to ensure the privacy of sensitive data and prevent fraud and misuse. Specifically, finding the VA’s Office of Information and Technology inappropriately set the security risk level for BFFS at moderate instead of high. Risk managers did not follow established standards and did not consider whether information for beneficiaries and fiduciaries stored in the system’s database was sufficiently protected.”

Yet, the VA is now making available to third-parties, the health records of veterans.  Does anyone else see a problem?  Previously I have written about the continuing risk of veteran’s files from being accessed by persons unknown, and how this problem does not slow, simply how the VA has stopped reporting how bad the problem continues to be.  Personally, I have been a victim of ID Theft from VA Data breaches three times.  I have had VA Employees surf my medical records and then use this data to discriminate against me.  I have witnessed blatant HIPAA violations by VA Employees without hospital leaders taking any action.  Now, the VA is going to “share” my medical record access with “interested parties.”  I have some concerns!

Just in case your attention was drifting due to fallacious impeachment proceedings, the VA inappropriately sole-sourced contracts for ambulance services in three separate Veteran Health Administration Regional Procurement Offices (RPO).  The significance of this event is evidenced in the lack of competition for government contracts.  Designed incompetence was the origination of this issue, the contracting officer claimed, “I didn’t know.”  The contracting officer, who must go to school to obtain authority to enter into contracts for the Federal Government, somehow “didn’t know” about the regulations and rules for sole-sourcing a contract.  I have some doubts!

In further news from VA-OIG investigations, we find another contracting officer who claims, “I don’t know,” to hide behind designed incompetence in sole-sourcing contracts.  From the VA-OIG inspection report, “15 sole-source contracts awarded by RPO West with a total value of about $19 million, were inspected to determine whether they were properly justified and approved, and found that this was not done for five contracts worth about $6 million.”  The contracting officers in RPO West, who “misunderstood who the proper approval authority was.”  Are you kidding me?

Blue Money BurningThe VA-OIG reports, “when contracting officers violate federal regulation by failing to obtain the required approval for sole-source contracts, they exceed their contracting authority.”  Contracting officers work with the approving authority, how can they not “know” who they work for and how to obtain proper authorization?  The excuses are weak and inexcusable; as an operation professional, the first step in getting to know the business is to know who answers the questions, who has the authority, and where that person is located.  For contracting officers, the approving authority is the boss, either the employees do not know who they are working for, or there are significant issues in lines of authority, and both situations speak of phenomenal incompetence and failure of leadership.

Just like the Home Shopping Network is always claiming, “But wait, there’s more!”  RPO East, not to be outdone by RPO West, had the VA-OIG inspect “20 sole-source contracts awarded by RPO East totaling $41.4 million. The OIG found RPO East contracting officers did not obtain required approval before awarding 10 contracts worth about $14.2 million.”  The reason these contracts were not appropriately sole-sourced, “because officials did not follow the proper approval process, did not receive the correct guidance, and misinterpreted regulations.”  If RPO West is suffering from “phenomenal incompetence and failure of leadership,” then RPO East is beyond saving under the current leadership, and I call upon Secretary Wilkie and his team to scrub RPO East leadership and start over under strict quality review teams to ensure compliance and correction.  I repeat, only for emphasis, this situation is inexcusable.  The contracting officers must attend school, must know the regulations, and must not “individually interpret” the purchasing rules, and they know this from the first second on the job.  I was made aware of sole-source contracting regulations, and I was not a contracting officer.

RPO West has the follow-through needed to boil someone’s blood.  “The VA-OIG reviewed 15 sole-source contracts awarded by RPO West with a total value of about $19 million to determine whether they were properly justified and approved, and found that this was not done for five contracts worth about $6 million.”  The reason these contracts were not appropriately sole-sourced, “because officials did not follow the proper approval process, did not receive the correct guidance, and misinterpreted regulations.”  I rescind my earlier comments about the ability to save RPO West, I call upon Secretary Wilkie to personally ax the leadership at both RPO East and West, to start on a clean slate the contracting officers, leadership, and then strictly observe and implement a quality control mechanism to protect the taxpayer.

People ProcessesSpeaking of “phenomenal incompetence and failure of leadership.”  Please allow me to prepare the groundwork for the subsequent VA-OIG investigation.  To be a supervisor in the VHA, VBA, or National Cemetery, you first must work in the positions you will be supervising.  This information was passed during a job-interview by the hiring authority and confirmed by several VA directors since.  From the VA-OIG Report, we find, “a supervisor at the VA regional office in Boston, Massachusetts, incorrectly processed system-generated messages known as “work items.”  The supervisor, “incorrectly canceled 33 of 55 work items out of 110 reviewed (that’s a less than 50% accuracy), and improperly cleared another nine work items from the electronic record. Because of these incorrectly processed cases, VA made about $117,300 in improper payments to veterans or other beneficiaries, along with about $8,600 in delayed payments.”  Best of all, the supervisor claimed these work items were improperly handled because, “he did not intentionally process the work items incorrectly, and the errors were the result of working too quickly and misunderstanding procedures.”  You are the supervisor, you are in charge, you should know who to approach for guidance and clarification, you have caused significant harm to veterans who either are not being paid or now must repay funds improperly provided.  There is an obvious question here, “If the supervisor is less than 50% accurate, what is the accuracy of the supervisor’s team?”  While the VA-OIG cannot investigate this question, is the director investigating this question?

If the accuracy of claims handling personnel is less than 50%, how can any veteran be sure their claim has been handled properly?  Having been forced to repay funds to the VA, I can attest to the financial impact these over and underpayments cause for veterans.  When will these decision-making officers be held personally accountable for improper decisions?  Senators, members of the House of Representatives, what are you doing to support improving the VA, in conjunction with Secretary Wilkie?  From what I witness, not enough!

You're FiredFrom the files of “Not Enough,” comes another egregious example.  A patient in a psychological ward in the Philadelphia Pennsylvania VA Medical Center was killed because of a drug-to-drug interaction, were due to insufficient observation, insufficient monitoring, and inadequate action when the patient coded, and a veteran died at the hands of caregivers.  When a patient in a hospital ward, which is monitored electronically and physically, commits suicide, I become very agitated.  When any patient dies at the hands of the healthcare provider, I have officially lost my “cherub-like demeanor” and begin resembling a grizzly bear with a bum tooth, hemorrhoids, and woken too soon from my winter nap.  The VA-OIG Report states the following, “… providers did not monitor the patient for electrocardiogram changes or drug-on-drug interactions.  Staff and providers documented signs consistent with over-sedation but did not intervene, communicate directly with each other, or add team members on as additional signers to the electronic health record.  The facility did not comply with the Veterans Health Administration requirements for issue briefs, root cause analyses, and peer reviews.  The staff did not follow the facility’s observation policy.  Facility providers did not adhere to policies requiring discussion, documentation, and patient signed informed consents prior to initiating methadone treatment.”  The providers knew they had a problem, before the patient got into trouble, and did nothing!  In any civilian hospital, this is called malpractice; but in the VA Hospital system, “this is an unfortunate incident.”  While I am undoubtedly glad leadership acted to remedy this situation in the future; I am very displeased to note it ever occurred.  With all the publicity over the power of methadone as an opioid, with the technology to remedy these problems before the patient dies, I cannot accept this situation could occur in the first place!  This veteran’s death should never have happened and the fact that this veteran died at the hands of providers from over-sedation, is a testament to the incompetence designed into the VA processes that excuses accountability and rewards malfeasance.

Speaking of opioid medication problems, the VA-OIG inspected 779,000 VA patients prescribed opioids, and for 73% (568,670) of those patients there was an insufficient investigation by the primary care providers in consulting the state-operated prescription drug monitoring programs (PDMPs) to ensure over-medication did not occur.  The VA-OIG estimated that 19% of those files improperly handled placed patients at risk because of medications prescribed outside the VA Medical System.  With the constant harangue from the mainstream media over opioid addiction and deaths from opioids, a person might ask, where is the concern?  Why isn’t this a talking point in a Congressional Investigation to understand why, and then begin to implement changes to ensure the VA is not stained with more veteran deaths over opioids.  Finally, with an accuracy rate of less than 25%, it appears to me this problem needs immediate rectification using technology and quality control measures at the local level to improve adherence.

blue-moneyI would like to take a moment and thank the VA-OIG for stepping up to the plate and correcting pre-award contract pricing to save the American taxpayer $515 million because the contracting officer on 16 of 22 proposed pharmaceutical contracts was improperly priced.  In case you are wondering, the accuracy of the contracting officers was less than 75%.  I know of no industry, business, or service organization that can have a 75% or less accuracy rate and remains in business.  As a business operation and purchasing professional, these numbers appear to suggest that the contract officers are either intentionally neglectful, or they are counting on pre-award review to protect them from price gouging; both situations are inexcusable for a contracting officer for the Federal Government.

Thank you!As the Los Angeles Vocational Rehabilitation and Employment program (LA VOCREHAB) was recently featured in an article, I am pleased to see that hiring additional staff has improved performance, per the findings of the VA-OIG.  The VA-OIG Report found accuracy in spending money had increased, compliance, and helping veterans to gain employment had all increased since the damning report from the VA-OIG; thus, congratulations to the LA VOCREHAB program!

© 2019 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.

 

Uncomfortable Truths – More News from Albuquerque Public Schools

Some friends discovered I was attempting, again, to work as a substitute teacher for Albuquerque Public Schools (APS) and told me to not waste my time and talents.  They then shared with me some of the recent changes and more issues at APS that shocked and horrified me.  I do not have a student in the APS school district; thus, all I can do is relate their stories here in the hopes of generating enough angst that someone in the Department of Education will rip the scab off the injury called APS, and begin some sunshine disinfectant.

Government Largess 2An Educational Assistant (EA; Teacher’s Aide) was called upon to be a substitute teacher in Seventh Grade math; because APS is bereft of substitute teachers and is experiencing a teacher drought.  The EA is not a licensed substitute teacher; thus, when asked how this is legal, to have an EA substituting outside her regular work and expertise, she said she “didn’t know” and then acknowledged this is standard practice.  The EA went on to further elaborate saying that when she has asked for a substitute teacher because her teacher was out or off, she had a very low probability of ever getting a licensed substitute teacher and generally had to teach the class, with no extra money for doing extra work.  Why does the NM Professional Licensure classify licenses, and charge horrendous fees for licensure, if EA’s can be “regularly called upon to substitute teach?”  My friend has worked in four other states in the US as an Educational Assistant/Teacher’s Aide, and has never been licensed to be a substitute teacher; yet, somehow in APS, she can be regularly called upon to substitute teach.

While discussing teacher performance, another classic APS child abuse issue was uncovered, all while a good teacher is being forced out of her position.  Because of the teacher drought, APS is experiencing, and due to reduced registrations in a Bi-Lingual education school, an illiterate teacher in both Spanish and English, who had to pass a state-mandated test to get the license to teach bilingual students, is going to keep her job for another year.  This intellectually challenged teacher has been reported to APS more than a dozen times for swearing, insulting, and not being able to teach; but this teacher was just offered a full-time position teaching bilingual students, when she cannot speak/read/write in either English or Spanish at an academically acceptable level to teach others.  Due to falling registrations, a Kindergarten teacher, who was the last one hired at this school, is being laid-off.  The teacher, being terminated is a stellar teacher, works hard, is well-liked by staff, parents, and students.  Since joining APS, this phenomenal teacher has been assigned to “catch” those students from the most impoverished homes and get them up to speed academically.  Reported by all who know this teacher, she is exemplary in her assigned duties; fully 180-degrees separate from the illiterate teacher who landed her job under shady circumstances or nepotism.  Yet the bad teacher is being kept and the good discharged.  APS, and by extension, the NM Professional Licensure board, are committing child abuse on such a scale, there should be criminal charges.

I have been in business a long time, and one of the fundamental rules of business is if people are assigned to work, and mandatorily required to put in extra time, those people must be paid for their extra time.  In discussing job mandates and requirements with more than forty-different full-time, substitute, and EA instructional staff members of APS, a regular theme arises; if the school mandates the instructional staff is required to work, they will not be paid for their extra time.  For example, the EA discussed above, was called to substitute teach, spent 90-minutes after work writing notes to the regular teacher, and will not be reimbursed for her extra time.  Please note, this is 90-minutes on top of her regularly scheduled, non-paid, mandatory overtime.  Thus, every day, this EA loses 90-minutes of pay at the end of the day and between 60 and 90 minutes at the start of the day, with no reimbursement to cover this employer-mandated time.  With a regular school year average of 38-weeks, 5-days per week average worked, and roughly 150-minutes per day unpaid, an average EA salary of $15,116.50 ($9.95 per hour), this EA is losing approximately $2,836.70 each school year.  Where is the NM Department of Labor?  Where is the NM Legislature?  Where is the NM Public Education Department (NM PED), who also happens to be in charge of overseeing licensure?  As I understand this is a widespread general practice for all teaching staff, but I can attest that the administrators leave promptly on time and arrive on time, and if they must work late they are reimbursed for their time.  Why is the teaching staff treated differently?

Government Largess 4With a total grant budget of $1.6 Billion, no numbers have been found for the amount of tax revenue APS is handed, the school district is certainly well funded.  From the 2018-2019 school survey on APS performance, we find a common theme from the citizens to the APS school district, reduce administration costs.  The answer from APS school administrators was to, “Increase Counselors, Social Workers, Security and other staff to support our student’s mental and physical health … Increase Custodians across the schools [sic].”  The Albuquerque Journal reports that APS is the lead agency for taking tax dollar revenues.  With Bernalillo County and City of Albuquerque, plus property taxes, all being collected at ridiculous rates, APS must be getting a significant chunk of revenue; still, APS demands more money “For the children.”

Understanding checkpoint, we have more than one instance of a teacher unable to perform their duties, and verbally abusing students.  We have a functionally illiterate teacher who landed her position based on either shady circumstances, or through nepotism, and we have a recorded phenomenal teacher being summarily discharged during a teacher drought.  We have citizens, parents, and a concerned community begging for reduced administration, where APS then responds they are increasing administration.  Then we have non-licensed staff forced to work outside their licensure because the administration cannot obtain substitute teachers, and teaching staff forced to work extra hours without proper compensation.  Where is the public outrage?  Where are the lawyers?  Where are the politicians demanding answers?  These problems are not new to APS; why the silence?

You're FiredDuring the summer of 2019, for the first time in 15-years, APS full-time licensed teachers received a pay raise.  Not for the first time in 15-years, the teachers saw a slew of additional requirements, mandates, and reductions in alternative licensure to “pay” for the teacher pay raise.  All while the school board received yet another pay increase.  The voters have already told APS NO on a slew of tax increases and bond sale schemes; however, in November 2019, APS is trying again to raise taxes, raise money, and raise administrator salaries.  Albuquerque, the next time Bernalillo County, City of Albuquerque, or APS asks you for more money, ask them when they will deliver education to students, a reduced administration, and fix the teacher drought?  It is blatantly apparent to me that when APS, City of Albuquerque, or Bernalillo County claim, “It’s for the children,” they really mean they want a pay raise on your blood, sweat, and tears; tell them no!

© 2019 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.