NO MORE BS: Bureaucratic Fiat, a Veteran Suicide – Scrutinizing the Government

ApathyThe 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.

LinkedIn VA ImageVeteran 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!

DetectiveThe 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.

Detective 3Do 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.

LookNow, 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.”

DutyI 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.

Millstone of Designed IncompetenceAfter 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.

NO MORE BS: Diversity, Equality, Inclusion, and Assimilation

Public Service Announcement:  The following article is probably longer than desired.  However, I am trying to cover a lot of basics where tyrants have invaded and are attempting to gain control.

LookLet me be perfectly clear; I do not care what you look like, your handicaps, abilities, or disabilities, or frankly, anything other than how you do your job and live your life to not interfere with other people’s freedom.  Hence, when the discussion inevitably turns to diversity, equality, and inclusion (DEI) in the workplace, I fully believe that you are the number one driver of equality and inclusion in the workplace and society.  You choose to become offended if you feel not included at work.  You decide to feel marginalized, and in choosing to feel marginalized, your choices and consequences are solely yours.  Except, you demand your consequences be the problem of the business and community.  That behavior is childish, selfish, and reveals your ignorance!

Does discrimination occur, absolutely; but discrimination does not disappear magically when a diversity, equality, and inclusion workplace initiative is launched!  Discrimination does not disappear because someone passed a law.  Your attitude, actions, and decisions are all choices you make that come with natural consequences for you.  You drive your ability to be included the majority of the time.  Individual choice and consequence are the reality never spoken of during DEI initiatives.  Failure to include personal choice, assimilation, and consequence remains a glaring hole in DEI training topics.

quote-mans-inhumanityAssimilation

Assimilation is the act of assimilating, and assimilating is all about taking in and understanding something fully.  The Borg from Star Trek gave assimilation a bad name.  Worse, some people erroneously proclaim that when you assimilate, you give up pieces of yourself.  Assimilation is all about taking the best of you, adding to the best of us, and making the whole stronger than the individual parts.  Yet, every DEI training I have been forced to attend has been pessimistic about assimilation and assimilating into a stronger whole.  Assimilating is also about absorbing and integrating into a wider society or culture.

For example, a balanced diet includes non-favorite foods, but those foods are good for you.  Your body assimilates the good and the bad foods consumed, eat enough poor nutritional foods, and the body suffers physical and mental health problems.  Eat too many good foods, and your body will assimilate foods differently and possibly begin to reject certain foods.  Hence, balance is needed to properly diet and strengthen the body.  Extremes in food, like attitudes, are bad for the body as a whole.  The same choice and consequence cycles that drive the assimilation of foods into the body are the same choices and consequences when applied to workplace assimilation into existing cultures.  Extremes are hazardous to health!

Editorial - Educational TruthDiversity

Diversity is all about variety and including variety in a social environment.  Diversity has been stretched to become a practice of including people of various backgrounds, ethnicities, and other societies into a greater community.  The problem with the plastic second definition of diversity is the assumption that a variety of different people are automatically not wanted or desired in the social environment currently.  History has never been kind to different people in a society.  This is true of ethnicities, cultures, disabilities, and abilities, and nothing will change discrimination in any organization made up of human individuals.

A friend invited me to a bar; I was not accepted into that bar’s culture as I am a veteran and do not share other lifestyle choices of the bar’s dominant culture.  Discrimination happens; if you choose to become offended by the selection of diversity in a community, that is your problem.  I did not become offended at the other patrons in a bar and demand that they accept me, it did not matter to me one way or the other if I was accepted or not, and this should be the same stance everyone should be taking!

Life ValuedEquality

Of all the terms we are discussing, equality is by far the most plasticized, twisted, deformed, and dangerously laden with unnecessary baggage!  Equality is all about a state of being equal.  Equality comes from the “Rule of Law” and the application of “The Rule of Law” for all in society.  Except, equality is not what is desired in the term equality when speaking of DEI, but “Social Equality.”

Social equality is a state of affairs in which all people within a specific society or isolated group have the same status in certain respects, including civil rights, freedom of speech, property rights, and equal access to certain social goods and services.  Essentially, social equality is all about twisting “The Rule of Law” into exceptions for specific socially acceptable groups; instead of equality, social equality is all about bringing all onto unequal grounds before the law.  There is no equality in social equality, ever!

Andragogy - The PuzzleInclusion and Discrimination

Inclusion is all about the practice of being included.  That’s it, the whole enchilada; inclusion is all about being included.  However, what does it mean to be included; here is where ideas like fit, temperament, desire, and choice and consequences enter a social group, community, or organization.  Where DEI is concerned, inclusion is all about shifting the margins, dropping the individual decisions, and forcing all to be lumped together regardless of personal desire.  Worse, inclusion is forced with the power of law without regard; hence all are injured in an attempt to be “socially inclusive.”

Discrimination is the unfair or prejudicial treatment of people and groups based on characteristics such as race, gender, age, or sexual orientation.  Except, discrimination happens all the time, and efforts to be more “inclusive” have done nothing to reduce discrimination.  I was hired for an inside sales position with a 90-day trial period.  My wife dropped off some equipment I had left at home one day.  The bosses learned my wife is older than I am; from that day to the end of my trial, when I was released without cause, the attitude towards me was significantly and tangibly different.  Skin color, ethnicity, gender choice, sexual bedroom choices, and every other possible thing can be the source of discrimination, and nothing will change this facet of human behavior.

Admitting that discrimination is happening is not being defeatist, nor am I suggesting that discrimination laws should be scrapped.  I am relating a truth about human behavior and why the law cannot dictate moral behaviors!  Demanding inclusion does nothing to reach the core roots of the problems with discrimination in society.  Which is another truth for certain that must be recognized and discussed.

Andragogy - LEARNExclusion

Exclusion is the opposite of inclusion but also represents a risk.  The risk of exclusion is found in the legal arguments from discrimination, not the risk of being omitted.  More, exclusion has stricter requirements than elements of inclusion ever will.  For example, insurance policies have specific criteria that exclude coverage as a means for controlling risk.  The same thinking on insurance policies is the same as what occurs in social environments when a person is actively excluded.

For example, in the US Army, my platoon sergeant and my squad leader had a group of people they were comfortable with both on and off duty.  I was not welcome because I hit more of the exclusion criteria than the inclusion criteria.  I did not enjoy sports, wasn’t a drinker, a womanizer, and several other items.  Off duty, this wasn’t that big of a deal.  On duty, this exclusion caused me tremendous problems as I learned to be a soldier.  Still, the choices for inclusion or exclusion came down to preference and accountability.  As the First Sergeant and the Commanding Officer allowed these discriminatory practices to exist, I had no right to complain, and my mistakes were my own.  It was a difficult period in my life, but I survived and was stronger for the challenge.

Literary FiendIndividual Identity

Who are you?  What makes you an individual identity in a socially expanding group?  The United Nations has declared your culture, gender, sexual preferences, and race are all personal choices as part of a unique identity created, changed, and designed for and by the person making the choices.  What the UN fails to mention are the consequences.

In the US Navy, I served with a woman who was as white as the freshly driven snow, but she identified as black.  According to the United Nations, this is acceptable.  This sailor spoke, acted, and identified culturally as black even though she was white, blonde hair, blue-eyed, and the antithesis of cultural black identifying characteristics.  I am not one to judge and, frankly, could have cared less how she identified herself.  But the command through a total fit when she showed up to morning quarters with dredlocks.

Remember, your identity is your choice.  I care less about your identity than I do about a fly.  How you work, what you do, and your respect for others’ rights matters to me.  But, do not make your choices to be an individual affect my life.  Do not thrust your identity into my world and demand respect; I do not care about your identity!

CourageGroup Identity

Group identity is the melding and assimilation of identities and behaviors needed to work together effectively.  That’s it; the whole casserole!  Take any sports team, any sport, and you will find the same in winners and losers, those who choose to assimilate the group identity gain success.  Those who refuse to assimilate will lose every time.  Pick a sports movie; here are a couple of suggestions where you will see for yourself the truth of the power in assimilation:

        • We Are Marshall
        • Friday Night Lights
        • Glory Road
        • Hoosiers
        • Invincible
        • Miracle
        • Radio

Group identity requires sacrificing individual identity for a cause bigger than oneself.  Yet, for DEI training, when is this ever discussed?  Winning business organizations cannot be successful without individuals sacrificing their individual identity for group success.  How have we forgotten this rule of nature?

Lever UpSubordinate Culture

Subordinate cultures, micro-networks, ol’ boys network, whatever you call it, subordinate cultures are designed around those who refuse to assimilate and make their choices the problems of managers and leaders.  Consider those who hyphenate their cultures, Indian-American, Russio-Chinese, Irish-Israeli, etc.  You will find someone who refuses to assimilate and cannot understand the need to be whole culturally and who could be more without the hyphen.

In the US Navy, I met more than ten first-generation Americans from Jamaica, Africa, Cuba, Brazil, Puerto-Rico, and other places.  Not a single one of them would consider hyphenating their status as American.  Yet, too often, people who have been in America for multiple generations feel a need to hyphenate to identify themselves.  Why establish a subordinate culture?  A subordinate culture is assumed to be lower in status than a dominant culture.  The subordinate culture is treated of lesser importance, deemed under the control of something else, and all because of the hyphenation.  Is being subordinate desired; if so, why?

President AdamsDominant Culture

The dominant culture is the most powerful or influential culture in an organization.  Essentially, more people assimilated and sacrificed for the success that the organization is enjoying than refused.  Yet, in DEI training, dominant culture carries negative baggage and is not allowed as it could be misunderstood.  Seriously, the concept peddled in this training blew my mind.  What happens if the LGBTQ+ community became the dominant culture in a country; would it be accused of the same claptrap the LGBTQ+ community currently claims they suffer?

Why did Rome fail; they lost the “Rule of Law,” and the subordinate cultures took power and could not unify the majority of people when invaders came.  One of the greatest Republics in the history of man is responsible for improving millions of people’s lives.  Failed and fell an unpitied sacrifice in a contemptible struggle over the same issues every single business and democratic country in the world is facing right now.

Grit is a MarathonIndividual Choice

I was part of a first-day introduction activity for new hires (2016), and one of the new hires made an individual choice to identify themselves in the following manner, “I am John Smith, I am non-binary queer with a passion for anal sex.”  What does this have to do with the position they were hired to fill?  Which audience member in a professional setting needed or wanted this information?  The declaration automatically put the entire audience on the defensive; the Human Resources representative was placed into a difficult position and called a 10-minute break to regain composure and finish the introductions.

How you choose is your business!  I will respect your ability to choose as you desire; keep your choices to yourself, as I will keep my preferences to myself.  Believe it or not, we can work together really well without disclosing our personal choices and lifestyles outside of employment.  But, when you make your preferences my problem, I will deal with them the same as I deal with that pesky fly, ignore!

Content of their CharacterConsequences

Self-awareness, curiosity, and empathy are what I was told today that will make DEI work, and through learning and unlearning, DEI can make an organization stronger.  I agree the learning is vital, curiosity is always a valuable tool, self-awareness is important, but empathy is dangerous, divisive, and deadly!  Failure to recognize the need for assimilation and sacrifice places the burden onto people who have enough on their plate with their responsibilities in their work.

quote-mans-inhumanity-2Imperative to the improvement and liberation of thought and the power of people is the eradication of litigated moral behavior.  We, the individuals who make up our communities and businesses, must recognize the 800# gorilla in the room, mandating inclusion, refusing assimilation, denying the need to sacrifice individual identity for group success; these must be enshrined into our cultures, again!  Let us embrace these truths and design our “Liberty FIRST Cultures” around a single “Rule of Law,” where people are respected and freedom blossoms!

© 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.

NO MORE BS: Lest We Forget

With multiple religions having records, beliefs, and access to Isaiah’s writings, I begin with a compelling point from the Old Testament.

Surely your turning of things upside down shall be esteemed as the potter’s clay: for shall, the work say of him that made it, he made me not?  Or shall the thing framed say of him that framed it, he had no understanding? (Isaiah 29:16)”

Having watched the events of this new year unfold, this verse of scripture has taken on a new life.  Consider how the naysayers have turned the speech from President Trump to a spontaneous show of support, into a call to storm the capitol.  Turning things upside down for a political point is a revered tool of the political left, and the world has watched, many in glee, to see this trouble and torment occur.  Frankly, my honest man betrayed sensibilities feel like a Sherman Tank hit them!

Life ValuedThe verse above from Isaiah also speaks to another point needing discussion; the work we do has consequences we cannot escape!  Accountability and responsibility follow the choices we make, like shadows; accountability and responsibility are ours to accept or reject, but they never go away!  For example, Speaker Pelosi spent the better part of 6-months refusing to help Americans during this governmentally fed emotional hysteria called “COVID,” but as soon as Biden/Harris won, fraudulently, the presidency, it was time to hurry up and act!  Now, Speaker Pelosi has exercised her “Trump Derangement Syndrome (TDS)” and ramrodded another erroneous impeachment through the US House of Representatives.  Aided and abetted by, if the count is correct, ¾’s of the GOP, acting as craven yellow-belly spineless entities.

What will the future say of harassing an innocent person, all because it was “politickly expedient?”  Nothing Good!  The accountability for this disaster entirely rests upon the shoulders of those participating in the public lynching of a sitting president, and that is beyond detestable behavior!

Theres moreCompanies can give and take at their discretion to the political parties of their choice; that matters not.  But, if you claim to represent the American People, duly elected, and you weaponize government to browbeat, hammer, control the electorate, you will be held accountable!  Hence, I call for the voters to begin holding the newly formed 117th Congress to task for their misbehavior.

Speaker Pelosi, why did you invite COVID positive people with acute flu-like symptoms to vote in the House?  How much money did you spend on useless plexiglass partitions?  The erection of those partitions occurred in the dark of night, with no oversight, no discussion, no knowledge of the American people.  What funds did you take the people’s money from to pay for the wages and materials?  What was the contract process for the work to be accomplished?  How did these sick representatives arrive in Washington and leave Washington?  If COVID is as bad as you have been harping on from Jan 2020 to today, why were these House members exempt from the COVID-related security checks and other nonsense heaped upon Americans?

The Duty of AmericansIf your two supporters for your speakership were allowed to travel freely, then COVID is not as dire and dangerous as you have been preaching.  What about those members who were exposed and have now tested positive because your decisions put them in the House of Representatives while contagious?  May their families sue you personally for lost wages, harm, and being infected with COVID?

Speaker Pelosi, how did the metal detectors get added over a weekend?  Why has the security to the “People’s House” been increased, and where did the funds originate?  Why were the previous security measures acceptable for other capitol groups, but somehow after what appears to be a staged riot, the security measures are no longer adequate?  Do you know why the riot and the response to the extreme citizen behavior appear staged; the security people had lots of warnings from the FBI for months that a demonstration of support for President Trump was being arranged on social media.  Why were the capital guards not doubled?  Why were the security entrances not better manned?

BLMTake another large group who came to the capital, BLM.  The guards for the House were doubled, on alert, and ready if anything happened.  As House Speaker, Speaker Pelosi has the power to direct DC Police and other law enforcement agencies. Still, for a Trump Support event, magically, all the security protocols were purposefully not instituted, but after damage and a riot that left five people dead, it is suddenly time to tighten security checks and policies.  Something is wrong and smells to high heaven!

While we are on the subject of the riot and the potential for that riot to have been staged and managed, where is individual accountability?  President Trump never encouraged violence or violent demonstrations.  I have watched the speech he gave; President Trump said exactly the opposite and urged for law and order.  In President Trump, America has witnessed a politician who is 100% supportive of the “Rule of Law.”  Totally the opposite of you, Speaker Pelosi, previous presidents (Clinton and Obama come readily to mind), and so many other elected officials in and out of Washington, it makes me sick.

Wasting TimeYet, you have wasted valuable time in the 117th Congress to blackball, criticize, shame, and express disdain while weaponizing the Federal Government against President Trump, his family, his associates, his administration representatives, and a host of other private citizens.  Why?  I cannot believe this is all TDS, especially since before Donald Trump became President Trump, you and the rest of the liberal-leftists loved Donald Trump.  Explain why you and your politically connected cronies have belittled, attacked, and heaped shame on a person you used to admire for his work, dedication, and kindness?  All of you sure took his money fast enough as political donations; Et Tu, Brute?

America is in a crisis, largely made by politicians of both parties, fed by an emotional media, and protected by a weaponized government.  How many times has Pelosi promised to “Drain the Swamp” the metaphorical reference to the appalling actions and behaviors, largely from her party, and yet, has never lifted a finger in action?  Another verse of scripture fits here with a little adaptation.

“My soul is sore vexed: but thou, O Lord, how long” (Psalm 6: 3)?

LinkedIn ImageHow long Speaker Pelosi?  How long liberal leftists?  How long will America have to be sorely vexed before charges are brought for your treason and vilification of America?  How long will America be patronized by one-side of your mouths and vilified from the other side?  How long will honest men and women be called terrorists for serving in America’s military arms while you enjoy the liberty of their service?  My soul is sore vexed; I know millions of other people share in that sentiment.  Thus, how long will you proclaim to be the head of the People’s House of elected representatives and continue to ignore, shame, and abhor the people of these the United States of America, a free people, under law, a Republic like none other in history?

© Copyright 2021 – 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:
https://www.linkedin.com/in/davesalisbury/

Updated Inspector General Reports – Department of Veterans Affairs: These Actions Must Cease!

I-CareLong have I written about the Department of Veterans Affairs (VA) and the Office of Inspector General (VA-OIG) reports which cross my inbox.  Long have I been utterly disgusted with the waste, fraudulent behavior, and the utter disregard for the patient witnessed in the VA Medical Centers across America.  As a veteran and taxpayer, it is past time to begin to see action to rectify these types of issues.

The VA-OIG conducted an inspection to evaluate concerns related to a Virtual Pharmacy Services (VPS) pharmacist’s discontinuation of antidepressant medication for a patient of the Minneapolis VA Health Care System, which resulted in the patient not having prescribed antidepressant medication for approximately six weeks before dying by suicide.  The VA-OIG found that the pharmacist never notified the psychologist, never checked the patient’s record, simply discontinued the medication.  While the VA-OIG found process and procedure issue, the fact that a medication could be arbitrarily discontinued without a “Red Flag” being raised with the provider and the patient is deeply troubling.  Worse, the quality control processes in the pharmacy did not trigger a problem when a medication was discontinued without a provider order; why?

There is a dead veteran, and a pharmacist who claimed they did not know they could access a patient file; and the excuses do not hold water!  This incident is a tragedy of epic proportion and I must ask, how many more veterans will die because medications are arbitrarily turned off?

ProblemsThe next VA-OIG inspection is a bit of a pretzel, there is another dead veteran by suicide, and processes and procedures were recommended by the VA-OIG to correct some small issues in bariatric surgery patients.  Reading this report, it appears that this veterans’ suicide was not directly connected to preoperative counseling for bariatric surgery which was essentially the scope of the VA-OIG investigation.  If there is a connection between the bariatric surgery and the suicide, it was beyond the VA-OIG investigatory scope.  Hence, the VA might not be at fault for the suicide, but the VA-OIG recommendations indicate more can and should be done in the future to decrease the risks postoperatively.

Let me be clear, room for improvement to decrease risk does not assign or negate blame in this situation.  The death of a veteran through suicide remains a tragedy and the VA can and should be doing more to help reduce veterans committing suicide.  With the convoluted processes and the contradictory bureaucracies inside the VA, much more can be done as an organization to streamline and bring efficiency, transparency, and responsibility to the employees making patient decisions.

Chinese CrisisAnother VA-OIG report does clearly reflect the responsibility and lack of care a patient received at the VA.  The Tennessee Valley Healthcare System in Nashville is responsible for test results still not being properly communicated to the veteran in a timely manner, which delays treatment and care.  Fall 2018, a patient went undiagnosed and untreated for pancreatic cancer due to failures in communicating test results, collaborating with the primary care providers, and for the electronic health records not containing a system of alerting providers that an adverse test result occurred.  Hence, this patient’s problems have three root causes:

  1. Failure to notify the patient.
  2. Failure to collaborate between different hospital units for patient care and safety.
  3. Failure of the electronic health records programming to include alerts.

From personal experience, I must wonder if any patient notification would have made a difference.  The patient notifications are simply the results, not definitions, no descriptions, just ranges, and results.  Hence, the patient notification process must include clarity of the results so non-medical people can understand what was found and the implications.

While I applaud the VA-OIG for insisting that an internal review is conducted and problems rectified, I have significant doubts that change will occur.  It appears that unless the VA-OIG is following up on their recommendations; which is outside the VA-OIG’s authority, the change will not occur.  A truly unfortunate series of events occurred in this patient’s life and the bureaucracy of the VA will prevent anyone from being held accountable for the failures, nor will change occur to protect another veteran.

The W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina, was recently inspected for concerns regarding anesthesia provider’s practice.  While no issues were found under the VA-OIG scope regarding the provider’s practices, other issues were discovered.  The problems found were all administrative in nature and included the usual training, timely record keeping, following the policies established by VHA, etc.  Juran’s Rule states that “When there is a problem, 90% of the time the problem lies with policies and procedures, not people.”  How, and when, a person does their job is more often the root of the problem and is evidenced again with this VA-OIG investigation report.  The fact that this problem continues at all VA Medical Centers (VAMC) across America is indicative of a systematic issue in poor organizational design, then in the individual employee.  The VA must address these organizational issues that breed complacency in employee adherence!

LinkedIn VA ImageWith confirmed cases of nepotism still occurring in the VA, this time in Miami.  With continued issues regarding ethics violations and the proper use of time and materials for teleworking employees.  With the continued employee obstruction witnessed in so many cases of records not being readily available to VA-OIG inspectors.  The VA desperately needs to have a deep cleaning and reorganization.  Why has the VA not adopted ISO-9001 for Hospitals?  Why hasn’t the VA adopted ISO-9001 for the VBA or National Cemetery as a coherent process for organizational change and improvement?

Consider that there remains a dearth of written processes, procedures, and policies in the VA.  So much so that more than one VA Hospital operates on “Gentlemen’s Agreements” between departments, instead of official policy statements and procedural plans.  This lack of written policies and procedures is the excuse and the general recommendation of so many VA-OIG inspection reports that I am shocked Congress has not begun asking about this single issue.  The first rule I learned as an EMT was, “If it is not written down, it never happened.”  I was told this is the first rule of medicine; yet, somehow the VA can escape without writing down how to perform work.  Doesn’t that seem strange to anyone else?

Where the lack of written procedures is most noticeable, is at the Veterans Benefits Administration (VBA), where the quality control people missed 35% of the errors routinely, never checked each other’s work, never learned lessons to improve performance, and were not properly supervised.  Yet, training, communication, and written procedures are routinely used as excuses, and corrective action is outside the VA-OIG investigatory scope.  So, while the problems are being identified, the leaders are refusing to do their jobs!  From the VA-OIG report comes the following details:

“The VA-OIG estimated that during the review period, regional office managers inappropriately overturned errors in 430 of 870 quality reviews (about 50 percent) where claims processors requested a reconsideration from a quality review specialist- identified errors. The VBA has not established adequate oversight or accountability to ensure the timeliness of error corrections. The OIG estimated that during the review period 2,000 of 4,400 identified errors (45 percent) were not corrected in a timely manner and 810 of 4,400 identified errors (18 percent) were not corrected at all.” [Emphasis Mine]

Again, I ask, where are the written procedures that form the standards of work which are used to hold employees accountable?  With an 18% error rate never being addressed by quality control, this means that veterans are being underpaid or overpaid for their benefits, and the VBA does not care that these issues are killing veterans.

Survived the VAPersonally, I experienced a VA overpayment that took more than 3-years to payoff.  Three years where my benefits were docked for an administrative mistake that was not found until the next decision was made on my claim several years after the original mistake was made.  What is worse, the mistake I paid for, was not a mistake at all, and the funds were later returned as another quality person found the error and corrected the documents accordingly, but the discovery took another VBA claim decision to catch, from beginning to end this issue of overpayment took three different decisions by the VBA and more than 8 calendar years from beginning to end.

Every single taxpayer in America has a personal stake in seeing the VBA do their jobs timely, efficiently, and correctly.  Every single veteran in America has a vested interest in seeing the VBA perform their roles with fewer rates of error than those reported by the VA-OIG.  Every elected official in America benefits in some way from the decisions of the VBA and should be able to demand higher quality decisions, better performance, and more transparency from the VBA.  Consider, if the problems of performance are this bad for a spot check analysis by the VA-OIG, how bad are the real numbers?

The VBA was also investigated for improper payments to schools through the Vocational Rehabilitation and Employment Program (VR&E) to the tune of $554,998.  Most of the errors were in transcribing numbers and the electronic program did not raise any alerts or attempt to rectify the problems, and no quality control system is in place to protect against human error.  The VA-OIG investigatory scope included 1.8 million payment transactions from 01 Jan 2014 to 30 Dec 2019.  While this is a much better error rate; the fact that the technology and the work processes were not catching these errors timelier, which means more billing issues, more wasted resources, and more problems for the VA, the VBA, the VR&E program, the taxpayer, the colleges and universities, and the impact goes on and on.

The VBA was also recently inspected for failing to accurately decide service-connected heart diseases.  The root cause was the questionnaire developed to ascertain what and when regarding the heart diseases experienced.  Six months, 01 Nov 2018 through 30 Apr 2019, were selected and 12% of the claims were improperly decided which totals $5.6 Million in improper payments where a veteran either received too much or too little for their claim.  Necessitating repayments or backdated payments once new and material evidence was procured to force the VBA to make a new determination.  Inaccurate decisions on claims involve a lengthy appeals process, expenses for testing, and the veteran is always responsible for the mistakes made on their claim.  Thus, the exasperation of these mistakes on the families, friends, and communities of the veteran involved in a VBA mistake.

When the VA-OIG finds errors made by the VBA the veterans affected are not notified that the VBA made an error in their determinations.  The VBA does not form a task force to evaluate these errors and correct them internally unless money is owed and then the collections department is left to muddle through the decision, not the VBA.  Thus, when veterans ask for transparency in the VBA processes, we are asking for the VBA to own their mistakes, fix the problems they are creating, and correct the errors in a timely fashion.  It should not require new and material evidence to trigger the VBA to make a new determination when the VBA made the original mistake in determining eligibility in the first place!

All because the quality controllers do not have written procedures to measure standards of performance against.  All these errors are due to improper organizational design and old computer systems, which are ready-made excuses for not performing work in a timely and efficient manner.  All because the leadership fails to delegate, monitor, observe, and function.  Why are the leaders missing, because they are all in meetings, all day, every day, and not at their desks!

Military CrestsJust like the labor union provided bumper sticker proclaims, “SAVE the VA!” [Emphasis in original], it is time to “SAVE the VA!”

© 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/

Let’s Talk About the VA – The Insanity Must Cease!

I-CareWhen the Department of Veterans Affairs (VA) does something good, I praise them.  The VA recently had a good report come from the Department of Veterans Affairs – Office of Inspector General (VA-OIG), apparently there was progress made in improving performance once policies were written down, training of employees occurred, and over time there has been an improvement, however small and seemingly insignificant.  I offer my sincerest congratulations on making progress and change on this issue.

Carl T. HaydenHowever, I will castigate and deride all abuses of veterans, myself included.  At the Phoenix VA Medical Center, the Carl T. Hayden VA Hospital remains a hotbed of bureaucrats on a power trip weekend from Dante’s first ring.  The abuses at this hospital continue and the leadership needs to be corrected!

For those who do not remember, the Carl T. Hayden VA Hospital in Phoenix, AZ used to be an award-winning hospital, a pillar of good performance, and an example of how VA Hospitals could be run.  Then, the director was changed, the hospital staff changed, awards stopped coming, and veterans started dying.  Leading to the fiasco of dead veterans on paper waiting lists, during Pres. Obama’s reign.  CNN reported on April 30, 2014, that at least 40 United States Armed Forces veterans died while waiting for care at the Phoenix, Arizona, Veterans Health Administration facilities.

On 29 June 2020, I reported to the VA ER sick and in desperate need of assistance.  The assistance was refused because I cannot physically wear a mask.  In my medical records, it is noted that I suffer from shortness of breath and any mask exasperates this problem.  In direct violation of Federal Law that commands all emergency rooms to see whoever walks in, the ER staff refused me service due to the “Mask Policy” as part of their “Covid-19 response.”  No options, no exceptions, no excuses, I as the patient could either endanger my health or find a different hospital ER.

The Emergency Medical Treatment and Labor Act (EMTALA; 1986) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.  EMATALA also dictates that no person can be refused treatment in any Emergency Room.  The EMTALA is not new and is part of the training from day one for all staff at the VA.  For ER staff, this is the golden ticket and special care is taken to ensure this law is followed to the letter; rather, this law is supposed to be the premier standard from which good health care policy is built for emergency rooms.  Except, the Carl T. Hayden VA Hospital in Phoenix, AZ., and the Raymond G. Murphy VA Hospital in Albuquerque, NM., both appear to be the exception to EMTALA, by order of the staff bureaucrats, who are supported in their illegal and nefarious behavior by the hospital administration collectively, and the hospital leadership specifically.

Raymmond G. MurphyI have written previously of the patient abuse I witnessed, and reported, at the Raymond G. Murphy VA Hospital, in Albuquerque, NM.  I have written about the patients turned away by nurses and other staff because these staff members refused to follow the law.  I reported the risks and problems being run by refusing patients in the ER, and this all fell on deaf ears.  Well, I will not stop raising this illegal practice as a major concern for the hospital leadership all the way to Secretary Wilkie and the elected officials in Congress who refuse to act to improve the toxic culture found in the VA.

You, the bureaucrats in the VA cannot break the law with impunity and your actions are leading to major patient safety concerns, increased hospital operating costs, and putting real people in real harm!  I spent more than an hour in the VA Parking lot trying to calm my breathing down to safely operate a motor vehicle, so as to drive to a different hospital emergency room, where I was treated without ever having to deal with the mask issue.  While in the VA Parking lot, I was attended to by three Federal Police Officers who were willing to try and get me seen at the ER but were stuck trying to force the “Mask Policy,” regardless of my physical inability to wear a mask without causing additional harm and injury.  The Federal Officers were called because the ER staff reported a violent and non-responsive patient had just left the building.  I was both responsive and never violent in the ER.  Regardless of the fact that I was extremely short of breath, unable to walk, and unable to be seen at the VA.  When the officers found me in the parking lot, I could barely breathe and was so weak from lack of oxygen that I was graying out in vision and other major issues; thus, how the ER staff can say I was violent and non-responsive is beyond my comprehension.

The behavior of the ER Staff at the Carl T. Hayden VA Hospital in Phoenix is beyond the pale and bordering on obscene, as well as illegal!  Where is the accountability?  Where is the patient advocate?  Where is the Administrator on Duty who has the power to demand corrective action?  Where is the rightful opposition; well, I know where the rightful opposition is, it is buried with the dead veterans, who died awaiting care at the hands of the VA!

VA SealWhere is the patient advocate in this problem; well, that night after being refused care I reported the problem to the patient advocates office via secure message, and the following morning, the patient advocate replies that “It is VA policy to mandate all people wear masks if they desire treatment.”  Not caring about the federal laws governing ER visits, not even bothering to mention that the treatment by the staff as reported was ludicrous and vile, and not even to bother to ask if I was seen elsewhere.  Just a brief, less than 100-word, statement telling me my concerns for my safety and health are not important and policy must come first.  The perfect bureaucrat, with the most detestable response it has been my displeasure to experience since the last time I visited the DMV.

I am sorry but everyone is required to wear a mask at the VA Facility. I understand you may have shortness of breath but you can wear a mask and undo one side every couple of minutes. This is for your safety and the others around you.

T. C. M. [Name Shortened for Privacy]
Patient Advocate

Will someone please explain how this can occur?  Will an elected official please demand a behavior change at the VA, and remain interested long enough to facilitate the solutions Sec. Wilkie needs to effect change?  How many veterans will have to die needlessly at the hands of the VA before the elected officials decide that veterans’ lives matter and the VA is taking our lives?

I get it, there are a lot of problems in America, and more in the world.  But, the US House of Representatives, instead of passing a budget, which they are statutorily mandated to do, is writing letters, and meddling in Israel’s business.  If the US House has the time to meddle and jump down every rabbit hole on the political landscape, they must have time to assist the veterans and improve the VA.  If the US Senate has the time to meddle, postulate, and pander, then they have the time to review the plethora of VA-OIG reports and begin assisting the VA Secretary in correcting the problems in the VA.

The saga continued this over the first two days of July and forms the bitter cherry on top of the crap sundae the VA is trying to serve the veterans.  I received a call from my primary care provider’s nurse who has the attitude of supreme petty authoritarian to a lesser subject, reminding me several times that the mask policy was political, trying to blame all hospitals in the region of implementing a similar policy (which is fake), and then trying to excuse himself by claiming he was just a messenger and not involved in the policy implementation.  Concluding the call, with the temerity to tell me that I was in the wrong to not follow VA policy.  The patient advocate had the effrontery of sending a message to me stating that I should have asked for a full-face shield instead of a mask.  Seeing as no face shields were offered as a workaround, seeing as the policy enforcers demanding only a mask as the single viable and allowed option, and seeing as I spent more than an hour while in extreme pain trying to be seen to no avail, none of that mattered, the patient was at fault, per the patient advocate.

LinkedIn VA ImageMy cherub-like demeanor has taken a bloody beating over this incident.  Worse, my health has suffered tremendously and I have had to question myself and my advocacy of the VA.  The behavior of the bureaucrats and petty authoritarians of the VA at the Carl T. Hayden VA Hospital in Phoenix, AZ is detestable, and I can only conclude and wonder if I am having these problems, what are less outspoken and less knowledgeable veterans suffering?  I will not be the quiet little mouse in the corner where my safety and the safety of other veterans are being endangered by the politics and illegal actions of Federal Employees.  The policy is wrong and needs immediate revision before more veterans die at the hands of the VA!I-Care

© 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/

Insane Abuse – The VA Edition: The Leaders of the VA Must Shift the Paradigm

I-CareDuring new hire training for working at the Department of Veterans Affairs (VA) New Mexico Medical Center (NMVAMC), the first day contains a lot of warnings about what you can and cannot do as a Federal Employee.  Annually, there are mandatory classes that must be passed to remind an employee of their obligations as a Federal Employee.  Leading to a question, “How could an attorney for the Department of Veterans Affairs – Office of General Counsel (OGC), be allowed to break the law for eight years?”  The department of Veterans Affairs – Office of Inspector General (VA-OIG) investigated after a second complaint about the same person was received, and only then did the OGC take action.  The attorney in question was released from government employment, but where is 8 years’ worth of wages being requested back?  Did the attorney lose anything other than an undemanding job and title where they could be paid for not working for the Federal Government while advancing their private practice, violating ethical laws, and breaking several Federal Statutes along the way?

What this attorney has done is insane, it is an abuse of trust, and for it to go reported and not acted by the senior leaders at OGC represents inexcusable abuse!

ProblemsOn the topic of insane and inexcusable abuse of the VA, the VA-OIG investigated the Greater Los Angeles Healthcare System in California and found a supervisor in an “other than spouse” relationship with a vendor and they used the VA property to improperly conduct business on contracts the supervisor oversaw.  These actions are a clear and blatant violation of the Federal Statutes on contracting as a Federal Employee, even if these consenting adults were married, it would remain illegal, unethical, immoral, and inexcusable!  Yet, because the supervisor quit during the investigation, the VA-OIG has no power to take any action.

Federal Employees are blatantly breaking the law, abusing the trust and honor of their stations, flagrantly flaunting ethical, moral, and legal regulations with impunity.  Why?

From the VA San Diego Healthcare System, California, we find another VA-OIG inspection. Staff manipulated time cards for seven fee-basis medical providers to pay these individuals on a salary or wage basis rather than a per-procedure basis.  While the medical center took appropriate action and no VA-OIG recommendations were made, the question remains, “Why was this behavior allowed in the first place?”  Another supervisor, improperly acting in their office, and abusing the VA; this behavior is inexcusable!

moral-valuesThe VA-OIG performed an audit, also referred to as a “data review.” “The data review consisted of a sample of 45 employees and found the employees were paid an estimated $11.6 million for overtime hours for which there was no evidence of claims-related activity in the Fee Basis Claims System in fiscal years 2017 and 2018, representing almost half of the total overtime paid. Significantly, 16 of the 45 employees each received more than $10,000 in overtime for hours during which there was no claims-related activity.”  The Department of Veterans Affairs – Office of Community Care (OCC) is backlogged and this is leading to late payments to providers, delays in care, and is generally a bad thing.  However, the sole reason for the overtime being abused was due to a lack of processes, poor supervision, and training.  These are the same three excuses that are used by the Department of Veterans Affairs – Veterans Benefits Administration (VBA) and is designed incompetence at its most disdainful and egregious level.  Worse, this was a sample of employee misconduct on overtime pay.  How many more cases are floating in the OCC that were not included in the audit that will pass unresearched because the VA-OIG did not refer the cases for disciplinary recommendations?

The VA-OIG cannot be everywhere and clean every hole in the VA organizational tapestry.  This is why supervisors and leaders are in place to execute organizational rules, regulations, policies, and monitor employee performance.  Why are the supervisors and mid-level leaders not being held accountable for failing to perform their jobs?  If overtime pay is going to be clawed back from the employee, the managers, team leaders, and supervisors need first to write and train to a policy standard.

Root Cause AnalysisThe VA-OIG conducted a comprehensive inspection of the Eastern Kansas Health Care System, Kansas, and Missouri.  The findings are startling for several reasons, one of which being the deficient lack of leadership leading to poor employee satisfaction, patient care issues, lack of knowledge in managers and supervisors, and minimally knowledgeable about strategic analytics.  Essentially, there is a lack of leadership in this healthcare system.  The director has been working with a team for 2-months, but the director has been in charge in 2012.  Leading to questions about long-term staffing replacement, staff training, building the next generation of leaders, and why this long-term director can brush off the criticisms of leadership failure because the team has only been in place for two months at the time of the inspection.

Again, the VA-OIG audited a system and found a lack of training, lack of oversight, lack of leadership, and made recommendations to “close the barn door, after the horses got out.”  From the VA-OIG report we find:

“The VA-OIG found that VA lacked an effective strategy or action plan to update its police information system [emphasis mine]. In September 2015, the VA Law Enforcement Training Center (LETC) acquired Report Exec, a replacement records management system, for police officers at all medical facilities. Inadequate planning and contract administration mismanagement caused the system implementation to stall for more than two years [emphasis mine]. LETC spent approximately $2.8 million on the system by the fiscal year 2019 [emphasis mine], but police officers experienced frequent performance issues and had to use different systems that did not share information. As of April 2019, only 63 percent of medical facility police units were reportedly using the Report Exec system, while 37 percent were still using an incompatible legacy system. As a result, administrators and law enforcement personnel at multiple levels could not adequately track and oversee facility incidents involving VA police or make informed decisions on risks and resource allocations. The audit also revealed that information security controls were not in place for the Report Exec system that put individuals’ sensitive personal information at risk [emphasis mine].”

Behavior-ChangeNo controls, no direction, no strategy, no tactical action, losing money, and not even scraping an F in performance.  The repetition in these VA-OIG investigations is appalling!  Where is the accountability?  Where is the responsibility and commitment to the veterans, their dependents, and the taxpayers?  Where is the US House of Representatives and Senate in demanding improvement in employee behavior?  Talk about a culture of corruption; the VA has corruption in spades, and no one is taking the VA to task and demanding improvement.

The VA is referred to as a cesspit of indecent and inappropriate people acting in a manner to enrich themselves on the pain of veterans, spouses, widows, and orphans.  There have been comments on several articles I authored which would make a non-veteran blush in describing the VA.  These actions by supervisors and those possessing advanced degrees do not help in trying to curb or correct the poor image the VA has well and truly earned.  A behavior change is needed, culture-wide, at the VA for the tarnished reputation of the VA to begin recovering.

Only for emphasis do I repeat previous recommendations for a culture-wide improvement:

  1. Start a VA University.  If you want better people, you must build them!  Thus, they must be trained, they must be challenged to act, and they must be empowered from day one in the classroom to be making a difference to the VA.
  2. Immediately launch Tiger Teams and Flying Squads from the VA. Secretary’s Office, empowered to build, train, and correct behavior. These groups must be able to cut through the bureaucratic red tape and make changes, then monitor those changes until behavior and culture change.
  3. Implement ISO 9000 for hospitals. If a person does not know their job but has held that job for over a year, every person in that employee’s chain of command is responsible for training failures.  Employees need better training, see recommendation 1, need clearer guidelines and written policies.  Hence, with the VA University training, each process, procedure, rule, regulation needs written down, and then trained exhaustively, so employees can be held accountable.

There is a theory in the private sector called appreciative inquiry.  Appreciative inquiry is the position that whatever a business needs to succeed, it already has in abundance, the leaders simply need to tap into that reservoir and pull out the gems therein.  Having traveled this country and witnessed many good and great employees in the VA Medical Centers from Augusta ME to Seattle WA, and from Phoenix AZ to Missoula MT I know that appreciative inquiry can help and promote a cultural change in the VA.  I do not advocate a “one-size fits most” policy for the VA, as each VISN and Regional Medical Center has a different culture of patients, thus requiring differing approaches.  However, the recommendations listed above can improve where the VA is now, and form a launch point into the future.Military Crests

© 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/

Fiscal Insanity is not Fiscal Responsibility – Reports From the VA

I-CareConsider your home finances, you and your significant other are working hard for the paycheck.  Your significant other comes in and reports they have improperly paid the mortgage company, the electric company, the car loan, the gas company, and the credit cards over the last year to the tune of $100,000.  These funds are not recoverable, did not reduce your balances, did not pay ahead, did not apply to your account, and your significant other expects to be praised for improperly paying the bills.  What is your response?

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) released a report on how the Department of Veterans Affairs (VA) remains out of compliance with the Improper Payments Elimination and Recovery Act (2010) for fiscal year (FY) 2019.  The report is replete with the obvious, the VA refuses to be fiscally responsible for American Taxpayer dollars.  Consider the following from the VA-OIG report:

In FY 2019, VA reported improper payment estimates totaling $11.99 billion for 14 programs and activities, $2.74 billion less than the total reported in FY 2018 for 12 programs and activities.

The quote is supposed to be good news, and a major gain, and deserving of applause.  Except, two programs were added between FY 2018 and 2019, thus reducing the overall performance.  The VA-OIG report states something that should be obvious to every household in America, “Improper payments are any payments that should not have been made or were made in an incorrect amount.”  Please keep in mind, the VA is not being tasked with eliminating improper payments, simply following the legislation, and reducing those payments.  The VA has legislatively mandated targets they are “strongly suggested” to meet.

VA did not meet annual reduction targets for a program considered at risk for improper payments and did not report a gross improper payment rate of less than 10 percent for six programs and activities as required. VA satisfied the other four IPERA requirements.”

The VA-OIG inspection for improper payments was not an audit, does not demand full and open books to be reviewed by third-party auditors for accountability of taxpayer dollars, reading the VA-OIG report is simply looks like the VA, including the Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), and the National Cemeteries, self-report compliance estimates for meeting the targets.

Wrapped up in the VA-OIG report is the following gem of bureaucrat complicity.

“… Identified that four programs and activities have been noncompliant for five consecutive fiscal years, and two activities were noncompliant for three years.”

Thus, further reducing the overall adherence to Congressional oversight and fiscal sanity in properly handling the American Taxpayer money.  The VA-OIG reported that the VA is required to submit to Congress plans to come into compliance, and it was considered good news that the VA was able to do this for two high-priority programs with a monetary annual loss of $100 Million; but overall, I have to rate the VA’s ability to self-identify and self-correct fiscal problems at a very low F-.  The audacity of the VA Bureaucrats to not even follow all the VA-OIG recommendations, on such a softball legislative requirement mystifies.  From FY 2018 to FY 2019, the VA refused to comply with a VA-OIG recommendation, and this same recommendation has been carried over into FY 2020 in the hopes that the VA will come into compliance.

Blue Money BurningReturning the original analogy, if your significant other was reporting these failures to comply, how long would that person remain a significant other?  Yet, somehow, we, the American Taxpayer, accepts this type of poor performance from government bureaucrats.  The legislation is not working to improve performance after 10 consecutive fiscal years of trying.  Leading to the following recommendations for immediate Congressional action.

  1. Order a full, open, and transparent audit of the VA.  I don’t care what is found in FY 2019, just perform a complete audit and bring all the books and budgets of the VA into a single source.
  2. Set mandates for compliance with hard deadlines to meet. Without accountability built into a system for improvement, you cannot expect improvement.  Deadlines insist upon compliance.
  3. Start holding actual people accountable for not acting fiscally responsible. The charade has to end, the suggestions for improvement should never have started, and you, the elected Congressional Representatives, are responsible for correcting the fiscal ship of state!
  4. Insist upon adherence through personal liability. If a bureaucrat cannot handle the position they have been hired to hold, they need to be removed.  Not coddled, not protected, not another paycheck!

Congress demands every business in America be held accountable to basic accounting practices; why then does the VA get a pass?

© 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/

Department of Veterans Affairs – Xray Follies – Shifting the Paradigms

I-CareDuring the COVID-19 pandemic, I have been trying to give the benefit of the doubt to the VA; I was wrong to extend this kindness.  The Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin, was investigated by the Department of Veterans Affairs-Office of the Inspector General (VA-OIG) due to reports of leadership failure and manipulation of radiology reports.  The VA-OIG found gross errors in treatment delays, misleading reporting in records, and the leadership both knew and were tolerating this behavior.  From the report, we find that the VA-OIG, “… found evidence of manipulation and vulnerability of the electronic health record and mismanagement of the Medical Imaging Service. Facility leaders failed to successfully manage or address the impact of interpersonal conflicts within the Medical Imaging Service that included intimidation of staff radiologists.

Sadly, I am not surprised at the findings in this investigation; for a considerable time now, the VA has suffered from leadership irregularities, poor leadership, mismanagement, and over management in the majority of the local hospitals.  This situation remains highly frustrating to the veterans cursed with needing the VA’s services, and this madness must cease!  If it were not for another VA-OIG report declaring follies and leadership failure specifically in the radiological department, the dire situation would not have been so egregious.

The VA-OIG began their report of the VA Illiana Health Care System in Danville, Illinois, stating the following:

This report is compelling because it discusses significant patient safety issues including a radiologist’s error rate, the facility’s radiology quality assurance program, and a recommendation to the Under Secretary for Health regarding adopting national radiology guidelines.”

The VA-OIG inspection began due to radiological concerns and a high error rate.  The VA-OIG discovered such a poor error rate, a second investigation was required to expand upon the issues found in the first investigation.  A radiologist had an incredibly high error rate, and the facility leaders did nothing.  Does this not initiate a leadership cleaning of the house to remove the rot and begin to build community trust; if not, why?

To be clear, both the local hospital leaders and the Veterans Integrated Service Network (VISN) leaders are at fault for poor leadership decisions.  From the VA-OIG report, we find, “Veterans Integrated Service Network and facility leaders failed to conduct a thorough and impartial review related to the OIG request to evaluate the original allegations.”  Leading to another question, actually repeated now for multiple years, why are the local leaders, who created the problems, “conducting a review” during the VA-OIG investigation?  Isn’t this akin to placing a bank robber in charge of the criminal investigation into the bank robbery?

X-RayThe primary care doctor, emergency room doctors, and more all depend upon the radiologist report as the VA doctors no longer read x-rays, MRI’s, CT Scans, due to the complexity of the imaging.  Thus, any error in the radiological report causes significant patient care delays, harm, or death.  Yet, at two geographically separate VISN’s and Hospitals, the VA-OIG is reporting poor QA and high error rates in radiological reporting.  Compounded by leadership failure at both the local hospital and the VISN level.  The VA-OIG reports do not relate that anyone was fired, forced to change jobs, or other remedial actions taken beyond making “suggestions” for improvement at the federal, VISN, and local hospital levels.  What significantly increases the problem, these same radiological records form the backbone of the compensation and pension decisions.  Downstream issues were not in the scope of either radiological investigation. Still, every error in the VA bureaucracy has a significant downstream impact that always seems to be forgotten or overlooked.

Secretary Wilkie, lacking a downstream review from the VA-OIG investigations, places patients at significant risk and incredible harm.  Consider the following; the VA-OIG reported last year (2019) that radiological reports on spinal problems were not adjudicated correctly in compensation and pension claims from 2002-2006 roughly.  No downstream review occurred, and thousands of veterans’ claims are locked in the appeals process for decisions that should have triggered an automatic analysis and new radiological reports ordered immediately upon the conclusion of the VA-OIG’s investigation.  Where is the culpability and responsibility to the veterans harmed and suffering all because the VA did not do their collective job?

Problems

Now, at least two VA facilities are hindered by radiological errors and poor leadership at the hospital and VISN level.  Thus, the veterans need to know, can any radiological reporting be trusted with this blemish on the VA record?  Quality assurance (QA) is the backbone of the radiological imaging and reporting processes to assure the patient that proper diagnosing is happening.  Yet, QA is the problem in two different VA-OIG investigations of the radiological departments, and how many other VA Medical Centers have the same problem but have not been caught?  Where is the accountability for preventing these issues in other VA Medical Centers?

Here are five suggestions for rebuilding the reputation in the community, and in the VA Health Care System (VHA):

  1. Downstream investigations are critical and need initiation upon discovery by the VA-OIG of wrongdoing. Downstream investigating includes compensation and pension decisions, patient medical record discovery, and fixing the problems in the healthcare record.  Build an internal team of various professionals who can investigate and initiate these reviews.  Doing so will build trust, save millions of dollars in wrongly adjudicated compensation and pension claims, and saves lives in the VHA.
  2. Since the leadership failures are so common, so prevalent, and creating such an incredible talent drain, all while risking patient health, it is time for the VA to begin growing leaders through a VA University program. Do not allow leadership currently working for the VA to apply without good reasons; allow open applications where students can learn, can graduate with a degree, and can work in VA leadership roles as they gain a formal education.
  3. Begin weeding the leadership for the most disingenuous, detestable, and despicable leaders, replacing them with people who have never worked for the VA but are capable and willing from other industries. The VA needs new ideas, new leaders, and new methods if they are to fix the current problems.
  4. Put teeth into the VA-OIG investigations. These problems as so egregious and widespread that the VA-OIG needs tools to demand compliance and insist upon remediation.  In three VA Medical Centers in Albuquerque, NM., Salt Lake City, UT., and a VA Clinic in Ashtabula, OH., I have heard the following, or something similar, from employees regarding VA-OIG investigations, “Don’t worry.”  Never again should any VA Employee not worry about being investigated by the VA-OIG.
  5. ISO9001Start using an ISO 9001 for healthcare as a QA program where processes and procedures are written down and followed. QA should be a program that fits holistically and improves people.  Quality assurance should be a constant learning evaluation that never ends.  Yet, somehow the VA, including the VBA, the VHA, and the National Cemeteries, always seem to not have a quality program.  Implement the ISO 9001 one VA Medical Center at a time until a whole VISN is working under the ISO program.  This allows the VA to learn and use these learning moments to build anew that which has fallen into disrepute.

Leadership CartoonSecretary Wilkie, some will suggest these ideas are expensive, but how expensive has the revolving door in human resources been for talent drain?  How costly has failed training programs been?  How expensive is the appeals process to compensation and pension decisions both in green and blue money?  The short answer, too bloody expensive.  Thus, it is time to begin looking for innovative ideas, using new ideas, employing new talent, and demanding higher returns for the taxpayer investment in the Department of Veterans Affairs.

©Copyright 2020 – M. Dave Salisbury

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Uncomfortable Truths – Procedural Breakdown and Leadership Failures

I-CareOn the 5th of August 2019, a VA-OIG report was delivered, but I was unable to comment due to the tragic incident documented in that VA-OIG report.  A veteran died, and while this of itself is troubling, the tragedy was how that veteran died.  Thus, the delay in writing about this veteran’s death and the VA-OIG report.

For the record, I worked at the Albuquerque VA Medical Center from 2018-2019.  From my first day to my last, I asked for, begged, pleaded, and reported that a lack of written procedures opens the VA to avoidable risks.  I was instructed several times by employees who had a minimum of five years in the administration of the hospital, who led the hospital mainly after hours, that writing anything down means responsibility.  But, responsibility is avoided at all costs by the leadership who are keen to keep from losing their power and job if something went wrong.  I countered that written procedures, where training on those procedures is documented, means that responsibility and accountability do not, automatically, result in lost employment, all to no avail.  Thus, the VA Medical Center in Albuquerque operates by gentlemen’s agreements, verbal directives, gossip, and personal opinion.

How is this accountable leadership?  What will it take to change this culture of irresponsibility?

The VA-OIG report documents that a nurse inappropriately labeled the patient as dead and did not commence resuscitation efforts.  Documentation was not completed, appropriate processes and procedures were not followed, and proper training was not conducted.  The crash cart, for a Code Blue emergency, was unlocked and deficient.  The leadership teams and committees did not correctly follow procedures and review the incident.  Reprehensible, detestable, and criminal are just some of the adjectives I have been using on this incident; but, the VA-OIG made nine recommendations.  Why does this not comfort me, comfort the family who lost a loved one, or suggests to America the problem will not be repeated?

I know the written procedure problem exists in the Phoenix Arizona VA Medical Center, the Cheyenne Wyoming VA Medical Center, and the Albuquerque New Mexico VA Medical Centers as I have been a patient of all three.  From the VA-OIG report, I must presume this problem is VA-Medical Center-wide, and I have to ask, why?  The military believes in writing everything down, redundancies, and accountability for records and documentation are taught from day one.  How is the VA able to operate without documentation, written processes, and documented procedures?

A running theme in the VA-OIG reports delivered since I began tracking VA-OIG reports in 2015, continues to be that documents are not properly completed, not maintained correctly, not audited timely and appropriately, or missing entirely.  Missing written procedures detailing how to perform tasks, and leadership were not forthcoming with the written procedures and policies needed to complete the tasks appropriately assigned.  A hospital in the private sector with these problems would be inundated with malpractice lawsuits, Federal inquiries, and threatened with closure; yet, the VA can operate without document controls, written processes and procedures, and escape any consequences, why?

The VA-OIG report detailing the death of a veteran in a behavioral health unit is not the first, nor will it be the last; but it should be!  This veteran’s death should be a clarion call for every hospital director in the Department of Veterans Affairs, Veterans Health Administration, to demand an immediate correction, that leads to written procedures, clearly defined directions, and training in following those procedures — then monitoring those procedures for updates and shelf-life.  This veteran’s death doesn’t even raise the eyebrows or curiosity of the lowest congressional staffer, and that is shameful!

Senators and Congressional Representatives, what are you doing to support Secretary Wilkie and his team in demanding answers and implementing corrective action?  Hospital directors, what are you doing to fix this abhorrent behavior in your hospitals?  Hospital directors, what are your directors, supervisors, and leaders doing to improve performance and follow Secretary Wilkie’s leadership to enhance the VA?  There is no excuse for another dead veteran at the hands of the providers and nursing staff in the VA Health Administration.

America, please join me in mourning another veteran’s passing.

This veteran did not have to die!

 

© 2019 M. Dave Salisbury

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The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

 

The 3-E’s of the Employee/Employer Relationship: Is your Organization Practicing all Three?

The 3-E’s, early, eminently, and equality, thus forming the fundamental principles of the employee/employer relationship.  Too many times only early is practiced, and the problems emanating result in reduced employee morale, purposeful negative actions, and disruption of the business by both customers and employees acting in a resentful manner.  In order to fully understand the power of combining the 3-E’s, we must first detail, define, and describe.

Early is often considered as akin to new, fresh, and initial; yet, the better application for this topic is in timeliness, punctuality, and promptness.  For example, when a problem occurs, the earlier it is addressed the faster and less damaging the problem becomes to the business as a whole.  Not taking precipitous action leaves the problem festering and infecting eventually leading to organizational cancer (Dandira, 2012), low employee morale, and managerial inertia slowing business processes and increasing the damage.  Hence, prompt, punctual, and timely action to address a situation early enough to affect positively the outcome remains the order of the day and the strongest power business leaders can take with the 3-E’s, but early action is not enough.

Eminent is often considered as akin to celebrity, paramount, and superior; yet a more preferred definition for this topic is often conspicuous and influential.  When an eminent action is taken, the action tends to supersede current policies, procedures, and overlaps or drowns normal work.  Overlaps and superseding are dangerous actions leading to increased costs, lost work, customer complaints, and a general lack of trust in business leadership to properly prior plan and produce positive performances from the business structure.  These thoughts are fed with celebrity-like marketing on new policies, business leaders, and changes, which are not fully understood and appreciated by the employees most affected.  Hence, the need to be frequently engaged, seen being influential in the lives of employees, and known as a person who cares remains the key leadership quality developed by eminent action; yet eminent actions, even if conducted early, are insufficient to properly influence and meet the demands of business.

Equality is often considered as sameness, fairness, and uniformity; yet, all of these definitions fail to capture what equality truly is and the power of equality.  For this topic, consider the following:  equipoise, parity, and concurrence.  Employees are individuals. They might have similar job titles and responsibilities, but the individual approach to the position provides power and separates the individuals and does not collect, compress, and concentrate into carbon copies.  Hence, the same approach of uniform application is not meeting the needs of the employees nor is it meeting the definition of fair.  Thus, the employee needs equality that treats them as individuals concurring in practice, but are individual in approach, and brings parity into treatment as an expression of equipoise.  While early is good and early mixed with eminence is better, but without early, eminent, and equal combined into an action, the employee and the employer suffer in an environment of disaster fed by chaos, corruption, and cancer as detailed by Dandira (2012).

Consistency remains key to employee/manager relationships.  While the principles of 3-E’s are important, all the work of the 3-E’s can be wasted if consistency is not honored and observed by the employees.  Consistency requires flexibility, firmness, and fungibility to meet the demands of creating success in using the 3-E’s appropriately.  The main factor in employee/employer relationships continues to be the individual nature of each employee, not the requirement to make all employees the same carbon copy of another employee or an “ideal” of the desired employee.

Putting these principles into practice requires asking questions, such as “Are employee communications being expressed early, eminently, and equally?”  “Are actions taken by business leaders being perceived as meeting the 3-E’s?”  “Do the trend lines in application indicate consistency or inconsistency?”  While employee perceptions can and often remain hidden, except through properly capturing actionable data in key performance indicators, the answers to these questions and more are evident.  Look at the employees, who show up to work excited, enthused, and enthralled.  Ask them why they possess these qualities.  Then, ask those employees not possessing them and hone in on the differences.  Will employees change from day-to-day; probably, but the answers continue to be important indicators as to whether communication in the organization is occurring.

Sinek (2009) offers that asking why and truly listening to the answers being returned remains the most effective question and action series employers can take from day-to-day as the pulse of the organization.  Gitomer (1998) adds that leaders after asking “why” should ask “what” to empower change and drive motivation.  Consider for a moment, an employee is asked “why” they feel the way they feel, then “what” would that employee like to see changed to aid in feeling differently, and project the employee’s reaction to having been heard.  Project that employee’s reaction if they see the changes they offered implemented into business practice.

Are all employee suggestions implemented; no, this is not feasible and the employees know this when making suggestions.  Yet, when employee suggestions are implemented, this changes the employee dynamic for all employees.  Ask yourself, when was the last time an employee suggestion was implemented and marketed to the other employees?  If the time is longer than 6-months, the program is not consistently being implemented and there is a problem with using the 3-E’s.

Steenhuysen (2009) reported on research discussing the power of praise.  Where praise is offered genuinely, praise has the power to change, and the research supports that the power of genuine praise operates on the same reward sections of the brain as cash. Anecdotal evidence shows many employees appreciate genuine praise, sometimes more than cash.  As a business leader or employer, ask yourself, “When was the last time I caught someone doing good and offered praise?”  If the answer was not yesterday, there is a problem with the 3-E’s, and consistency will be needed to rectify this problem.  Are you setting the goal to not leave the office without offering genuine praise?  Remember, Steenhuysen (2009) is reporting that praise is its own reward.  The research and anecdotal evidence present praise as being as good as cash to the brain.  Hence, praise is its own reward; can objects be added to potentially increase the reward, yes.  But start with praise, honestly provided and employing the 3-E’s.

Case in point, I have worked with a VP of Customer Service Operations who carries with them yellow and purple post-it notes.  The purple are for catching people in the act of good.  From simple actions to amazing calls, they all get recognition on purple post-it notes as a very noticeable action the business leader can take to catch and praise the good.  The yellow post-it notes go to the team leader when training is needed.  Consistent action over the years has developed a spirit of competition to earn and be caught doing an act of good.  The yellow notes are not remembered at bonus time; more serious infractions have a set process to follow, and the less serious yellow post-it notes are simply a means of providing timely feedback employing the spirit of the 3-E’s.  Upon starting this program, almost a full year passed before the employees caught on and the word of this action spread.  Let consistent action be seen, not marketed, and let the word spread by enthused employees.

The best part of the program from an employee perspective is the highest earners of purple post-it notes eventually began earning additional non-cash rewards also presented in a quiet manner.  The rewards ranged from leaving an hour early with pay, longer lunches or breaks with pay, to movie tickets and dinner cards.  These extra steps were implemented when trends reflected some employees were taking extra efforts to be caught thus necessitating a need for other levels of reward to keep the interest of the employees in acting and performing to a higher level.  Never are these employees recognized openly, e.g., at a company meeting, marketed to other employees, e.g., in a company newsletter, and receiving the purple notes is not a competition.

These purple post-it notes are an expression of gratitude from a person in leadership to an employee working hard.  Quiet, consistent, application of the 3-E’s provided a failing business unit new life in employee interactions with each other and the external customers.  The actions taken here should not be rare or the exception in employee/employer relationships, but the standard and personalized to each business and business leader.  What can we learn here to apply to all business units and organizations?

  1. Whatever is done consistent action remains critical.
  2. Simple, quiet, and direct remain key to affecting positive results on a personal level. Be brave!  Be honest!  Be courageous!  Be seen acting as you would see all employees act.  These will provide an impetus for others to emulate actions taken and good will develop.
  3. Know the 3-E’s, whether you are currently an employee or a business leader of hundreds or thousands. The 3-E’s are a two-directional action possessing power for positive results.  Use this power to drive a solution that can be consistently applied.
  4. If what is being tried is not working, do not act abruptly. Quietly adjust until positive actions can be seen and verified through trend lines.  What is being done currently might simply need more time or more quiet publicity to be discussed by the employees.  Make small adjustments and act for the interest of individuals; the whole population will catch on.
  5. A word of caution. Never use this program for self-aggrandizement; this will kill the program faster than a bullet to the 10-ring.  Do not enter into this program and offer non-genuine praise or false and ambiguous words and canned phrases.  Be specific and capture the incidents exactly, ask questions if needed, but be genuine and specific.

 

References

Dandira, M. (2012). Dysfunctional leadership: Organizational cancer. Business Strategy Series, 13(4), 187-192. doi: http://dx.doi.org/10.1108/17515631211246267

Gitomer, J. (1998). Customer satisfaction is worthless – Customer loyalty is priceless. Atlanta, GA: Bard Press.

Sinek, S. (2009). Start with why: How great leaders inspire everyone to take action. New York, NY: Penguin Group.

Steenhuysen, J.  Praise as good as cash to brain: study. (2009, February 26). Reuters. Science. Accessed from: http://www.reuters.com/article/scienceNews/idUSN2343219520080424?feedType=RSS&feedName=scienceNews

© 2016 M. Dave Salisbury

All Rights Reserved