Weep America! – The VA Leadership is Becoming Worse! – Part 2

Angry Wet ChickenOne of the first rules in overseeing junior people working is to make available someone to answer questions, immediately, and render support if needed.  I have had the pleasure of training junior people in a myriad of tasks over the years.  When I read this Department of Veterans Affairs – Office of Inspector General (VA-OIG) report, a plethora of questions arise, and I deeply question the professionalism and competence of the doctor overseeing the work of residents in a VA Hospital who are performing procedures.

  • Ophthalmology Resident Supervision – Important to note, the patient did not experience any long-term loss of sight over this issue. Congratulations to the resident and the other ophthalmology doctors present!  From the VA-OIG report we find the following:

“… The subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case.”  Essentially, the doctor charged with overseeing residents was AWOL, and then compounded his error by falsifying patient records.  The VA-OIG report continues by claiming this falsification was the result of an oversight when using pre-recorded notes for patient files.

Draw your own conclusions.  Personally, I think this doctor needs to be released of all duties where overseeing residents is concerned.  I would also question his ethics and morals for falsifying patient records.  You hold a double position of trust, first as a doctor, second as a teacher and leader of residents, and the behavior witnessed should come with steep repercussions professionally!VA 3

Knowledge Check!On the topic of professional duties, and steep repercussions, drug interactions killed a veteran at the Marion VAMC in Illinois.  Before launching into the VA-OIG’s report, please allow me a moment of your attention.  Drug interactions can arise due to vitamin usage, over-the-counter medications, and from illegal and legal but illicit drug use.  Often, I have claimed that people are walking chemistry experiments, and even vaccines need to be carefully evaluated for drug interaction potential.  Foods can cause drug interactions due to the chemicals in the food.  Drug interactions are a growing problem and every medical professional I have spoken to admits drug interactions are becoming worse by the day.  I do not say this lightly, but I do not hold the medical professionals as fully competent in fighting the drug interaction problem due to the amount of chemicals the average person interacts with daily.  The problem is Big-Parma and the continual push towards more specialized medicines, we are going to see more drug interaction issues.  Unfortunately, drug interaction issues come with the risk of death!

From the VA-OIG report we find the following:

The VA-OIG substantiated that high cholesterol contributed to the patient’s death; however, the death certificate indicated that the primary cause of death was accidental acute multi-drug intoxication. The psychiatrist and staff failed to document providing the patient with education during a telephone encounter regarding potential side effects or adverse drug-drug interactions of medication changes. Contrary to clinical guidance, the psychiatrist prescribed long-term benzodiazepine use for a patient diagnosed with posttraumatic stress disorder. The psychiatrist also failed to address the patient’s two negative urine drug screens for a prescribed medication and failed to address a positive urine drug screen for cannabis. Due to COVID-19, the facility failed to launch the Psychotropic Drug Safety Initiative Phase Four Plan. The primary care provider did not comply with facility policy by failing to enter a return-to-clinic order following an appointment but could not determine if this affected the patient. Primary care and behavioral health staff did not comply with facility policy to telephone the patient or send a letter after the patient missed appointments” [emphasis mine].

The lack of staff to follow procedures and do their job, I will certainly hold them accountable for, especially since Cannabis is involved!  Please do not believe that Cannabis is a non-toxic drug, especially when mixed with other drugs, it can be the fatal trigger in a multi-drug intoxication!VA 3

At 18, low those many years ago, I took the EMT-Basic class, but left for US Army Basic Training before I could certify.  Since then, I have received certification as a combat medic and a Journeyman Firefighter (Any industry) which required a lot of hours studying emergency medicine.  I am experienced in drawing blood, starting IVs in difficult circumstances, and handling a myriad of injuries.  I am not a medical professional by any stretch of the imagination, I simply have a healthy desire to learn, and emergency medicine is a fascinating topic I regularly pursue.  I am not a chemist; I rely upon peer reviewed resources and legal and medical websites to stay current on a host of topics.  With this as my qualifier I am going to make several statements and you can judge their merit.  Feel free to comment.

      1. The first rule of medicine is document everything! My first lesson, first day of EMT training, this point was driven home.  If you do not write it down, it never happened!  Yet, what does the VA-OIG find time after time in reviewing cases at the VHA, lack of documentation of steps taken!  Can you say, “Asinine and abysmal behavior by credentialed professionals?” I know I can!
      2. Aspirin and Alcohol can cause a drug interaction that can be deadly. Both chemicals are readily available in the home and over the counter.  Why is spray paint now requiring proper ID, because people are huffing the stuff and getting a multi-drug intoxication.  Oven cleaner and spray pain can cause serious breathing issues and when mixed together can cause a cheap high, as well as a multi-chemical intoxication leading to breathing paralysis and death!
      3. Cannabis continues to be modified, changed, enhanced, and designed to trigger different chemical reactions in the body. Continuing work that began in earnest in the 1960s for the pot-smokers who wanted a more serious high.  Guess what, cannabis and aspirin along with vitamins can cause multi-drug intoxication problems leading to death!
      4. Vitamin D and Vitamin C have both caused serious drug intoxications during COVID-19. People became frightened and took too many of both or just one and wound up in the ER with life-threatening health problems from toxicity of these vitamins.  India has reported a spike in black mould that has caused serious long-term health problems for diabetics after recovering from COVID.  It is currently presumed that the chemicals used to fight COVID allowed for a natural mould to grow in the body, and that became life-threatening.

The VA-OIG conducted another virtual comprehensive healthcare inspection, and found the same problems continue at another VAMC.  Do you know how tired I am of reading these “comprehensive inspection” results and finding the same problems time after time?  When will the VA actually start enforcing some of these VA-OIG recommendations to effect change?  Better, when will the politicians who are charged with scrutinizing the government tire of seeing the same recommendations and not seeing any change?  Bloody frustrating reading these reports and not seeing improvement!VA 3

Broken RobotFinally, we come to what I was hoping to be a great report, where the politician’s heads were going to explode at the inefficiencies, the detestable behavior, and the horrendous responses to legally mandated IT infrastructure changes, and why those changes are not happening at the VA.  I was not disappointed; I was thoroughly disgusted that his report fell on plastic ears speaking plastic words from wax lips!  Statement of Michael Bowman, Office of Inspector General, Department of Veterans Affairs, Director of IT and Security Audits Division, Before the Subcommittee on Technology Modernization, Committee on Veterans’ Affairs, U.S. House of Representatives, Hearing on Cybersecurity and Risk Management at VA: Addressing Ongoing Challenges and Moving Forward May 20, 2021.  Notice something, the failures at the VA in the IT Department are being called “ongoing challenges.”

Millstone of Designed IncompetenceLet me remind you, FISMA was released on 29 April 2021, and I wrote about the abysmal findings of the VA-OIG.  This report is the accountability statement to the Congressional representatives who should have skewered this bureaucrat and roasted him on a spit with onions and peppers, then served him up for public ridicule after firing him!  For the Director of IT and Security Audits Division to make the following statement is flat out beyond comprehension, “The OIG’s conclusions in the FY 2020 FISMA audit are not new or revelatory—rather, they repeat many of the same concerns with VA’s IT security that the OIG has found for many years.”  What incredible chutzpah to make this comment after that scathing report showed just how deplorable the leadership of the IT and Security Audits Division revealed!  Director Bowman then goes on to downplay the band-aid solutions implemented while decrying the time for improvement is too short and there is not enough money.  Do not forget, “Of the 26 recommendations, 21 have been included in every FISMA audit dating back to at least 2017.”  With at least 15 of these recommendations dating back even further.  Want a full list, as well as how old these recommendations are; you will not find it in the Director’s report to Congress!  Is anybody incensed enough to demand a full accounting of just how old these IT recommendations are?

Detective 4The gall of this director to continue to blame legacy systems that were legislated to have been scrapped between 2000 and 2010 continues to highlight the incompetence of the director in conducting business and holding people accountable for failed projects and overspending of taxpayer monies!  The director went further and stated the following, at which time, every single Congressional Representative should have stood and demanded his head.  The “VA does not properly manage and secure their IT investments.”  Tell me director, why should you remain employed if the VA does not properly manage and secure their IT investments?  Is the failure to manage and secure IT investments the root cause for veterans to continue to suffer identity theft from the VA losing their identity?

The director’s next statement puts his other outrageous comments to sleep.  “Security failures also undermine the trust veterans put in VA to protect their sensitive information and can affect their engagement with programs and services” [emphasis mine].  Talk about such an obvious statement, it’s like the sun coming up on a cloudy day, you just cannot miss that sun rise; you also cannot miss the absurdity of making this statement!  Did some intern write his speech?  You are the director of IT Security and you make this type of comment, did you make this comment with a straight face?  I cannot find the video-record of this Congressional hearing so I can only guess he delivered his lines with a straight face!  Most detestable of all, he continued to make outrageous comments, his plan to move the IT security program at the VA forward is weak, lacking firm deadlines, and continues to allow him and his staff to escape accountability and responsibility.VA 3

Angry Grizzly BearAmerica, with these bureaucrats in charge, why shouldn’t we be weeping and wailing, and gnashing our teeth in frustration?  When will we, the owners of this atrocious government, finally scream ENOUGH and demand a full change of heads at the ballot box?  For until the elected representatives are forced out, the bureaucrats abusing us, will only continue!  The VA is sick, but the problem lies in the bureaucrats, administrators, and directors leading the VA at the Federal and VISN levels.  So many other government agencies are just as sick, or worse, and the same problem arises, the leadership refuses to act, but still expects a big titanium parachute when they leave office!  I say it is time to tell them NO!

© 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: Revisiting Designed Incompetence

Dont Tread On MePlato has a point, “The price of apathy towards public affairs is to be ruled by evil men.”  When writing about the Department of Veterans Affairs, the Internal Revenue Service, or the United States Postal Service, one must remember, these organizations have been intentionally designed to be as bad as they are.  The government worker refuses accountability, shuns responsibility, and simply wants to exist doing as little as possible for as much as possible.

In the private sector, the employee is expected to shoulder responsibilities, share in the companies struggles, trials, and the eventual victories.  Yet, the government employee is the exact opposite.  I have heard it said that government workers are a necessary evil, a scourge, and a disgrace.  Except, often times the government employee is just a rule follower and the really pernicious and dastardly government employee are those seeking power in their government employment.  The directors, the supervisors, the managers, and the undersecretaries.  The staff that never goes anywhere.  Political appointees come and go, but the staff is a scourge for life.

Never Give Up!While Plato has a point about apathy in public affairs leading to being ruled by evil men, what is lost in the discussion are the staff members.  Tom Clancy wrote about how a jet airliner took out both houses of the Congress, SCOTUS, and Vice President Jack Ryan suddenly found himself as President Ryan, rebuilding the entire US Government.  This Tom Clancy novel takes a person into the inner workings of the US Constitutional Government like no other book I have ever seen.  Best of all, he explains the intoxicating power the staff members, the executive assistants, and undersecretaries hold over the political appointees to hinder progress, stymie change, and control their fiefdoms against all forces of influence.  This is the root of designed incompetence.

What is an excuse?

An excuse is a method to reduce blame attached to an action, defend, or justify one’s actions, an attempt to release one from accountability, or a poor or inadequate example of something.  As children, we are taught excuses are like noses; everyone has one and picking it in public is disgusting.  Yet, when something happens, two types of people emerge, those who make excuses and those who take responsibility and work to fix the problem.

What is designed incompetence?

Designed incompetence is a ready-made excuse for inadequacies created in business operations, a method to avoid responsibility and accountability. Due to the cost of designed incompetence, it is generally only found in government operations.  Designed incompetence can also be intentional actions designed into business operations, so the expected functions are designed to fail purposefully.  Designed incompetence is always harmful and destructive in nature, generally will make no logical sense, and will always be the preplanned leadership fallback position.Apathy

Example of an excuse:

    • The USPS is running slow, so the delivery of mail is taking longer to deliver than usual.
    • COVID has a lot of employees out sick, so operations are slower.
    • The person who wrote the order requesting the work to be completed did not do their jobs properly, and the original order must be rewritten.

Examples of designed incompetence:

    • The VBA communicates using terminology not universal in medicine to intentionally confuse and hinder making appropriate decisions on veterans’ claims.
    • The VHA refuses to write policies and procedures due to a fear of risk; thus, when the VA-OIG investigates, the same recommendation can be made multiple times to write down procedures.  The leadership team can escape accountability for failure.
    • The USPS has mail carriers dumping mail in dumpsters, these employees are protected by the labor union, so the employee can keep their job, move them to a non-letter carrier position.

Designed Incompetence Feeds Inert and Toxic Cultures

Knowledge Check!Designed incompetence is the root cause for the toxic government employee workplace cultures.  When responsibility is shirked, the human psyche feels moral distress, and as the moral distress grows, so to does the self-loathing, self-hate, and feelings of hopelessness.  Worse, some people, who have constantly been ethically challenged or morally bankrupt, will use these feelings of self-loathing to capture power.  Once captured, the power becomes a drug, and that drug is highly addictive.  Thus, a self-fulfilling prophecy from Plato becomes true, “Apathy towards public affairs is to be ruled by evil men.”  The more the morally bankrupt and ethically challenged win power, the bigger an example to others of how to obtain power in government they become.  But the remaining people who do not receive power are left with a toxic workplace, full of inert people.  Motivating inert people in a toxic culture, who are already feeling the stress of acting morally indifferent will leave multi-generational scars on the workforce.

An important point that requires mentioning, “it is not for the lack of money or technology to pinpoint abuses and problems with employees; it is all the inertia of the leadership towards action and the toxic culture which allows and encourages pushing the boundaries that are killing veterans in the VA.”  The same is true for any of the alphabet agencies created by the Federal Government, state government, and local government.  Walk into a DMV and tell me if you cannot sense a toxic and inert culture is driving down customer service levels.  Walk into a welfare office and tell me the people working one side of the counter are not inert.  Worse, walk into any IRS field office and tell me how you feel being around the morally bankrupt and ethically challenged.Plato 2

I met some school board officials in Albuquerque, New Mexico, and was appalled at the lack of ethics and morals they displayed.  Judges and lawyers are driving drink and skating accountability because of their positions and so much more.  All because the designed incompetence in government promotes those who have the least reason and ability to be promoted.  Plato is absolutely correct, “The punishment which the wise suffer, who refuse to take part in the government, is to live under the government of worse men.”  For too long, government employees have been allowed to run the asylum while the best and brightest pursue goals in the private sector.  If America is to win back her government, the citizen must stand and boldly proclaim “NO!” and then get into government service to change the toxic and inert cultures.

Plato might have been mentioning the following about elected officials, but I find it apt and applicable to the designed incompetence by the staff members, “One of the penalties for refusing to participate in politics is that you end up governed by your inferiors.”  The first time I met my director as a VA employee, I knew two things, she hated me, and I was doomed to suffer under her inadequacies.  Both of which came true over the following 360-days.  The intransigency of the leadership in administrative positions at the VA is frightening.  Ending these abuses of power is the preeminent position of every citizen in every democratically elected society.

Plato 3The scourge of designed incompetence must end.  If this means eating soup with a knife, then we must eat the bowl of soup to the dregs.  But, we must act if we are to save our countries from the politicians and the staff that have infested our governments!

© 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.

VISN 22 – The Bureaucrats Operationally Living as Petty Tyrants

Survived the VA23 February 2021:  UPS delivered a letter package containing a single sheet of paper from Dr. Karen MacKichan MD, auto signed, and dated 09 February 2021.  Declaring that the Phoenix VA is absolutely correct in behaving as petty tyrants and denying me medical care, illegally sharing and knowing my HIPAA information with VA Police Officers, breaking EMTALA, and treating me to injuries, all because I cannot safely wear a mask.  My only infraction at the Phoenix VA is not to wear a mask.  Yet, this is considered a “behavioral problem,” and I am wrong for behaving in a manner that insists that my safety comes first!

From June 2020 to date, the charge has been, “Wear a mask or a face shield to receive service in the VA.”  Then, I got arrested while wearing a face shield and told my failure to wear a mask is “disruptive behavior.”  Seriously, not wearing a mask somehow disrupts the entire hospital and keeps it from running efficiently.  Refusing to believe the letter my VA provided Primary Care Provider wrote (August 2020) for my employer regarding my inability to breathe while wearing a mask.  The VA Police have continued to escalate situations to reflect “disruptive behavior patterns.”  Yet, I am the one punished, and I am the one injured; I am the one being denied care.

Literary FiendWhat are petty tyrants?

James Abyad quoted the Urban Dictionary for the definition of petty, which exactly expresses the sentiment of petty.  Urban Dictionary defines petty as “making things, events, or actions normal people dismiss as trivial or insignificant into excuses to be upset, uncooperative, childish, or stubborn.”  It further defines it as “a person who is purposefully childish with the intent of eliciting a reaction,” or “someone who does something in an attempt to hurt another person but makes themselves look stupid.”  Tyrant is a cruel and oppressive ruler, per Webster.  Hence, a Petty Tyrant is a childish, insignificant, oppressive ruler.

Well, Dr. MacKichan, Deputy Chief Medical Officer VISN 22, 300 Oceangate, Suite 700, Long Beach, California, 90802, you are incorrect!  I have followed all written VA directives. Do not assume that it is my fault the Phoenix VAMC leadership cannot write down a COVID Mask Directive and operational policy that supports all veteran health contingencies.  Then train the staff coherently upon written guidelines and directives, and engage in an honest and forthright manner with veterans seeking care.  Where are the written directives governing COVID Mask Wearing?  You claimed to have reviewed all the information; I have asked for these documents and been pointed to a sign.

VA SealOn the topic of written directives, written operational policies, written patient guidelines, and written job descriptions and duties, let’s talk about how the VA Police can injure people and not be held accountable!  The VA Police attacked me on 07 December 2020, violently pushed, then spun into a wall.  My C-and L-Spines did not move, and my T-Spine turned; I dropped like a rock sustaining spinal injuries, knee injuries, and got cut on my right hand and arm.  Worse, being handcuffed with my arms behind my back caused bruised wrists that were jerked by more VA Police officers on 10 December when I sought medical attention.  I am an 80% disabled person with mobility issues, yet your letter claims all the action of the Phoenix VAMC was in accordance with written policies, guidelines, and directives.  Well, I possess a Missouri mindset, “Show ME!”  Show me the written and published policies, guidelines, and procedures that allow VA Police Officers to physically assault patients!  Show me the written and published policies, guidelines, and procedures that allow me to be refused treatment.  Prove through written and accessible documents how the decision for this hodgepodge of ineptitude can label me a “behavioral issue” when my only discretion is not physically and safely wearing a mask!

The Duty of AmericansYou claim to have reviewed the actions of the police officers who routinely have medically protected HIPAA information about people being arrested, joke about this information, act in a manner that brings shame to all Federal Police Officers.  What happens to these unprofessional officers and their despicable commander?  When do my rights to have my HIPAA-protected information withheld from parties who do not need this information?  When do all the other veterans being served and not being served by the Phoenix VAMC become protected under HIPAA?  I am not the only veteran being refused service, denied care, and abused and injured by the VA Police for not wearing a mask, while also not being a “behavioral issue.”

Since your letter proclaims loudly that your review was thorough, independent, and comprehensive, and as the VISN 22 Chief Medical Officer, surely you cannot condone illegal activities being masked by calling a patient a “behavioral issue.”  The Emergency Medical Treatment and Labor Act (EMTALA; 1986), a federal law, requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.  EMTALA was regularly abused at the Albuquerque VAMC, and I reported this issue multiple times. EMTALA’s abuse and illegal activity at the Phoenix, VA Medical Center are worse, and I have reported this issue multiple times.  Twice I have followed my primary care provider’s instructions to report to the VA ER for treatment, and twice I have been refused service.  Thus, what is to be done to correct this obvious deficiency in VISN 22 treatment of veterans, service members, and dependents by VISN 22 emergency medical care providers and the staff, including the VA Police, who should have no influence upon care being received or who should receive care?

Theres moreYour letter discusses “the most effective manner to have the behavioral flag lifted” as “checking-in with the VA Phoenix Police.”  Do you know what that entails?  Did your “thorough, comprehensive, and independent” investigation uncover what happens at this “check-in?”  I was told clearly what happens; I will be evaluated for wearing a mask, found not wearing a mask, arrested, cited, and denied service for not wearing a mask.  Then, I will have a black mark on my behavioral flag record for disorderly conduct!  I am not disorderly in my behavior because I cannot safely wear a mask!  What part of this do you, as a medical doctor, fail to comprehend?

I had my gallbladder removed in a Phoenix hospital (Sept 2020), never had a problem not wearing a mask.  I have had MRIs completed (Aug 2020), never had to wear a mask.  I have been seen three times in an emergency room and never had to wear a mask (Jun 2020, Sept 2020, Jan 2021).  The only medical service provider demanding through compulsion and fear that I wear a mask, which would place my health at risk, is the Phoenix VAMC.  Yet, you as a medical doctor cannot understand this issue, the problems with unwritten policies and directives, leadership failures to train staff properly, and you allow petty authoritarians wearing VA Police Badges to enforce a reign of terror at the VAMC in Phoenix.  Hence, you are part of the problem in failed leadership, poor management, and detestable petty authoritarianism!

InertiaI always interact with the staff at VAMC’s, even when they are wrong, in a respectful manner, knowing that the problems of dumb policies, time-wasting procedures, and bureaucratic inertia are the fault of the leaders hiding in their offices and cubicles.  I have been interacting with the VAMC’s across America, and the inept staff, since I left the service in 2004!  Never having a problem, never having an issue, and never getting injured by or even interacting with VA Police.  This all changed in June 2020.  The VAMC refused to write down a comprehensive directive for COVID Patient Mask Wearing.  I get blamed for following the unwritten policy and directives, then falsely accused of being “disorderly” in my behavior, then falsely accused, again, for being a “behavioral issue!”  I am not in the wrong here!  I am not a “behavior issue!”  I am not disrupting hospital operations, placing other patients at risk, or being violent!  Where are my rights in this farrago and railroading scheme?

Image - Eagle & FlagYour boilerplate response indicates this issue has reached the final point.  I beg to differ!  I will have my name cleared of these false charges.  I will not be blamed for the ineptitude of the leadership at the Phoenix VAMC and VISN 22!  I will not be silent and meek in the corner because you cannot tell the difference between standing for one’s rights against tyranny and compulsion and oppression through bureaucratic fiat!  I have done nothing worthy of these fallacious claims, false accusations, and the Phoenix VAMC and VISN 22 will admit this publicly when I am done cleaning my name of the scum you have thrown upon it!  Make no mistake; I am not angry, but I will have my rights restored, my name clear, and satisfaction from the injuries and treatment I have been made to suffer!

© 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.

Symptoms Not Cause – Shifting the Paradigm at the Department of Veterans Affairs

I-CareFor Memorial Day (2020), the National Cemetery, through the directive of the Department of Veterans Affairs (VA), restricted the placing of flags at several national cemeteries, upsetting the plans of Boy Scouts, and angering countless veterans, survivors, dependents, and extended families.  However, the intransigence of the VA on this matter is but a symptom of a larger problem.

ProblemsThe Department of Veterans Affairs – Office of Inspector General (VA-OIG) recently released two additional reports on behavior unbecoming at the VA.  The first report concerns the delays in diagnosis and treatment in dialysis patients, as well as patient transport at the Fayetteville VA Medical Center in North Carolina.  The second is another death of a patient, as well as deficiencies in domiciliary safety and security at the Northeast Ohio Healthcare System in Cleveland.

The VA report from North Carolina includes significant patient issues, especially since two veterans died while in the care of the VA.  Significant issues are generally code words for incredibly lax processes, and procedures that are easily avoided, provided people care enough to do their jobs correctly, succinctly, and thoroughly.  Where patients are concerned a dead patient is pretty significant.  Two dead patients are beyond the comprehension of a reasonable person to not ask, “Who lost their jobs over these incidents?”

Patient A, has leukemia, and from the VA-OIG’s report we find the following responsible parties:

“… A primary care provider failed to act on Patient A’s abnormal laboratory results and pathologists’ recommendations for follow-up testing and hematology consultation. Community Care staff did not process a consult and schedule Patient A’s appointment.

Patient A died from a gastrointestinal bleed while waiting for transport to a hospital from a (VA Contracted) [long-term] care facility.  Patient A’s delays in care led to death in hospital, and the failure of a hospitalist to initiate emergency procedures contributed to the veteran’s passing.  Patient A’s death is a tragical farce of bureaucratic inaction, compounded by the same symptoms as that allowed for Memorial Day (2020) to come and go without the honored dead of America being remembered.  Symptoms not cause.

Patient B, was also in a (VA Contracted) [long-term] care facility, in need of transport back to the hospital, and the administrative staff’s delays had Patient B arrive at the hospital in cardiac failure, where the patient subsequently died.  In the case of both patient’s facility leaders did not initiate comprehensive analyses of events surrounding the patients’ deaths or related processes. But, this is excusable behavior at the VA due to frequent executive leadership changes impeding the resolution of systemic issues.  I have been covering the VA-OIG reports for the better part of a decade and this excuse is always an acceptable excuse for bureaucratic inaction.  Hence, the first question in this madness is to the VA-OIG and it needs to answer, “Why is this an allowable excuse?”  Don’t the people remaining know their positions sufficiently to carry on when the executive team is in flux?  Again, symptoms not cause.

The patient death in Northeast Ohio, started with the domiciliary, on a VA Contract care facility.  Essentially, the patient died because of methadone being provided without first gaining an electrocardiogram.  Oversight of the contracted domiciliary did not include accuracy checks on paperwork, but the VA-OIG found that for the most part, the contracted domiciliary was following VA Contracting guidelines.  From the report, no gross negligence led to the veterans passing, and for the most part risk analysis and other post mortem analysis were conducted properly.  Why is this case mentioned; symptoms not cause.

When I worked at the New Mexico VA Medical Center (NMVAMC) I diagnosed a problem and was told, repeatedly, to not mention the problem as the director would be furious.  The problem is bureaucratic inertia.  Bureaucratic inertia is commonly defined as, “the supposed inevitable tendency of bureaucratic organizations to perpetuate the established procedures and modes, even if they are counterproductive and/or diametrically opposed to established organizational goals.”  Except, the bureaucratic inertia I witnessed daily was not “supposedly inevitable,” it was a real and cogent variable in every single action from most of the employees.

I spent 12 months without proper access to systems, but the process to gain access was convoluted, unknown, ever-changing, and so twisted that unraveling the proper methods to complete the process and gain access was never corrected, and this was a major issue for patient care in an Emergency Department.  Why was the process so bad; bureaucratic inertia.  Obtaining information about the problem took two different assistant directors, two different directors, a senior leader, and the problem was identified that licensing requirements were the sticking point in the problem.

InertiaBureaucratic inertia is the cause of too many issues, problems, and dead veterans, at the Department of Veterans Affairs.  The symptoms include delays in administrative tasks that lead to patients dying for lack of transport to a hospital.  The symptoms include cost overrun on every construction project the VA commences.  The symptoms include abuse of employees, creating a revolving door in human resources where good people come in with enthusiasm, and leave with anger and contempt, generally at the insistence of a leader who refuses to change.  The symptoms include a bureaucrat making a decision that has no logical sense, costs too much and is never held accountable for the harm because the decision-maker can prove they met the byzantine labyrinth of rules, regulations, and policies of the VA.

Veterans are dying at the VA regularly because of bureaucratic inertia.  Hence, as bureaucratic inertia is the problem, and the symptoms are prevalent, it must needs be that a solution is found to eradicate bureaucratic inertia.  While not a full solution, the following will help curb most of the problem, and begin the process for the eradication of bureaucratic inertia.

  1. Give the VA-OIG power to enact change when cause and effect analysis shows a person is “the” problem in that chain of events. Right now, the office of inspector general has the power to make recommendations, that are generally, sometimes, potentially, considered, and possible remediations adopted, provided a different course of action is discovered.
  2. Give the executive committee, of which the head is Secretary Wilkie, legislative power to fire and hold people accountable for not doing the jobs they were hired, and vetted at $110,000+ per employee, to perform. Background checks on new employees cost the taxpayer $110,000+, and the revolving door in human resources is unacceptable.  But worse is when the leaders refuse to perform their jobs and remain employed.
  3. Implement ISO as a quality control system where processes, procedures, and policies are written down. The ability for management to change the rules on a whim costs money, time, patient confidence, trust in leadership and organization, and is a nuisance that permeates the VA absolutely.  The lack of written policies and procedures is the second most common excuse for bureaucratic inertia.  The first being, the ability to blame changing leadership for dead patients!
  4. Eliminate labor union protection. Government employees have negotiated plentiful benefits, conditions, and pay without union representation and the ability for the union to get criminal complaints dropped, and worthless people their jobs back is an ultimate disgrace upon the Magna Charta of the United States of America generally, and upon the seal of the Department of Veterans Affairs specifically.

Leadership CartoonSecretary Wilkie, until you can overcome the bureaucratic inertia prevalent in the ranks of the leadership between the front-line veteran facing employee and your office, lasting change remains improbable.  Real people are dying from bureaucratic inertia.  Real veterans are spending their entire lives in the appeal process for benefits and dying without proper treatment.  Real families are being torn asunder from the stress of untreated veterans because the bureaucratic inertia cannot be overcome from the outside.  I know you need legislative assistance to enact real change and improve the VA.  By way of petition, I write this missive to the American citizen asking for your help in providing Sec. Wilkie the tools he needs to fix the VA.

The VA can be fixed, but the solution will require fundamental change.

Change is possible with proper legislative support!

© 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.

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