NO MORE BS: Memorial Day 2021 – Are you sure this is “proper” remembering?

Knowledge Check!It is no secret that the Department of Veterans Affairs (VA) is a sick and twisted organization.  It is no secret that the Department of Veterans Affairs – Office of Inspector General (VA-OIG) tries to recommend how the VA should be operating in accordance with currently established procedures, methods, and policies for the benefit of the veteran community.  It is no secret that I continue to write about the VA in the hopes of sparking interest in communities and obtaining more fair, honest, transparent, and humane treatment for veterans by the Government agency tasked with caring for veterans.

On this Memorial Day, as you sit down to barbecue, family, friends, sports, I would ask that you take a moment and consider if this were how you would like to be remembered?  Are the actions described proper for remembering those who sacrificed and came home?  Are these actions, which are adding to veteran funerals, an appropriate way for veterans to be leaving this world?  If the answer is no, I ask for your help changing the Federal Government by electing people who will scrutinize the government more stringently and demand change in all government agencies.  If you deem this behavior acceptable, please leave a comment detailing why you think so.  I want to hear your thoughts.Image - Eagle & Flag

From a VA-OIG report published on Wednesday 26 May 2021, we find the following announcement:

Phillip Hill, a former VA program analyst, was sentenced to 46 months in prison for stealing personal information from veterans and VA employees while employed at the Central Arkansas Veterans Healthcare System. The investigation revealed that Hill contacted another individual and attempted to sell personal identifying information to a buyer for approximately $100,000.”

Now, I am thrilled this guy was caught.  I am glad he will do time behind bars.  Yet, why did Assistant US Attorney Jana Harris allow a plea deal?  Where are the VA supervisors who should have been monitoring this employee’s work and behavior?  What are the details of the deal?  The VA continues to have nothing but IT/IS security, and these problems are decades old.  Still, the elected representatives allow the criminal behavior to exist until the criminal is caught, and then the elected representative’s crow about cleaning the swamp.  Is this how you correctly remember veterans, their sacrifice, and their memories?VA 3

I suppose the following VA-OIG report, released 27 May 2021, should begin with congratulations.  The Department of Veteran Affairs – Veterans Benefits Administration (VBA) mostly processed monetary proceeds records accurately.  However, the following continues to astound and amaze me:

Service and pension center staff do not have timeliness measures for proceeds incorporated in their performance standards. Setting a timeliness standard would help encourage the closing of these proceeds. The OIG also found that ineffective monitoring contributed to delays in handling proceeds. The Debt Management Center had only limited internal monitoring but instituted new practices for monitoring proceeds in February 2020, shortly after this audit began” [emphasis mine].VA 3

Why are government employees not held to a productivity and quality standard?  Being a veteran with regular concerns involving the VBA, I cannot help but wonder why quality and productivity are not required?  As an industrial and organizational psychologist, the first step in improving responsiveness to customers is to increase productivity and implement quality measures.  I know the Federal Government’s legislative branch, e.g., Congress, has insisted on developing quality measures.  Yet, the same tired excuses built upon designed incompetence are allowed to survive, and all the VA-OIG can do is issue more recommendations.  Consider something; proceeds include payments to dead veterans.  How much financial hardship occurs at the passing of a loved one?  How much more difficult can that death become when months down the road, money spent is suddenly being demanded back because some incompetent bureaucrat failed to do their job in a timely manner?

QuestionIs this properly honoring and remembering the veterans and their sacrifice?  Is this behavior acceptable in your workplace?  Why do we allow this behavior from government workers?

While never having been a patient at the Chillicothe VAMC in Ohio, I have friends who are patients.  The stories they tell about care there would shock and amaze many.  What infuriates me, the VA-OIG just published their report of a comprehensive inspection of this VAMC, and the results are as tragic as a veteran’s death!  The information was released to the public on 27 May 2021.  Never forget, the Chillicothe VAMC in Ohio was recently investigated for improper cleaning and sterilization procedures, as well as employee monitoring for compliance for medically reusable equipment, which for this case refers to endoscopes.  With this fact in mind, let us review the comprehensive inspection report.

Limitations on findings:

      • The VA-OIG held interviews and reviewed clinical and administrative processes related to specific areas of focus that affect patient outcomes. Although the VA-OIG reviewed a broad spectrum of processes, the sheer complexity of VA medical facilities limits inspectors’ ability to assess all areas of clinical risk” [emphasis mine].

VA 3The statement provided here is pretty standard and represents the first limitation to the scope of the investigation; complexity limits inspector ability.  Yet, who made the VAMC so complex, the VA.  Who has allowed the complexity to grow as designed incompetence, the VA? Why is the VA allowed to cheat their inspector general through complex operations which limit inspector ability and increase patient risk?

The Focus of Inspection (Investigation Scope):

      • The VA-OIG team looks at leadership and organizational risks, and at the time of the inspection, focused on the following additional areas:

WhyLong have I wondered why the second item in the comprehensive inspection is “Quality, Safety, and Value.”  When the VA continues to present the bare minimum of quality, disregards patient safety, and due to complexity, offers less value than a broken wrench to a mechanic, but I digress.

Finding One:  The VA-OIG issues 12 recommendations to the leadership team, and “selected results showed respondents were generally favorable the national VHA results.”  I have been accused of being cynical, which generally is wrong.  However, when I see words like “selected results” in an investigation into patient care and concerns, I have to ask, “How hard did the VA-OIG have to dig to find favorable results?”VA 3

Finding Two:  Strategic Analytics for Improvement and Learning (SAIL) represents a value model to help define performance expectations within VA.  This is the standard language for comprehensive inspections.  “In individual interviews, the executive leadership team members were able to speak in-depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences.”  If we accept this as a true statement.  How was an employee able to fake documents, fail to clean reusable equipment properly, and repeatedly get away with this abysmal behavior at this VA?

VA 3Finding Three:  Under Quality, Safety, and Value, we find the following tidbit:

The VA-OIG noted concerns with protected peer reviews, utilization management, and root cause analyses.”

Essentially meaning there are problems with whistleblowers, privacy protection, retaliation against whistleblowers, proper utilization of policies and procedures, and the leadership could not find a problem using root cause analysis if their lives depended upon it.  The source for my interpretation of the VA-OIG results arrives from the following:

VHA Directive 1117, Utilization Management Program, 8 October 2020. Utilization management involves the assessment of the “appropriateness, medical necessity, and the efficiency of health care services, according to evidence-based criteria” [emphasis in the original report].

I have to ask the VA-OIG whether these findings were before or after the employee who endangered patient lives through improper cleaning and sterilization of reusable medical equipment were discovered?

VA 3Finding Four:  Under medication management, we find the following:

The VA-OIG team observed compliance with many elements of expected performance, including pain screening, aberrant behavior risk assessment, and documented justification for concurrent therapy with benzodiazepines. However, the VA-OIG identified opportunities for improvement with urine drug testing, informed consent, patient follow-up after therapy initiation, and quality measure monitoring” [emphasis mine].

VaccineIf you read any of the comprehensive inspection reports, you will see this is a common and recurring theme at the VA.  Some of the medication policies are being followed, but the same problem with drug testing, informed consent, patient follow-up, and quality measuring monitoring always remain a problem.  It is almost as if the SAIL learning matrices do not even exist as a quality improvement tool.

Finding Five:  Under High-Risk Processes, the VA-OIG report claims the following:

The medical center met the requirements for quality assurance monitoring and monthly continuing education. However, the VA-OIG identified deficiencies with standard operating procedures, an airflow directional device, and staff training and competency” [emphasis mine].

Are the SAIL metrics even accurate?  Where is the value in the “monthly training and monitoring if there are issues in following standard operating procedures, problems in staff training, as well as staff competency?  Do you get it?  The training sucks at the VA, and the SAIL metrics do nothing to fix the problem, address the deficiencies, or even improve competency?  The same question arises here, from quality, safety, and value; how was an employee able to successfully pencil-whip the paperwork while not doing their job in properly cleaning and sterilizing reusable medical equipment?  Where are the SAIL documents that should have identified a problem?  Where are the SAIL metrics in aiding in finding root causes for derelict employees?VA 3

Honestly, do you, the taxpayer, consider the Department of Veterans Affairs, which covers the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries adequate to remember the veteran correctly?  Do you, the taxpayer find value in the leadership and investigative arms of the VA to correct and improve performance?  Do you, the taxpayer find that the VA employees are doing their level best to honor, remember, and pass on the legacy of veterans?

Image - Eagle & FlagOn this Memorial Day weekend, please consider the data in this and the other VA-OIG reports regularly relayed on this blog, and ask yourself, are you doing enough to help veterans?  I love Memorial Day, and I love my country, but America has some serious problems, and only when the electorate awakens to the issues can real change begin to be implemented.  We, the veteran community, need you!  We need your voice as we struggle against the incessant attacks from the VA.  We need your votes for the elected representative’s intent on scrutinizing the government and demanding action.  We need you!  Please help us!

© 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: The Leadership at the VA Continues to Shame Themselves!!!

Bird of PreyI do not believe in coincidences, I just started reporting the VA leadership as being the problem at the VA; the Department of Veterans Affairs – Office of Inspector General (VA-OIG) finally appears to be blaming Department of Veterans Affairs (VA) leadership.  In my inbox are two VA-OIG reports where the facilities’ leadership is being called out for the detestable behavior they continue to exhibit!  In one of the VA-OIG reports, please do not allow the “YUCK!” factor to distract from the problems at hand in the VA Leadership refusing to do the jobs they have been hired to perform!

        1. Bradley Lane Croft, the owner of Universal K-9 Inc. in San Antonio, Texas, was sentenced to nearly 10 years of imprisonment for scheming to defraud the federal government of more than $1.5 million in GI Bill benefits to train service canines and their handlers. In addition to the prison term, Croft pays approximately $1.5 million in restitution.”

November 2019, Judge Ezra found Croft guilty on eight counts of wire fraud, four counts of aggravated identity theft, two counts of money laundering, and two counts of making a false tax return.  Testimony during trial revealed that beginning in 2015, Croft provided false information in applications to the Texas Veterans Commission, including instructors’ names, certifications and training documents to receive GI Bill educational benefit payments.”

VA 3If you have access to more details, please share.  This story did not make a ripple in the news, and I want to know why!  Worse, who at the VA lost their jobs, lost their retirement package, or were sanctioned for allowing this fraud to occur?  2015-2018, three years of deception, where the VA leadership and lower-level employees were supposed to investigate and research documents submitted before awarding contracts?  The court records read like this was an IRS audit for fraudulent tax filing that discovered the school fraud of GI Bill benefits.  The VA never knew until the IRS alerted them.  Hence, I ask again, where was the VA in properly executing its duties to protect the government and the taxpayer from fraud?

      1. During a comprehensive healthcare inspection (virtual) of the Aleda E. Lutz VAMC in Saginaw, Michigan, the VA-OIG was pretty vanilla, except for the following. “Selected employee satisfaction survey results indicated opportunities for the Associate Director for Patient Care Services to improve workplace perceptions and for the Chief of Staff to support an environment where employees felt less moral distress” [emphasis mine].

VA 3Now, I have never personally been a patient in this VAMC or one of its clinics.  However, “moral distress” is a pretty universal phrase meaning that employees feel pressure to commit immoral activities.  The actual term “moral distress” is found in an “All Employee Survey,” where the employees stated that they felt pressured to commit an immoral activity at least once per day.

In the past year, how often did you experience moral distress at work (i.e., you were unsure about the right thing to do or could not carry out what you believed to be the right thing)?”

If an employee feels anywhere between 1.0 and 1.7 times (on average) a day they are being pressured to commit immoral activities, surely this should raise some eyebrows and a lot of questions about the propriety of the leadership team.  Did the VA-OIG take a sample of employees and gather quantitative data on exact actions employees feel they are pressured to commit?  If so, why is the conclusion bereft of actionable items for leadership to take?  If not, why not?  Employees claiming pressure to act in an immoral manner are a significant risk to any business organization.  The VA is already on record for having inferior to worthless administrators; now the veterans and the taxpayers get to know the Aleda E. Lutz VAMC and its clinics have morality issue problems.  Nobody in the VA leadership at the Federal or VISN level cares!

        1. The VA-OIG conducted a review to assess aspects of the care provided to a patient who was struck and killed by a motor vehicle following elopement from a community living center (CLC). The patient suffered from paranoid schizophrenia and was involuntarily civilly committed to the CLC.”

Administrative failures began the day the patient was admitted to the CLC, as discovered by the VA-OIG, “… the patient’s admission to the CLC was inappropriate as indicated by the CLC’s own screening process.”  Added to these concerns, the VA-OIG expressed the following concerns, “… regarding the appropriateness of CLC admission and elopement prevention.”

The OIG determined that interventions implemented by staff were inadequate to mitigate the patient’s risk for elopement. The patient eloped multiple times, and facility staff failed to provide individualized, progressive, mental health-driven interventions to prevent the patient from eloping. The OIG also found that facility staff assigned to care for the patient were inadequately trained in mental health care, and patient safety reports were not completed as required.”

On the day of the patient’s death, the OIG found that facility staff did not follow missing patient procedures after the patient eloped. Facility staff failed to detect that the patient was missing for nearly three hours, and once the patient was noted as missing, facility staff failed to follow policy to locate the patient. In addition, the OIG found that facility leaders did not ensure the facility had a missing patient prevention policy or that staff completed annual missing patient training. The OIG expressed concern that the CLC may not have been utilized as intended, given the lack of mental health standards applicable to CLCs and the complex mental health needs of this patient.”

VA 3Take a minute, imagine you are a family member of this patient.  How are you going to feel when you see the consistent and ongoing problems with the facility?  How helpless would you feel knowing that your family member was missing for hours before it became known to staff this patient, with a history of elopement, was gone?  How frustrated would you be with the administration when you read this report and see that from Day 1 admissions, this CLC was inadequate to the task of seeing to this patient’s needs?  Now, do you understand why I, as a veteran, become so aggravated and upset with the lack of leadership at the VA?  These are my brothers and sisters in arms, and they are being abused and killed by the VA’s lack of leadership.  The only recourse we have is to try and share these horrible tales with our fellow citizens in the hopes of improving the political leadership, to demand change of the executive branch’s VA leadership!  Another needless death at the hands of the VA leadership!

Let me preface this final story a little.  First, if you have a weak stomach, feel free to skip this next story.  Second, an endoscope is an illuminated optical, typically slender, and tubular instrument (a type of borescope) used to look deep into the body and used in procedures called an endoscopy.  Endoscopes are considered reusable medical equipment, and special training and procedures are required to clean and sterilize these scopes properly.  Third, an endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inserted directly into the organ.  Again, if you have a weak stomach, feel free to skip the rest of this article.

      1. Let us travel to the Chillicothe VAMC in Ohio, where we find the VA-OIG with “concerns” over “… responses by facility leaders to a Sterile Processing Services (SPS) employee’s failure to follow endoscope reprocessing [cleaning and sterilization] procedures.” The VA-OIG report stresses the following, “… the VA-OIG also identified concerns related to actions taken by Veteran Health Administration (VHA) leaders.”  Thus, we have one (1) employee and several VHA leaders from the local to the VISN whose actions are at best “questionable” in the cleaning and sterilization processes for an endoscope.

Three separate and similar complaints were raised at this facility for this exact issue!

“… VA-OIG investigations substantiated that the employee did not follow facility reprocessing procedures and falsely documented compliance. The VA-OIG determined that the Facility Director did not develop and implement an adequate plan to monitor the employee’s compliance with SPS procedures following reinstatement to SPS duty, particularly given concerns regarding the employee’s integrity and compliance. Because multiple patients were potentially affected, facility and VISN leaders notified the VHA Clinical Episode Review Team (CERT) for review and disposition. The CERT concluded there was minimal risk to patients and that a large-scale disclosure was not warranted; however, the VA-OIG found that the CERT’s determination may have been based on an inaccurate understanding of the reprocessing equipment’s capabilities” [emphasis mine].

VA 3Here is the other side to this problem. This is not the first time or first facility having problems with employees failing to reprocess medically reusable equipment, refusing to document correctly, or risk patient complications from dirty medical equipment!  This is not the first time the CERT team has made the wrong decision not to warn the patients involved; they might have been put at risk by dirty medical equipment!  The last episode involved colonoscopy equipment, and it was not that long ago I was writing about that incident!  YUCK!!!

Why was the employee not immediately fired for falsification of official documents?  Why did the facility’s and VISN separate investigations not see the directors of patient safety and hospital director fired for failure to perform their jobs?  The Chillicothe VAMC’s entire leadership should be fired in disgrace over this incident.

PACT 1While a patient in the VA Hospital here in Phoenix, I was in a clinic where a mother was trying to gather sufficient records to hold the VA accountable for her son’s permanent disability from sepsis.  The veteran caught sepsis when improperly cleaned scopes were used during a gall bladder removal surgery.  Her son, the veteran, spent 9-months in and out of non-VA hospitals; she had pictures of his bruised and swollen abdomen from the doctors trying to treat the sepsis and keep the veteran alive!  I have no idea whether this mother was successful or not getting the VA to cover the medical expenses and increase her son’s disability.  I only know I never saw her at the VA again, and the VA Police shadowed her as she moved from clinic to clinic, gathering records.  I do not know why records release could not release the proper documents to save this mother the hassle of visiting individual clinics.  I do know I can still see this veteran in the photos his mom showed me, and my blood continues to boil!  Yet, the CERT team asserts that mass notification is not needed in these situations; I demand to know why they can make this decision!

ApathyThe leadership at the VISN levels and the individual hospital levels is sick, inadequate, and desperately in need of a complete replacement to end the culture of corruption found inside the VA.  When employees record moral distress, this should be an automatic red flag, alerting the VISN leaders poor leadership practices are happening, but the VISN never does anything!  Failure of this magnitude would have gotten any non-VA hospital or clinic shuttered and class-action malpractice lawsuits launched.  Yet, when the VA gets caught, the media cannot even be bothered to report on the problem in the local news.  Maximum endurance has been breached, and these administrator problems need immediate attention from the politicians!

Dont Tread On MeHence, I will ask you, dear reader, to please share these VA articles far and wide.  Action is needed before the next veteran to die unnecessarily is a friend or family member of yours!

© 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.