Moral Distress IS a Leadership Problem – More Shameful VA Chronicles!

Survived the VAA surprise occurred in this week’s Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports; the Boise VAMC in Idaho performed well in their comprehensive healthcare inspection (CHIp).  Even though 10 recommendations were left, the VAMC as a whole is performing above average, with no significant complaints found by the VA-OIG.  Congratulations to the Boise VAMC!

VA 3Let me stress something; leadership is the reason why a VA Healthcare System (VAHCS) or VA Medical Center (VAMC) performs well or poorly!  Yet, too often, the leadership IS the root cause of the problems in a VAHCS or VAMC.  The Boise VAMC just proved this point precisely; are any Department of Veterans Affairs (VA) leaders in Washington DC paying any attention?

The VA-OIG performed a CHIp in Portland VAHCS and found moral distress in the employees, again!  This means that the Eastern end of the state is receiving better care than the western end of Oregon State!  Yet another VAHCS or VAMC with employees feeling morally distressed by the commands and directives of their leadership in how they treat veteran patients!  The VA-OIG report makes everything sound like rainbows and lollipops at the Portland VAHCS, but if employees feel “morally distressed,” there are problems, just not those included in the CHIp scope!VA 3

Where problems outside the scope of an investigation are concerned, the following is GREAT NEWS!

Robert Seifert, 63, of Utica, New York, pleaded guilty to making telephonic threats to Albany Stratton VA Medical Center employees. Seifert, who has been convicted twice before of threatening VA employees, admitted that on 14 January 2021, he made three calls to employees for no reason other than to harass and threaten them.”

I am going to repeat it, only for emphasis, “Leave the families out of your anger!”  Never, EVER, attack, threaten, or speak against the families.  They are OFF LIMITS!  I become very frustrated with the VA Leadership, but violence is not the answer, and threatening families is repulsive and counterproductive!  Seifert is scheduled for sentencing on 06 October 2021; may the judge throw the book at him, for this is his third conviction for threatening families of VA Employees.VA 3

On the topic of frustrating leadership who need to lose their jobs and reimburse the government for all wages, the following VA-OIG report is the epitome of failed leadership in action!

The VA’s Office of National Veterans Sports Programs and Special Events (NVSPSE) granted $47 million to organizations with experience in managing adaptive sports programs from fiscal year (FY) 2017 to FY 2020. … The VA-OIG found that the NVSPSE was not effectively managing the program.  The NVSPSE’s director had not established adequate internal controls, including developing standard operating procedures for managing adaptive sports grants.  As a result, the NVSPSE could not effectively evaluate risks from grant recipients, did not reimburse some recipients’ expenses on time, did not always close out grants on time, and did not appropriately authorize extensions for using funds.  By not closing out grants on time, the NVSPSE failed to free up about $346,000 that could have been used for other purposes.  It also improperly allowed recipients to spend $328,000 in FY 2017 appropriations outside the approved period and improperly reimbursed 19 recipients a total of about $247,000.”

The VA-OIG recognizes that these failures to audit and control the adaptive sports program properly potentially violate both the Purpose Statute and the Antideficiency Act, federal laws with direct consequences for Federal Employees.  I am taking bets.  Will anything come out of the director being referred to the lawyers; I doubt any action will ever be taken!  That’s not just my cynicism speaking; that is the experience in watching directors at the VA skate accountability and responsibility better than gold-winning Olympic figure skaters.VA 3

In reporting the following VA-OIG report, do not rationalize that every suicidal person will eventually find a way or means to commit suicide.  I ask you do not think this for two reasons: one, it is a lie lazy people tell themselves to disregard the act; two, helping people with suicide ideation is not cut and dried textbook medicine. Assisting people with suicide ideation takes time, effort, getting to know the person, and a lot of interlocking care from professionals.

“The patient, who was over 70 years old at the time of death, had diagnoses that included post-traumatic stress disorder and major depression. After approximately 15 years of care at a California VA facility, the patient transferred care to the Las Vegas facility in summer 2019. The VA-OIG substantiated that the patient died by suicide from a VA resident mental health clinic on the day of dischargeThe emergency department social worker documented an incomplete comprehensive evaluation. The suicide prevention team did not assign the patient a high risk for suicide patient record flag despite the patient’s stressors and history of suicide behaviors. Staff did not adequately assess the patient’s substance use, incorporate relevant history into the treatment plan, or address the patient’s change in demeanor and concerning statements. The discharge safety plan had not been modified for approximately eight months despite significant life changes. Leaders had not established a mental health treatment coordinator (MHTC) policy. Staff assigned the patient an MHTC at the patient’s tenth visit and four MHTCs over nine months. Staff did not coordinate care with a geropsychologist, with whom the patient had nine appointments. Leaders did not effectively address the patient’s expressed complaints. The VA-OIG substantiated that leaders did not conduct an institutional disclosure” [emphasis mine].

The last sentence is the dead giveaway that the leadership knew there were problems and designed processes intentionally to have an excuse when a patient died!  This veteran was suffering to a great degree, and I hope that with his passing, his family and friends can find peace in the knowledge that the veteran is now pain-free.  But, the VA leadership should be held legally responsible for this death, they failed this patient, and the world is worse for the veteran’s passing.VA 3

Suicides are hard on family, friends, communities; suicides at any age are the ultimate declaration that failure occurred, the pain was missed, and the medical community and support systems failed.  Survivors often feel a great degree of guilt and carry that guilt to their graves.  But, when medical providers go out of their way to hide the problems, refusing to document, and declare, it means that the medical community had written the patient off as too costly to save.  Who speaks for the loss of intelligence and potential of the failed patient; I do!I-Care

I will continue to speak to the failures of the VA to provide the care they promised, and demand leaders are held accountable and responsible.  This was preventable, and the leadership must be held accountable if the system is to be changed!  This veteran did not have to die by his own hand, and the medical community at the VA in Southern Nevada HCS, located in Las Vegas, should be ashamed!

Follow this link if you would like to see a recap, with links, to the shenanigans reported by the VA-OIG in June.  June 2021 has been a month of incredible and horrendous behavior documented by the VA-OIG of the leadership failures at the VA.  The elected leaders of America either need to begin scrutinizing the VA more closely or vacate office.  There is no excuse for the continued irrational and detestable behavior at the VA.VA 3

The last two items are testimony recorded before a Senate and a House of Representatives Committee.  Statement of deputy inspector general David Case Office of Inspector General, Department of Veterans Affairs before the US Senate Committee on veterans’ affairs hearing on VA electronic health records: modernization and the path ahead 14 July 2021Statement of Leigh Ann Searight deputy assistant inspector general for audits and evaluations Department of Veterans Affairs – Office of Inspector General before the subcommittee on oversight and investigations committee on Veterans’ Affairs US House of Representatives hearing on modernizing the VA police force: Ensuring accountability 13 July 2021.  Frankly, both statements are pure vanilla because the subcommittees refused to act, which was known before making the statement and the hearings.  Hence, why should the VA-OIG prepare action plans if the Senate and House will not take action?

Knowledge Check!Repeating, only for emphasis, “Until the US Legislative Branch will do their jobs, and scrutinize the Executive Branch with the intent to demand accountability, no single government agency will ever change.”  Want to help veterans?  Contact your elected representatives and send them these articles, demanding they take action in support of legislation and scrutinization, demanding accountability and responsibility of government employees who are currently active in refusing to change!  Want to help veterans?  Share these stories far and wide.  Everyone should know what the VA is doing and realize that every government agency from the city to the President is employing tactics to steal liberty, rob freedom, and murder veterans!

© 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.

August VA-OIG Updates: More SHAMEFUL VA Conduct.

I-CareDue to personal issues with the Department of Veterans Affairs (VA), specifically the Carl T. Hayden VA Medical Center (VAMC) in Phoenix, AZ I fell a little behind in June/July/August of 2020.  As I work to clear the backlog of completed Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports from August, please keep in mind solutions to these problems are available. The failure of leadership to be held accountable, by the elected officials is staggering, and the lack of accountability and responsibility boggles the mind.  Without exception, I know the VA can be improved, developed, and saved.

August 2020 begins with an individual employee making a decision regarding healthcare decisions for a veteran at the Robley Rex VAMC in Louisville, Kentucky.  The VA has a process where individuals can be allowed to be surrogate decision-makers for a veteran who needs additional assistance.  This process works is legal and is a great tool for family and friends of veterans to play a significant role in the healthcare process of the veteran.  In this instance, the process failed, not because the process was bad, but because people did not do their jobs properly.

The VA-OIG assessed an allegation that providers permitted an individual with no legal authority to make medical decisions on behalf of a patient, and a host of other patient rights were trampled as documented.  “The patient experienced a three-week medical and mental health hospitalization with repeated episodes of confusion, agitation, and combative behavior. The patient was transferred to hospice care and died five days later.  The VA-OIG found that facility staff did not take the required appropriate steps to identify and confirm the eligibility of this surrogate.  The VA-OIG determined records did not contain sufficient documentation of physicians’ clinical assessments to support diagnoses and treatment decisions. Clinical communication and collaboration were inconsistent, insufficient, and negatively impacted the patient’s continuity and quality of care. Providers did not consistently document medication monitoring and oversight activities to ensure safe patient care. The patient’s transfer to hospice was completed without fully pursuing other diagnoses and treatment options and staff did not ensure the patient’s rights were upheld regarding involuntary admission and behavioral restraints. Facility leaders did not complete a thorough quality of care review to understand the reasons for the patient’s atypical hospital course and outcome” [Emphasis Mine].

Many times, the VA-OIG reports do not clarify all root causes due to employee privacy; however, from the report, the employees who repeatedly allowed the neighbor to make healthcare decisions were exceeding their legal bounds and made decisions that harmed the patient.  This veteran died and from the report, it is clear the veteran died confused, possibly due to medication changes, and the family was not notified in a timely manner because the neighbor, without legal and written authority, was allowed to make healthcare decisions for the veteran, even though there was written healthcare directives on file for a family member to make these decisions.  Utterly shameful behavior!

PatriotismThe Veteran Integrated Service Network (VISN), is a geographical grouping of VA Healthcare Systems, e.g. hospitals and clinics, under a combined leadership plan.  One of the tools the VA-OIG uses to monitor the quality of patient care inside VISN’s is called a “Comprehensive Healthcare Inspection Program (CHIP).  CHIP covers selected clinical and administrative processes all of which are deemed consistent with promoting quality patient care.  The CHIP occurs on a rotational 3-year periodicity and the focus is shifted slightly each 3-year cycle to, theoretically, encompass all administrative processes over time.  The VA reports the following are the specific areas that lead to quality patient care through administrative practices:

  1. Quality, safety, and value;
  2. Medical staff privileging;
  3. The environment of care;
  4. Medication management (specifically the controlled substances inspection program);
  5. Mental health (focusing on military sexual trauma follow-up and staff training);
  6. Geriatric care (spotlighting antidepressant use for elderly veterans);
  7. Women’s health (particularly abnormal cervical pathology result notification and follow-up); and
  8. High-risk processes (specifically the emergency department and urgent care center operations and management).

All of which is mentioned as an explanation providing details for the following VA-OIG inspection reports of CHIP received in August 2020.  A total of seven CHIP reports were received in August recording performance from inspections carried out.  These reports, while somewhat individualized for the specific VAHCS, reads like a carbon copy.  Repeatedly written procedures for standard operation are missing, staff training is inadequate or antiquated, risk analysis is not able to be competently and correctly conducted, patient safety issues abound, and the proper utilization of management processes remains glaring!

Root Cause AnalysisThe CHIP reports are so repetitive in nature, the VA-OIG recommendations are grouped, conveniently, into the eight administrative areas listed above.  According to proper management techniques, the VA-OIG then “encourages” the leadership team to select one or two areas for improvement and focus their efforts on leading change in those areas.  For example, if the VAHCS wants to improve in risk analysis, the leaders can begin by promoting training on properly conducting risk analysis online, hold meetings to review risk analysis procedures and begin to train and develop staff on improving n this area.

However, here is where reality meets theory, without written standard operating procedures risk analysis cannot be completed properly.  The bureaucracy protects itself and will thwart the implementation of written standard operating procedures as this removes designed incompetence that keeps the bureaucrat in power at the VA.  Thus, the root cause of improving root cause analysis is the lack of written procedures that measure performance against a single written standard.

CHIP Report after CHIP Report the same issues arise, are noted, recommendations from the VA-OIG are documented, and the same response is supplied; this represents the epitome of designed incompetence and the root of the problem the VA is facing.  Recommendations for improvement have been repeatedly provided and change can occur; but, not without dedicated leadership, not management, to thwart the bureaucratic quagmire that the VA has fallen into.

Leadership CartoonAnother regular entry on the CHIP reports is the following: “Employee satisfaction scores revealed opportunities for the Associate Director for Patient Care Services to improve employee attitudes towards senior leaders.”  Here is the problem, how many of the “senior leaders” are less than managers, promoted beyond their maximum level of incompetence, solely because they were the next warm body in line; too many!  When staff training is a repeated issue on CHIP reports, one must ask how employees are being measured?  Where are the written scorecards that reflect a process that was used to measure employee performance fairly and equitably?  Was the employee trained on how to perform their role according to the standards published?  Do the scorecards reflect that all employees have been trained, measured, and reported equally?

Guess what, since staff training remains a consistent problem, the staff leaders are the problem!  A major part of “Quality, Safety, and Value” is “Leadership and Organizational Risks.”  A lack of training in properly, timely, and correctly performing one’s role as hired is both a leadership and an organizational risk.  Failing to train employees is the absolute worst comment a leader should be informed of by a third-party inspection team.  Yet, the training of staff is consistently the root cause after a lack of standardized operating procedures.  Every mid-level supervisor, trainer, manager, director, etc. titled individual at the VA should be embarrassed when told their staff is untrained; but, it appears these same leaders do not care!

The Duty of AmericansHow can a person draw the conclusions that the VA appears to not care about improvement, or that the lack of caring is rampant across the entire VA structure; look no further than the site visit VA-OIG inspection report of the Department of Veterans Affairs – Veterans Benefits Administration (VBA).  The deputy undersecretary for field operations expected regional office managers to be aware of issues raised in other regional office site visit reports, but there was no written policy for addressing frequently identified errors.  So, the mid-level regional office managers must be told to investigate internal websites to gather lessons learned and apply those lessons in their regional offices.  What an incredibly inept excuse; shameful conduct by a senior leader, and how much worse does this attitude become as it filters down to the troops?  The behavior that claims a new policy is needed to improve performance is utterly bereft of logic and demonstrates the lackadaisical attitude being discussed.  Then these same leaders wonder why their staff is disengaged, disconnected, and distrusting of leadership; unbelievable!

One of the first lessons I learned in becoming a business professional was, “If you have to write your ethics down, you have already lost.”  The VA policies on ethics, ethical conduct, and ethical behavior are voluminous, trying to cover every detail, every loophole, every issue, and mostly the VA-OIG reports on ethical breaches reflect individual poor judgment at best, and designed incompetence at worst.  Yet, still, the VA tries to implement ethics without a source, moral behavior without a purpose, and the individual employee is left with plenty of excuses for not behaving in a properly ethical manner.  This is the topic of another article; but it must be made clear here and now, ethical lapses continue to abound at the VA.  From the nurse not giving drugs to patients and selling the drugs on the street, to hospital directors not disclosing what appears to be a conflict of interest, the VA remains afloat on a sea of ethical violations.

The remaining reports in August reflected an investigation that the VA-OIG was unable to substantiate due to a lack of reports filed in a timely and proper manner.  More designed incompetence on the part of the VA.  Also included in these final reports were more repetitions of issues discussed where staff training was the root cause for ethical violations, failure to properly perform duties as hired, and staff training was the problem with adherence and compliance issues.

The disconnect is obvious, and the direction forward is clear.  Hospital Directors, write the standard operating procedures, using the resources of how the work is performed currently as the baseline.  Then begin correcting and amending the written procedures over the following year to improve performance to a written standard.  Once the written standard is completed, e.g. the baseline, begin training of staff.  You cannot measure individual performance without standards, and standards cannot be followed without written operating procedures for conducting business.

Behavior-Change© Copyright 2020 – M. Dave Salisbury

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