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.

Society Needs the Family – Knowing the Paradigms That Shape American Society

School of DarknessA colleague said I should read a book, “The School of Darkness,” by Bella V. Dodd.  As an immigrant in the early 1900s, the book is discussing coming to America, losing one’s belief structure with its tenets, traditions, and ties that bind, and discovering the emptiness of society, which tried desperately to replace the family and religion.  The author only discovers this emptiness and the need for family and religion after a lifetime of fighting against the influence.

The ideal family, found in many cultures, religions, and communities across the world is of one father, loving one mother, and raising children in what is called a nuclear family.  Early in the 1900s, the families with close ties as a family, who kept the traditions of religion, found in America plentiful opportunities and made strong the American Society.  Those nuclear families without strong ties to a belief structure weakened American Society, but not in ways or methods cognizant at the time, and only understood through historical observation and dissection.Nuclear Family

Consider, for a moment, James Hardy’s writings (2015) on divorce in America; in the Colony of Massachusetts Bay, there was created a judicial tribunal that solely settled divorce matters in 1629. “This legislative body could grant divorces based on adultery, desertion, bigamy and in many cases impotence. In the North, the colonies adopted their own approaches that made divorce available, whereas the southern colonies did all they could to prevent the act even if they did have legislation in place.”  Notice the distinction between North and South that was apparent in pre-Revolutionary and Civil War society supporting both conclusions needed for a strong community, family, and a common religious belief structure.

Fast forward to 2020, and the current divorce rate is 2.9:1000 reporting from 45 states and the District of Columbia.  With the medium marriage lasting 11 years and falling, and around 30% of marriages suffering disruptions leading to divorce.  The future of the nuclear family in America remains grim, unless fundamental changes in, and desires of, people change; America is soon to disappear.  The American Civil War taught this lesson well, the need for strong families, based upon a core belief structure that lifts the human mind from pettiness, selfishness, and authoritarianism, remains the two keys an individual will control to keep the American Republic safe from enemies foreign and domestic.

Role of ReligionWhich religions lift the soul, I do not speculate; however, I can tell how you can tell.  The answer is the same from generation to generation, first know yourself.  Second, research the religion’s works.  Finally, seek religions that bring light to the world sickened mind.  I have known great and good people in all the different sects of religion in this world.  The key I have found comes in living the religion, not just professing that religion.  As one lives that religion the tenets of that religion will either inspire, uplift, edify, and grow the spirit and the soul, or it is time to find a new religious structure.  Regardless, before the traditions of religion, the traditions of the family must be understood and cemented together.

Religion QuoteThe Jewish religious tenets are deeply respected by this author for the blend of family and religion that is born from the belief structure.  Some Catholic tenets speak to the same family and religious mixture, several Christian religions also speak to this mixture of home-based family-centered religion.  The Muslim faith tends to support a community based around the mosque, and not as much on the individual family.  The religious foundations and actions of The Church of JESUS CHRIST of Latter-Day Saints are very like the Jewish religious beliefs, the Amish, Quakers, Dutch Calvinists, and more who also carry a strong family first, religion second, approach to building strong communities through strong religious traditions, by first focusing upon the family and home-based religious practices, building into strong religious communities, and then to strong and morally upright citizens.  Yet, I have witnessed the same in Atheist communities, where the beliefs of non-belief led to strong families asking questions, seeking truth and developing the person through strong familial bonds.

Building a child, with strong familial bonds, which will then build a community, a state, and a country, is the work of two parents in a nuclear family.  But what supports the parents in the difficult job of rearing children, the local community and the extended family are helpful and needful, but most important traditions of belief.  Dodd in, her book, reflects this lesson as she taught freshmen in college, generally from tearing the student from improperly rooted belief structures and transplanting them into the heady and hedonistic thoughts of social families replacing nuclear families, shucking religious traditions in the process.

Religion Quote 2Why is Communism doomed; because it attempts to replace the family with the government.  Why is Socialism doomed; it expands the power of government until the government becomes Communist and tries to replace the family with the government.  Why has Capitalism been such a breath of fresh air to the world through the American Republic; because it leaves the family alone from the fingers of government intrusion.  Government intrusion, which chokes the agency of man for the mind control of the government.  Fascism was doomed to failure, for it worked hard to replace the family with social groups, social families, and corroded the human spirit until nothing but violence and rage remained.  Does this sound familiar; it should, for this is the same path being used in education in 2020, learned in the early 1900s, and dedicated to the eradication of America through slow corrosion.

Religious ThoughtAs an older child in a large family, with a large extended family, I once asked, “Why do we gather as an extended family with all the expense, the work, the travel, the hard feelings, etc.?”  The answer never made sense to me then, and makes less sense now; yet, there is a truth in the answer that is more felt than understood, “We do it for family.”  In the movie “Fiddler on the Roof,” Tevye sings about “Tradition” and how familial and religious tradition extends into confidence and strength for the individual to understand who they are in society, and by extension in a country.

From the nuclear family comes confidence in knowing one’s self.  Does this mean that non-nuclear families are inferior; no!  It simply means there is a larger role for extended families and the community to render assistance.  Yet, the extended family and community cannot replace or render invalid the responsibilities of the parents.

Consider two families.  Family A loses their father as the oldest is just entering high school, the youngest daughter is just barely 18-months.  The mother is left to raise the family having married her high school sweetheart.  Family B is a product of divorce, the mother has custody of the children, and she and her new boyfriend work two jobs apiece, leaving the children to fend for themselves except when the grandparents can “take the kids.”  Family A the children continue to heal from their father’s abrupt passing and are strong in family and faith.  Family B the children have no roots, and they struggle with the religion of the parents and grandparents.  They struggle because their mother has no religious connections due to both employment and lifestyle choices.  The children are good kids, but they are confused, and the person who could settle their confusion, has abdicated the responsibility, and the grandparents can only do so much as partial parent replacements.  While the extended families and communities surrounding both families help and support as they can, the lack of parental responsibility and awareness of the mother in Family B, and the awareness and devotion in Family A, makes all the difference between these two families.

ReligionsHaving traveled across America for the last 25years, and ¾’s of the way around the world, I have a few observations that can strengthen the family.  I share the following as a warning, for if the family is not supported, the actions seen by the domestic terrorists in recent days, as evidenced by the riotings and lootings will only grow until America is lost forever.

  1. How much is enough? America is a capitalist and materialistic country; yet, for all that, there remains much good in America worth preserving.  Answering this simple question determines where standards, limits, and lines are drawn.  For example, how much sports watching is enough?  How much money is enough?
  2. We sacrifice for that which we love. It is a simple axiom, but the truth in a simple sentence.  Do we sacrifice that which is good for the better?  Do we sacrifice that which is better for the more desirable right now?  Do we sacrifice the best in us to fill an appetite?  Consider Family B, the mother chooses to never marry again and remains quite vocal about her decision; but, what is the cost for the sacrifice and the consequences of the decision?  Of her children, the first two are girls, who are confused.  Her young son struggles between the men of her mother’s life setting an example, and what he sees of his grandfather’s life and social circle.
  3. Social societies cannot replace the family. Social prominence cannot, and never will, fill the emptiness at the end of life.  My wife played for the funeral of a man who was politically well known, so much in fact, that the governor of AZ came to the man’s funeral, as well as many in the AZ State Legislature.  A couple of mayors of Phoenix were in attendance, some people with ambitions for federally elected posts were in attendance, and more.  Yet, I wonder today, 5years after his passing, if these same people remember the man.  My wife is still in touch with his wife, but I cannot help but wonder regarding this man’s children and grandchildren.
  4. Allow religious belief systems to change you personally, and your family collectively, through living a religious and moral centered life. President Adams, in discussing the US Constitution stated, “Our Constitution was made only for a moral and religious people. It is wholly inadequate to the government of any other.”  Look from the 1900s to 2020 and one inescapable fact emerges, the loss of the nuclear family has led to a degeneration of social values, morals, ethics, and people.  While the law has attempted to curb this dilemma, President Adams’ quote becomes ever more applicable.  America was founded upon a Judeo-Christian foundation of philosophies and the loss of religion is tearing America apart at its foundational core.

Martin Luther King in discussing individuals and society, morals, and religion, stated the following, “… you have got to change the heart and you cannot change the heart through legislation. You cannot legislate morals. The job must be done through education and religion.”  While the rest of the quote goes onto try and validate the opposite, Rev. King has a point, the law can only go so far in dictating behavior, legislating morals, and decreeing standards.  Without a moral and religious society, America has nothing, is nothing, and falls a failed experiment in improving the human condition.

moral-valuesAmerica needs strong families, which possess a core of religious traditions, practiced in the home, and acted upon in society.  The days of allowing truancy due to race, the communist teachings in schools and the lies that society can replace the family must be fought and won by families informed.  America can survive the current attacks but needs every citizen fighting for the survival of this set of ideals embodied in the US Constitution.  We need morality and religion to return as the core that motivates people to action for America to survive.  It is possible to win against the forces arrayed against America domestically and foreign, but we need nuclear families, and those families need a religious core; there is no other way.

© 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/