Congressional Mandate – DNC-Consulting

Scrutinize the Executive Branch – The Charge for the Legislative Branch: Part 1

In what has become typical and usual, the following stories arrive:

“From 2019 to 2021, Ira Westbrook of Bozeman, Montana, served as the fiduciary of an elderly relative who had suffered a stroke and became disabled. A multi-agency investigation found that, during these 16 months, Westbrook stole more than $57,000 in Social Security and VA benefits and used the stolen funds to purchase personal items, including a Jeep Wrangler, a travel trailer, and other day-to-day expenses.”

“From 2016 until 2018, Sloane Signal-Debose of Slidell, Louisiana, served as the fiduciary of a veteran who needed assistance managing his finances. During that time, she took more than $100,000 from the veteran’s accounts, used it as the down payment on a home in her name, and used additional funds from the veteran to pay contractors working on the home. Signal-Debose then submitted false records to VA to hide her misuse of the veteran’s funds. The former fiduciary pleaded guilty to misappropriating funds and faces up to five years in federal prison. The VA OIG conducted this investigation.”

“In 2013, Brandi Goldman of Jonesboro, Arkansas, was married to a US Army reservist who suffered a severe traumatic brain injury in a service-connected accident. As a result of this injury, her husband had many serious physical challenges, and Goldman was appointed as his guardian and fiduciary. Between April 2015 and November 2017, Goldman received more than $258,600 in VA disability payments and $36,000 in Social Security payments. During that timeframe, she withdrew close to $200,000 in cash and accrued about $900 in ATM and overdraft fees. Goldman admitted to spending much cash to fund her methamphetamine habit, spending $150 on methamphetamine two to three times per week. She also admitted that five other people moved into the residence with her and her husband, none of whom paid rent or contributed to expenses, some of whom she regularly gave cash to. She also admitted to paying $68,000 in cash for another home, furnishings for the home, multiple vehicles, and a motor home. Goldman was sentenced to 20 months in prison, three years of supervised release, and $143,000 in restitution after previously pleading guilty to misappropriation by a fiduciary. The VA OIG and Social Security Administration OIG conducted the investigation.”

Why are these stories of particular interest to the supreme legislative body in the United States of America? The executive branch has refused to police its branch of government, and crimes like this have become all too familiar. You, the Congressional bodies of these the United States, are duty-bound and sworn to perform two jobs, scrutinize the executive branch (harshly when necessary), and write laws. You have recently failed too often in monitoring the executive branch, and this story perfectly represents what happens when the executive branch is not examined minutely! Tell the US Public who put you in elected office, how these crimes continue and what programs and processes they MUST change to prevent them in the future.

By pleading for the legislative branch to scrutinize and audit the executive branch minutely, I am in no way condoning or diminishing the personal accountability of those who committed crimes. These three examples are from the October and November press releases of 2022. The widespread ability to commit fraud is a symptom of a more significant problem at the VA. Their leaders have consistently been able to boondoggle, evade, and profit from abusing veterans through designed incompetence, criminal neglect, and obtuse actions. When will Congressional leaders take action to clean up the Federal Government in general and the VA specifically?

The US House of Representatives holds the purse strings for the executive branch; use this leverage to claw back your powers and authority to balance the Federal Government and demand accountability from those empowered to lead their designated branches of the executive branch of government. Let’s talk about patterns; in less than 45 days, three cases of fiduciary fraud were closed, and the speed of closing these cases has escalated throughout 2022. The American people will see more, not less, of these fraudsters being underreported by the US Media before the year ends.

Shifting slightly, let’s talk about government employees and the need for more scrutiny of the executive branch.

“Bruce Minor, of Philadelphia, Pennsylvania, was sentenced to two years in prison, three years of supervised release, and ordered to pay $462,256 in restitution for his scheme to embezzle money from the Philadelphia VA Medical Center. Between December 2015 and September 2019, Minor, a former travel clerk, created fraudulent travel reimbursement claims in the names of at least three other VA medical center employees. He then diverted the funds into bank accounts he controlled. The VA OIG investigated this case.”

“Kyhati Undavia, of Houston, Texas, was sentenced to 27 months in federal prison after previously pleading guilty to conspiracy to commit healthcare fraud. From December 2012 to December 2018, Undavia hired employees to market Memorial Pharmacy, which she controlled and operated, to physicians as a place to submit compounded drug prescriptions. Instead of providing prescriptions directly to the patients who could select a pharmacy of their choice, physicians sent the prescriptions directly to Memorial Pharmacy. Then, Undavia paid the physicians illegal kickbacks for the prescriptions. Beneficiaries often received medicated creams that they did not need or want. Undavia received approximately $22 million from TRICARE, Department of Labor Office of Workers’ Compensation Programs, and CHAMPVA for the prescriptions.”

These stories also fall into the same timeframe mentioned above. But, they are not the only stories from 2022 where VA employees conducted long-term fraud for personal profit. Here’s the rub: hundreds of additional employees knew of these schemes, were probably running their schemes, and haven’t been caught, and nothing is being done by VA leadership to cease the fraud and abuse of veterans by VA employees. There is a culture of corruption at the VA, long hidden by scheming and abusive leaders and condoned by previous Congresses, that must be stopped! What will you, the congressional leaders of the United States, do to halt this insanity, demand personal accountability, and clean house of the designed incompetence that allows these criminal activities to flourish? The American People are waiting!

The following site holds press releases for the VA specifically, but investigations often cross into Social Security, the Department of Defense, state investigatory bodies, the FBI, and more. Suppose nothing else is learned from only perusing this site, that more scrutiny needs to be done to every single department of the executive branch. In that case, we, the American People, might count ourselves lucky. However, this is not the case. The rot from poor leadership, criminal mismanagement, and supreme dereliction of duty is etched deeply into the workings of the executive branch operations, and more needs additional discussion.

03 November 2022, the VA-OIG released a report titled, “VHA Progressed in the Follow-Up of Canceled Appointments during the Pandemic but Could Use Additional Oversight Metrics.” The report only covers the time from 2020 to the present, and regular readers know that the VA has been failing on every measurable metric for over a decade. To couch in politically correct non-threatening jargon, how designed incompetence continues to hamper and hinder is not surprising. That the current Congress has bought the excuses hook, line, and sinker, from the inept VA leadership, was not surprising either. This article is about the future, and the next Congress MUST take immediate and direct action to root cause and improve VA performance!

31 October 2022, the VA-OIG released the following: “Review of VA’s Staffing and Vacancy Reporting under the MISSION Act of 2018.” This is a report about how the VA continues failing to report improvements in hiring practices to the legislative branch. The report details VA leadership’s continued failures through designed incompetence. Tell me, if you were in charge of a report for your business that is essential to receiving funding, would you keep your job if, from 2018 to the present, you still cannot report what is happening and why and be held personally accountable for a report to a legislative body? Don’t take my word for it; read the report, and be careful of the temperature of your blood boiling!

Unfortunately, this behavior is the normal operating procedure for the VA. The same can be easily and quickly witnessed in every other Federal Department of the US Government under the executive branch. As the legislative branch, you are duty-bound to investigate and demand compliance in a timely manner. Where have you been; more importantly, will you allow these problems to continue or kill them?

Do you doubt designed incompetence is a standard operating procedure? Let’s discuss another part of the MISSION Act of 2018 that the VA-OIG recently reported on, “Additional Actions Needed to Fully Implement and Assess Impact of the Patient Referral Coordination Initiative,” dated 27 October 2022. The Referral Coordination Initiative (RCI) is a program to improve timely access to care using community providers. RCI sounds good in theory, but as usual, in the practical application, the program is full of self-serving charlatans, unsupervised or poorly supervised people, weak policies and procedures, and zero accountability! Plus, when the veteran runs into problems with local providers, reporting these problems is so time-consuming as to be ineffectual at best!

A personal example that was reported to the VA when it happened, and nothing was done but to issue the provider a check. Dr. Herekar, Neurologist, clinic: Advanced Neurology Epilepsy & Sleep Center, El Paso, Texas. A VA Primary Care Provider wrote to my employer on VA Letterhead with a wet signature, declaring my inability to wear a mask. Dr. Herekar’s office was presented with this letter and hassled me before both appointments for not wearing a mask, becoming hostile, argumentative, and a nuisance over the mask issue, even after I complied with putting on a face shield. 23 September 2021, over Facebook messenger, I was informed that I would be invited to find a different provider due to my refusal to wear a mask. Imagine that; Facebook Messenger became the medium of choice for ending a patient’s relationship with a medical provider. What did the VA tell me to do; file endless paperwork with TRICARE and then disregard the problem’s urgency. Worse, the medical care for the neurological issues decreased, and I have had to wait, sit, and hope for future consideration and possible treatment. Does this sound like an aberration; it is, unfortunately not!

The VA Leadership realized if community care succeeds, they lose power to control the destiny of veterans. Thus, they implemented the MISSION Act of 2018 with such feet dragging, designing incompetence into every facet of the program, to promote more complaints to Congress, and hopefully to squash the MISSION Act of 2018 and end community care. 07 November 2022, while waiting to speak to representatives of Community Care Services at the VA Out Patient Clinic in EL Paso, the veteran being served ahead of me was told, “The provider does not fax documents, so you will need to go to the provider, and then walk the paperwork back to us.”

The normalcy of reporting providers not submitting paperwork was beyond the pale. Not having secure document transfer processes between the VA and local providers is technically abysmal and unacceptable. Are we in the 1990s, where the cream of technology is sending and receiving a fax? The designed incompetence includes Luddite-like technical disciplines, and the VA_OIG and the Congress should be furious; I know I am!

Before the MISSION Act of 2018, I was making 5 and 6 trips to local providers to retrieve hard copies of medical records, going to the VA Records office, submitting the documents, and then following up 7-14 days later to find out I had to repeat this process as my VA Providers still had not received the records of my interactions with community providers. Interestingly, in 2020 I discovered the treatment records still had not been submitted from community providers into my VA eHealth Record, from treatment received from 2012-2016. Is the pattern of designed incompetence clearer? Is the VA Leadeship’s intransigence more apparent? How about the fraud, waste, and abuse of VA resources?

You, the congressional leaders, must take immediate action, not wait, not hold hearings, concrete action to demand compliance from the executive branch leaders to the congressional leaders who are held accountable to the citizens. America is a representative republic, and it is time the bureaucrats learned the citizens are awake and interested. You, the congressional leaders, are the people’s tool for correcting government abuses; you have two years to show you are dedicated to that principle, or you will be replaced!

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images. Quoted materials remain the property of the original author.

The Coffin Where Comedy Goes to Die – More VA Chronicles

I-Care Consider something with me: if you need to proactively reach out to a customer using a phone, would you call that customer’s or his spouse’s phone? Customer service is all about the customer experience; in an effort to provide customer support, do you call a customer’s or their spouse’s phone? The answer is obvious, yet the EL Paso VA Outpatient Clinic did the exact opposite of common sense, even though the customer had, within two previous hours, called the EL Paso VA OPC using his phone number on record.

Earlier in the week, a face-to-face patient appointment had to be changed to a VA Video Connect (VVC) appointment, and the provider never showed up. Later blaming the patient for not showing up to their appointment, even though the patient was online 15 minutes early to the VVC and every 30-minutes logged back into the VVC as the provider never showed. They are eventually blaming the patient for failing to communicate with the clinic. Facts essential to know, at 0200 of the morning of the appointment which the provider’s nurse had responded to. At 0900, the call center changed the in-person appointment to a VVC after contacting the provider for permission to change the appointment to VVC. VA 3

Irony remains critical to comedic gold; the irony of the Department of Veterans Affairs (VA) is the issues discussed above are how veterans are abused daily, and the bureaucrats running the VA do not realize how ironic the designed incompetence has become. Unfortunately, irony died, and comedy is being sealed into its coffin at the VA. Veterans are being abused to death, and I can no longer laugh at this ineptitude!

Atlanta VA, as reported by Military.com, 73-year-old Vietnam veteran Phillip Webb is filmed receiving hits and kicks from a VA Employee. The VA Employee, Lawrence Gaillard Jr., a patient advocate at the VA outpatient clinic in downtown Atlanta, was arrested and charged on April 28 for allegedly assaulting and suspended without pay. There is nothing to laugh at with this event. While this event remains under criminal investigation, the abuse at the VA towards veterans from the bureaucrats has not scratched the surface! Where are the Congressional leaders in demanding change at the VA? VA 3

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) has spent another month reporting on investigations of more malfeasance, misfeasance, and designed incompetence masquerading as bureaucratic inertia. If your job included the safe handling and storing of medicines, would you be motivated to properly refrigerate the medication, especially if it meant keeping your job? In January 2019, the VA reported a loss of over $1 million due to improperly stored medication, e.g., refrigerated. In 2019, the VA was told to improve their safe handling and storing of medicines to prevent additional losses. 2021 more than $1.5 million was lost for the same reason, improperly refrigerated medication. 2022 the VA-OIG has concluded that the VA has done nothing to improve the medication losses.

If we use the annual loss, rounding down to $1 Million, and then presume this has been going on since 2000, we have the potential for a loss of around $20 million. The Federal Government is always going on about Fraud, Waste, and Abuse, curbing these losses and reporting them. Will some congressional elected leader please tell me why Congress refuses to act to stop fraud, waste, and abuse? The full report is nothing but fraud, waste, and abuse, and while the VA-OIG suggests the VA has taken “some steps” to improve the potential of losses, more needs to be done; yet, where is Congress? Where is the VA Leadership in fixing the problem?

Regarding medication, let’s talk about how prescriptions continue to be delayed and shipped in wrong doses forcing the patient to cut and presume how much meets their needs and prescription level. Let’s discuss how the providers continue to play games with medications, especially the pain management medications, using the erroneous excuse, “Fighting the opioid crisis.” I know the political talking points; what I do not know is how these blatant excuses continue to possess traction. VA 3

The Albuquerque VAMC is back in the news due to the continued failure of leadership; why you ask is the Albuquerque VAMC in the VA-OIG reports, they are failing to help in the opioid crisis by delaying the delivery of medication. From the report, we find the following:

“The OIG substantiated that pharmacists declined early refills of buprenorphine despite prescribing providers’ documented clinical rationales, which increased patients’ risk for adverse clinical outcomes associated with interruption of buprenorphine treatment. The OIG substantiated that justification for declining early refills was incorrectly based on a facility policy that was not applicable to the use of buprenorphine for the treatment of opioid use disorder [emphasis mine].”

Did you get the why? Leadership at the VAMC is beyond subpar, has been failing the veterans of Albuquerque, and is protected by the ridiculously inept leaders at VISN 22, as documented multiple times over the last five years. Yet, still, nothing is done to remove the leaders, stop the abuse, and fix the problems; thus, I ask again, why? Where are the elected leaders in scrutinizing the executive branch? Even the VA-OIG has reported, “actions taken by leaders did not fully address the reported concerns.” If this is not a perfect definition of designing incompetence, I’ll eat my hat! VA 3

The VA-OIG’s recommendations reflect the inadequacy of the VA-OIG to demand change and then enforce corrective action effectively. More designed incompetence and the crosshairs are clearly on the executive and legislative branches to act. This means that you, the voter, have the power to demand change!

Dare you think the Albuquerque VAMC is the only VA having problems? The VA-OIG reports the VAMC in Hampton, Virginia is also back in the news. Consider the patient and the family in the following, “… multiple providers’ failure[d] to communicate, act on, and document abnormal test results from July 2019 until April 2021, when the patient was diagnosed with metastatic prostate cancer.” More failure of VA leaders to act, and “… facility leaders did not initiate peer reviews within three days, and facility staff did not submit patient safety reports as required.” Where is the outrage that another veteran is needlessly suffering, the family is needlessly struggling, and the VA Leaders keep their jobs? VA 3

We began this chronicle with a Vietnam Veteran being beaten and kicked by a VA employee who was employed to defend patients, where leaders did not act upon the incident for two months, leading to questions and concerns about the potential cover-up, hushing of witnesses, or manipulation of evidence to hide, what for all intents and purposes appears to be, employee criminal activity. While the attacker retains their constitutional right to innocence until proven guilty, significant questions need immediate redress, and the VAMC leadership needs to answer these questions.

Continuing on the failure of leadership, the Tuscaloosa VAMC in Alabama shows more leadership failure to address patients’ safety and security in long-term care. The VA-OIG identified that the administration could not fill critical staff positions, possibly due to the toxic nature of the leadership. One of the more critical failures of leadership deals with the elopement of patients from the care facility, and the leaders appear to remain inadequate to improve the facility and patient safety. Why are these leaders still in positions of power in this facility? VA 3

As an organizational psychologist, the continued failure of leadership represents a real and present danger. The VA-OIG appears to be aiding and abetting the absence of leadership at the VA. If you think I am exaggerating, consider the continued failure to comply with the payment integrity information act (PIIA). The VA was failing to comply before PIIA, and the following from the VA-OIG report is telling:

“In FY 2021, VA reported improper and unknown payment estimates totaling $5.12 billion for seven programs and activities. Of that amount, about $1.97 billion (around 39 percent) represented a monetary loss. The remaining approximately $3.14 billion (about 61 percent) was considered either a nonmonetary loss or unknown payment that cannot be recovered. Though VA had an overall decrease in total improper payments and unknown payments, the overall monetary loss more than doubled from $892 million in FY 2020 to $1.97 billion [emphasis mine].”

PIIA was legislated and put into effect in March 2020, FY 2021 is the first year, and the investigative reports represent the VA’s inaugural failure to comply. All facts are desperately pertinent in this report and necessary to understand just how ridiculously inept the VA leadership continues to act. 10% of $5.12 Billion is $512 Million; the VA leadership from the VA-OIG is “encouraged” to become compliant and lose less than $512 Million in FY 2022. Tell me how “encouraging” your leadership will be losing that much money?

From the VA-OIG Report, “VA satisfied nine of the 10 requirements; however, it is not considered to be compliant because it failed to report an improper and unknown payment rate of less than 10 percent.” PIIA was legislated to reduce improper payments to less than 10%; tell me, if you improperly paid someone $512 Million, would you keep your job? Never forget, every Federal Government facility must have posted a poster discussing how to Report Fraud, Waste, and Abuse; what do you call losing $512 Million? Would someone please explain why losing less than $512 Million is an improvement? How is losing less than 10% acceptable and not Fraud, Waste, and Abuse or credible accounting? VA 3

Finally, we conclude with additional reports of criminal enterprises by VA employees, as if anyone is surprised:

“Bethann Kierczak of Southgate, Michigan, a registered nurse at the John D. Dingell VA Medical Center in Detroit, pleaded guilty to charges related to COVID-19 vaccination record cards fraud. According to court records, Kierczak admitted to stealing or embezzling authentic COVID-19 vaccination record cards from the VA hospital—along with vaccine lot numbers necessary to make the cards appear legitimate—and then reselling those cards and information to individuals within the metro Detroit community. Kierczak began the scheme as early as May 2021 and continued through September 2021, selling the cards for $150 to $200 each. The VA OIG investigated this case with the VA Police and the Medicare Fraud Strike Force, a partnership among the Criminal Division, US Attorney’s Offices, and the US Health and Human Services OIG.”
“Melissa Flores was sentenced to two years in prison and $110,000 in restitution for her role in a scheme to defraud VA. Flores and a codefendant allegedly created aliases and obtained or created fraudulent documents to make it appear they were the heirs of various individuals who had died. Between 2013 and 2019, the two codefendants defrauded VA out of more than $430,000 and the Michigan Department of Treasury out of more than $40,000 in unclaimed property. Flores pleaded guilty to two counts of false pretenses last May and one count of forgery.”
“Bruce Minor of Philadelphia, Pennsylvania, pleaded guilty in connection with his scheme to embezzle money from his former employer, the Philadelphia VA Medical Center. In April 2022, Minor was charged with theft of government funds stemming from his theft of more than $487,000 in VA travel reimbursement funds, which he helped administer as part of his official duties as a travel clerk. To perpetuate the theft, Minor created fraudulent travel reimbursement claims in the names of at least three other VA employees and then diverted the fraudulently obtained funds into bank accounts he controlled. According to court documents, in an email to medical center management, Minor admitted to stealing approximately $13,000 in travel funds. However, a subsequent investigation showed that he stole upwards of $487,000 between December 2015 and September 2019. The VA OIG conducted this investigation.”

Patriotism What connects all three of these criminals; the failures of VA leadership to scrutinize their employees. Does this remind you of additional leaders, maybe those in Congress who continue to refuse to scrutinize the executive branch? The US Constitution established three co-equal branches, the judicial protects the Constitution, the Executive operates the government, and the Legislative has two jobs write laws for the executive branch to operate and scrutinize the executive branch as it operates. Each branch answers to the other, and all branches must operate inside the US Constitution. America needs the legislative branch to begin doing its job, and we, the voters, are the only way to begin demanding the change we need! ?u=https1.bp.blogspot.com-aqaqk18MHoEWRHHsCi_TyIAAAAAAAAAXc7hY4JQuyylIQHYudoR8sbezGZntic4SSwCLcBs640Betrayal2BSayings2Band2BQuotes2Bwww.mostphrases.blogspot.be.jpg&f=1&nofb=1

If comedy is dead, and it is, the VA is the coffin where comedy went to die. Let’s stop laughing and start acting! Join me?

NO MORE BS: Have You Heard? Chapter 2

Question The first week of June is often a period of recovery. I have no idea why, but the first week of June is usually a recovery time. Maybe it was all those years in school; I honestly do not know. However, the world does not stop, and while the media goes 24/7 over the Memorial Day Gun Violence, stories are evolving that need your attention more. I do not say this lightly, as I understand those wounded and killed in gun violence are tragedies and cause for grief, but the corporate media has always used these “major stories” to allow other things to slip past.

Why Have you heard Dr. Fauci’s emails from while he was a name in President Trump’s councils reflect a different story than the lies he peddled for political purposes? “The emails from the first half of 2020 reveal Fauci’s skepticism early on about masks to ward off COVID-19, his dismissal of the notion that the new coronavirus escaped a lab in China, and his vague reference to researching how to make the virus deadlier.” Why is this spineless invertebrate still a media mouthpiece, a paragon of dirty virtues and political connections? Fauci’s research from 1990 through 2020 was in Coronaviruses, and he still hyped, pushed, and peddled lies to obtain a political payoff. Knowing masks were useless, he pushed lies. Knowing the survival rate, he still pushed draconian government takeovers of liberty, freedom, and common sense. Knowing he could orchestrate a catastrophe, he pushed lies to initiate a public health emergency and stood back to reap the windfall in the chaos created. Of all the government officials with hands in the pot stirring the government mandates, I blame Fauci more than others!

Have you heard the Federal Government remains hell bound and down on destroying the family but is explicitly targeting black families? Would a minority please help explain why under a Republican President, the Federal Government’s actions are racist, but under a Democratic President, the same actions are “beneficial, needful, helpful, and not in any way demeaning?” Frankly, I do not care about the race factor; the fact that the US Government, from the Mayor and School Board to the President, seems bound and determined to destroy the foundation of society, the nuclear family, remains highly suspect and needs to be investigated! Ever since the US Government stole State’s Rights where Welfare Programs were concerned, the family has been directly targeted. Look at any race, and you will see the same hit in the data, where families went from working to be self-sufficient to the government dole. Unfortunately, black families have suffered some of the worst impacts. Now we are three generations into the destruction of the family as a government program, and I want answers!

Have you heard, the data is inescapable, the conclusions self-fulfilling, and the results are incredible. When you want more economic freedoms, which lead to more overall liberties, it is best to start by ending corruption in government. Who would ever believe that economic freedoms lead to individual liberty, and the best place to start is reducing government? I am absolutely… nonplussed! The founding fathers of The United States of America, a Free Republic (if we can keep it), understood these connections intimately and established the US Constitution to provide future generations the best chance of keeping the American Republic. So, who would like to start firing and cutting government? I am first in line; join me! Plato 3

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) released a report on 02 June 2021, detailing crimes so horrific and obscene, I can find no appropriate adjectives to describe this negligence and criminality of all administration leaders involved. January 2021, Dr. Robert Levy, who was a pathologist, who over his 12-year tenure at the VA Hospital in Fayetteville, Arkansas, made over 3000 diagnostic errors, manipulated the quality control process, and caused severe injury to 34 patients, received 20-years in what can only be called a “plea deal” that should never have been allowed! The good doctor admitted to long-term alcohol use. Now, will someone please hold the leadership teams accountable for this doctor’s behavior? This story makes me especially sick! Where are the politicians who were elected (hired) to scrutinize the government? Where are the “Blue-Ribbon Congressional Committees” to hold those accountable and responsible for 34 veterans severely injured over the actions of a VA provider? Who will speak for the victims and demand, then oversee and insist upon corrective actions by an executive branch of the government through the work of the legislative and judicial branches of government? VA 3

I was an operations manager, the safety of my workers was my paramount responsibility, and I could be held legally accountable for what happened on my manufacturing floor. I had two people go for lunch, lifting 40oz curls, and returned to work for the afternoon soused! I had to shut down my manufacturing facility, I had to keep these two from driving away, I had to call in the temporary employment agency to collect these gentlemen, and they could not have their keys back, for as soon as they returned to work in an alcoholic stupor, I was responsible under the bartender law. This incident still brings some emotional baggage and resentment at these two morons. How in the world was the good doctor able to be alcoholically impaired on the job, and nobody was aware? Impossible! Where is the accountability of the leaders in this situation? I could have been jailed for allowing employees to operate their vehicle under the influence; when will the administration be held responsible for allowing a drunk employee to operate a vehicle? Read the VA-OIG report; it is a criminal list of what not to do from day one of this doctor’s employment! Plato 2

Have you heard, the Department of Veterans Affairs (VA) killed a veteran in the emergency department of the Malcom Randall VAMC in Gainesville, Florida. Worse, the veteran should never have died, and the reason they did was due to inefficiency, inadequate care, and processes and procedures in the emergency department triage of patients. The patient had experienced hemicolectomy surgery, and between days 10 and 15 post-op recovery, he went to two outside ER’s and the VAMC ER, where he passed. Drunk employees for 12-years are abysmal, fail to recognize patient distress, delay care, and cling desperately to outdated and inefficient processes in patient care in an emergency room, are execrable, horrific, and so vile to have exceeded repugnant! VA 3

Again, one must ask, where are the elected officials in pushing changes to the VA Administration; Oh, I know where they are; they are trying to kill history and remove President Lincoln’s mission statement for the Department for Veterans Affairs. We need to understand priorities: Is a veteran’s life more important than being woke and having a small group of citizens begging for less sexism, who are always going to choose to be aggrieved, be satisfied for a small amount of time? I know what my priority is, and it has nothing to do with the permanently dissatisfied and everything with saving lives and honoring patients who deserve the honor!

Knowledge Check! I implore you to please join your voice to mine, and let’s remember Memorial Day 2022 as the day marking how in 2021 we changed the VA, we limited the government, and seized our liberties and freedoms, as the founding fathers intended! We can make a difference in the government, provided we band together without the petty names and distinctions currently being used to separate and divide. We, the American Citizens, deserve better from the government we pay for, even if we must use every legal tool in our arsenal to cull the politicians and take the freedoms they have stolen.

© 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.

Department of Veterans Affairs Chronicles of Shame

I-Care As a veteran who struggles with post-traumatic stress disorder (PTSD), stemming from military sexual trauma (MST), where a first-class petty officer jumped on my back and tried to rape me. When I see the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports on PTSD from MST, I pay close attention. Since the Department of Veterans Affairs (VA) continues to deny my MST claim because MST does not happen to men, I get agitated when I see these VA-OIG reports repeating year-over-year with the same excuses and designed incompetence. Designed incompetence is all about creating ready-made excuses for failing to perform correctly the role one has been hired or promoted to perform. Consider the following:

“In 2018, the VA Office of Inspector General (OIG) reported that nearly half of disability benefit claims that were denied service connection for post-traumatic stress disorder (PTSD) and were related to military sexual trauma were not processed properly.”

That is the first sentence of the VA-OIG report released on 08 December 2020 declaring that the improvements suggested by the VA-OIG in 2018 had not occurred. The following statistics come directly from the report issued.

- - 18,300 claims or approximately 16% were processed incorrectly in Fiscal Year 2019
  - 118,000 claims were submitted

Why were the claims processed incorrectly; because of designed incompetence by the Department of Veterans Affairs – Veterans Benefits Administration (VBA). From the report, we find the following five root causes, or excuses: emphasis mine.

1. Most errors occurred because claims processors did not verify or ask veterans to provide the disorder’s cause, known as an in-service stressor.
2. In other cases, claims processors did not request a medical examination, medical opinion, or clarification of inconsistencies in the examination as required.
3. Claims processors made these errors because they did not fully understand PTSD stressor types and the stressor verification process.
4. VBA’s Compensation Service did not mandate any national training for claims processors on these subjects except during the first year in the position.
5. In addition, VBA’s procedures manual was not effectively organized to allow staff to locate this information and lacked specific guidance for some aspects of PTSD claim processing.

VA Seal Why are the causes of the problems considered designed incompetence, because they never change! At the VBA, the processors all need constant training to remain current in their positions; but never receive the training. The VBA never holds value-added training sufficient to train the employees on their jobs, but this remains the number one excuse to justify poor performance in VA-OIG inspections. Failure to perform the job is also not a new excuse, where the VA-OIG reports are concerned. Not understanding how to ask for help is also not new, and frankly astounds and mystifies observers that those hired remain employed when their performance clearly remains insufficient to the job expectations. While it is unique to the VA to see a procedure manual, it is only natural and expected that the manual is poorly organized, poorly executed, hard to follow, difficult to find, and generally useless. The VA is famous for this designed incompetence trick.

You say, “Big Deal;” everyone knows the VA is messed up, full of failures, and is generally known for poor performance. Why this is a “Big Deal” stems primarily from the costs associated with poor performance. An annual salary is paid for the processors, the adjudicator, and the entire chain of command, totaling in the hundreds of millions of dollars. The veteran has to pay for lawyers and other services to appeal the original decisions, which take time. The veteran has to pay for a third-party Nexus Letter to accompany the claim to declare the original claim was faulty. All of this requires substantial time investments and other resources, all because the original work has to be duplicated. How many times the claim is duplicated depends upon the processors’ abilities to do the job they were hired to perform.

Your car breaks down; the tow truck driver only secures your vehicle 84% before driving to the auto repair facility, is this satisfactory performance? Your surgeon has an 84% success rate where his patients will live after surgery for tonsil removal, is this satisfactory performance? You are in hospital; your nurse only gets your pain medication to you 84% of the time or is only 84% accurate in providing the right patient the proper medication; is this satisfactory performance? Of course not, but for government employees, this level of performance is “award-winning.”

Military Crests Congress mandates VBA claim error rates; there is supposed to be a quality assurance check to reduce the error rates. Yet, with all the checks, the balances, and the quality assurance programs, the VBA continues to surpass the error rates and physically harms veterans due to their inefficiencies. Yes; a failure rate of 16% is a “Big Deal!”

Want to know how bad the VA is managing your taxpayer monies; read the audit released 14 December 2020. In that audit, you will find comments like the following:

- - The material weakness involving information technology security controls has been reported for more than 10 years.
  - VA did not substantially comply with federal financial management systems requirements and the United States Standard General Ledger at the transaction level, as required by the Federal Financial Management Improvement Act.
  - [The] VA’s complex, disjointed, and legacy financial management system architecture no longer supports stringent and demanding financial management and reporting requirements.
  - VA continued to be challenged [with] consistently enforcing established policies and procedures throughout its geographically dispersed portfolio of outdated applications and systems.

In light of the recent computer hacking issues the Federal Government is experiencing, knowing that the VA has dumped hundreds of millions of taxpayer dollars to patch and repair, and sometimes replace (sort of), legacy (old, expired, useless, insecure, unreliable, etc.) technology over the last 20-years, how is the VA able to keep getting away with these designed incompetence excuses? Congress, when will you hold the administrator’s feet to the fire for making progress on these glaring issues? Congress receives these VA-OIG reports and audits before they are made public, yet the elected representatives cannot take a moment to check this poor behavior. Why not?

Police and Government Lines of Congruence For the first time in more than a decade of chronicling the VA-OIG reports, I am mentioning a monthly highlight (lowlight) condensed report. This report is unique due to the insanity of criminal investigations mentioned, the results of audits, and the healthcare inspections. When you have 18 defendants in a bribery scheme, where 15 plead guilty, who defrauded untold Millions of dollars in Florida, the problem is not so much with the employees, but the organization that allowed this to occur since 2009! A noteworthy criminal investigation indeed.

The highlights (lowlights) of November 2020 also include a VA physician from West Virginia being indicted for abusive sexual contact and simple assault and a surgical supervisor in Northern Ohio who defrauded the VAMC of approximately $3.2 Million in two separate schemes. Regarding financial audits and the importance of improving that ancient technology, a VA Fiduciary has been indicted for misappropriating government funds from Pennsylvania to the tune of more than $155,000. Best of all, a husband and wife team from California, technical school owners, bilked the GI-Bill of more than $29 Million since 2015.

The criminal issues the VA is facing regularly are not a one-off issue, but an organizational design problem as the frauds, thefts, and malfeasance reported is ever only the very top 1% of the problem that is ongoing and systemic in the Department of Veterans Affairs! The November 2020 report discussed an incredible number of canceled patient appointments because veterans and COVID mask mandates do not play well together. Yet, the VA Federal Police cannot stop persecuting veterans for their physical inabilities to wear a mask.

Thus, where are the elected officials from the legislative bodies who possess oversight and funding responsibilities? Where is the executive branch of government in correcting and demanding specific action from the legislative branch? Where are the administrators at the Federal, VISN, and Local levels in performing their jobs? The designed incompetence must cease forthwith to allow for practical changes to be made and the organizational design to be corrected. For the VA-OIG to be forced to accept the same tired, lame, and detestable excuses, year-over-year is the epitome of abuse to the taxpayer and veteran alike!

The Duty of Americans Worst of all, this condensed version did not even scratch the surface of the issues reported in just three VA-OIG reports. Shame! Shame! Shame! Shame on the elected officials, Republican, Independent, and Democrat, who have allowed this problem to grow and done nothing! Shame on the myriad of presidents who have done nothing but throw good money after bad, without demanding progress and holding real people responsible for real results! Shame on every single VA employee who shirks their job for easiness to the pain and suffering of a veteran, dependent, or spouse!

© 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 images.
All rights reserved. For copies, reprints, or sharing, please contact through LinkedIn:
https://www.linkedin.com/in/davesalisbury/

Realities and Uncertainties – The Paradigm at the VA

I-Care The Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports they are returning to a more regular schedule of release for the inspection reports with the Department of Veterans Affairs (VA) recovering from COVID-19. Congratulations are in order, to the VA, as they begin returning to normal operations and procedures. The reality is that standard operating procedures (SOP) are regularly missing at the VA, this absence causes uncertainty, and forms the crux of this report. A question for the VA-OIG, “How can you assess employee competency without SOPs?” To the VA VISN leaders, “How can your directors and supervisors, conduct employee evaluations without written SOPs?” The short answer is you cannot!

Congratulations are in order, for the Marion VA Medical Center (VAMC) in Illinois. The Marion VAMC experienced a “comprehensive healthcare inspection” and were generally praised for the excellent work being conducted, the happiness of the patients, and the overall condition of the facilities. While there were recommendations made by the VA-OIG (29 in 8 different areas), the overall report was satisfactory, and this is mentionable. Hence, my heartfelt congratulations for your success in this inspection.

VA Seal The Marion VAMC VA-OIG report raises a common theme, and this is a reality the VA appears to be incapable of addressing training and two-directional communication. From the hospital director to the patient-facing staff, training always appears as a significant issue in VA operations. Having experienced the training provided by the VA for employees, and as an adult educator, I know the uselessness of the training program and have several suggestions. Perhaps the problem would be best addressed if more evidence was provided of a systemic failure in training employees at the VA.

In 2017 Congress mandated a change in research operations for the VA, specifically where canine research was concerned.

“The OIG found VHA conducted eight studies without the former or current Secretary’s direct approval, resulting in the unauthorized use of $393,606 in appropriated funds.VA continued research using canines after the passage of the funding restrictions, in part, because VHA executives perceived that then VA Secretary David Shulkin had approved the continuation of the studies before his departure.”

The cause of the problem, the VA-OIG discovered was, “Unclear communication, inadequate recordkeeping, and failure to ensure approval decisions were accurately recorded and verified all contributing to VHA’s noncompliance.” The researchers and executives relied upon two leading causes for not following regulations, designed incompetence, and a lack of training through clear and concise communications.

Congress mandated the documentation to assure approval was obtained before research commenced; yet, the researchers and administrative staff collectively failed to do their jobs and were able to hide behind the bureaucracy they established to excuse their poor behavior. Loopholes for designed incompetence and lack of training need closed; but, two incidents do not clearly illustrate the reality of the problem.

Problems The VA Southern Nevada Healthcare System in North Las Vegas, in response to a referral from the U.S. Office of Special Counsel (OSC), was investigated by the VA-OIG after a community healthcare worker was attacked. The VA-OIG findings are appalling, but the reasons for the problem are worse.

“The OIG determined that facility managers failed to timely respond after the social worker reported an assault during a home visit and did not address the social worker’s health needs after the assault. The social worker’s supervisor failed to immediately report the incident to the community and VA police. The facility’s policies lacked specific guidance regarding employee emotional and mental health injuries. Further, the OIG substantiated that the social worker was not informed by a supervisor of a homicidal threat, occurring subsequent to the assault, until two weeks after facility leaders became aware of the threat.”

The facility leaders knew there was a problem, yet did nothing before or after the event, that could have cost this healthcare worker their life! VA-OIG recommendations boil down to a need for clear communication and staff training. The recommendations highlighted another issue entirely that forms the reality and creates uncertainty at the VA, communication is not a two-directional opportunity to share information. Single directional communication is useless, and those leaders supporting the bureaucracy to only allow communication to flow in, need immediate removal from the VA. During my time at the VA as an employee on the front-lines, facing patients, I regularly experienced the lack of communication, and this issue is systemic to the entire VA as witnessed and observed at VA Medical Centers across the United States.

The Nevada incident is deplorable, reprehensible, and the potential for loss of life cannot be overlooked by VA leadership in Washington, at the VISN, or at the Medical Center any longer! The problems of communication cannot explain this incident, and failure for training cannot excuse this behavior! Since the OSC initiated the complaint, I am left to wonder, did the employee reporting this incident get fired and needed to appeal to the OSC for remediation? I ask because the knee-jerk reaction to problems at the VA is to fire the person reporting the issue, as previously observed and personally experienced, and as described to Congressional representatives during televised hearings. A more thorough investigation into causation needs to be concluded and reported to Congress for this incident reeks of politics and CYA.

Leadership Cartoon The Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri, and multiple outpatient clinics was recently provided a comprehensive healthcare inspection, and the leadership team provided 14 recommendations in 7 different areas for improvement. While congratulations are in order, for the patient scores, the employee scores, and the overall conditions discovered. Yet, again staff competency, e.g., training and communication, remain critical articles requiring targeted improvement. Is the pattern emerging discernable; in Nevada, an employee is assaulted and training and communication are blamed, comprehensive healthcare inspections are conducted in three different geographic areas and the same causation factors discovered; training and communication are systemically failing at the VA. But, the evidence continues.

The John J. Pershing VA Medical Center in Poplar Bluff, Missouri, recently underwent a comprehensive healthcare inspection. The VA-OIG issued 17 recommendations in 6 fundamental areas, including staff competency assessments, e.g., training and communication, as well as the inadequate written standard operating procedures. When discussing designed incompetence, the first step to correcting this problem is writing down the standards, operating methods, and procedures. Then the medical center leaders can begin training to those standards. Barring written instructions and published standards, employees are left to ask, “What is my job? and “How do I perform my job to a standard?”

The Oscar G. Johnson VA medical center, and multiple outpatient clinics in Michigan and Wisconsin recently underwent a comprehensive healthcare inspection, 11 recommendations in 3 critical areas. As did the Tomah VA Medical Center and multiple outpatient clinics in Wisconsin, 4 recommendations in 3 crucial areas. Both facilities are to be congratulated for their continual improvement and their success during the inspections. In case you were wondering, staff competency assessments, e.g. training and communication, are vital findings and variables in improving further for both facilities.

The VA has what it calls “S.A.I.L” metrics that form the core standard for performance. S.A.I.L. stands for Strategic Analytic (sic) for Improvement and Learning. Learning is a critical component in how the facility is measured and yet remains a constant theme in the struggles for improvement. Thus, not only is two-directional communication a systemic failure, but so is the poor training results found on all the comprehensive healthcare inspections performed by the VA-OIG. Poor communication almost cost a healthcare worker their life, and staff training was a key component for recovering from this incident in Nevada. How can the VA consistently fail at two-directional communication and training, designed incompetence? Those in charge require an excuse for not doing their jobs, and the most common excuse provided is a lack of training and poor communication.

I-Care It is time for these petulant and puerile excuses to be banished and extinguished. The following are suggestions to beginning to address the problems.

Easy listening is a musical style, not an action in communication. By this, it is meant that the VA needs to stop faking active listening and engage reflective listening. Reflective listening requires reaching a mutual understanding and is critical to two-directional communications. In the world of technology, not responding to email, not responding to text messages, and untimely responses to staff communication are inexcusable on the part of the leaders.
Staff training remains a core concept, but before staff can be properly and adequately trained, standards for performance, operational guidelines, and procedural actions must be clearly written down. The first question I asked upon hire was, “Where are the SOPs for this position?” I was told, “Do not mention SOPs as the director hates them and prefers to work without them.” Do you know why that director preferred to work at the VA without SOPs because she used it as an excuse to get out of trouble, to fire those she deemed trouble makers, and to escape with her pension and cushy job to another VA medical center? A repeatable pattern for poor leaders to spread their infamy. Shame on the VA Leaders for promoting this director to a level beyond her incompetence. Worse, shame on you for creating an environment where many like her have excelled and done damage to the VA reputation, mission, and patients, including killing them while they awaited care.
From the VA Secretary to the front-line patient-facing employee, cease accepting excuses. The private sector cannot hide behind immunity from litigation and act in a more responsible manner. Thus, the VA needs to benchmark what private hospitals do where staff training and SOP’s are concerned. Benchmark from the best and the worst hospitals for an average, then implement that average as the standard. One thing discovered in writing SOPs for the NMVAMC, the committee for approving SOPs, and the process for writing SOPs were so convoluted and time-intensive that the SOP was outdated by the time it could be implemented. Shame on you VA leadership for creating this environment!
Training should be an extension of an organizational effort and university. The VA is not properly training the next generation of leaders; thus, the problems multiply and exponentially grow from generation to generation. Launch the VA Learning University concept, staff that university with adult educators, and allow lessons learned from the university to trickle into operational excellence.
Form an independent tiger team in the VA Secretary’s Office who has the authority to travel anywhere in the VA System to conduct investigations with the ability to enact change and demand obeisance. The Nevada incident was a failure of leadership and needs a thorough reporting and cleansing of the bad actors who allowed that situation to occur. Worse, in my travels, I have heard many similar stories. I heard of a patient getting their ear chopped off when a veteran assaulted another veteran after becoming irate at waiting times in the VA ER. I have heard and witnessed multiple incidents of furniture being thrown, employees being assaulted, employees harassing and assaulting patients, staff property trashed, and so much more. These incidents need direct intervention and investigation by a party not affiliated with that affected VAMC and the leadership’s political policies.

04 October 2016, the VA-OIG released a report on dead veterans after the comprehensive investigation into the Carl T. Hayden VAMC in Phoenix, Arizona. The same event occurred in 2014, at the same hospital, with the same causes and the same conclusions. The core causes for the dead veterans, no written procedures, poor to no training, and reprehensible communication practices. The Phoenix VAMC went out of their way to fire all the employees who reported problems at the Phoenix VAMC before the veterans began dying in 2014, I can only speculate that the same occurred in 2016. Staff was frightened in 2014; they are demoralized in 2020. Nothing has changed at the Carl T. Hayden VAMC in Phoenix, Arizona, after two successive hospital directors, if anything the problems have worsened. The problems worsened because leadership failed to act, failed to write down SOPs, failed to communicate, and failed to train. The hospital directors since 2014 have been appointed from the same pool of candidates who created dead veterans in the first place, and that is a central failure of the VA Secretary and Congressionally elected representatives’ failure to act!

How many more veterans or staff must die before the VA is willing to act?

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.

https://www.linkedin.com/in/davesalisbury/

Tiger Teams – A Potential Solution to VA Issues: An Open Letter to Secretary Wilkie

I-Care To the Honorable Secretary Robert Wilkie
Department of Veterans Affairs
Washington D.C.

Dear Sir,

For almost a decade, I have read and studied the Department of Veterans Affairs (VA) from the position of patient, employee, concerned citizen, and now as an organizational psychologist. During this time, I have read many Department of Veterans Affairs – Office of Inspector General (VA-OIG) investigation reports, and yearned to be of fundamental assistance in improving the VA. I have an idea with potential for your consideration, “Tiger Teams.”

In the US Navy, we used “Tiger Teams” as “flying squads” of people, dedicated to a specific task, and able to complete work quickly. The teams included parts people, technicians, specialists, and carried the authority of competence and dedication to quickly fixing whatever had gone wrong during an evolution, an inspection, or even in regular operation. It is my belief that if your office employed a “Tiger Team” approach for speedy response, your job in fixing core problems the VA is experiencing would be easier. Please allow me to explain.

The VA-OIG recently released a report regarding deficiencies in nursing care and management in the Community Living Center (CLC) at the Coatesville VA Medical Center, Pennsylvania. The inspection team validated some complaints and were unable to validate all complaints because of poor complainant documentation. Having a Tiger Team able to dispatch from your office, carrying your authority, would provide expert guidance in rectifying the situation, monitoring the CLC, and updating you with knowledge needed to answer the legislator’s questions regarding what is happening. The VA-OIG found other issues in their investigation that were not covered under the scope of the investigation, leaving the VA-OIG in a difficult position. Hence, another reason for a Tiger Team being created, to back stop and support the VA-OIG in correcting issues found outside their investigatory scope.

Fishbone Diagram For a decade now, I have been reading how the VA-OIG makes recommendations, but where is the follow-up from the VA-OIG to determine if those recommendations are being followed and applied? Too often there is no return and report feature built into the VA-OIG investigation, as these investigators just do not have the time. Again, this is what a Tiger Team can be doing. Taking action, training leaders, building a better VA, monitoring and reporting, building holistic solutions, and being an extension of your office on the front lines. Essentially using the tools from your office to improve the operations locally, which builds trust between the patients and the care providers, building trust between the families and the VA, and delivering upon the Congressional mandate and VA Mission.

Another recent VA-OIG report also supports the need for a fast response Tiger Team. Coordination of care and employee satisfaction concerns at the Community Living Center (CLC), Loch Raven VA Medical Center, in Baltimore, Maryland. In geographic terms, this incident is in your backyard. While the VA-OIG inspection was rather inconclusive, and recommendations were made, it appears some things are working in this CLC and other things are not working as well as they should. By using a Tiger Team as a flying squad, intermittent and unannounced inspections by the Tiger Team can aid in discovering more than the VA-OIG could investigate, monitoring the situation, and reporting on progress made in improving performance.

As an employee, too often the director of HAS would claim, “That problem is too hard to fix because it requires too many people to come together and agree on the solution.” Or, “The solution is feasible, but not worth the effort to implement because it would require coordination.” Getting the doctors and nurses talking to and working with administration is a leadership role, providing support to leaders is one of the best tools a Tiger Team possesses one authority is delegated. The Tiger Team presents the data, presents different potential solutions, and the aids the leadership locally in implementation. As an employee I never found a problem in the VA that could not be resolved with a little attention, getting people to work together, and opening lines of communication. Thus, I know the VA can be fixed.

Root Cause Analysis The Tiger Teams need to be led by an organizational psychologist possessing a Ph.D. and a personal stake in seeing the VA improve. The organizational psychologist can build a team of like-minded people to be on the flying squad, and these team members should be subject matter experts in VA policies, procedures, and methods of operation, and should change from time to time. I have met many people from the VA who not only possess the passion, but are endowed with the knowledge of how to help the VA, and I would see the VA succeed. Yet, I am concerned that the VA is not changing, not growing, and not developing the processes and procedures needed to survive, and this is damaging the VA, which leads to wasted money and dead veterans.

Why not have a flying squad for each VISN, who can meet to benchmark, compare notes, and best practices. Who work from home and visit the local offices in the VISN, reporting directly to your office with a copy to the VISN leadership. Whose job is to build the Tiger teams needed to oversee, provide expert support, and practical analysis. The idea is to help you gather real time data, improve implementation of VA-OIG recommendations, and meet the demands of Congress. If a Tiger Team, with the functioning Flying Squad, can save one VA-OIG inspection in each VISN, by improving that VISN, medical center, CLC, etc. before it becomes a major problem on the sSix O’clock News, then the Tiger Teams have paid for themselves.

All veterans know of the Phoenix VA Medical Center debacle, where veterans died while waiting for appointments. I fully believe that had the VA Secretary had a Tiger Team in place, the root causes of that incident would have triggered the necessary flags to save lives and avoid or mitigate the catastrophe. Flying squads are the Tiger Team in action, and action should be the keyword for every member of the team. The mission of the Tiger Team should be to find and fix root causes, repair trust, and implement change needed to improve VA operations at the Veterans Benefits Administration (VBA), the Veterans Health Administration (VHA), and the National Cemeteries.

The VBA is especially vulnerable, and in need of outside resources to support change. Recently the VBA was involved in another scandal involving improper processing of claims for veterans in hospital over 21-days, resulting in millions of dollars either overpaid or underpaid to the veterans. Training, managerial oversight, and proper performance of tasks was reportedly the excuse the VBA used, again, to shirk responsibility. Tiger Teams can provide the support needed to monitor for, and encourage the adoption of, rectifying measures and VA-OIG recommendations, not just at the VBA, but across the full VA spectrum of operations.

Please, consider implementing Tiger Teams, from your office, assigned to a specific VISN, possessing the authority delegated to run the needed analysis, build support in local offices, and iron out the inefficiencies that keep killing veterans, wasting money, and creating problems. I firmly believe the VA can be saved and improved, built to become more flexible, while at the same time delivering on the promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.”

I-Care Thank you for your time and consideration.

Sincerely,

Dave Salisbury
Veteran/Organizational Psychologist

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.

https://www.linkedin.com/in/davesalisbury/

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