Last week, my primary care provider informed me that the VA is no longer responsible for providing my prescriptions as an outside provider that the VA Community Services team sent me to has increased my dosage. My primary care provider pulled a Pontius Pilot and washed her hands, and I am swinging in the wind with more bureaucracy and less service. The best part of the news delivered this last week, the fallacious, seditious, and felonious attack on my character, the behavior problem flag, is controlled by the primary care provider. Boy, I am sick of the bureaucracy of the VA; if only this were the worst of the bureaucratic baloney, the VA is pushing out.
From many VA-OIG reports during COVID, the following, or something close, was a regular statement:
“During COVID-19, VHA’s Office of Community Care (OCC) took steps to ensure veterans continued to have expanded access to health care in the community, as required by the VA MISSION Act of 2018. OCC issued policies to VA facilities to postpone non-urgent appointments and offer alternatives to in-person care, such as telehealth.”
The VA-OIG inspected to see how closely this statement was adhered to during the height of the COVID pandemic. What surprises no one is how badly the VA managed community care during the pandemic.
Findings:
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- The VA-OIG found that routine community care consults were unscheduled, averaging 42 days, not meeting VHA’s timeliness goal of 30 days.
- Community care staff faced significant challenges beyond their control that contributed to the scheduling delays, such as the lack of availability of appointments in the community.
- Some patients were hesitant to schedule appointments during the pandemic, failed to return phone calls, or declined care once it was offered. – While some of this is definitely patient-driven, what is not discussed is the abrupt shift, the lack of trust, and the confusion about the need to pay the community providers, among other things, faced by veterans forced into community care. As a reference point, it has been 24-months, and I am still facing requests to pay several community providers due to the VA not paying the bill due to a technicality. The VA claims the provider has to “eat the costs,” but I keep getting statements and calls from collection agencies. Guess the direction of my credit score, the direction of my insurance costs, and how happy I am with community care providers.
- The VA-OIG found community care providers and staff did not consistently comply with requirements to manage routine consults, and leaders lacked tools to sufficiently monitor program operations that could have identified the problems.
- Deficiencies emerged in documenting when patients were contacted about scheduling appointments, designating patients eligible for alternative care, and ensuring staff was trained in ways that would address those weaknesses. – Not to mention that pertinent medical records still haven’t been transmitted, received, and alerted the primary care provider. I had gallbladder removal surgery; no records ever made it to the VA. I have MRIs, CT scans, and ER notes that, even after being hand-delivered, have not been added to my VA electronic health record and presented to the primary care provider to discuss, dating back to 2010.
How’s that community service program working for you? In any other industry, this performance would represent an abysmal failure; but community care represents a healthy opportunity for improvement at the VA. The findings listed are a mere drop in the conclusions discussed in the report. I have a suggestion for the VA, stop overpromising and underdelivering. How about you under-promise and then over-deliver?
The following VA-OIG inspection report focused on the Veteran Health Administration facility’s adherence to guidelines for medication management, and the following explanation is quoted from the report:
“This report describes medication management findings from healthcare inspections initiated at 36 VHA medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff and clinical and administrative processes reviews. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.”
Before we get into the findings, let me elaborate on that statement. The VA-OIG cherry-picked/hand-selected call it what you will, the facilities to inspect. No criteria discuss how these facilities were selected. More, the processes chosen for review were also cherry-picked/hand-selected. Appearing to represent that, the VA-OIG stacked the deck to obtain success, and the VHA still failed, or rather showed weaknesses.
Generally, the VA-OIG rated the VHA facilities as “compliant.” But “weaknesses” were identified; read that as the VHA cannot follow established guidelines, protocols, and processes, even though they wrote and established these guidelines and medication protocols. I call this designed incompetence of a criminal nature, but I am not half as lenient and politically astute as the VA-OIG!
Findings:
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- Aberrant behavior risk assessments
- Concurrent benzodiazepine therapy
- Urine drug testing
- Informed consent
- Patient follow-up
- Quality measure oversight.
The following, also from the medication’s adherence inspection, remains significant:
“The OIG examined the following indicators of program
oversight and evaluation:
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- Performance of pain management committee activities
- Monitoring of quality measures
- Following the quality improvement process”
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For the weaknesses represented in the findings to be prevalent, the “Pain Management Committee activities” represent a general failure of the committee to function! For quality processes to be a finding, monitoring quality signifies that the bureaucrats are NOT doing the jobs they were hired to perform! A quality process fails when the humans tasked with oversight refuse to engage, and the VA-OIG findings testify to the truth of humans actively refusing to do their jobs individually and collectively!
Having read and written about the VA-OIG reports for almost ten years, I swear sentences containing the following represent a majority stake in why the VA-OIG cannot be trusted.
“VA-OIG inspections… underscored the value of independent oversight of care received in these settings to help VA make continuous improvements.”
Really? Are you sure the VA-OIG inspections provide “independent oversight” and spur “continuous improvement” at the inspected VA facilities? I have significant doubts the inspections do anything more than highlight the problems as the VA-OIG inspectors have no teeth, and lying has zero repercussions for the humans defrauding the taxpayer! How do I know this; the VA-OIG reports generally go on to make a claim similar to the following:
“The OIG’s findings show that immediate attention is needed in several critical areas….”
Do you, the dear reader, understand better the frustration of veterans and their families? When the Office of Inspector General (OIG) for the Department of Veterans Affairs (VA) covering the National Cemeteries, Veterans Benefits Administration (VBA), and Veterans Health Administration (VHA), can be deluded, distracted, and duped by conniving and conspiring people, what else can the veterans and their families do BUT become frustrated? This is behavior unacceptable in every industry. In fact, legislation overseeing non-government healthcare is strict in outlawing the conduct observed in government-provided healthcare, but somehow the VA is exempt. Yet, the VA continues to make claims such as the following:
“This is how the VA is delivering on its promise to care for the veteran who has borne the battle, his widow, and his children.”
But don’t take my word for it; the VA-OIG conducted several more Comprehensive Healthcare Inspections (CHIPs), resembling cookie-cutter inspections. Staff training continues to be a major delinquency labeled as “High-Risk.” Behavior Committee continues to be a central sticking point and inspection problem. Cleanliness, tagged under “Quality, Safety, and Value,” continues to represent an area for growth and development. Nurse-to-Nurse communications remain constant as a problem, and electronic medical records are not helping to improve on this problem. Inter-facility transferring of patients, policy, and documentation also resemble a constant issue. I feel like I could summarize a CHIPs report with my eyes closed; tell me, when does the “independent oversight” spur “continuous improvement?”
On the topic of “independent oversight” spurring “continuous improvement,” the VA-OIG conducted a VHA inspection of mental health activities for FY 2020. Declaring:
“This report describes mental health-related findings from healthcare inspections initiated at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020, and electronic health record review at five additional facilities. Each inspection involved interviews with facility leaders and staff and clinical and administrative processes.”
Again, how the facilities were selected and the items reviewed appears to have stacked the deck in the VHA’s favor. The VHA is still failing, showing weakness while generally being compliant.
Findings:
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- Completion of four follow-up visits within the required time frame
- Appropriate follow-up of veterans with high-risk patient record flags who do not attend mental health appointments
- Suicide prevention training
- Completion of five monthly outreach activities.
Under these four categories, recommendations for improvement included:
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- Registered Nurse Credentialling – Source verification of licenses.
- Staff training on Suicide Prevention
- Care Coordination – Especially in transferring the patient, form completion, and evaluating transferred patients
- Medication list transmission during transfers
- Staff Training
- Patient notification
- Attending the Disruptive Behavior Committee
For anyone else keeping record, most of the list above is a repeat from the last several years the mental health inspection has occurred. Color me shocked that the VA would still have issues remaining year-over-year, and if you cannot hear the sarcasm in that statement, I have some suggestions for you!
I am thoroughly sick to death of the VA failing in its mission, then bragging they are providing “Excellence in Healthcare.” If the staff is not trained, they cannot perform their jobs, representing a leadership failure. This is a truth for all industries, occupations, businesses, organizations, etc. Nobody is exempt from this statement of fact, yet the VA-OIG keeps on swallowing this excuse year-over-year, and NO PROGRESS is EVER made!
America, are you aware of what the various government agencies are doing with your money, on your time, and with your consent? If your neighbor took your checkbook and wrote checks you are legally responsible for paying, would you want better services rendered? Elected officials (yes, I am including those at the city, county, state levels of government), why are you NOT scrutinizing the government more effectively and rigorously? You, the elected officials, are the neighbor writing checks; why are YOU NOT doing the job we hired you to perform?
Elected officials, did you know that VA is not required to maintain records of returned bills, as a matter of policy, but those returned bills mailed to veterans are causing hardship for veterans. I cannot recount how many times I have changed my address and my spouse’s address with the VA, on the VA-approved websites, and in-person with VA representatives, and still have had mail not delivered for months due to a wrong address in a legacy system. Yet, the VA is not policy mandated to check returned mail, track that mail to a veteran, and check the different legacy and non-legacy systems for address veracity.
Elected officials, do you read the VA-OIG reports? Honest question, as the following is directly from a VA-OIG report.
“[VHA primary care] providers did not consistently
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- Identify a surrogate should the patient lose decision-making capacity
- Address previous advance directives, state-authorized portable orders, and/or life-sustaining treatment plans
- Address the patient or surrogate’s understanding of the patient’s condition.”
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The VA designed the PACT Team to improve care and deliver on the VA’s mission, yet the primary care provider has the following failures weaknesses showing. The VA-OIG can do nothing to improve this glaring oversight, but you were elected to force change and spur “continuous improvement” in the executive branch officers and employees. Well, where are you? The VA-OIG substantiated that a failure in the PACT team led to a delay in a cancer diagnosis, causing increased pain, problems, and resource loss for a veteran; where are the elected officials, and the media for that matter, in raising a holy rhubarb on the PACT Team failing this veteran?
Elected officials, did you catch that statement in the VA-OIG report on the cancer diagnosis?
“Facility leaders have an unwritten expectation that primary care providers conduct a thorough historical review of the patient’s electronic health record starting with the most recent annual note; however, the OIG found that not all of the patient’s providers conducted historical reviews, but instead focused on current issues and problems identified by the patient.”
Having transferred between PACT teams inside the VHA and state-to-state, I can affirm this is exactly what is transpiring in the PACT team; the second most important player, behind the patient, is the primary care provider. When the primary care doctor fails in their job, like dominoes falling, the care of the patients rapidly cascades into a dynamic failure of healthcare in a VHA facility. What are YOU doing to stop this madness and demand accountability?
The electronic health record has a section near the top of the record for “Problem List.” Guess what; when providers fail to keep this section updated, current, and accurate, the healthcare of the patient borders on malpractice requiring only a slight push to arrive with a dead veteran. The VA-OIG found providers and nursing staff failures to update the problems list accurately, keep the problems list current, and regularly discuss the problems list with the most critical member of the PACT team, the patient! Providers failed to comply with sound science, good business practices, and act appropriately for the patient’s health; do you think this might be a slight problem in the PACT team?
I have offered the VA several suggestions for plotting a path forward. Yet, the VA cannot and will not take advice without stern and reproachful measures taken by Congress. Elected officials, it is time for you to act and groundswell the changes needed in every government agency, even if it means reducing the size of government!
© 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.
It is no secret I am on several prescription medications. I take these under strict medical advice, and three of these prescriptions regard mental health improvements. However, my prescription reasons were subtly shifted because Phoenix’s last two primary care providers did not listen to the patient. Since the El Paso primary care physicians appear to be utterly incapable of even attempting to listen, I have now been without a mental health prescription for an entire week. This is called bureaucratic cold-turkey prescription stoppage!
I am a root cause kind of person; why do I bring this up? I have had three primary care providers since arriving in the El Paso VAHCS in May 2021. None of them have gotten any of the medications correct due to a blatant refusal to LISTEN to the patient with the INTENT to understand! Nurses with VA-provided primary care providers are expected to communicate with patients between 24 and 72 hours post any ER visit. Since moving to Las Cruces, I have visited the ER twice and have not spoken to the nurse yet!
Snide, rude, and disrespectful staff, all made possible by, supported through, and legally accepted under federal government fiat. Do you realize that the nurse not doing their job will have any number of valid and acceptable excuses, and these excuses are accepted because of designed intentional incompetence allowed under federal employment laws, regulations, and directives, established by and supported through Congressional oversight? In Disney’s “Princess Diaries 2: Royal Engagement,” Viscount Mayberry has a line,
When the VA publishes marketing materials claiming they set standards for excellence and lead the industry, I want them to prove their competence and abilities! Right now, their failures scream louder than the voices in their own ears, and they refuse to listen to anyone, and I am not happy! You, the taxpayer, should not accept the performance of ANY government agency, including the entire legislative, judicial, and executive branches of government at the local, county, state, and federal levels, until they correct their behaviors! It is time to end the charade and put paid to this contemptible behavior and abuse!
In physics, for every action, there is an equal and opposite reaction. I am not a fan of the word reaction, for a reaction places all the control of the action into the control of the original actor, and nature does not work like that. But, to reason, we sometimes must use language common to all to understand each other; thus, it is sufficient to my purposes to use the term reaction in this discussion. A similar law applies to psychology; a human chooses to act, natural consequences follow. The ability to as, agency, and the person being acted upon, the actor, play a significant role in how and why businesses succeed and fail.
Societies, cultures, governments, and countries all rise and fall on the moral agency of the individuals in power, the common citizen, and the collective leaders of those groups of people. I have always liked the movie “The Fiddler on the Roof,” Tevye makes a statement about how without tradition, they would be as shaky as a fiddler on the roof. Bringing a mental image of a fiddler, balancing upon a roof, and having two options, climb down and resume playing, or learn to balance on the roof while playing. Both choices offer natural consequences that are easily understood, especially if you have ever worked on a roof.
I have consistently written about VA Leadership failures for several weeks, rightly calling out the administrators at the local VAHCS and VAMC, the VISN, and the Federal levels. Hospital leadership is not so different than leadership in any other industry, even though the VA has tried to make hospital leadership distinct. Herein lay the problem, an employee, a 
I believe in public shaming; I am an equal opportunity shamer. Where the VA is concerned, well, I tend to be more motivated to pass out shame than any other government entity. Not that I won’t pass along shame, or congratulations, when warranted, the administration of the VA deserves a few more scoops from the shame bucket today!
I submit documents to the VA all the time, and every time I have to submit anything, the intake “officer” has to certify the document’s validity. Heck, the VA had my NGB Form 22 and both DD 214’s, and I still had to submit valid copies to ensure I was not defrauding the government. Forget innocent until proven guilty; submit forms to the VA, and you are guilty until they begrudgingly claim you are innocent. Submit documents to Social Security for a claim, same thing, same process, same everything. Yet, somehow three different people were able to defraud the government, stealing money, and are now hosts of the government.
The time for kid-glove treatment and soft-shoe approaches is past and dead; more positive and forceful measures are required. Where are the lawyers?
DNC-Consulting 