Absurdity so Repugnant it Takes Your Breath Away – More VA Chronicles

Angry Grizzly BearThe Department of Veterans Affairs – Office of Inspector General (VA-OIG)-released six investigation reports in the last two days.  Each one is mentally breathtaking at the egregious behavior of bureaucrats!  Stupidity that is so repugnant it breaches the laws of morality and leaves the reader stupefied.  Every year, for the last decade-plus, the behavior of the Department of Veterans Affairs (VA) has become more obscene, more outlandish, more detestable, and more openly hostile towards veterans; it sickens me to read the investigation reports, write, and catalog these abuses!

Beginning in Queen’s, New York, we find another dead veteran that should never have died the way they did.  Improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient.  Let that sink in for a moment, for the rest of the report only goes downhill from this point.  My time in medical training was replete with the following aphorism, “If it is not written down, it NEVER happened.”  The nursing staff failed to document meals properly. The electronic health record (EHR) was inaccurate and flawed, hindering resuscitation, which was poorly documented, and institutional disclosure acted more like CYA than a medical file.  People should have been fired and up on trial for this type of scandalous behavior, especially since a veteran died from this abuse and neglect.  But the VA-OIG made their recommendations, the leadership accepted the recommendations, and nothing else will happen.  Nobody but the family cares the veteran died needlessly and at the hands of the medical professionals.VA 3

Adjectives elude me.  The behavior in Queen’s is appalling, even for the VA.  Unfortunately, the list of ineptitude only gets worse!

VA SealNext, we travel to Austin, Texas, and discover yet another office of information technology (OIT) failing to work, secure data correctly, and protect veterans’ information, as demanded by legislation!  The VA-OIG and the local OIT used the same tools, and the local OIT only identified 150 problems, whereas the VA-OIG OIT inspectors found 246.  Improper sanitization of media was a pronounced issue, where patient load is upward of 300,000 annually.  Inventory practices were noticeable and apparent.  Worse, patch and vulnerability programs were practically non-existent if I understand this report correctly.VA 3

If you have read any of these VA Chronicles, you will know that the VA has not passed a Federal Information Security Modernization Act (FISMA) audit, ever!  The head of IT was recently in front of Congress to testify why, and the explanations were milk toast adequate at best!  But, the elected officials bought the excuse, hook, line, and sinker, as always, and the president wants to spend more money on the VA.  What a cathartic example of why elections matter!

Next, we travel to Detroit, Michigan, where a “comprehensive healthcare inspection (CHIp)” was performed at the John D. Dingell VAMC.  Before I even read the report, I knew it would say; opportunities exist to improve employee and patient experience.  Knowing veterans who are “served” at this VAMC, this was an obvious guess!  Again, we find “moral distress” in the workforce, signifying that the employees feel pressured to do everything but what is ethical, legal, moral, and appropriate for the patient at this VAMC.  Yet, the leadership team was rated as stable and doing a good job!  Quoting Colonel Potter from M*A*S*H here, “HORSE HOCKEY!”VA 3

I will be explicitly clear if a single employee feels “moral distress,” there is a leadership problem, and the leadership is criminally negligent in their duties to oversee staff leaders, supervisors, team leads, and training personnel!  This is not the first time “moral distress” was a point of discussion in a CHIp; but, the fact that this problem remains widespread and apparent does mean the problems are originating at a level higher than the VISN, and all the VA and VHA leadership should be losing their jobs!  Enough is enough, and the elected officials need to be scrutinizing the government before they lose their next election!

Survived the VAHaving been an employee of the Department of Veterans Affairs, working in the Emergency Department of the Albuquerque, NM., VAMC, this next story is exceptionally aggravating and extremely distressing.  The VA-OIG determined that the entire Veterans Health Administration (VHA) needs to better monitor, record, and document the timeliness of care and patient flow in the emergency department.  Having waited for more than 14 hours in a VA Emergency Department while waiting for care, I know first hand the problems of the Emergency Departments, and I know a lot of the reasons why the documentation is fouled and the flow of patients is amateurish, at best!

Raymmond G. MurphyI worked the shift where a regular, homeless veteran, wheelchair-bound, had fallen and broken his leg.  He waited with his broken leg swelling, stuck at an odd angle, and in obvious distress for more than 6-hours because the head nurse that day had a personal grudge against the veteran!  I saw how the charts were “adjusted” for timeliness of care, and I reported the problems up the chain to no avail!  I had witnessed nurses harangue patients, gossip about them, chart surf in violation of HIPAA, and never was anything done by leadership when it was reported.  A patient sat in an expedited treatment room for four hours, listening to the nurse’s gossip and joke, awaiting stitches for a bleeding wound, and never was treated.  All because the day shift was getting off and didn’t want to be bothered to treat the patient.  The patient’s family reported this behavior to me as they were leaving for a better hospital.  I reported the whole incident, included the family’s description, added my observations.  The leadership shook the whole incident off as a disgruntled employee (blaming me) making a less than desirable situation worse.VA 3

Thus, when I read this particular VA-OIG report about the inadequacies of the VA Emergency Departments across the entire VHA, it infuriates me into a mindless stupor!  Want more data on the failures of the VA Emergency Department; read the rest of the VA Chronicles.  I describe my experiences in detail and have logged other veterans who have had the same or worse problems at the VA Emergency Department!  I have witnessed doctors treat patients in a dissimilar manner based upon the political clothing the veterans wore into the Emergency Department!  So, no, I am not surprised at the record inadequacies of the VHA; if anything, I expect the problem is a lot worse than the VA-OIG was willing to report!VA 3

The VA-OIG collected data on an issue of grave significance from 58 VHA outpatient clinics’ regarding emergency preparedness for the delivery of telemental health care as of November 1, 2019. The review focused on clinic-specific emergency procedures, emergency procedure roles and responsibilities, emergency contact information of staff, and patient safety reporting methods.  Not included in the scope of the review was the quality and quantity of telehealth appointments.  I mention this oversight as the technical problems in receiving telehealth appointments are sub-par, at best, which would have seriously skewed the data.

The VA-OIG sent out 333 questionnaires, receiving a total of 187 responses, from the 58 identified clinics, and identified the following:

      1. Missing telehealth emergency plans and procedures.
      2. Emergency procedures are not specific to telehealthcare or the patient-clinic location.
      3. Lack of a process for annual updates to telehealth emergency procedures.
      4. Undefined emergency procedure roles and responsibilities for telehealth staff
      5. Missing or insufficient emergency contact information.
      6. Lack of a process to verify and communicate emergency contact information
      7. Lack of a consistent process to designate the telehealth setting in patient safety reporting methods.VA 3

Consider for a moment; you are a family member of a veteran needing telehealth mental support.  Now, how do you feel to know there are no written processes or procedures to support the telehealth provider if your family member gets into a mental health emergency.  Time is critical in mental health emergencies; I know this from personal experience as both a provider and a patient, and for these plans, procedures, and processes to be missing is the height of malpractice!  Would someone please tell me why elected officials and the media are not screaming mad at this particular report?  Especially since the proposed budget from the president wants to double suicide prevention spending at the VA.  I read this report and see that the VA-OIG made five recommendations.  Are you freaking kidding me?!?!?

Finally, we go to Hawaii and confront the most detestable, outside of the dead veteran, issue possible, failure of the National Cemeteries Administration (NCA) to properly care for the remains of veterans, qualified spouses, and dependents.  The NCA awards grants to states to build cemeteries where a veteran, qualifying spouse, and dependents can be laid to rest outside a national cemetery.  From the VA-OIG report, we find the following, emphasis mine:

Grants may be used to establish, expand, or improve veterans cemeteries. The VA-OIG audited the program to assess NCA’s governance and oversight. The audit team also assessed whether critical non-compliance issues at two cemeteries in Hawaii were addressed. The VA-OIG found grants program staff did not rank and award some cemetery grants as regulations required. After grants were awarded, program staff generally ensured cemeteries used grants for their intended purpose. However, NCA did not ensure cemeteries with grants met all national shrine standards for installing permanent markers, maintenance, and safety. The audit team observed non-compliance issues at eight state cemeteries, including critical issues in Hawaii’s Hilo and Makawao cemeteries. As a result, NCA lacks assurance that veterans and family members buried in state veterans cemeteries have been appropriately honored with timely and accurate grave markings, burial locations, and maintenance.VA 3

NCA, you have one job, ensure the remains of veterans and qualifying spouses and dependents are adequately remembered, safely entombed, and marked appropriately.  Yet, you fail at even this simple and easy job; how utterly disgraceful, disgusting, and detestable!  How many cemeteries in the Philippines are being adequately cared for?  At the last report, none of them were adequately maintained and respected.  Even here in the US, you refuse to do your jobs with competency, dignity, and professional pride.

Knowledge Check!The VA is one sick organization, where the mission is being denied, the veterans abused before and after death, and none of the elected representatives can find enough time in their day to even offer a mild rebuke or maintain sufficient interest to scrutinize.  America, we have gotten better as a culture in remembering and honoring those who serve and have served, and I, for one, am very grateful for your change of heart.  We, the voting citizens of America, need to demand the same culture change from the politicians representing us!  As a country, we have come a long way since Vietnam in honoring the military.  But those same people who spat and urinated on our troops in Vietnam are now in the Halls of Congress, and their attitudes have not changed in the interim!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

NO MORE – An Open Letter to the People of Arizona

To The Citizens of Arizona:

ArizonaIt has been my pleasure to have lived in Arizona four separate times since 1996.  Employment and pleasure have brought me relocation opportunities, and I have enjoyed my time in Arizona. However, since my return in 2005 to the present, I have feared for the soul of Arizona.  I have watched as despicable and detestable politicians have won political races that never should have been won.  I have witnessed governors act in cowardly and craven methods to thwart the people’s will.  I have witnessed those elected to Federal Offices from Arizona stop being held accountable to the electorate until the politicians have set up a hegemony and no longer fear the ballot box.  Most egregious of all, I have witnessed the veteran community become increasingly abused as every day ticks past.Patriotism

In April 2021, I wrote about my interactions with Rep. Greg Stanton (D) and his staff, where the VA is concerned.  For almost an entire year, I have been injured, cited, and arrested, denied care, had untold HIPAA violations, and other disgraceful conduct taken against me by the administration and leadership of the Carl T. Hayden VAMC.  In December 2020, I reached out again to the federally elected representatives, asking for help to clear my name and remove the atrocious behavior of the VA, all to no avail.The Duty of Americans

All four Senators rejected my pleas and never bothered to respond.  All of the members of the House of Representatives from Arizona refused to reply, save the staff of Rep. Greg Stanton (D).  Except, Rep. Greg Stanton (D) and his staff, did nothing!  Had no priority, refused to communicate, could not maintain pressure, and bought the lies and excuses of the Carl T. Hayden VAMC administrators.  These are the same administrators who create a crisis for veterans through inaction, duplicitous action, poor behavior, and refusal to perform the jobs they were hired to perform.  I have made it clear that the Administrators of the Carl T. Hayden VAMC and VISN 22 are but one dead veteran from another scandal to dwarf the death list scandal that originated with the VA administrators in 2012 and repeated in 2016.

VA 3No VA Administrator has addressed the root causes of those scandals, and without proper persuasion from Washington, D.C., they never will!  Worse, without continuous scrutinization, the bureaucrats will continue to exemplify the duplicity and failures, hiding behind designed incompetence and tissue paper-thin excuses for poor behavior.  Yet, what do we find from those enjoying elected office?  Zero interest, half-truths, straight lies, misinformation, smoke and mirrors, and plain laziness!  We, the electorate, find the politicians sitting on their hands, engaging in hopeless and stupid legislation that will go nowhere, and we find lackadaisical meandering in the House and Senate leadership.  I have witnessed amoebic life with more robust spines than the current political leadership in Arizona!Image - Quote Poltics is Dirty

It is true, Arizona is not the only state suffering from political abuse of the basest sort and blackest hue, but Arizona is where I have personally seen the destruction hit the hardest.  During Senator McCain’s tenure, my requests for help were rebuffed, but I could still obtain assistance from the House of Representatives members.  Now, the political party doesn’t matter, the politicians have plastic ears, and plastic lips, and their hearts are full of desire for political gain and not the electorate’s support.  Who loses, the electorate!  Who wins, nobody!

America, I ask you, in the year and change between today and the next election cycle, what will you do to change America’s government?  Arizona, you have been duped, lied to, and dishonored by those elected to power.  What will you do to reclaim the honor, integrity, and political government you deserve and pay so much for?Apathy

Personally, I have been betrayed, and I am sick to death of pleading for reprieve only to have lackluster performance, at best, provided so I would just go away.  I know of no honorable politician representing Arizona, and their respective staff is worse than the politician!  From the Mayor of Phoenix to the Governor, including the school boards, judges, and so many others, the fear of the ballot box is shrinking, and the bureaucrat is winning.   In contrast, the scrutinization of bureaucrats and other duties are dodged to win another term, always with a complicit media running interference.LinkedIn Image

I did not elect the media to their position, and since the media is not elected, they can be removed. However, while the politicians are elected, the fear of the ballot box needs to be retaught to the politicians.  How does a citizen get a politician to fear the ballot box; you first buck the trends and stand like a rock in a stream. Then, as additional rocks begin to stand, a dam is built, forcing change to that stream.Plato 3

If we are to change the government and retain our freedoms and liberties under the Rule of Law, we, the electorate, must first get the politicians to fear the ballot box!  We, the electorate, need to also teach accountability and responsibility to those who claim power but who only obtain power from those choosing to be governed!  We, the electorate, hold power over these politicians and the bureaucrats spawned in the legislative branch of government. So claim the power that is yours, and join your friends, neighbors, and communities in demanding better from those elected.

Knowledge Check!I heard the mayor’s office in Phoenix complain that they have no power over the Federal Government.  To think this is treason of the vilest kind.  Let me reiterate something discussed in several previous articles.  The local government stands as a bulwark against the county government overstepping its legal boundaries.  The city and county stand against the state encroaching against the freedoms and liberties of the state government.  The state government defends its citizens from the Federal Government’s encroachment, and the individual citizen is the most potent force in our Republican form of government.

Plato 2Cease the sophistry of plastic language and do your job!  End the tyranny of plastic words and work to aid the citizen in protecting their rights and freedoms from the ever-encroaching thieves of government and the bureaucrats spawned in the darkest pits of legislative fiat! So stand, every American citizen needs to stand and refuse to be governed until those elected are replaced with people willing to take action and honor the Rule of Law, holding previous politicians accountable and responsible for the mess America is currently suffering under.  Enough is enough, and I have reached the end of my tolerance, and my cherubic demeanor has been replaced with a hunger for justice!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

NO MORE BS: Come, Let us Reason Together

Knowledge Check!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.

Plato 2Societies, 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.

Detective 4I 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 nursing assistant, has just been sentenced to 7 consecutive life sentences for second-degree murder.

“Mays was employed as a nursing assistant at the VAMC, working the night shift during the same period of time that the veterans in her care died of hypoglycemia while being treated at the hospital. Nursing assistants at the VAMC are not qualified or authorized to administer any medication to patients, including insulin. Mays would sit one-on-one with patients. She admitted to administering insulin to several patients with the intent to cause their deaths” [emphasis mine].VA 3

We have an affect, but what was the cause?

“While responsibility for these heinous criminal acts lies with Reta Mays, an extensive healthcare inspection by our office found the facility had serious and pervasive clinical and administrative failures that contributed to them going undetected,” said VA Inspector General Michael J. Missal” [emphasis mine].VA 3

Regardless of her intention, an employee was allowed to commit murder because of the “pervasive clinical and administrative failures” of the VAMC leadership.  Now, two days prior to receiving the results of Reta Mays’ court proceedings, I received the Department of Veterans Affairs – Office of Inspector General report on the clinical leadership failures.  I have not witnessed a more despicable and damnable report of leadership failures in the decade-plus; I have been following and writing about the Department of Veterans Affairs or any other government agency!

“In June 2018, facility leaders identified nine patients with profound and concerning hypoglycemic events dating from November 2017 to June 2018” [emphasis mine].VA 3

The scope of the administrative investigation is as follows.  Staff from the VA-OIG’s Office of Healthcare Inspections (OHI) assessed the following areas, in parentheses is who owns the problem raised in the investigation:

      • Mays’s hiring and performance (Human Resources)
      • Medication management and security (Pharmacy and Security)
      • Clinical evaluations of unexplained hypoglycemic events (Nursing and Doctoral Staff)
      • Reporting of and responding to the events (Facility Leadership)
      • Quality programs and oversight activities (Facility Leadership)
      • Facility, Veterans Integrated Service Network (VISN), and VHA leaders’ responses and corrective actions (Local and area-wide administrators)
      • During the course of this review (investigation), the OIG also noted areas of concern regarding hospice and palliative care practices and nursing policies and practices (Nursing, Patient Care and Safety, and Hospital Administrators)VA 3

Just as logic tells the fiddler on the roof that he has two choices to live a long and musically fruitful life, the investigation reveals that the VAMC leadership had choices and made both poor and potentially criminal choices in this investigation of Mays’ conduct.

Ultimately, quality health care is dependent on leaders who promote a culture of safety that reduces or eliminates those risks whenever possible. Providing high-quality health care to a diverse and complex patient population demands the support of, and adherence to, an organization-wide culture of safety. When this occurs, a patient-centric environment becomes the “norm.” Conversely, systemic weaknesses in a facility’s culture of safety can have devastating consequences. The OIG found that the facility had serious, pervasive, and deep-rooted clinical and administrative failures that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier. The failures occurred in virtually all the critical functions and areas required to promote patient safety and prevent avoidable adverse events at the facility” (pg ii) [emphasis mine].VA 3

Before we go further into the report, it must be made clear; the investigation team found the leadership, the hospital administrators responsible for allowing Mays to kill seven patients.  Attack another patient with the intent to kill and a potential additional hypoglycemic patient who died under her care but could not be directly linked to Mays.  A question arises, how did Mays gain employment with the VA; the answer, a former HR employee, failed to do their job in conducting “… background investigation file and determining her suitability for employment!”  In a previous article, I wrote about the hazards the VA was purposefully opening themselves to by using “COVID” as an excuse to delay proper investigations into backgrounds when hiring.  Here is a classic case where “COVID” is not related, and failing to investigate a background led to people dying!Plato 3

The VA-OIG last year reported that hiring practices had been relaxed due to COVID and background checks delayed for employees being hired during a pandemic.  Yet, when will those background checks be completed?  If someone is found unfit due to background checks, will they be forced to return all their wages for lying on a government form?  If there is a testament to the need for comprehensive background checks on employees, the seven (7) dead patients who died at the hands of Reta Mays!  How many times will this story replicate because the hiring managers are not doing their jobs?VA 3

Let us reason together, is the VA administrators the problem with the VA?  Does the VA leadership require immediate and total removal?  How would you resolve the issues without breaking the system and further endangering the lives of veterans?  Please let me know in the comments section.

I-CareVA Secretary Denis McDonough signed onto the “I-Care” principles as core values in care for veterans in the VAHCS.  When can we, the veterans, see that these core principles have been onboarded and are correcting behavior?

“VA Core Values describe how VA will accomplish its mission and inform every interaction with our customers. These Core Values are Integrity, Commitment, Advocacy, Respect, and Excellence — better known as “I CARE.” VA’s Core Values will continue to serve as the right guide for all our interactions and remind us and others that “I CARE.”

          • I care about those who have served.
          • I care about my fellow VA employees.
          • I care about choosing “the harder right instead of the easier wrong.”
          • I care about performing my duties to the very best of my abilities.

Mr. Secretary…  The veterans are dying now!  We are waiting!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

NO MORE BS: VA Leadership IS the Problem!!!

Angry Grizzly BearPSA:  If you have a weak stomach, please feel free to not read this report.  This article is discussing the ongoing and continual problems of the VA leadership to ensure clean medically reusable equipment is available for practitioners use.  While the YUCK factor is high, the issue remains a leadership failure, and worse, it was purposefully designed into the VA organization to spread infectious diseases between veterans!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) conducted an investigation and reported its findings 16 June 2009.  While still not the first-time endoscopes and colonoscopes being dirty have caused patience significant risks, this report clearly details the failure of VA Leadership as an organizational design flaw.  From page i of the report, we find the following:

Facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans. Reprocessing of endoscopes requires a standardized, monitored approach to ensure that these instruments are safe for use in patient care. The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure” [emphasis mine].VA 3

Also, from page i the scope of the investigation and those requesting the investigation are detailed:

The VA Office of Inspector General received requests from the Secretary, Chairmen and Ranking Members of VA oversight committees, along with individual members of Congress, regarding the reprocessing of endoscopic equipment at several specific VA medical centers (VAMCs), and to assess the extent of related problems throughout the Veterans Health Administration (VHA). The purpose of the review is to describe the pertinent events at VAMCs where problems were reported, assess VHA’s response to the events, and conduct a system-wide evaluation of current reprocessing practices” [emphasis mine].VA 3

Let us be perfectly clear, since 2009, the VA Federal Officers have been informed and kept abreast of the problems with properly cleaning, sanitizing, and documenting reusable medical equipment, specifically endoscopes and colonoscopes, and have done nothing to fundamentally correct the direction of the VA, the VHA, or the offending VAMC’s.  What good is a memo when it is not applied as a standard operating procedure, where consequences are involved?  How is a memo going to be effective against a culture trained to not do their jobs, no matter the cost to patient safety?  To fully comprehend the problem with reusable medical equipment not being properly cleaned and sterilized (repurposed) see pages seven and eight of the following report linked.  There are a lot of acronyms, but the general sentiment is clear, the VA has an enormous problem with properly cleaning reusable medical equipment!

In a VA-OIG report dated 06 May 2021, we find an employee, after having been caught once, still not being properly supervised, not doing their job, and remaining employed.  This employee was caught falsifying legal documents on the cleanliness of endoscopes, and dirty equipment was used on multiple patients.  The facility conducted an investigation, the VISN conducted another investigation, neither investigation led to any type of fundamental organizational change to protect the patient.  Even the VA-OIG investigation has not led to fundamental organizational changes and improvements in cleaning and sterilizing reusable medical equipment.  Frankly, this should scare the daylights out of every veteran going in for any type of care at the VA.VA 3

Trust is hard won and easily lost.  Right now, can any provider at the VA assure any patient that the reusable medical equipment has been properly cleaned and sterilized before being used on that patient?  Since the VA-OIG report in 2009, the direct answer to this question is a resounding NO!  Again, I ask only for emphasis, if a non-VA hospital, clinic, or provider’s office was caught not properly cleaning, sterilizing, and documenting medically reusable equipment, how could they remain in operation?  The short answer is, they could not; unless they are an abortion clinic, but that’s and entirely different subject.  The Federal Government and the lawyers would descend en masse to shut down the facility, hold the administration accountable, and demand retribution for the patients involved.  Why is the VA Administration and VHA Administration, and the VAMC and VISN Administrations able to escape culpability in risking a patient’s health with dirty medical equipment?

Angry Wet ChickenEvery single Federally elected politician should be up in arms about the double standards between VA hospitals and non-VA hospitals.  If a non-VA hospital is caught with dirty medically reusable equipment, can they use the VA as an example in court as a defense?  NO!  Yet, here is a legal double-standard and precedence that opens the door to more questions.

Returning to the 2009 VA-OIG report, we find how the investigation was methodologically carried out.  The methodology reveals just how widespread and in-depth the investigation is, and how deeply this problem is organizationally wide for the VA.

We visited the facilities which had been the subject of considerable media attention: the Bruce W. Carter VAMC (Miami) in Miami, FL; the Tennessee Valley Healthcare System-Murfreesboro campus (Murfreesboro); and the Charlie Norwood VA Medical Center (Augusta) in Augusta, GA. We reviewed applicable regulations, policies, procedures, and guidelines. Furthermore, 26 inspectors conducted unannounced onsite visits for the total of 42 probability-based randomly selected VHA facilities to examine pertinent endoscope reprocessing documentation.

Because of the unannounced nature of the inspections and for cost-efficiency, a stratified clustering sample design was employed to maximize the number of facilities that could be inspected in a single day. Two probability-based random samples of VHA endoscope reprocessing facilities were selected from the study populations for the unannounced onsite inspection: one for colonoscope reprocessing and another for ENT endoscope reprocessing. With probability sampling, each unit in the study population has a known positive probability of selection. This property of probability sampling avoids selection bias and allows use of statistical theory to make valid inferences from the sample to the study population.”VA 3

Back in 2009, the media was very cognizant of VA issues, then the dead veteran scandal of 2012 and 2017, turned the media’s attention away from how the VA conducts business.  Let me direct your attention to the final sentence of the quoted material above.  As a researcher, this is a gold standard methodology statement for researching a complex organization like the VA, to pick proper probability samples, and to reduce individual inspector bias in the combined report of findings.  Thus, from this quoted material we can presume both that the methods of conducting the research were sound and conclude that the egregious behavior by administrators is VA wide!VA 3

If dirty medical equipment is how the VA defines excellence in the 21st Century, America’s veterans are in trouble deep!  I am now in my eleventh year of writing about the behavior of the VA and how they intentionally treat veterans.  I have witnessed detestable behavior by providers as an employee, and brought this behavior to the administrator’s attention, for which I was discharged without cause!  I have written about instances of negligence so terrible that there should have been a Congressional Blue-Ribbon panel assigned to demand correction and conduct and investigation, but nothing ever transpired.  I have personally experienced providers so inept, their qualifications should be questioned.  I have observed VA employees abuse, harass, threaten, and intentionally hinder treatment.  The behavior of the VA Administration where reusable medical equipment is concerned is so far beyond the pale, words escape me to describe.

Dont Tread On MeI believe in the little rocks that start landslides.  I know the power of tiny snowflakes that create an avalanche.  I know that if enough veterans, their families, friends, and communities rise up, the elected politicians responsible for scrutinizing the government will be forced to make veteran safety and health at the VA a priority and blessed change will finally arrive in the VA Administration and administrators.  Imagine how you would feel to learn a close friend or family member caught an infectious disease during treatment at the VA.  Please respond accordingly!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

NO MORE BS: Responsibility

LookDale Renlund made a powerful point:

“… Blaming others, even if justified, allows us to excuse our behavior.  By so doing, we shift responsibility for our actions to others.  When the responsibility is shifted, we diminish both the need and our ability to act.  We turn ourselves into hapless victims rather than agents capable of independent action.”

Consider this statement with me as we observe and review recent events in America and the world.

  1. The Department of Veterans Affairs – Office of Inspector General (VA-OIG) reviewed the administration of spina bifida benefits for children born to Vietnam veterans, found internal communication and data sharing were the root cause of administering the benefits program incorrectly. The Department of Veterans Affairs – Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA) blamed each other for administration failure.  Applying Renlund’s point, we find that blaming each other equally provided the excuse for neither bureaucratic administration to accept responsibility.  Blocking movement towards action in correcting the problem, and ultimately the victims will continue to be children born of Vietnam veterans who deserve better and cannot cut the red tape to reach help desperately needed.  Worse, the blaming has turned the VBA and VHA from independent administrations into victims who deserve pity, instead of a boot kicking for their customers’ abuse!
  2. The VA-OIG, in another inspection, found COVID to be the root cause for shortages and outages of personal protective equipment (PPE). Except none of the 42 facilities surveyed ran out of anything.  Stocks dipped low, but outages of supply never occurred.  The blame for the low stock was also found on data and lack of reporting data correctly.  While people were praised for acting to “shift supplies, create new processes, and order supplies promptly,” the people could not be blamed for the low stock levels and were made into victims of COVID and data mismanagement.

Detective 4Please allow me a brief public service announcement: in business, one finds Juran’s Rule.  Juran’s Rule states that when there is a problem, 80-90% of the time, the processes are blamed, not the people.  The processes, or the written (supposedly) directions to perform a task, are so convoluted in government that Juran’s Rule could slide into 98% of the problem and still not run out of process convolution before people can be blamed.  Yet, the leadership of the VBA, VHA, and every other government agency refuse to look at the processes and eliminate, change, correct or even take action to review the processes.

Thus, Renlund’s point steals potential from people, as people become hapless victims to processes and procedures, instead of the commander of their duties and roles as hired.  The shift of responsibility from people to processes is the danger found in Juran’s Rule, not the truth in Juran’s Rule.  Thus, action to correct is diminished because responsibility has been shifted from leaders to the processes they are already responsible for monitoring.  Hence, when I see the VA-OIG allowing data or business processes to be blamed for the failure of people to act, according to the roles they have been hired to fill, I doubt the ability to fix the right problem.

  1. Using Renlund’s point, here is a typical VA-OIG inspection summary. See if you can spot the responsibility shifting, the inaction, and the problems.
      • The Department of Veterans Affairs – Office of Inspector General (VA-OIG) examined whether the VHA had effective procedures for (1) purchasing, (2) inventorying, and (3) tracking biologic implants such as skin substitutes and corneal or dental implants. The VA-OIG found deficiencies in all three areas at four medical facilities it visited. The audit team determined that purchasing agents did not always record implant purchases correctly or use the appropriate funds. The purchasing agents did not register 2,931 of 10,305 purchased biologic implants in the proper system [emphasis mine]. Instead, agents documented the implants in various local spreadsheets, databases, and third-party systems. Purchasing agents improperly used logistics funds instead of prosthetic funds, making it difficult for VHA to account for biologic implant spending fully and effectively budget or use funds for other purposes. Due to inadequate guidance, the OIG found that the facilities visited had an inaccurate inventory of biologic implants, did not use a standardized system, and did not consistently review stock on hand. The staff could not locate 714 biologic implants in inventory at the four facilities visited, valued at almost $1.1 million [emphasis mine]. The audit team also found 288 additional unrecorded items, valued at nearly $433,000, in storage locations [emphasis mine]. Poor inventory management can jeopardize prompt care, as medical providers may need to delay or cancel procedures if implants are unavailable. The facilities visited failed to track at least 45 percent of implants reported as used from October 2017 through March 2019 [emphasis mine]. VHA did not designate responsibility for overseeing tracking, develop a national policy on how facilities should track biologic implants, or have a standard tracking system that meets accreditation requirements. Effective tracking is needed for facilities to notify veterans if the manufacturers recall their implants.
      • Are the problems of shifting responsibility and the magnitude of the problem more understandable? Feel free to use the comments to discuss this example.LinkedIn VA Image
  2. In the final example, we find another common problem at the VHA, the refusal to alert patients promptly about test results, with the same worn out and tired excuses, time, and refusal to employ and document according to standards. People did not do their jobs, and it took “several concerned members of Congress” to initiate a VA-OIG investigation to certify there was a problem. Still, the solution by the VA-OIG remains tepid at best!  Leading to questions for Congress to allow these problems to thrive and advance the issues that VHA hospital leadership intentionally designs incompetence into their processes and procedures, then dares the patients seeking care to find a solution to force the administration to do their jobs.  Irony strikes again in the VA-OIG reports; the same issue was investigated and reported with the same “recommendations” almost every month throughout the last two-years.  Why aren’t the VHA local leaders being held accountable by their VISN leadership teams for failure to act to fix their problems proactively?

DetectiveToo often, the pattern at the VA, is exemplified in every other government agency for the keen observer to witness; act in a manner unacceptable, hide behind broken processes intentionally designed to hide purposefully designed incompetence, and escape responsibility but retain their jobs into retirement.  Essentially, the leaders of government agencies have employed the pattern discussed by Renlund for personal gain at the expense of the frustrated taxpayer.

When responsibility has been dodged, the answer is not to allow retirement, but to demand correction, holding people accountable, and set performance standards that include penalties for failure.  Training will have to occur, but cannot happen until written directives, policies, and procedures appear, that form the standard for employees’ behavior not responsible for the designed incompetence created by leadership.

In a “Liberty First Culture,” the adults looking to demand change take the pattern offered by Renlund and recognize the behavioral issues that will need correcting.

“… Blaming others, even if justified, allows us to excuse our behavior.  By so doing, we shift responsibility for our actions to others.  When the responsibility is shifted, we diminish both the need and our ability to act.  We turn ourselves into hapless victims rather than agents capable of independent action.”

Gadsden FlagAmericans [A(h)-ME-I-CAN] are not hapless victims; we stare responsibility in the eye, accepting the responsibility, and choose to act in a manner that shows we have learned the lessons and are prepared to improve.  The time to correct the government that represents us is Right Now!  We must act, recognize the designers of incompetence for the traitors they are, and remove them from employment in government, promptly!

© 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.

Let’s Talk About the VA – The Insanity Must Cease!

I-CareWhen the Department of Veterans Affairs (VA) does something good, I praise them.  The VA recently had a good report come from the Department of Veterans Affairs – Office of Inspector General (VA-OIG), apparently there was progress made in improving performance once policies were written down, training of employees occurred, and over time there has been an improvement, however small and seemingly insignificant.  I offer my sincerest congratulations on making progress and change on this issue.

Carl T. HaydenHowever, I will castigate and deride all abuses of veterans, myself included.  At the Phoenix VA Medical Center, the Carl T. Hayden VA Hospital remains a hotbed of bureaucrats on a power trip weekend from Dante’s first ring.  The abuses at this hospital continue and the leadership needs to be corrected!

For those who do not remember, the Carl T. Hayden VA Hospital in Phoenix, AZ used to be an award-winning hospital, a pillar of good performance, and an example of how VA Hospitals could be run.  Then, the director was changed, the hospital staff changed, awards stopped coming, and veterans started dying.  Leading to the fiasco of dead veterans on paper waiting lists, during Pres. Obama’s reign.  CNN reported on April 30, 2014, that at least 40 United States Armed Forces veterans died while waiting for care at the Phoenix, Arizona, Veterans Health Administration facilities.

On 29 June 2020, I reported to the VA ER sick and in desperate need of assistance.  The assistance was refused because I cannot physically wear a mask.  In my medical records, it is noted that I suffer from shortness of breath and any mask exasperates this problem.  In direct violation of Federal Law that commands all emergency rooms to see whoever walks in, the ER staff refused me service due to the “Mask Policy” as part of their “Covid-19 response.”  No options, no exceptions, no excuses, I as the patient could either endanger my health or find a different hospital ER.

The Emergency Medical Treatment and Labor Act (EMTALA; 1986) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.  EMATALA also dictates that no person can be refused treatment in any Emergency Room.  The EMTALA is not new and is part of the training from day one for all staff at the VA.  For ER staff, this is the golden ticket and special care is taken to ensure this law is followed to the letter; rather, this law is supposed to be the premier standard from which good health care policy is built for emergency rooms.  Except, the Carl T. Hayden VA Hospital in Phoenix, AZ., and the Raymond G. Murphy VA Hospital in Albuquerque, NM., both appear to be the exception to EMTALA, by order of the staff bureaucrats, who are supported in their illegal and nefarious behavior by the hospital administration collectively, and the hospital leadership specifically.

Raymmond G. MurphyI have written previously of the patient abuse I witnessed, and reported, at the Raymond G. Murphy VA Hospital, in Albuquerque, NM.  I have written about the patients turned away by nurses and other staff because these staff members refused to follow the law.  I reported the risks and problems being run by refusing patients in the ER, and this all fell on deaf ears.  Well, I will not stop raising this illegal practice as a major concern for the hospital leadership all the way to Secretary Wilkie and the elected officials in Congress who refuse to act to improve the toxic culture found in the VA.

You, the bureaucrats in the VA cannot break the law with impunity and your actions are leading to major patient safety concerns, increased hospital operating costs, and putting real people in real harm!  I spent more than an hour in the VA Parking lot trying to calm my breathing down to safely operate a motor vehicle, so as to drive to a different hospital emergency room, where I was treated without ever having to deal with the mask issue.  While in the VA Parking lot, I was attended to by three Federal Police Officers who were willing to try and get me seen at the ER but were stuck trying to force the “Mask Policy,” regardless of my physical inability to wear a mask without causing additional harm and injury.  The Federal Officers were called because the ER staff reported a violent and non-responsive patient had just left the building.  I was both responsive and never violent in the ER.  Regardless of the fact that I was extremely short of breath, unable to walk, and unable to be seen at the VA.  When the officers found me in the parking lot, I could barely breathe and was so weak from lack of oxygen that I was graying out in vision and other major issues; thus, how the ER staff can say I was violent and non-responsive is beyond my comprehension.

The behavior of the ER Staff at the Carl T. Hayden VA Hospital in Phoenix is beyond the pale and bordering on obscene, as well as illegal!  Where is the accountability?  Where is the patient advocate?  Where is the Administrator on Duty who has the power to demand corrective action?  Where is the rightful opposition; well, I know where the rightful opposition is, it is buried with the dead veterans, who died awaiting care at the hands of the VA!

VA SealWhere is the patient advocate in this problem; well, that night after being refused care I reported the problem to the patient advocates office via secure message, and the following morning, the patient advocate replies that “It is VA policy to mandate all people wear masks if they desire treatment.”  Not caring about the federal laws governing ER visits, not even bothering to mention that the treatment by the staff as reported was ludicrous and vile, and not even to bother to ask if I was seen elsewhere.  Just a brief, less than 100-word, statement telling me my concerns for my safety and health are not important and policy must come first.  The perfect bureaucrat, with the most detestable response it has been my displeasure to experience since the last time I visited the DMV.

I am sorry but everyone is required to wear a mask at the VA Facility. I understand you may have shortness of breath but you can wear a mask and undo one side every couple of minutes. This is for your safety and the others around you.

T. C. M. [Name Shortened for Privacy]
Patient Advocate

Will someone please explain how this can occur?  Will an elected official please demand a behavior change at the VA, and remain interested long enough to facilitate the solutions Sec. Wilkie needs to effect change?  How many veterans will have to die needlessly at the hands of the VA before the elected officials decide that veterans’ lives matter and the VA is taking our lives?

I get it, there are a lot of problems in America, and more in the world.  But, the US House of Representatives, instead of passing a budget, which they are statutorily mandated to do, is writing letters, and meddling in Israel’s business.  If the US House has the time to meddle and jump down every rabbit hole on the political landscape, they must have time to assist the veterans and improve the VA.  If the US Senate has the time to meddle, postulate, and pander, then they have the time to review the plethora of VA-OIG reports and begin assisting the VA Secretary in correcting the problems in the VA.

The saga continued this over the first two days of July and forms the bitter cherry on top of the crap sundae the VA is trying to serve the veterans.  I received a call from my primary care provider’s nurse who has the attitude of supreme petty authoritarian to a lesser subject, reminding me several times that the mask policy was political, trying to blame all hospitals in the region of implementing a similar policy (which is fake), and then trying to excuse himself by claiming he was just a messenger and not involved in the policy implementation.  Concluding the call, with the temerity to tell me that I was in the wrong to not follow VA policy.  The patient advocate had the effrontery of sending a message to me stating that I should have asked for a full-face shield instead of a mask.  Seeing as no face shields were offered as a workaround, seeing as the policy enforcers demanding only a mask as the single viable and allowed option, and seeing as I spent more than an hour while in extreme pain trying to be seen to no avail, none of that mattered, the patient was at fault, per the patient advocate.

LinkedIn VA ImageMy cherub-like demeanor has taken a bloody beating over this incident.  Worse, my health has suffered tremendously and I have had to question myself and my advocacy of the VA.  The behavior of the bureaucrats and petty authoritarians of the VA at the Carl T. Hayden VA Hospital in Phoenix, AZ is detestable, and I can only conclude and wonder if I am having these problems, what are less outspoken and less knowledgeable veterans suffering?  I will not be the quiet little mouse in the corner where my safety and the safety of other veterans are being endangered by the politics and illegal actions of Federal Employees.  The policy is wrong and needs immediate revision before more veterans die at the hands of the VA!I-Care

© 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/

As the Department of Veterans Affairs Goes, So Does America – A Warning!

I-CareWould the honorable elected representatives please answer the following question: “Are the veterans of America’s armed services the next ‘Tuskegee Syphilis Study?’”

While we await this answer, here is why the question is raised.  The Department of Veterans Affairs – Office of Inspector General (VA-OIG) just posted their investigation results of the Critical Care Unit Staffing and Quality of Care Deficiencies at the Charlie Norwood VA Medical Center in Augusta, Georgia, and the results remind me of the game musical chairs and the disaster caused by the Tuskegee Syphilis StudyTuskegee Syphilis StudyMusical chairs because the VA-OIG was unable to ascertain direct harm because of record screw-ups, gross mismanagement, and a detestable and despicable perception of the patient.  The Tuskegee Syphilis Study because real harm to real people was caused, and the leadership did not care enough to fix the problems without an official investigation.

More on the Tuskegee Syphilis Study – History can be viewed in the link.

The VA-OIG report begins with the following:

“Critical Care Unit Staffing and Quality of Care Deficiencies at the Charlie Norwood VA Medical Center (VAMC) in Augusta, Georgia discusses significant patient safety issues including events related to noncompliance with pressure injury policy, intensive care unit cardiac monitoring, and sitter availability for high-risk patients.”

Pressure Injuries
Bedsores/Pressure Injury Progression

But concludes with the following:

“Publication is warranted so that other facility leaders and healthcare practitioners can be made aware of OIG-identified problems applicable to their own facility.”

Leading me to ask, of the VA-OIG, is this warning to proactively fix, or retroactively hide the nefariousness of poor management and dead patients?

Pressure injuries are exceedingly painful, can become deadly very quickly, and leave scarring and pain.  Pressure injuries are the nice term for bed sores, which are caused by critically ill patients who are already unable to move and circulate blood properly to the skin.  Thus, the tissue dies, a sore develops, then the skin breaks, and by this time that patient who is already in trouble, is now in danger of death.

Pressure Injuries - Example
Bedsore

Bedsores, pressure injuries, are serious conditions; yet, the Charlie Norwood VAMC has record-keeping problems, staffing issues, and without outside impetus refrained from fixing the problems.  All reminiscent of the “Tuskegee Syphilis Study.”

Hence the articles originating question, “Are the US Military Veterans the next ‘Tuskegee Syphilis Study?’”

If so, I refuse, and those leaders who think this conduct is allowable need to be held personally responsible for the harm they are causing.  If the answer is no, why are so many VA-OIG reports of leadership and management’s nefarious deeds being allowed until the VA-OIG comes knocking?  Even after the VA-OIG investigates, is anything being done?  Are people being held accountable?  The leadership issues are repeated, and while those repeats might not be an exact match from VAMC to VAMC, the leadership problems are real, glaring, and real people are dying!

America was shocked and angry when the whistle and plug were finally pulled on the Tuskegee Syphilis Study, and rightfully so.

Tuskegee-Patient
Syphilis wounds

Yet, it appears that the VA learned nothing from the history of Tuskegee except to keep playing musical chairs on responsibility, paperwork, and hiding the evidence from accountability.

America, your medical system, which before President Obama was the best in the world, is now on the same train of failure the VA Medical System is on.  Are you paying attention to the harm caused to veterans?  Do you want the same?  I do not!

America, to correct the problems at the Department of Veterans Affairs, and to reduce the costs to the taxpayers, as well as beginning to correct the damage done to your health care, the following is needed immediately.

  1. Legislation needs to be written and passed repealing ObamaCare.  Every single mandate, every single costly item, and sunder forever this socialism experiment.  The answers to the rising costs of medical care, including dental and vision, are not to be found in increasing the size of an already bloated government.
  2. Legislation needs urgent action to provide Secretary Wilkie the powers of any other CEO to clean the Department of Veterans Affairs. The leadership between the veteran facing employee and the Secretary’s office needs to be culled, and the only way to do this is through legislation.
  3. Demand accountability. The VA-OIG reports these issues constantly, the findings need to be on the news and be topics of conversation.  No longer should a bureaucrat be able to shift responsibility, harm patients, and keep their comfortable jobs and benefits.  Real harm to real people is being caused by the medical system paid for by your tax dollars, demand more!

Understand the following principle, know it well, and let us begin processing the reversal of this trend.  Charles Reich (1964) wrote a Yale Law Journal article describing “New Property.”  The new property Reich discusses is you and me, and how we are used by bureaucrats like property to be abused, harmed, and mistreated, all through the largess of the government we pay for.  Like a wheelbarrow or a hammer, we are the fodder upon which the bureaucrat steals money from one person to pay another person through government benefits, all to the enrichment and personal satisfaction of the bureaucrat.

Government Largess 2The actions of the nameless and faceless bureaucrat are unconstitutional, but allowed in the name of “government action.”  Every time you hear the government is acting on your behalf, it means that the power of the people has been stolen, and will be doled back to the taxpayer in infinitesimal amounts, while the bureaucrat keeps getting fatter.  Think Reich (1964) is wrong, here are some examples.

  • The government went to war against poverty, the poor have become poorer, poverty’s blight has spread, but the government offices “fighting” poverty are fat with people and taxpayer dollars.
  • The government went to war against drugs, the only winner so far has been the government.  The drug infestation has only gotten worse, and now states have begun selling harmful and illicit drugs for the tax money.
  • The government got into student loans, to “make the lending field fairer.” Students were harmed, colleges and universities tripled, or more, their tuitions, and students are saddled with increasing levels of debt.  But, the government officers in charge are living high on the debt and interest.
  • The government allowed labor unions to represent government workers, now the taxpayer is abused, treated like scum, taxes went up, but responsibility and accountability under the “Rule of law,” that all citizens are expected to live by, have all but disappeared for government workers.  Ever tried getting adjudication or remediation from a government worker?Government Largess 4
  • The government and some private citizens decided black health needed improvement. Planned Parenthood and the Tuskegee Syphilis Study are but two of the disasters that hit the black communities and have destroyed their community’s legacy, honor, and power, all for government largess, and the lining of private pockets.

Choose to stop being the property of the government; the US Constitution declares the government works for us, and we control them, not the other way around!

© 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/