Uncomfortable Truths – An Open Letter to the Department of Veterans Affairs and the Congressional and Senatorial Representatives of the United States of America


I write by way of greeting; I write by way of exhortation to action, as the current status quo is reprehensible and unacceptable.  Uncomfortable truths are those realities where bureaucracy has superseded logic and leadership, creating situations where the harm of the patient/customer is the first and only business.  There are good people at the Department of Veterans Affairs; but, these people are being crushed by the bureaucracy, the stifling mental inertia, and the lack of actionable leaders to propel change at the Veterans Benefits Administration (VBA), the Veterans Health Administration (VHA), and the National Cemetery.

An example of uncomfortable truths: I witnessed a veteran enter the emergency room of the VA Medical Center, and be actively, but passively, abused.  Because he was a regular, and sometimes came in and was obstinate, and because he was homeless, he had a history with this emergency room and staff.  The staff actively overlooked him, they talked bad about him, they cussed him out behind his back, and his service was suboptimal at best when he was finally treated.  As this veteran was not the only one being treated in this manner, this was brought to the attention of hospital leadership; the person reporting the abuse was terminated without cause.  This is a leadership issue, a process problem, and an excuse not to change.

Another example of uncomfortable truths: the VBA needs/wants “New and Material Evidence” to process/review/correct a claim.  The Primary Care Provider and all specialty clinics at the VA cannot provide “New and Material Evidence,” as they are not diagnosticians.  Thus, the veteran is left stuck between two bureaucracies that refuse to help, because the rules do not allow the providers to help; this a leadership problem and a process issue.  How can the veteran afford outside insurance to obtain the “New and material evidence?”

Earlier this month, the OIG sent out a report over death at the VA due to leadership inefficiencies and can be found here, VA-OIG report.  Over the last week, three more incident reports have been discharged from the VA-OIG.  Report 1: Has a veteran dying of suicide, because the decision-making process, a process designed specifically to improve communication to aid high-risk patients were not implemented, tracked, and reported properly.  The decision-making process is expected to employ a full patient-care team (PACT) in evaluating and making decisions that affect the patient’s care.  The process was not followed, and the veteran who is already at high-risk for suicide and known to the PACT was deactivated, leading to a veteran’s death.  The VA-OIG made a recommendation to improve the process, the same process that was disabled, leading to a dead veteran.  How does this make sense?

The uncomfortable truth is multi-faceted in this case.  Leadership does not do record audits to ensure the deactivation of high-risk patients does not become “lost” in the bureaucracy.  Leadership is not flagged when the PACT disagrees with the treatment of a patient.  Finally, the VA-OIG has no teeth to reprimand, insist, and improve compliance; they can only make recommendations after the fact.  Congressional representatives and Senators, you allowed the VA to have its own dedicated inspector general, why?  What will you do to enhance the leadership at the VA?  Do not tell me again; we will hold “Committee Meetings.”  These committee meetings have been, and continue to be a feckless waste of taxpayer time, money, and never addresses the core issues apparent.

Report 2: Covers a veteran needing an appendectomy and had to wait for three hours for the surgeon to become available to perform the surgery.  The VA-OIG confirmed the delay in care, but essentially settled for, “Well, the patient lived, so no problem here.”  If that statement seems overly simplified of the process, tell me why the patient had to wait.  Why pay records and timekeeping records were messed up for a single month (May 2018), and how pay and timekeeping records got messed up in the first place.  The VA uses a national system for reporting time worked, but not all employees use the same payment system.  If true, why aren’t all employees, to include residents, surgeons, and staff using the same pay system?  The wait is blamed on poor communication, communication in scheduling surgery, communication between resident and surgeons, and communication because the “appropriate documentation” was insufficiently maintained.

I know from sad experience that there are nurses and doctors who write things down in notebooks, on scrap paper, and on paper charts, when the computer on wheels (COWS) is readily available.  The excuse is always, “I am too busy to use that thing.”  I know the VA has spent an excessive amount of money to get digital records, installing digital records, getting digital records to work when needed, and delivering the digital record available to mobile stations to document what is happening with the patient.  I have some grave concerns for checkbox medicine; but, blaming a surgical delay on improperly maintained documentation remains a wholly inexcusable and unacceptable statement in an official investigation.  Why was this lame excuse allowed to stand?

Report 2, exemplifies a multi-faceted problem presenting a need for a multi-faceted approach to correction.  Leadership at the hospital must be actively engaged, ensuring processes and procedures are optimized to deliver the “I-CARE” customer promise.  Communication chains are a leadership tool, and when broken, correction demands accountability and responsibility to resolve correctly.  Reporting is a leadership function to ensure liability and corrective action as a normal operating procedure.  Did anyone ask why the documentation was not maintained?  Was this lack of documentation maintenance a design flaw to hide what happened during this incident as an extension of designed incompetence?

Report 2, demands answers on two distinct issues double-dipping, and the continued practice of collective design incompetence. Double-dipping by providers working for the VA at the same time they are working at other medical institutions, is this occurring?  Why?  I understand there is a provider shortage at the VA.  I know doctors need to make money, and doctors make money by seeing patients, surgeons make money performing surgery.  The VA-OIG report appears to gloss over the practice of double-dipping e.g., on-call from one hospital while working at another, or working at another hospital while the VA expects you to be at their hospital.  Senators and Congressional representatives, are you investigating the potential for double-dipping?  Will it take a dead veteran before you even care about double-dipping occurring?  I make no accusations; I am asking honest questions on this issue in an attempt to learn more.  Will you do the same?

One of the most egregious problems at the VA is designed incompetence to allow a malefactor the ability to hide behind bureaucracy to avoid accountability and responsibility.  Designed incompetence remains a significant problem and I do not see any of the mid-level managers, leaders, supervisors, trainers, etc. acting to eliminate designed incompetence to the improvement of the Department of Veterans Affairs.  During President Obama’s Administration, I watched a Congressional Committee meeting where whistle-blowers were invited and testified about the designed incompetence that allows for an individual to pass the buck, duck responsibility, and protect their jobs and power at the VA.  I keep discussing design incompetence, because the mid-level managers, directors, and supervisors at the VA refuse to address and correct this issue.  Senators and Congressional Representatives, why do you allow this practice to continue?  Did you know that this is the primary method for discriminating and harming whistle-blowers?  Of course, you did.  I have seen several committee meetings where this exact issue was discussed, and the bloviation from the committee does nothing.  You are the leaders in our Republican Society, when are you going to act, in concert with Secretary Wilkie (who’s doing an exceptional job), correcting and insist these practices cease?

Report 3: Involves 60,000+ veterans, is this number sufficient to warrant permanent action on the proper billing of insurance companies and veterans, or does this number need to exceed some other level before it warrants your attention.  If a different level is required, what is that magical number?  I guarantee that veterans from all states and territories are involved here, as their representatives, what will you do?

Directly from the VA Website, we find two different uses for funds collected:

  • “VA is required by Public Law 87–693; 42 USC. 2651, commonly known as the Federal Medical Care Recovery Act, to bill the health insurance carrier that provides health care coverage for Veterans to include policies held by their spouse. The money collected goes back to VA medical centers to support health care costs provided to all Veterans.
  • Funds that VA receives from third party health insurance carriers go directly back to VA Medical Center’s operational budget.”

You, the elected officials of the Republic of the United States of America, enacted these laws and improper billing of veterans and insurance companies, causes financial harm and distress; this is your problem!  Do you understand that even if money is returned to a veteran, the financial injury has been done?  Those veterans who have paid a bill, or the insurance company that paid a statement, they didn’t need to pay is an interest-free loan to the government, and this is wrong!

There are literally tons of money at stake here; I know my local VA Hospital said, “The funds collected when we bill insurance companies come directly to this hospital for construction projects, renovations, new equipment, and so forth.”  Report 3 is but one of how many VA-OIG reports where improper billing is occurring. Incorrect billing drives the cost of healthcare up.  Hence, Obamacare costs more because the VA is not accurately billing.  Medicare costs more because of improper billing.  You the elected officials are directly responsible for ensuring proper billing occurs as an aid in reducing the costs of healthcare.

Where are you? Will you act?


© 2019 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.

Hopelessly Confused: “Peace Be Still.”

I was casting around for a topic to write about and came across regarding leadership and decision-making when two topics, combined into the same single strand, thought, came into focus. Addressing the question, “how does one change their mind?” From one of my favorite authors, Robert Fulghum, author of “Everything I need to know I learned in Kindergarten, Uh-Oh, and several other books” comes a thought, “Hopelessly Confused.” This was a sign a woman was holding in Mr. Fulghum’s neighborhood witnessed by the author several times over a period of days/weeks and discussed the book referenced.

The other topic comes from the final phrase in James Allen’s “As a Man Thinketh” (1903) treatise on the mind, how the mind matters, and philosophy of thinking. Mr. Allen discussed the “tempest-tossed souls,” “whose thoughts are controlled” by the winds and storms of life instead of the other way round where control of thinking improves the steadiness and serenity of the individual. The idea is that one’s thoughts influence outcomes and becomes reality.

For many months, I have had as a status on my student profile at the University of Phoenix, the following, “Thoughts become things. QED how we think determines success.” I taught a class where we discussed this exact topic. Thoughts leading to words, words becoming actions, actions producing a product, and that product in turn, generating more thinking, thus fulfilling the cycle and moving the soul further down a path, regardless of whether that path is valued as good.

James Allen adds another interesting aspect to this puzzle, “Serenity is the last lesson of culture; it is the flowering of life, the fruitage of the soul.” “Peace be still!” Bringing to point the idea, choices and thinking remain relevant to the one who would enjoy serenity. Peace is a choice; thoughts, properly controlled, are choices; developing that choice, protecting, harboring, and controlling the ability to choose drives the choice and the result is serenity.

If the thoughts driving action are based upon choice, then “hopelessly confused” was a choice. The woman holding the sign chose to be confused, and the endless running of that thought placed her in a position to become “hopeless.” Let us take a moment to explore these two words for a moment. “Hopeless” as defined by Webster includes the terms “inadequate; incompetent; feeling despair.” Confusion as defined by Webster, contains the following: “the state of being unclear in one’s mind, lacking understanding, and embodying uncertainty.” Hence, the reader is left with a state of mind regarding personal inadequacies or incompetence leading to despair.

Since confusion is a state of mind, correcting thinking on the individual’s part remains a concrete action to be personally undertaken to end the current state of mind and discover a new state of thinking and acting. Yet, what would be the impetus for beginning this process of mental change, choice. Some religions would call this agency or the individual’s personal ability to choose. Many choices remain transactional in nature; we as individuals see value in a different track or course of action, and from that desire for increased value comes the motivation to exercise agency and choose.

At this moment in the choice cycle, the individual does not know that value will come and improve the current situation. The individual has simply completed a mathematical formula and discovered potential for a higher value in a different course of action. The next step moves from inaction to action, from thinking to doing, taking the information gleaned and applying it in a fundamentally different way to realize the desired, but still elusive, potential. By taking action, the individual has shifted slightly and this shift, while ever so slight, over time has energy to achieve greatness.

A religious leader, President Dieter F. Uchtdorf (2008), himself a pilot, described the change as “a matter of a few degrees.” Using an airplane analogy, the young pilot is only off a minor tenth of a degree, then corrects the course, then drifts ever so slightly to a new heading. Over time, the plane is now several hundred miles off course and the young pilot in serious trouble. The same can be said for the confused person, the slight change in position, over time, brings innumerable changes in thinking, understanding, and action into a life. While failure to change, drives the same individual further and further down the path of “hopelessly confused.”

Regarding highways, the degrees needed to change from one highway to another without a cloverleaf is generally 10-15 degrees. Starting small, tenths of a degree, time and distance become the variables of great change. Provided proper planning for the lane changes are made, the movement from one highway to another can be done quickly, easily, and safely, without undue wear and tear on the vehicle at highway speeds, which places the next step firmly into the thinking process, planning. Proper prior planning of thoughts takes understanding the variables, naming the problems, and plotting change.

Planning new thinking entails knowing what the end goal should look like. For example, if the starting point is “hopelessly confused” and serenity is desired, then serenity is the end goal or state of mind. This holds true for all desired end states; to plot and plan effectively, one must first know where to go. The second step in planning is knowing that which motivates the change. For example, what condition is driving a desired change in thinking; name the variables or individual desires feeding the change. Planning requires understanding these motivators on a level deeper than intimacy. Finally, the best plans remain flexible but fixed. While this might sound like a paradox, it is not.

Fixed but flexible speaks to the desired end state, not the journey to that end state. While the desired end goal remains serenity, understanding that the journey will involve and necessarily require setbacks, reroutes, and difficulties. The end desired goal thus remains fixed, and the journey to that end desire will fluctuate. This is the same thinking military commanders use when attempting to overcome obstacles. Fluidity in planning and flexibility in application provides for making mistakes, for opposition, and is a learned thinking trait that must be trained into operational thinking.

Finally, James Allen provides the concluding actions in changing mental states. “Self-control is strength; right thought is mastery [of self]; calmness is power [to break the mental chains which bind]. Say unto your heart, “Peace be still.” The mental change does not happen overnight, rarely occurs with the first attempt, and will always resemble the pattern of an hourglass, but like the hourglass, moving between areas is possible, requiring both effort and time. As the narrow neck that limits change becomes closer, understand this constriction, sometimes experienced as restriction of choice, and lack of growth is only temporary. Change is coming and with change comes freedom. This hope for additional freedom is required to maintain that effort to change. Agency starts the adventure of change, hope sustains the journey, motivation and desire feed the fires of hope, and the power generated by hope’s fuel propels the change. To thy heart, “Peace be still.”

 © 2016 M. Dave Salisbury

All Rights Reserved



Allen, J. (1903). As a man thinketh. New York, NY: Grosset & Dunlap.

Fulghum, R. (2007). What on earth have I done? Stories, observations, and affirmations. New York, NY: St. Martin’s Press.

Uchtdorf, D. F. (2008, April). A Matter of a Few Degrees. Retrieved June 20, 2016, from https://www.lds.org/general-conference/2008/04/a-matter-of-a-few-degrees?lang=eng&_r=1


Shifting the Leadership Paradigm – Escalation of Commitment

The question exists; does “rational escalation” exist? How does a leader capture the power of commitment without inducing irrational escalation issues in team actions? Rational escalation remains a fallacy in decision-making and remains an excuse to create illogical paradigms for business processes and pretend non-rational escalation does not exist. If a decision begins as irrational, or an escalation of previous decisions without conscious need and new logic, denying the rational does not change the problems created.

Non-Rational Escalation of Commitment is best defined as, “the tendency to base new decisions on previous decisions.” This quote sums it up well: “If at first you don’t succeed, try, try, again. Then quit. No use being a damn fool about it.” W.C. Fields. (ThinkExist.com, 2009) In the most simple terms, people make a decision, get used to the consequences of the decision, become complacent in the known outcomes of the decision, base more decisions off the current model, and then repeat ad nauseam. Political decisions regarding the Federal Medicare Program are perfect examples of non-rational escalation of commitment. Politicians know there is waste, abuse, and issues within the system; but because it looks good to support Medicare, no one wants to begin to question the problems, advance solutions, or threaten withholding funding until the problems are fixed.

Since the problems with Medicare touch sensitive nerves with voters, politicians prefer a favorable electorate. Each year waste and abuse reaffirm the theory of non-rational escalation of commitment. “… Medicare’s administrative costs are shockingly low, below 2 percent of costs, because Medicare is shockingly unsupervised. The amount of fraud and waste is huge, and supervision of the quality of medical care provided recipients is largely nonexistent (NY Times, 1997, para 1).”

The emotions surrounding many decisions lead people or decision makers into trouble. Pride, confidence, fear, greed, a desire to do good, etc., are emotions that provide the impetus for making a particular decision. Continuing on the same path of that decision, whether right or wrong, leads to an escalation of the decision; thus, ensuring the risks of failure becoming larger as time passes. We see this currently on the ObamaCare Health Debate in Washington. Politicians have invested a lot of time and energy into the President’s “signature issue” and refuse against all logic to stop, examine the needs of the people, and accept it might be better to start over again. “… [A]sk people with direct ties to healthcare negotiations, who have put their lives on hold to get a bill passed, and they have no idea how to move forward (FoxNews.com, 2010, para 2).” The same problem exists today in 2015 as in this 2010 proclamation simply due to emotional investment and irrationally escalating poor decisions.

Escalation is non-rational for one reason: it always leads to trouble. Going back to Medicare waste, leaders recognize the problem, realize there is tremendous abuses of the system occurring, but refuse to stop escalating the amount of money to spend and force change due to fear. As shown with both ObamaCare and Medicare, when fear is the motivating factor for a decision, basic human emotions are the only force and the most difficult force to overcome. Logic has fled, reason is hiding, and chaos is gaining speed. Consequently, in the Medicare system the American people have tremendous unfunded liabilities with no possible method for making good on the commitments. Since there is momentum in sustaining the poor decision, momentum in continuing to escalate the non-rational decision-making process, and momentum to perpetuate abuse and fraud without recourse, the cycle of escalation and abuse will continue, thus fulfilling W.C. Fields quote from above, “If a first you don’t succeed, try, try, again. Then quit. No use being a damn fool about it (ThinkExist.com, 2009).” The “quitting” part of the decision paradigm needs attention. Einstein adds a special note here on non-rational decision making practices, “Insanity is doing the same thing over and over again, expecting different results (Brainy Quote, 2008).”

            Understanding the irrationality in the escalated decision making process provides the impetus to leaders to begin changing the process of gathering data to improve decisions. The smart leader would halt the current decision-making process, ask probing questions about performance, customer service, and sustainability, then proceed to either justify continuing to make the decisions to engage without change or change the decision track to achieve different outcomes. I have heard the following too many times, “Taxpayers would be scared if the government was efficient, not wasteful and productive.” I disagree; elected leaders must on-board basic leadership principles, shun management philosophy, and then communicate in a two-directional manner their ideas, their reasoning, and logic. The expectation is for business leaders to act in this manner; why do elected officials get a pass on leadership?

The engaged leader will take the decision-making process and implement the following steps to improve decision-making performance as a step to improving organizational outcomes:

  1. Ask “Why.” This is a basic and simple step to take that possesses great potential to improve organizations. Asking “Why” leads to other basic questions arising, namely, “How,” “Who,” “What,” etc. Follow the string of logic and an irrational and escalated decision will be forthcoming.
  2. “Be strong and of a good courage,” remains a passage from the Christian Bible, repeated several times, that holds the key to improving decision-making, regardless of religious flavor. Think about the question asked. The leader is asked to stand for principled action and then boldly move forward in the direction chosen.
  3. Practice being aware. Being aware calls for the leader to be and remain engaged in the people, not the business, of the decision-making process. Tom Clancy, in the “Jack Ryan Novels,” made clear that the problem in Washington D.C. is not the politicians who change but the staff of the politicians and the special interest groups pushing a narrow agenda. The same process occurs in business organizations. People carve out a niche, develop power, gather those like themselves into a micro-network, and then influence organizational change and non-rational decision-making as a means to continuing in power.
  4. Make a decision, Act, Measure, Correct if necessary, Repeat (MADAM-CR) remains an acronym to remember and follow. Leaders make timely decisions, act, and then review for potential course correction changes or hold the course. MADAM-CR remains the pattern for making logical decisions, provided the first three steps discussed have been included.
  5. GIGO (Garbage In equals Garbage Out). GIGO remains the umbrella principle in decision-making. GIGO with non-rational escalation provides the input and product from the decision-making process. GIGO stands as the ultimate caution, not to halt action but to improve measuring for success and properly preparing.


Brainy Quote, (2008). Albert Einstein Quotes. Retrieved December 5, 2008, from BrainyQuote.com Web site: http://www.brainyquote.com/quotes/quotes/a/alberteins148814.html

FoxNews.com, Initials. (2010, January 22). Congress contemplates scaled back healthcare; obama slams door. Retrieved from http://congress.blogs.foxnews.com/2010/01/22/congress-contemplates-scaled-back-healthcare-obama-slams-door/

NY Times.com, Initials. (1997, August 01). Fraud and waste in medicare. New York Times, A-30.

ThinkExist.com, Initials. (2009). W.C. fields: quotes. Retrieved from http://thinkexist.com/quotation/if_at_first_you_don-t_succeed-try-try_again-then/227395.html

© 2015 M. Dave Salisbury

All Rights Reserved

A Consideration for Organizational Leaders

            Kahneman (2011) in discussing decision-making expounds upon heuristics and biases in showing how intuitively reached decisions usually are not intuitive at all. This process of decision-making advances through understanding Miles and Snow (1978) discussion regarding how structure and process constrain strategy. Miles and Snow (1978), quote fellow researchers March and Simon (1958) and Cyert and March (1963), on how organizations limit uncertainty in decision-making through the structure of the organization and the processes in the organization. This is a bedrock principle to understanding how any organization reaches a decision, whether the decision is to produce a certain product or hire a particular employee, Miles and Snow (1978) suggest that decision makers are so influenced by the structure and processes that limits and boundaries become more important than the idea. Miles and Snow (1978) begin their work with a discussion, based upon Chandler’s (1962) work, that strategy and structure link eternally and that the structure of the organization imposes both an adaptive cycle and strategic-choices upon an organization. These principles of strategy, discovered before leaps forward in desktop computing, have not changed with the human interaction to high technology, only enhanced by human technology. Thus, a bias in decision-making is the organizational structure and if the organization desires to improve decision-making by lower level managers and employees’, reducing the bias influence of the organizational processes remains crucial. At this point, many might claim, the dated materials from Miles and Snow (1978) render the argument null and void, except when examples emerge of this philosophy in action. For example, ENRON, the organizational structure purposefully changes to fit the new leadership style of the incoming CEO. Shortly after the new CEO takes the helm, lower-level employees begin making decisions based upon the new organizational structure mimicking the decisions of higher-level managers, directors, vice presidents, and the CEO. When this occurs, ENRON begins to come apart at the seams as an organization and ethical practice replaced for the flaunting of rules and regulations. The organizational rot or organizational cancer spread from the CEO to every employee along the organizational structure, until the problem became so big and engrained that only complete destruction of the organization could save the employees, the community, and the customers (Dandira, 2012; & Miles and Snow, 1978).


Dandira, M. (2012). Dysfunctional leadership: Organizational cancer. Business Strategy Series, 13(4), 187-192. doi: http://dx.doi.org/10.1108/17515631211246267

Kahneman, D. (2011). Thinking, fast and slow. New York, NY: Farrar, Straus and Giroux.

Miles, R. & Snow, C. (1978) Organizational Strategy, Structure, and Process. New York: McGraw-Hill


© 2014 M. Dave Salisbury

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