NO MORE BS: Memorial Day 2021 – Are you sure this is “proper” remembering?

Knowledge Check!It is no secret that the Department of Veterans Affairs (VA) is a sick and twisted organization.  It is no secret that the Department of Veterans Affairs – Office of Inspector General (VA-OIG) tries to recommend how the VA should be operating in accordance with currently established procedures, methods, and policies for the benefit of the veteran community.  It is no secret that I continue to write about the VA in the hopes of sparking interest in communities and obtaining more fair, honest, transparent, and humane treatment for veterans by the Government agency tasked with caring for veterans.

On this Memorial Day, as you sit down to barbecue, family, friends, sports, I would ask that you take a moment and consider if this were how you would like to be remembered?  Are the actions described proper for remembering those who sacrificed and came home?  Are these actions, which are adding to veteran funerals, an appropriate way for veterans to be leaving this world?  If the answer is no, I ask for your help changing the Federal Government by electing people who will scrutinize the government more stringently and demand change in all government agencies.  If you deem this behavior acceptable, please leave a comment detailing why you think so.  I want to hear your thoughts.Image - Eagle & Flag

From a VA-OIG report published on Wednesday 26 May 2021, we find the following announcement:

Phillip Hill, a former VA program analyst, was sentenced to 46 months in prison for stealing personal information from veterans and VA employees while employed at the Central Arkansas Veterans Healthcare System. The investigation revealed that Hill contacted another individual and attempted to sell personal identifying information to a buyer for approximately $100,000.”

Now, I am thrilled this guy was caught.  I am glad he will do time behind bars.  Yet, why did Assistant US Attorney Jana Harris allow a plea deal?  Where are the VA supervisors who should have been monitoring this employee’s work and behavior?  What are the details of the deal?  The VA continues to have nothing but IT/IS security, and these problems are decades old.  Still, the elected representatives allow the criminal behavior to exist until the criminal is caught, and then the elected representative’s crow about cleaning the swamp.  Is this how you correctly remember veterans, their sacrifice, and their memories?VA 3

I suppose the following VA-OIG report, released 27 May 2021, should begin with congratulations.  The Department of Veteran Affairs – Veterans Benefits Administration (VBA) mostly processed monetary proceeds records accurately.  However, the following continues to astound and amaze me:

Service and pension center staff do not have timeliness measures for proceeds incorporated in their performance standards. Setting a timeliness standard would help encourage the closing of these proceeds. The OIG also found that ineffective monitoring contributed to delays in handling proceeds. The Debt Management Center had only limited internal monitoring but instituted new practices for monitoring proceeds in February 2020, shortly after this audit began” [emphasis mine].VA 3

Why are government employees not held to a productivity and quality standard?  Being a veteran with regular concerns involving the VBA, I cannot help but wonder why quality and productivity are not required?  As an industrial and organizational psychologist, the first step in improving responsiveness to customers is to increase productivity and implement quality measures.  I know the Federal Government’s legislative branch, e.g., Congress, has insisted on developing quality measures.  Yet, the same tired excuses built upon designed incompetence are allowed to survive, and all the VA-OIG can do is issue more recommendations.  Consider something; proceeds include payments to dead veterans.  How much financial hardship occurs at the passing of a loved one?  How much more difficult can that death become when months down the road, money spent is suddenly being demanded back because some incompetent bureaucrat failed to do their job in a timely manner?

QuestionIs this properly honoring and remembering the veterans and their sacrifice?  Is this behavior acceptable in your workplace?  Why do we allow this behavior from government workers?

While never having been a patient at the Chillicothe VAMC in Ohio, I have friends who are patients.  The stories they tell about care there would shock and amaze many.  What infuriates me, the VA-OIG just published their report of a comprehensive inspection of this VAMC, and the results are as tragic as a veteran’s death!  The information was released to the public on 27 May 2021.  Never forget, the Chillicothe VAMC in Ohio was recently investigated for improper cleaning and sterilization procedures, as well as employee monitoring for compliance for medically reusable equipment, which for this case refers to endoscopes.  With this fact in mind, let us review the comprehensive inspection report.

Limitations on findings:

      • The VA-OIG held interviews and reviewed clinical and administrative processes related to specific areas of focus that affect patient outcomes. Although the VA-OIG reviewed a broad spectrum of processes, the sheer complexity of VA medical facilities limits inspectors’ ability to assess all areas of clinical risk” [emphasis mine].

VA 3The statement provided here is pretty standard and represents the first limitation to the scope of the investigation; complexity limits inspector ability.  Yet, who made the VAMC so complex, the VA.  Who has allowed the complexity to grow as designed incompetence, the VA? Why is the VA allowed to cheat their inspector general through complex operations which limit inspector ability and increase patient risk?

The Focus of Inspection (Investigation Scope):

      • The VA-OIG team looks at leadership and organizational risks, and at the time of the inspection, focused on the following additional areas:

WhyLong have I wondered why the second item in the comprehensive inspection is “Quality, Safety, and Value.”  When the VA continues to present the bare minimum of quality, disregards patient safety, and due to complexity, offers less value than a broken wrench to a mechanic, but I digress.

Finding One:  The VA-OIG issues 12 recommendations to the leadership team, and “selected results showed respondents were generally favorable the national VHA results.”  I have been accused of being cynical, which generally is wrong.  However, when I see words like “selected results” in an investigation into patient care and concerns, I have to ask, “How hard did the VA-OIG have to dig to find favorable results?”VA 3

Finding Two:  Strategic Analytics for Improvement and Learning (SAIL) represents a value model to help define performance expectations within VA.  This is the standard language for comprehensive inspections.  “In individual interviews, the executive leadership team members were able to speak in-depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences.”  If we accept this as a true statement.  How was an employee able to fake documents, fail to clean reusable equipment properly, and repeatedly get away with this abysmal behavior at this VA?

VA 3Finding Three:  Under Quality, Safety, and Value, we find the following tidbit:

The VA-OIG noted concerns with protected peer reviews, utilization management, and root cause analyses.”

Essentially meaning there are problems with whistleblowers, privacy protection, retaliation against whistleblowers, proper utilization of policies and procedures, and the leadership could not find a problem using root cause analysis if their lives depended upon it.  The source for my interpretation of the VA-OIG results arrives from the following:

VHA Directive 1117, Utilization Management Program, 8 October 2020. Utilization management involves the assessment of the “appropriateness, medical necessity, and the efficiency of health care services, according to evidence-based criteria” [emphasis in the original report].

I have to ask the VA-OIG whether these findings were before or after the employee who endangered patient lives through improper cleaning and sterilization of reusable medical equipment were discovered?

VA 3Finding Four:  Under medication management, we find the following:

The VA-OIG team observed compliance with many elements of expected performance, including pain screening, aberrant behavior risk assessment, and documented justification for concurrent therapy with benzodiazepines. However, the VA-OIG identified opportunities for improvement with urine drug testing, informed consent, patient follow-up after therapy initiation, and quality measure monitoring” [emphasis mine].

VaccineIf you read any of the comprehensive inspection reports, you will see this is a common and recurring theme at the VA.  Some of the medication policies are being followed, but the same problem with drug testing, informed consent, patient follow-up, and quality measuring monitoring always remain a problem.  It is almost as if the SAIL learning matrices do not even exist as a quality improvement tool.

Finding Five:  Under High-Risk Processes, the VA-OIG report claims the following:

The medical center met the requirements for quality assurance monitoring and monthly continuing education. However, the VA-OIG identified deficiencies with standard operating procedures, an airflow directional device, and staff training and competency” [emphasis mine].

Are the SAIL metrics even accurate?  Where is the value in the “monthly training and monitoring if there are issues in following standard operating procedures, problems in staff training, as well as staff competency?  Do you get it?  The training sucks at the VA, and the SAIL metrics do nothing to fix the problem, address the deficiencies, or even improve competency?  The same question arises here, from quality, safety, and value; how was an employee able to successfully pencil-whip the paperwork while not doing their job in properly cleaning and sterilizing reusable medical equipment?  Where are the SAIL documents that should have identified a problem?  Where are the SAIL metrics in aiding in finding root causes for derelict employees?VA 3

Honestly, do you, the taxpayer, consider the Department of Veterans Affairs, which covers the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries adequate to remember the veteran correctly?  Do you, the taxpayer find value in the leadership and investigative arms of the VA to correct and improve performance?  Do you, the taxpayer find that the VA employees are doing their level best to honor, remember, and pass on the legacy of veterans?

Image - Eagle & FlagOn this Memorial Day weekend, please consider the data in this and the other VA-OIG reports regularly relayed on this blog, and ask yourself, are you doing enough to help veterans?  I love Memorial Day, and I love my country, but America has some serious problems, and only when the electorate awakens to the issues can real change begin to be implemented.  We, the veteran community, need you!  We need your voice as we struggle against the incessant attacks from the VA.  We need your votes for the elected representative’s intent on scrutinizing the government and demanding action.  We need you!  Please help us!

© 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.

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

I-Care

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.