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.

Society Needs the Family – Knowing the Paradigms That Shape American Society

School of DarknessA colleague said I should read a book, “The School of Darkness,” by Bella V. Dodd.  As an immigrant in the early 1900s, the book is discussing coming to America, losing one’s belief structure with its tenets, traditions, and ties that bind, and discovering the emptiness of society, which tried desperately to replace the family and religion.  The author only discovers this emptiness and the need for family and religion after a lifetime of fighting against the influence.

The ideal family, found in many cultures, religions, and communities across the world is of one father, loving one mother, and raising children in what is called a nuclear family.  Early in the 1900s, the families with close ties as a family, who kept the traditions of religion, found in America plentiful opportunities and made strong the American Society.  Those nuclear families without strong ties to a belief structure weakened American Society, but not in ways or methods cognizant at the time, and only understood through historical observation and dissection.Nuclear Family

Consider, for a moment, James Hardy’s writings (2015) on divorce in America; in the Colony of Massachusetts Bay, there was created a judicial tribunal that solely settled divorce matters in 1629. “This legislative body could grant divorces based on adultery, desertion, bigamy and in many cases impotence. In the North, the colonies adopted their own approaches that made divorce available, whereas the southern colonies did all they could to prevent the act even if they did have legislation in place.”  Notice the distinction between North and South that was apparent in pre-Revolutionary and Civil War society supporting both conclusions needed for a strong community, family, and a common religious belief structure.

Fast forward to 2020, and the current divorce rate is 2.9:1000 reporting from 45 states and the District of Columbia.  With the medium marriage lasting 11 years and falling, and around 30% of marriages suffering disruptions leading to divorce.  The future of the nuclear family in America remains grim, unless fundamental changes in, and desires of, people change; America is soon to disappear.  The American Civil War taught this lesson well, the need for strong families, based upon a core belief structure that lifts the human mind from pettiness, selfishness, and authoritarianism, remains the two keys an individual will control to keep the American Republic safe from enemies foreign and domestic.

Role of ReligionWhich religions lift the soul, I do not speculate; however, I can tell how you can tell.  The answer is the same from generation to generation, first know yourself.  Second, research the religion’s works.  Finally, seek religions that bring light to the world sickened mind.  I have known great and good people in all the different sects of religion in this world.  The key I have found comes in living the religion, not just professing that religion.  As one lives that religion the tenets of that religion will either inspire, uplift, edify, and grow the spirit and the soul, or it is time to find a new religious structure.  Regardless, before the traditions of religion, the traditions of the family must be understood and cemented together.

Religion QuoteThe Jewish religious tenets are deeply respected by this author for the blend of family and religion that is born from the belief structure.  Some Catholic tenets speak to the same family and religious mixture, several Christian religions also speak to this mixture of home-based family-centered religion.  The Muslim faith tends to support a community based around the mosque, and not as much on the individual family.  The religious foundations and actions of The Church of JESUS CHRIST of Latter-Day Saints are very like the Jewish religious beliefs, the Amish, Quakers, Dutch Calvinists, and more who also carry a strong family first, religion second, approach to building strong communities through strong religious traditions, by first focusing upon the family and home-based religious practices, building into strong religious communities, and then to strong and morally upright citizens.  Yet, I have witnessed the same in Atheist communities, where the beliefs of non-belief led to strong families asking questions, seeking truth and developing the person through strong familial bonds.

Building a child, with strong familial bonds, which will then build a community, a state, and a country, is the work of two parents in a nuclear family.  But what supports the parents in the difficult job of rearing children, the local community and the extended family are helpful and needful, but most important traditions of belief.  Dodd in, her book, reflects this lesson as she taught freshmen in college, generally from tearing the student from improperly rooted belief structures and transplanting them into the heady and hedonistic thoughts of social families replacing nuclear families, shucking religious traditions in the process.

Religion Quote 2Why is Communism doomed; because it attempts to replace the family with the government.  Why is Socialism doomed; it expands the power of government until the government becomes Communist and tries to replace the family with the government.  Why has Capitalism been such a breath of fresh air to the world through the American Republic; because it leaves the family alone from the fingers of government intrusion.  Government intrusion, which chokes the agency of man for the mind control of the government.  Fascism was doomed to failure, for it worked hard to replace the family with social groups, social families, and corroded the human spirit until nothing but violence and rage remained.  Does this sound familiar; it should, for this is the same path being used in education in 2020, learned in the early 1900s, and dedicated to the eradication of America through slow corrosion.

Religious ThoughtAs an older child in a large family, with a large extended family, I once asked, “Why do we gather as an extended family with all the expense, the work, the travel, the hard feelings, etc.?”  The answer never made sense to me then, and makes less sense now; yet, there is a truth in the answer that is more felt than understood, “We do it for family.”  In the movie “Fiddler on the Roof,” Tevye sings about “Tradition” and how familial and religious tradition extends into confidence and strength for the individual to understand who they are in society, and by extension in a country.

From the nuclear family comes confidence in knowing one’s self.  Does this mean that non-nuclear families are inferior; no!  It simply means there is a larger role for extended families and the community to render assistance.  Yet, the extended family and community cannot replace or render invalid the responsibilities of the parents.

Consider two families.  Family A loses their father as the oldest is just entering high school, the youngest daughter is just barely 18-months.  The mother is left to raise the family having married her high school sweetheart.  Family B is a product of divorce, the mother has custody of the children, and she and her new boyfriend work two jobs apiece, leaving the children to fend for themselves except when the grandparents can “take the kids.”  Family A the children continue to heal from their father’s abrupt passing and are strong in family and faith.  Family B the children have no roots, and they struggle with the religion of the parents and grandparents.  They struggle because their mother has no religious connections due to both employment and lifestyle choices.  The children are good kids, but they are confused, and the person who could settle their confusion, has abdicated the responsibility, and the grandparents can only do so much as partial parent replacements.  While the extended families and communities surrounding both families help and support as they can, the lack of parental responsibility and awareness of the mother in Family B, and the awareness and devotion in Family A, makes all the difference between these two families.

ReligionsHaving traveled across America for the last 25years, and ¾’s of the way around the world, I have a few observations that can strengthen the family.  I share the following as a warning, for if the family is not supported, the actions seen by the domestic terrorists in recent days, as evidenced by the riotings and lootings will only grow until America is lost forever.

  1. How much is enough? America is a capitalist and materialistic country; yet, for all that, there remains much good in America worth preserving.  Answering this simple question determines where standards, limits, and lines are drawn.  For example, how much sports watching is enough?  How much money is enough?
  2. We sacrifice for that which we love. It is a simple axiom, but the truth in a simple sentence.  Do we sacrifice that which is good for the better?  Do we sacrifice that which is better for the more desirable right now?  Do we sacrifice the best in us to fill an appetite?  Consider Family B, the mother chooses to never marry again and remains quite vocal about her decision; but, what is the cost for the sacrifice and the consequences of the decision?  Of her children, the first two are girls, who are confused.  Her young son struggles between the men of her mother’s life setting an example, and what he sees of his grandfather’s life and social circle.
  3. Social societies cannot replace the family. Social prominence cannot, and never will, fill the emptiness at the end of life.  My wife played for the funeral of a man who was politically well known, so much in fact, that the governor of AZ came to the man’s funeral, as well as many in the AZ State Legislature.  A couple of mayors of Phoenix were in attendance, some people with ambitions for federally elected posts were in attendance, and more.  Yet, I wonder today, 5years after his passing, if these same people remember the man.  My wife is still in touch with his wife, but I cannot help but wonder regarding this man’s children and grandchildren.
  4. Allow religious belief systems to change you personally, and your family collectively, through living a religious and moral centered life. President Adams, in discussing the US Constitution stated, “Our Constitution was made only for a moral and religious people. It is wholly inadequate to the government of any other.”  Look from the 1900s to 2020 and one inescapable fact emerges, the loss of the nuclear family has led to a degeneration of social values, morals, ethics, and people.  While the law has attempted to curb this dilemma, President Adams’ quote becomes ever more applicable.  America was founded upon a Judeo-Christian foundation of philosophies and the loss of religion is tearing America apart at its foundational core.

Martin Luther King in discussing individuals and society, morals, and religion, stated the following, “… you have got to change the heart and you cannot change the heart through legislation. You cannot legislate morals. The job must be done through education and religion.”  While the rest of the quote goes onto try and validate the opposite, Rev. King has a point, the law can only go so far in dictating behavior, legislating morals, and decreeing standards.  Without a moral and religious society, America has nothing, is nothing, and falls a failed experiment in improving the human condition.

moral-valuesAmerica needs strong families, which possess a core of religious traditions, practiced in the home, and acted upon in society.  The days of allowing truancy due to race, the communist teachings in schools and the lies that society can replace the family must be fought and won by families informed.  America can survive the current attacks but needs every citizen fighting for the survival of this set of ideals embodied in the US Constitution.  We need morality and religion to return as the core that motivates people to action for America to survive.  It is possible to win against the forces arrayed against America domestically and foreign, but we need nuclear families, and those families need a religious core; there is no other way.

© 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.

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