Moral Distress IS a Leadership Problem – More Shameful VA Chronicles!

Survived the VAA surprise occurred in this week’s Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports; the Boise VAMC in Idaho performed well in their comprehensive healthcare inspection (CHIp).  Even though 10 recommendations were left, the VAMC as a whole is performing above average, with no significant complaints found by the VA-OIG.  Congratulations to the Boise VAMC!

VA 3Let me stress something; leadership is the reason why a VA Healthcare System (VAHCS) or VA Medical Center (VAMC) performs well or poorly!  Yet, too often, the leadership IS the root cause of the problems in a VAHCS or VAMC.  The Boise VAMC just proved this point precisely; are any Department of Veterans Affairs (VA) leaders in Washington DC paying any attention?

The VA-OIG performed a CHIp in Portland VAHCS and found moral distress in the employees, again!  This means that the Eastern end of the state is receiving better care than the western end of Oregon State!  Yet another VAHCS or VAMC with employees feeling morally distressed by the commands and directives of their leadership in how they treat veteran patients!  The VA-OIG report makes everything sound like rainbows and lollipops at the Portland VAHCS, but if employees feel “morally distressed,” there are problems, just not those included in the CHIp scope!VA 3

Where problems outside the scope of an investigation are concerned, the following is GREAT NEWS!

Robert Seifert, 63, of Utica, New York, pleaded guilty to making telephonic threats to Albany Stratton VA Medical Center employees. Seifert, who has been convicted twice before of threatening VA employees, admitted that on 14 January 2021, he made three calls to employees for no reason other than to harass and threaten them.”

I am going to repeat it, only for emphasis, “Leave the families out of your anger!”  Never, EVER, attack, threaten, or speak against the families.  They are OFF LIMITS!  I become very frustrated with the VA Leadership, but violence is not the answer, and threatening families is repulsive and counterproductive!  Seifert is scheduled for sentencing on 06 October 2021; may the judge throw the book at him, for this is his third conviction for threatening families of VA Employees.VA 3

On the topic of frustrating leadership who need to lose their jobs and reimburse the government for all wages, the following VA-OIG report is the epitome of failed leadership in action!

The VA’s Office of National Veterans Sports Programs and Special Events (NVSPSE) granted $47 million to organizations with experience in managing adaptive sports programs from fiscal year (FY) 2017 to FY 2020. … The VA-OIG found that the NVSPSE was not effectively managing the program.  The NVSPSE’s director had not established adequate internal controls, including developing standard operating procedures for managing adaptive sports grants.  As a result, the NVSPSE could not effectively evaluate risks from grant recipients, did not reimburse some recipients’ expenses on time, did not always close out grants on time, and did not appropriately authorize extensions for using funds.  By not closing out grants on time, the NVSPSE failed to free up about $346,000 that could have been used for other purposes.  It also improperly allowed recipients to spend $328,000 in FY 2017 appropriations outside the approved period and improperly reimbursed 19 recipients a total of about $247,000.”

The VA-OIG recognizes that these failures to audit and control the adaptive sports program properly potentially violate both the Purpose Statute and the Antideficiency Act, federal laws with direct consequences for Federal Employees.  I am taking bets.  Will anything come out of the director being referred to the lawyers; I doubt any action will ever be taken!  That’s not just my cynicism speaking; that is the experience in watching directors at the VA skate accountability and responsibility better than gold-winning Olympic figure skaters.VA 3

In reporting the following VA-OIG report, do not rationalize that every suicidal person will eventually find a way or means to commit suicide.  I ask you do not think this for two reasons: one, it is a lie lazy people tell themselves to disregard the act; two, helping people with suicide ideation is not cut and dried textbook medicine. Assisting people with suicide ideation takes time, effort, getting to know the person, and a lot of interlocking care from professionals.

“The patient, who was over 70 years old at the time of death, had diagnoses that included post-traumatic stress disorder and major depression. After approximately 15 years of care at a California VA facility, the patient transferred care to the Las Vegas facility in summer 2019. The VA-OIG substantiated that the patient died by suicide from a VA resident mental health clinic on the day of dischargeThe emergency department social worker documented an incomplete comprehensive evaluation. The suicide prevention team did not assign the patient a high risk for suicide patient record flag despite the patient’s stressors and history of suicide behaviors. Staff did not adequately assess the patient’s substance use, incorporate relevant history into the treatment plan, or address the patient’s change in demeanor and concerning statements. The discharge safety plan had not been modified for approximately eight months despite significant life changes. Leaders had not established a mental health treatment coordinator (MHTC) policy. Staff assigned the patient an MHTC at the patient’s tenth visit and four MHTCs over nine months. Staff did not coordinate care with a geropsychologist, with whom the patient had nine appointments. Leaders did not effectively address the patient’s expressed complaints. The VA-OIG substantiated that leaders did not conduct an institutional disclosure” [emphasis mine].

The last sentence is the dead giveaway that the leadership knew there were problems and designed processes intentionally to have an excuse when a patient died!  This veteran was suffering to a great degree, and I hope that with his passing, his family and friends can find peace in the knowledge that the veteran is now pain-free.  But, the VA leadership should be held legally responsible for this death, they failed this patient, and the world is worse for the veteran’s passing.VA 3

Suicides are hard on family, friends, communities; suicides at any age are the ultimate declaration that failure occurred, the pain was missed, and the medical community and support systems failed.  Survivors often feel a great degree of guilt and carry that guilt to their graves.  But, when medical providers go out of their way to hide the problems, refusing to document, and declare, it means that the medical community had written the patient off as too costly to save.  Who speaks for the loss of intelligence and potential of the failed patient; I do!I-Care

I will continue to speak to the failures of the VA to provide the care they promised, and demand leaders are held accountable and responsible.  This was preventable, and the leadership must be held accountable if the system is to be changed!  This veteran did not have to die by his own hand, and the medical community at the VA in Southern Nevada HCS, located in Las Vegas, should be ashamed!

Follow this link if you would like to see a recap, with links, to the shenanigans reported by the VA-OIG in June.  June 2021 has been a month of incredible and horrendous behavior documented by the VA-OIG of the leadership failures at the VA.  The elected leaders of America either need to begin scrutinizing the VA more closely or vacate office.  There is no excuse for the continued irrational and detestable behavior at the VA.VA 3

The last two items are testimony recorded before a Senate and a House of Representatives Committee.  Statement of deputy inspector general David Case Office of Inspector General, Department of Veterans Affairs before the US Senate Committee on veterans’ affairs hearing on VA electronic health records: modernization and the path ahead 14 July 2021Statement of Leigh Ann Searight deputy assistant inspector general for audits and evaluations Department of Veterans Affairs – Office of Inspector General before the subcommittee on oversight and investigations committee on Veterans’ Affairs US House of Representatives hearing on modernizing the VA police force: Ensuring accountability 13 July 2021.  Frankly, both statements are pure vanilla because the subcommittees refused to act, which was known before making the statement and the hearings.  Hence, why should the VA-OIG prepare action plans if the Senate and House will not take action?

Knowledge Check!Repeating, only for emphasis, “Until the US Legislative Branch will do their jobs, and scrutinize the Executive Branch with the intent to demand accountability, no single government agency will ever change.”  Want to help veterans?  Contact your elected representatives and send them these articles, demanding they take action in support of legislation and scrutinization, demanding accountability and responsibility of government employees who are currently active in refusing to change!  Want to help veterans?  Share these stories far and wide.  Everyone should know what the VA is doing and realize that every government agency from the city to the President is employing tactics to steal liberty, rob freedom, and murder veterans!

© 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 – Chapter 2

Bird of PreyAs American state, city, and county governments, begin to become greedy little children over the $350 Billion the Federal Government is “handing out for COVID relief” to “spur a national recovery from the economic toll of COVID-19.”  I wanted to take a minute and speak some reality to the situation.  Let us logically review what has happened since November 2019 in the light of a non-partisan, apolitical review.  I urge you to take what is said, conduct your own research, and come to your own conclusions.  As Dumbledore said, “I could be as wrong as Humphrey Belcher, who believed  the time was ripe for a cheese cauldron.”

    1. COVID-19 started in Wuhan Province, China. It was delivered around the world by the Chinese Government’s intentional decision to allow travel while infectious.  The virus was further enhanced by the political nature of Government, the intrusion of Government, and the mass hysteria whipped up by the global media.  Power-hungry people looked upon a virus with a 99.02% survivability rate and saw a golden opportunity to seize power from those who elected them to office.Apathy

These are basic COVID-19 facts that have never been refuted, and the adults in the room have recognized the power-mad politicians and the media usurpers from the beginning of the “pandemic.”  While politics continues to play an over-sized role in COVID, while people are still suffering, and while some “normality” is breaking out, the money spent to date will eventually need to be repaid, and no one is discussing this problem.  Worse, more money is being printed and pumped into the economies of the world to “spur growth,” and this is never good fiscal policy!

    1. Printing money causes inflation. Too much money, not enough goods, raises prices beyond sustainable limits to rebalance the economy; hence inflationary prices will continue until excess money is absorbed.  This is a fundamental economic fact everyone should know.  Money is created through several processes, but printing it to throw at a problem, does not resolve the issue; it only prolongs the misery of the original problem.   The original problem was not COVID-19 but a runaway government from the Obama reign, where the economy stalled, the money pumped in did nothing, and a recession dragged on artificially due to the political hands in the economy.  The same problem from Obama’s reign will lead to the same economic issues under the fraudulent president.Plato 3
    2. Fiscal insanity is not fixed by Federal impropriety and investment. Too many states, California, Illinois, Michigan, New York, Maine, and so many others, are in dire financial straits.  However, their fiscal health was already failing before COVID-19.  Investment by the Federal Government will not change the underlying issues and make a fiscally insane state fiscally sane.  In fact, the opposite will occur; the funds being handed to the states under the auspices of “spurring growth” will exacerbate fiscal problems.  More to the point, the excess money in the markets will mean more financial problems for the rest of the United States, which will bleed into the global economy!Plato 2

You cannot buy your way out of fiscal problems!  The only answer to spur growth is to reduce Government!  Reduce regulations!  Reduce the intrusion of Government!  Eliminate taxes!  Instead, the same tired act is being performed, print money, give it to the states, complain about inflationary prices, blame the rich, and increase taxes!  The only thing the Trump Presidency proved, without a shadow of a doubt, if America can get the millstone of Government off her neck, her economy BOOMS!  Yet, what has Washington and too many state capitals done, doubled down on policies that do not work and try to call this “progress.”

Knowledge Check!Agree or disagree, your choice and your consequences.  I have made my case; the money being pumped into the states will lead to inflationary prices, above and beyond a sustainable level.  The states all have sticky fingers and wet lips looking for these funds.  Sure, there are many promises regarding how these funds will be spent. Still, I guarantee most of the promises are empty. The politicians will have their special interests fed first—leaving the citizens to pay exorbitant fees for food, clothing, housing, services, and products until the extra money is consumed, which might occur sometime in the next 5-years at a minimum.  Who benefits, nobody!  Who loses, everyone!

© 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: Let’s Talk About Root Cause Analysis

Flying BuffaloSome of you are thinking, “I will skip this article because the title does not sound interesting.”  I beg your forbearance, just please keep reading.  I laughed today, long and loud, over the incompetence of the current elected leaders in America, fully supporting public mocking, public shaming, and public humiliation over the following piece of news.

You cannot make headlines like this up:

Kamala Harris Emphasizes “Root Causes’” of Border Surge, Says the Problem is “Complex” while blaming climate change for the border crisis.

Let that sink in for a minute; the person who cannot hold a press conference, cannot even get VP added to her title, and cannot do root cause analysis!  I have been working since I was twelve; I was taught root cause analysis as a shade-tree mechanic; you have to be able to diagnose the correct problem to fix the engine.  This article looks like VP Harris is fixing the tires on a car without an engine, claiming this will get the vehicle running real good.  Here is VP Harris’ actual quote:

We are looking at extensive storm damage because of extreme climate, we’re looking at drought in an area in a region where agriculture is one of the most traditionally important basis for their economy, we’re looking at what’s happening in terms of food scarcity as a result of that and in fact, incredible food insecurity, which we used to call hunger food insecurity.”

Detective 4Let me see if I understand this statement correctly.  Political instability, Venezuela’s continuing meltdown politically, and the invitation from many politicians with (D) after their names have nothing to do with the “border surge.”  Just like a stricter stance on illegal immigration by President Trump (R) didn’t slow down illegal immigration on the southern border; do I have that correct?  Let’s talk about incentives, mainly welfare, housing, education, and a political base that refuses to enforce immigration law, do these not influence a southern border crisis, and buffalo wings come from flying buffalo.

What is Root Cause Analysis?Root Cause Analysis

Root Cause Analysis (RCA) is a process of logically working through a problem as a solution is developed.  I know some of you have other definitions for RCA, and that’s okay.  I am just trying to be real simple here, for if VP Harris sees this article, I do not want her confused with big words.  There are three goals to simple RCA, discover the root of the problem, understand how to fix the problem, apply what is learned to prevent future issues.  VP Harris’s comment above has already failed the goals of RCA; hence we can conclude that RCA was not accomplished!Fishbone Diagram

Effective RCA processes possess core principles that are apolitical and easily understood:

      • Focus on fixing the problems, not band-aid solutions
      • Symptoms relief is a short-term answer to buy time for long-term solutions.
      • Multiple root causes are possible; however, each root cause requires factual justification and logical discussion.
      • Who is never part of RCA, just HOW and WHY.
      • Methodical cause and effect evidence is required for each root cause.
      • Future prevention requires increasing learning and understanding.
      • Corrective action requires information and ACTION.

I am not here to hurt VP Harris’s feelings, but her comment about the southern border crisis being climate-related still does not pass the smell test on the core principles of RCA.  Let alone any logical test for veracity.  Thus, again, we can conclude that RCA was never followed to justify her commentary!

The easiest and simplest RCA is the 5-Whys Approach.  Here is the 5-Whys Approach in a simple analogy:

      1. Why? – The car battery is dead. (First why)
      2. Why? – The alternator is not functioning. (Second why)
      3. Why? – The alternator belt has broken. (Third why)
      4. Why? – The alternator belt was well beyond its useful service life and not replaced in a timely manner to save the battery. (Fourth why)
      5. Why? – The vehicle was not maintained according to the recommended service schedule. (Fifth why, a root cause)

Using the 5-Whys Approach, one can also work backward from a completed RCA to double-check integrity in the process.

5 – I am holding the maintenance records showing timely maintenance was conducted.
4 – The alternator belt is broken, but so are the other belts in the engine. Are we sure the root cause is the alternator?
3 – The alternator is missing.
2 – The battery is missing.
1 – The car is not working; why?

Using VP Harris’s comment above, we can back check the climate-change excuse to the erroneous assumption using the same technique.

5 – How many illegals at the southern border are only from the three countries being blamed for illegal immigration?
4 – Guatemala, El Salvador, and Honduras, suffered from El Niño and El Niña in 2017 and 2018, but there was no increased immigration during those tumultuous years of extreme weather.
3 – Since 2015, food security has been an ongoing problem in Guatemala, El Salvador, and Honduras. Again, we do not find a surge in citizens from these countries immigrating illegally to the US Southern Border.
2 – According to the World Bank, regardless of the weather issues and the global financial crisis, Guatemala, El Salvador, and Honduras are still being favorably looked upon as places to invest in for good returns on investment.
1 – What is causing a southern border crisis immediately after a presidential election year?

Please note, I only researched to 2015 for the weather, economy, and food security issues, as obviously President Trump (R) never had a positive influence on the Southern Border Crisis.  President Biden just inherited President Obama’s mess.  Does the RCA backward and forwards process make sense?  I ask solely because we have had migration issues on the southern border before today.  The politicians in America never seem to find the root causes and act to protect America’s defensible borders!  Blaming the weather, which has been changing in cycles since recorded history, for recent events, is akin to blaming the position of the planet Mars for burning one’s hand on a hot stove.

ApathyYet, let’s give VP Harris the benefit of the doubt; maybe her staff did complete an RCA process to reach this conclusion, while she has been sequestered and unavailable since the election.  If so, it would be easier than stepping off a curb to produce the RCA in detail and allow us, the electorate, to see how and why she is blaming the weather for a migration crisis.  This is a reasonable request, produce the proof an RCA was completed, where climate change is the only root cause in a “complex problem.”  Want to raise the stakes a little; if you cannot produce the RCA and accompanying evidence, along with the plans of action, you leave American politics forever.  If you produce the evidence and RCA, I will issue a sizeable public apology and never write about politics again.  I am 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.