Appeal Letter – DBC Decision

Please note, this letter is both an appeal and a summary of everything that has happened at the Carl T. Hayden VAHCS since March 2020.  This is probably the longest letter I have ever written.

Dr. B. Vela MD
Interim Chief of Staff
Phoenix VA Healthcare System
650 East Indian School Rd
Phoenix, AZ 85012

Director Michael W. Fisher
VA Desert Pacific Healthcare Network
300 Oceangate, Suite 700
Long Beach, CA 90802

02 January 2021

Dr. M. Dave Salisbury PhD.
10002 N 7th St
APT 1125
Phoenix, AZ 85020

RE: Appeal of DBC Decision 11 December 2020.

Greetings Dr. Vela and Mr. Fisher,

On 02 Jan 2021, I signed for and received a certified letter postmarked 21 Dec 2020, dated 11 Dec 2020.  Why all the delays?  If I have 30-days from the day the letter is dated, why did the VA steal 10-days?  The letter originates from the Disruptive Behavior Committee (DBC), which claims I have been warned of causing disruptive behavior at the Carl T. Hayden VA Hospital in Phoenix, AZ.  The letter received claims,

On December 09, 2020, a member of our DBC contacted you by phone to discuss these concerns, provide behavioral expectations while in the medical center, and to remind you of the importance of maintaining a safe and respectful environment of care.”

I received a call from Nurse Crawford on or about 09 December 2020, who listened politely to the problem and said nothing else.  The conversation was useless as the nurse relayed nothing but platitudes, agreed that I have the right to be safe in the medical center, and then harped about the COVID Mask policy.  No intention, no motivation to aid or support, no opportunities for progress, no ability to come to a solution, nothing.  I got off this call, and my wife, who has heard my entire side, asked, “Did that call solve anything?”  No, that call solved nothing, provided no information, and wasted everyone’s time!

11 December 2020, Dr. Moore, the chair of the DBC Committee, calls me complaining of my disruptive behavior, declaring that while I have a right to be safe in the hospital, I must wear a mask, and now suffer under the onerous DBC committee rules to enter and exit the VA Hospital because of a pattern of non-compliance witnessed as behavioral issues.  Dr. Moore indicated that I have the right to be safe.  I have the expectation of being treated professionally, but since there is a pattern of “disruptive behavior,” my rights have been canceled, and I now must obey DBC requirements.

In plain speak, I am in the wrong for insisting that I cannot safely wear a COVID mask, and the policy problems and leadership issues at the VA are all my fault.  I am being blamed for the VA Police being tyrannical and obscene in their actions of discrimination against those who cannot physically and safely wear a mask.  The VA Hospital in Phoenix is closed to me until I comply with wearing a mask, which I cannot physically and safely perform.

Using Dr. Moore’s and Nurse Crawford’s logic and the Phoenix VA Health Care System (Paragraph 1 of the DBC Letter), let us see if I understand the problem because, frankly, I have no clue.

The Phoenix VA Health Care System [VAHCS] is committed to providing an environment where everyone feels safe and respected.  Our goal is to provide exceptional care that improves the health and well-being of our veterans.  We also work diligently to maintain a safe environment for staff, veterans, and visitors to our facility.”

If I, as the patient, have the ability and right to be safe from harassment, HIPAA violations, and respect, but cannot physically wear a mask, I have no right to service at the VA Hospital.  But, if somehow, I can wear a mask, I am not harassed, denigrated, derided, and injured by federal employees; however, my HIPAA and legal rights under EMTALA remain in doubt.  Do I interpret this statement correctly from the point of view of the employees of the VAHCS?  Because this is precisely the problem, I cannot wear a mask safely or without causing additional harm to myself, and my first obligation in the PACT team is to protect what health I still have.

I cannot physically wear a mask.  I have a letter from my VAHCS Primary Care Provider for my employer to establish workplace accommodations where I do not have to wear a mask.  Yet, this same letter is insufficient for the VA Employees who keep refusing me access to the ED, refusing to honor appointments, refusing to schedule appointments, causing a scene by crying to the VA Police when I do not immediately comply with their mandates to wear a mask, and all because I cannot safely wear a mask.

30 June 2020, I was refused service at the VA ER because I cannot wear a mask due to breathing issues.  Before entering, in the courtyard where the COVID screening was occurring outside in Phoenix Summer night heat, I was informed that I could hold the mask in front of my face, and this is an acceptable workaround or wear a face shield.  There were no face shields available at this person’s station, and I was informed to ask inside at the ER check-in for a face shield.  Upon entering the ER to be checked in, the office staff refused the information provided at the entrance and said, “If the mask is not worn, we are refusing service.”  I have had shortness of breath, not lung-related, for many years now, which continues to worsen, and I cannot safely wear a mask.  This information is noted in my VA Medical records.  I have been through several rounds of breathing tests, which confirm my lungs work great. Still, I remain short of breath, dizzy, unstable when walking.  When wearing any mask, my breathing problems increase and include lightheadedness and nausea, until eventually, my vision grays, and I pass out.  The original problem was diagnosed at the Salt Lake City VA Medical Center (2010/2011).

I stumbled to my vehicle, at which point I am shortly surrounded by VA Police Officers who claim they were called because a patient was disruptive in the ER.  I was not disruptive in the ER.  When I saw the intransigence of the ER Staff and was refused service, I walked out!  No screaming, no swearing, no throwing furniture, no issues.  I did not have sufficient breath to walk, let alone commit the atrocities I was accused of, and yet, this is supposedly the first incident in a “pattern of disruptive behavior.”  It appears to me the VA Employees breaking the law (EMTALA) needed a reason, so they created a handy excuse and blamed the patient!

08 July 2020, I walked into the VA through the south entrance, not wearing a mask, and those performing the COVID check did not offer a mask, offer a face shield, or say anything.  I walked to the ER; the admitting person did not mention my need for a mask, nor did they ask why I was not wearing a mask; I was checked in to be seen in the ER.  Shortly, I was triaged, and the triage nurse did not say anything about a mask.  I sat in the ER for 3-hours, and none of the medical staff, hospital staff, employees, or Federal Officers walking past ever mention the need for a mask.  I sat away from other people to avoid having any problems.

At the 3-hour mark, I told the ER staff I must get food, and I walked to the Patriot Store feeling sick because of diabetes, pain, and nerve issues, needing food.  On my way, an employee whines about me not wearing a mask, and I ignore this person as my medical information is private, and I should not have to explain to every nosy-nelly about why I am not wearing a mask.  I complete my purchases and suddenly, the VA Police, who were called by the unknown VA Employee, are there insisting I need to wear a mask.  The nosy employee stood around, crowing about how he was available if the police needed more information.  For the first of at least 40-times, I explain that I cannot physically wear a mask to protect my health and safety.  No swearing, no disruptive behavior, I cannot wear a mask, and I was on my way back to the ER to wait to be seen.

I am met in the ER by Officer LT. Hicks and a plainclothes officer claiming to be a LT.  At which point, I begin again to explain that I cannot wear a mask.  I was not causing a scene before this; I was not causing a scene after this; however, when 8-10 VA Police Officers surround a person, a scene is created, and it is not the patient’s fault that a disruptive scene has commenced.  I was not screaming; I was not swearing; I was not disruptive as this 40+ minute harassment began.  In the end, I will admit fully, my cherub-like demeanor had evaporated, and swearing did occur.  When you spend 40+ minutes saying the same thing over and over to no effect, my aggravation level went up.  I contend the scene was started, provoked, antagonized, aggravated, irritated, and exasperated by the Federal Police Officers who more than once accused me of “Blowing rainbows up their butts,” lying about my breathing problems, and riling the situation.  The officers accused me of lying about my medical records, medical problems, and reasons for not wearing a mask.  Let me repeat when this scene began with LT. Hicks, I was told I needed to either wear a mask or a face shield.  Nobody in the ER had a face shield, and when I was handed a face shield and put the face shield on, the officers continued to harass, torment, and rile the situation.  I complied, they changed the “policy,” and I got arrested and cited.

I do not have the breath to be hostile!  Because of the nerve issues I have and diabetes still needing food, I do not have the strength to be disruptive.  I do not have the breath to be hollering and screaming!  I do fully admit that the tinnitus I suffer from has me speaking louder than many other people, especially as my breathing worsens.  I gasp out words and do not care about polite volume, and I need to be left alone during these episodes to catch my breath and calm the nerves.  But this incident on 08 July is the epitome of VA Police Officers aggravating a problem when they could have simply left well enough alone as I was NOT breaking any rules, policies, or committing a crime on Federal Property.  If a policy is not written down, it is not a policy, and it is not enforceable.  Had the VA Officers ended the scene when I put the face shield on, there would not have been another problem, and I would have been seen in the ER for my medical issues.

15 October 2020, I reported to the Federal Courthouse without a mask and had my fines adjudicated from the 08 Jul incident. I paid $80 for “disorderly conduct” when I wasn’t disorderly, I paid $10.00 in parking fees.  The person deciding my case said, “If I have trouble entering the building in the future, I need to ask the volunteers doing the COVID screening to call their supervisor, who will then shepherd me around the VA.”  I was assured three times that there is a procedure to deliver healthcare services to the veterans who cannot physically wear a mask.  The person handling my case claimed they would take care of the other ticket received from the 08 July incident and introduced themselves as a Lieutenant of the VA Police Force.

21 October 2020, I arrive at the south entrance to the Phoenix VA from the parking garage.  I am confronted by a hysterical employee, claiming they were a supervisor, demanding I wear a mask at the COVID screening desk.  I followed the instructions from 15 October and asked for a supervisor.  The employee then requires I wait “outside the VA Hospital for privacy reasons.”  When I asked why, and for specifics, the employee becomes more hysterical, calls the VA Police instead of answering questions, and erroneously claims I am causing a disturbance.  The supervisor arrives, negates what was told me on the 15th of October, and claims that wearing masks is a policy, then demands that mask-wearing is not a policy but a directive. When I asked for a copy of the policy, directive, guideline, etc., I was pointed to a sign.  I asked for the supervisor’s supervisor, called this person for assistance, and the VA Police interrupt my call and demand I finish my business off VA Property and then shadow me off VA Property, meaning I cannot return for 24-hours.  I had around 10-VA Police Officers attempting to intimidate me, again, because I asked questions and insisted upon logical answers that the VA employees refused to deliver.  No swearing, no screaming, no disruptive behavior of any kind, and I was outside the VA Hospital the whole time.  The traffic and witnesses were displaced for the VA Police Officers, not because of me.

The VA Police do not have a copy of the mask policy, directive, guideline, etc., to pass out to people who ask for one.  The supervisor does not have a copy or document with the mask policy clearly spelled out, except to point to a sign demanding obeisance.  Yet, the person needing VA medical or other assistance is expected to blindly follow an unwritten “policy” that continues to shift from draconian to obscene and back again on the bureaucrat executing policy’s whims.  This is immoral, unethical, and illegal, plus it makes the VA the laughingstock of every other hospital and care facility.

While I was able to speak to the supervisor’s supervisor, Jennifer Russoniello, and discuss the most recent incident and conduct some of the business I went to the VA Hospital for; I remain not pleased.  The failure to access the VA to obtain the medication needed is directly contributory to the ER visit on the 28th of October.  The continued confusion at the VA sees patients being refused service if they cannot wear a mask, at the expense of the patient’s health.  It is important to note that the director possesses statutory authority to accommodate Washington D.C.’s policies for the local hospitals’ operation and patient safety.  Yet, the director continues to fail to execute leadership, demonstrate a concern for patient safety, or even clarify operational guidelines, policies, procedures, or work standards by writing them down and training the staff on how to enforce policy properly and legally.

Important to note, Jennifer Russoniello affirmed what the supervisor claimed, there is no written policy regarding COVD masking at the Carl T. Hayden VAHCS.  A memo was received directing the mask “policy.”  She further elaborated that because the COVID situation changes dramatically from day-to-day, and the CDC mandates change from hour-to-hour, the Carl T. Hayden Hospital Leadership had tasked her to help draft an acceptable policy that would benefit all veterans.  She then asked if she could use my story as support for preparing a cohesive policy, to which I agreed.

When Jennifer and I finished our conversation at the Wendy’s across the street from the Phoenix VAHCS, it was agreed that if I held a mask close to my face, it would be acceptable, and I could be seen at the Phoenix VAHCS.  I was told to keep the mask near my face anytime I was within 6’ of other people, and I could drop the mask when not talking or interacting with people.

28 October 2020, I wake up in a crisis, I have to get medication that has not arrived, and my body is in trouble.  Using the information from Jennifer Russoniello, my wife called the Phoenix VAHCS to alert Jennifer, and I headed to the hospital ER.  Jennifer called me back, and I was unable to speak to her due to my nerve condition.  I arrived at the VA, held my mask to my face, went to the ER, and was treated without a problem.  No police harassment, no issues, nothing.

04 and 07 December 2020, I receive two text messages from the VA regarding my upcoming appointment.  I called the Radiology Department at the Phoenix VA specifically because I cannot physically wear a mask and wanted to make sure that I had waited four months to obtain this appointment and would not have any difficulties completing it.  The VA previously has refused service by providers because I cannot physically wear a mask; canceled only after I had traveled to the VA, waited in the waiting room, only to be told by the provider to go home or wear a mask.  Thus, I wanted to ensure this would not be the case with this MRI.

After five phone transfers, I finally spoke to Scott, who identified himself as the Radiology Supervisor.  I explained my predicament, explained who he could call to discuss the problem, and called him a second time to provide the name of the person I have been working with a Jennifer Russoniello, along with her extension.  Later that afternoon, Jennifer Russoniello returned my call and assured me all was in order.  The workaround we worked out was for me to hold a mask in front of my mouth and nose.  That way, the mask is not causing breathing difficulties, and I am then in compliance with the mask mandates.  This arrangement had worked previously during an Emergency Room (28 October 2020) visit; thus, I kept my appointment.

For the MRI, I was ordered no food or drink 4-6 hours before the appointment.  Two-hours was the scheduled time to be on the MRI table.  I planned my day, including my medications, food, and drink, around returning home quickly and relaxing.  Because history has proved that an MRI leaves me weak, hurt, and highly nerve sensitive, along with the usual sore muscles and other issues.

I arrived for my appointment, cleared the useless “COVID Screening” at the south entrance to the Phoenix VA, and proceed to Radiology.  At Radiology, I meet a supervisor (Paul?) who was to escort me around the hospital to ensure I did not get hassled by the VA Police, per Jennifer Russoniello.  I checked into Radiology.  When my name is called, I am met at the traffic control door by Scott, the Radiology supervisor, and an MRI Technician.  Scott refuses to allow me entrance because I am not physically wearing my mask.  I explain I cannot physically wear a mask; I walk with a cane, so one hand is full, and the other was full of cellphone, MRI paperwork, glasses, and floppy cloth mask.  I held the mask up to my face and claimed this is the best I can do to follow the “COVID Policy.”  Then asked if the MRI appointment was still on or not, repeated 5-different times.  Scott visibly has confusion written all over his face and cannot or will not decide.  No swearing, no disruptive behavior, no loud talking, and still the supervisor who had already spoken to Jennifer Russoniello about my mask problems is refusing service at the VA because of the mask mandate.  I am doing nothing wrong, nothing illegal, and nothing that could be classified as disruptive.  That other patients laugh as they observe Scott’s unprofessional behavior is not my problem; I did not laugh, I did not swear, I did not raise my voice, and did not cause a problem.  I simply stated my mask issue and asked if the MRI was going to occur.

After the sixth question regarding the MRI being canceled or not, the MRI tech turns slightly to Scott and says, “Why don’t we just do the MRI?”  At which point, Scott clears the door, and the process of changing clothes, answering pre-MRI questions and waiting for a room to open begins.  I walk to the MRI room without a mask, without problems, and without further questions about my mask-less face.  I suffer through the MRI.  After the MRI, I am told that “To get back to the dressing room, you have to be masked,” and I am offered a washcloth to hold close to my face.  I follow this request to the best of my ability while walking/staggering down an empty hallway, physically weak and exhausted from the MRI, the pain, the exertion, and the lack of food.

My trip to the dressing room is vital for two reasons: 1) I kept losing my leg strength, which is normal after MRI’s but coupled with the lack of food, and I am in trouble if I cannot get food soon.  2) Nothing else is said about my not wearing a mask.  I exit the dressing room, walk out through the traffic control door, and spot two VA Police Officers looking like they are involved in a long discussion with Peter, the supervisor dispatched from Jennifer Russoniello, to help me navigate the bureaucrats at the Phoenix VA.

I walk out, headed for the elevator, and the two VA Police Officers start calling my name.  I intend to go home!  Yet, the VA Police are delaying this because I cannot physically wear a mask.  Officer Interpreter places himself directly into my path, shouting about my need to wear a mask; when I politely try to sidestep him, he pushes back, physically pushing me backward.  The second officer is a Sgt. I think his name tag read “HUFF,” I am not sure, but calling him Sgt. Huff is acceptable, places himself beside Officer Interpreter, blocking my immediate path to the elevators.  Please note, I do not have the breath to be disruptive, scream, holler, rant, rave, or cause a scene.  I physically do not have the strength to argue or to carry on.  I have to get food immediately, or I will be unable to drive.  I attempt to explain all this to the VA Police Officers. Whose only reply is delivered in raised voices with great hostility, “We are not here to debate you,” “We are NOT here to discuss this with you; put a mask on!” and, “If you do not put a mask on immediately, we will arrest you on a felony.”  When I asked for specific the felony I am the officers are accusing me of, they redirect the conversation because they know they are on shaky and illegitimate legal grounds.

For the next 10-minutes or so, these two officers will yell, threaten, cajole, attempt to intimidate, and eventually will choose to place me in handcuffs, threatening me with felonious charges unspecified.  When Officer Interpreter finally decided to act and arrest me, he ordered me to turn around.  Not being able to turn around and knowing that Sgt. Huff was already behind me, I would not move.  I had previously almost collapsed during these officer’s tirades, more than once, and any movement at this point would be hazardous to my remaining upright and safe; my legs are shaking and weak already from the MRI.  But Officer Interpreter refuses to listen to any explanation on my part.  At this point, without knowing the extent of my injuries, Officer Interpreter places two hands upon me, thumbs in the armpits, mid-top of the biceps, and attempts to spin me to the left, towards the wall, in a standard police maneuver seen on every police show Hollywood produces.  After which, my legs collapsed!  My Thoracic Spine turned to the left, while my Lumbar and Cervical Spine remained stationary.  I hit the floor hard, cutting two fingers in four places, and I begin bleeding like mad!  I also scratched my right arm in two places while falling. I did not realize until showering the next day; neither scratch is deep enough to need medical attention, but they are all apparent injuries sustained when violently attacked by Officer Interpreter.

Officer Interpreter then tells me, “You collapsed on purpose; your injuries are faked.”  The supposedly superior officer, Sgt. Huff quickly picks up this mantra.  This attack (07 Dec 2020) has left me with increased pain in both knees, cramps in the L-Spine, a feeling of disconnection between my T- and L-Spines, and my cut fingers just keep bleeding.  Sitting and standing are more painful, and I have less stamina for sitting, standing, walking, and more problems breathing.  Every time the officers handled me and collapsed my legs, shots of pain went through my body; I can only guess I screamed out.  That generally happens when someone who is already suffering from chronic pain suffers more pain; check my medical records, and you see, I typically live in the land of 6 and 7 pain levels.  No swearing: I worked very hard during this incident to maintain a sense of professionalism even in my weakened state.  I fully admit my cherub-like demeanor evaporated when I got pushed, but I worked hard to control my tongue.

Collapsing my legs on 07 December 2020, like every time the VA Police have manhandled me, ignites a pain and nerve storm inside my body.  I jerk, spasm, twitch, stutter, eventually lose my ability to speak, and involuntary movements explode out my arms, legs, neck/head, hands, and feet.  My breathing problems intensify.  I try explaining this to the officers every time, and every time I am insulted, denigrated, accused of faking the injuries, and causing a disturbance to cover their ineptitude and unprofessionalism.  In Holding Cell 1, as Officer Huff is removing one handcuff, my arm spasms involuntarily, and he complains I am trying to hit him.  False accusations abound in this sordid saga!

My safety is placed at risk when I wear a mask, yet the VA is the only medical facility in the Phoenix Metro area with a problem of me not wearing a mask.  I have had MRIs, consultations, a gall bladder surgery, which involved a full day in the ER, then two days in hospital, all without a mask.  Thus, even though the first, and allegedly, most important SAIL Matrix is Safety, as in the patient’s safety, I am discriminated against because I cannot wear a mask. The Phoenix VA leaders cannot sufficiently establish policies and guidelines to protect my safety.

Once standing, with officer assistance, I was placed in a wheelchair where I struggled to breathe.  Sitting in a wheelchair is hard for me because I cannot straighten out enough to breathe fully.  My fight or flight response goes haywire when the nerve issues begin and does not conclude for days afterward.  Yet, on top of all my other cautionary statements about handling me and not inflicting more pain, the officers insisted I sit in a wheelchair.  Worse, the officers felt it was needed to handcuff me with my arms behind my back while sitting in a wheelchair.  My back is in immense pain every time it is touched.  Yet, the officers continued to think it was acceptable to handcuff me, behind my back, where the cuffs, the bracelets around my wrists, are digging into my spine.  Every time we hit a bump, more pain shoots through my already injured and highly nerve sensitive body!  Sitting in a wheelchair, with my hands cuffed behind my back forces me to sit hunched over, making breathing even more difficult.  Where are my rights to patient safety in the VA Hospital?

The Federal VA Police officers repeatedly informed me, “You are doing this intentionally,” “Stop making a scene, you are not in that much pain,” and “You cannot be injured that badly.”  Let me be clear; the officers started this confrontation by not allowing me to go home!  My appointment was at the end of the day, so there were significantly empty hallways when I was scheduled to leave, meaning that I would not be disturbing people by not wearing a mask.  Then they compounded their errors by directly laying their hands upon me.  These two officers, and the officers from July, both felt they could violently lay hands upon a patient who is not being violent, are not acting irrationally, and this is WRONG!  If the patient is not acting in a manner that causes harm or injury to themselves, other patients, threatening the VA Police Officers, or damaging the VA physical facility, the policy should be HANDS OFF!

10 December 2020, south entrance to the VA Hospital, I approach the VA to file a complaint about the treatment received on the 08th of December and visit the ER.  I am stopped by the same overzealous supervisor from 21 October 2020, at the COVID screening station between the two entrance/exit doors.  I explain I cannot wear a mask when asked to wear a mask, and before the COVID screener can reply, the supervisor demands I stand out of the way, and he acts in a hostile and combative manner.  I followed directions; I stand out of the way while he goes further away to obtain instructions about me; supposedly, I was on some warning list.  With more apparent and palpable glee and hostility, the supervisor returns, informing me Jennifer Russoniello is coming to speak to me; she never arrived.  At this point, the supervisor demands I leave the hospital entrance, claiming I am blocking the path of traffic; yet, it is raining outside, I am out of traffic, and not causing a scene.  When the supervisor becomes more agitated and hostile, he calls the VA Police to have me removed.  The VA Police officer signals to leave me alone while I wait and the supervisor returns to his post.  Not 2-minutes later, another officer arrives, and the supervisor tells the arriving officer I am disturbing traffic and not following his commands.

Yet, except for my inability to wear a mask and stand in the rain, I have followed his commands; I am not disrupting the inbound or outbound traffic, I am standing out of the way, and I am silently waiting.  Soon a LT arrives, I didn’t get his name.  I got his attitude, antagonism, malevolence, and malice, but never witnessed his professionalism or ability to listen.  The LT, along with a SGT. and several other officers, proceed to block the doors so nobody can get in or out of the VA and proceed to blame me for blocking traffic.  I was not blocking traffic; I was not causing a scene. I was not disturbing anyone.  The VA Police officers did all these things.

I explain why I am there.  I explain I cannot wear a mask; I explain without swearing, screaming, or disrupting anyone I am waiting and trying to get to the ER.  The LT and the SGT then decide it is time to arrest me.  They grab my arms and jerk at the wrists to get my arms behind my back.  My wrists are still visibly bruised from the 07th of December incident, and I scream in pain.  To which they claim I am “faking my injuries,” then declaring, “If my wrists were really injured, there would be bandages on them,” among other derogatory comments.  My nerves kick-off and my pain jumps to 15, as I am manhandled into a wheelchair, from which I cannot breathe properly, and then taken through the rain to Holding Cell 2.  Is this clear? I am bodily removed from the VA, injured, arrested, and all this after spending two days flat on my back due to pain from the 07th of December arrest and injuries.  Under EMTALA, the Federal Emergency medicine law, this is illegal.  As a patient with rights, whose primary job is to look after my safety, I am left amazed at the treatment I keep receiving.

Every curb hit, every bump hit, every single expansion line in the sidewalks hit, my pain spikes, and I holler out in agony.  Yet, every time I mention this, I am told to shut up, stop acting, stop faking, and that I deserve the trouble I am receiving at the VA Police’s hands.  But the irony of the entire saga of illegal actions, immoral treatment, and unethical behavior from the VA Police and immature VA Federal employees is encapsulated in being reported to the DBC for behavioral issues.

I have not been disruptive.  I have not exhibited behavioral problems worthy of this charge and action by the VA Police or the DBC.  I have in no way broken any law or refused any reasonable demand.  I have been seen at the Phoenix VA historically two other times, and never a problem.  I have been seen at various other VA facilities across the continental United States and never had a problem with the Federal VA Police, anywhere.  The VA at a VA Hospital has employed me, and I never had a problem with the VA Police.  Since March 2020, the third time I am a patient with the Phoenix VAHCS, I have nothing but problems as professionalism has shrunk and the bureaucratism has increased exponentially!

Ask yourself this, if you are in pain, and you go to a hospital ER for services and are refused service, are you a happy person?  If you are in constant pain, and someone pushes you, violently spins you, and causes your pain to elevate, do you cry out in pain?  If so, according to the DBC and the VA Police’s pretzel logic, you disrupted the hospital and caused a disturbance.  If you explain something 50+ times to a person, are you still a pleasant and friendly person to be around?  I have explained hundreds of times why I cannot wear a mask, where to find this data in my medical records, and been accused of lying, “blowing rainbows up a person’s butt,” and had other derogatory and insulting remarks made about me and to me.

Tell me, if you hear your private medical diagnoses bandied about as a joke, do you take offense?  Do you become upset when your safety is threatened and your personal space is violated for no cause?  If so, then you cannot allow this atrocious decision by the DBC to stand.  Nor should you allow another minute to pass before ending the policies creating the problems and safety issues.  Three times I have needed emergency care at the Carl T. Hayden VAHCS since my return in March 2020 and been refused.  Refusing emergency care at an emergency room receiving federal funds to operate is against the LAW (EMTALA); yet, the VAHCS in Phoenix is somehow exempt?  Twice, I have had additional injuries heaped upon the pain I am already suffering, and thrice I have been cited for being disorderly when the VA Police Officers were the ones causing the scene, disrupting traffic, and antagonizing situations.

10 December 2020, in Holding Cell 2, in front of at least eight other officers, Major Kratz barges into the holding cell, screaming, hollering, and shaking his sausage-like fingers in my face.  Making demands and acting irrationally, yet I face DBC consequences, which does not make sense.  While trying to leave the VA, sitting in my POV, the LT who started all the trouble on the 10th of December, places his hands upon my vehicle, leans against my door, and refuses to allow me to leave until he has finished insulting, denigrating, and making stupid accusations!

I fully admit, my cherub-like demeanor with the VA Police is gone, and I refuse to replace the cherub-like demeanor while I remain criticized, insulted, dismissed, injured, and falsely accused!  I have documented my treatment and my proactive approach to correcting the issues experienced very closely because the VA continues to claim I am “non-compliant” and claiming that my behavioral problems are causing disturbances in the hospital.  According to the officers, on the 10th of December 2020, I am “deserving the injuries I receive because of my rebelliousness in not conforming to wear a mask.”  Even after I have explained, I cannot physically or safely wear a mask.

30 December 2020, a person declaring themselves the assistant deputy director of the VA Police at the Carl T. Hayden VA Medical Center in Phoenix, Arizona, called me.  When asked three times, directly, “Why are you calling me,” I received three different ambiguous answers that meant nothing and a redirection of the conversation.  Then the caller told me some “facts,” I stated the situation as declared above.  To which I was told, “Your evidence is not applicable because it is too old.”  Yet, he went on to claim his officer’s record of events was correct and factual, and the date did not matter.

But, like the Home Shopping Network claims, “Oh Wait, there’s more.”  The caller told me, “your non-compliance is what is causing the issues.”  Not the fact that zealot bureaucrats are enforcing a policy that endangers the patients.  Not that my safety concerns have any bearing on the issues or why I keep getting harassed by multiple VA Federal Police Officers who refuse to listen to the patient.  Not that I have legitimate physical problems with wearing a mask. He only informed me that I am not compliant, which is my problem, and the sole reason the VA Police Officers keep injuring me.

But “Oh wait, there’s more.”  After declaring I am non-compliant, the caller refused to listen to my rebuttal of why I am compliant.  Interrupting me constantly, and then claiming that I am “Riled up” and “not being professional” when conversing with him, an intransigent and openly hostile caller.  The caller then dared to declare that “Patients do not tell the hospital what they will and will not do.”  Seriously!?!?!  I have legitimate safety and health issues that have been recorded on the VA Medical records, and this caller duplicates what his officers did on the 10th of December when they declared they were smarter than my doctor and could know when someone was faking an injury or not!

But “Oh, wait, there’s more.”  In July 2020, I heard jokes and disparaging comments about me and my medical file while sitting in the holding cell.  On the 10th of December, more disparaging remarks were made that included details that can only be known had the VA Police looked at my medical diagnoses, mental health records, and other medical data.  Having non-medical personnel know this confidential data is a HIPAA violation, clear and straightforward.  The letter 644/00 dated the 13th of October 2020 from Dr. A. Smith, the Medical Center Director, claimed that the VA Police needed this data to do their jobs effectively.  But, the caller had the nerve to declare, “I am making this up, these allegations have no bearing on the 07th of December event, and I need to stop lying about my injuries and the verbal abuse of the arresting officers.”  Which is it, HIPAA claims that these officers are in direct violation of their duties when they know my private medical details and diagnoses.  The VAMC director claims it is legal.  The caller claimed they have never had this data.  I smell bureaucrats covering themselves, and it stinks!

I have now sat in Holding Cell 1 twice and Holding Cell 2 once at the Carl T. Hayden VA Police Offices.  I can tell you from my experience, the majority of these Federal Police Officers are unprofessional, unprincipled, unbefitting, unbecoming, and replete with the most egregious manners it has ever been my displeasure to encounter.  The Department of Motor Vehicles is more professional and dedicated than most of the Carl T. Hayden’s VA Police Officers – having this “leader” of VA Police Operations tell me I am lying is enough to boil my blood!

But “Oh, wait, there’s more.”  The caller then dared to accuse me of being hostile, not listening and refusing to comply.  How can I comply when you never told me why you were calling?  Why should I be anything but irate and wary when I have come to expect treatment that should shame any professional?  I listened very carefully to the bloviations and blather of this bureaucrat, which is why, at this point, I disconnected the call.

The call lasted 8 minutes, and was full of bureaucratic nonsense, and left me out of breath, gasping for air, and vehement to the Nth degree, and out of my mind with umbrage and indignation!  Why did the Assistant Deputy Director of VA Police call me?  What is his job?  Since his job does not include setting hospital policy at the VA, will this incident be referred to a policymaker at some future date, or do I have to be paralyzed first by a zealous VA Police Officer jerking my spine and cutting my spinal cord?  If patients cannot inform a police officer that what they are doing is causing injury, then the VA Police Officer is wrong!  If a patient who is not causing trouble, is continuously harassed, threatened, accused of lying, and injured, and then can be placed on DBC policies for unspecified behavioral issues, based solely upon the cowardly, unscrupulous, and disreputable conduct of the VA Police and the inadequate policies and directives of the hospital leadership, then the entire organizational leadership needs to be replaced, forthwith!

I fully admit, I got frustrated and swore!  I fully admit when my pain levels went up, and I got hit, spun, collapsed, and more, I screamed in agony.  I have repeatedly tried to be proactive and avoid being in a position where the VA Police are concerned. Still, I cannot safely and physically wear a mask, and this is NOT a crime worthy of all the bureaucratic lunacy and foolishness I keep suffering.  I have not caused a single-issue worthy of VA Police intervention, EVER!

I have been a victim of overzealous, hostile, inept, and incompetent supervisors who become ludibrium verius malum when someone asks them a question.  I have been a victim of unprincipled, unscrupulous, disreputable professionals gifted with a badge or authority above their competence who are policy tools off the VAHCS, whose policy is poorly dictated and inappropriately applied.  I have been illegally treated and mistreated to the pleasure of the ludibrium verius malum functionaries.  Thus, I refute the charges laid against my good name and character.  I refuse to be labeled as a “behavioral problem” when I have done nothing wrong!

In no uncertain terms, the decision from the DBC should be immediately rejected, and the entire record struck of all accusations. Immediately restitution needs to be made for causing me injuries by the hands of emotionally impassioned ludibrium verius malum tools!  I have committed no crime!

I have done nothing worthy of any of the treatment I have received since March 2020 at the hands of the VA.  I deserve justice, not accusations of behavioral misconduct.  I deserve justice for the misconduct, malfeasance, impropriety, delinquency, crime, and mistreatment I have suffered.  I deserve answers, and I intend to keep complaining until my rights are restored and my good name cleansed and scoured of the tyrannical, unjust, and oppressive actions of these disastrous federal employees.  There is NO excuse for what I have suffered!

As a professional organizational psychologist, I place my integrity and honor on what I have reported, observed, experienced, witnessed, heard.  I fully and unequivocally attest that the majority of the Federal Police Officers in the Carl T. Hayden VA Police Force need immediate retraining, except for those not fired for unprofessional behavior and misconduct!  There is NO EXCUSE for Officer Interpreter on the 08th of December 2020 to have grabbed me, after physically pushing me, and try to spin me into a wall.  There is no reason, at all, for a VA Police Lt. and a Sgt. to grab my wrists, bend my arms into positions they do not travel, aggravating the handcuff injuries from Monday, and then have the gall to tell me, “Well, how could I know you had painful wrists, you are not wearing a bandage.”  I told them about my injures before they started grabbing, jerking, yanking, and hurting me.  Then I get ordered to “Shut up; I was under arrest.”  But I never had my Miranda Rights read.  I complied on the 10th, I complied on the 8th, and I complied in July.

Let us be perfectly clear; hospital mandatory mask policies must have exceptions for patients who physically cannot wear a mask.  Patients unable to wear masks include some patients on cancer drugs, some asthmatic patients, people with breathing problems, and much more.  The Carl T. Hayden VA Medical Center policy is the biggest problem I face when obtaining treatment after the COVID Pandemic Declaration from Feb. 2020.  I am certainly not alone in having breathing issues with the COVID Masking Policies, and with the zealotry, the policies are being enforced.  The VA has established an organizational design that requires a veterans business to be conducted face-to-face.  Hence, the VA is a Ghost Town; patients are canceling their appointments, FOIA’s are not being submitted, and so much more because of the masking policies that endanger patient health and place patients at risk of further injury!

I repeat, only for emphasis; that the only medical offices, radiological departments, emergency rooms, and hospitals in the Phoenix, Arizona area where mask policies are causing discrimination and refusal of service is at the Carl T. Hayden Veterans Administration Health Care System, and this is 100% wrong!  The Entire VA Leadership Team should be highly embarrassed and entirely held accountable!

Where is respect for me at the VA?  Where is my patient safety?  Where is my ability to conduct business in an atmosphere free of harassment, intimidation, and discrimination?  If the Phoenix VAHCS desires atmospheres free of harassment, intimidation, and discrimination, they first must provide what they desire.

Sincerely,

Dr. M. Dave Salisbury
Ph.D./MBA/MAET
Dual Service-Disabled Veteran

CC: Meyers & Telles Attorneys at Law
Senator Mark Kelly
Rep. Greg Stanton

The Carl T. Hayden Veterans Hospital – An Abomination of Bureaucrats!

Carl T. HaydenAugust 2020, I was informed that I had been hired with a September 2020 start date.  The same day, I contacted my Department of Veterans Affairs Primary Care Doctor for a workplace accommodation letter. The doctor and I discussed my problems and what aids and equipment  I need to be more productive in a work environment, which during COVID mandates includes my inability to wear a mask.  The doctor wrote a workplace accommodation letter, and the employer and I have worked out a workplace accommodation.  I hope to work for the company on the 11th of January 2021.

July 2020, I was arrested by the VA Police and charged with non-compliance to signage by not wearing a mask.  I spent more than 40-minutes declaring my problems and safety issues with wearing a mask.  I begged the VA Police, who were harassing me, witnessed by more than 8 VA Officers, and more than 30-employees and other veterans, to no avail.  I was injured when the VA Police hit my back and collapsed to the floor due to my spinal injuries; this is normal for my injuries.  It is important to note that I was wearing the face shield that I was informed had to be worn instead of a mask when I was arrested.  Yet, even the face shield was inaccurate information provided by the VA Police when they started to harass me and make a scene in the VA ED Waiting area.

On the 08th of December 2020, I am arrested, again injured. This time was the first time I was accused of “faking my injuries,” additional jokes were made about me collapsing, as well as many other disparaging comments made during the arrest.  All this abuse came after I had already worked out a solution to access care at the VA with Jennifer, the head of patient advocacy, which had worked for an emergency room visit in early November.  I had called the VA Hospital Radiology Department to ensure the deal was still acceptable, and I would not have any issues.  Yet, the radiology supervisor called the VA Police to report a patient causing problems in the radiological department.

On the 10th of December 2020, I approach the VA to file a complaint about the treatment received on the 08th of December and visit the ER.  I am stopped by a zealous supervisor of the COVID testing at the South Entrance to the VA.  I am bodily removed from the VA, injured, arrested, and all this after spending two days flat on my back due to pain from the 08th of December arrest and injury.  Under EMTALA, the Federal Emergency medicine law, this is illegal, as was the VA’s detention and removal in July 2020.

Survived the VAThese are all provable facts.  I have documented my treatment and my proactive approach to correcting the issues experienced very closely because the VA continues to claim I am “non-compliant” and claiming that my behavioral problems are causing disturbances in the hospital.  According to the officers, on the 10th of December 2020, I am “deserving the injuries I receive because of my rebelliousness in not conforming to wear a mask.”  Even after I have explained, I cannot physically wear a mask.

When I put on any mask, including CPAP masks for sleep, KN95 COVID masks, shirts, or other cloth masks, and during surgery three times the surgical masks, my volume of air per breath drops to a point where I feel like I am choking.  I begin gasping for air.  A killer headache begins and lasts for up to 72-hours after.  My vision grays, and I either drop to an unhealthy sleep or pass out using any mask.  Shortness of breath has been getting worse since 2006.  Shortness of breath was first noticeable after sustaining a significant spine injury in the US Navy in 2002.  I went to medical, the corpsman on my ship increased my ibuprofen prescription, and said, “Since there is no pain, there is no spinal injury,” and marked me fit for full duty.  My last two years onboard the ship are replete with falls, body weaknesses, gains of weight, loss of breath, increased pain levels, insomnia, and medical visits to the corpsman.  All visits to the corpsman resulted in me being marked “Fit for Full Duty.”  Fit for full duty meant carrying tools, parts, flammable gas containers, refrigerant, and Halon Firefighting Gases off the pier and onto the ship—wearing an SCBA regularly where my legs would collapse—handling HAZMAT, cleaning up HAZMAT, and much more.  All of this is documented and factual.

1247 hours, the 30th of December 2020, a person declaring themselves the assistant deputy director of the VA Police at the Carl T. Hayden VA Medical Center in Phoenix, Arizona, called me.  When asked three times, directly, “Why are you calling me,” I received three different ambiguous answers that meant nothing and a redirection of the conversation.  Then the caller told me some “facts,” I stated the situation as declared above.  To which I was told, “Your evidence is not applicable because it is too old.”  Yet, he went on to claim his officer’s record of events was correct and factual, and the date did not matter.

Theres moreBut, like the Home Shopping Network claims, “Oh Wait, there’s more.”  The caller told me, “your non-compliance is what is causing the issues.”  Not the fact that zealot bureaucrats are enforcing a policy that endangers the patients.  Not that my safety concerns have any bearing on the issues or why I keep getting harassed by multiple VA Federal Police Officers who refuse to listen to the patient.  Not that I have legitimate physical problems with wearing a mask. He only informed me that I am not compliant, which is my problem, and the sole reason the VA Police Officers keep injuring me.

Theres moreBut “Oh wait, there’s more.”  After declaring I am non-compliant, the caller refused to listen to my rebuttal of why I am compliant.  Interrupting me constantly, and then claiming that I am “Riled up” and “not being professional” when conversing with him, an intransigent caller.  The caller then dared to declare that “Patients do not tell the hospital what they will and will not do.”  Seriously!?!?!  I have personal safety and health issues that have been recorded on the VA Medical records, and this caller has now duplicated what his officers did on the 10th of December when they declared they were smarter than my doctor and could know when someone was faking an injury or not!

Theres moreBut “Oh, wait, there’s more.”  In July 2020, I heard jokes and disparaging comments made about me and my medical file while sitting in the holding cell.  On the 10th of December, more disparaging remarks were made that included details that can only be known had the VA Police looked at my medical diagnosis, mental health records, and other medical data.  Having non-medical personnel know this confidential data is a HIPAA violation, clear and simple.  The letter 644/00 dated the 13th of October 2020 from Dr. A. Smith, the Medical Center Director, claimed that the VA Police needed this data to do their jobs effectively.  But, the caller had the nerve to declare, “I am making this up, these allegations have no bearing on the 08th of December event, and I need to stop lying about my injuries and the verbal abuse of the arresting officers.”  Which is it, HIPAA claims that these officers are in direct violation of their duties when they know my private medical details and diagnosis.  The VAMC director claims it is legal.  The caller claimed they have never had this data.  I smell CYA, and it stinks!

I have now sat in Holding Cell 1 twice and Holding Cell 2 once at the Carl T. Hayden VA Police Offices.  I can tell you from my experience, the majority of these Federal Police Officers are unprofessional, full of verbal diarrhea, and replete with the most egregious manners it has ever been my displeasure to encounter.  The Department of Motor Vehicles is more professional and dedicated than most of the Carl T. Hayden’s VA Police Officers – having this “leader” of VA Police Operations tell me I am lying is enough to boil my blood!

Theres moreBut “Oh, wait, there’s more.” The caller then had the audacity to accuse me of being hostile, not listening, and refusing to comply.  How can I comply when you never told me why you were calling?  At this point, I disconnected the call.

The call today lasted 8 minutes, and was full of bureaucratic nonsense, and left me out of breath, gasping for air, and madder than a soaked chicken with a raging case of hemorrhoids.  Why did the Assistant Deputy Director of VA Police call me?  What is his job?  Since his job clearly does not include setting hospital policy at the VA, will this incident be referred to a policymaker at some future date, or do I have to be paralyzed?  Because another zealous VA Police Officer jerks my spine and cuts my spinal cord.  If patients cannot inform a police officer that what they are doing is causing injury, then the VA Police Officers need better tactics, approaches, and policies.

LinkedIn VA ImageAs a professional organizational psychologist, I place my integrity and honor on what I have reported, observed, experienced, witnessed, heard, and I fully and unequivocally attest that the majority of the Federal Police Officers in the Carl T. Hayden VA Police Force need immediate retraining; except for those fired for unprofessional behavior and misconduct!  There is NO EXCUSE for Officer Interpreter on the 08th of December 2020 to have grabbed me, after physically pushing me, and try to spin me into a wall.  There is no reason, at all, for a VA Police Lt. and a Sgt. to grab my wrists, bend my arms into positions they do not travel, aggravating the handcuff injuries from Monday, and then have the gall to tell me, “Well, how could I know you had painful wrists, you are not wearing a bandage.”  I told them about my injures before they started grabbing, jerking, yanking, and hurting me.  Then I get ordered to “Shut up; I was under arrest.”  But I never had my Miranda Rights read.  I complied on the 10th, I complied on the 8th, and was in compliance in July.

LinkedIn ImageLet’s be perfectly clear; hospital mandatory mask policies must have exceptions for patients who physically cannot wear a mask.  Patients unable to wear masks include some patients on cancer drugs, some asthmatic patients, people with breathing problems, and much more.  The Carl T. Hayden VA Medical Center COVID Mask policy is the biggest problem I face when trying to obtain treatment after the COVID Pandemic Declaration from Feb. 2020.  I am certainly not alone in having breathing issues with the COVID Masking Policies, and with the zealotry, which those policies are being enforced.  The VA has established an organizational design that requires business to be conducted face-to-face.  Hence, the VA is a Ghost Town; patients are canceling their appointments, FOIA’s are not being submitted, and so much more because of the masking policies that endanger patient health and place patients at risk of further injury!

I repeat, only for emphasis, the only medical offices, radiological departments, emergency rooms, and hospitals in the Phoenix, Arizona area where mask policies are causing problems is at the Carl T. Hayden Veterans Administration Medical Center, and this is 100% wrong!  The Entire VA Leadership Team should be highly embarrassed and entirely held accountable!I-Care

© Copyright 2020 – M. Dave Salisbury
The author holds no claims for the art used herein. The pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.
All rights reserved. For copies, reprints, or sharing, please contact through LinkedIn:
https://www.linkedin.com/in/davesalisbury/

Department of Veterans Affairs Chronicles of Shame – Round 2

Survived the VAIn reading the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports, it never ceases to amaze me the designed incompetence the leaders will stoop to use to thwart criticism.  For example, the length of time a leadership team has served together is an acceptable excuse for not making changes.  Yet, this same excuse is employed year-over-year, and location after location.  It was reported on one inspection summary that the leadership team had been together for 10-years, but recent changes in roles was to blame for the continued lack of compliance.  These are the Department of Veterans Affairs (VA) employees who would rearrange the deck chairs on the Titanic to obstruct passenger evacuation and blame the passengers for failing to get out of the way of the chair!

In recent reports from the VA-OIG, leaders have been apprised of problems, admitted they were “engaged in finding solutions,” and the VA-OIG gave the leaders a pass along with several additional recommendations to consider.  Yet, given the height and breadth of malfeasance at the VAMC’s where health problems occur, can anyone trust that the leadership team is actually working to resolve the problems?  If the VA-OIG returned unannounced in 3-6 months after the initial complaint, would progress have been made?

The problem with designed incompetence is that these excuses do not just evaporate, the excuses either survive long enough to become organizational design errors, or they are purposefully addressed until resolved.  There is no magic wand, potion, or witches brew that erases designed incompetence; but that is exactly what a person is led to believe when reading the VA-OIG reports.

VA SealThe VA-OIG performs comprehensive healthcare inspections as a regular inspection for the medical treatment facilities of the Department of Veterans Affairs – Veterans Health Administration (VHA).  I have personally reviewed hundreds of these reports over the last 10-years of monitoring the VA.  The regular nature of the inspection report indicates some VA healthcare facilities can perform like trained seals for their inspections.  Always, I am left to wonder what the reality in those same facilities looks like.

Albuquerque is a great VAMC to exemplify this point.  One ER room, on the inside of the door, held a blood spot for more than 18-months.  The spot was there and noticed, and reported to the doctor and nurse, when I was in that treatment room in the spring of 2016, and the same spot was still there in the spring of 2019 when chance had me in the same room for another exam.  But cleanliness was never a problem for this VHA facility in the VA-OIG inspection reports.

At the Albuquerque Hospital, in the Emergency Department, it was common to witness homeless veterans be abused by the staff.  The staff justified their actions, beliefs, and biases, where never censured, and physical harm was delivered to the veterans.  No one on the ED leadership team, or on the hospital leadership team, when notified of the problems, ever acted to remedy the situation.  When reported to the OIG, the OIG found no basis for the complaints, but the abuse continues.

LinkedIn VA ImageThe VA-OIG has published an end of year survey of COVID preparation and response to the COVID pandemic by the VHA.  68 separate facilities responded to the invitation.  These same facilities who brag about how quickly they adapted processes and procedures, are the same facilities bemoaning a considerable increase in cancelled appointments and severe reductions in patients served.  Not a single respondent mentioned the draconian measures taken to keep veterans from accessing care or the zealous employees who are enforcing those draconian measures.  No single respondent is discussing the failure to follow EMTALA when patients seeking care are turned away for not wearing a mask.  There is a correlation between patients not being served by the VA and how many are using non-VA facilities, but that is a data point outside the COVID survey, and that data point might not support the hand clapping and cheering by the providers and administrators of VHA facilities.

I cannot see any reason to cheer and clap over the COVID response by the VHA.  When I have accessed the VA Hospitals from Feb to present, the empty halls are a testament to the absurdity of the government response to a viral disease.  Being turned away by a provider for not wearing a mask, after waiting for 45-minutes is a testament to the futility of mask mandates and the uselessness and ineffectiveness of the draconian operating procedures for a virus.  Watching patients coughing their lungs out sitting beside a patient bleeding, and another patient throwing up does not cause me to celebrate the “COVID Response” by the emergency room administrators.  Watching empty treatment rooms sit empty while the waiting room is packed full of people waiting to be seen in an ER is not a cause to celebrate employee retention plans and patient treatment options.

Carl T. HaydenThe Carl T. Hayden facility in Phoenix, has had every one of the same issues in care as any other VHA facility in America, and frankly, the leadership team should be ashamed, disbarred, and unemployed!  Since 1996, I have crisscrossed the continental United States.  I have observed nurses drawing blood or giving shots without gloves, or with fingers ripped off the gloves.  I have witnessed patients with broken bones forced to wait for hours on end because they were homeless, and the nursing staff didn’t want to see that homeless patient one more time.  I have watched dependents turned away from receiving treatment which under EMTALA is illegal.  I have been turned away from treatment multiple times, still illegal under EMTALA.  I have made countless suggestions on how to improve, I have written letters to hospital administrators, VISN leaders, and the Federal VA Leadership all to no avail.  Yet, the VA has the audacity to cheer and congratulate each other on the “fine response to COVID the VA has made.”  Worse, the complaints fell on deaf ears, attached to plastic lips, and hiding vindictive hearts.

Before the VA’s cheers again for their great job fighting a flu virus, remember this, there is nothing to cheer about!  No activity made by the VA from Feb 2020 to present is worthy of cheering, clapping, or congratulations.  No business process has been laudable.  No daily operating procedure is worthy of acclaim.  Not a single event is worth even an honorable mention or a participation trophy.  Your job is to serve the veterans, spouses, and dependents and you are failing your first and only mission!

I-CareShame!  Shame! Shame!  Shame on the elected officials, Republican, Independent, and Democrat, who have allowed this problem to grow and done nothing!  Shame on the myriad of presidents who have done nothing but throw good money after bad, without demanding progress and holding real people responsible for real results!  Shame on every single VA employee who shirks their job for easiness to the detriment, pain, and suffering of a veteran, dependent, or spouse!

© 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 images.
All rights reserved. For copies, reprints, or sharing, please contact through LinkedIn:
https://www.linkedin.com/in/davesalisbury/

Symptom, Not Disease – A VA Chronicle

Carl T. Hayden10 December 2020, The Carl T. Hayden Phoenix VA Medical Center (VAMC), I was arrested for the third time, hassled for the fifth time, and injured for the third time at the hands of the VA Police over my physical inability to wear a mask. The zealous supervisor of the COVID Screening staff threw a fit, for the second time (first in October, again in December), when I asked him about his authority to refuse me care at the VA under EMTALA. Thus, for the third time, I have been denied emergency care under EMTALA by the Phoenix VAMC. I was taken to Holding Cell 2, where multiple officers of the VA Federal Police Force decided that making jokes about my injuries, claiming I was faking my injuries, and insisting they knew more about my injuries than my doctors was an acceptable VA Policing policy. Major Kratz is the bitter cherry on this “crap sundae,” by entering the room, shaking his sausage-like finger in my face, and accusing me of lying about having created an action plan with Jennifer, the supervisor of Patient Advocacy. A symptom, not the disease!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) has made some startling reports to Congress. Consider, “U.S. Attorney Justin Herdman announced on 20 November 2020, that a grand jury sitting in Cleveland has returned a 28-count indictment charging William H. Precht, age 53, of Kent, Ohio, with theft of government property, conspiracy to commit wire fraud and honest services fraud, wire fraud, and false statements relating to health care matters.” Let me stress; the defendant remains innocent until proven guilty in a trial of his peers. Still, I also stress this incident cost the Department of Veterans Affairs (VA) more than $1,066,348. The scheme was in place from 2010 to 2019, is but another symptom, not the disease, endemic to the VA.

The VA-OIG continues to report, “the owner of a for-profit trade school has been charged with defrauding the U.S. Department of Veterans Affairs and student veterans, announced U.S. Attorney for the Northern District of Texas Erin Nealy Cox.” The defendant, who remains innocent until proven guilty in a court of law by a jury of his peers, defrauded veterans seeking education to the tune of $71 million in GI Bill benefits from the VA and is facing up to 184 years in federal prison. Symptom, not disease, and the VA is full of this type of rot.

VA SealI would never expect a person to believe that the entire VA is full of these symptoms from three examples. Consider that electronic wait-lists, and wait-lists in general, has been a leading cause of death for veterans awaiting care and that the Phoenix VAMC has been in severe trouble on this single issue twice in recent years. Yet, the VA-OIG found, “… wait-list entries were not reviewed and validated as required. Patients were not removed from the wait-list when appropriate, indicating that employees at medical facilities did not review entries daily, and supervisors did not validate the wait-list weekly.” Supervisors not doing their job to oversee work is appropriately performed is the symptom that led to the first two incidents reported in this article. Again, symptoms, not disease.

Another recent example that was buried in “COVID-Media Hysteria,” “Ergonomic office furniture maker Workrite Ergonomics LLC, a Delaware company, and its parent, Knape & Vogt Manufacturing Co. (collectively, Workrite), have agreed to pay $7.1 million to resolve allegations under the False Claims Act that they overcharged the federal government for office furniture under General Services Administration (GSA) contracts, the Department of Justice announced on 3 December 2020.”  This settlement is over a contractual obligation clause to lower prices. “The settlement resolves allegations that Workrite did not fulfill its contractual obligations to provide GSA with accurate information about its commercial sales practices during contract negotiations and did not subsequently extend lower prices to government customers as required by the GSA contract’s price reduction clause.” Not mentioned here are the VA Employees whose job is to monitor the purchases made under the contract, ask questions during contract negotiations, and oversee the contractors and purchasing contracts. Fascinating that the employees responsible for catching these issues early never seem to be held liable for their failures to perform the jobs they have been hired to perform. Symptom, not the disease.

Speaking of symptoms, where supervisors and employees are not performing their jobs properly. “U.S. Attorney Andrew Murray announced on 2 December 2020 that John Paul Cook, 57, of Alexander, N.C. is facing multiple federal charges for defrauding the U.S. Department of Veterans Affairs (the VA) by receiving veteran benefits based on fraudulent service-connected disabilities from 1987 to 2017.” Thirty-years of VA Disability payments, but no VA employee ever asked if he had a driver’s license or other proof of disability. How is this possible; symptom, not disease!

Military Crests“A Florida attorney, on 1 December 2020, admitted his role in a scheme to extort $7.5 million from a California bank, Attorney for the United States Rachael A. Honig announced. Richard L. Williams, 73, of Miami, Florida, pleaded guilty by video-conference before U.S. District Judge Susan D. Wigenton to an information charging him with conspiracy to transmit an interstate communication with the intent to extort.”  Symptom, not disease!

“A Michigan woman was sentenced on 4 December 2020, to three years and five months in prison after pleading guilty to carrying out a scheme to defraud the U.S. Department of Veterans Affairs (VA) of more than $1.7 million in veterans benefits, announced U.S. Attorney Nicholas A. Trutanich for the District of Nevada.” Where were the IT and IS Controls to check for doubled veterans claims? Where were the employees asking for more information when blood types and other medical records mismatched? Administrative controls at the VA are a symptom, not the disease, and the VA Employees who have aided and abetted in allowing this type of trickery need to be held accountable.

Consider the following quote “VA employees are public servants with a solemn duty to care for our nation’s veterans,” said David Spilker, Special Agent in Charge of the VA OIG’s Southeast Field Office. This quote comes from the following case of fraud where the defendants have pled guilty. “Miller Wilson, Jr. (50, Sparr), his daughter, Myoshi Wilson (26, Citra), and his ex-wife, Erica Wilson (43, Ocala) were sentenced today by Senior United States District Judge James D. Whittemore for their roles in a scheme to defraud the U.S. Department of Veterans Affairs health care benefits.” The VA Employee Miller Wilson, Jr., was in charge of VA Payments for non-medical transportation. He established a company to transport VA Patients, received kickbacks for steering work to other companies, and got the other two family members involved in the scheme. Where was his supervisor during all of this “irregular behavior?” Symptom, not the disease.

ProblemsThe VA’s disease comprises numerous large organizations, especially those in the government sector, disconnections between leadership and front-line service providers. This disease goes by several names, but all have the following characteristics:

    • Lack of training
    • Lack of supervision
    • Lack of interest
    • Lack of caring
    • A socially shared sense of entitlement

Frankly, the disease is apathy, compounded by generations of knowledge in protecting oneself to the detriment of all others, including other employees. For example, as an employee, I was physically and verbally assaulted by a senior employee. When another employee and I complained of the maltreatment, the assistant director gave patently false information on how to report the problem, promoted the employee doing the assaulting, and then castigated those who reported this employee’s malbehavior. As the behavior intensified, the director became involved and used other employees on a quid pro quo to remove everyone who reported the employee doing the assaulting.

I-CareBecause this behavior is so ingrained, it has become a defining characteristic and is part of the organizational design. Correcting this behavior requires the same tactic used in pruning trees. Start small, get a core group of people who can work, act, and lead.

  1. Start in the local clinics and hospitals, for the Veterans Benefits Administration and the National Cemetery. Start local, where the worst rot is the most visible.
  2. Write down processes, procedures, operational standards, and behavior guidelines. Once written, begin training, publishing, and speaking about this new managerially acceptable behavior by first living these behaviors.
  3. Start setting organizational examples as fraud and malfeasance raise their heads, remove those involved, promote from within, and train the new leaders using the small core group as mentors.
  4. Cut out the obviously poor growers, first. For example, remove employees for cause, and publicize why. While publicizing why they were removed, communicate the new standards of managerially acceptable behavior.
  5. Train, train, and train. That training is a powerful organizational behavior, cannot be stressed enough. Set exacting standards, do not deviate for the easy and quick, and train others to meet those standards. Training includes mentoring and coaching. Use this opportunity to train, mentor, and coach as tools for encouraging managerially acceptable behaviors that meet the new standards, which begins new growth when the old rot is removed.
  6. Be Brave! Change in an organization requires the same type of bravery that wins soldier medals in battle. Standing when you want to sit is key to pushing back against organizational cancer represented in the current leadership.
  7. Do not quit! Too often, the VA has good intentions, uses valuable marketing tactics, and then drops the delivery ball, and the desired organizational change fizzles. Why does the change fizzle; because the leaders tasked with implementation run out of steam before the entrenched management runs out of excuses. Ending this requires smaller steps and people invested in making the change happen.

Image - Eagle & FlagThe VA has become detestable and is absolutely failing in the VA’s mission, as President Lincoln provided. Get outside the regular hiring pool, demand legislation that allows for change, and begin to prune. The veterans in America are counting on you, the leaders of the VA, to act! Do not let these veterans die because of your apathy and fear!

© 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 images.
All rights reserved. For copies, reprints, or sharing, please contact through LinkedIn:
https://www.linkedin.com/in/davesalisbury/

July Updates: OIG Reports That Should SHAME the VA!

Survived the VALate last week, I received a call from the Chief of police at the Phoenix VA Medical Center.  In July, I had been arrested for not wearing a mask.  By late August, I had figured the Phoenix VA Medical Center Director was going to just “forget me” and hope I go away, then the call comes in.  The Chief of police begins by stating, “I do not know why I am calling you, but I was requested to call and see what I can do to help.”

This response of the chiefs can be viewed two ways, he honestly does not know and needs to be updated, or he is using this as a conversation starter and does know.  I choose to see the best in people and gave the chief the benefit of the doubt.  I explained the situation, the multiple different stories regarding “VA Policy on Mask Wearing,” my multiple visits where I was not hassled about not wearing a mask, the confusion with the face shield, and the behavior of his officers in trying to implement poor policy.  To which the chief replied, I cannot help here and will return this issue to the director’s office where I had initially filed the complaint.

I do not blame the VA Police for arresting me.  They are tools of policy, as I have discussed previously and you can review here.  The police in my situation are stuck in the middle between a ridiculously inept hospital director, and the need to enforce the policies which issue forth.  At the beginning of COVID-19 hysteria, the director received a memo from the Department of Veterans Affairs (VA) regarding how to handle COVID-19.  The director did not adapt the policy to the local hospital, placing patients at risk who wears a mask in Phoenix summer conditions; nor, did the director include the ability for individual adaptation to individual patient health concerns, SAIL Metrics.  Thus, the VA Police are stuck, they cannot allow exceptions, they cannot allow for individual accommodations, and this places more burden upon the veterans seeking and requiring care at the Phoenix VA Medical Center and clinics.

The VA provides the rating of VA’s and the following website: Why not the best VA which will easily explain in a numeric format the indicators of problems with each VA.  What I find interesting is how many times the worst VA hospitals find themselves on the Department of Veterans Affairs – Office of Inspector General (VA-OIG) for egregious breaches of common sense, customer service, and common decency.  The Phoenix VA Medical Center is in VISN 22, and knowing the various hospitals intimately in VISN 22, the only conclusion possible in reviewing the data is that the 8 different hospitals in VISN 22 are in a dead heat race to the bottom, and the Albuquerque NM VA Medical Center is the best of the worst.

Carl T. HaydenThe VA-OIG conducted a healthcare inspection at the Atlanta VA Health Care System (VAHCS) in Decatur, Georgia, and found they had a backlog of open community care consults, and the OIG found deficiencies in processing, scheduling, and timeliness of these consults. Important to note, the contributory factors included but were not limited to, inconsistent scheduling processes, inconsistent oversight, and deficiencies with third-party administrator scheduling oversight, shortages of scheduling staff, and lack of training and supervision for scheduling staff. The facility did not consistently meet facility process requirements for scheduling audits and lacked a process to identify consults that were missing documentation after administrative closure.  While the Decatur VAHCS should be praised for not having any critical patient concerns due to the scheduling failures, this appears to be more luck on the patient’s part, than efficiency on the scheduling staff part.

The VA-OIG conducted a healthcare inspection at the Nashville VA Medical Center in Tennessee to evaluate alleged deficiencies in cardiac telemetry monitoring services including policies, staffing, and communication.  The facility should be praised for its progress in fixing deficiencies without the recommendations of the VA-OIG investigatory team.  The facility leaders also deserve praise for their attention to details, improvements in communication, and other facility improvements made since Feb 2019.  The last time this facility made the VA-OIG inspection report, the investigation was not pretty and their improvement needs to be praised; while more progress is needed, congratulations on the progress made.

Speaking of providing praise where praise is due, the VA-OIG conducted a comprehensive healthcare inspection of the Kansas City VA Medical Center (VAMC) and multiple outpatient clinics in Kansas and Missouri.  While this VAMC and outpatient clinics still have significant growth in improving SAIL metrics, they have progressed and growth is happening.  I send my regards, and sincere congratulations on the progress made.  I also wish them the best in continuing to improve.  This VAMC has a long road to recovering, but I know with patience, improved organizational design, and better staff training, they can get where they need to be.

ProblemsImagine you’re a patient, or worse a family member escorting the patient, with suicidal ideation, and you hear the doctor say, “the patient can go shoot themselves. I do not care,”  How would you feel about the 12-hour stay in the Emergency Room, after seeing seven different providers who did not read the notes, complete adequate patient handoff between the ER and outpatient mental health, which also includes deficiencies in the hand-off processes, and providers’ failure to read the outpatient psychiatrist’s notes, which led to a compromised understanding of the patient’s medical needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan.  Completing six-days later in the veteran taking their life.  This exact scenario should NEVER have occurred but did at the Washington DC VA Medical Center.  Now, the physician making that detestable comment had previously made similar comments about other patients; crickets from leadership.  The ER physician making this incredibly obtuse statement has a history of making “inappropriate comments” about patients in the ER, and this has been known to leadership since Feb 2019.  No action, no investigation, no remediation, and now we have a dead veteran because the representative of the VA had the gall to say, “the patient can go shoot themselves. I do not care.”

I-CareWhen any veteran dies by their own hand, it is a tragedy.  But, when the VA has any responsibility in that veteran committing suicide, heads should roll, individual people should be held accountable, and in this case, especially, criminal proceedings should commence!  I worked in the VA ER, I know what the providers, nurses, and other staff providing patient interactions say.  I have reported several inappropriate comments that the patients heard to no avail, no recourse, and no action by hospital leadership.  I know, intimately, the political chicanery that occurs at the VA, and I can tell you, this IS a pet issue with me, and I am unapologetic in calling for criminal charges on these providers who are abusing veterans and their families!

Leadership CartoonThe VA-OIG inspected the VA Illiana Health Care System (VAHCS) and multiple outpatient clinics in Illinois.  The VA-OIG also inspected the William S. Middleton Memorial Veterans Hospital and multiple outpatient clinics in Illinois and Wisconsin.  I have been in both and I can say unequivocally, more progress is needed and the leadership desperately needs to improve professionalism among staff, improve patient safety from the bureaucrats not providing care, staff competencies, and staff training.  All of which were among deficiencies mentioned by the VA-OIG.  There is great potential in these VAHCS’ for achieving greatness, but the bureaucrats need deep cleaned, and removed!

What continues to astound me is the replication of excuses and issues between VAMC’s and VAHCS’ when these comprehensive healthcare inspections are conducted.  On average, I can expect 3-5 comprehensive healthcare inspection results from VA-OIG per week in my email box.  Yet, the same exact issues and excuses are used time after time, location after location.  Those VAMC’s and VAHCS’ who are failing know they are failing, and the lack of care witnessed by the inaction of the hospital leadership infuriates this veteran.  Leaving me asking, “Who will care enough to demand change and cease allowing these tepid and weak excuses to be allowed?”  Are the elected officials even looking at the repetitive nature of the issues and asking follow-up questions, demanding answers, or even bothered by failures in comprehensive healthcare inspections?

I have not personally visited or been a patient in the following VAMC; however, the stories I hear from my friends and colleagues tell me the VA-OIG might have missed a few indicators of problems in this inspection and bought the excuses for designed incompetence.  The VA-OIG conducted a review at the Ioannis A. Lougaris VA Medical Center in Reno, Nevada. The review proactively identified and evaluated declining performance metrics that could affect the quality of care and patient safety.  The staff blamed the falling metrics on “losing focus, staff pay, other change initiatives, inefficient processes, which all contributed to performance deficits.  These are standard excuses for designed incompetence and I refuse to accept these conclusions by the VA-OIG.  Will the Ioannis A. Lougaris VA Medical Center in Reno, Nevada be the next Phoenix, AZ VAMC to kill a couple hundred veterans before these excuses are no longer accepted?

VA SealThe behavior of the VA as recorded in these VA-OIG investigations and inspections continues to reveal significant problems with staff, where the staff has designed processes and procedures to allow a ready excuse for any problems that arise and continues to prove that a veteran takes their life in their hands when visiting the VA.  These actions must cease forthwith.  There is no excuse for the behavior investigated and reported.

© Copyright 2020 – M. Dave Salisbury

The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the pictures.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

https://www.linkedin.com/in/davesalisbury/

Updated Inspector General Reports – Department of Veterans Affairs: These Actions Must Cease!

I-CareLong have I written about the Department of Veterans Affairs (VA) and the Office of Inspector General (VA-OIG) reports which cross my inbox.  Long have I been utterly disgusted with the waste, fraudulent behavior, and the utter disregard for the patient witnessed in the VA Medical Centers across America.  As a veteran and taxpayer, it is past time to begin to see action to rectify these types of issues.

The VA-OIG conducted an inspection to evaluate concerns related to a Virtual Pharmacy Services (VPS) pharmacist’s discontinuation of antidepressant medication for a patient of the Minneapolis VA Health Care System, which resulted in the patient not having prescribed antidepressant medication for approximately six weeks before dying by suicide.  The VA-OIG found that the pharmacist never notified the psychologist, never checked the patient’s record, simply discontinued the medication.  While the VA-OIG found process and procedure issue, the fact that a medication could be arbitrarily discontinued without a “Red Flag” being raised with the provider and the patient is deeply troubling.  Worse, the quality control processes in the pharmacy did not trigger a problem when a medication was discontinued without a provider order; why?

There is a dead veteran, and a pharmacist who claimed they did not know they could access a patient file; and the excuses do not hold water!  This incident is a tragedy of epic proportion and I must ask, how many more veterans will die because medications are arbitrarily turned off?

ProblemsThe next VA-OIG inspection is a bit of a pretzel, there is another dead veteran by suicide, and processes and procedures were recommended by the VA-OIG to correct some small issues in bariatric surgery patients.  Reading this report, it appears that this veterans’ suicide was not directly connected to preoperative counseling for bariatric surgery which was essentially the scope of the VA-OIG investigation.  If there is a connection between the bariatric surgery and the suicide, it was beyond the VA-OIG investigatory scope.  Hence, the VA might not be at fault for the suicide, but the VA-OIG recommendations indicate more can and should be done in the future to decrease the risks postoperatively.

Let me be clear, room for improvement to decrease risk does not assign or negate blame in this situation.  The death of a veteran through suicide remains a tragedy and the VA can and should be doing more to help reduce veterans committing suicide.  With the convoluted processes and the contradictory bureaucracies inside the VA, much more can be done as an organization to streamline and bring efficiency, transparency, and responsibility to the employees making patient decisions.

Chinese CrisisAnother VA-OIG report does clearly reflect the responsibility and lack of care a patient received at the VA.  The Tennessee Valley Healthcare System in Nashville is responsible for test results still not being properly communicated to the veteran in a timely manner, which delays treatment and care.  Fall 2018, a patient went undiagnosed and untreated for pancreatic cancer due to failures in communicating test results, collaborating with the primary care providers, and for the electronic health records not containing a system of alerting providers that an adverse test result occurred.  Hence, this patient’s problems have three root causes:

  1. Failure to notify the patient.
  2. Failure to collaborate between different hospital units for patient care and safety.
  3. Failure of the electronic health records programming to include alerts.

From personal experience, I must wonder if any patient notification would have made a difference.  The patient notifications are simply the results, not definitions, no descriptions, just ranges, and results.  Hence, the patient notification process must include clarity of the results so non-medical people can understand what was found and the implications.

While I applaud the VA-OIG for insisting that an internal review is conducted and problems rectified, I have significant doubts that change will occur.  It appears that unless the VA-OIG is following up on their recommendations; which is outside the VA-OIG’s authority, the change will not occur.  A truly unfortunate series of events occurred in this patient’s life and the bureaucracy of the VA will prevent anyone from being held accountable for the failures, nor will change occur to protect another veteran.

The W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina, was recently inspected for concerns regarding anesthesia provider’s practice.  While no issues were found under the VA-OIG scope regarding the provider’s practices, other issues were discovered.  The problems found were all administrative in nature and included the usual training, timely record keeping, following the policies established by VHA, etc.  Juran’s Rule states that “When there is a problem, 90% of the time the problem lies with policies and procedures, not people.”  How, and when, a person does their job is more often the root of the problem and is evidenced again with this VA-OIG investigation report.  The fact that this problem continues at all VA Medical Centers (VAMC) across America is indicative of a systematic issue in poor organizational design, then in the individual employee.  The VA must address these organizational issues that breed complacency in employee adherence!

LinkedIn VA ImageWith confirmed cases of nepotism still occurring in the VA, this time in Miami.  With continued issues regarding ethics violations and the proper use of time and materials for teleworking employees.  With the continued employee obstruction witnessed in so many cases of records not being readily available to VA-OIG inspectors.  The VA desperately needs to have a deep cleaning and reorganization.  Why has the VA not adopted ISO-9001 for Hospitals?  Why hasn’t the VA adopted ISO-9001 for the VBA or National Cemetery as a coherent process for organizational change and improvement?

Consider that there remains a dearth of written processes, procedures, and policies in the VA.  So much so that more than one VA Hospital operates on “Gentlemen’s Agreements” between departments, instead of official policy statements and procedural plans.  This lack of written policies and procedures is the excuse and the general recommendation of so many VA-OIG inspection reports that I am shocked Congress has not begun asking about this single issue.  The first rule I learned as an EMT was, “If it is not written down, it never happened.”  I was told this is the first rule of medicine; yet, somehow the VA can escape without writing down how to perform work.  Doesn’t that seem strange to anyone else?

Where the lack of written procedures is most noticeable, is at the Veterans Benefits Administration (VBA), where the quality control people missed 35% of the errors routinely, never checked each other’s work, never learned lessons to improve performance, and were not properly supervised.  Yet, training, communication, and written procedures are routinely used as excuses, and corrective action is outside the VA-OIG investigatory scope.  So, while the problems are being identified, the leaders are refusing to do their jobs!  From the VA-OIG report comes the following details:

“The VA-OIG estimated that during the review period, regional office managers inappropriately overturned errors in 430 of 870 quality reviews (about 50 percent) where claims processors requested a reconsideration from a quality review specialist- identified errors. The VBA has not established adequate oversight or accountability to ensure the timeliness of error corrections. The OIG estimated that during the review period 2,000 of 4,400 identified errors (45 percent) were not corrected in a timely manner and 810 of 4,400 identified errors (18 percent) were not corrected at all.” [Emphasis Mine]

Again, I ask, where are the written procedures that form the standards of work which are used to hold employees accountable?  With an 18% error rate never being addressed by quality control, this means that veterans are being underpaid or overpaid for their benefits, and the VBA does not care that these issues are killing veterans.

Survived the VAPersonally, I experienced a VA overpayment that took more than 3-years to payoff.  Three years where my benefits were docked for an administrative mistake that was not found until the next decision was made on my claim several years after the original mistake was made.  What is worse, the mistake I paid for, was not a mistake at all, and the funds were later returned as another quality person found the error and corrected the documents accordingly, but the discovery took another VBA claim decision to catch, from beginning to end this issue of overpayment took three different decisions by the VBA and more than 8 calendar years from beginning to end.

Every single taxpayer in America has a personal stake in seeing the VBA do their jobs timely, efficiently, and correctly.  Every single veteran in America has a vested interest in seeing the VBA perform their roles with fewer rates of error than those reported by the VA-OIG.  Every elected official in America benefits in some way from the decisions of the VBA and should be able to demand higher quality decisions, better performance, and more transparency from the VBA.  Consider, if the problems of performance are this bad for a spot check analysis by the VA-OIG, how bad are the real numbers?

The VBA was also investigated for improper payments to schools through the Vocational Rehabilitation and Employment Program (VR&E) to the tune of $554,998.  Most of the errors were in transcribing numbers and the electronic program did not raise any alerts or attempt to rectify the problems, and no quality control system is in place to protect against human error.  The VA-OIG investigatory scope included 1.8 million payment transactions from 01 Jan 2014 to 30 Dec 2019.  While this is a much better error rate; the fact that the technology and the work processes were not catching these errors timelier, which means more billing issues, more wasted resources, and more problems for the VA, the VBA, the VR&E program, the taxpayer, the colleges and universities, and the impact goes on and on.

The VBA was also recently inspected for failing to accurately decide service-connected heart diseases.  The root cause was the questionnaire developed to ascertain what and when regarding the heart diseases experienced.  Six months, 01 Nov 2018 through 30 Apr 2019, were selected and 12% of the claims were improperly decided which totals $5.6 Million in improper payments where a veteran either received too much or too little for their claim.  Necessitating repayments or backdated payments once new and material evidence was procured to force the VBA to make a new determination.  Inaccurate decisions on claims involve a lengthy appeals process, expenses for testing, and the veteran is always responsible for the mistakes made on their claim.  Thus, the exasperation of these mistakes on the families, friends, and communities of the veteran involved in a VBA mistake.

When the VA-OIG finds errors made by the VBA the veterans affected are not notified that the VBA made an error in their determinations.  The VBA does not form a task force to evaluate these errors and correct them internally unless money is owed and then the collections department is left to muddle through the decision, not the VBA.  Thus, when veterans ask for transparency in the VBA processes, we are asking for the VBA to own their mistakes, fix the problems they are creating, and correct the errors in a timely fashion.  It should not require new and material evidence to trigger the VBA to make a new determination when the VBA made the original mistake in determining eligibility in the first place!

All because the quality controllers do not have written procedures to measure standards of performance against.  All these errors are due to improper organizational design and old computer systems, which are ready-made excuses for not performing work in a timely and efficient manner.  All because the leadership fails to delegate, monitor, observe, and function.  Why are the leaders missing, because they are all in meetings, all day, every day, and not at their desks!

Military CrestsJust like the labor union provided bumper sticker proclaims, “SAVE the VA!” [Emphasis in original], it is time to “SAVE the VA!”

© Copyright 2020 – M. Dave Salisbury

The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the pictures.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

https://www.linkedin.com/in/davesalisbury/

The Power of Tiger Teams – Shifting the VA Paradigms

I-CareA key aspect of Tiger Teams is their ability to stress test, beta test, and routinely check how operations are performing and recommend changes from the position of the customer.  Recently the Department of Veterans Affairs (VA) – Office of Inspector General (VA_OIG) investigated a critical piece of the Mission Act of 2018, the health information exchanges.  While the VA-OIG received useful and valuable information from the VA and the community provider side, the customer/patient side was not included. From experience, I can affirm this is broken!

Recently, a veteran needed emergency care and received that care through the community providers under the Mission Act of 2018.  The records from the community care provider never transferred to the VA, the billing has been a mess of letters and notifications, and the patient’s issues were never followed up with the VA provider until the patient called and made it an issue.  One of the main selling points for community providers was to share electronic health information easily with the VA, which included notifying the primary care providers when a patient was seen in the community.  This aspect remains a “pie-crust promise” as well as a frustrating issue for patients and VA providers alike.

Before the Mission Act of 2018, if the veteran patient was sent to a community provider, the patient transferred manually all records to and from the VA and the community provider.  Allowing for lost records, duplicated records, and a host of problems in bureaucracy.  One of the issues the veteran experienced in seeking community care was the historicity of medical records to reduce costs and not duplicate tests; however, the community provider was never able to obtain that historicity and the emergency room costs were greater for the VA.

Thus, the need to operationally check the system, processes, and patient experiences using Tiger Teams.  A Tiger Team is a group of experienced people who interact with the business as customers, who have been granted the authority to make changes and see those changes implemented.  These are a selected group who work from a central office and are dedicated to improving business performance.  While I applaud the progress made with conforming to the Mission Act of 2018, there remains significant work in the patient experience to be completed and currently, the situation is not the roses and rainbows the VA-OIG is portraying.

ProblemsTiger Teams are also helpful in another way, that of “bird-dogging,” or acting as the researchers, and developers of ideas towards making improvements.  The VA-OIG recently brought to light that the VA needs to expand retail pharmacy drug discounts.  With the number of prescriptions filled by the VA hourly, the fact that the VA does not have volume discounts was surprising, but unfortunately, not unexpected.  The VA-OIG estimated that of the $181 million spent on retail drugs in fiscal year (FY) 2018, $69 Million would have been saved.  From the VA-OIG report:

“VA is one of four federal agencies eligible by law to receive at least a 24 percent discount for prescription drugs purchased for its facilities and dispensed directly to patients. However, for prescription drugs purchased through retail pharmacies for beneficiaries, VA pays the higher average contracted wholesale price because it does not have the authority to require drug manufacturers to provide the drugs at discounted prices.”  [Emphasis Mine]

Unfortunately, the program inspected for savings on retail pharmacy prescription was but one of several VA drug programs lacking statutory authority to save the taxpayers from being gouged on prescription drugs dispensed through retail programs at the hands of the VA.  Hence, the findings are surprising, but not unexpected.  How long before the VA secretary will collaborate with the Office of Regulatory and Administrative Affairs to pursue whatever changes are required to give VA the appropriate legal authority to purchase all prescription drugs through retail pharmacies at discounted prices?  At the tune of one program saving $69 Million a year, the benefits add up in a hurry.

How would Tiger Teams help in this situation; by doing the legal leg work, establishing relationships, initiating inquiries, and discovering all the other programs where the statutory authority is missing to close a gap and save money.  While the VA Secretary is responsible, delegating this authority to a Tiger Team saves time and improves the patient and taxpayer experiences.  This is why the Tiger Team must work from the VA Secretary’s Office, endowed with the power of the secretary, to make and affect change for the good of VA.

Leadership CartoonFinally, the power of Tiger Teams is also manifested to the VA in another way, returning to a situation after the VA-OIG has made recommendations to ensure compliance occurs.  Another recent VA-OIG report shows that after a scathing VA-OIG inspection, the Department of Veterans Affairs – Veterans Benefits Administration (VBA), was still out of compliance in their internal quality control procedures, systems, and processes.  While some improvement had been made to spot errors, the procedures and processes that allowed those errors to occur were receiving zero attention by the internal quality inspectors.  Which is akin to noticing the horse is out of the barn, but not shutting and locking the door to keep the horse in the barn.  There is no valid excuse for the VBA quality controllers to not have been doing their jobs since the last VA-OIG Inspection.

The Tiger Team, with sufficient and specific authority, has the power to cut through the excuses, the red tape, and the intransigence of federal employees to root out the why, and establish a path to correction.  Yet, the VA Secretary is not using the Tiger Team concept as a tool to effect change, power compliance, and intervene to improve the veteran experience with the VA, the VBA, the VHA, and the National Cemetery.

Suggestions for improving the processes at the VA continue to include:

  1. Establish forthwith a roving Tiger Team, provide these employees with proper authority, and set them to work fixing the VA.  Allow the Tiger Team to establish flying squads inside the agency, hospital, medical center, etc. to report back on compliance issues, and any pushback they receive in correcting errors.
  2. Cut the bureaucracy that intransigent employees are using as a tool to stop or slow down change. The VA’s internal bureaucracy is the tail that wags the dog and since it is out of control, it requires an external force to regain control and proper order.
  3. Imbue the Tiger Team with an active mission statement, purpose, and organizational design. The Tiger Team is an active, not passive, tool that requires people dedicated to making change and seeing results.

VA SealNever has the axiom, “If it ain’t broke don’t fix it,” been less true.  The VA is broken and desperately needs fixing.  With the help of those dedicated VA Employees, the proper leadership, and a Tiger Team to aid, the VA can be fixed and fixed quickly!

© Copyright 2020 – M. Dave Salisbury

The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the pictures.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

https://www.linkedin.com/in/davesalisbury/

Patient Health and Safety Concerns – Phoenix, VA Medical Center

Alyshia Smith
Medical Center Director
Carl T. Hayden VA Hospital
650 E Indian School Rd
Phoenix, AZ 85012

08 July 2020

Dr. M. Dave Salisbury Ph.D.
10002 N 7th St
APT 1125
Phoenix, AX 85020

Subject: Healthcare policies that endanger patients.

Dear Ms. Smith,

I have been a patient of the Carl T. Hayden VA Hospital since 1998 when my family first moved to Phoenix.  I was a witness to the award-winning days, and have been a witness to the dead veterans, paper waiting lists, and incredible fall of the Phoenix VA Medical Center.  I want to help fix this VA Medical Center and moved back to Phoenix specifically for this purpose.  As an organizational psychologist, I have made a careful study of the VA, as a patient, as a previous employee, and as a concerned citizen.  I blog about VA issues because “I-Care” about the VA.

One of the first lessons taught me in new hire orientation training, concerned the Emergency Room and the Emergency Medical Treatment and Labor Act (EMTALA; 1986), a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.  EMTALA was being abused in the hospital I worked at and I reported this issue.  EMTALA is being abused at the Phoenix, VA Medical Center.  Twice I have followed my primary care providers’ instructions to report to the VA ER for treatment, and twice I have been refused service.

30 June 2020, I was refused service at the VA ER because I cannot wear a mask due to breathing issues.  I was informed upon entering that I could hold the mask in front of my face and this is an acceptable workaround.  Upon entering the ER to be checked in, the office staff refused the information provided at the entrance, and said: “If the mask is not worn, we are refusing service.”  I have had shortness of breath, not lung-related, for many years now and cannot wear a mask.  This information is noted in my VA Medical records.  I have been through several rounds of breathing tests which confirm my lungs work great, but I remain short of breath, and when I wear any mask my problems breathing include lightheadedness, dizziness, nausea, and eventually my vision grays and I pass out.  The original problem was diagnosed at the Salt Lake City VA Medical Center (2010/2011).

08 July 2020, I walked into the VA through the South Entrance.  Not wearing a mask and those performing the COVID check did not offer a mask, offer a face shield, or say anything.  I walked to the ER, the admitting person did not mention my need for a mask, nor did they ask why I was not wearing a mask, I was checked in to be seen in the ER.  I was triaged and the triage nurse did not say anything about a mask.  I sat in the ER for 3-hours and none of the medical staff, hospital staff, employees, or Federal Officers walking past ever mentioned the need for a mask.  I walked to the Patriot Store feeling sick because of diabetes and needing food.  On my way, an employee whines about me not wearing a mask, and I ignore this person as my medical information is private and I should not have to explain to every nosy-nelly about why I am not wearing a mask.  I go to complete my purchases and suddenly the VA Police, who were called by the unknown VA Employee, are there insisting I need to wear a mask.  I explained, for the first of at least 40-times that I cannot physically wear a mask to protect my health and safety.

I realize the VA Police are executioners of policies that they have no say in forming and I refused to be anything less than professional as we walked back to the ER.  By the time I arrive back in the ER, my police escort has grown from 2 to 7 or 8, led by one plainclothes person claiming to be a Lieutenant and the other was a uniformed Lieutenant.  My intransigence at wearing a mask was not disorderly conduct, but a patient safety issue. I have a hard time breathing and when I must speak, this exacerbates my breathing condition.  I was accused of yelling, and before I could explain, I am being threatened with being arrested, cited, and thrown out of the VA ER.  By this time, I am in trouble physically and neurologically, between diabetes and my need for food, and the neurological condition I suffer through, my stress levels are making a bad situation worse.

A person identifying themselves as a doctor handed me a face shield and my wearing of the face shield did not stop the harassment from the VA Police over not wearing a mask.  During my conversations with Timothy Mikulski from the Patient Advocates Office after the last time, I was refused care illegally at the VA ER, I was told wearing a face shield is acceptable.  Thus, when I put the face shield on, I was expecting to be left alone.  Instead, I was demanded to either wear a mask or be arrested.  My third threat in less than 5-minutes for not wearing a mask, even though I now had the face shield properly worn for the same 5-minutes.

Eventually, I am arrested, I experience a seizure where I fell to the floor and injured my knee, then was hit repeatedly in the spine while being “patted down,” which continued to collapse my legs and increase my pain.  I was handcuffed to a bench in a holding cell where I bruised my right wrist because my seizures include my arms jerking and with one arm handcuffed to an immovable bench, I could not control my body and the handcuff was not allowing my involuntary movements increasing patient harm.  I have a bruise and scratches from the handcuff on my right wrist.

Here is the problem, the policy for wearing a mask does not have exclusions for those of us who cannot wear a mask.  Thus, wearing a mask creates more health problems, the potential for injury, and issues for the medical staff who are already overworked.  If a face shield is acceptable as a replacement for a mask, why was my wearing the face shield insufficient to closing the police issue?  If a face shield is not acceptable as a replacement for the mask, why is the patient advocates claiming this is acceptable?  If wearing a mask is so important, why was no one bothered by my not wearing a mask until the nosy employee called the Federal Police?

I sat in the bench seat beside the bookshelf in the ER.  Multiple officers, staff, and more walked past and no one was bothered, no one said anything, no one made any fuss over my not wearing a mask for three full hours while I was waiting in the ER.  Even when I interacted with the employee’s passing nobody made any comments.  This is a failure of policy, or it is the unfair harassment of a single person by overzealous police officers.

Let us talk about access to medical records.  The Federal Officers harassing me, sent one of their own to view my medical record for a statement from my PCP regarding my inability to wear a mask for health reasons.  I told the officers what they would find, “Records pertaining to my being diagnosed with shortness of breath and difficulty breathing.”  They claimed that since those records were from my time in Albuquerque, I was “blowing rainbows up their butts.”  Hence, even if my medical records had reported a message from my PCP, I would still have been in the wrong.

From my time as an employee, Medical Support Assistant, VA ER, Albuquerque, I know that the police do not have a reason to be surfing my medical records.  Yet, in the holding cell, I heard them discussing my medical records, my mental health diagnosis and cracking wise about details in my medical folder.  How did they get my medical records?  Why did they have possession of my medical records?  What is the purpose of the police having access to my personal medical files?

I freely admit, by the time the VA Police handcuffed me, my “cherub-like demeanor” had melted away.  When I am in extensive pain, I cannot think clearly, speak coherently, and my ability to suffer fools and liars is non-existent.  But this entire affair was brought about by a policy that does not make sense, a nosy employee who does not need to know my medical history and two overzealous lieutenants who need their ego’s clipped!

Another issue, why is my full SSN, DOB, and Full Name printed on the triage wrist bands?  Why are all VA ER patient’s data displayed in human-readable data on the wristbands?  This is a HIPPA and PII security issue that was supposed to have been corrected back in 2014.  Human readable data being bandied about places patients at greater risk for having their identity stolen.  This is especially true on an item regularly thrown away.  As someone who has followed the VA problems with protecting veterans, protecting data, and adhering to rules and regulations, I find this lapse highly questionable.

The following is requested:

  1. Remove the arrest and cancel the citations.
  2. Correct the policy.
  3. Train so the policy is properly applied, fairly communicated, and a standard is set. Removing individual adaptation and personal interpretation.
  4. Correct the PII on the wrist bands and other printed patient documents to protect the identity of the veterans. This is a simple fix of programming and your IT department should be able to complete this task easily.

Thank you for your prompt response in this regard.

Sincerely,

Dr. M. Dave Salisbury Ph.D./MBA

© Copyright 2020 – M. Dave Salisbury

The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the pictures.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

https://www.linkedin.com/in/davesalisbury/

Tiger Teams – A Potential Solution to VA Issues: An Open Letter to Secretary Wilkie

I-CareTo the Honorable Secretary Robert Wilkie
Department of Veterans Affairs
Washington D.C.

Dear Sir,

For almost a decade, I have read and studied the Department of Veterans Affairs (VA) from the position of patient, employee, concerned citizen, and now as an organizational psychologist.  During this time, I have read many Department of Veterans Affairs – Office of Inspector General (VA-OIG) investigation reports, and yearned to be of fundamental assistance in improving the VA.  I have an idea with potential for your consideration, “Tiger Teams.”

In the US Navy, we used “Tiger Teams” as “flying squads” of people, dedicated to a specific task, and able to complete work quickly.  The teams included parts people, technicians, specialists, and carried the authority of competence and dedication to quickly fixing whatever had gone wrong during an evolution, an inspection, or even in regular operation.  It is my belief that if your office employed a “Tiger Team” approach for speedy response, your job in fixing core problems the VA is experiencing would be easier.  Please allow me to explain.

Tiger TeamThe VA-OIG recently released a report regarding deficiencies in nursing care and management in the Community Living Center (CLC) at the Coatesville VA Medical Center, Pennsylvania.  The inspection team validated some complaints and were unable to validate all complaints because of poor complainant documentation.  Having a Tiger Team able to dispatch from your office, carrying your authority, would provide expert guidance in rectifying the situation, monitoring the CLC, and updating you with knowledge needed to answer the legislator’s questions regarding what is happening.  The VA-OIG found other issues in their investigation that were not covered under the scope of the investigation, leaving the VA-OIG in a difficult position.  Hence, another reason for a Tiger Team being created, to back stop and support the VA-OIG in correcting issues found outside their investigatory scope.

Fishbone DiagramFor a decade now, I have been reading how the VA-OIG makes recommendations, but where is the follow-up from the VA-OIG to determine if those recommendations are being followed and applied?  Too often there is no return and report feature built into the VA-OIG investigation, as these investigators just do not have the time.  Again, this is what a Tiger Team can be doing.  Taking action, training leaders, building a better VA, monitoring and reporting, building holistic solutions, and being an extension of your office on the front lines.  Essentially using the tools from your office to improve the operations locally, which builds trust between the patients and the care providers, building trust between the families and the VA, and delivering upon the Congressional mandate and VA Mission.

Another recent VA-OIG report also supports the need for a fast response Tiger Team.  Coordination of care and employee satisfaction concerns at the Community Living Center (CLC), Loch Raven VA Medical Center, in Baltimore, Maryland.  In geographic terms, this incident is in your backyard.  While the VA-OIG inspection was rather inconclusive, and recommendations were made, it appears some things are working in this CLC and other things are not working as well as they should.  By using a Tiger Team as a flying squad, intermittent and unannounced inspections by the Tiger Team can aid in discovering more than the VA-OIG could investigate, monitoring the situation, and reporting on progress made in improving performance.

As an employee, too often the director of HAS would claim, “That problem is too hard to fix because it requires too many people to come together and agree on the solution.”  Or, “The solution is feasible, but not worth the effort to implement because it would require coordination.”  Getting the doctors and nurses talking to and working with administration is a leadership role, providing support to leaders is one of the best tools a Tiger Team possesses one authority is delegated.  The Tiger Team presents the data, presents different potential solutions, and the aids the leadership locally in implementation.  As an employee I never found a problem in the VA that could not be resolved with a little attention, getting people to work together, and opening lines of communication.  Thus, I know the VA can be fixed.

Root Cause AnalysisThe Tiger Teams need to be led by an organizational psychologist possessing a Ph.D. and a personal stake in seeing the VA improve.  The organizational psychologist can build a team of like-minded people to be on the flying squad, and these team members should be subject matter experts in VA policies, procedures, and methods of operation, and should change from time to time.  I have met many people from the VA who not only possess the passion, but are endowed with the knowledge of how to help the VA, and I would see the VA succeed.  Yet, I am concerned that the VA is not changing, not growing, and not developing the processes and procedures needed to survive, and this is damaging the VA, which leads to wasted money and dead veterans.

Why not have a flying squad for each VISN, who can meet to benchmark, compare notes, and best practices.  Who work from home and visit the local offices in the VISN, reporting directly to your office with a copy to the VISN leadership.  Whose job is to build the Tiger teams needed to oversee, provide expert support, and practical analysis.  The idea is to help you gather real time data, improve implementation of VA-OIG recommendations, and meet the demands of Congress.  If a Tiger Team, with the functioning Flying Squad, can save one VA-OIG inspection in each VISN, by improving that VISN, medical center, CLC, etc. before it becomes a major problem on the sSix O’clock News, then the Tiger Teams have paid for themselves.

All veterans know of the Phoenix VA Medical Center debacle, where veterans died while waiting for appointments.  I fully believe that had the VA Secretary had a Tiger Team in place, the root causes of that incident would have triggered the necessary flags to save lives and avoid or mitigate the catastrophe.  Flying squads are the Tiger Team in action, and action should be the keyword for every member of the team.  The mission of the Tiger Team should be to find and fix root causes, repair trust, and implement change needed to improve VA operations at the Veterans Benefits Administration (VBA), the Veterans Health Administration (VHA), and the National Cemeteries.

The VBA is especially vulnerable, and in need of outside resources to support change.  Recently the VBA was involved in another scandal involving improper processing of claims for veterans in hospital over 21-days, resulting in millions of dollars either overpaid or underpaid to the veterans.  Training, managerial oversight, and proper performance of tasks was reportedly the excuse the VBA used, again, to shirk responsibility.  Tiger Teams can provide the support needed to monitor for, and encourage the adoption of, rectifying measures and VA-OIG recommendations, not just at the VBA, but across the full VA spectrum of operations.

Please, consider implementing Tiger Teams, from your office, assigned to a specific VISN, possessing the authority delegated to run the needed analysis, build support in local offices, and iron out the inefficiencies that keep killing veterans, wasting money, and creating problems.  I firmly believe the VA can be saved and improved, built to become more flexible, while at the same time delivering on the promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.”

I-CareThank you for your time and consideration.

Sincerely,

Dave Salisbury
Veteran/Organizational Psychologist

© Copyright 2020 – M. Dave Salisbury

The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the pictures.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

https://www.linkedin.com/in/davesalisbury/

Structured Incompetence – The Department of Veterans Affairs and Congress

I-CareThe Department of Veterans Affairs (VA) is allowed the ability to govern themselves, provided they meet specific guidelines and legislated goals and directions.  The Department of Veterans Affairs – Office of Inspector General (VA-OIG) was established to provide legislators and the VA with tools and processes to improve, as well as to investigate root causes, and make recommendations for improvement.  But, here is the rub, the VA-OIG has no teeth to help their recommendations hold the attention of those in charge to make changes.

In December 2014, the Federal Information Technology Acquisition Reform Act (FITARA), passed Congress and was signed into law by the president; FITARA is a historic law that represents the first major overhaul of Federal information technology (IT) in almost 20 years. Since FITARA’s enactment, OMB published guidance to agencies to ensure that this law is applied consistently governmentwide in a way that is both workable and effective.  2014 saw the VA slow the loss of private data from the VA, the Office of Personnel Management (OPM) Data Breach is gaining momentum and will crest in 2015, and in case memory has failed 2014 saw an explosion in VA malfeasance get uncovered starting with the Carl T. Hayden VA Hospital in Phoenix, AZ.

December 2020 will mark the sixth anniversary of FITARA, and President Trump signed a five-year FITARA bill in May 2018.  The VA-OIG in reporting progress on FITARA at the VA has this to report,

“… The audit team evaluated two groups of requirements involving the role of the VA chief information officer during [the] fiscal year 2018. They related to the CIO (1) reviewing and approving all information technology (IT) asset and service acquisitions across the VA enterprise and (2) planning, programming, budgeting, and executing the functions for IT, including governance, oversight, and reporting. The audit team found that [the] VA did not meet FITARA requirements and identified several causes.”

The number one reason for non-compliance after almost six-years was, “VA policies and processes that limited the chief information officer’s (sic) review of IT investments and the oversight of IT resources.”  Not mentioned in the VA-OIG report is how many of these processes and policies had been enacted since 2014.  The VA’s own processes and policies reflect structured incompetence, making a ready excuse to be out of legal compliance with legislated obligations.  If this was a private business, and the legislated obligations were not being followed exactly, no excuse could keep the leadership team out of jail and the business in operation.  Hence, Congress why do you allow this egregious behavior by public servants?

On the topic of structured incompetence, foot-dragging, and legislated obedience, the VA-OIG issued a glowing report of compliance because the VA was found to be in compliance with three of the five recommendations from a VA-OIG inspection on the Mission Act from June 2019.  The progress made was on all aspects of the Mission Act except mandatory disclosure.  Why does this not surprise me; of course, the VA has had, and continues to suffer from, a horrible case of refusing to report, disclose, and communicate without severe prodding and legislated mandates.  Thus, I congratulate the VA on being in compliance with the Mission Act for the last three consecutive quarters on a total of three recommendations from the VA-OIG; this is a good beginning, when can we expect improvement on mandatory disclosure?  Structured incompetence relies upon disclosure malfeasance, collective misfeasance, and leadership shenanigans.

On the topic of structured incompetence, the VA-OIG reported that the Northport VA Medical Center in Northport, New York, prior medical center leaders did not plan effectively to address deficiencies in aging infrastructure.  Which is the polite way of saying, the buildings are old and maintenance has been creatively haphazard, so when steam erupts from fittings and contaminates patient treatment rooms with asbestos, lead paint, live steam, and other construction debris, a small problem becomes a multi-month catastrophe.  Thankfully, the VA-OIG reported no harm to the patients or patient care restrictions from this episode.  Unfortunately, the VA-OIG cannot hold the managers and directors of engineering services responsible.  Having worked in several capacities in engineering I am astounded at the following recommendation from the VA-OIG, and covered under creatively structured incompetence:

“… The OIG recommended that the medical center director develop processes and procedures for submitting work orders—including for notifications when work orders are assigned and reviewed for accuracy and consistency—to help the center’s engineering service prioritize work and manage [the] resource.”

Will the VA-OIG please answer the following questions, “Why is this the hospital directors’ job?”  You have an entire engineering plant, with a supposedly competent director to oversee engineering operations, why and how should the hospital director be focusing such extensive amounts of time on the job that rightly belongs to the engineering plant director?  There are several technology-based programs and options that can perform this work, and form reports automatically based upon performance by engineering staff in completing work orders.  Why is the VA-OIG recommendation not including an automated process to improve performance?  The lack of oversight in the engineering department is both creatively and structured incompetence, because the VA-OIG report recommended following the master plan, reporting progress to the master plan, and suggested that the director of the engineering plant needs to be doing the job they are collecting a wage to perform.

Behavior-ChangeOn the topic of creatively structured incompetence, we find the following from the Department of Veterans Affairs – Veterans Benefits Administration (VBA).  A veteran patient that spends more than 21-days in hospital for treatment is supposed to be placed on 100% disability, and be paid at the higher disability amount.  Those veterans with mental health concerns are supposed to have additional support to aid them in managing their benefits from the VA.

The VA-OIG estimated VA Regional Office employees did not adjust or incorrectly adjusted disability compensation benefits in about 2,500 of the estimated 5,800 cases eligible for adjustments, creating an estimated $8 million in improper payments in the calendar year 2018. The OIG estimated 1,900 cases did not have competency determinations documented for service-connected mental health conditions.”

Why is this another case of creatively structured incompetence, because every time the VBA gets caught not doing their job, the reason is training, reports not properly filed, and lack of managerial oversight.  I could have predicted these reasons for structured incompetence before the investigation began.  That managerial oversight, employees not filing proper and timely reports, and training not occurring for employees has been an ongoing and repeated theme in VBA incompetence since early 2000 when magically the VBA was behind in processing veterans’ claims for disability.  This theme stretches to the VBA inappropriately deciding claims for spine issues.  The same theme was reported in the VBA improperly paying benefits.  The list of offenses by the VBA is long, and the excuse is tiresome.  The VA-OIG reported:

Employees who processed benefit adjustments also lacked proficiency. They lacked sufficient ongoing experience and training to maintain requisite knowledge. This is also why employees were unclear on the requirement to document the relevant competency of veterans admitted for service-connected mental health conditions.”

ProblemsHow ironic that the root causes of a VA-OIG inspection would find people being paid to perform a job, but are not actually doing the job because they lack proficiency, training, managerial oversight, and are unclear on what they are expected to do in their jobs.

To the elected officials of the US House of Representatives and the Senate, the following are posed:

  1. If you hired a carpenter to enter your home, perform work, and you discover that the carpenter does not know the job they were hired and contracted to perform, what would be your response?  If your answer is to keep that non-working carpenter in that position, in your home, I must wonder about your intellect.
  2. How can you allow this structured incompetence to live from one VA-OIG report to the next? How can you justify this behavior at the VA?  How many other offices of inspectors general reports are reporting the same structured incompetence in Federal Employment and you are not taking immediate action to correct these deficiencies?
  3. Why should anyone re-elect you; when we the taxpayers endure this incompetence, paying you and them to abuse us. You were elected to oversee and manage that which we cannot; yet, you continually strive to perform everything but this essential role.  Why should we re-elect you to public office?

GearsThe following suggestions are offered as starting points to curb structured incompetence, improve performance, and effect positive change at the Department of Veterans Affairs, which includes the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries.

  1. Implement ISO as a quality control system where processes, procedures, and policies are written down. The lack of written policies and procedures feeds structured incompetence and allows for creativity in being out of compliance with legislated mandates.
  2. Eliminate labor union protection. Government employees have negotiated plentiful benefits, working conditions, and pay without union representation, and the ability for the union to get criminal complaints dropped and worthless people their jobs back is an ultimate disgrace upon the Magna Charta of this The United States of America generally, and upon the seal of the Department of Veterans Affairs specifically.
  3. Give the VA-OIG power to enact change when cause and effect analysis shows a person is the problem specifically. Right now, the office of inspector general has the power to make recommendations, that are generally, sometimes, potentially, considered, and possible remediations adopted, maybe at some future point in time, provided a different course of action is not discovered and acted upon, or a new VA-OIG investigation commenced.  This insipid flim-flam charade must end.  People need to be held liable and accountable for how they perform their duties!
  4. Launch a VA University for employees and prospective employees to attend to gain the skills, education, and practical experience needed to be effective in their role. I know from sad experience just how worthless the training provided to new hire employees is and this is a critical issue.  You cannot hold front-line employees liable until it can be proven they know their job.  Employee training cannot occur and be effective without leadership dedicated to learning the job the right way and then performing that job in absolute compliance with the laws, policies, and procedures governing that role.  Training is a leadership function; how can supervisors be promoted and not know the role they are overseeing; a process which is too frequent in government employment.

I-CareI – Care about the VA!

When will the elected officials show you care and begin to assist in improving the plight of veterans, their dependents, and their families?

 

© Copyright 2020 – M. Dave Salisbury

The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the pictures.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

https://www.linkedin.com/in/davesalisbury/