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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

Las Cruces – The Come To Visit Stay a Lifetime City

Monumental award | Las Cruces BulletinIn 2016, my wife and I washed up as flotsam against the Sandia Mountains in Albuquerque, NM.  We enjoyed our time in Albuquerque, but the politics and politicians are really extreme and insane, to boot!  We thought about, briefly, moving to Santa Fe, Angel Fire, Las Vegas, and several other northern cities and locations in New Mexico, but nothing worked out.  So, we began looking into southern New Mexico.

Very Large Array Radio Telescope - Electronic Manufacturing Services | Carlton IndustriesNot having much luck, I took my wife to Phoenix for her birthday and showed her the “Very Large Array,” which took her breath away and showed her places in Arizona and New Mexico I thought she might enjoy.  On the return trip, I took the southerly route through Tucson, and we spent a night in Las Cruces.  My wife was amazed at the green that just “popped up” in the desert.  The green she mentioned were the miles and miles of pecan and pistachio trees that line the highways of Las Cruces.

Christmas in Cruces - Visit Las Cruces New Mexico - Las Cruces CVBLas Cruces, New Mexico (U.S.)Well, some time passes, and in trying to find a home, we finally found something in Las Cruces.  The longer I stay here, the more the place feels like home.  Better, the people and the architecture, the policies and politics, and New Mexico State University in Las Cruces make this southern location an incredible jewel hidden in southern New Mexico.  El Paso is close enough to visit if you want the big-city experience, but truth be told, everything you need can be found in Las Cruces; the people are friendlier, and the climate is fun.

While living in Albuquerque, too many people thought Albuquerque was all to New Mexico and referred to their time as time spent in the land of entrapment.  Thankfully, employment took me around the state several times.  I got to see the influence of federal government policies on land use, and despise them for the theft of this land.  I had the privilege of seeing just how logically insane the government in Santa Fe is and detest them for their inaction, stupidity, politicking, and infernal bickering.  But, every time I came south, Las Cruces captured my attention, my notice, and my wonder.

Best things to do in Las Cruces, New MexicoDeming is another location in southern New Mexico, but they are struggling.  Mainly because of the government politics and previous economic choices, which are still creating problems in the town.  Dependence upon the federal government in New Mexico is endemic, robbing potential, crushing souls, and destroying hopes and dreams.  This reality can only be changed if the federal government shrinks to the 1940 (pre-WWII) level of government.  However, if you look, you can find small pieces of potential, like spring flowers poking up out of snow, especially in Deming, Las Cruces, and the other southern New Mexico towns and locations that are missing, almost entirely, from northern New Mexico.

At a time when people seem to be restless, are looking for new horizons, and want an escape from the insanity of politicians who refuse to listen to the electorate, may I suggest a visit to Las Cruces and Southern New Mexico.  The change is refreshing, the potential is exciting, and the possibilities for growth and development are all but limitless.  Better still, there is an undercurrent of enthusiasm found here that appears to be missing in a lot of the other places my wife and I have visited in our 26 years of marriage and 28 different moves across the continental United States.

Outdoors in Las Cruces - Biking and Running - Visit Las Cruces New Mexico - Las Cruces CVBPlease note, Las Cruces is not all roses and rainbows, lollipops, and chocolate-covered peanuts.  There are growth areas in politics, agriculture, the railroad, the highways, and the need for manufacturing industry.  Some growth areas include an embedded mañana attitude where a business operates a little slower; outdoor workers quit before the heat comes on too bad.  Siestas and taking your time is problematic if you want things done in a hurry.  But, these are also some of the things that make this little city such an exciting experience.

One of the growth areas that might not be a growth area, except for volume, is the food!  Holy…  Gustatory Experience!  The food in Southern New Mexico is like an inverted food chart for Italy.  Northern New Mexico has different foods entirely from southern New Mexico, and Southern New Mexican food is head and shoulders above Northern New Mexico.  In Italy, it is said, if you want good food, eat in Northern Italy; in New Mexico, when you eat, eat in the south!

Las Cruces makes most overlooked cities listSure, Northern New Mexico has Monroe’s, which is a phenomenal gustatory experience capturing New Mexican food at its finest.  The Owl Café in Albuquerque is a gustatory experience not to be missed in any visit to New Mexico, save room for dessert and order a Chili milkshake.  However, Monroe’s and The Owl Café are but two places for food in Albuquerque worth visiting.  Las Cruces has Caliche’s Frozen Custard, La Neuva Casita Café, A Bite of Belgium, and Salud! De Mesilla, just to name a few!  The food in southern New Mexico is incredible, and the small places are wonderful.  Just remember about mañana.  Get impatient, and you get rude service.

Hasta mañana - TnRelacionesI cannot stress this enough, mañana is in the culture, in the air you breathe, the dirt, the sand, and in every action taken.  You do not come to southern New Mexico to be in a hurry!  Want hurry, eat fast food and flee at your earliest opportunity, for southern New Mexico is not for you.  Want a little slower pace, time to enjoy conversation, time to explore, and time to get to know people; come to Las Cruces and enjoy the experience!

Knowledge Check!When you visit, bring your manners!  Say please and thank you.  Say you’re welcome.  Hold the door for strangers and ladies.  Wave, especially if someone waves at you.  Drive the speed limit!  When I was in the US Army, I was given some advice for my visit to South Korea, “show respect, get respect.”  Well, the same is true to Southern New Mexico, show some respect, and you will have a great time here.

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.