Oh, how I wish and long for, and am working for, the day when the VA is cleaned up, cleaned out, and corrected completely! The Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) has been busy reporting more on the failures of the VA to act. Yet, where is Congressional action in scrutinizing the executive branch’s actions? Honest question, repeated only for emphasis; we elected you to do two jobs, write fair and equal legislation for all citizens, and scrutinize the executive branch; when are you going to do your jobs?
Let’s begin with some softball issues repeated from previous VA-OIG comprehensive healthcare inspections (CHIPs), specifically how employees report feeling morally distressed while working at the VA. Moral distress is a leadership failure and is widespread enough to reflect the problem is not limited to a single VAMC/VAHCS. From Virginia to California, Maine to Florida, and Montana to Arizona, too many VA facilities are poorly led, poorly administered, and poorly executed. The VA is actively abusing the veterans for political gain; some have asked why I consider the VA is actively abusing veterans; let me see if additional disclosure can explain the problem.
“VHA Directive 1004.08. VHA defines an institutional disclosure as “a formal process by which VA medical facility leader(s), together with clinicians and others as appropriate, inform the patient or personal representative that an adverse event has occurred during the patient’s care that resulted in, or is reasonably expected to result in, death or serious injury, and provide specific information about the patient’s rights and recourse.”
The above quote is from the regulations governing VA care. The VA-OIG quotes this directive, which has been published and is openly available, yet repeatedly the VA-OIG finds directors. Hospital administrators who are informed and able to repeat this directive. Who repeatedly refuse to follow this directive or train their staff to follow this directive. When sentinel events occur (death, permanent injury, non-permanent injury, disability, etc.), the families report having no idea what to do because the disclosures were never provided to the veteran or designated caregiver. Is this not abuse of the patient? Is this abuse not driven by ideologues who gain from the harm they cause others? Should this abuse not be scrutinized until it is eliminated? Please feel free to read some of these comprehensive healthcare inspection reports from the VA-OIG, see the resulting injuries and problems caused by the failures of government medical providers, and then tell me whether these atrocious actions need more or less scrutiny and qualify for the title abuse.
North Carolinian veterans, VISN 6 is all yours, and would you be shocked to learn that even with newer leadership, moral distress remains a persistent problem in the VA employees throughout VISN 6, which just happens to include Durham, Asheville, Fayetteville, Hampton, Richmond, Salem, and Salisbury North Carolina? Probably this is not unfamiliar as the patient experience survey scores remain persistently below VA averages, reflecting that new leadership is akin to putting lipstick on a pig. Interestingly, medical staff credentialing remains a significant concern in North Carolina.
Western New York veterans, especially those receiving patient services in the Buffalo VAHCS, do you agree with the VA-OIG report? The Buffalo VAHCS includes Buffalo, Batavia, Jamestown, Dunkirk, Niagra Falls, Lockport, West Seneca, and Olean, and the comprehensive report is mystifying to me. For example, the VA-OIG reports that “Patients generally appeared satisfied with their care.” At the same time, “Employee survey data revealed opportunities for leaders to improve workplace satisfaction and reduce feelings of moral distress.” This is a combination not generally found in these CHIP inspection reports. Something is definitely off, and I would love to know what, especially since the leadership needs significant improvement in identifying and reporting sentinel events. Do you agree with the VA-OIG findings? Please let me know your firsthand experiences, for the double-talk in this CHIP report is above what I usually observe.
With almost identical findings and recommendations in the Syracuse NY VAMC’s comprehensive healthcare inspection, covering communities of Syracuse, Auburn, Freeville, Potsdam, Rome, Binghampton, Watertown, and Oswego, NY., I am concerned that the veterans in New York are in as bad or worse shape than Phoenix’s veteran community. Hence, I have to ask the VA-OIG, has something changed in your measurement and analysis tools to report such disparate findings as “Employee survey data revealed opportunities for leaders to improve servant leadership and decrease employees’ feelings of moral distress. Patients generally appeared satisfied with the care provided?” The double-talk level is higher in these CHIPs from NY, which is rarely observed outside of Phoenix and VISN 22. Two final thoughts on the CHIPs, staff training, continues to be a high-risk finding, and this continues to be a leadership failure for every VAMC/VAHCS/VISN in the VA; why has progress not occurred? Training is a system, and leadership and organizational risk, system redesign, and improvement is a quality, safety, and value problem of the highest importance; why is action never taken by leadership or the congressional representatives who are expected to scrutinize the executive branch?
28 March 2022, the VA-OIG released their long-awaited annual “Comprehensive Healthcare Inspection Summary Report: Evaluation of Medical Staff Privileging in Veterans Health Administration Facilities, Fiscal Year 2020.” I have been interested to see what, if anything, the VA had accomplished in improving their medical staff privileging. If I were a congressional representative, knowing that medical staff continues to harm and kill veterans, I would have been anxiously awaiting to see if the repeated hits from past years had finally been rectified. Unfortunately, the VA continues to live down to expectations (digging the hole ever deeper), suffers from failed leadership, and the veterans continue to die or suffer abuse.
What did the VA-OIG discover? Understand, “The OIG conducted detailed inspections at 36 VHA medical facilities to ensure leaders implemented medical staff privileging processes in compliance with requirements. The OIG subsequently issued six recommendations for improvement to the Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders. The intent is for VHA leaders to use these recommendations to help guide improvements in operations and clinical care at the facility level. The recommendations address findings that may eventually interfere with the delivery of quality health care.” The OIG identified deficiencies with focused and ongoing professional practice evaluation, provider exit review, and state licensing board reporting processes. Specifically:
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- use of minimum criteria for selected specialty licensed independent practitioners’ focused professional practice evaluations
- inclusion of service-specific criteria in ongoing professional practice evaluations
- completion of ongoing professional practice evaluations by other providers with similar training and privileges
- recommendation by executive committees to continue licensed independent practitioners’ privileges based on professional practice evaluation results
- completion of provider exit review forms within seven business days of licensed independent practitioners’ departure from a medical facility
- the signing of exit review forms by service chiefs, chiefs of staff, and medical facility directors if licensed healthcare professionals failed to meet generally accepted standards of care
- initiation of state licensing board reporting within seven business days of supervisors’ signatures on exit review forms to indicate licensed healthcare professionals failed to meet generally accepted standards of care.
The OIG found ongoing issues from the fiscal year 2019 CHIP summary report that warranted repeat recommendations for improvement. The OIG issued three repeat recommendations related to the following:
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- inclusion of minimum specialty criteria for focused professional practice
evaluations - inclusion of service-specific criteria in ongoing professional practice evaluations
- recommendation by executive committees of the medical staff in continuing licensed independent practitioners’ privileges based on professional practice evaluation results.
- inclusion of minimum specialty criteria for focused professional practice
Boiling the findings of the VA-OIG down, essentially, the administrators and leadership are not weeding out poor and horrible practitioners, reporting these underperforming practitioners, and not acting in the best interests of the veterans seeking care at VAMCs and VAHCSs across the country. I repeat, only for emphasis: Is this not abuse of the patient? Is this abuse not driven by ideologues who gain from the harm they cause others? Should this abuse not be scrutinized until it is eliminated? Please feel free to read some of these comprehensive healthcare inspection reports from the VA-OIG, see the resulting injuries and problems caused by the failures of government medical providers, and then tell me whether these atrocious actions need more or less scrutiny and qualify for the title abuse. The link to the full report is available; please feel free to make your conclusions and post your thoughts in the comments section.
On a final note for today, consider with me the problems of the Atlanta VAHCS with pallets of unopened mail containing patient health information, community care provider claims needing payment, and a plethora of other unopened mail. Understand that when community care providers cannot obtain compensation from the VA, they go to the veterans, who then send in correspondence, which is unopened, thus causing more problems, concerns, and issues for an already abused veteran community! Want your head to explode? Look at the pictures the VA-OIG helpfully sent along with this VA-OIG report, and ask yourself if any other business or organization could get away with this type of abuse of the customer.
What did the VA-OIG find? Well, prepare for your head to explode, again:
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- VA Leadership should have established a formal agreement explicitly detailing each office’s responsibilities.
- VA HCS leaders did not include responsible managers in decision-making discussions and lacked a clear understanding of the volume of mail processing work they were accepting.
- Atlanta VA HCS did not ensure mailroom staff was adequately prepared or trained to handle or sort the influx of mail. POM (Payment Operations Management) officials were later reluctant to help, citing the verbal agreement.
Buried in the report is this tidbit, “POM is implementing similar transitions at sites across the country; POM and medical facilities need to ensure adequate staff with sufficient training to handle the mail processing workload. VA concurred with the OIG’s five recommendations.” Meaning that in a VAMC/VAHCS near you, unopened mail due to verbal agreements will soon add more distress and disgust to the veteran experience.
I have documented in these articles how verbal agreements, verbal standards of work performance, and verbal processes and procedures are the problem and way of life in too many CHIPs and observed practices at the VA. Yet, these verbal shenanigans are more apparent than in the dilemma Atlanta faces due to unopened mail. Payment operations to community care providers are on a controlled and fixed timeline. Failure to process these payments according to the required timeline leaves providers unpaid, which diminishes the community care provider pool of providers. Talk to a community care provider, and they will discuss the risks of doing business with the VA and the real possibility of not being paid timely enough or being caught in sufficient red tape never to receive payment.
I know of a provider who called me three years after receiving care and was still trying to appeal and correct the paperwork to receive payment. A provider recently contacted me who wanted to ruin my credit for failing to pay the balance due from care received, and they are charging interest. Correcting this problem cost me 48 business hours, 20 calls, and frustrations galore. By the way, the problem still has not been rectified, an appeal is in process, and we have to wait for the VA to make a decision; this incident was caused by the VA changing the process and the paperwork. The provider told me they are not accepting any more veterans seeking care, the risk is too significant, the timeline to receive payment is too long, and the VA never pays what is charged. For example, I recently received a declaration declaring payment to a community care provider. The VA sent me to this provider, which means they knew the prices beforehand and agreed to the fees. The declaration declared the VA was charged $2,000 and paid $120, not actual amounts, but close enough to communicate the problem. With inflation, or without inflation, if you were paid less than 1/10th of what you billed (invoiced), would you continue to conduct business with that company or organization? Now add the unopened mail problem to the mix. Would you continue to conduct business with this entity?
America, the Department of Veterans Affairs is sick. All of the other alphabet agencies in the Federal Government are sick. We continue to elect people who actively refuse to care enough to act according to their mandated duties. We cannot afford the government we currently have, which is part and parcel of the problem with inflation in America right now! Debt is entered into to pay for this bloated feckbeast called government; from the city to the federal government, the bloat is too great to be sustained! Why is the VA able to skirt responsibility, accountability, and improvement? They can hide behind the size of their convoluted and twisted organizational shield. Why can the Post Office and the IRS get away with deplorable, at best, customer service? They are protected by the congress refusing to scrutinize and hold people accountable. When your head is done exploding, please remember and act in the ballot box to hire better representatives!
© Copyright 2022 – 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. Quoted materials remain the property of the original author.
I promised a follow-up article after 
On a side topic, VA-OIG, how do you define a “significant complaint” and separate it from other types of complaints? Honest question, the information was, to quote my PCP, “remarkably” missing from your investigation report! Would the VA-OIG like to know why so many veterans’ complaints have risen to a “serious” level? You reported the exact problem:
Elected officials, where are you? The VA-OIG presents copies of their findings to you, and I have yet to witness a single one of you holding the VA Leadership criminally responsible for the failures at the VA. Even when the VA is killing hundreds of veterans, the US Congress refuses even to act upset, let alone scrutinize for a change! Remember how many veterans were intentionally killed in Phoenix waiting for treatment? How many VA employees lost their jobs and pensions or were forced in front of a judge for murder? It is a fair question, where are the elected officials in the legislative branch working to end the criminal “fraud, waste, abuse,” and designed incompetence in the executive branch?
Recently I was asked an interesting question that needs further elaboration, than the 30-seconds I could devote to the answer. The question, “As a disabled person, in a professional setting (workplace), do I expect others to accommodate me?” At the time, I used pieces of Douglas Malloch’s poem “Good Timber” as an analogy to help answer this question, stating that a tree in a forest does not demand another tree stop growing in their direction for sunshine, air and water. Thus becoming a forest giant through individual growth, adaptation, individual choice, time, goal setting, and working with other trees.
True story, I learned to swim by being thrown into the deep end of a lake and told to get back to shore on my own; my mother was never one for “easy lessons.” The conflict made me understand and learn how to coordinate movement, and I learned to swim. Not well, and to this day, I swim like I am beating the water into submission, not in a manner that is conducive to smooth and flowing coordinated movement. The conflict of motion and resistance, movement and flow has taught me a lot about science, engineering, hydraulics, and much more; but I do not thank my mother for this “swimming” lesson!
As a process of learning and developing, conflict has been the driving factor in all of our lives. Conflict is a tool, and like all tools, when used appropriately, it can build, enhance, strengthen, and create. Whereas, if the tool is improperly used, destruction, damage, and chaos are spawned. Regardless, life lessons can be learned in both uses of conflict when two additional tools are added, self-reflection over time. It took a long time to realize the value of science in the lessons of swimming taught in almost drowning. Remember, the forest giant in Douglas Malloch’s poem did not become a forest king without scars.
Conflict happens; what a person chooses to do with that conflict and how that person considers conflicting occurrences is how the labels “good,” “bad,” “valuable,” “beneficial,” etc., are applied. McShane and Von Gilnow (2004, p. 390) postulated, “conflict as beneficial [when] intergroup conflict improves team dynamics, increase cohesiveness, and task orientation. … [C]onditions of moderate conflict, motivates team members to work more efficiently toward goals increasing productivity.” The sentiment regarding conflict as a tool and beneficial is echoed throughout the research of Jehn (1995). Jehn (1995) reflected that the groups researched labeled the conflict as beneficial, good, bad, etc. based on the group’s dynamics and the conflicts faced and settled, the groups formed an integrated model for organizational conflict. Essentially, how the conflict is approached and used by the team members individually and collectively dictates how beneficial the conflict is for the team and the organization.
Thus, it cannot be stated enough, nor without sufficient emphasis, the leader who chooses to minimize conflict is leading their team to destruction, ruination, and despair. But, isn’t the path of less conflict more restful and peaceful? What about all those people who claim conflict is bad, fighting and war are terrible things and should be avoided at all costs. Let us examine Douglas Malloch further:
Thompson (2008) calls those who actively work to avoid conflict as those taking “trips to Abilene;” included in those making trips to Abilene are those who take conflict personally and choose to become offended, as well as those who choose not to see conflict, as a method of ignoring conflict. Thomas (1992) captured how individual choices about the valuation of conflict open or close the door to the productive use of conflict. Ignoring conflict, avoiding conflict, and other strategies to avoid conflict form the most dangerous people to be around, for when conflict grows beyond a point where it can no longer be ignored or avoided, that is the conflict that can destroy people, places, and things.
As we catalog the VA, occasionally, local services providers must be recognized for their service or their deficiencies. In the spirit of fairness and transparency, it is time to discuss one of those community providers, Advanced Neurology Epilepsy & Sleep Center (
I support citizens who desire to become elected leaders. I refuse to support politicians! Worse, I detest with every fiber of my being politics in its many forms. I hate politics and those who engage in politics from business to the military, from the classroom to the boardroom, and from the private sector to the government sector! Elections matter until they are stolen and become a farce by those who desire to rule, and this is why California, the recall election of that detestable politician Gavin Newsom, and politics matter to every single person in America. In the US Navy, when my department officer told me to “Play the game,” he meant to play politics. To the minions of hell who delight in playing politics, I have found being honest, forthright, and valiant is better, and you will not win!
Please note that emphasis has been added to key phrases to support knowledge of the complete etymology and enhance awareness. Frankly, I would be ashamed to be called a politician. Being called a politician means I possess a derogatory approach to my constituency and am only concerned with seeking power, usually through devious means. As a Noun, politics are “the activities associated with the governance of a country or other area, especially the debate or conflict among individuals or parties having or hoping to achieve power.”
Politics is a descriptive tool used to identify certain human activities where power is sought, and devious means and divisive gestures are employed to obtain that power. Every action tied to securing power through devious means and divisive gestures is politics or political, which means derogatory. For those needing more, derogatory is “showing a critical or disrespectful attitude.” Thus, at the root, politicians by their very name and nature are derogatory towards those who elect them into power.
Elections are the formal process for selecting another for an office, leadership, or choosing a person or favorable course of action. Key to elections is that they are formal, which means there are rules, laws, guidelines, regulations, and penalties for the officers selected to monitor the election process. One of the most egregious actions of the 2020 elections was breaking the rules, laws, and regulations of the formal election process in the primaries, which then extended into the actual election day results. Why bring up the 2020 Federal Election farrago? Because as of 25 August 2021, the same pattern is occurring in California, again! Ballots are going missing, ballots are being dumped in trash cans, mail-in ballots without signatures, fraudulent ballots are being injected into the counts, etc., ad nauseam ad infinitum.
Thus, the problem for ALL of AMERICA right now! Primaries are coming, political futures hang in the balance, and the media know that the liberal madness and tyranny from COVID-Mandates has left a bitter taste in every person’s mouth. The polls show no politician being trusted, and if the political machines are to keep paying dividends to special and private interests, then those investing in their favorite politician are going to have to pony up serious cash to buy the elections officials right now to protect the sleaze in office from the school board and Mayor to the president!
You, the American citizen, are needed! Awake and Arise! Find your strength and stand before it is too late and your country has fallen an unpitied sacrifice in a contemptible struggle while you slept! History will judge you and me for what we do and say right now; let them record we did not allow the American Experiment to fail on our watch; we fought back against the tide of tyranny and oppression and won!
President Biden, you, and your administration disgust me! I did not vote for you, but I was willing to support you as president back in January and show you respect. Even though I continue to have reservations regarding the veracity of the 2020 Elections, the transparency of the election counts, and the skullduggery witnessed, I was willing to give you a chance. Your actions in Afghanistan have sundered my cherub-like demeanor and turned the extended olive branch into a torch for your pyre!
Finally, we come to the absolute crux of the matter. As Commander in Chief, the honor of commanding men and women in the military comes with a corresponding responsibility. The country loves her military and trusts you to treat them appropriately. You did not do so in January and got a minor backlash. You are not doing so in Afghanistan and will catch a much higher backlash as the media watches a repeat of Saigon in Kabul as the Embassy is evacuated. Your buddy Obama has a dead Ambassador he has never answered for, which (historically) has always been a declaration of war. What do you have? An entire country laid to waste, the waste of millions of dollars in materials, millions of lives destroyed, and the wasted efforts of millions of people and multiple presidents. You have betrayed the American people’s trust, and you will be held accountable, just like your good friend Mayor Lightfoot (with stickyfingers) is being held accountable in Chicago, only many, many magnitudes worse!
Paul Harvey is a hero of mine. I miss his voice on the radio. He exuded a calm demeanor, regardless of the terror, the trials, and the terribleness of the news reported and discussed. I do not have Paul Harvey’s sense of calm. When I heard about the 
This week, the final three emails from the VA-OIG reflected a VISN wide comprehensive healthcare inspection (CHIp) conducted virtually, a VAMC/VAHCS CHIp conducted in Spokane, Washington, and a program report on the failures in the Veteran-Directed Care Program. The most interesting finding in the CHIps was how short the leadership teams had worked together, a month, and how many open positions for leaders there were, more than half. Talk about glaring symptoms of leadership failure, were the leadership teams broken up from employee turnover? If so, did the employees retire, or were they retired to avoid criminal convictions? With all the investigations for fraud, as discussed on these pages frequently, I can only guess how leaders churn in a VAMC/VAHCS/VISN.
Traveling further to North Carolina, we find that 
24 May 2021 – 1200-1500 I visited the Las Cruces Community Based Outpatient Clinic (CBOC) in Las Cruces, New Mexico. Upon entry, I was asked to wear a mask. I described I could not wear a mask, and the employee said I might be required to wear one but left the decision to those working more closely with me. I waited in line and was called to the Team 2 window, where a gentleman was more than happy to assist me in getting the paperwork started to change VA hospitals after relocating. About 45-minutes into my time in this CBOC, the gentleman asked me to wear a mask. I told him I could not and had brought my VA Doctor’s note as proof. The gentleman read the letter, confirmed I was good to receive care without the mask, and provided exceptional customer support.
By tracing behaviors, attitudes, and influence to their source, the police chief acts as he considers appropriate, but the underofficers generationally multiply and mirror his behaviors. The same is true for the chief who takes his example from the assistant director, director, and hospital leadership. Chains of command always have this consequence; the example of those above are mirrored, replicated, and multiplied to impress the higher officers to gain attention and promotion opportunities. Want to take a measure of a leader; look to the most junior person in the chain of command and watch them for behaviors, attitudes, and actions that originate in the leadership.
Case in point, long have I detailed and described the failures of leadership at the VA. The latest is a wire fraud scheme in 
Did you catch that; the office specifically tasked with handling estimates intentionally low-balled estimates, did not include all necessary contractual requirements, and then lied to Congress to cover their hides, and fell back upon designed incompetence to skirt blame, responsibility, and accountability when the VA-OIG came investigating. 
I have consistently written about VA Leadership failures for several weeks, rightly calling out the administrators at the local VAHCS and VAMC, the VISN, and the Federal levels. Hospital leadership is not so different than leadership in any other industry, even though the VA has tried to make hospital leadership distinct. Herein lay the problem, an employee, a 
DNC-Consulting 