NO MORE BS: Come, Let us Reason Together

Knowledge Check!In physics, for every action, there is an equal and opposite reaction.  I am not a fan of the word reaction, for a reaction places all the control of the action into the control of the original actor, and nature does not work like that.  But, to reason, we sometimes must use language common to all to understand each other; thus, it is sufficient to my purposes to use the term reaction in this discussion.  A similar law applies to psychology; a human chooses to act, natural consequences follow.  The ability to as, agency, and the person being acted upon, the actor, play a significant role in how and why businesses succeed and fail.

Plato 2Societies, cultures, governments, and countries all rise and fall on the moral agency of the individuals in power, the common citizen, and the collective leaders of those groups of people.  I have always liked the movie “The Fiddler on the Roof,” Tevye makes a statement about how without tradition, they would be as shaky as a fiddler on the roof.  Bringing a mental image of a fiddler, balancing upon a roof, and having two options, climb down and resume playing, or learn to balance on the roof while playing.  Both choices offer natural consequences that are easily understood, especially if you have ever worked on a roof.

Detective 4I have consistently written about VA Leadership failures for several weeks, rightly calling out the administrators at the local VAHCS and VAMC, the VISN, and the Federal levels.  Hospital leadership is not so different than leadership in any other industry, even though the VA has tried to make hospital leadership distinct.  Herein lay the problem, an employee, a nursing assistant, has just been sentenced to 7 consecutive life sentences for second-degree murder.

“Mays was employed as a nursing assistant at the VAMC, working the night shift during the same period of time that the veterans in her care died of hypoglycemia while being treated at the hospital. Nursing assistants at the VAMC are not qualified or authorized to administer any medication to patients, including insulin. Mays would sit one-on-one with patients. She admitted to administering insulin to several patients with the intent to cause their deaths” [emphasis mine].VA 3

We have an affect, but what was the cause?

“While responsibility for these heinous criminal acts lies with Reta Mays, an extensive healthcare inspection by our office found the facility had serious and pervasive clinical and administrative failures that contributed to them going undetected,” said VA Inspector General Michael J. Missal” [emphasis mine].VA 3

Regardless of her intention, an employee was allowed to commit murder because of the “pervasive clinical and administrative failures” of the VAMC leadership.  Now, two days prior to receiving the results of Reta Mays’ court proceedings, I received the Department of Veterans Affairs – Office of Inspector General report on the clinical leadership failures.  I have not witnessed a more despicable and damnable report of leadership failures in the decade-plus; I have been following and writing about the Department of Veterans Affairs or any other government agency!

“In June 2018, facility leaders identified nine patients with profound and concerning hypoglycemic events dating from November 2017 to June 2018” [emphasis mine].VA 3

The scope of the administrative investigation is as follows.  Staff from the VA-OIG’s Office of Healthcare Inspections (OHI) assessed the following areas, in parentheses is who owns the problem raised in the investigation:

      • Mays’s hiring and performance (Human Resources)
      • Medication management and security (Pharmacy and Security)
      • Clinical evaluations of unexplained hypoglycemic events (Nursing and Doctoral Staff)
      • Reporting of and responding to the events (Facility Leadership)
      • Quality programs and oversight activities (Facility Leadership)
      • Facility, Veterans Integrated Service Network (VISN), and VHA leaders’ responses and corrective actions (Local and area-wide administrators)
      • During the course of this review (investigation), the OIG also noted areas of concern regarding hospice and palliative care practices and nursing policies and practices (Nursing, Patient Care and Safety, and Hospital Administrators)VA 3

Just as logic tells the fiddler on the roof that he has two choices to live a long and musically fruitful life, the investigation reveals that the VAMC leadership had choices and made both poor and potentially criminal choices in this investigation of Mays’ conduct.

Ultimately, quality health care is dependent on leaders who promote a culture of safety that reduces or eliminates those risks whenever possible. Providing high-quality health care to a diverse and complex patient population demands the support of, and adherence to, an organization-wide culture of safety. When this occurs, a patient-centric environment becomes the “norm.” Conversely, systemic weaknesses in a facility’s culture of safety can have devastating consequences. The OIG found that the facility had serious, pervasive, and deep-rooted clinical and administrative failures that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier. The failures occurred in virtually all the critical functions and areas required to promote patient safety and prevent avoidable adverse events at the facility” (pg ii) [emphasis mine].VA 3

Before we go further into the report, it must be made clear; the investigation team found the leadership, the hospital administrators responsible for allowing Mays to kill seven patients.  Attack another patient with the intent to kill and a potential additional hypoglycemic patient who died under her care but could not be directly linked to Mays.  A question arises, how did Mays gain employment with the VA; the answer, a former HR employee, failed to do their job in conducting “… background investigation file and determining her suitability for employment!”  In a previous article, I wrote about the hazards the VA was purposefully opening themselves to by using “COVID” as an excuse to delay proper investigations into backgrounds when hiring.  Here is a classic case where “COVID” is not related, and failing to investigate a background led to people dying!Plato 3

The VA-OIG last year reported that hiring practices had been relaxed due to COVID and background checks delayed for employees being hired during a pandemic.  Yet, when will those background checks be completed?  If someone is found unfit due to background checks, will they be forced to return all their wages for lying on a government form?  If there is a testament to the need for comprehensive background checks on employees, the seven (7) dead patients who died at the hands of Reta Mays!  How many times will this story replicate because the hiring managers are not doing their jobs?VA 3

Let us reason together, is the VA administrators the problem with the VA?  Does the VA leadership require immediate and total removal?  How would you resolve the issues without breaking the system and further endangering the lives of veterans?  Please let me know in the comments section.

I-CareVA Secretary Denis McDonough signed onto the “I-Care” principles as core values in care for veterans in the VAHCS.  When can we, the veterans, see that these core principles have been onboarded and are correcting behavior?

“VA Core Values describe how VA will accomplish its mission and inform every interaction with our customers. These Core Values are Integrity, Commitment, Advocacy, Respect, and Excellence — better known as “I CARE.” VA’s Core Values will continue to serve as the right guide for all our interactions and remind us and others that “I CARE.”

          • I care about those who have served.
          • I care about my fellow VA employees.
          • I care about choosing “the harder right instead of the easier wrong.”
          • I care about performing my duties to the very best of my abilities.

Mr. Secretary…  The veterans are dying now!  We are waiting!

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

NO MORE BS: VA Leadership IS the Problem!!!

Angry Grizzly BearPSA:  If you have a weak stomach, please feel free to not read this report.  This article is discussing the ongoing and continual problems of the VA leadership to ensure clean medically reusable equipment is available for practitioners use.  While the YUCK factor is high, the issue remains a leadership failure, and worse, it was purposefully designed into the VA organization to spread infectious diseases between veterans!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) conducted an investigation and reported its findings 16 June 2009.  While still not the first-time endoscopes and colonoscopes being dirty have caused patience significant risks, this report clearly details the failure of VA Leadership as an organizational design flaw.  From page i of the report, we find the following:

Facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans. Reprocessing of endoscopes requires a standardized, monitored approach to ensure that these instruments are safe for use in patient care. The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure” [emphasis mine].VA 3

Also, from page i the scope of the investigation and those requesting the investigation are detailed:

The VA Office of Inspector General received requests from the Secretary, Chairmen and Ranking Members of VA oversight committees, along with individual members of Congress, regarding the reprocessing of endoscopic equipment at several specific VA medical centers (VAMCs), and to assess the extent of related problems throughout the Veterans Health Administration (VHA). The purpose of the review is to describe the pertinent events at VAMCs where problems were reported, assess VHA’s response to the events, and conduct a system-wide evaluation of current reprocessing practices” [emphasis mine].VA 3

Let us be perfectly clear, since 2009, the VA Federal Officers have been informed and kept abreast of the problems with properly cleaning, sanitizing, and documenting reusable medical equipment, specifically endoscopes and colonoscopes, and have done nothing to fundamentally correct the direction of the VA, the VHA, or the offending VAMC’s.  What good is a memo when it is not applied as a standard operating procedure, where consequences are involved?  How is a memo going to be effective against a culture trained to not do their jobs, no matter the cost to patient safety?  To fully comprehend the problem with reusable medical equipment not being properly cleaned and sterilized (repurposed) see pages seven and eight of the following report linked.  There are a lot of acronyms, but the general sentiment is clear, the VA has an enormous problem with properly cleaning reusable medical equipment!

In a VA-OIG report dated 06 May 2021, we find an employee, after having been caught once, still not being properly supervised, not doing their job, and remaining employed.  This employee was caught falsifying legal documents on the cleanliness of endoscopes, and dirty equipment was used on multiple patients.  The facility conducted an investigation, the VISN conducted another investigation, neither investigation led to any type of fundamental organizational change to protect the patient.  Even the VA-OIG investigation has not led to fundamental organizational changes and improvements in cleaning and sterilizing reusable medical equipment.  Frankly, this should scare the daylights out of every veteran going in for any type of care at the VA.VA 3

Trust is hard won and easily lost.  Right now, can any provider at the VA assure any patient that the reusable medical equipment has been properly cleaned and sterilized before being used on that patient?  Since the VA-OIG report in 2009, the direct answer to this question is a resounding NO!  Again, I ask only for emphasis, if a non-VA hospital, clinic, or provider’s office was caught not properly cleaning, sterilizing, and documenting medically reusable equipment, how could they remain in operation?  The short answer is, they could not; unless they are an abortion clinic, but that’s and entirely different subject.  The Federal Government and the lawyers would descend en masse to shut down the facility, hold the administration accountable, and demand retribution for the patients involved.  Why is the VA Administration and VHA Administration, and the VAMC and VISN Administrations able to escape culpability in risking a patient’s health with dirty medical equipment?

Angry Wet ChickenEvery single Federally elected politician should be up in arms about the double standards between VA hospitals and non-VA hospitals.  If a non-VA hospital is caught with dirty medically reusable equipment, can they use the VA as an example in court as a defense?  NO!  Yet, here is a legal double-standard and precedence that opens the door to more questions.

Returning to the 2009 VA-OIG report, we find how the investigation was methodologically carried out.  The methodology reveals just how widespread and in-depth the investigation is, and how deeply this problem is organizationally wide for the VA.

We visited the facilities which had been the subject of considerable media attention: the Bruce W. Carter VAMC (Miami) in Miami, FL; the Tennessee Valley Healthcare System-Murfreesboro campus (Murfreesboro); and the Charlie Norwood VA Medical Center (Augusta) in Augusta, GA. We reviewed applicable regulations, policies, procedures, and guidelines. Furthermore, 26 inspectors conducted unannounced onsite visits for the total of 42 probability-based randomly selected VHA facilities to examine pertinent endoscope reprocessing documentation.

Because of the unannounced nature of the inspections and for cost-efficiency, a stratified clustering sample design was employed to maximize the number of facilities that could be inspected in a single day. Two probability-based random samples of VHA endoscope reprocessing facilities were selected from the study populations for the unannounced onsite inspection: one for colonoscope reprocessing and another for ENT endoscope reprocessing. With probability sampling, each unit in the study population has a known positive probability of selection. This property of probability sampling avoids selection bias and allows use of statistical theory to make valid inferences from the sample to the study population.”VA 3

Back in 2009, the media was very cognizant of VA issues, then the dead veteran scandal of 2012 and 2017, turned the media’s attention away from how the VA conducts business.  Let me direct your attention to the final sentence of the quoted material above.  As a researcher, this is a gold standard methodology statement for researching a complex organization like the VA, to pick proper probability samples, and to reduce individual inspector bias in the combined report of findings.  Thus, from this quoted material we can presume both that the methods of conducting the research were sound and conclude that the egregious behavior by administrators is VA wide!VA 3

If dirty medical equipment is how the VA defines excellence in the 21st Century, America’s veterans are in trouble deep!  I am now in my eleventh year of writing about the behavior of the VA and how they intentionally treat veterans.  I have witnessed detestable behavior by providers as an employee, and brought this behavior to the administrator’s attention, for which I was discharged without cause!  I have written about instances of negligence so terrible that there should have been a Congressional Blue-Ribbon panel assigned to demand correction and conduct and investigation, but nothing ever transpired.  I have personally experienced providers so inept, their qualifications should be questioned.  I have observed VA employees abuse, harass, threaten, and intentionally hinder treatment.  The behavior of the VA Administration where reusable medical equipment is concerned is so far beyond the pale, words escape me to describe.

Dont Tread On MeI believe in the little rocks that start landslides.  I know the power of tiny snowflakes that create an avalanche.  I know that if enough veterans, their families, friends, and communities rise up, the elected politicians responsible for scrutinizing the government will be forced to make veteran safety and health at the VA a priority and blessed change will finally arrive in the VA Administration and administrators.  Imagine how you would feel to learn a close friend or family member caught an infectious disease during treatment at the VA.  Please respond accordingly!

© 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.

August VA-OIG Updates: More SHAMEFUL VA Conduct.

I-CareDue to personal issues with the Department of Veterans Affairs (VA), specifically the Carl T. Hayden VA Medical Center (VAMC) in Phoenix, AZ I fell a little behind in June/July/August of 2020.  As I work to clear the backlog of completed Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports from August, please keep in mind solutions to these problems are available. The failure of leadership to be held accountable, by the elected officials is staggering, and the lack of accountability and responsibility boggles the mind.  Without exception, I know the VA can be improved, developed, and saved.

August 2020 begins with an individual employee making a decision regarding healthcare decisions for a veteran at the Robley Rex VAMC in Louisville, Kentucky.  The VA has a process where individuals can be allowed to be surrogate decision-makers for a veteran who needs additional assistance.  This process works is legal and is a great tool for family and friends of veterans to play a significant role in the healthcare process of the veteran.  In this instance, the process failed, not because the process was bad, but because people did not do their jobs properly.

The VA-OIG assessed an allegation that providers permitted an individual with no legal authority to make medical decisions on behalf of a patient, and a host of other patient rights were trampled as documented.  “The patient experienced a three-week medical and mental health hospitalization with repeated episodes of confusion, agitation, and combative behavior. The patient was transferred to hospice care and died five days later.  The VA-OIG found that facility staff did not take the required appropriate steps to identify and confirm the eligibility of this surrogate.  The VA-OIG determined records did not contain sufficient documentation of physicians’ clinical assessments to support diagnoses and treatment decisions. Clinical communication and collaboration were inconsistent, insufficient, and negatively impacted the patient’s continuity and quality of care. Providers did not consistently document medication monitoring and oversight activities to ensure safe patient care. The patient’s transfer to hospice was completed without fully pursuing other diagnoses and treatment options and staff did not ensure the patient’s rights were upheld regarding involuntary admission and behavioral restraints. Facility leaders did not complete a thorough quality of care review to understand the reasons for the patient’s atypical hospital course and outcome” [Emphasis Mine].

Many times, the VA-OIG reports do not clarify all root causes due to employee privacy; however, from the report, the employees who repeatedly allowed the neighbor to make healthcare decisions were exceeding their legal bounds and made decisions that harmed the patient.  This veteran died and from the report, it is clear the veteran died confused, possibly due to medication changes, and the family was not notified in a timely manner because the neighbor, without legal and written authority, was allowed to make healthcare decisions for the veteran, even though there was written healthcare directives on file for a family member to make these decisions.  Utterly shameful behavior!

PatriotismThe Veteran Integrated Service Network (VISN), is a geographical grouping of VA Healthcare Systems, e.g. hospitals and clinics, under a combined leadership plan.  One of the tools the VA-OIG uses to monitor the quality of patient care inside VISN’s is called a “Comprehensive Healthcare Inspection Program (CHIP).  CHIP covers selected clinical and administrative processes all of which are deemed consistent with promoting quality patient care.  The CHIP occurs on a rotational 3-year periodicity and the focus is shifted slightly each 3-year cycle to, theoretically, encompass all administrative processes over time.  The VA reports the following are the specific areas that lead to quality patient care through administrative practices:

  1. Quality, safety, and value;
  2. Medical staff privileging;
  3. The environment of care;
  4. Medication management (specifically the controlled substances inspection program);
  5. Mental health (focusing on military sexual trauma follow-up and staff training);
  6. Geriatric care (spotlighting antidepressant use for elderly veterans);
  7. Women’s health (particularly abnormal cervical pathology result notification and follow-up); and
  8. High-risk processes (specifically the emergency department and urgent care center operations and management).

All of which is mentioned as an explanation providing details for the following VA-OIG inspection reports of CHIP received in August 2020.  A total of seven CHIP reports were received in August recording performance from inspections carried out.  These reports, while somewhat individualized for the specific VAHCS, reads like a carbon copy.  Repeatedly written procedures for standard operation are missing, staff training is inadequate or antiquated, risk analysis is not able to be competently and correctly conducted, patient safety issues abound, and the proper utilization of management processes remains glaring!

Root Cause AnalysisThe CHIP reports are so repetitive in nature, the VA-OIG recommendations are grouped, conveniently, into the eight administrative areas listed above.  According to proper management techniques, the VA-OIG then “encourages” the leadership team to select one or two areas for improvement and focus their efforts on leading change in those areas.  For example, if the VAHCS wants to improve in risk analysis, the leaders can begin by promoting training on properly conducting risk analysis online, hold meetings to review risk analysis procedures and begin to train and develop staff on improving n this area.

However, here is where reality meets theory, without written standard operating procedures risk analysis cannot be completed properly.  The bureaucracy protects itself and will thwart the implementation of written standard operating procedures as this removes designed incompetence that keeps the bureaucrat in power at the VA.  Thus, the root cause of improving root cause analysis is the lack of written procedures that measure performance against a single written standard.

CHIP Report after CHIP Report the same issues arise, are noted, recommendations from the VA-OIG are documented, and the same response is supplied; this represents the epitome of designed incompetence and the root of the problem the VA is facing.  Recommendations for improvement have been repeatedly provided and change can occur; but, not without dedicated leadership, not management, to thwart the bureaucratic quagmire that the VA has fallen into.

Leadership CartoonAnother regular entry on the CHIP reports is the following: “Employee satisfaction scores revealed opportunities for the Associate Director for Patient Care Services to improve employee attitudes towards senior leaders.”  Here is the problem, how many of the “senior leaders” are less than managers, promoted beyond their maximum level of incompetence, solely because they were the next warm body in line; too many!  When staff training is a repeated issue on CHIP reports, one must ask how employees are being measured?  Where are the written scorecards that reflect a process that was used to measure employee performance fairly and equitably?  Was the employee trained on how to perform their role according to the standards published?  Do the scorecards reflect that all employees have been trained, measured, and reported equally?

Guess what, since staff training remains a consistent problem, the staff leaders are the problem!  A major part of “Quality, Safety, and Value” is “Leadership and Organizational Risks.”  A lack of training in properly, timely, and correctly performing one’s role as hired is both a leadership and an organizational risk.  Failing to train employees is the absolute worst comment a leader should be informed of by a third-party inspection team.  Yet, the training of staff is consistently the root cause after a lack of standardized operating procedures.  Every mid-level supervisor, trainer, manager, director, etc. titled individual at the VA should be embarrassed when told their staff is untrained; but, it appears these same leaders do not care!

The Duty of AmericansHow can a person draw the conclusions that the VA appears to not care about improvement, or that the lack of caring is rampant across the entire VA structure; look no further than the site visit VA-OIG inspection report of the Department of Veterans Affairs – Veterans Benefits Administration (VBA).  The deputy undersecretary for field operations expected regional office managers to be aware of issues raised in other regional office site visit reports, but there was no written policy for addressing frequently identified errors.  So, the mid-level regional office managers must be told to investigate internal websites to gather lessons learned and apply those lessons in their regional offices.  What an incredibly inept excuse; shameful conduct by a senior leader, and how much worse does this attitude become as it filters down to the troops?  The behavior that claims a new policy is needed to improve performance is utterly bereft of logic and demonstrates the lackadaisical attitude being discussed.  Then these same leaders wonder why their staff is disengaged, disconnected, and distrusting of leadership; unbelievable!

One of the first lessons I learned in becoming a business professional was, “If you have to write your ethics down, you have already lost.”  The VA policies on ethics, ethical conduct, and ethical behavior are voluminous, trying to cover every detail, every loophole, every issue, and mostly the VA-OIG reports on ethical breaches reflect individual poor judgment at best, and designed incompetence at worst.  Yet, still, the VA tries to implement ethics without a source, moral behavior without a purpose, and the individual employee is left with plenty of excuses for not behaving in a properly ethical manner.  This is the topic of another article; but it must be made clear here and now, ethical lapses continue to abound at the VA.  From the nurse not giving drugs to patients and selling the drugs on the street, to hospital directors not disclosing what appears to be a conflict of interest, the VA remains afloat on a sea of ethical violations.

The remaining reports in August reflected an investigation that the VA-OIG was unable to substantiate due to a lack of reports filed in a timely and proper manner.  More designed incompetence on the part of the VA.  Also included in these final reports were more repetitions of issues discussed where staff training was the root cause for ethical violations, failure to properly perform duties as hired, and staff training was the problem with adherence and compliance issues.

The disconnect is obvious, and the direction forward is clear.  Hospital Directors, write the standard operating procedures, using the resources of how the work is performed currently as the baseline.  Then begin correcting and amending the written procedures over the following year to improve performance to a written standard.  Once the written standard is completed, e.g. the baseline, begin training of staff.  You cannot measure individual performance without standards, and standards cannot be followed without written operating procedures for conducting business.

Behavior-Change© Copyright 2020 – M. Dave Salisbury

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

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