National Cemetery – DNC-Consulting

LIC and The Department of Veterans Affairs

What is LIC?

Low-Intensity Conflict (LIC) is the official name for when individuals or governments hire intermediaries to conduct violent operations from a secure position. LIC is a misnomer; those who have become victims of the barbaric cruelty of those practicing LIC find nothing “Low” about the experience. The conflict is intense, the actions brutal, and the practitioners remain cunning adversaries using and employing willing dupes to hide the true depths of moral decay inherent in the societal destructions and depravations the practitioners are enacting. Many confuse LIC in describing the actions of unbridled violence committed by ideologues under the banner of terrorism. The US Military Joint Chiefs of Staff define LIC as:

“A limited political-military struggle to achieve political, social, economic, or psychological objectives. It is often protracted and ranges from diplomatic, economic, and psychological pressures through terrorism and insurgency. Low-intensity conflict is generally confined to a geographic area and is often characterized by constraints on the weaponry, tactics, and levels of violence (Tinder 1990) [emphasis mine].”

Green (1997) adds a key ingredient to the description of LIC from Tinder (1990).

“… Non-international conflict is a refined term for what [was] formerly known as revolutions or civil wars, particularly when these have developed into major operations with the likelihood or reality of atrocities being committed against non-combatants. Whether civilians or those [rendered] hors de combat, a fact that is often more common in non-international … conflicts, especially when ideological, ethnic, or religious differences are in issue. It is for this reason that it must be borne in mind that the term low-intensity [conflict] has no relation to the severity or violence of the conflict” [emphasis mine].

Lt. Colonel Alan J. Tinder wrote a paper for the Air War College in 1990 titled: “Low-Intensity Conflict.” I have learned much from the Colonel and benchmarked this principle to more thoroughly understand LIC, recognize LIC, and detail LIC for others. The other compelling source is L. C. Green’s paper on “Low-Intensity Conflict and the Law.” I aim to synthesize this information into a manageable topic and aid understanding. Let me state emphatically that the Department of Veterans Affairs (VA) leadership’s actions are nothing short of LIC where employees and veterans/customers are concerned.

Regularly, the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports on a comprehensive healthcare inspection of a VHA facility, reports on employee morale in the VBA, or sum analysis of an employee or customer surveys, and include in the report a fairly descriptive, yet starkly utilitarian phrase, “reduce staff feelings of moral distress at work.” Generally, the efforts to reduce “moral distress” is left to an underling, an assistant, or a person for whom this is a secondary or collateral duty and is not considered important or relevant.

Do the actions of a leader represent complicity in creating moral distress fit the general definition of LIC? Absolutely. Consider that the leader sets the culture through actions, words, and behaviors, which originate in the thoughts and feelings of the leader. Correcting moral distress is pawned off on a junior staff member as a collateral duty, another method for displaying disrespect and communicating principles of abuse to employees. But there is no physical violence; how does this apply to LIC? Aren’t dead veterans’ examples enough of violent tendencies to justify the definition of LIC? The VA leader operates from a place of security, exemplifies the culture they deem acceptable, and then works through minions to achieve a “to achieve the political, social, economic, or psychological objective.”

Never forget these two critical points in the description of LIC:

“Often protracted and ranges from diplomatic, economic, and psychological pressures.”

“LIC has no relation to the severity or violence of the conflict.”

At the VA, the leadership calls their example politics; keeping your position or advancing is economical, and the psychological pressure to conform is palpable. All fundamental keys to conducting LIC against veterans, taxpayers, dependents, and non-conforming employees. Multiple times Congress has held hearings and listened to how the VA Leadership exacted revenge and retaliation upon those who reported problems to the VA-OIG, their elected congressional leaders, and other investigative parties. Feel free to peruse some of these hearings; you will hear victims relating physical, economic, and mental abuse, and the VA leadership never takes action. Elected officials never scrutinize and hold accountable those executing LIC, and the victims are victimized a second time.

Want another indicator that LIC is being practiced, the VA-OIG, after learning there are problems with moral distress at work, makes the following to slide the issues under the proverbial rub:

“The OIG’s review of the medical center … did not identify any substantial organizational risk factors.”

Signifying that even though the VA-OIG found moral distress is affecting and influencing employee behavior, the VA considers employee moral distress not an “organizational risk factor.” What does an employee who feels morally distressed do in performing their duties? Delay patients’ appointments, make mistakes on medication shipped, slow walk any responsibility to make things more complicated and take longer than they should. Does any of these actions sound familiar; they should, for this is the standard operating procedure for VA employees.

As reported previously, while I worked at the VA, I had intimate observations of what morally distressed employees do. When I wrote to the VA-OIG, I was informed that since I had my employment terminated, I could not be a whistleblower and get my job back. Plus, what I reported could not be actioned because it did not apply. How’s that for protecting the guilty? The VA Leadership is writing procedures and policies to target anyone and everyone who would report problems and seek help. An employee physically assaulted me; the camera mysteriously broke when I reported it, so no evidence was available. Who was at fault? Me; the assistant director promoted the attacker, and I got ostracized. The attacking employee took moral distress to new heights after this incident, and anyone who reported their behavior felt the wrath of the attacker and the VA leadership at the Albuquerque VAMC.

What is horrendous, this is not an isolated incident. What happened to me frequently repeats daily across every VA office. LIC is the overarching term, LIC is the behaviors named, and LIC is what the taxpayers are forced to pay for, all at the expense of veterans, dependents, and employees who see, know, and can do nothing. Repetitions of moral distress in employees, reported by the VA-OIG, are more than 20 just in 2022. The problem is cultural, and the elected officials desperately need to begin doing their second job, scrutinizing the executive branch and holding people accountable, including canceling the retirement packages of those practicing LIC.

Before someone tries to make this a Republican vs. Democrat issue, it is NOT political. LIC is never political, just as LIC is never religious, never racist, not sexist, or any other distinction. These distinctions are excuses, and the reasons do not justify the means for being violent. The leadership at the VA, and many other government agencies, have found that abusing the taxpayer pays well, provides protection, and allows them to exercise dominion to their heart’s content, all with the power of government to justify their deeds.

Do you realize that the VA-OIG has a metric for measuring moral distress, and the only time the VA-OIG reports moral distress among employees is when the results are higher than national averages? How scary is that to ponder? The problem is so prevalent that it only warrants reporting when it exceeds the norm. Thus, moral distress is declared less frequently when the average worsens. Official protection for LIC is provided by LIC, increasing, and the taxpayer is footing the bill.

I have read reports where the moral distress has worsened from year to year. The same leaders exacerbating the problem of employee moral distress are promoted and moved instead of reprimanded, punished, or fired. One of the VA-OIG reports is particularly heinous in hiding moral distress in employees.

“Selected employee survey responses demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected and discrimination was not tolerated. Patient experience survey data implied general satisfaction with the outpatient care provided; however, leaders had opportunities to improve inpatient care satisfaction [emphasis mine].”

Mark Twain is oft quoted as stating, “There are lies, damn lies, and statistics.” How much more valid are these words when results are “selected,” “cherry-picked,” or allowed to “imply generalities?” Those who engage in LIC are criminals, they are comparable to terrorists, and they have infiltrated the bureaucratic halls of government. Employing government power, they form unholy unions with social media outlets and media companies to further silence and abuse, all while increasing protection.

Where does it end? How do we put paid to the tyranny?

It ends when ordinary people decide they have had enough. Ending the LIC-powered tyranny requires nothing more than elected officials scrutinizing the government and doing the jobs they swore to commit. No violence, problematic or arduous tasks, merely following established law and doing the jobs we elected them to accomplish. LIC is always destroyed when the citizens being oppressed stand up for their rights and demand the bullies, tyrants, and fiends cease and desist!

Thomas Paine, writing in “Common Sense,” discussed simplicity, stating:

“I draw my idea of the form of government from a principle in nature, which no art can overturn, viz. that the more simple anything is, the less liable it is to be disordered; and the easier repaired when disordered.”

The American government was established on simplicity, and the US Constitution is a simple document. Using Thomas Paine’s pattern, the disorder in the government is simple to correct; all we need are people insisting that the infection is terminated. Using the systems established in the US Constitution, the US government can be brought to heel, the rot removed, and justice can be delivered to those tyrants employing LIC for personal gain and political profit. LIC is happening in every government agency, and it is time for change to begin. Where are the politicians willing to do the job we elected them to perform?

Mark Twain provides the final word, “The government of my country snubs honest simplicity but fondles artistic villainy, and I think I might have developed into a very capable pickpocket if I had remained in the public service a year or two.” From artistic villainy to LIC is not an arduous shift, merely the extension of abuse of power to a larger audience. Learn, choose, and then make your voice known through elections and peaceful assembly for redress per the US Constitution and Bill of Rights.

© 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.

“That’s Crazy!!!” – More Chronicles from the VA Chapter 5

I-Care I had originally planned on writing something else today, but my mental train was derailed, caught on fire, and I had to change my plans. 18 March 2022, I received an email signed from Sonja Brown of the Albuquerque VAMCS, who discussed how it takes 10-20 years for the VA to make a decision about which clinics to close, how to build new clinics, and the possibility of change (not) occurring in the New Mexico VA Medical System. Doesn’t that warm your heart; two decades is a maximum timeframe for ending unprofitable clinics to save the taxpayer money. Now multiply this problem by every government agency, and we find the reason for reducing the government bloat! VA 3

Luckily, I still have VA-OIG reports to discuss, not that I got behind, but February and March have been especially prolific. In January, the pace set appears to be sustained, at least for the first quarter of 2022. Some have commented that I do not write very often about the National Cemetery side of the VA’s voluminous bureaucracy. Your wish is granted; a whistleblower reported that the Houston National Cemetery was not being operated properly. The VA-OIG substantiated “some of the claims made by the whistleblower.” However, the leadership at the Houston National Cemetery had, for the most part, already begun making changes before the VA-OIG arrived.

Thus, I congratulate the Houston National Cemetery leadership for being almost proactive and 100% more responsible than any leadership in the VHA and VBA. My heartiest gratitude to you and your staff. May you continue to show initiative, forward-thinking, and attention to detail, and may the rest of the VA’s hegemonically impotent leaders learn from your example. VA 3

A Comprehensive Healthcare Inspection (CHIP) was conducted at the James J. Peters VAMC in the Bronx, NY. While a lot of the report is cookie-cutter, similar to all the other CHIPs that cross my inbox, I remain fascinated with a frequently used term from the report, “Servant Leadership.” From the website linked, we find the following to define “servant leadership” at the VA:

“We are all leaders, all of the time.
Servant Leadership is an approach for optimizing the delivery of client-centered services by strengthening employees to be an engaged and empowered workforce. The philosophy and practice of Servant Leadership is one that emphasizes caring, authenticity, and putting clients and employees first, and ahead of personal goals or leadership aspirations. Servant Leaders strive to meet both organizational objectives and the growth / development of their workforce.”

Please note ALL the grammar and punctuation errors are included in that quote. Far be it for me to pass along any advice on grammar, spelling, punctuation, and proper communication techniques. But, even this quoted material reflects the fact that there is a Grand Canyon-like chasm between DC leadership and the worm’s eye-view in a VA Hospital, VBA operations center, or the National Cemetery. Be a leader at the VA, and you will NOT last your probationary period after hire; I have experienced this personally! VA 3

Worse, try and help the VA from the worm’s eye to see the problems and fix the issues, and the VA Leadership will chop you into little tiny pieces and feed your carcass to the fishes. Yet, every single CHIP report mentions problems with “servant leadership” as opportunities for growth and development. More bureaucratese for designed incompetence as an excuse, the VA-OIG will believe. How sick to death I am of these shenanigans! Don’t believe me; check out the full CHIP report, it’s linked above, read a few of the other CHIP reports from the VA-OIG, and discuss the actual problems you think the VA is experiencing.

Servant Leadership is officially defined, by Purdue University, quoting Robert Greenleaf from 1970, as:

“The servant-leader is servant first. It begins with the natural feeling that one wants to serve first … a philosophy and set of practices that [enrich] the lives of individuals, builds better organizations and ultimately creates a more just and caring world.”

Notice a problem between the two definitions of servant leadership? Recognize an issue yet with the entire concept of servant-leadership? Let me give you a hint through a question, What does a “just and caring world” really define? The whole concept of servant leadership is easily twisted, plasticized, and framed in a way that removes liberty, destroys justice, and wrecks havoc on a free society, all because the philosophy sounds good, but the practice leaves chaos and destruction in the name of creating a more just and caring world. Servant Leadership and Health Care: Critical Partners in Changing Times

I am not condemning anyone who wants to try and improve their leadership skills through learning servant leadership or applying some of the servant leadership philosophies in their leadership toolbox. I am merely stating that care and caution should be used when trying to reshape the world on such ambiguous and amorphous terms as “just and caring.” The VA is trying to force a leadership template for all leaders to follow. This type of leadership philosophy warps the world and makes leaders into managers with excuses for failure, e.g., designed incompetence.

On a different topic, please read the following carefully:

“The VA Office of Inspector General (VA-OIG) reviews nonpharmaceutical proposals submitted to the VA National Acquisition Center (NAC) for Federal Supply Schedule (FSS) contracts valued annually at $10 million or more for high tech medical equipment, $3 million or more for all other FSS contracts, $100,000 or more based on manufacturer sales under dealers or resellers, or as requested by the NAC.”

Here is why the above is critical:

“The VA-OIG determined commercial disclosures were accurate, complete, and current for only 24 of the 103 proposals reviewed. This means 24 proposals were reliable for determining negotiation objectives and fair and reasonable pricing. The remaining 79 could not reliably be used for negotiations until the noted deficiencies were corrected. The OIG recommended lower prices than offered for 76 proposals.”

If you, in your employment, had a 23% accuracy rate, and someone else had to come behind you, redoing all of your work, how long would you last in your job? Note there are still 3 proposals that do not meet regulations and requirements out of 103 contract reviews. Read the rest of this incredible report for yourself and know what your elected representatives are failing to curtail and control. Then answer the following question: “Why should we re-elect ANY of the current elected officials?” VA 3

On the topic of designed incompetence of an almost criminal nature, we find the VBA still making headlines and breaking rules of ethics, morals, and logic with aplomb! Before getting into the VA-OIG report, it is crucial to note that the VBA has exclusively gone to a third-party model for Compensation and Pension exams. The most important part of the VBA’s operations, the comp and pen exam, is now conducted solely by third-party contracts companies. A VA doctor sees a person trying to get their benefits from the VBA no longer but a third-party physician’s assistant at best, who is (supposedly) overseen by a medical doctor. The lack of transparency and the complicated processes of the VBA are gordian, and transparency is hidden; read that as missing entirely. You know it's true - Imgflip

Here comes the VA-OIG, not to the rescue, but to rub salt into the wounds of veterans whose claims continue to be denied for lack of evidence.

“[The] VBA complied with the requirements of the law by reinstating 69 questionnaires on its public-facing website. However, disability benefits questionnaires that were incomplete, inaccurate, or of questionable authenticity from non-VA medical providers were not always processed correctly when determining benefits entitlement—causing underpayments of about $13,900 and overpayments of $74,800 over the nine months studied.

Improper processing occurred because VBA lacked sufficient controls to ensure disability benefits questionnaires from non-VA medical providers were properly relied on when determining entitlement to benefits.”

Let’s let this sink in for a moment. The VBA moved to a third-party model, then denied access to the VBA’s questionnaires to determine benefits, then had to be forced to reinstate the questionnaires. Improper VBA processes and procedures led to over and underpayments of benefits, and claims processors still do not have the tools to make informed and logical decisions reliably. Best of all, veracity (questionable authenticity) remains questioned in the process when the third-party contractor submits the forms for benefits. VA 3

You cannot make this stuff up; fiction writers can come nowhere close to creating a story this inane! Is designed incompetence as a concept clear now? The VBA developed a process using a more expensive model and then questioned the inputs for veracity from the contracted party, and the veteran suffered more! Do you think the VBA intentionally designs its processes to help and create a more just and caring world (servant leadership)? I think the VBA intentionally designed their processes to screw veterans in the hope they die before the government ever pays money on their claims. Let me know what you think in the comment section, for this is a travesty of justice anyway I slice the data.

As a veteran who has been trying to get a compensation and pension decision corrected since leaving the service in 2004, having suffered both overpayments, which I had to repay, underpayments, and erroneous overpayments where the funds paid were (eventually) refunded, the news from the VBA designed incompetence is a particular form of hell for me to read and discuss. I have had the third-party comp and pen exam doctors refuse to see me three times in the last two years. Delaying a VBA decision repeatedly. I have had the VBA reject the third-party data and a new comp and pen exam scheduled, rescheduled because I cannot wear a mask, and then conducted by a hostile and infuriating provider who refused to listen to the patient. Are you an Incompetent Developer? - Web Development & Web Design Blog

When veterans talk about fighting the VBA for a fair and honest decision, they mean a literal fight! Don’t take my word for it; ask veterans how their comp and pen exam has gone; when you find those struggling with the VBA, listen carefully to their stories, and you will hear very similar stories. The VBA represents government inefficiency, designed incompetence, and bureaucratic inertia to the Nth degree!

The following link might, or might not, work as intended; the link directs you to all testimony recorded from congressional hearings. If it works, you will be able to read the statement of David Case, Deputy IG, who was testifying before the HVAC subcommittee on drafted legislation “Quality Education for Veterans Act of 2022”. A brief synopsis from his testimony is included below:

“This bill would significantly strengthen the OIG’s efforts to prevent fraud in VA’s education and training programs. Given that more than $10 billion in taxpayer funds is expended on education and training programs each year and hundreds of thousands of veterans, service members, and family members receive these benefits, the OIG supports efforts to strengthen programmatic and beneficiary protections. The statutory changes in the draft bill do not appear to be burdensome or costly to educational institutions or VA, and yet they have the potential to make a significant impact on the amount of education fraud that occurs. The OIG agrees that these changes would work to lessen the harm suffered by veterans and beneficiaries and reduce losses to the government.”

Ever wonder how much a VA-OIG inspection costs or where and how the VA-OIG is funded; here is the answer and the problem. Tell me, why is the VA-OIG not financed from the VA budget? Simple question, not hard, and requires an explanation! The explanation should be detailed, transparent, and I guarantee that the answer will reflect the designed incompetence and failure to scrutinize the executive branch adequately. The VA is one of the few, if not the only, Federal Government Agency with a specialized inspectorate general, dedicated solely to independent oversight and continuous improvement of the VA. I think the VA-OIG might be failing in its mission. VA 3

Fraud is rampant in the VA because the VA refuses to act, work, change, and improve. How will throwing more money at VA programs alleviate the hurt, stop the fraud, and spur continuous improvement? Almost every week, my inbox fills with accounts of fraud occurring, but the roots of the problems are never addressed, and people are not held accountable for failing to perform the work they were hired to complete. Failing to hold people responsible promotes fraud, waste, and abuse. Allowing whistleblowers to be fired promotes a discouraged whistleblowing culture, and the perpetrators are allowed to continue their nefarious misdeeds! How is the VA-OIG going to tackle these systemic issues in the culture at the VA? When will continuous improvement begin; I do not want to miss growth and development!

Knowledge Check! America, the VA is sick. A symptom not a disease; the larger disease is a refusal to act morally upright. The majority of those employed in the behemoth of government service have little to no moral compunction, are not servants of the taxpayer, and consider themselves “Too BIG to fail.” We need a smaller government, and I hope this message helps enlighten and support shrinking the government!

“That’s Crazy!!!” – More Chronicles From The VA

Bobblehead Doll The week of 27 September 2021 started funkily and has gone downhill rapidly! I reported Monday being refused medical service for not wearing a mask. On Tuesday, I visibly struggled for breath, standing in the VA pulmonologist’s office in front of the pulmonologist who was holding my pulmonology function test results. I am holding a letter showing I cannot wear a mask, wearing a face shield, and being told by the doctor, “I do NOT care, he needs to WEAR A MASK, or I AM NOT SEEING HIM” [emphasis his]. Eventually, the doctor agrees to see me, provided I remain more than 6 feet from him, and he does not have to touch me. The doctor then proceeds to lecture me about getting the vaccine, wearing a mask, and of course, breathing through my breathing difficulties.

As they say on the Home Shopping Network, “But wait, there’s more!” Crazy has only just begun, unfortunately!

A patient with iron-deficiency anemia died at the hands of VA Doctors at the San Juan Puerto Rico VAHCS (2017), and the VA-OIG is just completing and reporting on their death in 2021. The patient who came in for a colonoscopy developed rectal bleeding, which required an anticoagulant, and the patient subsequently died. A tragic set of dominoes was set up and knocked down in this patient’s case, and the VA is entirely at fault for the patient’s death. How badly the patient’s family must feel with this report in hand and knowing they can do absolutely nothing! VA 3

100% crazy indeed; but wait, there’s more!

Justice was served cold and raw, and while I was hoping for a harsher sentence by far, I am still hoping his victims can recoup some of their losses and obtain retraining. “Jonathan Dean Davis, the owner of Retail Ready Career Center in Texas, was sentenced for deceiving the VA of $72 million. Beginning in 2014, he offered six-week heating, ventilation, and air conditioning course, promising to prepare veterans for careers in the HVAC industry. However, upon entering the workforce, many of these veterans discovered that the course had failed to teach them many of the basic skills necessary for entry-level technician jobs. Davis was also ordered to pay $65.2 million in restitution and forfeit $72.5 million to the federal government.”

It is very hard to describe what goes into the GI Bill besides money and time in service. It is even tougher to explain how cheated you feel when the benefit is cut by the government, stolen by school administrators, and reduced by petty rules and regulations. To see your benefits stolen through shoddy training and see your hopes and dreams dashed, as well as your benefit, turned into useless paper, the heartbreak is incredible! The punishment for all involved should have been greater, and some federal employees should have shared the blame for failing to do their jobs! I-Care

Hold onto your seat, folks; the insanity has not even reached its peak yet; there’s more!

“The VA Office of Inspector General (OIG) inspected the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (CLC), of failure to observe infection control practices, failure to minimize the risk of exposure to COVID-19, inconsistent ongoing testing, and failure to notify residents, families, and staff of positive test results. During the inspection, the OIG identified concerns related to leaders’ post-outbreak actions. The VA-OIG substantiated a failure to observe general infection control practices, including in the following areas:

- Leaders failed to minimize the risk of exposure to COVID-19.
- Leaders did not respond adequately to staff exposure.
- Leaders did not have a plan for the transfer and isolation of residents.
- Leaders did not implement recommended infection control measures when performing aerosol-generating procedures and continued to hold group therapies.

The VA-OIG substantiated the lack of a post-baseline testing plan and a failure to test CLC staff after potential exposure. The OIG identified actions taken by leaders following the CLC outbreak that lacked input from frontline staff to identify corrective actions and opportunities for improvement.” This is the politically correct way of saying that the community living center leaders are thoroughly incompetent and should not be trusted in their current positions.

Leadership failure in spades, employees, patients, families all placed at risk because of incompetence and politics of the facility leaders, and the VA-OIG does not have the teeth needed to FIRE and REPLACE the leaders who are clearly out of their depth and ability! For months the media and political leaders have been harping and preaching how dangerous COVID as a viral infection is. Yet, the leaders in the Illiana VAHCS seem to be operating to a different set of rules and policies. Will any elected leader be asking why? Insanity runs deep in Illinois! VA 3

On the topic of COVID-19, and the failures of VA providers to do their jobs, we find another dead veteran due to what in the private sector would be a classic case of malpractice! Yet, care at the VA is protected from malpractice, and the providers are safe from responsibility and accountability for their failures. While the following is specific to North Carolina, similar examples are found across the United States. Insanity thy name is represented in spades at the VA! Angry Wet Chicken

“The VA OIG conducted a healthcare inspection at the Fayetteville VA Coastal Health Care System in North Carolina to assess concerns related to the quality, coordination, and timeliness of care, and the impact of COVID-19 on a patient with unintentional weight loss who was later diagnosed with oral cancer and died at another VA medical center.”

- The VA-OIG substantiated that the primary care provider and dietitians did not provide quality care to the patient.
- The VA-OIG substantiated that dietitians conducted incomplete nutritional assessments.
- The VA-OIG substantiated that the patient’s PACT nurse and dietitians failed to coordinate care by not communicating the family’s request for a face-to-face appointment and the patient’s declining nutritional status to the primary care provider.
- The VA-OIG found that incorrect scheduling resulted in the patient not being seen by a dietitian for a follow-up appointment and a delay in scheduling a non-VA dental appointment.

“The VA-OIG concluded that COVID-19 impacted the care provided by dietitians because of the use of telephone visits, which did not allow dietitians to visually assess the patient’s physical characteristics caused by a declining nutritional status.”

Blaming a viral disease for the failure of people to do their jobs is the height of skullduggery, showing pusillanimous disregard for the patient and a timid weak-kneed, and yellow-bellied timorous approach to medicine. None of you deserve to be in the medical field if you cannot properly take personal protection and see patients who need to be physically seen! Now, let’s call a spade a spade and call out your wimpy, limp-wristed, lily-livered weakling leaders who refuse to act like leaders in a hospital and prefer to act like scared amoebas in a petri dish! There is NO EXCUSE for your paltry excuses, your shady practices, and your hiding in offices and behind the disruptive behavioral committees when your policies and procedures FAIL when YOUR training plans fall apart, and when reality bites hard enough to disrupt hospital operations and your policies are the problem endangering patients! VA 3

Crazy… Thy name is abused in the VA, and the leaders are failing to understand sanity! But … wait, there’s more!

There are times when I describe the insanity at the VHA, VBA, National Cemeteries, and the Department of Veterans Affairs (VA) as designed incompetence. The following is the purest example of designed incompetence witnessed to date. Consider with me the following:

?u=http3.bp.blogspot.com-CIl2VSm-mmgTZ0wMvH5UGIAAAAAAAAB20QA9_IiyVhYss1600showme_board3.jpg&f=1&nofb=1 Blue Water Navy Outreach requirements were met, but processing and procedures remain lacking and need improvement. The VBA was legislatively mandated to extend veteran benefits to a classification of sailors who operated in blue water conditions off Vietnam or within 12 Nautical Miles of Vietnam. The VBA went forward and established the computers, the records, the systems, etc., to handle these claims. The results, a complete farrago!

“The VA-OIG substantiated that the VBA has not established procedures for its employees to follow when the computer search tool they use to determine ship locations during claimant service dates returns unlikely results (for example, providing an inland location in a search for an aircraft carrier). In addition, VBA employees inaccurately decided approximately 46 percent of veterans’ claims (2,100 of 4,600) from April through June 2020, which led to about $37.2 million in improper payments to veterans ($25.2 million in overpayments and $12 million in underpayments) during that period. About 95 percent of these errors resulted from VBA employees deviating from policies governing disability-rating decisions.”

Did you catch that the VBA intentionally designed a system that failed to perform the task because humans and computers were lenient to deviate? Nobody is held accountable for the continued loss of benefits, treatment, and wasted resources of the government and the veterans involved! Here’s the rub, this is NOT the first time this has happened! The VBA is notorious for failures like this and never held accountable by the elected officials hired to scrutinize the government! Name a military excursion where benefits had to be carved out by legislative order, and you will find foot-dragging, designed incompetence, inconsistencies in decision making, and piss-poor performance at every level of the VBA. Why?

Let’s imagine you hold a job that has a reporting requirement to an authorizing body that can shut you down. You arbitrarily change language in metrics and reporting, do not tell the authority but still expect the authority to license you and your efforts. How likely do you think the governing body will look favorably upon your changes? The VA is legislatively mandated to report to Congress on its capacity in five areas, spinal cord injuries, traumatic brain injuries, blind rehabilitation, prosthetics and sensory aids, and mental health. But, by changing the language, metrics, and methods of talking about injuries, the VA can hide, misreport, underreport, overreport, and play reporting games with the report to Congress and the VA-OIG second look get away with the deception. Never forget, the maskirovka comes with veteran patient abuse! Angry Grizzly Bear

The VA-OIG has reported continuously to Congress, to deaf ears and plastic lips, the following, “… VA cannot compare its current mental health capacity with its 1996 capacity because of changes in diagnosis and treatment, service provision, and data collection. For example, VA must report on the number of veterans with “serious mental illness,” but VA no longer uses that term. And non-VA care, which veterans increasingly seek, must be excluded from reports on VA’s capacity to provide care. The OIG believes that by modernizing the reporting metrics, Congress would be better positioned to assess VA’s capacity to provide care for today’s disabled veterans.”

Congress continues NOT to push the VA to adopt 1996 language and metrics for reporting, or change the law to update the language and metrics to capture the data more accurately, thus allowing the lies and deceptions to continue. Will anyone in the media EVER ask Congress WHY? VA 3

What kills me, the insanity discussed in this summation of VA-OIG reports does not even scrape the iceberg. In my email inbox, I have to select between continued financial failures by leaders, veteran suicide during an inpatient residency, and the continued moral distress of employees by facility leaders. I have twenty more VA-OIG reports sitting awaiting summation because the insanity has blossomed, and the VA-OIG is working hard to clear their reports for the end of the calendar year. Each and every one of these reports deserve analysis, discussion, and mega-doses of sunshine disinfectant. The sheer enormity of the insanity means that timely discussion physically cannot occur. By overloading the system, the perpetrators of veteran abuse can escape sunshine disinfectant, and that is a sore injustice!

Pray for the families of those who have died at the hands of the VA providers and for those currently dying under the hands of VA providers. Congress needs to act, and we, the electorate, must hold their feet to the fire until they are consumed, or they stand and do their jobs! There are no excuses for the insanity contained in these VA-OIG reports!

© 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.

Ineffective Governance – Chronicling the VA

I-Care In a scheme fit to fully infuriate patients and pad wallets, the VA providers prescribe medications; generally, the medication provided is a cheap knock-off, a generic mixture, or drugs with rebate incentives where the hospital providers are “encouraged” to use one drug more than another and the “higher cost” is rebated back the hospital in a profit-sharing scheme. All these schemes and more play out at your local hospital and VA facilities, so please do not think this is industry-specific to the government. However, as proved by the Department of Veteran Affairs (VA) – Office of Inspector General (VA-OIG) reports, t improper controls and governance wastes the rebates, harms patients, and still cannot get the programs correct.

Angry Wet Chicken I have three prescriptions hindered by the pharmacy practices of the VA, where the knock-off drug is useless, the mixture of the medication does not do as well as the original medicines prescribed, and where the cost of an ingredient has changed one medication to another and made the prescription less effective to the point where more medication is required for less overall effectiveness. If the patient has to take more medication, does that mean that the cost savings never happened or that the cost savings were pushed down to the customer? Does the patient even have a voice in the pharmaceutical decisions? Why?

We begin the VA-OIG reports with a New Jersey man, who from 2017 thru 2020 stole more than $8.2 million in HIV medication from the VA. Where were the supervisors when procurement officers for the VA over-ordered medication, stole the excess, sold the stolen goods, and pocketed the profits? Where were the oversight accountants? Where were the hospital directors? People had to know, yet somehow the scheme could exist and thrive; this is as much a failure of leadership as it is ineffective governance, poor inventory control, and useless organizational controls. Truly a pathetic example of VA leadership! VA 3

On the topic of ineffective governance of pharmaceutical contracts, and diversions of drugs, the VA-OIG report the following:

“The Veterans Health Administration (VHA) spent about $6.6 billion on prescription drugs in fiscal year (FY) 2019. Most were dispensed to veterans by medical facility pharmacies. VHA pharmacies can return drugs that become damaged or expire before use through a reverse distributor for credit or destruction. In FY 2019, VHA expected to receive about $52 million from drug returns. The VA-OIG found VHA pharmacy chiefs did not effectively implement the program and did not follow requirements in VA’s contract with the reverse distributor, Pharma Logistics. These issues increased the risk of drug diversion and ultimately put about $18.1 million at risk. Pharmacy chiefs did not always secure, and track drugs held for return or complete required analyses to maximize returns. They also failed to meet contract requirements to return for credit-only drugs due to expire within 120 days. VA’s National Contract Service and network contracting officers needed to do more to ensure contract terms were met. The Office of the Deputy Under Secretary for Health for Policy and Services and the Office of the Deputy Under Secretary for Health for Operations and Management did not effectively govern the program or communicate requirements to medical facilities” [emphasis mine].

VA 3 Someone help me out, for I cannot understand how incompetence can be designed into these systems, policies, procedures, and responsible parties retain their positions of power. What happened in 2018, 2017, 2016, and earlier? We have a single fiscal year (FY) snapshot at a program that is an absolute failure. By any measurable standard, that should have ignited a full audit of previous years until finding a successful year when the program worked. Will there be a follow-up to this investigation to see if the VA-OIG’s recommendations are followed and implemented? The VA-OIG has the leadership caught dead to rights on ineffective governance of a program worth $6.6 Billion to the American Taxpayer, and no accountability or responsibility of personnel is to be found anywhere. Why?

Plato 2 In a separate investigation, the VA-OIG found:

“In October 2020, VA ended its contract with Pharma Logistics. The vendor continues to process and issue final invoices to facilities as the returned drugs become eligible for and receive manufacturer credit. The final invoice process will continue until at least April 2022. VHA medical facility pharmacies lost at least an estimated $2.1 million worth of drug return credits because pharmacy chiefs did not always effectively monitor or review job settlement statements before Pharma Logistics issued final invoices. In addition, although the vendor established a dashboard that provided information on the status of drug return credits at the facility level, it cannot provide a national report on all outstanding credits. This hurt VHA’s ability to maximize potential drug return credits and minimize the risk of lost credits. VHA will continue to be unable to ensure it is receiving all credits for drugs returned by medical facilities if pharmacy chiefs do not routinely monitor preliminary invoices, reconcile job settlement statements to identify outstanding credits, and request extensions to final invoices to allow additional time for credit processing. This risk will persist for any future drug return contract(s)—whether awarded nationally or locally—if the reimbursement structure remains the same” [emphasis mine]. VA 3

Did you catch that; the vendor created software to help track medications, making it easier to return medicines, and the VA pharmacy chiefs could not follow the dashboard and increased the risk of losing money for the VHA. You were hired to perform a job; a collateral duty of your job is inventory management, tools are provided and supported to aid you in making decisions, and you refuse to use these tools. How is this the vendor’s fault? Why do you still retain your position? Ineffective governance is barely the tip of the VA’s problematic iceberg created the good ship America has hit!

Liars, Thieves, and Fraud Artists Beware

Gavel A Norwood, Massachusetts woman has been indicted, remains presumed innocent until proven guilty in a court of law, by a jury of her peers, for stealing social security and workman’s compensation benefits. The Norwood woman’s actions are continuing to support the claim that complexity breeds criminal abuse. Unfortunately, also proving that the government is not doing their jobs in checking tax records before providing benefits.

A man from Georgia has pled guilty to running a Ponzi scheme and defraud the American government during the COVID pandemic. Frankly, I am thrilled to see another fraudster being stopped before his crimes become astronomical in scale. I remain convinced that the government procurement system is wide open to abuse, and the complexity of the procurement system is too costly, cumbersome, and risk inviting. The criminals see too much opportunity in the government procurement system, and the complexity breeds the ability to lie, steal, cheat the American taxpayer.

Question The following remains a case where there are too many lawyers and not enough truth to ascertain what in the world is going on. If you have further insight, please weigh in. “Sunrhys LLC, a landlord and property management company, headquartered in Tacoma, Washington, agreed to pay $16,618 to resolve allegations that it violated the False Claims Act by overcharging a tenant and by fraudulently obtaining federal funds from a federal program designed to provide housing to homeless Veterans. The United States alleged that Sunrhys violated the agreement and the HUD-VA Support Housing program requirements by fraudulently overcharging a veteran for monthly rent between July 2019 and April 2020.”

Highlights, Audits, and Inspections

July 2021 – Highlights:

“Each month, the Office of Inspector General (OIG) publishes highlights of our investigative work, congressional testimony, and oversight reports. Each month’s highlights are meant to provide a brief overview of the most significant OIG work conducted in that period.”

blue-money-burning The VA-OIG conducted a financial efficiency review of the Miami VAHCS. From the findings, the VHA, VBA, National Cemeteries, specifically, and the VA generally, could learn much about fiscal responsibility. But this was already well documented! The VA has never successfully passed an audit with transparency, accountability, and responsibility; why am I the only person demanding to know why? Want to laugh; the VA-OIG recommends “more scrutiny” for financial transactions to the VA as a recommendation. Like the current system for scrutiny is working, and just a bit more effort will help. Go ahead and read the report for more specifics; my stomach cannot handle writing about the gross inefficiencies, the actual harm, and out-of-control governance failures. Fiscal insanity is one thing; what is occurring at the Miami VAHCS is beyond insane and bordering on the unbelievable! Almost the beginning of the Twilight Zone.

Survived the VA The Sheridan VAMC in Wyoming continues to be performing well and deserves hearty congratulations for the results of their latest comprehensive healthcare inspection. I prefer to issue congratulations than butt-kickings, and the congratulations are well deserved. Keep up the good work moving forward.

© 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.

Weep America! – The VA Leadership is Becoming Worse! – Part 3

I-Care In the less than 10-days since I last wrote on the Department of Veterans Affairs (VA), the Department of Veterans Affairs – Office of Inspector General (VA-OIG) has dumped more than ten inspection results over the last three days into my inbox. Not a record, but the recorded actions are certainly hitting record lows. Worse, the culture of the VA remains unchanged, even through all the recorded crimes and indignities the veterans suffer under. Recording and summating the crimes of the VA is so depressing, mainly because of the failure to reform. But, a little depression will not slow or halt the reporting of these detestable actions of the VA!

The first VA-OIG investigation is more of a report on criminal proceedings concluding with sentencing. A total of five people, including one VA Employee, have been stung in this investigation. How thrilling to see accountability and justice served cold!

“Francis Engles of Bowie, Maryland, was sentenced to 30 months in prison and ordered to pay $150,000 in restitution for defrauding a VA program dedicated to rehabilitating military veterans with disabilities. As the owner of Engles Security Training School, Engles falsely represented to the VA that his company was providing veterans with months-long courses when, in fact, the school offered veterans far less.”

“February 2019, four other individuals were sentenced in related cases following their guilty pleas. First, James King, a former VA employee, was sentenced to 11 years in prison for committing bribery, defrauding the VA, and obstructing justice. Second, Albert Poawui, the owner of Atius Technology Institute, was sentenced to 70 months in prison for committing bribery. Third, Sombo Kanneh, Poawui’s employee, was sentenced to 20 months in prison for conspiracy to commit bribery. Finally, Michelle Stevens, the owner of Eelon Training School, was sentenced to 30 months in prison for committing bribery.” VA 3

Apparently, bilking the GI Bill is a regular fraud opportunity, and the VA employees need to be held more accountable for the loss of these funds! The GI Bill is a precious commodity and sometimes the only lifeline for a soldier for retraining while awaiting the VBA’s decisions. Therefore, stealing these funds should come with more substantial sentences, more accountability for the employees in the know of fraud, and scrutiny from elected officials!

For the next story, we have several crimes co-occurring; the most egregious is reporting to have been a veteran, fraudulently obtaining benefits, and then trying to use veteran status for preferential contract awarding. The VA-OIG reports:

“Robert S. Stewart, the former owner of Federal Government Experts LLC in Arlington, Virginia, was sentenced to 21 months in prison with three years of supervised release for making false statements to multiple federal agencies in order to fraudulently obtain multimillion-dollar government contracts, COVID-19 emergency relief loans, and undeserved military service benefits.” VA 3

I know the Supreme Court of the United States (SCOTUS) has declared that lying about military service is a freedom of speech issue and not a crime. However, stolen valor continues to make me sick, and the liars should lose all US Constitutional Rights, as well as be sentenced to punishment most vile! Having served twice (US Army and US Navy), having been deployed to S. Korea (US Army) and the Persian Gulf (US Navy Multiple Times), stealing valor infuriates me into a raging juggernaut! I hate liars and thieves, but to steal valor from those deserving goes above and beyond being just a liar and thief, and the conduct deserves punishment most vile! No, I am not apologetic in taking this stance either! Burn the American Flag; I disagree with SCOTUS again and becoming a raging juggernaut! There are lines you do not cross with impunity, and if you cannot scream fire in a crowded theater as “Free Speech,” then acts of stealing valor or burning the American Flag are reasonable restrictions!

I do agree with Justice Oliver Wendell Holmes’ statement:

“The ultimate good desired is better reached by free trade in ideas — that the best test of truth is the power of the thought to get itself accepted in the competition of the market, and that truth is the only ground upon which their wishes safely can be carried out.” Angry Grizzly Bear

But stealing valor and burning the American Flag is not “free trade in ideas,” and I support social shaming as part of the punishment most vile for these lepers of society! Before you burn the Flag or steal valor, serve in uniform, watch a military funeral as a dependent, and then let’s talk about reasonable and valid restrictions upon “free speech!”

Another case, another criminal act, only this time, I am left asking, “How long has this individual been doing business with the VA?” Regardless, as this is an ongoing case, the following firstly applies: “The charges in the indictment are merely accusations. The defendant is presumed innocent unless and until proven guilty.” From the VA-OIG report:

“Muhammad Z. Aabdin of Bronx, New York, was indicted for offering bribes to a VA contracting officer in exchange for the award of VA contracts for personal protective equipment.” VA 3

It will be interesting to watch this case and future (potential) investigations occur. However, I have several questions needing to be answered, and the report does nothing to aid in answering the questions raised in the defendant’s arrest and the grand jury indictment. More to come as the VA-OIG and the US Attorney produce information. May the US Attorney NOT allow a plea deal!

The VA-OIG has often investigated improper fiscal practices at several VA sites for the VBA, the VHA, and the National Cemeteries. I could almost quote the following investigation results, only differing on how much money is involved.

“The VA Office of Inspector General (VA-OIG) conducted a review to examine whether VA’s Maryland Health Care System appropriately managed purchases and payments for medical equipment and supplies. Fiscal oversight of purchase cards and internal controls governing the use of overtime were also reviewed. The VA-OIG found ineffective processes, internal control weaknesses, and inadequate oversight in five areas: 1. The healthcare system and the Enterprise Equipment Request (EER) portal need improved controls for approving equipment purchases. 2. Healthcare system staff and the prime vendor should prepare timely and accurate planning information to ensure adequate supplies are on hand to fill orders. 3. Even though no inaccurate inventory payments were identified, VA’s inventory system needs controls to ensure correct recording of supply units and costs. 4. The healthcare system purchase card program requires closer monitoring to ensure purchases are authorized and supported by documentation. 5. The healthcare system should strengthen its overtime payment controls to ensure supervisors verify overtime hours were completed before approving timecards for payment. The VA-OIG team also identified more than $5 million in questioned costs related to identified issues such as undocumented or unapproved purchases” [emphasis mine]. VA 3

I have heard the term “Criminal Stupidity” and often wonder when “Criminally Designed Incompetence” will become adopted into common vernacular. I am so fed up with the excuses, the missing money, and the abuse of taxpayer forbearance by bureaucrats; I could rip my hair out and scream until my voice gives out! But, unfortunately, both actions do absolutely nothing to correct the problem and would make me miserable. The VA has problems with criminals without and stupidity masked as “designed incompetence” within, and the solution continues to be leadership!

Gravy Train 2 What adds fire to my mental processes on criminally designed incompetence, the VA-OIG has two other investigations in my inbox on the need to strengthen fiscal controls, , and more correctly track accounting practices. Under current legislation, if a private business accounted for their money like the VA, they would be shuttered, and criminal charges levied! Yet, somehow, the elected representatives cannot apply the same accounting behavior standard to a government agency, as they mandate for private companies! Anyone else thinks we need stronger demands for scrutiny of government agencies?

Plato 2 Adding more fuel to the fire for the IT/IS Departments of the VA, the VA-OIG discovered that the VA still cannot regularly and appropriately log records into its own electronic health record systems! Are you surprised; as a patient, I know I am not surprised at all. Worse, the lack of medical records being properly handled influences (negatively, of course) how the VBA makes decisions on claims!

“The Office of Inspector General (VA-OIG) evaluated whether VA’s community care staff accurately uploaded records for non-VA medical care to veterans’ electronic health records. Veterans receive non-VA care based on certain criteria, such as the distance from the veteran to the nearest VA facility or the wait time for a VA facility appointment. Records for non-VA care enable Veterans Health Administration (VHA) providers continuity of care and inform treatment decisions. The audit team found that staff at six of the seven VA medical facilities reviewed did not always index, or categorize, these records accurately. Inaccurate indexing of medical records poses a risk to veteran care. It increases the burden on the VHA staff who locate and correct the errors, reducing their time for other tasks. The team reviewed 209 veterans’ mental health medical records that VHA community care staff indexed between April 1, 2019, and September 30, 2019, and found 108 indexing errors for 92 veterans. (Some veterans’ records had more than one error.) Errors included using ambiguous or incorrect document titles, indexing records for non-VA care to the wrong referral or veteran, and entering duplicate records. These errors occurred, in part, due to inadequate procedures, training, quality checks, and quality assurance monitoring and a lack of local facility-level policies.” VA 3

Of course, training and local policies were blamed for the failure to log records properly! These are automatic designed incompetence excuses that appear every single time the VHA fails, the VBA fails, or they both make significant life-altering decisions for veterans, and the VA-OIG investigates! The VBA claims it is my duty to ensure outside providers send records to the VA in a timely manner. The VHA claims they have the documents the VBA wants, and they should read the file. Who is inconvenienced, not the VHA and the VBA, the veteran? The person who cannot even look at his digital file without a “Freedom of Information Act” (FOIA) request and 30-45 days of waiting, and even then, the document is heavily redacted for privacy! Whose privacy, I wonder, the providers, the employees, or the veterans? Because I guarantee the VA is conducting serious CYA on the records produced! Let alone IT’s continued failure to protect the veteran from identity theft or IS to protect the files from being accessed without reason by employees. Apathy

May 2021 was a tumultuous month for the VA and the VA-OIG. If you would like to review how tumultuous or think you might have missed an article or two reporting the VA’s designed incompetence, feel free to review using the following link. Frankly, I want to see action taken based upon the investigations to clean house, more fully scrutinize the VA, and improve the veteran experience at the VA. But, I do not tell you how to think or feel about an issue. Instead, I report and summate and leave the rest to you! VA 3

As always, I report and summate upon the good and bad. If you are a citizen of Indiana or receive your care from either Fort Wayne, Marion, or through the Northern Indiana Health Care System, please count yourself lucky, and pass on the praise to the VAHCS employees. The VA-OIG conducted a comprehensive Healthcare Inspection and found, “The VA-OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors” [emphasis mine]. While improvements can still be made, this is HUGE news, and the Northern Indiana VAHCS leadership team needs to be back-slapping and congratulating their employees.

Knowledge Check! Thus, my sincerest congratulations go to the Northern Indiana VAHCS, and heaps of shame and scorn remain served cold to the ineffective leadership and useless employees of the VA in general! America, we should weep, for the VA is not alone in the government agencies in providing world-class detestable service, abuse of the customer (taxpayer), and skirting accountability and responsibility through designed incompetence! But, when we are done weeping, it is time for action! Changing the elected representatives, demanding higher scrutinization with actual penalties for failure, and insisting upon fiscal restraint equivalent to the private sector!

© 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.

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

I-Care Long 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?

Problems The 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 Crisis Another 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:

Failure to notify the patient.
Failure to collaborate between different hospital units for patient care and safety.
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!

With 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 VA Personally, 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 Crests Just like the labor union provided bumper sticker proclaims, “SAVE the VA!” [Emphasis in original], it is time to “SAVE the VA!”

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.

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

The Power of Tiger Teams – Shifting the VA Paradigms

A 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.

Tiger 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.

Finally, 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:

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.
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.
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.

Never 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!

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.

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

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

I-Care To 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.

The 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 Diagram For 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 Analysis The 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-Care Thank you for your time and consideration.

Sincerely,

Dave Salisbury
Veteran/Organizational Psychologist

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.

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

Structured Incompetence – The Department of Veterans Affairs and Congress

I-Care The 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-Change On 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.”

Problems How 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:

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.
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?
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?

Gears The 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.

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.
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.
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!
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 – 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?

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.

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

Symptoms Not Cause – Shifting the Paradigm at the Department of Veterans Affairs

I-Care For Memorial Day (2020), the National Cemetery, through the directive of the Department of Veterans Affairs (VA), restricted the placing of flags at several national cemeteries, upsetting the plans of Boy Scouts, and angering countless veterans, survivors, dependents, and extended families. However, the intransigence of the VA on this matter is but a symptom of a larger problem.

Problems The Department of Veterans Affairs – Office of Inspector General (VA-OIG) recently released two additional reports on behavior unbecoming at the VA. The first report concerns the delays in diagnosis and treatment in dialysis patients, as well as patient transport at the Fayetteville VA Medical Center in North Carolina. The second is another death of a patient, as well as deficiencies in domiciliary safety and security at the Northeast Ohio Healthcare System in Cleveland.

The VA report from North Carolina includes significant patient issues, especially since two veterans died while in the care of the VA. Significant issues are generally code words for incredibly lax processes, and procedures that are easily avoided, provided people care enough to do their jobs correctly, succinctly, and thoroughly. Where patients are concerned a dead patient is pretty significant. Two dead patients are beyond the comprehension of a reasonable person to not ask, “Who lost their jobs over these incidents?”

Patient A, has leukemia, and from the VA-OIG’s report we find the following responsible parties:

“… A primary care provider failed to act on Patient A’s abnormal laboratory results and pathologists’ recommendations for follow-up testing and hematology consultation. Community Care staff did not process a consult and schedule Patient A’s appointment.”

Patient A died from a gastrointestinal bleed while waiting for transport to a hospital from a (VA Contracted) [long-term] care facility. Patient A’s delays in care led to death in hospital, and the failure of a hospitalist to initiate emergency procedures contributed to the veteran’s passing. Patient A’s death is a tragical farce of bureaucratic inaction, compounded by the same symptoms as that allowed for Memorial Day (2020) to come and go without the honored dead of America being remembered. Symptoms not cause.

Patient B, was also in a (VA Contracted) [long-term] care facility, in need of transport back to the hospital, and the administrative staff’s delays had Patient B arrive at the hospital in cardiac failure, where the patient subsequently died. In the case of both patient’s facility leaders did not initiate comprehensive analyses of events surrounding the patients’ deaths or related processes. But, this is excusable behavior at the VA due to frequent executive leadership changes impeding the resolution of systemic issues. I have been covering the VA-OIG reports for the better part of a decade and this excuse is always an acceptable excuse for bureaucratic inaction. Hence, the first question in this madness is to the VA-OIG and it needs to answer, “Why is this an allowable excuse?” Don’t the people remaining know their positions sufficiently to carry on when the executive team is in flux? Again, symptoms not cause.

The patient death in Northeast Ohio, started with the domiciliary, on a VA Contract care facility. Essentially, the patient died because of methadone being provided without first gaining an electrocardiogram. Oversight of the contracted domiciliary did not include accuracy checks on paperwork, but the VA-OIG found that for the most part, the contracted domiciliary was following VA Contracting guidelines. From the report, no gross negligence led to the veterans passing, and for the most part risk analysis and other post mortem analysis were conducted properly. Why is this case mentioned; symptoms not cause.

When I worked at the New Mexico VA Medical Center (NMVAMC) I diagnosed a problem and was told, repeatedly, to not mention the problem as the director would be furious. The problem is bureaucratic inertia. Bureaucratic inertia is commonly defined as, “the supposed inevitable tendency of bureaucratic organizations to perpetuate the established procedures and modes, even if they are counterproductive and/or diametrically opposed to established organizational goals.” Except, the bureaucratic inertia I witnessed daily was not “supposedly inevitable,” it was a real and cogent variable in every single action from most of the employees.

I spent 12 months without proper access to systems, but the process to gain access was convoluted, unknown, ever-changing, and so twisted that unraveling the proper methods to complete the process and gain access was never corrected, and this was a major issue for patient care in an Emergency Department. Why was the process so bad; bureaucratic inertia. Obtaining information about the problem took two different assistant directors, two different directors, a senior leader, and the problem was identified that licensing requirements were the sticking point in the problem.

Inertia Bureaucratic inertia is the cause of too many issues, problems, and dead veterans, at the Department of Veterans Affairs. The symptoms include delays in administrative tasks that lead to patients dying for lack of transport to a hospital. The symptoms include cost overrun on every construction project the VA commences. The symptoms include abuse of employees, creating a revolving door in human resources where good people come in with enthusiasm, and leave with anger and contempt, generally at the insistence of a leader who refuses to change. The symptoms include a bureaucrat making a decision that has no logical sense, costs too much and is never held accountable for the harm because the decision-maker can prove they met the byzantine labyrinth of rules, regulations, and policies of the VA.

Veterans are dying at the VA regularly because of bureaucratic inertia. Hence, as bureaucratic inertia is the problem, and the symptoms are prevalent, it must needs be that a solution is found to eradicate bureaucratic inertia. While not a full solution, the following will help curb most of the problem, and begin the process for the eradication of bureaucratic inertia.

Give the VA-OIG power to enact change when cause and effect analysis shows a person is “the” problem in that chain of events. Right now, the office of inspector general has the power to make recommendations, that are generally, sometimes, potentially, considered, and possible remediations adopted, provided a different course of action is discovered.
Give the executive committee, of which the head is Secretary Wilkie, legislative power to fire and hold people accountable for not doing the jobs they were hired, and vetted at $110,000+ per employee, to perform. Background checks on new employees cost the taxpayer $110,000+, and the revolving door in human resources is unacceptable. But worse is when the leaders refuse to perform their jobs and remain employed.
Implement ISO as a quality control system where processes, procedures, and policies are written down. The ability for management to change the rules on a whim costs money, time, patient confidence, trust in leadership and organization, and is a nuisance that permeates the VA absolutely. The lack of written policies and procedures is the second most common excuse for bureaucratic inertia. The first being, the ability to blame changing leadership for dead patients!
Eliminate labor union protection. Government employees have negotiated plentiful benefits, 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 the United States of America generally, and upon the seal of the Department of Veterans Affairs specifically.

Leadership Cartoon Secretary Wilkie, until you can overcome the bureaucratic inertia prevalent in the ranks of the leadership between the front-line veteran facing employee and your office, lasting change remains improbable. Real people are dying from bureaucratic inertia. Real veterans are spending their entire lives in the appeal process for benefits and dying without proper treatment. Real families are being torn asunder from the stress of untreated veterans because the bureaucratic inertia cannot be overcome from the outside. I know you need legislative assistance to enact real change and improve the VA. By way of petition, I write this missive to the American citizen asking for your help in providing Sec. Wilkie the tools he needs to fix the VA.

The VA can be fixed, but the solution will require fundamental change.

Change is possible with proper legislative support!

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.

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

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