Absurdity so Repugnant it Takes Your Breath Away – More VA Chronicles

Angry Grizzly BearThe Department of Veterans Affairs – Office of Inspector General (VA-OIG)-released six investigation reports in the last two days.  Each one is mentally breathtaking at the egregious behavior of bureaucrats!  Stupidity that is so repugnant it breaches the laws of morality and leaves the reader stupefied.  Every year, for the last decade-plus, the behavior of the Department of Veterans Affairs (VA) has become more obscene, more outlandish, more detestable, and more openly hostile towards veterans; it sickens me to read the investigation reports, write, and catalog these abuses!

Beginning in Queen’s, New York, we find another dead veteran that should never have died the way they did.  Improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient.  Let that sink in for a moment, for the rest of the report only goes downhill from this point.  My time in medical training was replete with the following aphorism, “If it is not written down, it NEVER happened.”  The nursing staff failed to document meals properly. The electronic health record (EHR) was inaccurate and flawed, hindering resuscitation, which was poorly documented, and institutional disclosure acted more like CYA than a medical file.  People should have been fired and up on trial for this type of scandalous behavior, especially since a veteran died from this abuse and neglect.  But the VA-OIG made their recommendations, the leadership accepted the recommendations, and nothing else will happen.  Nobody but the family cares the veteran died needlessly and at the hands of the medical professionals.VA 3

Adjectives elude me.  The behavior in Queen’s is appalling, even for the VA.  Unfortunately, the list of ineptitude only gets worse!

VA SealNext, we travel to Austin, Texas, and discover yet another office of information technology (OIT) failing to work, secure data correctly, and protect veterans’ information, as demanded by legislation!  The VA-OIG and the local OIT used the same tools, and the local OIT only identified 150 problems, whereas the VA-OIG OIT inspectors found 246.  Improper sanitization of media was a pronounced issue, where patient load is upward of 300,000 annually.  Inventory practices were noticeable and apparent.  Worse, patch and vulnerability programs were practically non-existent if I understand this report correctly.VA 3

If you have read any of these VA Chronicles, you will know that the VA has not passed a Federal Information Security Modernization Act (FISMA) audit, ever!  The head of IT was recently in front of Congress to testify why, and the explanations were milk toast adequate at best!  But, the elected officials bought the excuse, hook, line, and sinker, as always, and the president wants to spend more money on the VA.  What a cathartic example of why elections matter!

Next, we travel to Detroit, Michigan, where a “comprehensive healthcare inspection (CHIp)” was performed at the John D. Dingell VAMC.  Before I even read the report, I knew it would say; opportunities exist to improve employee and patient experience.  Knowing veterans who are “served” at this VAMC, this was an obvious guess!  Again, we find “moral distress” in the workforce, signifying that the employees feel pressured to do everything but what is ethical, legal, moral, and appropriate for the patient at this VAMC.  Yet, the leadership team was rated as stable and doing a good job!  Quoting Colonel Potter from M*A*S*H here, “HORSE HOCKEY!”VA 3

I will be explicitly clear if a single employee feels “moral distress,” there is a leadership problem, and the leadership is criminally negligent in their duties to oversee staff leaders, supervisors, team leads, and training personnel!  This is not the first time “moral distress” was a point of discussion in a CHIp; but, the fact that this problem remains widespread and apparent does mean the problems are originating at a level higher than the VISN, and all the VA and VHA leadership should be losing their jobs!  Enough is enough, and the elected officials need to be scrutinizing the government before they lose their next election!

Survived the VAHaving been an employee of the Department of Veterans Affairs, working in the Emergency Department of the Albuquerque, NM., VAMC, this next story is exceptionally aggravating and extremely distressing.  The VA-OIG determined that the entire Veterans Health Administration (VHA) needs to better monitor, record, and document the timeliness of care and patient flow in the emergency department.  Having waited for more than 14 hours in a VA Emergency Department while waiting for care, I know first hand the problems of the Emergency Departments, and I know a lot of the reasons why the documentation is fouled and the flow of patients is amateurish, at best!

Raymmond G. MurphyI worked the shift where a regular, homeless veteran, wheelchair-bound, had fallen and broken his leg.  He waited with his broken leg swelling, stuck at an odd angle, and in obvious distress for more than 6-hours because the head nurse that day had a personal grudge against the veteran!  I saw how the charts were “adjusted” for timeliness of care, and I reported the problems up the chain to no avail!  I had witnessed nurses harangue patients, gossip about them, chart surf in violation of HIPAA, and never was anything done by leadership when it was reported.  A patient sat in an expedited treatment room for four hours, listening to the nurse’s gossip and joke, awaiting stitches for a bleeding wound, and never was treated.  All because the day shift was getting off and didn’t want to be bothered to treat the patient.  The patient’s family reported this behavior to me as they were leaving for a better hospital.  I reported the whole incident, included the family’s description, added my observations.  The leadership shook the whole incident off as a disgruntled employee (blaming me) making a less than desirable situation worse.VA 3

Thus, when I read this particular VA-OIG report about the inadequacies of the VA Emergency Departments across the entire VHA, it infuriates me into a mindless stupor!  Want more data on the failures of the VA Emergency Department; read the rest of the VA Chronicles.  I describe my experiences in detail and have logged other veterans who have had the same or worse problems at the VA Emergency Department!  I have witnessed doctors treat patients in a dissimilar manner based upon the political clothing the veterans wore into the Emergency Department!  So, no, I am not surprised at the record inadequacies of the VHA; if anything, I expect the problem is a lot worse than the VA-OIG was willing to report!VA 3

The VA-OIG collected data on an issue of grave significance from 58 VHA outpatient clinics’ regarding emergency preparedness for the delivery of telemental health care as of November 1, 2019. The review focused on clinic-specific emergency procedures, emergency procedure roles and responsibilities, emergency contact information of staff, and patient safety reporting methods.  Not included in the scope of the review was the quality and quantity of telehealth appointments.  I mention this oversight as the technical problems in receiving telehealth appointments are sub-par, at best, which would have seriously skewed the data.

The VA-OIG sent out 333 questionnaires, receiving a total of 187 responses, from the 58 identified clinics, and identified the following:

      1. Missing telehealth emergency plans and procedures.
      2. Emergency procedures are not specific to telehealthcare or the patient-clinic location.
      3. Lack of a process for annual updates to telehealth emergency procedures.
      4. Undefined emergency procedure roles and responsibilities for telehealth staff
      5. Missing or insufficient emergency contact information.
      6. Lack of a process to verify and communicate emergency contact information
      7. Lack of a consistent process to designate the telehealth setting in patient safety reporting methods.VA 3

Consider for a moment; you are a family member of a veteran needing telehealth mental support.  Now, how do you feel to know there are no written processes or procedures to support the telehealth provider if your family member gets into a mental health emergency.  Time is critical in mental health emergencies; I know this from personal experience as both a provider and a patient, and for these plans, procedures, and processes to be missing is the height of malpractice!  Would someone please tell me why elected officials and the media are not screaming mad at this particular report?  Especially since the proposed budget from the president wants to double suicide prevention spending at the VA.  I read this report and see that the VA-OIG made five recommendations.  Are you freaking kidding me?!?!?

Finally, we go to Hawaii and confront the most detestable, outside of the dead veteran, issue possible, failure of the National Cemeteries Administration (NCA) to properly care for the remains of veterans, qualified spouses, and dependents.  The NCA awards grants to states to build cemeteries where a veteran, qualifying spouse, and dependents can be laid to rest outside a national cemetery.  From the VA-OIG report, we find the following, emphasis mine:

Grants may be used to establish, expand, or improve veterans cemeteries. The VA-OIG audited the program to assess NCA’s governance and oversight. The audit team also assessed whether critical non-compliance issues at two cemeteries in Hawaii were addressed. The VA-OIG found grants program staff did not rank and award some cemetery grants as regulations required. After grants were awarded, program staff generally ensured cemeteries used grants for their intended purpose. However, NCA did not ensure cemeteries with grants met all national shrine standards for installing permanent markers, maintenance, and safety. The audit team observed non-compliance issues at eight state cemeteries, including critical issues in Hawaii’s Hilo and Makawao cemeteries. As a result, NCA lacks assurance that veterans and family members buried in state veterans cemeteries have been appropriately honored with timely and accurate grave markings, burial locations, and maintenance.VA 3

NCA, you have one job, ensure the remains of veterans and qualifying spouses and dependents are adequately remembered, safely entombed, and marked appropriately.  Yet, you fail at even this simple and easy job; how utterly disgraceful, disgusting, and detestable!  How many cemeteries in the Philippines are being adequately cared for?  At the last report, none of them were adequately maintained and respected.  Even here in the US, you refuse to do your jobs with competency, dignity, and professional pride.

Knowledge Check!The VA is one sick organization, where the mission is being denied, the veterans abused before and after death, and none of the elected representatives can find enough time in their day to even offer a mild rebuke or maintain sufficient interest to scrutinize.  America, we have gotten better as a culture in remembering and honoring those who serve and have served, and I, for one, am very grateful for your change of heart.  We, the voting citizens of America, need to demand the same culture change from the politicians representing us!  As a country, we have come a long way since Vietnam in honoring the military.  But those same people who spat and urinated on our troops in Vietnam are now in the Halls of Congress, and their attitudes have not changed in the interim!

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

NO MORE BS: Affirmative Action – A Discussion for Eradication!

VirtueI wonder if maybe affirmative action is not just dead but ready for the waste pits of history.  Cohen (1996) acknowledged that federal hiring has a set of laws, with exceptions for every rule, to justify not hiring individuals.  I have personally witnessed this in Albuquerque, NM., for the better part of three years.  At the V.A. Hospital and Social Security Offices, the hiring managers refuse to hire veterans, and multiple other hiring paths to keep “undesired people” from being hired.”

As a dual-service (U.S. Army & U.S. Navy) disabled veteran with a handicap that is visible (neurological shaking, twitching, and muscle spasms, which include trouble speaking) too often, I am the best candidate until the interview.  Walking into an interview with a cane, spasm, or twitch a couple of times, and the faces of those interviewing reflect their discomfort, and I will not be hired.  Government, private sector, for-profit, not-for-profit, none of these matters, people are uncomfortable around those of us with visible disabilities.  Affirmative action has never helped, and as an experiment in social behavior, should be scraped from the law as soon as legislation can be written to effect this change!Patriotism

Undesired people” includes people with handicaps (though Schedule A hiring has top priority in government hiring), veterans, spouses, and dependents with specific federal benefits, minorities (including men, people of color of all shades, American Indians, etc.) also have priority in hiring.  All the best jobs, positions, and perks are awarded through nepotism and the court of public opinion.  The system is structured in such a way as to remain in legal compliance to affirmative action; thus, affirmative action is a shield protecting lousy behavior instead of as a tool to improve workforce hiring.  My assertion of the uselessness of affirmative action is not just based upon my experiences.  I have witnessed people get into car accidents, get a disability, and go from productive worker to shunned worker almost overnight, all due to the disability sustained.The Duty of Americans

Harasztosi and Lindner (2015) discussed how the minimum wage costs jobs and excluded the neediest citizens from employment.  I contend that affirmative action has negatively impacted minorities, men and women, disabled people, etc., most significantly using the principles and logic of Harasztosi and Lindner (2015).  Rules demanding social behavior always will substantially and negatively impact those designed in the law to enjoy the most benefit.  I believe in the Missouri State Motto; “Show ME!”  Show me a single piece of legislation that has helped those it was written for.  Legislation cannot dictate behavior or morals in society; hence the following from John Adams applies, the U.S. Constitution “… was made only for a moral and religious people. It is wholly inadequate to the government of any other.” Hence, the path forward is not more laws to avoid, but less.  The way forward is the societal education in morals as governed through a religious society.Editorial - Educational Truth

Historically, there are no legal, moral, or ethical reasons for affirmative action.  Affirmative action, and the diversity policies feeding the modern workplace adopted after affirmative action was legislated, barely have a legal foothold, let alone a justifiable reason for existence (Brazelton, 2016; Oppenheimer, 2016; Pierce, 2013; Young, 2001).  Human Resources is the capitalization of human capital to meet organizational needs.  When capitalization of human abilities is appropriately affected, the effort becomes work, leading to finished products or services for sale to consumers.  When not adequately modified, capitalization of human skills turns into waste, loss, confusion, and the organization will eventually “fall an unpitied sacrifice in a contemptible struggle” (Bloom, & Kamm, 2014; Typographical Journal, 1892).Apathy

Sykes (1995) defined affirmative action as “… [T]he set of public policies and initiatives designed to help eliminate past and present discrimination based on race, color, religion, sex, or national origin.”  As promising as this sounds, affirmative action remains the biggest farce crammed down the business community’s throats since the Federal Income Tax.  By focusing, as this definition states, on “eliminating discrimination past and present,” the entire country forgets the wise words from Master Oogway in Kung Fu Panda, “Yesterday is history, tomorrow is a mystery, today is a gift; that is why it is called the present.”  By focusing on the past, we project the same problems of the past, ruining both the present and the future.  While providing fodder for ill-advised politicians and media hacks to accuse everyone of racism, sexism, and a host of other “-ism” claims that are erroneous.  I repeat, only for emphasis, you cannot legislate human behavior and morals, and hiring an employee is the epitome of human behavior and morals.President Adams

Affirmative action is not necessary, needed, or applicable; affirmative action, and the diversity programs replacing affirmative action, were never required, helpful, or valuable enough to create from whole cloth the legal precedent to justify implementation (Brazelton, 2016; Oppenheimer, 2016; Pierce, 2013; Young, 2001). No, the short answer remains clear, Affirmative Action was not needed in 1964 and is still not needed today. Before 1964 when the Civil Rights Legislation was passed, the educational and experience gap between those working and not working caused pay problems, yet new professional opportunities naturally occurred as educational opportunities increased.  Affirmative action was not needed.  Let’s be clear, the executive orders and complicit Congress during President Woodrow Wilson’s tenure are the reasons the 1960s were so tumultuous, and the Civil Rights movement became needed.  But the reliance upon a government fix for personal behavior and morals was the wrong answer in the 1960s and remains a horrible answer today!

Dont Tread On MeNow that Affirmative Action has pampered more than two generations, we have more women and minorities in the workplace with the same skills as white males, and the same problem exists in deferential hiring, differential treatment based upon race, gender, and other politically acceptable groups. People who want to work, start early, work hard, and prepare for better jobs through education, experience, and single-minded determinedness. Those who do not wish to work create excuses, live off the government dole, and remain entrenched in ignorance, causing poverty, loss of self-esteem, ruined families, and a host of social problems that those who are working have to deal with and pay taxes to the government, who started the problem in the first place. These same workers have to fight affirmative action and diversity policies for new jobs, promotions, pay increases, etc., including all the issues associated with a minimum wage and associated costs (Harasztosi, & Lindner, 2015; Hawkins & Sowell, 2011).

References

Bloom, R., & Kamm, J. (2014). Human resources: Assets that should be capitalized. Compensation & Benefits Review, 46(4), 219-222. doi:10.1177/0886368714555453

Brazelton, S. (2016). A hollow hope? Social change, the U.S. supreme court, and affirmative action. The Journal of Race & Policy, 12(2), 84-95. Retrieved from https://search-proquest-com.contentproxy.phoenix.edu/docview/1940981339?accountid=134061

Cohen, C. (1996). Should federal affirmative action policies be continued? Congressional Digest, 75, 181-181.

Harasztosi, P. & Lindner, A. (2015). Who pays for the minimum wage?UC Berkeley.Hawkins, J., & Sowell, T. (2011). Right-wing news: An interview with Thomas Sowell. Retrieved from http://www.rightwingnews.com/interviews/sowell.php

Master, Oogway (Character). (2008). Kung Fu Panda [DVD].

Oppenheimer, D. B. (2016). The disappearance of voluntary affirmative action from the U.S. workplace. The Journal of Poverty and Social Justice, 24(1), 37-50. doi: http://dx.doi.org.contentproxy.phoenix.edu/10.1332/175982716X14538098991133

Pierce, J. L. (2013). White Racism, Social Class, and the Backlash Against Affirmative Action. Sociology Compass, 7(11), 914–926. https://doi-org.contentproxy.phoenix.edu/10.1111/soc4.12082

Sykes, M. (1995, August). The origins of affirmative action. Retrieved from http://www.now.org/nnt/08-95/affirmhs.html

Typographical Journal. (1892). Typographical Journal, Volume 4 [Google Play]. Retrieved from https://books.google.com/books?id=FydFAQAAMAAJ&pg=RA10-PA4&lpg=RA10-PA4&dq=%E2%80%9Cfall+an+unpitied+sacrifice+in+a+contemptible+struggle%E2%80%9D&source=bl&ots=DW3MDox1Xu&sig=vd-U9cqe7PVSqLbA27FIX5DgJOs&hl=en&sa=X&ved=2ahUKEwi4zp3I-ZTeAhXqwlQKHZfZC6QQ6AEwA3oECAoQAQ#v=onepage&q=%E2%80%9Cfall%20an%20unpitied%20sacrifice%20in%20a%20contemptible%20struggle%E2%80%9D&f=false

Young, I. M. (2001). Equality of Whom? Social Groups and Judgments of Injustice. Journal of Political Philosophy, 9(1). Retrieved from https://search-ebscohost-com.contentproxy.phoenix.edu/login.aspx?direct=true&db=a9h&AN=4335602&site=ehost-live&scope=site

© 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.

Insane Abuse – The VA Edition: The Leaders of the VA Must Shift the Paradigm

I-CareDuring new hire training for working at the Department of Veterans Affairs (VA) New Mexico Medical Center (NMVAMC), the first day contains a lot of warnings about what you can and cannot do as a Federal Employee.  Annually, there are mandatory classes that must be passed to remind an employee of their obligations as a Federal Employee.  Leading to a question, “How could an attorney for the Department of Veterans Affairs – Office of General Counsel (OGC), be allowed to break the law for eight years?”  The department of Veterans Affairs – Office of Inspector General (VA-OIG) investigated after a second complaint about the same person was received, and only then did the OGC take action.  The attorney in question was released from government employment, but where is 8 years’ worth of wages being requested back?  Did the attorney lose anything other than an undemanding job and title where they could be paid for not working for the Federal Government while advancing their private practice, violating ethical laws, and breaking several Federal Statutes along the way?

What this attorney has done is insane, it is an abuse of trust, and for it to go reported and not acted by the senior leaders at OGC represents inexcusable abuse!

ProblemsOn the topic of insane and inexcusable abuse of the VA, the VA-OIG investigated the Greater Los Angeles Healthcare System in California and found a supervisor in an “other than spouse” relationship with a vendor and they used the VA property to improperly conduct business on contracts the supervisor oversaw.  These actions are a clear and blatant violation of the Federal Statutes on contracting as a Federal Employee, even if these consenting adults were married, it would remain illegal, unethical, immoral, and inexcusable!  Yet, because the supervisor quit during the investigation, the VA-OIG has no power to take any action.

Federal Employees are blatantly breaking the law, abusing the trust and honor of their stations, flagrantly flaunting ethical, moral, and legal regulations with impunity.  Why?

From the VA San Diego Healthcare System, California, we find another VA-OIG inspection. Staff manipulated time cards for seven fee-basis medical providers to pay these individuals on a salary or wage basis rather than a per-procedure basis.  While the medical center took appropriate action and no VA-OIG recommendations were made, the question remains, “Why was this behavior allowed in the first place?”  Another supervisor, improperly acting in their office, and abusing the VA; this behavior is inexcusable!

moral-valuesThe VA-OIG performed an audit, also referred to as a “data review.” “The data review consisted of a sample of 45 employees and found the employees were paid an estimated $11.6 million for overtime hours for which there was no evidence of claims-related activity in the Fee Basis Claims System in fiscal years 2017 and 2018, representing almost half of the total overtime paid. Significantly, 16 of the 45 employees each received more than $10,000 in overtime for hours during which there was no claims-related activity.”  The Department of Veterans Affairs – Office of Community Care (OCC) is backlogged and this is leading to late payments to providers, delays in care, and is generally a bad thing.  However, the sole reason for the overtime being abused was due to a lack of processes, poor supervision, and training.  These are the same three excuses that are used by the Department of Veterans Affairs – Veterans Benefits Administration (VBA) and is designed incompetence at its most disdainful and egregious level.  Worse, this was a sample of employee misconduct on overtime pay.  How many more cases are floating in the OCC that were not included in the audit that will pass unresearched because the VA-OIG did not refer the cases for disciplinary recommendations?

The VA-OIG cannot be everywhere and clean every hole in the VA organizational tapestry.  This is why supervisors and leaders are in place to execute organizational rules, regulations, policies, and monitor employee performance.  Why are the supervisors and mid-level leaders not being held accountable for failing to perform their jobs?  If overtime pay is going to be clawed back from the employee, the managers, team leaders, and supervisors need first to write and train to a policy standard.

Root Cause AnalysisThe VA-OIG conducted a comprehensive inspection of the Eastern Kansas Health Care System, Kansas, and Missouri.  The findings are startling for several reasons, one of which being the deficient lack of leadership leading to poor employee satisfaction, patient care issues, lack of knowledge in managers and supervisors, and minimally knowledgeable about strategic analytics.  Essentially, there is a lack of leadership in this healthcare system.  The director has been working with a team for 2-months, but the director has been in charge in 2012.  Leading to questions about long-term staffing replacement, staff training, building the next generation of leaders, and why this long-term director can brush off the criticisms of leadership failure because the team has only been in place for two months at the time of the inspection.

Again, the VA-OIG audited a system and found a lack of training, lack of oversight, lack of leadership, and made recommendations to “close the barn door, after the horses got out.”  From the VA-OIG report we find:

“The VA-OIG found that VA lacked an effective strategy or action plan to update its police information system [emphasis mine]. In September 2015, the VA Law Enforcement Training Center (LETC) acquired Report Exec, a replacement records management system, for police officers at all medical facilities. Inadequate planning and contract administration mismanagement caused the system implementation to stall for more than two years [emphasis mine]. LETC spent approximately $2.8 million on the system by the fiscal year 2019 [emphasis mine], but police officers experienced frequent performance issues and had to use different systems that did not share information. As of April 2019, only 63 percent of medical facility police units were reportedly using the Report Exec system, while 37 percent were still using an incompatible legacy system. As a result, administrators and law enforcement personnel at multiple levels could not adequately track and oversee facility incidents involving VA police or make informed decisions on risks and resource allocations. The audit also revealed that information security controls were not in place for the Report Exec system that put individuals’ sensitive personal information at risk [emphasis mine].”

Behavior-ChangeNo controls, no direction, no strategy, no tactical action, losing money, and not even scraping an F in performance.  The repetition in these VA-OIG investigations is appalling!  Where is the accountability?  Where is the responsibility and commitment to the veterans, their dependents, and the taxpayers?  Where is the US House of Representatives and Senate in demanding improvement in employee behavior?  Talk about a culture of corruption; the VA has corruption in spades, and no one is taking the VA to task and demanding improvement.

The VA is referred to as a cesspit of indecent and inappropriate people acting in a manner to enrich themselves on the pain of veterans, spouses, widows, and orphans.  There have been comments on several articles I authored which would make a non-veteran blush in describing the VA.  These actions by supervisors and those possessing advanced degrees do not help in trying to curb or correct the poor image the VA has well and truly earned.  A behavior change is needed, culture-wide, at the VA for the tarnished reputation of the VA to begin recovering.

Only for emphasis do I repeat previous recommendations for a culture-wide improvement:

  1. Start a VA University.  If you want better people, you must build them!  Thus, they must be trained, they must be challenged to act, and they must be empowered from day one in the classroom to be making a difference to the VA.
  2. Immediately launch Tiger Teams and Flying Squads from the VA. Secretary’s Office, empowered to build, train, and correct behavior. These groups must be able to cut through the bureaucratic red tape and make changes, then monitor those changes until behavior and culture change.
  3. Implement ISO 9000 for hospitals. If a person does not know their job but has held that job for over a year, every person in that employee’s chain of command is responsible for training failures.  Employees need better training, see recommendation 1, need clearer guidelines and written policies.  Hence, with the VA University training, each process, procedure, rule, regulation needs written down, and then trained exhaustively, so employees can be held accountable.

There is a theory in the private sector called appreciative inquiry.  Appreciative inquiry is the position that whatever a business needs to succeed, it already has in abundance, the leaders simply need to tap into that reservoir and pull out the gems therein.  Having traveled this country and witnessed many good and great employees in the VA Medical Centers from Augusta ME to Seattle WA, and from Phoenix AZ to Missoula MT I know that appreciative inquiry can help and promote a cultural change in the VA.  I do not advocate a “one-size fits most” policy for the VA, as each VISN and Regional Medical Center has a different culture of patients, thus requiring differing approaches.  However, the recommendations listed above can improve where the VA is now, and form a launch point into the future.Military Crests

© Copyright 2020 – M. Dave Salisbury

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

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