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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thought and Character – A Discussion

WhyIn Proverbs, Old Testament, we find an oft-quoted aphorism, “As a man thinketh in his heart so is he.”  If we first accept this aphorism as truth, then the following from James Allen, from “As a Man Thinketh (1903)” can also be presumed truthful.  “A man is literally what he thinks, his character being the complete sum of all his thoughts.  As the plants springs from, and could not be without, the seed, so every act of a man springs from the hidden seeds of thought, and could not have appeared without them.”  Bringing into sharp reflection the connection between how a person thinks and their character.

In high school, the football and wrestling coaches played mind games to help us players think and become winners. Then, we went through drills to practice thinking and planning moves, so our most important muscle, the mind, was prepared to act when challenged physically.  Likewise, as a firefighter, I know the value of mentally walking through situations to prepare my mind and my fire teams’ minds before being challenged physically to respond to a threat or incident.

Ziggy on Political WeatherI once met a professional soccer player; we shared a bus trip from Salt Lake City to Vernal, Utah, as he traveled to catch a plane in Denver, Colorado.  While I do not envy him, his travel scheduler, we had a very interesting conversation on how thinking builds character.  Professional sports players have similar mental walk-throughs as a regular part of their daily exercises.  Here I had always been under the impression this was for non-professional sports players and was pleasantly surprised to hear his experiences.

James Allen insists that “Man is made or unmade by himself; in the armory of thought he forges the weapons by which he destroys himself; he also fashions the tools with which he builds himself heavenly mansions of joy and strength and peace.”  In the US Army, while serving as a Chaplain’s Assistant, I was wandering through the line company barracks and stumbled across a tank crew having “Sergeant’s Time” in the hallway.  There I met the most interesting character; he held a doctorate from MIT, he was utterly brilliant, and he was a specialist who drove tanks for a living.  When asked why driving tanks and not working in his field of study, he stated, “I do not like my field of study.”  Through education, this soldier had made himself tools for building a career he detested in a field he was bored with, and in seeking adventure, he joined the US Army as an enlisted man and found something he preferred.

ToolsThe tools of education became the chains of bondage and weapons that left him without passion.  His thoughts had turned his desires in his chosen field into a trap, where he thought his only way out was doing something radical and “out of character.”  Except for those who knew him, his character was always bent towards being a soldier, but he had not thought thru this character aspect himself.  His thoughts had already revealed his character, but he had not become cognizant of this aspect of himself.  How many times has this happened to you?

President Thomas S. Monson, a previous leader of The Church of JESUS CHRIST of Latter-Day Saints, was quoted as saying, “Decisions Do Determine Destiny” [emphasis in original]. Likewise, James Allen maintains, “… Man is the master of thought, the molder of character, and the maker and shaper of condition, environment, and destiny.”  Think of how vital thought is to the grand scheme of a person, and you will find the power to be and do anything!  “Man is always the master, even in his weakest and most abandoned state … [as a conscious master] man can only thus become by discovering within himself the laws of thought; which discovery is totally a matter of application, self-analysis, and experience.”  Doesn’t this assertion fill you with the hope that the chains of bondage in your mind are only there until you allow yourself to change how you think?

LaughterHow did I finally kick the cigarette habit, so the mental addiction could no longer tempt me to smoke; I change my thinking.  Instead of allowing myself to find second-hand smoke delightful, I began seeing it as something to avoid.  As I changed my thinking, my body stopped reacting in a manner to claim a need for the cigarettes.  It was not easy, but I had physically quit smoking 10-years before my mental processes, and mental addictions were finally conquered.  The power to correct my body’s behavior towards cigarettes was always mine to claim and apply, but first, I had to change how I think about cigarettes, then my mental needs changed, and then I was free of the mental addiction.  Changing thoughts and time, experience, was required, and slowly my body obeyed.

I have seen the same occur in reverse.  A female friend of mine claims she needs chocolate during her menstrual cycle to maintain mental health.  When she discovered that chocolate was the main factor in her deteriorating health and obesity, she still maintained that chocolate was healthy and blamed everything but chocolate for the problems.  When she went through menopause, she discovered that chocolate had no power over her body and was left without her mental crutch and excuses.  What could have been a life-altering discovery did not change behavior because the thoughts never changed.  I moved and lost contact before her story ended, but the failure to change thinking has always left me wondering what thoughts I need to change to avoid a similar fate.

Bait & SwitchThe New Testament records, “He that seeketh findeth; and to him that knocketh it shall be opened.”  To which James Allen has added, “… for only by patience, practice, and ceaseless importunity can a man enter the Door of the Temple of Knowledge.”  I remember reading about a famous diamond mine in Africa, the largest diamond mine in the world, and how even with technology, the mining process continues to be one of patiently gathering, carefully digging, and unending repetition to haul diamonds from the dirt.  In L. Ron Hubbard’s book, “Battlefield Earth,” one finds the same pattern in digging for gold.  Patience, careful gathering, unending repetition, and still the results are teaspoons of gold for the tons of rock and dirt shifted.

The mind is the same.  Changing thoughts requires time, patience with yourself, and care in selecting new thoughts to plant.  Care in how old thoughts are removed so as not to damage those thoughts being cultivated, and unending repetition to remove the seeds of thoughts that would be the weeds in your mental garden.  But, with the pattern comes the promise; those who put forward the work will reap a garden of benefits.  What are those benefits of changing our thoughts, “As a being of power, intelligence, and love, [being the] lord [and master] of his thoughts, a man holds the key to every situation and contains within himself that transforming and regenerative agency by which he can make himself what he wills.”

Knowledge Check!What benefit could be grander, to will something into existence through the power of thought!  How amazing a world we could make when all people realize this power and claim this power by changing how we think.  There is a benefit to cause and effect; that benefit is realization, wisdom, and eventually power to will into being that which is powered by our thoughts. So choose to consider changing how you think and watch how the world shifts around you.  You can change yourself by changing your thinking!

© 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.