Oh, the bitter tears President Lincoln must weep…
One of the most troubling issues facing many organizations is exemplified perfectly by the VA, specifically the Post 9/11 GI Bill. Previously I worked for an online university in a position where I saw GI-Bill problems affecting students on active duty, reserve, guard, and veterans, all being treated in wildly different manners. The school GI-Bill office was expected to be subject matter experts on all things GI-Bill, but they regularly made decisions that harmed the students. By interpreting the regulations and operating procedures differently from student to student. Yet, the Department of Veterans Affairs (VA) is just as confused as the universities trying to bill GI-Bill charges for students.
From a recent VA Office of Inspector General (VA-OIG) report, we find the following:
“The Veterans Benefits Administration (VBA) did not always accurately process enrollments. An estimated 2,500 of 10,000 enrollments from August 1, 2020, through April 1, 2021. About 790 of the estimated errors involved officials either not reporting or underreporting vacation breaks. VBA claims examiners often mishandled enrollments even when the correct information was submitted. The VA-OIG estimated claims examiners incorrectly processed accurately reported vacation breaks for about 1,700 of 2,500 enrollments with errors.”
Why are these enrollments not processed correctly:
“Insufficient training and guidance meant school certifying officials frequently made mistakes.” The VA takes legislation and writes the processes, procedures, and training materials for universities to use for operations and enrollment of military and veteran students. Front office workers interact with students, back office workers interact with internal employees, the VA keeps the records current, and the VA forms the universities’ oversight resembling the blind leading the blind. Yet, the VA cannot write effective training materials, processes, and procedures, conduct training, and support those who support students.
Per the VA-OIG report, the VBA is looking to implement an automated system to prevent these oversight issues from continuing. I do not expect any automated system created by the VBA to work efficiently because of a simple principle, GIGO. The garbage the VBA will put into the system will ALWAYS result in garbage coming out, creating more problems, costing too much money, and still creating issues for students and student-facing employees at universities and colleges across the country. Somehow, the VA-OIG continues to buy these excuses and pipe dreams and reports the same to Congress, which is also purchasing these excuses and poor performances.
Before someone tries to claim this is isolated to the GI-Bill program, and the GI-Bill program has always been confusing. Using this logic, the health complications at birth can be blamed on the father alone, and the mother’s behaviors do not influence the baby’s health. Here the VA-OIG is reporting on another program governing VA employees, overseen by the OMB, and is incredibly useless as this is a repeated complaint between 2020 and 2022.
“Identity, credential, and access management (ICAM) is a set of tools, policies, and systems used to ensure the right individual has access to the right resource, at the right time, for the right reason in support of federal business objectives. In February 2021, the VA Office of Inspector General (VA-OIG) received a hotline complaint claiming the Office of the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness and the Office of Information and Technology have not agreed since 2016 on roles and responsibilities for VA’s ICAM program. Failures of ICAM contribute to the VA’s inability to effectively comply with the Office of Management and Budget (OMB) policy. The VA-OIG reviewed to determine whether VA effectively governs its ICAM program as required.”
What did the VA-OIG find?
-
-
- The VA did not effectively manage and coordinate its ICAM program, not meeting three of the four OMB governance requirements.
- The VA did not effectively assign roles and responsibilities, implement a single comprehensive ICAM policy, or meet its technology solutions roadmap goals for fiscal years 2020 and 2021.
- The VA failed to implement updated digital identity risk management requirements.
-
Why can’t the VA obey OM oversight?
“These issues occurred primarily because leaders of the different offices performing VA’s ICAM functions have not agreed on how it should be governed. VA risks restricting information from users who need it to perform their job functions without proper governance and leaving information vulnerable to improper use” [emphasis mine].
In this report, the OMB sits as oversight of the VA. The employees are the frontline, and the leaders continue to fail to provide tools, policies, and resources to employees conducting the VA business. What is still an incredibly terrible idea allowing the VA to remain self-governing. Why isn’t the OMB more interested in demanding compliance? Where is Congress scrutinizing how the executive branch agencies are failing and monitoring to improve conduct?
The VBA cannot still properly and timely adjudicate claims. Again, the VA-OIG lambasted the VBA for improperly adjudicating claims, even with “Special-Focused Reviews.” Essentially the quality assurance (QA) process in claim adjudication continues to fail to help improve claim processing accuracy. From the report:
“The Office of Inspector General (VA-OIG) reviewed VBA’s design and implementation of its special-focused review process, including applying Government Accountability Office (GAO) standards. The VA-OIG team assessed ten special-focused reviews completed from January 2019 through April 2021 and identified weaknesses in all five of GAO’s internal control components. The VA-OIG also found the VBA Compensation Service’s standard operating procedure related to these special-focused reviews does not provide sufficient guidance to support disability claims-processing improvement fully.”
When I worked in QA, root causation was required to prevent future problems. The VA-OIG found that the QA Special-Focused Reviews do not include root causes or explanations for why the claims were readjudicated, stopped, or delayed in VBA processing. Do not repeated issues reflect the need to restrict self-governance until compliance can be observed?
Why should the VA have its self-governance restricted or prohibited? The following VA-OIG makes clear that the VA cannot govern itself and correct the problems leadership continues to create. Follow the timeline here, quoted directly from the VA-OIG report:
“The VA Office of Inspector General (VA-OIG) conducted this review to determine whether the Veterans Benefits Administration (VBA) accurately adjusted compensation and pension benefit payments for fugitive felons as mandated by law. If VBA does not adjust payments, veterans who are fugitive felons will continue to receive benefits during periods of ineligibility.
In April 2012, VBA instructed regional offices to postpone making decisions on fugitive felon cases while it prepared new guidance. During 2012 and 2013, VBA did not process fugitive felon cases. In June 2014, VBA updated its definition of a fugitive felon to include only referrals indicating escape, flight, or violation of probation or parole conditions. Although VBA then resumed adjusting payments, it did not review the unprocessed 2012 and 2013 cases.
In addition, due to inadequate monitoring, VBA did not process about 46 percent of cases referred by the VA-OIG in 2019 and 2020. Finally, the team found VBA’s notification letters to veterans providing notice of the proposed action and right to a hearing did not always provide the required information. Most commonly, VBA failed to include the reason for the issuance of the arrest warrant.”
The VA has been informed by the VA-OIG multiple times during the decade this problem has been surviving, and 46% of the cases the VA-OIG told the VA to fix still weren’t fixed in 2022. How can any oversight agency still permit the VA to govern itself? The leaders of the VA cannot self-govern, correct course, and make changes timely enough not to create additional expensive problems for veterans. Each of these cases represents either an overpayment, where the VA is clawing funds back, or an underpayment, where the veteran has been shortchanged and is owed money.
When the VA claws money back from making a mistake that overpaid a veteran, dependent, spouse, or other entity, the VA-OIG has found that even here, the VBA cannot act per their policies, follow procedures, or notify veterans in a timely manner. A veteran I got to know who served in Vietnam and caught a round in the heart that blew away a large chunk of his heart. For 50 years or so, this was sufficient to have a 100% disability. On the day he turned 69, his disability rating dropped to 80%, with a coinciding reduction in monthly benefits. The VBA investigated this claim decision and found they had made a mistake, but their mistake would not significantly change the rating, so the veteran was stuck with an 80% rating and was told to go back to work.
To the best of my knowledge, the claim remains stuck in claims appeal hell, awaiting the judgment of the dark and benighted realms to act. The veteran, who cannot hold a job due to weakness from lacking a significant part of his heart muscles, is driven into bankruptcy. His heart will not regrow, but because his age has met the age when heart problems are actuarially known, the decision was made. The decision was made without notification to the veteran, and the veteran only became aware of the situation when he had monies clawed back by the VA. From the time the decision was made to the date he knew, 18 months had transpired, and the veteran was automatically sent to collections. While this was never allowed to become a VA-OIG investigation, I have spoken to family members and the veteran while volunteering to help disabled people find employment.
To add the bitter cherry to this crap sundae, this is not the worst abuse I heard in my volunteer efforts. Worse, this is not the worst story I have had related while talking to veterans in my travels across the continental 48 United States. Veterans sit forever in claim hell; they cannot afford to go forward, they are abused when seeking medical help, and every interaction with VA medical providers runs the risk of being the victim of an “adverse medical event.”
To this point, the VA and the VBA have been central to proving that the VA cannot self-govern, oversight is failing, and the back office administrators are hindering the front office operations. Surely the Veterans Health Administration (VHA), where people’s lives are at risk, would not have a similar problem. Unfortunately, you would be wrong, and here is one VHA example, of many, to support this conclusion:
“A VA Medical Center (VAMC) community living center (CLC) staff delayed life-sustaining treatment for a patient (Patient A) who experienced cardiac arrest and died. The VA-OIG also reviewed an allegation regarding a second patient (Patient B) who had resuscitation initiated, despite a do not resuscitate (DNR) order in the electronic health record (EHR).”
Why did one patient die without resuscitation and another get resuscitation without wanting it? The policies and procedures were complicated, and the use of armbands confused the providers. The providers (doctors and nurses) overseeing care had a person in the medical records of these patients and still could not properly act for patient care. The patients had armbands and proper medical documents on file, and the providers still got confused and provided poor care, at best, to the patients involved.
In another long-term care facility under VA operation, the following occurred:
“The VA-OIG found that the day charge nurse’s assessment was delayed and incomplete, and the day charge nurse failed to properly document the resident’s reassessments, treatments, and interventions. The VA-OIG substantiated that nursing staff failed to document and carry out a telephone order to transfer the resident to the Emergency Department but could not determine if this impacted the patient’s outcome.”
Let’s take a moment to allow this to sink in fully. Failure to follow a doctor’s orders might have been part of the problem the patient DIED! Yet, the chain of events is sufficiently blurry to mystify the investigators – this I find HIGHLY SUSPECT! But, as the Home Shopping Network reports, “There’s more!”
“The VA-OIG determined that following the resident’s death, facility staff failed to conduct a comprehensive review of events leading up to and contributing to the resident’s death and, due to a lack of coordination of care at the time of discharge from the inpatient unit, the resident did not have the needed equipment upon admission to the CLC.”
I accept that a nurse’s role is stressful, the VA policies do not make their jobs less stressful, and the healthcare leadership (overall) is abysmal on the best days. However, killing a patient is still a BAD thing! Yet, here we have another dead veteran at the hands of the medical care providers, and the best the VA-OIG can do is make ten (10) recommendations for change. Does anyone believe the VA can continue to self-govern under its current misguided leadership and convoluted organizational structure?
Ask yourself, would the abuse of the veterans mean more if this was your uncle, brother, father, mother, sister, or aunt? They are your family members for the problems which they face; we all face in our constitutional republic. Where is Congress scrutinizing the government? Please become interested, active, and engaged, or we will lose this constitutional republic to the tyranny of the power-hungry despots.
© Copyright 2023 – 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.
My wife is mad at me; I was relating an email survey experience where a financial institution had sent me a customer service survey. I described the truth, I have no reason to remain a customer and feel less than enthused at remaining a customer. My wife fearing I had been insulting, derogatory, or denigrating, got mad at me. I explained my position and how I had answered the rote questions, and she is still not happy. But, her position and my position bring up an interesting point, centered around the following question, “Why should a customer remain a customer?”
I have several titles, want my business, know and use my titles. Pick one, and use it! How can a company claim they “know their customers” when that company cannot use the customer’s preferred name or title in addressing that customer? I have worked hard to earn a Ph.D.; I do not expect everyone to call me “Dr.,” but it sure as anything beats being called “mister” all the bloody time. Worse, I still hold several ranks and positions that come with titles. I could be addressed using them, but even with a preferred name on many company customer profiles, I get that lazy customer service representative that calls me Mr. Salisbury! Guess what company I am going to ditch at the first opportunity?
Business processes matter; honoring your word matters, displaying trust, integrity, and fulfilling a promise made all matters in the customer relationship long before the product or service is discussed. Yet, how often are these issues on shaky ground, before the ink is dry on the service contract or the receipt for goods? I have a cell phone provider I detest; I long for the day I can finally walk free of this provider and never look back. Because their customer attention is deplorable, I feel used and abused every time I interact with this company. I have the same problem with my current Internet provider. When your customer service is so deplorable, you have to climb to become terrible; there is a problem that colors, signage, marketing, and gimmicks cannot fix!
These are but three basics, fundamental points at the start of the customer relations journey. If you cannot get these three points right, the rest of the trip will be short, painful, and not fulfilling for you or your customers. Worse, the experiences will be remembered, and people have this nasty habit of not forgetting bad experiences. Why do the majority of people despise the DMV; because the majority of customers have experienced the most frustrating issues of their professional lives at the hands of the DMV agents. Governments abuse their customers, which is as bad as customer interactions get, and everyone feels betrayed when the government and bureaucrats use them.
Parents, how many times have you witnessed a toddler going about their day, an idea crosses their face, and you can tell they are about to do something that gets that toddler in trouble? I heard a comedian talk about witnessing this as the toddler saw the cat sleeping in the sun, the toddler crossed the room and kicked the cat. When asked why the toddler claims “it was accident.”
Consider these definitions for a moment and the story about the toddler kicking the cat. We have a plan, a purpose, and a deliberate action. How does the parent discern the act was deliberate; the use of observation as to what the toddler had done to the cat previously, what the toddler was doing immediately before they kicked the cat, and the attempt to use an excuse to get out of trouble.
When defining discernment, I am not entering holy waters to discuss the pieces of discernment that belong to discerning for religions. Discernment is the ability to obtain sharp perceptions, observations that empower decision-making. Discernment can be psychological, moral, or aesthetic. Discernment is also defined through the contexts; scientific, normative, and formal. The process of discernment involves going past the mere perception of something and making nuanced understandings about its properties or qualities.
Unfortunately, this pattern repeats too often, and thus the need to understand discernment and correctly discerning intention. My intent is not to make you as adept at this practice as a police officer. In a Republic, and even in many democratic societies, the citizens need to discern and discern intention, two separate processes. The media will sell a lurid and emotionally charged story with all the bias of a bull in a China Shop and never care about the consequences. But, the citizen does not have the same luxury or legal protections as the media. Hence, we must discern what the media relates and discern the media’s intention before we ever read or listen to their story/reporting of events. Thus my intent in this article and bringing up this topic, we, the citizens, are held to a higher law than the media and cannot afford to form mobs, trust the media’s reporting, or even rely upon the press reported “facts” to discern and discern intent.
The process for critical thinking, leading to intentional decision-making, with purposeful action, generally follows the following pattern:
These steps are useless unless we understand our own intention before launching a decision-making process. Consider, do you intentionally believe that others are doing their best or giving their best efforts? Do you intentionally shut down your own opinion to consider the perceptions of others in making decisions? Where in those steps do you stop and take a moment to ponder the short and long-term consequences of the solution devised? When making decisions, do you ever consider the axiom, “If a solution is not Win/Win, everyone loses?” Do we fear failing to make a correct decision if the future teaches us something new about the data changing the pattern of decision-making? How do you learn?
In going back to the analogy of the toddler kicking the cat. Does the solution in the short-term mean corrective behavior modification for a long-term lesson learned? Does the better solution involve instruction as well as behavior modification? Have we, the parents, discerned correctly the intention of the toddler sufficient to justify our decision? Will the cat be safe around the toddler in the future because of the action we take at that moment?
I close with a challenge, use discernment more intentionally in learning your way through failure to success. Liberty and freedom allow us the power to fail our way to success, but only if we consciously choose to learn and discern better our steps in decision-making. Know your intent, take a moment every day to consider your intent, and purposefully make decisions to live your intentions. Trust yourself to discern. Your confidence in discerning is key to understanding and using your intention to power decision-making as a process. Please remember, what I am discussing requires time, you will fail, but you will also win and win BIG! Enjoy the journey of discovery!
DNC-Consulting 