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?
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- 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.
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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.
Warehouse or call center, manufacturing or non-profit, service industry or product sales, the role of quality continues to be misunderstood. Sometimes, it appears that quality is intentionally misunderstood. Often it seems as if quality and compliance are synonymous, even though quality is a small part of compliance. Some businesses call quality “Quality Assurance,” “Quality Control,” or the “Quality Department.” Regardless of the name, quality is the only path to improving productivity; however, productivity is measured.
Quality is a process of striving to improve. Interestingly, people inherently know when they have received quality or not. Be it a person, a company, a community, a state, a government, etc., how one approaches quality as a process for improvement defines that person, company, community, state, etc. Some companies think, “We have a quality department, we are meeting quality metrics, we are doing just fine in quality.” To which I reply, in my best imitation of Colonel Potter from M*A*S*H 4077, “HORSE HOCKEY!”
Now, someone might think, these are hypotheticals, not real businesses. Those examples are directly from my experience. Yes, these examples are slightly oversimplified for brevity; however, not having a whole company quality culture hinders productivity. This is a truth inescapable.
Productivity, however measured in your company for goods or services, should be a co-equal part of quality. Yet, if equality cannot be achieved, err on the side of increased quality until productivity catches up. The value of productivity is measured in green money, cash. The value of quality is measured in blue money, potential. Bringing up my favorite axiom, “Burn enough blue money, and cash evaporates, and no one can trace where the cash went!”
Want a secret; it does not work in reverse! Erring on the side of increased productivity increases costs elsewhere, burns potential, and ruins company bottom-lines. Quality cannot “catch up” to productivity — an example best witnessed in manufacturing and warehouses. The potential costs between manufacturing or multiple handling of products carry a potential cost, with no means of recovery. Thus, it remains imperative to understand the roles of productivity and quality defined early, and placed in the proper order, to avoid significant cash hits to the bottom line.
A quality culture is an extension of the individual’s professionalism, always striving to be better. Not faster, not slower, but better every day. Training is a dynamic part of quality, and learning something new should be encouraged. Yet, training, especially in call centers, always seems to take a back seat to operations and productivity. All because productivity is not correctly understood and placed in its proper role. Training and quality are potential or blue money expenses where the return on investment will be unknown. Why; because quality and training place tools into the hands of employees, who then go on to build or destroy based upon the examples of leadership.
Quality should be felt in every conversation, in every process, in every program, in every interaction. As the most important customer in a business is other employees, the quality program is the most important activity and process for enhancing the business’s goals, aspirations, and daily production rates. A culture of quality will then have the ground to grow and room to expand. But, a quality culture will not grow overnight, nor will it grow without causing stagnant processes to change.
Consider a seed. To grow, that seed has to be destroyed completely; but no one ever mourns the loss of the seed for the potential fruit to be born from that seed growing. The same is true for a quality culture growing; the culture will destroy the seeds of stagnation, the apathy of indifference, and the processes and procedures that are not valuable to the new quality culture. Will you allow a quality culture to grow?
Is this properly honoring and remembering the veterans and their sacrifice? Is this behavior acceptable in your workplace? Why do we allow this behavior from government workers?
Long have I wondered why the second item in the comprehensive inspection is “Quality, Safety, and Value.” When the VA continues to present the bare minimum of quality, disregards patient safety, and due to complexity, offers less value than a broken wrench to a mechanic, but I digress.
If you read any of the comprehensive inspection reports, you will see this is a common and recurring theme at the VA. Some of the medication policies are being followed, but the same problem with drug testing, informed consent, patient follow-up, and quality measuring monitoring always remain a problem. It is almost as if the SAIL learning matrices do not even exist as a quality improvement tool.
The Department of Veterans Affairs (VA) has really outdone themselves this week. I am used to being ashamed of what passes for leadership and administrators at the VA, but this week, they have surpassed themselves. The Department of Veterans Affairs – Office of Inspector General (VA-OIG) filled my inbox with seven investigations results, and the reports of leadership failure should leave every American weeping and madder than wet chicken with a raging case of hemorrhoids!
The failures of the quality assurance team are not new, 
The following is a recap of findings by the 
The following are findings highlighted from the report on the Office of Accountability and Whistleblower Protection (
DNC-Consulting 