Bottle-Necks and Push-Back – Problems in Production Goal Attainment

Knowledge Check!Let me begin with an affirmation when you believe that a problem is insurmountable, you are 100% correct, and nothing will ever change.  If you tell me a problem is insurmountable, I will say to you BULL!  Every time!  Why; because if people built it, people can disassemble it.  We might have to push at it, swear at it, sweat at it, and kick at it some, but people can disassemble it!  When we believe no problem is insurmountable, we are more than ½-way to solving the problem!

At work right now, a colleague has a problem; trainers do not want to come in early and train new hires.  Because new hires cannot be trained in off-hours, his team is slipping in production goal attainment.  When he drops far enough, his regional bosses will decide more resources need to be spent, and public shaming begins to occur because public notice accompanies greater resource allocation.  The bottle-neck is training; the push-back comes from trainers.

Fishbone DiagramThe trainers are pushing back because they are already double and triple tasked to training new hires in two other more “important” departments.  Except, because those other departments are considered “more important,” production goals for the entire facility will never be met.  A core philosophy is missed; when quality fails, nobody meets production goals.  The vicious cycles keep going around; training cannot spare people to train quality, quality fails to meet goals, and production goals are missed due to training.

Exclamation MarkThere are times I have wished this was an isolated example; however, this repeats so often I should have cards made.  Breaking the training bottle-neck requires thinking outside the standard paradigm, or in more basic vernacular, get out of the box and start thinking anew!  While the following solutions are explicitly geared to fixing the training bottle-neck, the pattern for thinking is helpful as a conversation starter.  Start the conversation rolling!

Here’s some ideas:

  1. Off-hours shift training. Look at your operational schedules.  Do you have times when equipment is not operating, when the production floor is down, and when people can be trained?  Use that time!
        • I worked at a manufacturing facility where after the first three days of new-hire orientation, all manufacturing and warehouse employees worked the third shift for their first four months. Why?  Training could operate the floors and equipment and work around maintenance without crimping operational schedules or hindering production.  Then, new hires went onto the day shift where two extra managers could offer management-by-walk around for additional OJT.
        • I have observed warehouses where new hires work a split shift; they come in for 4-hours of training when nobody else is around but trainers, and then 4-hours when the rest of the warehouse is around—giving new hire equipment operators experience in operating in both a quiet environment and a busy environment.
        • The idea is to find times when you can safely train without hindering operation tempo. Use the calendar, use a shift rotation, be honest with people and be upfront on expectations and the reality of business needs.  Guess what, when you are honest, people respond!
  2. Appreciative Inquiry – Believe it or not, when you have a problem, a pressing business need, or an urgent issue, your people will pleasantly surprise you with solutions if you listen and act. Too often, I have been stunned ever to forget this lesson; people have brains and ideas, use them, give them credit, and watch them blossom into your best problem solvers!
  3. It should go without saying, treat people as the professionals you hired.
        • My first boss in supply chain quality control did not teach me basic stuff, e.g., this is a part, how you count the pieces, a SKU, etc. The boss presumed I knew or would ask questions, which saved both of us time and resources.  More to the point, by treating me as a professional, I grew into being a supply quality control officer and loved the job.  I have witnessed the opposite too often to know my experience is not the norm in supply chains, which is detestable.
        • You hired a professional; treat them as a professional. Set standards, show them, explain, train them, and build them into greater professionals, primarily by getting out of their way!
        • Encourage people never to stop learning through example!
  4. Who is your customer? Who are your vendors?  Who are your stakeholders?  Why is this information important?
        • Customer service is dead; however, if you do not know your customer, vendors, and stakeholders are, so is your business model!
        • Customer helping is alive and well; however, your business model is dead if you do not know your customer, vendors, and stakeholders!
        • Managers, let me give you a hint, your customer is your employees. When was the last time you got to know your customers?  When was the last time you helped your customers?  Why did you last help your customers?

LookWhen it comes to bottle-necks and push-back, knowing your customer is the first step in solving the bottle-neck and charting a positive path through push-back.  Consider my colleague, his customer are his employees needing training, his vendor is the training department, and the stakeholders are the rest of the business, those setting production goals, those relying upon his team meeting production goals, and ultimately the paying external customer.  Yet, my colleague, cannot see who his customer is, does not think of training as a vendor, and the rest of the business as a stakeholder, for this is not how he was trained.  Worse, his business unit refuses to accept this method of thinking to improve production goal attainment.

  1. Leadership must lead by first embracing new thinking and possibilities.

Previously in my career, it was a pleasure and adventure to be on a project where the leadership wanted a solution to their problem.  However, the leaders did not want to change, at all.  They wanted a solution, but refused to change in any shape, form, or method.  Worse, the leaders did not admit they did not want to change because they themselves had not considered that a solution would require change.  Thus, when the solution was delivered, it looked like a great idea, on paper.  But, the second it was implemented, reality bit, change was coming, and this scared the leadership team into panic mode.  Add in the coming economic downturn that had already started to hurt the company, and panic turned into a full-on disaster.

?u=http3.bp.blogspot.com-CIl2VSm-mmgTZ0wMvH5UGIAAAAAAAAB20QA9_IiyVhYss1600showme_board3.jpg&f=1&nofb=1Leaders, it is imperative that you lead first by example personally, then by actions professionally, then only if necessary by words.  When you observe new thinking on an old idea, embrace that and see where it goes.  Even if the new idea fails, build people!  Production goals are about human efforts distilled into statistical symbols.  Never forget about the human element.  Build people, and you meet production goals.  Build quality into every single transaction, and you meet production goals.  Fail people, and you will never meet production goals!  Fail quality, and you will fail to meet production goals.

I cannot make this any simpler!

© 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.

The Role of Quality – The Only Path to Improving Productivity

LookWarehouse 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.Inspiring Quotes on Quality - Fortune of Africa Swaziland

I have worked with businesses that used quality as a stick to beat employees and ultimately fire them.  This is an absolute abuse of quality and the quality people!  Worse, it hinders productivity because everyone becomes worried about meeting quality demands and not meeting customer expectations.  The employees who meet “quality” in these organizations are depressed, morale is pathetic, and the brand suffers significantly.  What really hurts, everything costs too much takes too long, and the company is not competitive, flexible, viable, or even worth mentioning.

What is Quality?

Bobblehead DollQuality 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!”Quality Quotes (40 wallpapers) - Quotefancy

Why; because that company cannot define what drives the metrics being reported.  That company has a quality department but not a quality attitude, quality focus, and quality determination.  It cannot be stressed enough if your people are not quality first; you are losing between 33% and 50% of your potential!  Worse, the loss of potential is always hard to pin precisely to a direct problem when the problem is lodged in something as amorphous as “quality.”Chinese Crisis

Recognizing Quality Value

Let’s do the numbers together.  A manufacturing plant, a call center, and a warehouse are examples A, B, and C, respectively.

Example A: Employee A has been trained on making a part; he has never been told how his parts affect the finished product and is sometimes sloppy in creating pieces.  But, because he is within set standards, his sloppy work can be cleaned up at another station, so Employee A does not want to improve quality.  Producing 200 parts made per day, with anywhere between 5 and 75 pieces, needing additional work; Employee A has an overall cost to the company above and beyond expected costs.  Regardless if Employee A increases his productivity to 250 to 300 pieces per day, his defects remain potential lost.Blue Money Burning

Example B:  XX Team has 15 agents; each agent is expected to handle 80-100 calls per day.  But the quality metrics are so stringent; the team can only meet 35-40 calls per day on average.  However, the business processes to complete work, and meet the quality standards, handicap any single agent from meeting the 80-100 calls per day.  Does the company look at the agents or their business processes and quality standards?  The business will demand higher productivity and never realize that the churn increase is from burned-out good employees walking away!blue-money

Example C:  Inbound product receivers, outbound product shippers, and quality are the three departments in a warehouse.  Inbound, they do not consider themselves part of a quality initiative; their productivity is driven by how many items get properly stowed per day.  Outbound is where the company focuses as this is where the customer satisfaction is directly observed; how much an outbound picks and prepares for shipping is productivity.  Quality is considered someone else’s job as a quality department counts for compliance to SOX and other legislation.  Inbound and outbound employees know their positions, and because they are not quality, they can create quality problems intentionally or not, and someone else will always take care of the problem.  Dirty part locations with inventory from other areas don’t matter; quality will fix it.  Torn or damaged product in a location, it doesn’t matter quality will fix it.  In this case, 2/3rds of the employee potential for improving quality is AWOL!

TOP 25 POOR QUALITY QUOTES | A-Z QuotesNow, 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.

Co-Equal but not Co-Valuable

kpiProductivity, 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!”

Returning to Example A, the employee does not know, has not been trained, and is unaware that their actions are directly costing the company.  Since there is a quality person to check and “fix” the mistakes, the loss of potential is immeasurable until the business leaders have to increase the manufacturing price to account for the added work in quality to correct the errors.  Hence, when all metrics are equal between quality and productivity, err on the side of quality, and productivity will catch up.

Exclamation MarkWant 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.

Quality – A Culture, Not Just a Department!

cropped-2012-08-13-07-37-28-1.jpgA 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 Image Quotation #4 - Sualci QuotesQuality 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.

Knowledge Check!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?

© 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: Memorial Day 2021 – Are you sure this is “proper” remembering?

Knowledge Check!It is no secret that the Department of Veterans Affairs (VA) is a sick and twisted organization.  It is no secret that the Department of Veterans Affairs – Office of Inspector General (VA-OIG) tries to recommend how the VA should be operating in accordance with currently established procedures, methods, and policies for the benefit of the veteran community.  It is no secret that I continue to write about the VA in the hopes of sparking interest in communities and obtaining more fair, honest, transparent, and humane treatment for veterans by the Government agency tasked with caring for veterans.

On this Memorial Day, as you sit down to barbecue, family, friends, sports, I would ask that you take a moment and consider if this were how you would like to be remembered?  Are the actions described proper for remembering those who sacrificed and came home?  Are these actions, which are adding to veteran funerals, an appropriate way for veterans to be leaving this world?  If the answer is no, I ask for your help changing the Federal Government by electing people who will scrutinize the government more stringently and demand change in all government agencies.  If you deem this behavior acceptable, please leave a comment detailing why you think so.  I want to hear your thoughts.Image - Eagle & Flag

From a VA-OIG report published on Wednesday 26 May 2021, we find the following announcement:

Phillip Hill, a former VA program analyst, was sentenced to 46 months in prison for stealing personal information from veterans and VA employees while employed at the Central Arkansas Veterans Healthcare System. The investigation revealed that Hill contacted another individual and attempted to sell personal identifying information to a buyer for approximately $100,000.”

Now, I am thrilled this guy was caught.  I am glad he will do time behind bars.  Yet, why did Assistant US Attorney Jana Harris allow a plea deal?  Where are the VA supervisors who should have been monitoring this employee’s work and behavior?  What are the details of the deal?  The VA continues to have nothing but IT/IS security, and these problems are decades old.  Still, the elected representatives allow the criminal behavior to exist until the criminal is caught, and then the elected representative’s crow about cleaning the swamp.  Is this how you correctly remember veterans, their sacrifice, and their memories?VA 3

I suppose the following VA-OIG report, released 27 May 2021, should begin with congratulations.  The Department of Veteran Affairs – Veterans Benefits Administration (VBA) mostly processed monetary proceeds records accurately.  However, the following continues to astound and amaze me:

Service and pension center staff do not have timeliness measures for proceeds incorporated in their performance standards. Setting a timeliness standard would help encourage the closing of these proceeds. The OIG also found that ineffective monitoring contributed to delays in handling proceeds. The Debt Management Center had only limited internal monitoring but instituted new practices for monitoring proceeds in February 2020, shortly after this audit began” [emphasis mine].VA 3

Why are government employees not held to a productivity and quality standard?  Being a veteran with regular concerns involving the VBA, I cannot help but wonder why quality and productivity are not required?  As an industrial and organizational psychologist, the first step in improving responsiveness to customers is to increase productivity and implement quality measures.  I know the Federal Government’s legislative branch, e.g., Congress, has insisted on developing quality measures.  Yet, the same tired excuses built upon designed incompetence are allowed to survive, and all the VA-OIG can do is issue more recommendations.  Consider something; proceeds include payments to dead veterans.  How much financial hardship occurs at the passing of a loved one?  How much more difficult can that death become when months down the road, money spent is suddenly being demanded back because some incompetent bureaucrat failed to do their job in a timely manner?

QuestionIs 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?

While never having been a patient at the Chillicothe VAMC in Ohio, I have friends who are patients.  The stories they tell about care there would shock and amaze many.  What infuriates me, the VA-OIG just published their report of a comprehensive inspection of this VAMC, and the results are as tragic as a veteran’s death!  The information was released to the public on 27 May 2021.  Never forget, the Chillicothe VAMC in Ohio was recently investigated for improper cleaning and sterilization procedures, as well as employee monitoring for compliance for medically reusable equipment, which for this case refers to endoscopes.  With this fact in mind, let us review the comprehensive inspection report.

Limitations on findings:

      • The VA-OIG held interviews and reviewed clinical and administrative processes related to specific areas of focus that affect patient outcomes. Although the VA-OIG reviewed a broad spectrum of processes, the sheer complexity of VA medical facilities limits inspectors’ ability to assess all areas of clinical risk” [emphasis mine].

VA 3The statement provided here is pretty standard and represents the first limitation to the scope of the investigation; complexity limits inspector ability.  Yet, who made the VAMC so complex, the VA.  Who has allowed the complexity to grow as designed incompetence, the VA? Why is the VA allowed to cheat their inspector general through complex operations which limit inspector ability and increase patient risk?

The Focus of Inspection (Investigation Scope):

      • The VA-OIG team looks at leadership and organizational risks, and at the time of the inspection, focused on the following additional areas:

WhyLong 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.

Finding One:  The VA-OIG issues 12 recommendations to the leadership team, and “selected results showed respondents were generally favorable the national VHA results.”  I have been accused of being cynical, which generally is wrong.  However, when I see words like “selected results” in an investigation into patient care and concerns, I have to ask, “How hard did the VA-OIG have to dig to find favorable results?”VA 3

Finding Two:  Strategic Analytics for Improvement and Learning (SAIL) represents a value model to help define performance expectations within VA.  This is the standard language for comprehensive inspections.  “In individual interviews, the executive leadership team members were able to speak in-depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences.”  If we accept this as a true statement.  How was an employee able to fake documents, fail to clean reusable equipment properly, and repeatedly get away with this abysmal behavior at this VA?

VA 3Finding Three:  Under Quality, Safety, and Value, we find the following tidbit:

The VA-OIG noted concerns with protected peer reviews, utilization management, and root cause analyses.”

Essentially meaning there are problems with whistleblowers, privacy protection, retaliation against whistleblowers, proper utilization of policies and procedures, and the leadership could not find a problem using root cause analysis if their lives depended upon it.  The source for my interpretation of the VA-OIG results arrives from the following:

VHA Directive 1117, Utilization Management Program, 8 October 2020. Utilization management involves the assessment of the “appropriateness, medical necessity, and the efficiency of health care services, according to evidence-based criteria” [emphasis in the original report].

I have to ask the VA-OIG whether these findings were before or after the employee who endangered patient lives through improper cleaning and sterilization of reusable medical equipment were discovered?

VA 3Finding Four:  Under medication management, we find the following:

The VA-OIG team observed compliance with many elements of expected performance, including pain screening, aberrant behavior risk assessment, and documented justification for concurrent therapy with benzodiazepines. However, the VA-OIG identified opportunities for improvement with urine drug testing, informed consent, patient follow-up after therapy initiation, and quality measure monitoring” [emphasis mine].

VaccineIf 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.

Finding Five:  Under High-Risk Processes, the VA-OIG report claims the following:

The medical center met the requirements for quality assurance monitoring and monthly continuing education. However, the VA-OIG identified deficiencies with standard operating procedures, an airflow directional device, and staff training and competency” [emphasis mine].

Are the SAIL metrics even accurate?  Where is the value in the “monthly training and monitoring if there are issues in following standard operating procedures, problems in staff training, as well as staff competency?  Do you get it?  The training sucks at the VA, and the SAIL metrics do nothing to fix the problem, address the deficiencies, or even improve competency?  The same question arises here, from quality, safety, and value; how was an employee able to successfully pencil-whip the paperwork while not doing their job in properly cleaning and sterilizing reusable medical equipment?  Where are the SAIL documents that should have identified a problem?  Where are the SAIL metrics in aiding in finding root causes for derelict employees?VA 3

Honestly, do you, the taxpayer, consider the Department of Veterans Affairs, which covers the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries adequate to remember the veteran correctly?  Do you, the taxpayer find value in the leadership and investigative arms of the VA to correct and improve performance?  Do you, the taxpayer find that the VA employees are doing their level best to honor, remember, and pass on the legacy of veterans?

Image - Eagle & FlagOn this Memorial Day weekend, please consider the data in this and the other VA-OIG reports regularly relayed on this blog, and ask yourself, are you doing enough to help veterans?  I love Memorial Day, and I love my country, but America has some serious problems, and only when the electorate awakens to the issues can real change begin to be implemented.  We, the veteran community, need you!  We need your voice as we struggle against the incessant attacks from the VA.  We need your votes for the elected representative’s intent on scrutinizing the government and demanding action.  We need you!  Please help us!

© 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.

The Power of Tiger Teams – Shifting the VA Paradigms

I-CareA 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.

ProblemsTiger 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.

Leadership CartoonFinally, 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:

  1. 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.
  2. 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.
  3. 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.

VA SealNever 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!

© 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.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

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

Questions, Suggestions, More Uncomfortable Truths – Shifting the VA Paradigm

I-CareWhile receiving a call from the local VA to schedule an appointment, where the VA initiated the call, I discovered a genuinely despicable practice had spread at my local VA.  I have a name, that name is not “Honey,” “Darling,” “Sweetie,” or other terms of endearment.  If you employ a term of endearment in professional exchanges, you are practicing the height of disrespect.  I expect to be called “Darling” when I visit independent truck stops in the Southeastern US and Texas.  My wife does not use these terms, my friends use my name; why is the VA, specifically in New Mexico, allowed to employ such disrespect?  My name is on the computer in front of you, why are you choosing to not use my name?  Where is quality control?  Where is the leadership team in preventing problems from becoming a VA-OIG inspection issue?

People ProcessesQuality control is powered by actively engaged leadership and includes call monitoring, training materials, risk control, attitudes, behaviors, and so much more.  When there is no quality control, the business experiences a phenomenon comparable to a herd of dairy cows, fresh from milking.  Each cow will head off in different directions, the adventurous cows will run to the farthest fence and push against the boundaries, finding a definite boundary, they return to the middle of the field and graze.  Finding weak limits, or no boundaries, the cows will wander all over the place and never eat properly.  The less adventurous cows will plop themselves down, and be intransigent until they discover the boundaries are gone, and then the crazy in cows comes out.  Some of the cows will bawl incessantly, some will stop eating, others think they can be adventurous and get tangled in fences or eat the wrong food and become sick, and so much more.  Fences protect the cows, durable fences are required to promote a healthy herd; quality controls are the boundaries that protect the worker, promote sound action, and prevent some of the behaviors that create the roots of the Department of Veterans Affairs Office of the Inspector General (VA-OIG) reports that keep crossing my desk.

As previously stated, several times, in fact, the complicated organizational structure of the Department of Veterans Affairs (VA) is a root cause as to why the veterans suffer so much at the hands of bureaucrats.  The VA is geographically broken into Veterans Integrated Service Networks (VISN), these VISN’s oversee geographically grouped, generally by state, Veteran Health Care organizations (VA Hospitals and clinics).  In theory, how the VISN acts is supposed to trickle down to the hospital and clinics improving performance and generalizing operations across a broad geographical area.  Unfortunately, what is passed down to hospitals and clinics in the VISN is often the dregs, the poor practices, and the insanity of a complicated bureaucracy.  When one hospital in a VISN is in trouble, look to the VISN, and see replication.  Happens everytime; thus, change the organizational structure, simplify the hierarchy, and clean out the drones.

For example, the Chief of Staff in VISN 10, hired an ophthalmological surgeon who was not credentialed, not properly certified, and inadequately trained, and then repeated their mistake at the end of the probationary period by hiring the surgeon on full-time.  From the VA-OIG report, we find the following description of the surgeon, “… the surgeon lacked adequate training to perform cataract and laser surgery as the surgeon did not satisfactorily complete an approved residency training program, was ineligible for board certification in ophthalmology, and did not meet the facility’s ophthalmologist hiring requirements. Several credentialing and privileging activities did not comply with Veterans Health Administration requirements and included inadequate primary source verification from foreign educational institutions and insufficient references attesting to the surgeon’s suitability to perform cataract surgeries.”  The VA-OIG report then proceeds to discuss “multiple leadership deficiencies” that led to this surgeon being hired and allowed to practice.  The Chief of Staff caused a problem for veterans, but the language is “leadership deficiencies.”  Where is the accountability?  Where is the demand for replacing the leader?  While the surgeon was eventually terminated, what about recompense for the malpractice committed?  The VA-OIG report documents, “… the surgeon’s productivity, competency, and [deficient] technical skills began within months of hire. The surgeon did not consistently demonstrate the skills to assure good outcomes, was unable to meet surgical productivity expectations, and surgery times exceeded norms.”  Where is the Chief of Staff’s culpability in this dangerous affair?

Speaking of leadership culpability, there remains a recurring theme in several recent VA-OIG reports, failing quality ratings, but the leadership team is new.  I understand that new leaders will require time to positively influence organizational attitudes and behaviors, what I do not understand is why time is used as an excuse and nowhere in the VA-OIG report is a list of leadership tenure to justify the time excuse, nor is a reinspection time identified.  When I audited business for performance, these factors are always in the report, time on station, efforts to change since appointment, when the next inspection will occur, and recommendations to improve between the end of the examination and the reinspection.  More needs declared in these inspections, as the VA-OIG just does not appear to inspect an entire health care system without cause.

Regarding leadership and quality controls, here is an example of a construction project where leadership and quality controls were desperately needed, yet remain missing.  The Ralph H. Johnson VA Medical Center approved a series of construction projects by awarding contracts.  Instead of construction beginning within 150-days, construction began around day 743 on average.  Instead of blueprints costing $74,000, the final cost was $441,000.  While other claims of misappropriation were alleged, the VA-OIG did not investigate or could not validate those claims.  Where is the leadership of the VISN to proactively ask tough questions of the local hospital leadership to determine where problems are occurring?  Where are the quality control officers, the risk control officers, and other leaders in demanding compliance with VA regulations?  Construction was averaged at 743-days after contract award, which is a minimum of 593-days out of compliance, and there are costs associated with delaying construction contracts; what were those penalty costs, and why are they not included in the VA-OIG report?  Where is the discussion on why the delays occurred?  Where are the leadership and quality controls?

As the home shopping channel is always proclaiming, “But wait, there’s more!”  The VA has six fiduciary hubs to look after the resources of those veterans deemed unable to manage their own finances.  The Salt Lake Fiduciary Hub got behind in their workload and leadership, and quality control were the reasons why the workload backlogged, add in staff churn, and the fiduciary hub fell significantly in arrears in their work.  The VA-OIG documented a need for workload management plans, training on how to prioritize work action items, a process for weeding out duplicate tasks, and how to measure production to ensure goals are met.  The recommendations from the VA-OIG reads like the primary duties a director must already possess to meet the demands of the job they fill; yet, this director is not documented as being replaced for failure to do their job.  Basic leadership skills require a knowledge of how to help schedule work, balance workloads, train on prioritization of tasks, communicating, and building a team.  Where is the leadership and quality controls to ensure productive work is performed, and leadership is doing their jobs?  The VA-OIG is not the solution to these leadership deficiencies!

The Hampton VA Medical Center in Virginia is reported to have had $1.8 million in improperly marked, inventoried, or accounted for inventory in forgotten rooms of the hospital.  The supplies had been sitting for “an indeterminate amount of time.”  Stock supplies had been improperly ordered, and the staff was inadequately supervised to protect the medical center and the taxpayer from fraud, waste, and abuse.  The facility in May 2017, and again in May 2018, had identified the same deficiencies the VA-OIG documented and did nothing to rectify the situation.  While the VA-OIG has made “several recommendations” the problem remains, the leadership failed to act in 2017, and 2018, what steps were put into place to ensure action finally occurs in 2019?  Audits are part of an integrated quality control process; where is the rest of the quality control program?  Where was the hospital leadership in 2017 and 2018?  Quality control audits cost money and not correctly responding to an audit should have penalties; where is the accountability for design incompetence that has allowed this problem to survive two audits and an OIG inspection?

NetworkingSome of the VA-OIG reports crossing my desk discuss what the VA-OIG terms, “Comprehensive Healthcare Inspections.”  Unfortunately, too many of these reports include the verbiage to this effect, “The OIG issued 22 recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Infection control and general cleanliness • Mental health unit panic alarm testing response times • Mental health unit seclusion room flooring • Emergency generator testing (3) Controlled Substances Inspections • Reconciliation of dispensing and return of stock • Controlled substances order verifications • Routine inspections by controlled substances coordinators (4) Military Sexual Trauma (MST) Follow-up and Staff Training • Providers’ training (5) Antidepressant Use among the Elderly • Patient/caregiver education on medications (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership (7) Emergency Departments and Urgent Care Centers • Waiver for 24-hour operations • Staffing and call schedules • Use of required tracking program • Directional signage • Equipment/supply availability.”  The root cause of many of these VA-OIG recommendations is leadership and quality control; yet, never is quality controls mentioned, even though the inspection, and the SAIL and CLC metrics are quality control programs.  Congressional representatives where is your leadership in insisting upon full implementation of a quality control program, follow-through on the program’s application, and demands for quality improvement?  The elected representatives of the American Republic must be held to task for failing to act to improve the bureaucratic nightmare they created through inaction and legislative fiat.

Another recurring theme, where leadership and quality control are non-existent, and which happens to profoundly impact the quality of life for patients, are those issues emanating from long-term care facilities and the veterans living in those facilities.  55 patients in San Juan, Puerto Rico were impacted by, “… staff inadequately monitoring the patient.  Documentation was insufficient, and there were no care coordination agreements between the care facility and other service providers.  Licensed practical nurses did not add registered nurses as co-signers to notes to alert them of changes in the patient’s status, and the patient’s care plan had not been modified to include the initiation of chemotherapy.” Mainly, the staff failed the patients, the patients suffered harm, and the injury was caused because of a lack of leadership and quality control.

Thank you!I want to conclude this article with a major thank you to the officers and staff in the Milwaukee VA who saved the life of a non-veteran.  From the story, “Instantaneous response by Milwaukee VA police, followed by immediate action from emergency room personnel, saved the life of a non-veteran who was within minutes of dying of a heroin overdose.”  Having worked at a VA medical center where veterans committed suicide in the parking lot of the VA, it is good to see that the measures being implemented by the Federal Police are having a positive effect on veterans and visitors alike.  To all involved in this incredible story, “Thank you!”

© 2019 M. Dave Salisbury

All Rights Reserved

Any images used herein were obtained in the public domain, this author holds no copyright to the photos displayed.