Realities and Uncertainties – The Paradigm at the VA

I-CareThe Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports they are returning to a more regular schedule of release for the inspection reports with the Department of Veterans Affairs (VA) recovering from COVID-19.  Congratulations are in order, to the VA, as they begin returning to normal operations and procedures.  The reality is that standard operating procedures (SOP) are regularly missing at the VA, this absence causes uncertainty, and forms the crux of this report. A question for the VA-OIG, “How can you assess employee competency without SOPs?”  To the VA VISN leaders, “How can your directors and supervisors, conduct employee evaluations without written SOPs?”  The short answer is you cannot!

Congratulations are in order, for the Marion VA Medical Center (VAMC) in Illinois.  The Marion VAMC experienced a “comprehensive healthcare inspection” and were generally praised for the excellent work being conducted, the happiness of the patients, and the overall condition of the facilities.  While there were recommendations made by the VA-OIG (29 in 8 different areas), the overall report was satisfactory, and this is mentionable.  Hence, my heartfelt congratulations for your success in this inspection.

VA SealThe Marion VAMC VA-OIG report raises a common theme, and this is a reality the VA appears to be incapable of addressing training and two-directional communication.  From the hospital director to the patient-facing staff, training always appears as a significant issue in VA operations.  Having experienced the training provided by the VA for employees, and as an adult educator, I know the uselessness of the training program and have several suggestions.  Perhaps the problem would be best addressed if more evidence was provided of a systemic failure in training employees at the VA.

In 2017 Congress mandated a change in research operations for the VA, specifically where canine research was concerned.

The OIG found VHA conducted eight studies without the former or current Secretary’s direct approval, resulting in the unauthorized use of $393,606 in appropriated funds.VA continued research using canines after the passage of the funding restrictions, in part, because VHA executives perceived that then VA Secretary David Shulkin had approved the continuation of the studies before his departure.”

The cause of the problem, the VA-OIG discovered was, “Unclear communication, inadequate recordkeeping, and failure to ensure approval decisions were accurately recorded and verified all contributing to VHA’s noncompliance.”  The researchers and executives relied upon two leading causes for not following regulations, designed incompetence, and a lack of training through clear and concise communications.

Congress mandated the documentation to assure approval was obtained before research commenced; yet, the researchers and administrative staff collectively failed to do their jobs and were able to hide behind the bureaucracy they established to excuse their poor behavior.  Loopholes for designed incompetence and lack of training need closed; but, two incidents do not clearly illustrate the reality of the problem.

ProblemsThe VA Southern Nevada Healthcare System in North Las Vegas, in response to a referral from the U.S. Office of Special Counsel (OSC), was investigated by the VA-OIG after a community healthcare worker was attacked.  The VA-OIG findings are appalling, but the reasons for the problem are worse.

The OIG determined that facility managers failed to timely respond after the social worker reported an assault during a home visit and did not address the social worker’s health needs after the assault. The social worker’s supervisor failed to immediately report the incident to the community and VA police. The facility’s policies lacked specific guidance regarding employee emotional and mental health injuries. Further, the OIG substantiated that the social worker was not informed by a supervisor of a homicidal threat, occurring subsequent to the assault, until two weeks after facility leaders became aware of the threat.”

The facility leaders knew there was a problem, yet did nothing before or after the event, that could have cost this healthcare worker their life!  VA-OIG recommendations boil down to a need for clear communication and staff training.  The recommendations highlighted another issue entirely that forms the reality and creates uncertainty at the VA, communication is not a two-directional opportunity to share information.  Single directional communication is useless, and those leaders supporting the bureaucracy to only allow communication to flow in, need immediate removal from the VA.  During my time at the VA as an employee on the front-lines, facing patients, I regularly experienced the lack of communication, and this issue is systemic to the entire VA as witnessed and observed at VA Medical Centers across the United States.

The Nevada incident is deplorable, reprehensible, and the potential for loss of life cannot be overlooked by VA leadership in Washington, at the VISN, or at the Medical Center any longer!  The problems of communication cannot explain this incident, and failure for training cannot excuse this behavior!  Since the OSC initiated the complaint, I am left to wonder, did the employee reporting this incident get fired and needed to appeal to the OSC for remediation?  I ask because the knee-jerk reaction to problems at the VA is to fire the person reporting the issue, as previously observed and personally experienced, and as described to Congressional representatives during televised hearings.  A more thorough investigation into causation needs to be concluded and reported to Congress for this incident reeks of politics and CYA.

Leadership CartoonThe Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri, and multiple outpatient clinics was recently provided a comprehensive healthcare inspection, and the leadership team provided 14 recommendations in 7 different areas for improvement.  While congratulations are in order, for the patient scores, the employee scores, and the overall conditions discovered.  Yet, again staff competency, e.g., training and communication, remain critical articles requiring targeted improvement.  Is the pattern emerging discernable; in Nevada, an employee is assaulted and training and communication are blamed, comprehensive healthcare inspections are conducted in three different geographic areas and the same causation factors discovered; training and communication are systemically failing at the VA.  But, the evidence continues.

The John J. Pershing VA Medical Center in Poplar Bluff, Missouri, recently underwent a comprehensive healthcare inspection.  The VA-OIG issued 17 recommendations in 6 fundamental areas, including staff competency assessments, e.g., training and communication, as well as the inadequate written standard operating procedures.  When discussing designed incompetence, the first step to correcting this problem is writing down the standards, operating methods, and procedures.  Then the medical center leaders can begin training to those standards.  Barring written instructions and published standards, employees are left to ask, “What is my job? and “How do I perform my job to a standard?”

The Oscar G. Johnson VA medical center, and multiple outpatient clinics in Michigan and Wisconsin recently underwent a comprehensive healthcare inspection, 11 recommendations in 3 critical areas.  As did the Tomah VA Medical Center and multiple outpatient clinics in Wisconsin, 4 recommendations in 3 crucial areas.  Both facilities are to be congratulated for their continual improvement and their success during the inspections.  In case you were wondering, staff competency assessments, e.g. training and communication, are vital findings and variables in improving further for both facilities.

The VA has what it calls “S.A.I.L” metrics that form the core standard for performance.  S.A.I.L. stands for Strategic Analytic (sic) for Improvement and Learning.  Learning is a critical component in how the facility is measured and yet remains a constant theme in the struggles for improvement.  Thus, not only is two-directional communication a systemic failure, but so is the poor training results found on all the comprehensive healthcare inspections performed by the VA-OIG.  Poor communication almost cost a healthcare worker their life, and staff training was a key component for recovering from this incident in Nevada.  How can the VA consistently fail at two-directional communication and training, designed incompetence?  Those in charge require an excuse for not doing their jobs, and the most common excuse provided is a lack of training and poor communication.

I-CareIt is time for these petulant and puerile excuses to be banished and extinguished.  The following are suggestions to beginning to address the problems.

  1. Easy listening is a musical style, not an action in communication.  By this, it is meant that the VA needs to stop faking active listening and engage reflective listening.  Reflective listening requires reaching a mutual understanding and is critical to two-directional communications.  In the world of technology, not responding to email, not responding to text messages, and untimely responses to staff communication are inexcusable on the part of the leaders.
  2. Staff training remains a core concept, but before staff can be properly and adequately trained, standards for performance, operational guidelines, and procedural actions must be clearly written down. The first question I asked upon hire was, “Where are the SOPs for this position?”  I was told, “Do not mention SOPs as the director hates them and prefers to work without them.”  Do you know why that director preferred to work at the VA without SOPs because she used it as an excuse to get out of trouble, to fire those she deemed trouble makers, and to escape with her pension and cushy job to another VA medical center?  A repeatable pattern for poor leaders to spread their infamy.  Shame on the VA Leaders for promoting this director to a level beyond her incompetence.  Worse, shame on you for creating an environment where many like her have excelled and done damage to the VA reputation, mission, and patients, including killing them while they awaited care.
  3. From the VA Secretary to the front-line patient-facing employee, cease accepting excuses. The private sector cannot hide behind immunity from litigation and act in a more responsible manner.  Thus, the VA needs to benchmark what private hospitals do where staff training and SOP’s are concerned.  Benchmark from the best and the worst hospitals for an average, then implement that average as the standard.  One thing discovered in writing SOPs for the NMVAMC, the committee for approving SOPs, and the process for writing SOPs were so convoluted and time-intensive that the SOP was outdated by the time it could be implemented.  Shame on you VA leadership for creating this environment!
  4. Training should be an extension of an organizational effort and university. The VA is not properly training the next generation of leaders; thus, the problems multiply and exponentially grow from generation to generation.  Launch the VA Learning University concept, staff that university with adult educators, and allow lessons learned from the university to trickle into operational excellence.
  5. Form an independent tiger team in the VA Secretary’s Office who has the authority to travel anywhere in the VA System to conduct investigations with the ability to enact change and demand obeisance. The Nevada incident was a failure of leadership and needs a thorough reporting and cleansing of the bad actors who allowed that situation to occur.  Worse, in my travels, I have heard many similar stories.  I heard of a patient getting their ear chopped off when a veteran assaulted another veteran after becoming irate at waiting times in the VA ER.  I have heard and witnessed multiple incidents of furniture being thrown, employees being assaulted, employees harassing and assaulting patients, staff property trashed, and so much more.  These incidents need direct intervention and investigation by a party not affiliated with that affected VAMC and the leadership’s political policies.

Carl T. Hayden04 October 2016, the VA-OIG released a report on dead veterans after the comprehensive investigation into the Carl T. Hayden VAMC in Phoenix, Arizona.  The same event occurred in 2014, at the same hospital, with the same causes and the same conclusions.  The core causes for the dead veterans, no written procedures, poor to no training, and reprehensible communication practices.  The Phoenix VAMC went out of their way to fire all the employees who reported problems at the Phoenix VAMC before the veterans began dying in 2014, I can only speculate that the same occurred in 2016.  Staff was frightened in 2014; they are demoralized in 2020.  Nothing has changed at the Carl T. Hayden VAMC in Phoenix, Arizona, after two successive hospital directors, if anything the problems have worsened.  The problems worsened because leadership failed to act, failed to write down SOPs, failed to communicate, and failed to train.  The hospital directors since 2014 have been appointed from the same pool of candidates who created dead veterans in the first place, and that is a central failure of the VA Secretary and Congressionally elected representatives’ failure to act!

How many more veterans or staff must die before the VA is willing to act?

© 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/

Structured Incompetence – The Department of Veterans Affairs and Congress

I-CareThe Department of Veterans Affairs (VA) is allowed the ability to govern themselves, provided they meet specific guidelines and legislated goals and directions.  The Department of Veterans Affairs – Office of Inspector General (VA-OIG) was established to provide legislators and the VA with tools and processes to improve, as well as to investigate root causes, and make recommendations for improvement.  But, here is the rub, the VA-OIG has no teeth to help their recommendations hold the attention of those in charge to make changes.

In December 2014, the Federal Information Technology Acquisition Reform Act (FITARA), passed Congress and was signed into law by the president; FITARA is a historic law that represents the first major overhaul of Federal information technology (IT) in almost 20 years. Since FITARA’s enactment, OMB published guidance to agencies to ensure that this law is applied consistently governmentwide in a way that is both workable and effective.  2014 saw the VA slow the loss of private data from the VA, the Office of Personnel Management (OPM) Data Breach is gaining momentum and will crest in 2015, and in case memory has failed 2014 saw an explosion in VA malfeasance get uncovered starting with the Carl T. Hayden VA Hospital in Phoenix, AZ.

December 2020 will mark the sixth anniversary of FITARA, and President Trump signed a five-year FITARA bill in May 2018.  The VA-OIG in reporting progress on FITARA at the VA has this to report,

“… The audit team evaluated two groups of requirements involving the role of the VA chief information officer during [the] fiscal year 2018. They related to the CIO (1) reviewing and approving all information technology (IT) asset and service acquisitions across the VA enterprise and (2) planning, programming, budgeting, and executing the functions for IT, including governance, oversight, and reporting. The audit team found that [the] VA did not meet FITARA requirements and identified several causes.”

The number one reason for non-compliance after almost six-years was, “VA policies and processes that limited the chief information officer’s (sic) review of IT investments and the oversight of IT resources.”  Not mentioned in the VA-OIG report is how many of these processes and policies had been enacted since 2014.  The VA’s own processes and policies reflect structured incompetence, making a ready excuse to be out of legal compliance with legislated obligations.  If this was a private business, and the legislated obligations were not being followed exactly, no excuse could keep the leadership team out of jail and the business in operation.  Hence, Congress why do you allow this egregious behavior by public servants?

On the topic of structured incompetence, foot-dragging, and legislated obedience, the VA-OIG issued a glowing report of compliance because the VA was found to be in compliance with three of the five recommendations from a VA-OIG inspection on the Mission Act from June 2019.  The progress made was on all aspects of the Mission Act except mandatory disclosure.  Why does this not surprise me; of course, the VA has had, and continues to suffer from, a horrible case of refusing to report, disclose, and communicate without severe prodding and legislated mandates.  Thus, I congratulate the VA on being in compliance with the Mission Act for the last three consecutive quarters on a total of three recommendations from the VA-OIG; this is a good beginning, when can we expect improvement on mandatory disclosure?  Structured incompetence relies upon disclosure malfeasance, collective misfeasance, and leadership shenanigans.

On the topic of structured incompetence, the VA-OIG reported that the Northport VA Medical Center in Northport, New York, prior medical center leaders did not plan effectively to address deficiencies in aging infrastructure.  Which is the polite way of saying, the buildings are old and maintenance has been creatively haphazard, so when steam erupts from fittings and contaminates patient treatment rooms with asbestos, lead paint, live steam, and other construction debris, a small problem becomes a multi-month catastrophe.  Thankfully, the VA-OIG reported no harm to the patients or patient care restrictions from this episode.  Unfortunately, the VA-OIG cannot hold the managers and directors of engineering services responsible.  Having worked in several capacities in engineering I am astounded at the following recommendation from the VA-OIG, and covered under creatively structured incompetence:

“… The OIG recommended that the medical center director develop processes and procedures for submitting work orders—including for notifications when work orders are assigned and reviewed for accuracy and consistency—to help the center’s engineering service prioritize work and manage [the] resource.”

Will the VA-OIG please answer the following questions, “Why is this the hospital directors’ job?”  You have an entire engineering plant, with a supposedly competent director to oversee engineering operations, why and how should the hospital director be focusing such extensive amounts of time on the job that rightly belongs to the engineering plant director?  There are several technology-based programs and options that can perform this work, and form reports automatically based upon performance by engineering staff in completing work orders.  Why is the VA-OIG recommendation not including an automated process to improve performance?  The lack of oversight in the engineering department is both creatively and structured incompetence, because the VA-OIG report recommended following the master plan, reporting progress to the master plan, and suggested that the director of the engineering plant needs to be doing the job they are collecting a wage to perform.

Behavior-ChangeOn the topic of creatively structured incompetence, we find the following from the Department of Veterans Affairs – Veterans Benefits Administration (VBA).  A veteran patient that spends more than 21-days in hospital for treatment is supposed to be placed on 100% disability, and be paid at the higher disability amount.  Those veterans with mental health concerns are supposed to have additional support to aid them in managing their benefits from the VA.

The VA-OIG estimated VA Regional Office employees did not adjust or incorrectly adjusted disability compensation benefits in about 2,500 of the estimated 5,800 cases eligible for adjustments, creating an estimated $8 million in improper payments in the calendar year 2018. The OIG estimated 1,900 cases did not have competency determinations documented for service-connected mental health conditions.”

Why is this another case of creatively structured incompetence, because every time the VBA gets caught not doing their job, the reason is training, reports not properly filed, and lack of managerial oversight.  I could have predicted these reasons for structured incompetence before the investigation began.  That managerial oversight, employees not filing proper and timely reports, and training not occurring for employees has been an ongoing and repeated theme in VBA incompetence since early 2000 when magically the VBA was behind in processing veterans’ claims for disability.  This theme stretches to the VBA inappropriately deciding claims for spine issues.  The same theme was reported in the VBA improperly paying benefits.  The list of offenses by the VBA is long, and the excuse is tiresome.  The VA-OIG reported:

Employees who processed benefit adjustments also lacked proficiency. They lacked sufficient ongoing experience and training to maintain requisite knowledge. This is also why employees were unclear on the requirement to document the relevant competency of veterans admitted for service-connected mental health conditions.”

ProblemsHow ironic that the root causes of a VA-OIG inspection would find people being paid to perform a job, but are not actually doing the job because they lack proficiency, training, managerial oversight, and are unclear on what they are expected to do in their jobs.

To the elected officials of the US House of Representatives and the Senate, the following are posed:

  1. If you hired a carpenter to enter your home, perform work, and you discover that the carpenter does not know the job they were hired and contracted to perform, what would be your response?  If your answer is to keep that non-working carpenter in that position, in your home, I must wonder about your intellect.
  2. How can you allow this structured incompetence to live from one VA-OIG report to the next? How can you justify this behavior at the VA?  How many other offices of inspectors general reports are reporting the same structured incompetence in Federal Employment and you are not taking immediate action to correct these deficiencies?
  3. Why should anyone re-elect you; when we the taxpayers endure this incompetence, paying you and them to abuse us. You were elected to oversee and manage that which we cannot; yet, you continually strive to perform everything but this essential role.  Why should we re-elect you to public office?

GearsThe following suggestions are offered as starting points to curb structured incompetence, improve performance, and effect positive change at the Department of Veterans Affairs, which includes the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries.

  1. Implement ISO as a quality control system where processes, procedures, and policies are written down. The lack of written policies and procedures feeds structured incompetence and allows for creativity in being out of compliance with legislated mandates.
  2. Eliminate labor union protection. Government employees have negotiated plentiful benefits, working conditions, and pay without union representation, and the ability for the union to get criminal complaints dropped and worthless people their jobs back is an ultimate disgrace upon the Magna Charta of this The United States of America generally, and upon the seal of the Department of Veterans Affairs specifically.
  3. Give the VA-OIG power to enact change when cause and effect analysis shows a person is the problem specifically. Right now, the office of inspector general has the power to make recommendations, that are generally, sometimes, potentially, considered, and possible remediations adopted, maybe at some future point in time, provided a different course of action is not discovered and acted upon, or a new VA-OIG investigation commenced.  This insipid flim-flam charade must end.  People need to be held liable and accountable for how they perform their duties!
  4. Launch a VA University for employees and prospective employees to attend to gain the skills, education, and practical experience needed to be effective in their role. I know from sad experience just how worthless the training provided to new hire employees is and this is a critical issue.  You cannot hold front-line employees liable until it can be proven they know their job.  Employee training cannot occur and be effective without leadership dedicated to learning the job the right way and then performing that job in absolute compliance with the laws, policies, and procedures governing that role.  Training is a leadership function; how can supervisors be promoted and not know the role they are overseeing; a process which is too frequent in government employment.

I-CareI – Care about the VA!

When will the elected officials show you care and begin to assist in improving the plight of veterans, their dependents, and their families?

 

© 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/

 

Communication: The Devil is in the details – Shifting the VA Paradigm

I-Care23 January 2020, I wrote about how a medical support assistant (MSA) was negatively influencing communication between my primary care provider and myself.  Today, I discovered the Department of Veterans Affairs – Office of the Inspector General (VA-OIG) is reporting the same problems in several other VA Medical Centers across the country.  One veteran waited 36-calendar days for a positive test result notification; yet, because there were no “adverse patient events as a result,” the lack of communication is not considered an issue.  Another example involves a patient and do not resuscitate (DNR) orders, along with family concerns and end-of-life home hospice care.  The VA physician/hospitalist in charge had four incidents raising concerns the VA-OIG investigated, where the need to improve communication is the problem with no solution, support, or quality controls.

I guarantee, if there is a 36-day lag in a positive test result notification to me, there would be an adverse patient reaction.  While the VA-OIG made communication recommendations, I would bet dollars to doughnuts that the problems in communicating remain a significant customer service issue.  Why, because the majority of comprehensive inspections the VA-OIG conducts include failures in communication, and the amount of communications issues resemble bunny rabbits in a field with no predators.

The “I-Care” customer service program at the VA reports the following in every I-Care class:

“How we treat veterans today determines if the veterans choose the VA tomorrow.”

On the I-Care Patient Experience Map, how communication is used influences how the veteran feels about choosing the VA for their needs.  Yet, the VA continues to communicate like the veteran has no choice, no options, and does not matter.  Here are some communication tips, tailored specifically to the VA; may they find application quickly in VA customer operations.

  1. The VA claims that the primary care provider, the nurse, the MSA, and the patient are a healthcare team.  If this is the case, then the first step in improving communication is a technical fix opening as many channels of two-directional communication as possible.  Including email, voicemail, text messaging, telephone, fax, and instant messaging.  If the patient has all these channels, and they do; why can’t the nurse, the doctor, and the MSA use all the same technology to communicate?
  2. The VA has improved on this issue, but there is considerable improvement still to make; when test results come out, copy the patient on the results, automatically. But, where the patient’s results are concerned, explain the results.  Have the nurse or a physician assistant write some comments about the results, before sending them onto the patient.  Currently, I receive bloodwork results and have to Google/Bing my way through the results and guess when discussing the results with my spouse.  I received bloodwork results from UNM, the results came in digitally to my email box, with hyperlinks to explanations by doctors in the UNM system.  I received X-Ray and MRI results that claimed “all normal;” this does not tell me anything and increases the problems in understanding what was observed in the X-Ray and MRI.
  3. Face-to-face customer service is a skill that requires training, quality assurance, and monitoring. Yet, the MSA’s at the VA, who do the most customer influencing communication, are not trained, monitored, or quality assured.  The result, patients are treated horribly or are treated amazingly well, based solely upon the individual.  Unfortunately, the leadership in charge of customer service are often the worst offenders for poor customer service.  This must change; implementing a quality assurance program is not difficult, or expensive, and provided the quality assurance does not become the stick to beat people into submission, will provide positive fruit.  But, everyone who communicates with a veteran needs training and needs methods for improvement.
  4. Stop active listening as the standard for communication. In a hospital environment, especially, the standard should be reflective listening to achieve mutual understanding.  Active listening skills can be faked, thus inhibiting proper communication.  As an example, review the physician hospitalist who was able to fake care for patients sufficiently to fool the VA-OIG, but the patients and their families were left without feeling they had communicated sufficiently to act with confidence.
  5. “I-Care” is a good program; why has it not become the standard for all customer interactions? There is no reason for this program to not be a mandatory baseline standard of employee behavior from Secretary Wilkie to the newest new hire.  Yet, hospital directors can dismiss “I-Care,” refuse to implement “I-Care,” and disregard “I-Care.”  To grow the “I-Care” culture, every employee needs to onboard and commit; where is this being insisted upon?

Too often, the root cause analysis is either poor communication as the issue, or a substantial sub-issue; yet, even with the insistence of the VA-OIG, communication failures remain.  No more!  The VA must implement “I-Care” for every employee, implement a quality assurance program for communication, hold communication training, and design communication goals for every classification of employee.  Most importantly, every single leader must exemplify the customer standards they want to see in their employees.  There are no valid excuses for failing to communicate!

 

© 2020 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.

Uncomfortable Truths – Where is the Accountability for Designed Incompetence?

I-CareThe Department of Veterans Affairs Office of the Inspector General (VA-OIG) conducted a review and sent the following report on their findings, “… the Veterans Benefits Administration (VBA) incorrectly processed more than half of the 62,500 claims decided in the first six months of 2018.”  A less than 50% accuracy rate is unacceptable in every business, organization, and school; yet, the VBA gets a pass on designed incompetence?  Why?  Already veterans must scrounge, dig, and provide endless reams of supporting proof, or new and material evidence, to obtain a “service-connected rating” for injuries and disabilities stemming from military service.  For the most part, the veteran accepts this as the cost of receiving treatment, and for the VBA to incorrectly process less than 50% of the claims, where spines are concerned, is deplorable performance.

In support of the claim that this is designed incompetence, the following is quoted from the VA-OIG report, “… incorrectly decided claims resulted from VBA’s inadequate process for ensuring accurate and complete evaluation. VBA’s primary means of evaluating disability contains minimal guidance, and a procedure manual is too subjective in key areas, which can lead to an inconsistent evaluation for related conditions stemming from the primary disability.”  The VA designed the processes for the VBA to follow.  Hence the incompetence is designed into the system to create additional problems, issues, and pain for the veteran.  Leading to a question for the elected officials in Federal Service, “Why are you allowing this nightmare to continue?”

Spine AnatomyAs a business consultant and industrial-organizational psychologist, I counsel those hiring me to never allow a process to reach a second birthday without a full and complete review.  When training deficiencies are found, immediate action is required, and that action must be documented.  Why is the VBA getting a pass on not training, not designing competent and reliable working processes, and not held accountable for performance that meets a passing score?  Not mentioned in this VA-OIG report, due to being outside the scope of the investigation, is the longevity of this single issue.  Why is a Congressional Blue-Ribbon panel not demanding historical information, and detailing for the American Taxpayer, especially the veterans involved, the significance of the rating problems and holding accountable those who designed the incompetence into the process?  By the time the VA-OIG reports are released for public distribution, there is supposed to be an alert to the Congressional Committees overseeing these government agencies.  The media is often alerted at the same time the Congressional Committees are informed; yet, a failing score in rating the “Spinal conditions [accounting] for two of VA’s top 10 service-connected disabilities, doesn’t even merit crickets.  Media why not stop reporting junk, and start reporting problems needing rectification?

If you want the full report, use the following link.  The full report is design incompetence of the greatest magnitude.  Elected officials, it is past time for action on the issue of design incompetence that allows substandard performance in government service!

Where designed incompetence continues to be the applicable excuse for poor performance, look no further than the Veterans Health Administration (VHA).  The VA-OIG report on Hospice and Palliative Care (HPC) is a full-on description of design incompetence to rival the VBA and maintain their lead on abusing veterans for personal power.  Consider the following, “… The OIG determined that 10.3 percent of the reviewed patients had a formal HPC consult or an HPC-related interaction/conversation without a designated HPC consult or stop code.”  Of those records, the 10.3% who were appropriately handled, and the 87.3% handled improperly, 100% of the patients reviewed experienced issues where “… administrative data did not reflect all HPC services provided by VHA. Inaccurate administrative data indicate that VHA has an incomplete understanding of how much HPC service it is providing or how much is needed, which could affect [the] allocation of resources and planning.”  Design incompetence allowed for every patient to have problems with information related, services the HPC provided, and the “VHA has opportunities to ensure that HPC consults are documented and coded accurately to account for HPC services.”  “Opportunities,” 100% of the records had administrative issues, 89.7% were improperly handled, “opportunities” might be a slight understatement.  Show me a successful business where 89% of the customers are mishandled, and 100% of the customers are provided inaccurate information when contacting the company for answers, and I will show you the floating mountains of Pandora in reality!

Secretary Wilkie has his hands full, and entirely tied, by the bureaucracy, employee inertia, and the uphill battle with intentional design incompetence that allows people who have been in their jobs since Adam and Eve left the Garden of Eden, to still not know how to perform their job.  Federally elected officials, I must ask, “How can a VA employee qualify for retirement or continued employment, without knowing the job, or doing, the job they were hired or promoted for?”  Like fingers on a hand, the Federally Elected Officials have employees placed in leadership positions doing the business of the elected officials, if those employees cannot honorably do the jobs, they do not need to remain in your service, as you serve those who chose you on the ballot.  Is this pattern clear?  The voters hold you responsible for how well the government works, why are you not holding those in your service accountable and responsible for their inaction and their designed incompetence that promotes a ready-made excuse for dismal performance?

From personal experience, design incompetence is the only excuse many VA employees have, and the excuse is worthless.  There is a director of a major department of a statewide VA Health Care System, who refuses to write things down for fear of being held accountable.  Hence, every employee under this director’s leadership has adopted the same philosophy, no written guidance, written policy, no written procedures, and this situation is considered acceptable direction to this directors’ superiors.  Design incompetence is fought by holding individuals personally accountable, training, and using the performance management process to improve adherence and compliance.  For the VBA and the VHA to continue to allow design incompetence to excuse the inexcusable is a leadership issue which needs immediate Federal Elected Official intervention in support of Secretary Wilkie.  Please give him the tools needed to clean house, correct deficiencies, and establish sound policies to move the VA forward successfully!  The tools include a muzzle on the union, improved hiring, and support for eliminating thugs, criminals, and incompetence at every level of the VA hierarchy.

© 2019 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.

 

Experience + Education + Time + Reflection = Knowledge: Understanding the Formula for Knowledge

The newest baby in the physical begins life with urges, desires, but must learn everything, and along the way discovers a fact as incontrovertible as the rising sun, knowledge requires effort.  From the desire to be dry instead of wet, the baby cries.  From a desire for food, the baby cries.  Thus, physical life begins.  Muir (1930) makes clear that “Thought is matter; thought rules the world.  Thinking is intelligence (knowledge) at work.”  Please keep in mind, this topic continues to be fiercely debated and time does not allow a full exploration of each nuance; however, from seminal thinkers the following attempts to simplify the debate and showcases why the formula for building knowledge is the way portrayed:

Experience + Education + Time + Reflection = Knowledge

Returning to the baby analogy, the baby experiences light, but cannot describe why their eyes hurt from the light.  Thus, the first step in learning is an experience.  Through experience, choices are made, but the lack of understanding of consequences and communicating leads the baby to cry in frustration.  Thus, we can conclude that the first step in knowledge creation is experimenting and the resulting experience teaches preferences (Muir, 1930).  The movie “Teacher’s Pet” provides a quote solidifying the role of experience “… knowledge is the horse experience rides” (Perlberg, Seaton & Seaton, 1958).

Partanen, Kujala, Naatanen, Liitola, Sambeth, and Huotilainen (2013) conducted research on babies in the womb and stated that it is logical that the baby in the womb is learning a language.  Thus, providing the conclusion that the first education lessons are taught and experienced in the womb.  Upon birth, everything is being taught, smiling, laughing, crying, etc. are all lessons to be experienced with educational lessons.  For example, a baby responds to parental cues, smiling when they smile, laughing to make them laugh, crying when the parents are upset or angry.  All learned responses ever before a formal classroom.

Education and experience provide the first step in knowledge, often referred to as A Priori or knowledge gleaned from the world.  For example, the preference to have a dry diaper over a wet diaper.  No one has to explain to the baby that being wet is uncomfortable, creates pain, and is not desirable.  Epistemologists continue to debate whether education and experience are both involved in A Priori knowledge, but common sense tells the student that knowledge that we cannot describe where we learned it, is A Priori knowledge (Moser, 1987; Williamson, 2013).

The next type of knowledge is referred to as A Posteriori or knowledge that comes after a lesson (Moser, 1987; Williamson, 2013).  Consider the difference between hot and cold; how many babies touch something hot, get burned, have pain, and then learn the difference between hot and cold?  A Posteriori knowledge requires the next element in the formula for the full lesson to be taught, reflection.  A Posteriori knowledge requires time to reflect, and time and reflection bring more nuances of the hot/cold lesson to the enquiring mind.  For example, burns have blisters, scabs, pain, and so much more is experienced through the senses.  The smell of burning flesh stinks.  The redness, when touched brings back pain.  If the burn is severe enough, there are hospitals, nurses, doctors, and so much more added to the lesson regarding the difference between hot and cold.

The remaining types of knowledge are as follows, with a brief description:

  • Explicit knowledge and tacit knowledge. A Priori and A Posteriori are opposite ways to learn, so too are explicit and tacit knowledge opposites.  Explicit knowledge is recorded data that can be accessed through books, videos, recordings, and is generally found in formal classrooms and upon the Internet (Collins, 2010; Smith, 2001).
  • Tacit knowledge is the knowledge that is both difficult to translate into words and difficult to separate from emotions. For example, music performed by a young performer may be technically correct, but the emotions are stripped from the performance.  A master musician, in concert, translates the emotions effortlessly, while remaining technically accurate, and is astute to the audience during the performance.  If a junior musician asks a master how to translate emotions, the master musician will find it very difficult to explain how but will encourage the junior to explore their own emotions and continue practicing (Collins, 2010; Reber, 1989; Smith, 2001).
  • The next two opposing classes of knowledge are propositional and non-propositional. These classes of knowledge are also referred to as descriptive or declarative knowledge (propositional) and procedural (non-propositional).  Propositional knowledge is the knowledge that is passed through declarative or descriptive statements, where the teacher knows something is true, but cannot adequately detail how they know it is true.  Propositional knowledge is generally found in closely held beliefs, religions, opinions, and is the embodiment of experiential knowledge.  Propositional knowledge is embodied in formal education (Klien, 1971).
  • Procedural knowledge is usable knowledge. For example, technical manuals are full of procedural knowledge or step-by-step instructions to complete a task.  Procedural knowledge is the only knowledge that can be cited in a court of law and is the fundamental description behind intellectual property.  Procedural knowledge can be bought, sold, traded, protected, the rights to procedural knowledge can be leased, all because of the usefulness of procedural knowledge.  Procedural knowledge is all about gaining experience (Corbett & Anderson, 1994; Willingham, Nissen, & Bullemer, 1989).

To gain knowledge in any of the classes identified, we have shown that experience and education need time and reflection to empower the knowledge gained into usefulness.  Each of the classes of knowledge has learning theories to aid the student to explore that class of knowledge and more fully draw out lessons for future use.  For example, procedural knowledge could be learned through cognitive learning theories (Atherton, 2009; 2010), through Pavlov’s classical learning theories (Clark, 2004; Bitterman, 2006), and many more theories.  There is no explicit right or wrong in knowledge attainment, the formula provided simply reflects the steps to creating knowledge, and each individual will reorder these ingredients based upon needs, desires, and personal application.  A master artist in sculpture might have a different order for their knowledge attainment than a master painter or musician; however, all the masters will be able to communicate due to their mastery, not the order they place the ingredients in knowledge attainment.  Key to the knowledge attainment formula provided is that learning never ceases.  Each experience provides new lessons that will require time and reflection to completely master, or attain.  Hence the need to know how knowledge is created and the importance of the formula for future experiences, formal and informal educational opportunities, and desires for new knowledge.

A final aspect of knowledge is that knowledge can be gained and lost (Howells, 1996).  A lack of choosing to learn or experience robs time and costs knowledge.  For example, the ability to read can be taught, but when not practiced, it becomes harder and harder until the ability to read is lost.  Understanding what is read, can be taught, but the harder reading becomes, the less the words are understood until all understanding in the written words has been lost.  Due to the nature of gains and losses in knowledge creation and retention, it behooves the individual to choose to be continually learning, experiencing and employing time and reflection to capture the available knowledge (Teece, 2000; Tough, 1979).

References

Atherton J. S. (2009) Learning and Teaching; Cognitive theories of learning [On-line] UK: Retrieved from: http://www.learningandteaching.info/learning/cognitive.html

Atherton, J. S. (2010, February 10). So what is Learning? Retrieved from http://www.learningandteaching.info/learning/whatlearn.html

Bitterman, M. E. (2006). Classical conditioning since Pavlov. Review of General Psychology, 10(4), 365-376. doi:10.1037/1089-2680.10.4.365

Clark, R. E. (2004). The Classical Origins of Pavlov’s Conditioning. Integrative Physiological & Behavioral Science, 39(4), 279-294.

Collins, H. (2010). Tacit and explicit knowledge. University of Chicago Press.

Corbett, A. T., & Anderson, J. R. (1994). Knowledge tracing: Modeling the acquisition of procedural knowledge. User modeling and user-adapted interaction, 4(4), 253-278.

Howells, J. (1996). Tacit knowledge. Technology analysis & strategic management, 8(2), 91-106.

Klein, P. D. (1971). A proposed definition of propositional knowledge. The Journal of Philosophy, 68(16), 471-482.

Moser, P. K. (Ed.). (1987). A priori knowledge. Oxford: Oxford University Press.

Muir, L. J. (1930). The upward reach. Salt Lake City, UT: Deseret News Press.

Partanen, E., Kujala, T., Naatanen, R., Liitola, A., Sambeth, A., & Huotilainen, M. (2013). Learning-induced neural plasticity of speech processing before birth. Proceedings of the National Academy of Sciences of the United States of America, 110(37), 15145-15150. doi:10.1073/pnas.1302159110

Perlberg, W., & Seaton, G. (Producers), & Seaton, G. (Director). (1958). Teacher’s pet [Motion picture]. USA: Paramount Pictures.

Reber, A. S. (1989). Implicit learning and tacit knowledge. Journal of experimental psychology: General, 118(3), 219.

Smith, E. A. (2001). The role of tacit and explicit knowledge in the workplace. Journal of Knowledge Management, 5(4), 311-321.

Teece, D. J. (2000). Strategies for managing knowledge assets: the role of firm structure and industrial context. Long range planning, 33(1), 35-54.

Tough, A. (1979). Choosing to Learn.

Williamson, T. (2013). How deep is the distinction between A Priori and A Posteriori knowledge? The a priori in philosophy, 291.

Willingham, D. B., Nissen, M. J., & Bullemer, P. (1989). On the development of procedural knowledge. Journal of experimental psychology: learning, memory, and cognition, 15(6), 1047.

© 2019 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.

Tragedies, Travesties, and Uncomfortable Truths – Shifting the Paradigm at the Department of Veterans Affairs

For the uninitiated, the Department of Veterans Affairs (VA) has three chief administrations the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemetery (NC).  The majority of the problems a veteran is going to experience originates in decisions from the VBA, which then influence care with the VHA.

I believe in giving credit where, and when credit is due; thus, please join me in congratulating the VBA for meeting a significant milestone.  From the VBA press release we find the following:

“On August 11th, VA updated portions of the rating schedule that evaluate infectious diseases, immune disorders and nutritional deficiencies. By updating the rating schedule, Veterans now receive decisions based on the most current medical knowledge of their condition.”

The reason this is good news stems from so many veterans leaving the military with problems caused in the service where the VBA has dictated there is no injury due to the rating scales, forcing the VHA into a treatment problem where the patient is concerned.  More on the rating scales issue momentarily.

I-CarePlease join me in mourning another death at the hands of the VHA, which is labeled by the Department of Veterans Affairs Office of Inspector General (VA-OIG) as “largely preventable.”  A patient in the West Palm Beach VA Medical Center was in a mental health unit and committed suicide.  Largely preventable is a vast understatement when hospital leaders only begin caring about the veteran committing suicide after the suicide, where training and policy adherence was not mandated prior to the suicide, and the lack of cameras and staff monitoring allowed for a patient, already having trouble and this trouble is known to the hospital providing treatment, to take their own life.  No staff monitoring every 15-minutes was occurring; why?  Why were the cameras non-functioning?  How long had these problems been known and nothing was being done to correct these discrepancies.

Let me emphasize a truth about suicide.  A person expressing desire to suicide is not weak or lazy, and they will not “find a way.”  Having had depression sufficient to consider suicide in the past, I can tell you from personal experience that friends help, talking openly and honestly helps, and the emotional burdens placed upon a family when a suicide is successful are tremendous, as well as the guilt the surviving family must overcome.  This veteran did not have to die, their death was “largely preventable,” and for their death to occur on VA property, in a mental health ward, remains a tragedy.  That the VHA dropped the ball and allowed, through leadership failures, non-working technical means, and training deficiencies, this veteran to die is disgraceful!

The VBA is committing travesties of justice every day.  Consider the following, in the past 15+ years since I left the US Navy, I have had discussions with veteran service officers (VSO’s) across the continental United States on my own claim, and while supporting other veterans with their claims.  A recent example serves to illustrate the problem.  A Spine Anatomyveteran has bulging disks in the cervical spine.  The MRI shows disk degeneration, stenosis, and other problems in the cervical spine.  The veteran has an “S-Curve” in the thoracic spine caused by carrying bottled gas containers from the pier into the ship.  There is stenosis and disk degeneration in the thoracic spine.  The lumbar spine has bulging disks, degeneration, and stenosis.  Three separate areas of the spine, three distinct injured areas, yet, the VBA calls the spine issues, “Lumbar strain.”

Any person who has taken human biology in K-12 education can tell that spine issues in cervical and thoracic are not “lumbar strain” and would not need “new and material evidence” to understand that the first decision was flawed.  Yet, for the veteran to obtain a rating for their spinal issues, they must find an orthopedic spinal specialist, not affiliated with the VHA, and get a letter of diagnosis detailing why these separate areas of the spine are not “lumbar strain.”  The current corporate medicine world, finding an orthopedic specialist will require a non-VHA doctor as a primary care provider (PCP) to refer the veteran to a specialist.  Without a significant cash investment, time investment, and replication of VHA completed tests, x-rays, and MRI’s, the veteran will not be able to obtain a letter detailing the issues sufficient to sway the VBA in correcting their initial judgment.

The veteran will be stuck between three bureaucracies, the VBA who is denying the claim for spinal injury, the VHA who cannot diagnose and document a problem sufficient to meet the VBA standards, and the corporate medicine outside the VHA.  Yet, anyone with a passing understanding of human anatomy and biology can logically make the leap that the spinal issues cannot all be lumped under “lumbar strain.”

I continue to ask, “What is a veteran to do?”  Many times, the veterans in this position are either unemployed or employed below their skill level because they are in pain, they have medical issues requiring treatment, and they cannot obtain the treatment needed because the VBA has not allowed a military service claim to be placed upon the medical records for the VHA to treat.  To chain medical professionals to a rigid and dead bureaucracy, by refusing their ability to diagnose a problem for another VA administration is, without a doubt, a terrible decision, and dangerous practice.  To refuse to investigate a medical problem, restricted breathing with chest pain because the pain is not related to heart and lungs remains a travesty and an abuse of the patient.

To the elected Federal officials, why are you not demanding improvement to the VHA and the VBA?  Why do veterans have to die in the care of the VHA before any improvement is made to the bureaucracy you created?  Where does a veteran go to obtain relief from the bureaucratic nightmare where the VBA and the VHA are refusing to help the veteran?  The tragedy in this entire article is that the VA cannot enforce policy adherence, controlling the risks to avoid incidents like those detailed, and demand better performance from the people and the systems that are supposed to help the veterans.  The travesty in this article is the policymakers between Secretary Wilkie and the front-line employees; who is helping the veteran navigate these rocky shoals and dangerous waters of government policy?

I have met some great VSO’s, employees of the VBA and VHA, and interviewed with phenomenal people working in the National Cemetery; yet, they all have the same problem, the millstone around their necks is the regulations, policies, procedures, and red-tape of the VA that has been designed to refuse help as the first response to every question posed.  Thus, as I have asked Senator Udall (D-NM) and Representative Haaland (D-NM), as well as countless other Federally elected officials between 1997 and the present, what is a veteran to do to obtain the help they need from the VA?  Who would the veterans approach for guidance and support?  When the VBA is demanding “new and material evidence” before acting to support a veteran, how does a veteran obtain this evidence?

I know of hundreds of veterans who were affected by an independent duty corpsman in the US Navy who threw records over the side of the ship to avoid being held accountable for bad decisions and patient abuse.  Because these records are not in the medical files, injuries sustained in the service are not documented, and the VBA will use this as an excuse to deny claims.  What is a veteran to do?  Where does the veteran go?  How does a veteran correct something that occurred beyond their control to obtain treatment for decades-old injuries?  You the elected officials allowed the bureaucracy to be built, you are responsible for correcting these issues experienced, what are you doing to affect change and support Secretary Wilkie in fixing the VA, and by extension the VBA, the VHA, and the NC?

The American people are watching how you treat veterans, and we are not pleased!

 

© 2019 M. Dave Salisbury

All Rights Reserved

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

 

Defining Customer Service: Some Examples – Shifting the Paradigms

Gitomer’s, “Customer Service is Worthless: Customer Loyalty is Priceless (1998),” customer service has changed in ways that motivate me to investigate, cheer when found, and when negatives are experienced I want to help fix the problems. Several books and research papers in my library confirm every point Gitomer makes; thus, the following four interactions are compared to Gitomer’s text to supply solutions that can be benchmarked as Gitomer is much easier to read. The intent of this article is to power enthusiasm for change in how customer service is found and improved to inspire customer loyalty.

The Chase bank app delivered an error that made no sense. I called the “Mobile Banking Line,” and then was transferred to another department with “tech-savvy people who could assist me further.” Those representatives were not only unable to aid, but they also could not understand the problem as described, and offered a “local branch.” Upon learning that I lived 264 miles to the nearest Chase bank branch in El Paso, Texas, the representative had no other solution, offered no additional explanation, and for being a senior, tech-savvy representative, was less useful than the first representative I spoke with. Thus, I drove the four hours to El Paso, to be at the Chase Bank branch by opening. Not only was the teller having difficulty performing the transaction, the Chase Bank “Customer Service Star” desktop guide posted where I could see and evaluate performance. I was correctly greeted, in the standard big bank demanded-greeting that means nothing and has no humanity, good-job. Everything after that went downhill. When the teller was told that the El Paso branch is the “local” branch for Albuquerque, NM., there was no response. Eventually, the transaction was finally completed, and I was offered a big corporate bank, no humanity farewell, good-job. For a transaction that I can normally complete on my phone, to take 25-minutes in the branch, after a four-hour drive, you would think the teller would have cared, responded, or simply had humanity.

Gitomer offers several suggestions that a customer needs; I offer the most critical customer need, “Response!” When the customer begins a conversation about having to drive from another state to your location, respond. Show an attitude of gratitude, express amazement, ask about the trip, but to ignore the customer and only focus on the transaction, I could have stayed in Albuquerque and gotten that response from the telephone line. Gitomer claims the best customer variable is loyalty. Washington Mutual was my bank; I was loyal from the first thing in the morning to the last thing at night, I told everyone to change to Washington Mutual. Chase acquired Washington Mutual during the banking crisis, and I have been provided a reason to be loyal to Chase to date. I have not been presented a reason to enjoy banking with Chase. Why; because every transaction is ruled by the corporate thinking and inflexibility of big banks who consider themselves “Too big to fail.” Well, lose some more customers, keep ignoring the customers you still have, and another merger to an even bigger corporate bank will be the future.

AT&T, there are several issues in the following story of recent customer service. Frequent readers of my articles will see a common trend, training. Here is another matter where training wins customers. February, I called AT&T looking for a solution; I got a larger price plan and thought all is well. March, I am introduced to the mouse print and discover that “Unlimited Data” has several limits; who knew, obviously not the AT&T telephone representative, or the online Chat representative, I had to visit a local store for an explanation. April more calls to the telephone line, more guesses to close the call. Another visit to the local store for help. Like the shampoo bottle’s instructions, “Wash, Rinse, Repeat” May, June, July, and August will see me going into the local store again on Monday. I promise, my trips to the store are not because I am finding customer service, especially since I must keep dodging sales to get questions answered. AT&T, what is your company training philosophy, procedures, and strategical and tactical reasons for conducting employee training? The current results are not satisfactory, and that problem is not improving.

Gitomer discusses how converted employees become loyal employees. I was a converted and loyal customer to Cingular Wireless, which was bought by AT&T. I was a converted customer of Alltel, which was merged into Verizon and AT&T. I was converted to these companies for the service, clarity, and the lack of mouse-print conditions that the employees do not even know or can explain. Banking and Cellphones have something in common, the product is remarkably similar, and the service provided by employees is the only separating variable between your company and your competition. Chase, AT&T, where is the employee training on distinguishing service and building customer loyalty?

“#6 WOW! Variable: Truthful – Customers want the truth! The customer will find out eventually, so you may as well start with the truth – [especially] if [the truth] hurts” (Gitomer, 1998, p. 97; emphasis mine). AT&T, please heed! Chase, you might want to have the same conversation in your call center as well. When customers start with the telephone line looking for information and receive a lie, you are building a customer event that will cost your company customers! Lying loses customers; this equation should be the number one discussion with every employee. I have spent hours on the phone receiving one piece of information, only to walk into the AT&T store and get handed more mouse print. Thus, when training, emphasize the need for clear, concise, truth; served openly and with conviction.

Like many US Military Veterans, I am regularly stuck between two bureaucracies in dealing with the Veterans Administration. However, there is nothing more frustrating than getting the same issues in non-government health administrations. Corporate medicine began in the late 1980s in America, and since then community hospitals have become giant behemoths where bureaucracies reign.  These establishments have yet to understand they must pay attention to the customer/patient, not the insurance company, and indeed not the voices in their heads. Hospital directors, leaders, and providers, what do you do when a patient/customer walks in with cash and asks for service? I walked into the University of New Mexico, Orthopedics Department, plopped $2000.00 in cash down and asked for 60-minutes of time with any provider who was available for a letter I need. Records were available, x-rays, MRI’s, and a host of data. The letter would take less than 60-minutes, and I do not know anyone who would turn down cash and a payday of $2000.00 for an hour or less of work. Yet, not only was I turned away by the bureaucracy, I was informed I would have to travel an hour to another location instead of where I was, because I had been treated there two-years prior. But, I would still not be able to obtain the letter I needed as the other department is neurology. To receive treatment at the specialist demanded by the VA bureaucracy, I must first find a primary care provider who would refer me to a specific provider in orthopedics, before I could finally discuss the potential to fill my need.

Gitomer talks about this principle. The customer does not care about your processes, procedures, policies, and propaganda. The customer cares about what they need, what they offer, and how to obtain what they need. When I called AT&T this week, the third person I spoke with started every answer with “I apologize.” The UNM representative did the same thing in refusing my money and their services. The UNM representative also pulled the “Let me check” run out the office, reappear, helpless, act, to attempt actually to be helpful. The same act is done by telephone representatives who place a customer on hold to “check with a supervisor.” The customer knows what you are doing, and I, for one, am not impressed! Gitomer emphasizes on this point, and if the apology does not come with a solution that gets the customer to what they need, the apology is an excuse that is lame, weak, and useless.

03 August 2019 email messages were sent to three Federally elected representatives of New Mexico, Congresswoman Debra Haaland (D), Senator Tom Udall (D), Senator Martin Heinrich (D). I asked them if they were interested or cared about the veterans in their districts and what is occurring in the Albuquerque VA Medical Center. Their silence testifies to their disregard to their constituents. Unfortunately, this treatment or abuse of their constituents is not limited to the few representatives from New Mexico. Friday, I received a boilerplate email response from Senator Tom Udall’s staff, auto signed, with wording that clearly claims, I do not care about you or your issue, leave me alone, and stop bothering me. As the sole respondent in three elected officials, as the customer, voter, and citizen, I am not pleased!

Each of the above situations breeds a question; “Why should I remain a customer, patient, voter?”

The solutions are clear:

  1. Train employees. Encourage employees to walk customers through different solutions using the truth mentally. Apologize only when you have a solution and mean you are sorry. False apologies are as useful as a blunt needle, you might get the job done, but you are going to drive yourself and everyone else crazy doing the job. Show why training is occurring. State the strategy, so the tactical actions requested make sense to those being trained.
  2. Respond to the customer. Active listening is only half the communication effort, forming proper responses means building upon what the customer said with your response. Failure to respond appropriately, and the customer situation is worsened for the next person to communicate with this customer.
  3. Gitomer asks the following question, “What will it take to end measuring ‘[customer] satisfaction’ in your business” (Gitomer, 1998, p. 257)? I guarantee that the answer to this question is going to cause significant angst in why and how you communicate with customers. I am fairly certain, the answer to this question is going to disrupt every communication channel’s operations and daily tactical actions requiring a review of operational strategy. Business leaders, do you dare to ask the question? Are you prepared for the answer?
  4. Gitomer, Chapter 16 (p. 234-248) details change and how to make the change effective in your operations. The 10.5 points are useful, but what comes next is the best plan for moving forward successfully.

Leading to the final question:

“What will you do now?”

 

Reference

Gitomer, J. (1998). Customer Satisfaction is Worthless, Customer Loyalty is Priceless: How to Make Customers Love You, Keep Them Coming Back and Tell Everyone They Know. Atlanta, GA: Bard Press.

 

© 2019 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.

Uncomfortable Truths – Procedural Breakdown and Leadership Failures

I-CareOn the 5th of August 2019, a VA-OIG report was delivered, but I was unable to comment due to the tragic incident documented in that VA-OIG report.  A veteran died, and while this of itself is troubling, the tragedy was how that veteran died.  Thus, the delay in writing about this veteran’s death and the VA-OIG report.

For the record, I worked at the Albuquerque VA Medical Center from 2018-2019.  From my first day to my last, I asked for, begged, pleaded, and reported that a lack of written procedures opens the VA to avoidable risks.  I was instructed several times by employees who had a minimum of five years in the administration of the hospital, who led the hospital mainly after hours, that writing anything down means responsibility.  But, responsibility is avoided at all costs by the leadership who are keen to keep from losing their power and job if something went wrong.  I countered that written procedures, where training on those procedures is documented, means that responsibility and accountability do not, automatically, result in lost employment, all to no avail.  Thus, the VA Medical Center in Albuquerque operates by gentlemen’s agreements, verbal directives, gossip, and personal opinion.

How is this accountable leadership?  What will it take to change this culture of irresponsibility?

The VA-OIG report documents that a nurse inappropriately labeled the patient as dead and did not commence resuscitation efforts.  Documentation was not completed, appropriate processes and procedures were not followed, and proper training was not conducted.  The crash cart, for a Code Blue emergency, was unlocked and deficient.  The leadership teams and committees did not correctly follow procedures and review the incident.  Reprehensible, detestable, and criminal are just some of the adjectives I have been using on this incident; but, the VA-OIG made nine recommendations.  Why does this not comfort me, comfort the family who lost a loved one, or suggests to America the problem will not be repeated?

I know the written procedure problem exists in the Phoenix Arizona VA Medical Center, the Cheyenne Wyoming VA Medical Center, and the Albuquerque New Mexico VA Medical Centers as I have been a patient of all three.  From the VA-OIG report, I must presume this problem is VA-Medical Center-wide, and I have to ask, why?  The military believes in writing everything down, redundancies, and accountability for records and documentation are taught from day one.  How is the VA able to operate without documentation, written processes, and documented procedures?

A running theme in the VA-OIG reports delivered since I began tracking VA-OIG reports in 2015, continues to be that documents are not properly completed, not maintained correctly, not audited timely and appropriately, or missing entirely.  Missing written procedures detailing how to perform tasks, and leadership were not forthcoming with the written procedures and policies needed to complete the tasks appropriately assigned.  A hospital in the private sector with these problems would be inundated with malpractice lawsuits, Federal inquiries, and threatened with closure; yet, the VA can operate without document controls, written processes and procedures, and escape any consequences, why?

The VA-OIG report detailing the death of a veteran in a behavioral health unit is not the first, nor will it be the last; but it should be!  This veteran’s death should be a clarion call for every hospital director in the Department of Veterans Affairs, Veterans Health Administration, to demand an immediate correction, that leads to written procedures, clearly defined directions, and training in following those procedures — then monitoring those procedures for updates and shelf-life.  This veteran’s death doesn’t even raise the eyebrows or curiosity of the lowest congressional staffer, and that is shameful!

Senators and Congressional Representatives, what are you doing to support Secretary Wilkie and his team in demanding answers and implementing corrective action?  Hospital directors, what are you doing to fix this abhorrent behavior in your hospitals?  Hospital directors, what are your directors, supervisors, and leaders doing to improve performance and follow Secretary Wilkie’s leadership to enhance the VA?  There is no excuse for another dead veteran at the hands of the providers and nursing staff in the VA Health Administration.

America, please join me in mourning another veteran’s passing.

This veteran did not have to die!

 

© 2019 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.

 

Leadership and the Department of Veterans Affairs – Shifting the Paradigm on Killing Veterans

I-Care

Since the beginning of 2019, a running theme in the Department of Veterans Affairs Office of Inspector General (VA-OIG) reports, that I have delivered via email, has been the lack of leadership.  Today’s VA-OIG report is a perfect example of discussion and remains significant due to a veteran being killed by the Spinal Cord Unit in San Diego, CA.  I fully submit that VA Secretary Wilkie is trying to reform the Department of Veterans Affairs.  I fully offer that the nurses and providers, as well as other front-level employees at the Department of Veterans Affairs, are trying to do a difficult job in a bureaucratic nightmare.  I contend that the mid-level managers between the supervisors and Secretary Wilkie need removed and processes redesigned.

Using today’s report, we find causation for removing mid-level managers to streamline leadership effectiveness and potentially save patients.  The VA-OIG claimed, “At the time of the patient’s death, the SCI unit used an outdated nurse call system that required the use of a splitter to connect the ventilator to the call system, none of the respiratory therapy staff had training or competency assessments related to PMV use, staff failed to report the patient’s ventilator tubing disconnections through the Patient Safety reporting system, and SCI leaders failed to follow the standard operating procedure for the management of clinical alarms.”

Outdated technology is inexcusable, especially for all the money continually pumped into the Department of Veterans Affairs to update technology.  Who are the mid-level managers in charge of procurement that have failed to do their job and improve technology effectively?  VA-OIG, was the role of technology procurement included in this investigation?  If not, why?  If so, where is that report?  I have personally witnessed 10+-year-old technology used for patient care due to inadequate leadership efforts and procurement people wasting time, as well as other resources.  If a root cause in a patient dying is old technology, why are we not holding those in procurement an IT accountable?

Training at the Department of Veterans Affairs is a colossal joke; either the training is bloated, and the user cannot identify which parts are valuable to their job duties specifically, or the training is so shallow that the topics are considered a waste of time.  But, there is also a third option for training; training only applies to managers due to the labor union collective bargaining agreement.  Thus, the front-line worker could use the knowledge, but the union is preventing that knowledge from spreading as that policy has not been approved.  The leaders in charge of training cannot answer basic questions regarding applicability, usefulness, or point to policies and procedures that govern why certain topics are required to specific audiences.  The lines of communication breakdown in training have reached monumental proportions, and as witnessed, is killing patients.  Worse, the training at the VA is governed by third-party LMS software that can quickly be completed without ever influencing the actions of the individual.  Classroom training is a rehash of the LMS training and does not cover the gaps or explain why.  Front-line supervisors cannot answer basic questions about the why behind a process or procedure, nor can they point to a resource where the information can be discovered.

The VA-OIG noted a root cause in their investigation, “The OIG could not determine what the ventilator settings were at the time of the patient’s death, because facility staff who inspected the ventilator immediately thereafter changed the settings to check whether alarms were functional and then reportedly returned the settings to the previous levels.”  If the setting on a piece of equipment is required for a patient safety report, why are there not digital pictures taken?  I find the VA-OIG being unable to ascertain equipment settings to be a complete failure of current technology.  How many smartphones are possessed by patients, staff, providers, etc. that could snap a picture of a piece of equipment for an official record?  Does not the VA issue phones to mid-level managers?  One of the most egregious problems at the VA is designed incompetence to allow a malefactor the ability to hide behind bureaucracy to avoid accountability and responsibility.  Designed incompetence is the problem and I do not see any of the mid-level managers, leaders, supervisors, trainers, etc. acting to eliminate designed incompetence to the improvement of the Department of Veterans Affairs.  Consider for a moment the hundreds of millions of dollars lost in bloated construction projects.  The project leader has vague, inaccurate, old, etc. processes and procedures to blame the failures upon; this is an example of systemic designed incompetence, that protects a lazy employee and costs the taxpayers resources, and the Department of Veterans Affairs reputation.

The VA-OIG reported more root causes in the death of a patient to include, “… the facility did not implement risk mitigation strategies for the use of the in-line Passy-Muir® Valve (PMV) on ventilated patients. The facility did not have a backup monitoring plan when the ventilator alarms were off, patient criteria to determine when the valve should be removed, policies for facility staff and patient/family education on the use of the PMV, policies or procedures for monitoring and documenting ventilator and alarm settings while using the PMV, or a policy to use anti-disconnect devices.”  Risk mitigation is everyone’s job in a VA Medical Center.  Risk mitigation is a facet of every post and included in the third-party software training programs for providers, nursing staff, and clerical staff.  Why did this patient die from a lack of risk mitigation?  What are the tactical risk mitigation actions that support risk reduction strategies?  I have asked this exact question, as an employee and a patient, in two separate VA Medical Facilities and never received an answer beyond simple platitudes.  A root cause in a patient dying was risk mitigation strategies; VA-OIG, there is a bigger problem here that merely making a recommendation to leadership can resolve.  If a strategy is not supported with tactical action, there are no strategies; simply wishful thinking and hope statements.  Are the mid-level managers going to be held accountable for dropping the tactical ball here and letting a patient die from systemic designed incompetence?

The US Military believes in redundancy; every mechanical system has a backup, that backup has a backup, and there is a manual backup for when all else fails.  How can the Department of Veterans Affairs claim to serve America’s military veterans without redundancies?  Without training on redundancies?  Without education and real-life training scenarios, to prod thinking before an emergency occurs?  The simple answer, the VA cannot represent, serve, or support America’s veterans without these core competencies built into the processes and procedures that power a learning organization.

I am sick and tired of seeing veterans harmed, abused, and killed at the hands of bureaucratic ineptitude and systemic incompetence that protects the lazy and useless at the expense of veterans.  I am beyond disgusted that mid-level managers, supervisors, directors, etc. have the power to arbitrarily pick winners and losers based solely upon the worship that employee does to the boss when the employee cannot do the job they were hired to accomplish.  It is beyond inexcusable to see no job-specific duties, processes, and procedures that provide tactical action for strategic aims at every workstation where training is held daily to meet the strategic goals of the medical facility.  The Department of Veterans Affairs needs to begin cleaning house of the criminals, the incompetent, and the lazy that are supporting a reputation of killing veterans through designed incompetence, as they masquerade as supervisors, directors, managers, etc.; there is no excuse for killing another veteran!

© 2019 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.

Shifting the Paradigms: A Hybrid Leadership Theory Plan – Allowing One’s Self to Create a Leadership Theory Template

Man, as defined as a species, learns by doing; this principle of learning is best showcased by the poem “What man may learn, What man may do” penned by Robert Louis Stevenson.  First, we see, and then we do; if “Imitation IS the sincerest form of flattery,” as proclaimed, then leaders are neither born nor made; thus, leaders are formed through the flattery of perception and emulation (Martin, 2012) [Emphasis Mine].  For example, a new recruit in the military, any military, learns how to be a leader by following, perceiving, and copying those placed above them.  The same pattern is copied time and time again until the top of the leadership pile is obtained or until something drastic happens to the top rung, i.e., premature death, elections, and other influences. This theory of leadership evolution places the training of the leader squarely upon the individual aspiring to lead.  The aspiring leader must choose whom to emulate, and in choosing, form decisions about why he chose that leader over another of equal or greater rank to emulate.

Emulation as a leadership theory places personality, emotional intelligence, preferred organizational culture and environment, and every other aspect of the leadership environment into the hands of the person aspiring to lead as choices of preference, while also removing excuses and leaving the leader fully responsible, accountable, and liable for the consequences.  As a species, we not only mimic those we hold in esteem, we magnify them.  Thus, a learner emulates certain behaviors and increases those behaviors (Coloroso, 2008).  Just as a child is taught to hit by watching his parents beat each other and the child, the child will not only hit but also will not understand hitting is unacceptable and will increase violence past hitting to using weapons other than fists.  The third generation of being taught hitting is acceptable generally moves to murder and incarceration.  Upon emulation, magnification occurs, and patterns will continue until stopped.

More often than not, leadership through emulation theory is interconnected to spiritual leadership theory. Fry (2005) claims spiritual leadership theory “… was developed within an intrinsic motivation model that incorporates vision, hope/faith, and altruistic love, theories of workplace spirituality, and spiritual survival through calling and membership.”  While Fry (2005) continues to justify this position, leadership through emulation remains a great-uncharted unknown or only researched through the bias of religious lenses and discounted.  Yet, the great truth remains; humans learn through seeing and doing, and thus, leadership occurs through emulation and agency.

Religion is merely a set of beliefs and practices people adhere to voluntarily.  The term spiritual discusses closely related character interests, attitudes, and outlooks.  While not devoid of religion, spiritual leadership theory does not entirely apply to the reality of life with enough applicable strength to overcome individual zealots or the anti-religious zealotry found in many organizations.  Many people do not realize that allowing religious freedom means accepting the term religion without feeling encumbered to onboard a religious theory.  Fry (2003) expounds upon the spiritual leadership theory, and while this theory includes many aspects of corporate responsibility personally held dear, the reliance upon religion can be a hindrance for those followers who might choose to lead but remain anti-religious.  Wren (1995) discusses leadership theories but focuses too much on a few while denigrating those not mentioned.  By relying too heavily upon charismatic, transactional, and transformational leadership, Wren (1995) loses the forest grandeur by focusing on seeds, not that this diminishes seeds, but there is so much more to see and experience.  The following leadership plan relies heavily upon what works and includes pieces of spiritual leadership for the active moral and ethical code, emulation leadership theory, and flexible thinking in organizational structure design.  The result is a highly trained, experienced, effective leader, capable of creating success in many different industries, environments, and situations.

All successful leaders like Presidents Lincoln, Jefferson, and Washington, Thomas Paine, Benjamin Franklin, among others emulate moral fortitude and character as well as personal integrity to leadership principles and existence in productive work efforts.  These leaders stood firm for core beliefs including truth, justice, mercy in the face of war, and built followers, who could then lead in difficult times and lead well.  The primary chain linking all these leaders remains a single item: when faced with a decision, they acted with no hesitation, no spinelessness, and no hypocrisy.  By choosing whom to emulate, in emulation leadership theory, the best can be onboared, magnified, and broadcast back into the organization forming a bulwark anchoring other people aspiring to become leaders.  Brady (2005) discusses levels of influence in launching a leadership revolution.  Part of the first level requires the aspiring leader to know the environment, history, basics of the organizational culture, and much more.  The main point in the plan is to emulate the best, choose new principles to include, discover new ideas that work, and employ this knowledge in direct personalized solution.  Due to the high amount of emotional intelligence inherent in the current employer organization, transactional and charismatic leadership are of limited functionality.  Transformational leadership theory has more application but does not include many elements needed to enforce the plan or to achieve success.  Leadership requires follow-on levels of influence that include preparation, desire, understanding the role of learning and adversaries, loving people, and developing people, who will choose to develop others.  Of particular importance is the principle of loyal opposition, also known as a courageous follower.  Building upon Chaleff’s (1995) discussion about the “Courageous follower” becoming a courageous leader, who can influence change, lead-in difficulty, and conquer, it remains imperative for followers to become those they emulate or the entire period of training is not valued by followers (Yukl, 2006, p. 134-139).

Personal strengths include a vast repertoire of benchmarks, successes and failures, working knowledge of psychology, depth as being a follower in stressful situations, and the drive of a bloodhound to find and fix.  Skills and talents under constant construction include communication, manners, modesty, and developing interpersonal skills between peers and current leaders without causing insult.  Personal weaknesses include a distrust of followers leading to problems with the delegation of authority, a reluctance to allow failure in followers, and an own abhorrence to perform tasks a second time after a failure.

The leader currently in existence needs experience to improve as described by Brady (2005), Jossey-Bass (2003), and others.  The leader imagined and envisioned for the future needs seasoning to become a reality; thus, allow yourself or your followers time to build into the leadership plan outlined.  The gaps are minor, and the weaknesses cannot improve without more experience in handling complicated situations.  In vague terms, the timeline might look something like this.  Within the next year, advancement would be from customer care professional in fraud to a curriculum designer or teacher/trainer/coach of adults for the current employer.  Within the next three years, or by the conclusion of an academic degree program, advancement would be from designer/coach/trainer into leading other coaches/designers. Within the next eight years, progress would be to a service delivery leader guiding leaders of other coaches/designers/trainers and eventually be advanced to a director of corporate training or vice president of training delivery and human resources.  Keeping this euphemistic plan on track requires sticking with a single employer, building a solid personal brand based upon successes, leveraging educational degrees while maximizing the previous experience and new experiences into solutions for the employer.

Recognizing that attitude, failures, and other people acting as variables on this plan requires communicating intent, working with people to convince them that end goals are attainable and the change needed to realize the end result.  Until this plan launches, it remains imperative to exemplify Chaleff’s (1995) descriptions of a “Courageous follower.”  This type of follower can emulate those in leadership positions while supporting the good and learning from current leadership mistakes.  In a seamless transition, the “courageous follower” employs emulation theories of leadership and gains the advantage while building the needed personal brand and accomplishments and preparing for future leadership (Yukl, 2006, p. 134-139).

Avolio (2008), Brady (2005). Paine (1995), and Wren (1995) among others, discuss another aspect of being a good follower and future leader, liberty.  America throughout history has provided excellent examples of what occurs when free people band into a society dedicated to liberty, freedom, and individuals empowered to choose their destiny.  Being a courageous follower requires freedom of choice, and all future leaders, regardless of theories espoused, need to remember the power of freedom when leading.  While some leadership writers discuss empowerment as a panacea term for everything from agency to low-level decision making, empowerment merely is freedom by a different name.  Free followers are naturally empowered to choose, and with training, proper guidance, and organizational support choose with confidence.  This is known as agency or the power to choose with responsibility and accountability for the consequences.  Honing this power to choose wisely, while protecting the opportunity to succeed and fail, promotes a level of trust and commitment to current leaders that improve morale, lifts people, and builds robust organizations.

While less than bare bones in many aspects, the leadership plan described remains flexible enough for significant changes in future prospects while being detailed enough to fit into the current lifestyle of potential interested leaders.  Experience has taught that detailed plans tend to force a locked down mentality in thinking, creating a box that hinders, hampers, and delays.  While some details must be included, a delicate balance is preferred when dealing with the vicissitudes of life.  Staying on track with this plan requires courage, fortitude, and emulation of the best and brightest to become a reality.

References

Avolio, B. J., & Yammarino, F. J. (2008). Transformational and charismatic leadership: The road ahead. Vol 2. Bingley, United Kingdom: JAI Press – Emerald Group Publishing Limited.

Brady, C., & Woodward, O. (2005). Launching a leadership revolution: Mastering the five levels of influence. New York, NY: Business Plus – Hachette Book Group.

Coloroso, B. (2008). The bully, the bullied, and the bystander. (Living ed.) New York, NY: Harper Collins.

Fry, L. W. (2005). Positive psychology in business ethics and corporate responsibility. (pp. 47-83). Charlotte, NC: Information Age Publishing. Retrieved from http://www.iispiritualleadership.com/resources/publications.php

Jossey-Bass, R. (2003). Business leadership: A jossey-bass reader. San Francisco, CA: John Wiley & Sons.

Martin, G. (2012). The phrase finder: Imitation is the sincerest form of flattery. Retrieved from http://www.phrases.org.uk/meanings/imitation-is-the-sincerest-form-of-flattery.html

Stevenson, R. L. (n.d.). What man may learn, what man may do. Retrieved from http://www.poetryloverspage.com/poets/stevenson/what_man_may_learn.html

Wren, J. T. (1995). The leader’s companion: Insights on leadership through the ages. New York, NY: The Free Press.

Yukl, G. (2006). Leadership in Organizations. 6th Edition. Upper Saddle River, NJ: Pearson Prentice Hall.

© 2018 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.