VA Benefit Claims – DNC-Consulting

Front Office vs. Back Office vs. Oversight – Additional VA Horror Stories

Lincoln Weeps Oh, the bitter tears President Lincoln must weep…

One of the most troubling issues facing many organizations is exemplified perfectly by the VA, specifically the Post 9/11 GI Bill. Previously I worked for an online university in a position where I saw GI-Bill problems affecting students on active duty, reserve, guard, and veterans, all being treated in wildly different manners. The school GI-Bill office was expected to be subject matter experts on all things GI-Bill, but they regularly made decisions that harmed the students. By interpreting the regulations and operating procedures differently from student to student. Yet, the Department of Veterans Affairs (VA) is just as confused as the universities trying to bill GI-Bill charges for students.

From a recent VA Office of Inspector General (VA-OIG) report, we find the following:

“The Veterans Benefits Administration (VBA) did not always accurately process enrollments. An estimated 2,500 of 10,000 enrollments from August 1, 2020, through April 1, 2021. About 790 of the estimated errors involved officials either not reporting or underreporting vacation breaks. VBA claims examiners often mishandled enrollments even when the correct information was submitted. The VA-OIG estimated claims examiners incorrectly processed accurately reported vacation breaks for about 1,700 of 2,500 enrollments with errors.”

Why are these enrollments not processed correctly:

“Insufficient training and guidance meant school certifying officials frequently made mistakes.” The VA takes legislation and writes the processes, procedures, and training materials for universities to use for operations and enrollment of military and veteran students. Front office workers interact with students, back office workers interact with internal employees, the VA keeps the records current, and the VA forms the universities’ oversight resembling the blind leading the blind. Yet, the VA cannot write effective training materials, processes, and procedures, conduct training, and support those who support students.

Per the VA-OIG report, the VBA is looking to implement an automated system to prevent these oversight issues from continuing. I do not expect any automated system created by the VBA to work efficiently because of a simple principle, GIGO. The garbage the VBA will put into the system will ALWAYS result in garbage coming out, creating more problems, costing too much money, and still creating issues for students and student-facing employees at universities and colleges across the country. Somehow, the VA-OIG continues to buy these excuses and pipe dreams and reports the same to Congress, which is also purchasing these excuses and poor performances. VA 3

Before someone tries to claim this is isolated to the GI-Bill program, and the GI-Bill program has always been confusing. Using this logic, the health complications at birth can be blamed on the father alone, and the mother’s behaviors do not influence the baby’s health. Here the VA-OIG is reporting on another program governing VA employees, overseen by the OMB, and is incredibly useless as this is a repeated complaint between 2020 and 2022.

“Identity, credential, and access management (ICAM) is a set of tools, policies, and systems used to ensure the right individual has access to the right resource, at the right time, for the right reason in support of federal business objectives. In February 2021, the VA Office of Inspector General (VA-OIG) received a hotline complaint claiming the Office of the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness and the Office of Information and Technology have not agreed since 2016 on roles and responsibilities for VA’s ICAM program. Failures of ICAM contribute to the VA’s inability to effectively comply with the Office of Management and Budget (OMB) policy. The VA-OIG reviewed to determine whether VA effectively governs its ICAM program as required.”

What did the VA-OIG find?

- - The VA did not effectively manage and coordinate its ICAM program, not meeting three of the four OMB governance requirements.
  - The VA did not effectively assign roles and responsibilities, implement a single comprehensive ICAM policy, or meet its technology solutions roadmap goals for fiscal years 2020 and 2021.
  - The VA failed to implement updated digital identity risk management requirements.

Why can’t the VA obey OM oversight?

“These issues occurred primarily because leaders of the different offices performing VA’s ICAM functions have not agreed on how it should be governed. VA risks restricting information from users who need it to perform their job functions without proper governance and leaving information vulnerable to improper use” [emphasis mine].

In this report, the OMB sits as oversight of the VA. The employees are the frontline, and the leaders continue to fail to provide tools, policies, and resources to employees conducting the VA business. What is still an incredibly terrible idea allowing the VA to remain self-governing. Why isn’t the OMB more interested in demanding compliance? Where is Congress scrutinizing how the executive branch agencies are failing and monitoring to improve conduct? VA 3

The VBA cannot still properly and timely adjudicate claims. Again, the VA-OIG lambasted the VBA for improperly adjudicating claims, even with “Special-Focused Reviews.” Essentially the quality assurance (QA) process in claim adjudication continues to fail to help improve claim processing accuracy. From the report:

“The Office of Inspector General (VA-OIG) reviewed VBA’s design and implementation of its special-focused review process, including applying Government Accountability Office (GAO) standards. The VA-OIG team assessed ten special-focused reviews completed from January 2019 through April 2021 and identified weaknesses in all five of GAO’s internal control components. The VA-OIG also found the VBA Compensation Service’s standard operating procedure related to these special-focused reviews does not provide sufficient guidance to support disability claims-processing improvement fully.”

When I worked in QA, root causation was required to prevent future problems. The VA-OIG found that the QA Special-Focused Reviews do not include root causes or explanations for why the claims were readjudicated, stopped, or delayed in VBA processing. Do not repeated issues reflect the need to restrict self-governance until compliance can be observed? VA 3

Why should the VA have its self-governance restricted or prohibited? The following VA-OIG makes clear that the VA cannot govern itself and correct the problems leadership continues to create. Follow the timeline here, quoted directly from the VA-OIG report:

“The VA Office of Inspector General (VA-OIG) conducted this review to determine whether the Veterans Benefits Administration (VBA) accurately adjusted compensation and pension benefit payments for fugitive felons as mandated by law. If VBA does not adjust payments, veterans who are fugitive felons will continue to receive benefits during periods of ineligibility.

In April 2012, VBA instructed regional offices to postpone making decisions on fugitive felon cases while it prepared new guidance. During 2012 and 2013, VBA did not process fugitive felon cases. In June 2014, VBA updated its definition of a fugitive felon to include only referrals indicating escape, flight, or violation of probation or parole conditions. Although VBA then resumed adjusting payments, it did not review the unprocessed 2012 and 2013 cases.

In addition, due to inadequate monitoring, VBA did not process about 46 percent of cases referred by the VA-OIG in 2019 and 2020. Finally, the team found VBA’s notification letters to veterans providing notice of the proposed action and right to a hearing did not always provide the required information. Most commonly, VBA failed to include the reason for the issuance of the arrest warrant.”

The VA has been informed by the VA-OIG multiple times during the decade this problem has been surviving, and 46% of the cases the VA-OIG told the VA to fix still weren’t fixed in 2022. How can any oversight agency still permit the VA to govern itself? The leaders of the VA cannot self-govern, correct course, and make changes timely enough not to create additional expensive problems for veterans. Each of these cases represents either an overpayment, where the VA is clawing funds back, or an underpayment, where the veteran has been shortchanged and is owed money.

When the VA claws money back from making a mistake that overpaid a veteran, dependent, spouse, or other entity, the VA-OIG has found that even here, the VBA cannot act per their policies, follow procedures, or notify veterans in a timely manner. A veteran I got to know who served in Vietnam and caught a round in the heart that blew away a large chunk of his heart. For 50 years or so, this was sufficient to have a 100% disability. On the day he turned 69, his disability rating dropped to 80%, with a coinciding reduction in monthly benefits. The VBA investigated this claim decision and found they had made a mistake, but their mistake would not significantly change the rating, so the veteran was stuck with an 80% rating and was told to go back to work. VA 3

To the best of my knowledge, the claim remains stuck in claims appeal hell, awaiting the judgment of the dark and benighted realms to act. The veteran, who cannot hold a job due to weakness from lacking a significant part of his heart muscles, is driven into bankruptcy. His heart will not regrow, but because his age has met the age when heart problems are actuarially known, the decision was made. The decision was made without notification to the veteran, and the veteran only became aware of the situation when he had monies clawed back by the VA. From the time the decision was made to the date he knew, 18 months had transpired, and the veteran was automatically sent to collections. While this was never allowed to become a VA-OIG investigation, I have spoken to family members and the veteran while volunteering to help disabled people find employment. I-Care

To add the bitter cherry to this crap sundae, this is not the worst abuse I heard in my volunteer efforts. Worse, this is not the worst story I have had related while talking to veterans in my travels across the continental 48 United States. Veterans sit forever in claim hell; they cannot afford to go forward, they are abused when seeking medical help, and every interaction with VA medical providers runs the risk of being the victim of an “adverse medical event.”

To this point, the VA and the VBA have been central to proving that the VA cannot self-govern, oversight is failing, and the back office administrators are hindering the front office operations. Surely the Veterans Health Administration (VHA), where people’s lives are at risk, would not have a similar problem. Unfortunately, you would be wrong, and here is one VHA example, of many, to support this conclusion:

“A VA Medical Center (VAMC) community living center (CLC) staff delayed life-sustaining treatment for a patient (Patient A) who experienced cardiac arrest and died. The VA-OIG also reviewed an allegation regarding a second patient (Patient B) who had resuscitation initiated, despite a do not resuscitate (DNR) order in the electronic health record (EHR).”

Why did one patient die without resuscitation and another get resuscitation without wanting it? The policies and procedures were complicated, and the use of armbands confused the providers. The providers (doctors and nurses) overseeing care had a person in the medical records of these patients and still could not properly act for patient care. The patients had armbands and proper medical documents on file, and the providers still got confused and provided poor care, at best, to the patients involved.

America Weeps In another long-term care facility under VA operation, the following occurred:

“The VA-OIG found that the day charge nurse’s assessment was delayed and incomplete, and the day charge nurse failed to properly document the resident’s reassessments, treatments, and interventions. The VA-OIG substantiated that nursing staff failed to document and carry out a telephone order to transfer the resident to the Emergency Department but could not determine if this impacted the patient’s outcome.”

Let’s take a moment to allow this to sink in fully. Failure to follow a doctor’s orders might have been part of the problem the patient DIED! Yet, the chain of events is sufficiently blurry to mystify the investigators – this I find HIGHLY SUSPECT! But, as the Home Shopping Network reports, “There’s more!”

“The VA-OIG determined that following the resident’s death, facility staff failed to conduct a comprehensive review of events leading up to and contributing to the resident’s death and, due to a lack of coordination of care at the time of discharge from the inpatient unit, the resident did not have the needed equipment upon admission to the CLC.”

I accept that a nurse’s role is stressful, the VA policies do not make their jobs less stressful, and the healthcare leadership (overall) is abysmal on the best days. However, killing a patient is still a BAD thing! I-Care Yet, here we have another dead veteran at the hands of the medical care providers, and the best the VA-OIG can do is make ten (10) recommendations for change. Does anyone believe the VA can continue to self-govern under its current misguided leadership and convoluted organizational structure?

Ask yourself, would the abuse of the veterans mean more if this was your uncle, brother, father, mother, sister, or aunt? They are your family members for the problems which they face; we all face in our constitutional republic. Where is Congress scrutinizing the government? Please become interested, active, and engaged, or we will lose this constitutional republic to the tyranny of the power-hungry despots.

© Copyright 2023 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images. Quoted materials remain the property of the original author.

Updated Inspector General Reports – Department of Veterans Affairs: These Actions Must Cease!

I-Care Long have I written about the Department of Veterans Affairs (VA) and the Office of Inspector General (VA-OIG) reports which cross my inbox. Long have I been utterly disgusted with the waste, fraudulent behavior, and the utter disregard for the patient witnessed in the VA Medical Centers across America. As a veteran and taxpayer, it is past time to begin to see action to rectify these types of issues.

The VA-OIG conducted an inspection to evaluate concerns related to a Virtual Pharmacy Services (VPS) pharmacist’s discontinuation of antidepressant medication for a patient of the Minneapolis VA Health Care System, which resulted in the patient not having prescribed antidepressant medication for approximately six weeks before dying by suicide. The VA-OIG found that the pharmacist never notified the psychologist, never checked the patient’s record, simply discontinued the medication. While the VA-OIG found process and procedure issue, the fact that a medication could be arbitrarily discontinued without a “Red Flag” being raised with the provider and the patient is deeply troubling. Worse, the quality control processes in the pharmacy did not trigger a problem when a medication was discontinued without a provider order; why?

There is a dead veteran, and a pharmacist who claimed they did not know they could access a patient file; and the excuses do not hold water! This incident is a tragedy of epic proportion and I must ask, how many more veterans will die because medications are arbitrarily turned off?

Problems The next VA-OIG inspection is a bit of a pretzel, there is another dead veteran by suicide, and processes and procedures were recommended by the VA-OIG to correct some small issues in bariatric surgery patients. Reading this report, it appears that this veterans’ suicide was not directly connected to preoperative counseling for bariatric surgery which was essentially the scope of the VA-OIG investigation. If there is a connection between the bariatric surgery and the suicide, it was beyond the VA-OIG investigatory scope. Hence, the VA might not be at fault for the suicide, but the VA-OIG recommendations indicate more can and should be done in the future to decrease the risks postoperatively.

Let me be clear, room for improvement to decrease risk does not assign or negate blame in this situation. The death of a veteran through suicide remains a tragedy and the VA can and should be doing more to help reduce veterans committing suicide. With the convoluted processes and the contradictory bureaucracies inside the VA, much more can be done as an organization to streamline and bring efficiency, transparency, and responsibility to the employees making patient decisions.

Chinese Crisis Another VA-OIG report does clearly reflect the responsibility and lack of care a patient received at the VA. The Tennessee Valley Healthcare System in Nashville is responsible for test results still not being properly communicated to the veteran in a timely manner, which delays treatment and care. Fall 2018, a patient went undiagnosed and untreated for pancreatic cancer due to failures in communicating test results, collaborating with the primary care providers, and for the electronic health records not containing a system of alerting providers that an adverse test result occurred. Hence, this patient’s problems have three root causes:

Failure to notify the patient.
Failure to collaborate between different hospital units for patient care and safety.
Failure of the electronic health records programming to include alerts.

From personal experience, I must wonder if any patient notification would have made a difference. The patient notifications are simply the results, not definitions, no descriptions, just ranges, and results. Hence, the patient notification process must include clarity of the results so non-medical people can understand what was found and the implications.

While I applaud the VA-OIG for insisting that an internal review is conducted and problems rectified, I have significant doubts that change will occur. It appears that unless the VA-OIG is following up on their recommendations; which is outside the VA-OIG’s authority, the change will not occur. A truly unfortunate series of events occurred in this patient’s life and the bureaucracy of the VA will prevent anyone from being held accountable for the failures, nor will change occur to protect another veteran.

The W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina, was recently inspected for concerns regarding anesthesia provider’s practice. While no issues were found under the VA-OIG scope regarding the provider’s practices, other issues were discovered. The problems found were all administrative in nature and included the usual training, timely record keeping, following the policies established by VHA, etc. Juran’s Rule states that “When there is a problem, 90% of the time the problem lies with policies and procedures, not people.” How, and when, a person does their job is more often the root of the problem and is evidenced again with this VA-OIG investigation report. The fact that this problem continues at all VA Medical Centers (VAMC) across America is indicative of a systematic issue in poor organizational design, then in the individual employee. The VA must address these organizational issues that breed complacency in employee adherence!

With confirmed cases of nepotism still occurring in the VA, this time in Miami. With continued issues regarding ethics violations and the proper use of time and materials for teleworking employees. With the continued employee obstruction witnessed in so many cases of records not being readily available to VA-OIG inspectors. The VA desperately needs to have a deep cleaning and reorganization. Why has the VA not adopted ISO-9001 for Hospitals? Why hasn’t the VA adopted ISO-9001 for the VBA or National Cemetery as a coherent process for organizational change and improvement?

Consider that there remains a dearth of written processes, procedures, and policies in the VA. So much so that more than one VA Hospital operates on “Gentlemen’s Agreements” between departments, instead of official policy statements and procedural plans. This lack of written policies and procedures is the excuse and the general recommendation of so many VA-OIG inspection reports that I am shocked Congress has not begun asking about this single issue. The first rule I learned as an EMT was, “If it is not written down, it never happened.” I was told this is the first rule of medicine; yet, somehow the VA can escape without writing down how to perform work. Doesn’t that seem strange to anyone else?

Where the lack of written procedures is most noticeable, is at the Veterans Benefits Administration (VBA), where the quality control people missed 35% of the errors routinely, never checked each other’s work, never learned lessons to improve performance, and were not properly supervised. Yet, training, communication, and written procedures are routinely used as excuses, and corrective action is outside the VA-OIG investigatory scope. So, while the problems are being identified, the leaders are refusing to do their jobs! From the VA-OIG report comes the following details:

“The VA-OIG estimated that during the review period, regional office managers inappropriately overturned errors in 430 of 870 quality reviews (about 50 percent) where claims processors requested a reconsideration from a quality review specialist- identified errors. The VBA has not established adequate oversight or accountability to ensure the timeliness of error corrections. The OIG estimated that during the review period 2,000 of 4,400 identified errors (45 percent) were not corrected in a timely manner and 810 of 4,400 identified errors (18 percent) were not corrected at all.” [Emphasis Mine]

Again, I ask, where are the written procedures that form the standards of work which are used to hold employees accountable? With an 18% error rate never being addressed by quality control, this means that veterans are being underpaid or overpaid for their benefits, and the VBA does not care that these issues are killing veterans.

Survived the VA Personally, I experienced a VA overpayment that took more than 3-years to payoff. Three years where my benefits were docked for an administrative mistake that was not found until the next decision was made on my claim several years after the original mistake was made. What is worse, the mistake I paid for, was not a mistake at all, and the funds were later returned as another quality person found the error and corrected the documents accordingly, but the discovery took another VBA claim decision to catch, from beginning to end this issue of overpayment took three different decisions by the VBA and more than 8 calendar years from beginning to end.

Every single taxpayer in America has a personal stake in seeing the VBA do their jobs timely, efficiently, and correctly. Every single veteran in America has a vested interest in seeing the VBA perform their roles with fewer rates of error than those reported by the VA-OIG. Every elected official in America benefits in some way from the decisions of the VBA and should be able to demand higher quality decisions, better performance, and more transparency from the VBA. Consider, if the problems of performance are this bad for a spot check analysis by the VA-OIG, how bad are the real numbers?

The VBA was also investigated for improper payments to schools through the Vocational Rehabilitation and Employment Program (VR&E) to the tune of $554,998. Most of the errors were in transcribing numbers and the electronic program did not raise any alerts or attempt to rectify the problems, and no quality control system is in place to protect against human error. The VA-OIG investigatory scope included 1.8 million payment transactions from 01 Jan 2014 to 30 Dec 2019. While this is a much better error rate; the fact that the technology and the work processes were not catching these errors timelier, which means more billing issues, more wasted resources, and more problems for the VA, the VBA, the VR&E program, the taxpayer, the colleges and universities, and the impact goes on and on.

The VBA was also recently inspected for failing to accurately decide service-connected heart diseases. The root cause was the questionnaire developed to ascertain what and when regarding the heart diseases experienced. Six months, 01 Nov 2018 through 30 Apr 2019, were selected and 12% of the claims were improperly decided which totals $5.6 Million in improper payments where a veteran either received too much or too little for their claim. Necessitating repayments or backdated payments once new and material evidence was procured to force the VBA to make a new determination. Inaccurate decisions on claims involve a lengthy appeals process, expenses for testing, and the veteran is always responsible for the mistakes made on their claim. Thus, the exasperation of these mistakes on the families, friends, and communities of the veteran involved in a VBA mistake.

When the VA-OIG finds errors made by the VBA the veterans affected are not notified that the VBA made an error in their determinations. The VBA does not form a task force to evaluate these errors and correct them internally unless money is owed and then the collections department is left to muddle through the decision, not the VBA. Thus, when veterans ask for transparency in the VBA processes, we are asking for the VBA to own their mistakes, fix the problems they are creating, and correct the errors in a timely fashion. It should not require new and material evidence to trigger the VBA to make a new determination when the VBA made the original mistake in determining eligibility in the first place!

All because the quality controllers do not have written procedures to measure standards of performance against. All these errors are due to improper organizational design and old computer systems, which are ready-made excuses for not performing work in a timely and efficient manner. All because the leadership fails to delegate, monitor, observe, and function. Why are the leaders missing, because they are all in meetings, all day, every day, and not at their desks!

Military Crests Just like the labor union provided bumper sticker proclaims, “SAVE the VA!” [Emphasis in original], it is time to “SAVE the VA!”

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.

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

Insane Abuse – The VA Edition: The Leaders of the VA Must Shift the Paradigm

I-Care During new hire training for working at the Department of Veterans Affairs (VA) New Mexico Medical Center (NMVAMC), the first day contains a lot of warnings about what you can and cannot do as a Federal Employee. Annually, there are mandatory classes that must be passed to remind an employee of their obligations as a Federal Employee. Leading to a question, “How could an attorney for the Department of Veterans Affairs – Office of General Counsel (OGC), be allowed to break the law for eight years?” The department of Veterans Affairs – Office of Inspector General (VA-OIG) investigated after a second complaint about the same person was received, and only then did the OGC take action. The attorney in question was released from government employment, but where is 8 years’ worth of wages being requested back? Did the attorney lose anything other than an undemanding job and title where they could be paid for not working for the Federal Government while advancing their private practice, violating ethical laws, and breaking several Federal Statutes along the way?

What this attorney has done is insane, it is an abuse of trust, and for it to go reported and not acted by the senior leaders at OGC represents inexcusable abuse!

Problems On the topic of insane and inexcusable abuse of the VA, the VA-OIG investigated the Greater Los Angeles Healthcare System in California and found a supervisor in an “other than spouse” relationship with a vendor and they used the VA property to improperly conduct business on contracts the supervisor oversaw. These actions are a clear and blatant violation of the Federal Statutes on contracting as a Federal Employee, even if these consenting adults were married, it would remain illegal, unethical, immoral, and inexcusable! Yet, because the supervisor quit during the investigation, the VA-OIG has no power to take any action.

Federal Employees are blatantly breaking the law, abusing the trust and honor of their stations, flagrantly flaunting ethical, moral, and legal regulations with impunity. Why?

From the VA San Diego Healthcare System, California, we find another VA-OIG inspection. Staff manipulated time cards for seven fee-basis medical providers to pay these individuals on a salary or wage basis rather than a per-procedure basis. While the medical center took appropriate action and no VA-OIG recommendations were made, the question remains, “Why was this behavior allowed in the first place?” Another supervisor, improperly acting in their office, and abusing the VA; this behavior is inexcusable!

moral-values The VA-OIG performed an audit, also referred to as a “data review.” “The data review consisted of a sample of 45 employees and found the employees were paid an estimated $11.6 million for overtime hours for which there was no evidence of claims-related activity in the Fee Basis Claims System in fiscal years 2017 and 2018, representing almost half of the total overtime paid. Significantly, 16 of the 45 employees each received more than $10,000 in overtime for hours during which there was no claims-related activity.” The Department of Veterans Affairs – Office of Community Care (OCC) is backlogged and this is leading to late payments to providers, delays in care, and is generally a bad thing. However, the sole reason for the overtime being abused was due to a lack of processes, poor supervision, and training. These are the same three excuses that are used by the Department of Veterans Affairs – Veterans Benefits Administration (VBA) and is designed incompetence at its most disdainful and egregious level. Worse, this was a sample of employee misconduct on overtime pay. How many more cases are floating in the OCC that were not included in the audit that will pass unresearched because the VA-OIG did not refer the cases for disciplinary recommendations?

The VA-OIG cannot be everywhere and clean every hole in the VA organizational tapestry. This is why supervisors and leaders are in place to execute organizational rules, regulations, policies, and monitor employee performance. Why are the supervisors and mid-level leaders not being held accountable for failing to perform their jobs? If overtime pay is going to be clawed back from the employee, the managers, team leaders, and supervisors need first to write and train to a policy standard.

Root Cause Analysis The VA-OIG conducted a comprehensive inspection of the Eastern Kansas Health Care System, Kansas, and Missouri. The findings are startling for several reasons, one of which being the deficient lack of leadership leading to poor employee satisfaction, patient care issues, lack of knowledge in managers and supervisors, and minimally knowledgeable about strategic analytics. Essentially, there is a lack of leadership in this healthcare system. The director has been working with a team for 2-months, but the director has been in charge in 2012. Leading to questions about long-term staffing replacement, staff training, building the next generation of leaders, and why this long-term director can brush off the criticisms of leadership failure because the team has only been in place for two months at the time of the inspection.

Again, the VA-OIG audited a system and found a lack of training, lack of oversight, lack of leadership, and made recommendations to “close the barn door, after the horses got out.” From the VA-OIG report we find:

“The VA-OIG found that VA lacked an effective strategy or action plan to update its police information system [emphasis mine]. In September 2015, the VA Law Enforcement Training Center (LETC) acquired Report Exec, a replacement records management system, for police officers at all medical facilities. Inadequate planning and contract administration mismanagement caused the system implementation to stall for more than two years [emphasis mine]. LETC spent approximately $2.8 million on the system by the fiscal year 2019 [emphasis mine], but police officers experienced frequent performance issues and had to use different systems that did not share information. As of April 2019, only 63 percent of medical facility police units were reportedly using the Report Exec system, while 37 percent were still using an incompatible legacy system. As a result, administrators and law enforcement personnel at multiple levels could not adequately track and oversee facility incidents involving VA police or make informed decisions on risks and resource allocations. The audit also revealed that information security controls were not in place for the Report Exec system that put individuals’ sensitive personal information at risk [emphasis mine].”

Behavior-Change No controls, no direction, no strategy, no tactical action, losing money, and not even scraping an F in performance. The repetition in these VA-OIG investigations is appalling! Where is the accountability? Where is the responsibility and commitment to the veterans, their dependents, and the taxpayers? Where is the US House of Representatives and Senate in demanding improvement in employee behavior? Talk about a culture of corruption; the VA has corruption in spades, and no one is taking the VA to task and demanding improvement.

The VA is referred to as a cesspit of indecent and inappropriate people acting in a manner to enrich themselves on the pain of veterans, spouses, widows, and orphans. There have been comments on several articles I authored which would make a non-veteran blush in describing the VA. These actions by supervisors and those possessing advanced degrees do not help in trying to curb or correct the poor image the VA has well and truly earned. A behavior change is needed, culture-wide, at the VA for the tarnished reputation of the VA to begin recovering.

Only for emphasis do I repeat previous recommendations for a culture-wide improvement:

Start a VA University. If you want better people, you must build them! Thus, they must be trained, they must be challenged to act, and they must be empowered from day one in the classroom to be making a difference to the VA.
Immediately launch Tiger Teams and Flying Squads from the VA. Secretary’s Office, empowered to build, train, and correct behavior. These groups must be able to cut through the bureaucratic red tape and make changes, then monitor those changes until behavior and culture change.
Implement ISO 9000 for hospitals. If a person does not know their job but has held that job for over a year, every person in that employee’s chain of command is responsible for training failures. Employees need better training, see recommendation 1, need clearer guidelines and written policies. Hence, with the VA University training, each process, procedure, rule, regulation needs written down, and then trained exhaustively, so employees can be held accountable.

There is a theory in the private sector called appreciative inquiry. Appreciative inquiry is the position that whatever a business needs to succeed, it already has in abundance, the leaders simply need to tap into that reservoir and pull out the gems therein. Having traveled this country and witnessed many good and great employees in the VA Medical Centers from Augusta ME to Seattle WA, and from Phoenix AZ to Missoula MT I know that appreciative inquiry can help and promote a cultural change in the VA. I do not advocate a “one-size fits most” policy for the VA, as each VISN and Regional Medical Center has a different culture of patients, thus requiring differing approaches. However, the recommendations listed above can improve where the VA is now, and form a launch point into the future. Military Crests

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.

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

Desperate Changes Needed at the VA – A Letter to the President

President of the United States
Attn: The Honorable Donald Trump
1600 Pennsylvania Ave NW
Washington, DC 20500

10 May 2020

Dave Salisbury
1947 Edith Blvd SE
Albuquerque, NM 87102

Subject: The Department of Veterans Affairs

Dear Mr. President,

Please forgive my presumptuousness in writing to you directly. I have made several attempts at raising the issues contained herein at lower levels, to no avail. As the Chief Executive Officer of the United States of America, I come to you as the person of last resort. The Department of Veterans Affairs (VA), especially Healthcare and Benefits departments are sick, and in desperate need of urgent corrective action.

The VA-OIG has documented multiple times when claims have been improperly been decided, where training was lacking, leadership failed, and the veteran suffered. Yet, never in the VA-OIG report is a discussion on correcting the past decisions. The process for a veteran to have a previous decision, more often than not improperly decided by the VA, is to produce new material evidence, and wait interminably for the VA to decide they need to act. This single issue is a leadership failure of enormous proportions, that Congress refuses to act upon; thus, the leadership failure begins and ends with the House of Representatives and the Senate refusing to do the jobs they were elected to complete.
While the following is specific to the New Mexico VA Healthcare System (NMVAHCS), the problem is rampant throughout the entire VA healthcare system. I witnessed, 11 December 2019, a VA employee tell a veteran that they would not submit paperwork for the veteran, to the doctor, in the clinic unless the paperwork was “processed correctly.” Meaning that the veteran took an envelope, placed the VA forms inside the envelope, and then mailed that paperwork to the VA Hospital. The veteran lives a significant distance to the hospital and was trying to do in person what had failed through the USPS, this was made clear to the VA Employee. The employee went as far as to claim, “If that form is placed on my desk, I will throw it away because it is not being presented to the doctor in a manner acceptable to the employee.” Never have I witnessed such blatantly disrespectful behavior by a bureaucrat. In true bureaucrat fashion, he created rules to thwart, obfuscate, and dodge work; unfortunately, this is standard practice with the majority of employees in customer-facing positions in the VA. The leadership failure, the protected status of termed (beyond first-year) employees at the VA, and the dearth of customer service skills are all aspects to the core problem the VA is terminally suffering from, bureaucratism.
From June 2018 to June 2019 (5-days short of completing my first year) I was an employee of the NMVAHCS, working in the Emergency Room as a Medical Support Assistant (MSA). I was discharged through lies, deceit, and under the auspices of Quid Pro Quo, where my termination was required for two others to be promoted. While employed, I regularly reported to the leadership team my supervisor, the HAS director, the hospital director, the VISN 21 director, and the VA-OIG problems like HIPAA violations, a physical attack by a senior MSA on my person, fraud, waste, and abuse, as well as potential solutions to improve the ER operations. All to silence and platitudes from the leadership team. Did you know there is a loophole in the whistleblower protections if you are under term employment, (1, 2, or 3 years term) you have no whistle-blower protections, and if your job is lost, you have no whistle-blower protections? The abusers have worked out many angles to protect the dregs of society while allowing malfeasance and misfeasance to proliferate in government employment. Please allow me to elaborate upon the specific issues witnessed:

A 14-year old is being treated in the ER. A 16-year old is turned away. The difference, the triage nurse who decided who gets seen and who gets bumped because the NMVAHCS cannot treat children. When asked what age is considered a “child” under the hospital policy, no answer in 12-months of regularly asking. I saw several times when this repeated, the most egregious was a new military spouse, 17 years old, denied treatment at the ER that services the Air Force Base next door due to being “too young” per the triage nurse. By the way, under Federal Law, this is illegal for an ER to do; yet, this was regular practice while employed.
A health technician supporting ER patient care comes out of the ER and begins to harangue a patient currently being seen, expressing comments that made clear the health technician knew intimate details of that patients’ chart, past care received at the NMVAHCS and other VA Hospitals across the southwester US, and treatment received. Under HIPAA this behavior is illegal, as well as being immoral, unethical, and plain wrong. Yet, HIPAA is regularly broken by MSA’s, Health Technicians, and other care providers in this VA Hospital. Every time these HIPAA violations were brought to the attention of the HAS Director, excuses, platitudes, and professional brush-off occurred, including the deletion of emails reporting these problems. On more than one occasion, the HIPAA violator was promoted to “treat” the problem. When these issues were brought to the attention of the VISN 21 Director, the problem was pushed back onto the assistant hospital director in NM for further consideration. When complained of to Congressional Representatives, lame excuses were generated by the Assistant Hospital Director and the HAS Director and accepted by the Congressional Representatives staff. HIPAA Abuse continues unabated!
Homeless veterans regularly received substandard treatment when compared to other veterans. I saw nurses bad-mouth, scream, and yell at homeless patients. I saw a homeless patient with a broken leg, get delayed treatment for more than four hours because the duty nurse was tired of treating this particular patient and didn’t believe the veteran had broken his leg after a fall. I saw nurses put patients into treatment rooms and left for anywhere between 45-120 minutes because the shift was changing and the nursing staff did not want to treat another patient before their shifts ended. The nurses stood outside the patient’s door, joking, carrying on, and gossiping while the patient listened and waited to be seen. Every time these issues were raised the lamest excuses came from leadership, platitudes, and pie-crust promises were delivered. I reported these issues and more via both verbal and email, to no avail; yet, when a member of Congress’ staff contacted the hospital, there is no email proof that the leadership was ever made aware of these problems. If these are examples of “World-Class Care” being delivered to veterans, I shudder to consider what poor service would include.
The NMVAHCS has a reputation for killing the employment of term employees all the way up to their last day under the term. For example, a house-cleaner employee, a good worker, well-liked by the staff where she cleaned, got into a disagreement with her supervisor and was terminated at lunch on her 364^th day of employment in a 365-day probationary term. Her supervisor did not need a reason to discharge her and used their disagreement to end her employment. By the way, the employee was in the right, and the supervisor made the needed changes after discharging the employee. An MSA male employee, hard worker, came in on his 361^st day of term and was terminated, no reason, no excuse, no justification, simply told to scrape his employment parking sticker and leave. This pattern has repeated so often, that the veteran employment counselor at workforce connections warned me to not accept employment with the VA due to the NMVAHCS’ reputation for ruining people.

The NMVAHCS is one dead veteran from becoming the next Phoenix VA Hospital incident. I am not without hope, but it will take the House and the Senate to enact the type of change needed in the VA to truly see significant and lasting change. Towards this end, I suggest the following:

Draft legislation, one a single sheet of paper canceling the collective bargaining agreement (CBA) of all Federal Government Labor Unions immediately, and forever sundering the death grip the labor unions have on policies and procedures that protect the criminal and steal valuable resources from government coffers through direct and indirect means and methods. The cost of labor unions in government is astronomical and removing this single cost will open funds in Federal Budgets that are desperately needed. I know this is a political hot potato, and I know the impeachment farce continues to be a mental and physical drain. But, as the German Philosopher has said, “The hard is good.”
Draft on a separate sheet of paper, new legislation giving the Secretary of the VA plenipotentiary power, the likes enjoyed by every CEO in the private sector, to enact change. You have a good VA Secretary, but the staff is a hodgepodge of weak-kneed political cronies that should have been retired years ago! This legislation also would allow for a cleaning of house at the VA, realigning the entire organization, placing the power to positively affect veteran lives into the hands of the PACT team and out of the hands of the bureaucrats.
Place power into the hands of a roving IG team to have benefit claims immediately reviewed after a lapse in the procedure is discovered. Meaning that the veteran’s claim affected by bad decision-making by the VA is immediately checked by the VA-OIG instead of waiting around in record purgatory for new and material evidence. Another VA-OIG team should be put to work reviewing past claims where the VA was caught, and getting this backlog cleared out. The appeals process for benefits claims needs a complete overhaul. While this legislation and action might require more than a single sheet of paper to enact, it is the right thing to do.
The Mission Act was a good first step, but the entrenched bureaucrats are hindering and hampering the roll-out for personal gain, e.g. retirement. Encourage Congress to take up the legislation proposed, insisting that nothing else is added to these bills to protect the veracity and simplify the approval process.

I appreciate the work you do. I especially appreciate your classy wife, your well-behaved and intelligent children, and the gains made in “Making America Great Again.” I know the proposals are difficult; but I also know if we do not attempt the impossible, we can never know the realization of the legacy left to each American by those who have sacrificed before and leave a legacy of hope for our children’s children. Thank you for your sacrifice and service.

Sincerely,

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.

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

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