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

I-CareDuring 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!

ProblemsOn 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-valuesThe 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 AnalysisThe 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-ChangeNo 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:

  1. 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.
  2. 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.
  3. 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

© 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/

Tiger Teams – A Potential Solution to VA Issues: An Open Letter to Secretary Wilkie

I-CareTo the Honorable Secretary Robert Wilkie
Department of Veterans Affairs
Washington D.C.

Dear Sir,

For almost a decade, I have read and studied the Department of Veterans Affairs (VA) from the position of patient, employee, concerned citizen, and now as an organizational psychologist.  During this time, I have read many Department of Veterans Affairs – Office of Inspector General (VA-OIG) investigation reports, and yearned to be of fundamental assistance in improving the VA.  I have an idea with potential for your consideration, “Tiger Teams.”

In the US Navy, we used “Tiger Teams” as “flying squads” of people, dedicated to a specific task, and able to complete work quickly.  The teams included parts people, technicians, specialists, and carried the authority of competence and dedication to quickly fixing whatever had gone wrong during an evolution, an inspection, or even in regular operation.  It is my belief that if your office employed a “Tiger Team” approach for speedy response, your job in fixing core problems the VA is experiencing would be easier.  Please allow me to explain.

Tiger TeamThe VA-OIG recently released a report regarding deficiencies in nursing care and management in the Community Living Center (CLC) at the Coatesville VA Medical Center, Pennsylvania.  The inspection team validated some complaints and were unable to validate all complaints because of poor complainant documentation.  Having a Tiger Team able to dispatch from your office, carrying your authority, would provide expert guidance in rectifying the situation, monitoring the CLC, and updating you with knowledge needed to answer the legislator’s questions regarding what is happening.  The VA-OIG found other issues in their investigation that were not covered under the scope of the investigation, leaving the VA-OIG in a difficult position.  Hence, another reason for a Tiger Team being created, to back stop and support the VA-OIG in correcting issues found outside their investigatory scope.

Fishbone DiagramFor a decade now, I have been reading how the VA-OIG makes recommendations, but where is the follow-up from the VA-OIG to determine if those recommendations are being followed and applied?  Too often there is no return and report feature built into the VA-OIG investigation, as these investigators just do not have the time.  Again, this is what a Tiger Team can be doing.  Taking action, training leaders, building a better VA, monitoring and reporting, building holistic solutions, and being an extension of your office on the front lines.  Essentially using the tools from your office to improve the operations locally, which builds trust between the patients and the care providers, building trust between the families and the VA, and delivering upon the Congressional mandate and VA Mission.

Another recent VA-OIG report also supports the need for a fast response Tiger Team.  Coordination of care and employee satisfaction concerns at the Community Living Center (CLC), Loch Raven VA Medical Center, in Baltimore, Maryland.  In geographic terms, this incident is in your backyard.  While the VA-OIG inspection was rather inconclusive, and recommendations were made, it appears some things are working in this CLC and other things are not working as well as they should.  By using a Tiger Team as a flying squad, intermittent and unannounced inspections by the Tiger Team can aid in discovering more than the VA-OIG could investigate, monitoring the situation, and reporting on progress made in improving performance.

As an employee, too often the director of HAS would claim, “That problem is too hard to fix because it requires too many people to come together and agree on the solution.”  Or, “The solution is feasible, but not worth the effort to implement because it would require coordination.”  Getting the doctors and nurses talking to and working with administration is a leadership role, providing support to leaders is one of the best tools a Tiger Team possesses one authority is delegated.  The Tiger Team presents the data, presents different potential solutions, and the aids the leadership locally in implementation.  As an employee I never found a problem in the VA that could not be resolved with a little attention, getting people to work together, and opening lines of communication.  Thus, I know the VA can be fixed.

Root Cause AnalysisThe Tiger Teams need to be led by an organizational psychologist possessing a Ph.D. and a personal stake in seeing the VA improve.  The organizational psychologist can build a team of like-minded people to be on the flying squad, and these team members should be subject matter experts in VA policies, procedures, and methods of operation, and should change from time to time.  I have met many people from the VA who not only possess the passion, but are endowed with the knowledge of how to help the VA, and I would see the VA succeed.  Yet, I am concerned that the VA is not changing, not growing, and not developing the processes and procedures needed to survive, and this is damaging the VA, which leads to wasted money and dead veterans.

Why not have a flying squad for each VISN, who can meet to benchmark, compare notes, and best practices.  Who work from home and visit the local offices in the VISN, reporting directly to your office with a copy to the VISN leadership.  Whose job is to build the Tiger teams needed to oversee, provide expert support, and practical analysis.  The idea is to help you gather real time data, improve implementation of VA-OIG recommendations, and meet the demands of Congress.  If a Tiger Team, with the functioning Flying Squad, can save one VA-OIG inspection in each VISN, by improving that VISN, medical center, CLC, etc. before it becomes a major problem on the sSix O’clock News, then the Tiger Teams have paid for themselves.

All veterans know of the Phoenix VA Medical Center debacle, where veterans died while waiting for appointments.  I fully believe that had the VA Secretary had a Tiger Team in place, the root causes of that incident would have triggered the necessary flags to save lives and avoid or mitigate the catastrophe.  Flying squads are the Tiger Team in action, and action should be the keyword for every member of the team.  The mission of the Tiger Team should be to find and fix root causes, repair trust, and implement change needed to improve VA operations at the Veterans Benefits Administration (VBA), the Veterans Health Administration (VHA), and the National Cemeteries.

The VBA is especially vulnerable, and in need of outside resources to support change.  Recently the VBA was involved in another scandal involving improper processing of claims for veterans in hospital over 21-days, resulting in millions of dollars either overpaid or underpaid to the veterans.  Training, managerial oversight, and proper performance of tasks was reportedly the excuse the VBA used, again, to shirk responsibility.  Tiger Teams can provide the support needed to monitor for, and encourage the adoption of, rectifying measures and VA-OIG recommendations, not just at the VBA, but across the full VA spectrum of operations.

Please, consider implementing Tiger Teams, from your office, assigned to a specific VISN, possessing the authority delegated to run the needed analysis, build support in local offices, and iron out the inefficiencies that keep killing veterans, wasting money, and creating problems.  I firmly believe the VA can be saved and improved, built to become more flexible, while at the same time delivering on the promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.”

I-CareThank you for your time and consideration.

Sincerely,

Dave Salisbury
Veteran/Organizational Psychologist

© 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/

The Department of Veterans Affairs: The Liars and Thieves Edition

I-CareIn December 2019, I witnessed an employee of the Department of Veterans Affairs, Hospital Administration, create rules to inconvenience a veteran, lie to a veteran, obfuscate, and generally mock a veteran.  The incident included the employee threatening the veteran with throwing away documentation, the primary care provider needed because the veteran was not mailing the forms to the doctor as the employee demanded of the veteran.  The veteran must travel and thought dropping off the forms would be acceptable; until he met this employee.  23 January 2020, I was the veteran being lied to, and my “cherub-like demeanor” evaporated faster than dew in a July sun.  For the December incident, I signed my name to a letter going to the Hospital Director Andrew M. Welch, written by the abused veteran, and testified that I witnessed the treatment this veteran received.  To the best of my knowledge, no action was taken by the hospital leadership where this employee is concerned, I asked.  A copy of this article will be sent to hospital leadership.  If any additional information comes available on this issue, I will write an addendum and update this article.

23 January 2020, 1505-1510, I went to my primary care provider’s clinic at the Albuquerque, New Mexico VA Hospital.  I had another appointment, was early, and went to ask why I am receiving letters claiming the primary care clinic is “having difficulty” contacting me.  The employee is titled “Advanced MSA,” which means they are a Medical Support Assistant who has been promoted.  For my other appointment, I have received two text messages, one automated call, and three appointment emails.  For my next appointment, 24 January 2020, I have received two text messages, one automated call, and three emails.  For my appointment in December 2019, I received two text messages, one automated call, and three emails.  I regularly receive calls from other clinics in the VA Hospital.  My cellphone has voicemail, and the voicemail is regularly checked and responses made.  Yet, the MSA claims, “I have tried calling you, and you do not have voicemail.”  I checked my recent calls, and showed the MSA where I had not received any calls from the VA on the days indicated, and asked why I can receive all these other calls from the VA, including the text messages, but only his calls are not showing up.  The MSA then became intransigent, resolute, and adamant, raised his voice, and told me our conversation was done.  After observing the ways and means of this VA employee over the course of many months previously, I wonder, “how many other veterans are not being contacted in a timely manner, while this person lies, cheats, and steals?”

Quality of FindingsUnfortunately, this is the standard, not the exception for the MSA’s in the HAS (Hospital Administration Services) Department, led by Maritza Pittore, at the Albuquerque VA Hospital.  I have witnessed multiple MSA’s committing HIPAA violations through record diving, gossiping about veteran patients, acting rudely, ignoring veteran patients and their families to complete conversations, and refusing to do their jobs.  As a point of fact, one assistant director one told me, “if what the VA does was replicated by a non-government hospital, they would be closed down and sued.”  While employed from June 2018 thru June 2019, I brought this to the attention of the leadership, including multiple emails and voice conversations with Maritza Pittore, Sonja Brown, and several other high-ranking leaders and their assistants, all to no avail.  I have had nursing staff tell me confidentially that they cannot do anything where the MSA’s are concerned because “it’s none of their business and outside their job duties.”  Yet, the VA continues to proclaim the MSA, the Nurse, and the doctor, along with the patient, are a “healthcare team.”  Upon being discharged, without cause, reason, or justification, I brought this information to the OIG, my congressional and senate representatives, among many others, all to no avail.  The level of customer service, especially at this VA Hospital, is far below the pale because the leadership refuses to engage and set standards for customer service, with enforced penalties. I-CareMore to the point, the employees mimic the customer service they receive from the leadership team.  Thus, even though the Federal VA Office has launched “I-Care” as a customer service improvement initiative, the customer service in this hospital continues to fall and will continue to fail until the leadership exemplifies the standards of customer service expected.

As a dedicated customer service professional, I have offered multiple solutions to the continuing problems veteran patients experience in the Albuquerque VA Hospital at the hands of the MSA’s and other front-line customer-facing staff; but the suggestions all continue to fall upon deaf ears.  I do not paint all the MSA’s and staff as liars, thieves, and cheaters, because there are some great people working at this VA Hospital.  Unfortunately, the rotten apples far exceed the good workers by multiple factors and powers, to the shame of the leadership team who continues to ignore the problem, deleting emails, and generally lying when placed on the spot about the problems.

An example of this occurred recently where a member of the staff of a congressional representative asked about communications sent from an employee to the Director of VISN 18, with carbon copies being sent to Maritza Pittore HAS Director, Ruben Foster MSA Supervisor, and Sonja Brown Associate Director of the Hospital.  None of those emails “magically” exist when asked for, and the verbal conversation included outright lies, misdirection, and complete fallacies.

Since the VA-Office of Inspector General (VA-OIG) continues to appear disinterested, I can only ask, “what does a person do to see action taken to correct the problems, right the abuses, and bring responsibility and accountability to the employees of the Federal Government?”  President Trump is providing great leadership, VA Secretary Wilkie is doing a good job and needs more help, but the elected officials in the House and Senate refuse to do their job, and the middle management of the VA is entrenched, obtuse, and inflexible.  The US Media treats veterans’ issues as a punchline to a bad joke.  Still, the problem worsens; still, the abusers maliciously treat people abhorrently; and still, those placed in leadership positions stall, obfuscate, and hinder.

My treatment at the VA Hospital in Albuquerque includes being physically assaulted by an employee, my medical records perused by, and then gossiped across at least four separate clinics, and still that MSA remains employed.  In fact, this employee was promoted for her “good work and dedication to helping veterans.”  I am sick and tired of the poor treatment, the harassment, and the vindictiveness served to veterans of all types, sizes, and colors, at the hands of petty bureaucrats as they visit the Department of Veterans Affairs.  The Albuquerque VA Hospital is one of the most egregious examples of bad behavior and nepotism in the country and it is past time the leadership was replaced and the assaults and crimes brought into the sunshine for some “sunshine disinfectant.”

cropped-snow-leopard.jpgUpdate to this article, 10 May 2020: By the first week in April 2020, the Advanced MSA in the clinic was moved to a less customer-facing post and a new MSA hired.  The quality of that individual was never experienced due to relocating.  The supervisor of the MSA was not very interested in correcting the problems and that showed when I visited with them while trying to obtain an appointment that the Advanced MSA refused to schedule.  Change must come to the VA!

© 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.

Desperate Changes Need 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.

  1. 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.
  2. 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.
  3. 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 364th 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 361st 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:

  1. 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.”
  2. 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.
  3. 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.
  4. 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

© 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/

 

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.

 

Chapter 3 – Shifting the Department of Veteran Affairs Paradigm – A Letter to our Elected Officials

Admiral Jackson, I am sorry to see you go! I feel you would have been a good VA Secretary and can understand the reasons behind removing your name for consideration for this post. Thank you for trying.  I am sincerely sorry for how your nomination was hijacked, slandered, and the stress and frustration that came from being attacked. Mr. Wilkie, I am looking forward to your leadership at the VA and hope to see leadership improve the engrained intransigent culture into a flexible and growing organization, cognizant of the trust of the American voter and veteran alike. I wish you the best of luck.

President Trump, you are doing a GREAT job, and I thank you, your family, and your staff, for doing hard and difficult work in an atmosphere of negativity thicker and more detestable than London Fog, Haggis, or Blood Pudding. I remain absolutely astounded at the pressures unnecessarily applied to you and your family and am grateful for your efforts, successes, and failures!

Senator McCain, I am utterly ashamed of your conduct, your staff, and your record. Every time I see you speak, it repents me for ever having voted for you. After dealing with your staff, it repented me, after your failed bid for the Presidency, it repented me, but the latest small-minded, bitter, diatribes, I have repented again. What an abysmal disgrace you have turned into, and I regret, with my entire soul, for having once voted for you.

I cannot understand, except through seeing daily the likes of Senator McCain, how the Department of Veteran Affairs could slide so far into the depths of bureaucracy. Since my last open letter to our Elected Federal Officials, the following examples have crossed my desk through email from Inspector General reports of investigations and through news feeds. Please note, this list is not conclusive as too many cross my desk daily to list here, even briefly.

13 May 2018 – News reports of a double-amputee being turned away from the VA Medical Facility in Atlanta without receiving assistance with a prescription. From personal experience and having spoken to hundreds of veterans traveling and needing medications, I know exactly what the veteran went through, and the VA should be ashamed of their behavior. “Joey” Jones is correct, veterans are told by their Primary Care Providers and the “Ask a Nurse” phone line if you need help go to the ER. What is not told is the time required to wait in the ER, the doctors being able to not risk anything and tell a veteran they will not receive help or the fact that while waiting for help in the ER you run the risk of getting worse. To be perfectly clear, the problem uncovered by “Joey” is nationwide and is not an abnormality but an established practice in place at every VA Medical Center I have visited for treatment.

07 May 2018 – An OIG report covers the results of an audit of a program specifically designed to aid in helping cover the cost of transportation to a VA Medical Facility. The results of the audit showed grand malfeasance and extreme misfeasance with the projected loss to the American Taxpayer of $173.8 Million through December 31, 2020. With all the technology we have, why can’t the veteran needing services, arrive at their local hospital and have the treatment completed instead of having to travel to receive treatment at a VA Medical Center or VA Clinic? I understand needing to use various supportive modes of transportation for some patients, and a contract for those fees should be handled carefully, succinctly, and at the local level, not at the national level. Using the numbers from the OIG Report, for the one-year period 11,900 beneficiaries received 5.034 payments each, where the total payments amounted to $23 million inappropriately made or problematic payments making each payment average merely $383, 973 each. Of the $23 million spent, $11 million could have been saved, per the IG’s reckoning. After reading the variables the OIG reported, I firmly believe more than $11 million could have been saved by putting local VA Medical Centers in charge of transportation costs, contracts, and reimbursements.

As a side question, why is the use of contracted services so disconnected from reality? Having used the external services, records do not get logged properly (received and connected to the veteran’s medical records), contracts seem to always lag beyond 120-days before remittance, and veterans and those contracted are left in perpetual confusion at the mercy of VA bureaucrats. I personally spent three days tracking down records from contract services, walked the records to the receiving center, and still, the records were missing when my Primary Care Provider (PCP) went looking for them to discuss moving forward in a treatment plan. Why have you, the Federal Elected Officials, allowed these diseases of bureaucracy to exist?

03 May 2018 – We find an OIG report “Appropriation Irregularities” to the tune of $11.7 million dollars of unauthorized services obtained and paid for from wrong accounts. In my home, an appropriation irregularity is when I spend money on a candy bar or soda without telling my wife who budgets our money. How are 11.7 million dollars an “irregularity?” More importantly, where are the consequences? I get it, the funds were then taken out of the proper accounts, training was held, and the received OIG promises to never do it again. This accounting irregularity was discovered only because of a hotline tip; how many more offices in the VA and across the Federal Government are creating “appropriation irregularities” and no one is saying or seeing anything wrong?

What is the solution to the continued failures in the VA?  I propose the following:

1.     Sunlight! It is said that sunlight is the best disinfectant, and I propose OIG reports begin containing names, so these workers creating problems receive public embarrassment as an encouragement to improve performance. It is past time for those causing problems to be brought into the light of day and public scrutiny. I also propose civil penalties for the malfeasance and misfeasance done in government employment; you have the public’s trust, and when that trust is violated, the public should be able to know all the details.

2.    Let’s call things what they are. In the case of the “appropriation irregularities,” it should have been called a failure to know and follow established regulations either with or without intent to defraud. If a citizen cannot use ignorance of the law before a judge, the government employee cannot use ignorance of regulations and policies in the administration of their duties. What happened to the veteran in Atlanta is malpractice and nothing less; if the VAMC in Atlanta cannot police their own in this issue, it is past time for the OIG to step in, bring appropriate charges, and civil penalties on behalf of the veteran harmed and the nationwide policy reviewed post-haste to halt further abuse of veterans.

3.    In business, to protect the bottom-line and to affect customer service decision making, power is placed on the lowest level of the hierarchy to do the most good. This principle of business needs to be the cornerstone of every VA policy, procedure, and process to conduct work. Stop the madness of central command in DC and put the decisions for local veteran care on the local level. While even this might not fix all the problems, having decisions made locally means that the community knows who is making decisions and who to hold responsible for malfeasance and misfeasance occurring in government.

4.    Common knowledge in America is the following:

“Red tape – the complex procedures and rules that bureaucrats follow in completing their tasks.

Conflict – when the goals of various bureaucratic agencies just do not match up, and they end up working at cross purposes.

Duplication – when agencies seem to be doing the very same thing.”

The VA is infected with all the diseases of bureaucracy and you, the Federal Elected Officials, are charged with using the tools at your disposal to enact change, support the new VA Secretary, and honor the commitment to veterans in improving the tools the veterans have been provided by you the Federal Elected Officials. Get technology useful, use technology at every level of improving veteran care, and demand more technology tools to push the power to make decisions as low as effectively possible to aid the most veterans.

5.    The VA has a LEAN program, and has had the program since at least 2015, when will the leaders employ the LEAN program to improve the VA processes and procedures? Through the total quality management (TQM) philosophies provided through LEAN programs, there should have been tangible and visible change to the VA by now.

I cannot describe how incredibly futile the customer service surveys being demanded after every encounter in the VA truly represents. The disease of bureaucrats is too expensive to veterans, to American Taxpayers, and to American Communities who need the wasted funds at the VA to be employed in infrastructure improvements, housing, utility protection, and so many other areas. You, the Federal Elected Officials, are in charge, will you please stand up, exert your power, and fix the government?

© 2018 M. Dave Salisbury

All Rights Reserved

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

A Recent Customer Service Issue – Or, An Example of Why it is Past Time to Shift the Employment Paradigm

            Many sources, most of them veterans, will agree with this statement, “Dealing with the Veterans Administration is an activity fraught with hostility.”  On March 2013, I had the misfortune to experience another hostile occurrence.  Following is what happened.  The VA Hospital left a message in my voicemail alerting me that they had scheduled an appointment for me.  The message included instructions for me to call if this appointment caused scheduling difficulties, which it did.  I called the number, punched in the extension, was hung up on once, called back, and reached an appointment scheduler. The VA had scheduled my appointment for the middle of my workday, which required that I take time off my job to make the return call to discuss the scheduling conflict of the appointment.  The request was simple; please change the appointment to either early morning or late afternoon.  Although I requested no date preferences, travel and loss of work considerations were important and difficult to arrange and especially significant because I was a new employee and attendance is critical.

            The attitude of the appointment scheduler went from simple hostility to overt and active hostility at my request to move the appointment time.  The appointment scheduler reminded me in the most descriptive tones bordering, but not crossing into, profanity that it is “YOUR RESPONSIBILITY” [Emphasis his, meaning my responsibility] to keep the appointments as scheduled by the VA regardless of the inconvenience it causes me.  December 2012, before the start of my current employment, this appointment had been scheduled three times.  The VA canceled the appointment three times, and only once was the cancellation communicated to me prior to my driving to the hospital, checking in, and waiting for the appointment.  The same appointment scheduler provided the same hostile attitude in person as on the phone and made the following statements, quoted verbatim:

“Employment is NOT an excuse for moving an appointment with the VA Hospital System.” [Emphasis his]

“Moving your appointment is a privilege being extended to you that has not been earned.”

Judging by certifications on the walls of this person’s office, he is an example of award winning customer service at the VA Medical Center.  Having been a patient at several VA Medical Centers across the country, having been a customer at several of the VA Regional Offices, and having been a customer of the various VA Call Centers, unfortunately I have found this attitude typical.  This conversation was reported to the Patient Aligned Care Team (PACT) for review.  I declined further follow-up as unnecessary.  The PACT team member did have a unique thought process; she continually returned with the same descriptive term for this incident, ‘not compassionate’.  I refuted this determination several times claiming unprofessional, irresponsible, and ludicrous, but the main complaint continued to be ‘not compassionate’.  The term simply does not fit the incident.  This incident was not created by a lack of compassion, but through an organizational culture gone rogue, hostile, and grown wild.

Returning to the incident, let us be clear and simple; the problem is not the workload the scheduler was quick to point out and often stated the amount of appointments scheduled in a month; it is not the individual; always the problem remains with the system, the organization, the processes and procedures, and finally the training.  This is institutional deterioration at its most egregious level.  “Juran’s rule (Tribus, n.d., pg 5) whenever there is a problem, 85% of the time it is in the system; only 15% of the time will it be the worker.”  This is very telling in this situation.  Before looking to the worker, examining the system will be the answer 85% of the time.  Organizational cultures are the “system” described by Tribus (n.d.) and Juran.  Organizational Designers will specify cultural steps for improvement, thus the PACT team, the focus on compassion, and the ultimate deception ‘customer focus’ hidden under the guise “Patient Aligned Care.”

The problem is a dual core issue, no personal responsibility for outcomes and no personal accountability for results.  This is the organizational culture feeding the hostility, the derision, and animosity found in all VA/Veteran interactions.  The front-facing customer service agent is not held accountable nor feels a responsibility towards the work he or she performs.  Because the same employee is protected in his work by the system, the system becomes a detriment to patient/customers and safeguards the individual from criticism and censure preventing the possibility of change in the individual.  The incredible amount of bureaucracy legislated, litigated, and lumped upon the VA must be exposed to the disinfectant of sunshine i.e. brought to the public attention, reduced bureaucracy in support of veterans and their families, and new solutions created to improve service.  The real solution is not focusing upon a culture grown wild, but short-circuiting the existing corporate culture to jumpstart a new culture.  It is past time, especially where all government agencies are concerned, to shift the paradigm, remove the job security, and breathe the life of freedom and true customer centered focus, i.e. the taxpayer, back into the various government and non-government organizations.

Considering the above incident, if the scheduler was an independent knowledge contractor whose contract extension rested solely upon the referrals and customer surveys of the VA’s customers, the above incident would not have occurred because accountability and responsibility would demand the patient receive higher value as a customer.  If the same accountability and responsibility were carried to the entire chain of command, to all the processes and procedures, and to the organizational hierarchies, the VA would not be the punchline before the epithet in a veteran’s story, but become respected for the work it does.  Yes, the VA has a difficult task to perform.  Yes, the workload is daunting.  Yes, as a government entity, cost constraints and budget decisions matter more than patient care.  Nevertheless, the patient should be more respected, valued, and serviced more appropriately.  By shifting the employment paradigm, an advantageous outcome to all stakeholders involved in the organization is a firmly projected possibility.

Reference

Tribus, M. (n.d.). Changing the Corporate Culture Some Rules and Tools. Retrieved December 5, 2008, from: Changing the Corporate Culture Some Rules and Tools Web site: http://deming.eng.clemson.edu/den/change_cult.pdf