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