NO MORE BS: Putting Shame in the Right Place at the VA – Administration

Angry Grizzly BearI have found great and good providers at the VA, as well as some truly awful and detestable providers.  The Doctors, Nurses, Medical Support Assistant (MSA), and the patient are supposed to form a PACT team to improve the health and welfare of the patient in the VA Health Care System (VAHCS).  The PACT Team is a VA organizational program to assist in improving care and stands for Patient Aligned Care Team (PACT), as an extension of patient care services.  The PACT Team also includes the Patient Advocate and several others, as detailed in the image below.PACT_model

I mention all this because I have heard from a veteran, we are going to call him “Boats,” a chief Boatswain mate for over 20-years in the US Navy, honorably discharged, and a disabled veteran of the Vietnam Era.  Boats’ doctor changed clinics, thus shaking the PACT team to its core.  Since the doctor was reassigned to a different clinic, the nurse has been changed but not explicitly assigned, so the coverage nurse cannot be reached by phone, and secure message falls on deaf ears and plastic lips.  Hence, reaching his PACT team has become a burden, his health has suffered greatly, and the mask mandate makes his safety in the VA Clinic doubtful at best, as the mask aggravates his ability to breathe.

PACT 1Because his clinic has no doctor, other doctors have been sharing their time in the clinic.  This means that if treatment requires time and interactions over multiple visits, the patient loses any type of continuing care and is left frustrated, with continuity of care hindered.  Here’s the rub, this has been an ongoing situation for a long time, and the continuity of care has become a root cause in the failing health of this veteran.  Unfortunately, this is not a new or rare problem for the VA, and as shortages in providers continue to increase, it will only worsen.

PACT 3Boats is in the same situation as many other veterans.  While misery loves company, this type of misery costs lives, and that is an administrative problem Congress legally bound the VA to fix, and they refuse to address.  Like the mask policy that does not include a face shield option or include the verbiage for approved medical conditions, the administration of the VA continues to market lofty and grand standards and fails even to meet minimum legal requirements.  I have witnessed the administrative officers, known by their online pictures, refuse to help veterans, pawn off veterans, and even go so far as to hide from veterans to avoid providing customer service.

The hospital administrators have been schooled in the VA; many have “come up through the ranks.”  These administrators have been taught how to avoid accountability, responsibility, and work the VA Bureaucracy to keep their jobs, even when veterans are dying from the administrative problems they created.  While an employee, I heard the tales of how my Hospital Administration Services Director got her job; draw your own conclusions, all I do know is someone was promoted to an exceedingly great height above her maximum level of incompetence!

Detective 4Consider the hospital director moved, at taxpayer expense, from Seattle to Phoenix.  She had been killing veterans in Seattle and took over an award-winning hospital, which very shortly became a national joke for where veterans go to die!  Her lessons are still being taught, veterans are still dying, and the administration is still the problem!  The mask mandate that has stopped my prescription from being refilled, my abusive PACT Team led by a doctor who invited me to find a new provider, refused to contact me for two months about needed blood work to refill diabetes medication.  After two weeks without diabetes medication, magically, diabetes medication arrives. No blood work ever occurred because I cannot access the VA due to my approved medical condition that makes wearing a mask impossible.

The administration of VA Hospitals is a crime!  I had an assistant director, while an employee, who said, “If a non-VA Hospital did anything like the VA does things, they would be shut down for malpractice.”  The assistant director is now a clinic director for the VA; her resume included 20-years in non-VA hospital administration.  She joined the VA to help veterans.  Where is the VA-Office of Inspector General in rooting out these administrative landmines of ineptitude that makes hiring more difficult and retaining talent near impossible?  Where is Congress in scrutinizing the VA and helping those working to change the VA to succeed instead of actively contending with them?

LinkedIn VA ImageBoats has serious problems.  The legacy of the VA is to kill him instead of fixing their administrative problems.  But, the VA’s mission statement is still, “To fulfill President Lincoln’s 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.
“Our department remains fully committed to fulfilling the sacred obligation that we have to those who serve in uniform.” ~VA Secretary Denis McDonough.

VA SealWhere is the VA acting in accordance with the mission statement and fulfilling its “sacred obligation?”  The answer, with the current leadership in administration, nowhere!  The VA has been purposefully designed to kill veterans and can be fixed.  The fix must include Congress, and we all know how Speaker Pelosi (D) feels about veterans; when she called them terrorists, it was clear her scrutinizing the government where the VA is concerned will not happen.

I-CareVA Secretary Denis McDonough signed onto the “I-Care” principles as core values in care for veterans in the VAHCS.  Well, when can we, the veterans, see that these core principles have been on-boarded and are correcting behavior?

“VA Core Values describe how VA will accomplish its mission and inform every interaction with our customers. These Core Values are: Integrity, Commitment, Advocacy, Respect, and Excellence — better known as “I CARE.” VA’s Core Values will continue to serve as the right guide for all our interactions and remind us and others that “I CARE.”

  • I care about those who have served.
  • I care about my fellow VA employees.
  • I care about choosing “the harder right instead of, the easier wrong.”
  • I care about performing my duties to the very best of my abilities.

DutyMr. Secretary…  The veterans are dying now!  We are waiting!

Like my enlistment oath, I signed onto the I-Care principles and even though I am no longer employed by the VA, I live I-Care!  Where is the VA in proving “I-Care?”

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

NO MORE BS: The VA Chronicles of Shame Continue

VA SealWhile I have been fighting the Carl T. Hayden VA Medical Center for humane treatment (June 2020) and medical services, making no progress, the Department of Veterans Affairs (VA) has undoubtedly been busy oppressing others, allowing their employees to skate responsibility, and avoiding accountability.  For the record, I have not deep-dived the legal proceedings reported below and would remind everyone that those charged are not guilty until a jury of their peers says so in a court of law.  I am not passing judgment and am only reporting from official VA-OIG reports, leaving the conclusions mainly to you, the reader.  The conclusions offered are mine alone, and you are free to draw your conclusions based upon the data delivered and your due diligence.

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) has been busy filling my inbox all week.  Here are the latest stories of shame from the VA Chronicles:

  1. VA Health Care System (VAHCS) Fort Harrison, Montana, the investigation began with two people calling for help to the Veterans Crisis Line (VCL). From the VA-OIG report, we find the following:

The VA-OIG substantiated a VCL responder failed to assess caller 1’s homicidal risk factors, address lethal means restriction, complete an adequate risk mitigation plan, communicate critical information to a supervisor, and take actions to prevent a family member’s death. VCL leaders did not consider an administrative investigation board to review the responder’s potential misconduct. The VA-OIG substantiated that two social service assistants (SSAs) failed to dispatch local emergency services for caller 2 following a responder’s rescue request. The VA-OIG identified deficiencies in SSA oversight.
VCL leaders did not fully adhere to Veterans Health Administration (VHA) policies related to reporting and disclosure of adverse events. A facility primary care provider failed to include caller 1’s mental health diagnosis in the assessment and plan of care. Also, the primary care provider did not submit caller 1’s non-VA medical records for scanning into the electronic health record or document a review of the records, as expected by VHA policy.

Angry Wet ChickenI have been trained in emergency psychological triage; this was part of my training as a Chaplain’s Assistant in the US Army.  When you work on a crisis line, you cannot not take immediate action to save a life!  When my friend called me all depressed and intimated he wanted to end his life, I called 911, explained the situation, and asked for help.  They provided help.  I was not acting in any official capacity; I was not working a crisis line; I was simply a concerned friend.  How can these crisis line employees, managers, and other staff escape accountability and responsibility?  The whole chain of events is a lurid report of failure to take action by people duty-bound and placed in positions to act, and they refused to take action; this conduct is inexcusable!

As a substitute teacher, I was a mandatory reporter.  If I heard anything untoward, I had to act!  As a Chaplain’s Assistant, I was a mandatory reporter, and I was empowered to act, even without my chaplain’s permission, which by the way, pissed off my chaplain; but he refused to see specific soldiers in crisis.  Not my fault, but I took my Article 15 with pride!  Taking us back to the VA employees who failed miserably the need to take action, and still escaped accountability and responsibility!

  1. Survived the VAOur next story is a back-slapping congratulatory declaration regarding a soldier committing fraud.

Shawn Pierre Hobbs, a soldier for the Connecticut Army National Guard and a Rikers Island correction officer employed by the New York City Department of Correction, was arrested yesterday in El Paso, Texas, on wire fraud and aggravated identity theft charges. VA Inspector General Michael J. Missal said, “The charges unsealed today are the result of the hard work and dedication of the VA-OIG’s special agents working with our law enforcement partners. The VA-OIG will seek to hold accountable those who perpetrate fraud and steal benefits that are intended for deserving veterans.”

LinkedIn VA ImageThere are still many details missing in this story that I bet the public will never see.  Since no VA Employees were mentioned, I can only surmise that they escaped accountability because the main perpetrator was caught, so according to the VA-OIG, no harm, no foul.  I believe that as much as I believe in buffalo wings originating from flying buffalo!Flying Buffalo

  1. Our next report is one of such supreme idiocy that words can barely describe the situation and the current findings. Consider the following, you arrive at your doctor’s office and need several routine shots.  If the doctor and nurse fail to document these shots properly were delivered, and you have an adverse reaction, they can be held liable for medical negligence under the law.  Why does the same not apply to the VA?  The following comes from a memorandum issued by the VA-OIG, declaring an investigation is ongoing on this issue, but problems have already been found!

While reviewing the Veterans Health Administration’s (VHA) plans to document receipt and distribution of the COVID-19 vaccine, the VA Office of Inspector General (VA-OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA’s Community Living Centers (CLCs).
The VA-OIG determined that VHA could not know at a national level whether the vaccine was offered to some CLC residents, and if so, what their status was. Because CLC residents are in the highest COVID-19 vaccine priority group, they should be offered the vaccine, when possible, before other groups of veterans. With vaccine supplies limited, VHA should know which CLC residents still need to be vaccinated.
The VA-OIG found VHA has made important strides in distributing vaccines to CLC residents, but [needs to] move toward more comprehensive and consistent data collection to guide ongoing actions and protect this vulnerable population. Doing so would include making sure all CLCs routinely track refusals and contraindications in a consistent manner. Guidance should be clear that all communications should be consistently documented in accordance with VHA processes.
Similarly, clear guidance and consistent oversight should help ensure CLCs are properly tracking veterans who fall in the 23 percent of CLC residents missing information needed to determine their vaccination status. It was not possible by January 2021 to establish which of the 1,899 veterans in this cohort had been offered the vaccine. The VA-OIG will continue its oversight work on vaccinations within VHA and plans to issue a full report, including specific recommendations. In the meantime, the VA-OIG requests to know what action, if any, VHA takes to mitigate the potential risks identified in this memorandum and the outcome of those actions.”

Angry Wet Chicken 2Essentially, the VA-OIG is claiming the VHA cannot document in their long-term care facilities which residents have and have not been vaccinated against COVID.  Can you believe the incredible negligence being witnessed; I cannot!  In the US Army, due to chiggers and a violent allergic reaction to them, I spent several weeks in what is called the “Reception Battalion.”  My job was documenting who got vaccinated, what shots were received, and I was held responsible if the documentation was incorrect.  I have worked in long-term care facilities not owned by the VA and witnessed the time and energy spent documenting everything the patient experiences.  I have visited family members in long-term facilities and witnessed the documentation procedures.  Yet, miraculously, the VHA does not have to submit themselves to the same level of documentation requirements.  Where is that memo, policy guideline, or written procedure?  Where are the lawyers?  For the VHA to have a problem with documentation of a patient is 100% inexcusable, and people’s heads should roll over this failure to document!

  1. Our next chronicle of shame is both a good and bad report.

Muhammad Z. Aabdin, 30, of New York City, has been charged by complaint with offering a bribe to a VA contracting officer in September 2020. Specifically, Aabdin allegedly offered to share profits with the officer in exchange for her awarding VA contracts to Aabdin for personal protective equipment.”

That the VA employee reported, the bribe is a good thing.  That a contractor felt comfortable enough to offer a bribe is considerably less of a good thing.  Are there additional questions being asked and investigated in this procurement office regarding the offering of bribes and the potential of having previously taken bribes?  Where are the supervisors in this affair?  The VA persists in hiring from inside for the advancement of careers, not a bad thing, but when a contractor is comfortable offering bribes, there should be many questions being asked of supervisors, directors, and so forth.I-Care

The fact that the behavior of VA employees breaking the law is both widespread and well known should be a wake-up call to the leaders of the VA and the elected officials charged by law to scrutinize the government.  Except, this behavior has never been scrutinized sufficiently to end the behavior, only scrutinized enough to encourage the behavior, the negligence, and the extreme indifference.  Every American Citizen should be outraged and motivated to shout at their elected officials using all communication channels until this abhorrent behavior is sundered forever from the VA body!

ApathyExcept, I am preaching to crickets.  Your taxpayer dollars are funding the abuse of veterans at the hands of the government.  Shameful!  Inexcusable!  Outright blasphemous!  Yet, allowed to continue because of apathy; Plato was right!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

NO MORE BS: COVID Mask Discrimination Policies and Your Health

Millstone of Designed IncompetenceThe Atlantic published an article well worth reading, “End the Hygiene Theater.”  To summarize, SARS-COV-2 (COVID-19’s official name) is an aerosol and does not survive in the outdoors or on surfaces.  Just like 99.9% of all viral infections.  Consider how much money the government mandates had wasted on power cleaning surfaces since August 2020 when the scientific peer-reviewed journals began publishing the science of aerosol viral fighting tips.

Angry Grizzly Bear15 April 2020 was a high watermark day for me; I was forced to go to the Sandra Day O’ Connor Federal Courthouse to fight three citations for not physically being able to wear a mask at the VA Hospital here in Phoenix.  My injury at the hands of the VA Police was not allowed as evidence; the policy that continues to hinder care at the VA Hospital was not allowed as evidence.  However, it was used frequently as an excuse, and my being erroneously declared a behavior problem at the VA was inadmissible as that is an internal policy of the VAMC.  The end result, I lost more money to pay the fines.

In the US Republic of America, you have the right and freedom to wear a mask if you choose. Suppose you desire that face diaper as a safety blanket, even though peer-reviewed science has found zero evidence that masks help; feel free to wear a mask.  Please understand that thousands of people cannot wear a mask due to medical conditions, medications, and other breathing problems, which means alternative health measures are needed.  Medical policies should never be written as one-size-fits-all.  The policies writers are discriminating and putting people’s health at risk.

ApathyAs my breathing has become more labored since my spinal injuries in 2002, at the hands of a First-Class Petty Officer, I have had to exercise more healthy options to keep myself safe.  I take vitamin supplements, including C & D, at both a medical professional’s request and my wife’s knowledge.  I drink tonic water, which has quinine in it, specifically the tonic water sold at Trader Joe’s, for it has no high-fructose corn syrup and less sugar than soda, so my diabetes does not take a hit.  I was told by my primary care provider, at the VA almost 10-years ago that quinine will help my nighttime leg cramps, it worked for me.

I am not a medical professional, and am not saying everyone will have the same benefits; the quinine in tonic water has helped me, and overtime I have experienced less sick time from common colds, flues, and other aerosol borne sicknesses.  Always discuss with your doctor the vitamins and drugs being taken, this is also your right and freedom!

Historically, quinine has been used as an anti-malarial drug, and is effective in calming muscle cramps, leg restlessness, and is a base ingredient in chloroquine and hydroxychloroquine.  “Use of chloroquine (tablets) shows favorable outcomes in humans infected with coronavirus including faster time to recovery and shorter hospital stay.  US CDC research shows that chloroquine also has strong potential as a prophylactic (preventative) measure against coronavirus.  Chloroquine is an inexpensive, globally available drug that has been in widespread human use since 1945 against malaria, autoimmune diseases, viruses, and various other conditions.”  Facts are coming from multiple peer-reviewed resources since 1950, including Dr. Fauci.

Angry Wet ChickenTo arrive at court, I had to walk more than ¼ of a mile from the closest parking spot to the 2nd floor mezzanine of the Federal Court House.  By the time I got through the US Marshall security buttress, I was completely out of breath, and the first words out of security’s mouth, “Where is your mask?”  I explained I have breathing problems, and they insisted I at least carry a mask to meet the “stringent judge mandated legal requirements for mask policies.”  Thankfully, they did not insist I wear the mask, as I would have become an emergency right then and there.

Leaving me with an incredible question, “How can the US Marshall’s in charge of security at a Federal Courthouse use common sense and keen observation and make executive decisions, but the VA Police on Federal Property cannot do the same?”

The answer to that question lies with the draconian leadership and the egos inherent in the VA.  Same Federal Policy regarding masks but applied with 180-degrees of separation.  The VA Police Officer who oversaw my asset forfeiture/remediation did not have a problem with my not wearing a mask the entire time we spoke.  We maintained 6’ of separation and conducted business like adults.  Yet, in the VAMC, this officer would have been under obligation first to arrest me, which always leads to me being injured, cite me, then kick me off the property.  All Federal Property, all handled by sworn legal officers possessing arrest authority, and we have two different outcomes.

Foghorn Leghorn - MedicationAs a point of reference, there are more than several hundred thousand people like me in America right now who have breathing conditions that preclude wearing a mask for personal health and safety.  Polio victims with lung scarring are especially susceptible to COVID and should not wear a mask.  I know veterans who are missing a lung, who struggle to breathe, they cannot access the VA for medical care; this is mask discrimination!  I know cancer patients who, due to the drugs and cancer, cannot wear a mask and cannot access the VA for cancer treatment; this is mask discrimination.  I am one of several thousand people on a steroid to help breathing problems, where a mask is warned against wearing for physical safety and personal health.  However, I am still denied VA Medical Care over the mask policy.  The list of medical conditions and breathing issues is endless. Still, the policy from the Federal VA Director’s office, supposedly, does not come with a line, “except for those with approved medical conditions.”  I claim allegedly, as I have yet to receive a copy of this mask mandate policy or find a copy anywhere online.  I have even gone so far as to use an FOIA request for the policy and never have received a response.

I asked a supervisor about the policy at the VAMC and was pointed to a marketing sign.  I asked a hospital director, in fact, the patient advocate director, and was told there is no official policy.  Because that would require writing things down, and the VA refuses to document anything for fear of reprisal and recrimination.  Also, a topic I have covered ad nauseam and ad infinitum in these articles to no avail, as an excuse for designed incompetence.

Never Give Up!Ask yourself this question, “Who is the primary person responsible for my health, myself, the media, the insurance companies, or the government?”  For how you answer that question will determine how you approach situations where your health is jeopardized.  We have programmable vaccines being passed off as a cure-all for a virus that makes up the common cold, yet people are still catching the common cold and testing negative for COVID.  We have had flu vaccines around since the 1930s, with mass vaccination campaigns since 1945; yet until COVID came along, we still had people dying from the flu every year!  By the way, an interesting fact, no one has caught the flu since February 2020; do you believe the COVID testing works?

America has witnessed years when the flu guessers guessed the wrong flu variant strain, and the flu vaccine people got was 100% ineffective.  Yet magically, this COVID vaccine comes along to end all those problems without long-term testing and in-depth research, and how many are lining up to get their COVID shot?  After getting the COVID jab, how many still are forced to live under COVID mandates?  See, the problem is not COVID; the problem is who controls your health decisions, the government, the media, the insurance companies, or you?

Non Sequitur - DecisionsThe discrimination we have been told all through school is “bad,” but the VAMC can mask discriminate against the population they are duty-bound to serve, and there are no legal consequences; where are the lawyers?  We have people who have been and are suffering from COVID-related vaccine sicknesses who lost their legal rights to sue the pharmacological manufacturer; where are the lawyers?  I would think the ACLU would be head over heels angry at this blatant abuse of people’s rights, except they are silent on these issues.  We have hundreds of thousands of veterans who cannot access their medical center, their doctors, and so forth due to a policy that isn’t a policy and are dying; where are the lawyers?

Dont Tread On MeWho controls your healthcare choices, you or the government?  I know my answer!

Reference

Sturrock, B. R., & Chevassut, T. J. (2020). Chloroquine and COVID-19–a potential game-changer? Clinical Medicine, 20(3), 278.

Todaro, J. M., and Rigano Esq, G. J. An Effective Treatment for Coronavirus (COVID-19). In consultation with Stanford University School of Medicine, UAB School of Medicine, and National Academy of Sciences researchers. Retrieved from: https://docs.google.com/document/d/e/2PACX-1vR1adodKPhWalV9djnerI2x_v1LGgGyhZZxpl0O5r-ZNyDdagqFq1rTCxXBqaeicfxgvypDOqKCZVyV/pub (Google is blocking access to this information)

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

NO MORE BS: Bureaucratic Fiat, a Veteran Suicide – Scrutinizing the Government

ApathyThe Department of Veterans Affairs (VA) is in trouble due primarily to the employees’ lack of written directions, procedures, and processes to complete work.  Of the poor Veterans Health Administration (VHA), there is none worse than the Carl T. Hayden VA Hospital system in Phoenix, AZ.  I support this conclusion with both personal observations and through comparative analysis.  Much research has gone into this conclusion, and while there are other VHA’s that compete for the bottom, the clear winner remains the Phoenix VA Medical Center (VAMC).

What is bureaucratic fiat?

Bureaucratic fiat is government employees who make decisions in their positions who rigidly adhere to any rule not to perform their job, inconvenience the customer, or thwart responsibility, accountability, and maintain their positions.  Bureaucratic fiat survives sections from the Office of Inspector General (VA-OIG) through designed incompetence, lack of training, confusing processes, unwritten rules and guidelines, and simple negligence.

LinkedIn VA ImageVeteran Suicide!

Outside of first responders and active military, the suicide rates of veterans are too high and rising.  The suicide rate is disgusting to behold and tragic beyond words.  Of all the topics I discuss, veteran suicide remains my pet topic.  When veterans or military members (Reserve, National Guard, or Active) commit suicide, this rips a hole in communities, families, and the guilt the family and friends carry is so intense, they struggle not to commit suicide themselves.

Scrutinizing the Government!

DetectiveThe VA-OIG reported on a veteran who committed suicide, with ties to the Carl T. Hayden VA Medical Center in Phoenix.  The veteran reported to the hospital, asking for help.  The VA-OIG found that processes were intentionally not followed.  Help was not forthcoming, and the veteran committed suicide before the VA got their thumbs out and offered this veteran help.  The VA-OIG found the following:

      • “While the patient awaited the testing, facility staff failed to offer mental health treatment.
      • The social worker did not complete a suicide risk assessment and relied on another social worker’s suicide risk assessment completed eight months prior.
      • A family member called and left a voicemail message for the social worker. However, the social worker’s documentation did not include essential information, specifically that the patient died by suicide.
      • Upon learning of the patient’s death by suicide, a Suicide Prevention Coordinator failed to complete timely documentation of outreach to the patient’s family… the mental health delegate did not approve the community care psychology consult within three business days, as required by VHA.
      • The third-party administrator scheduled the patient for therapy rather than psychodiagnostics testing.
      • The facility scheduling staff did not complete required outreach efforts when the patient missed a primary care appointment one day before the patient’s death by suicide.
      • The Suicide Prevention Coordinator did not complete the patient’s behavioral health autopsy within 30 days, as required.”

One incident, one VAMC, one veteran, and nothing from the VA will protect veterans and improve the adherence to the policies and procedures moving forward; why even investigate by the VA-OIG?.  I weep with this family who lost their loved one to suicide.  I scream in frustration that the VA can continue to kill veterans struggling with suicide with impunity.

Detective 3Do not be deceived; this is not the only incident in Phoenix or all of the VA Healthcare System.  A veteran reaches out for help with suicide ideation, receives bureaucratic nonsense instead of support, and is treated to the red tape that becomes the noose in the suicide of that veteran.  One event a year is a tragedy of epic proportions.  The list never seems to end, nor do the bureaucrats ever get held accountable for their inactivity, contributing to veteran suicide.

12 November 2020, The Military Times reported that from 22005 through 2018, veterans committing suicide had risen dramatically, to a high in 2014 of 6,587.  Is the epicness of this tragedy more apparent?  Presuming that each of these veterans had two parents who came together and invested time to create the child that became the veteran,  13,174 parents now weep to lose their son or daughter who committed suicide.  According to the US Census, families in America had 1.9 children per couple (2014), rounding up to 26,348 is the potential parents and grandparents affected by suicide, and 52,696 is the pool when siblings are added.  If each of these suicides had a significant other, with two parents and two siblings, the potential affected by suicide is now approximately 105,392.  Add employers, friends from employment, communities, and educational or academic acquaintances, and the number of people affected by suicide can quickly reach a million people.  I used 2014 as the year to base the numbers upon as this was the highest number currently available, but 2020 saw a dramatic increase in suicide among all age groups and those with the Census delays; I doubt America will learn the full impact from COVID government madness any time soon.

LookNow, consider the following, each of those veterans who committed suicide in 2014 (6,587) had a suicide prevention team in place at the VA who failed to act.  6,587 people who deserved better treatment at the hands of the government employees, who have pledged to fulfill President Lincoln’s 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.  Failed the veteran and played a role in the suicide of the veteran.  Rarely do the veterans who commit suicide, in VA parking spots, on Federal property receive the attention they deserve.  I am intimately aware of one such issue with the VA Medical Center in Albuquerque.  The veteran could not get help, became frustrated, walked to his car, and killed himself.

2019, The Washington Times, who proudly continues to declare that “Democracy Dies in Darkness,” ran a story about veterans who take their lives on VA Campuses, is a “form of protest” against the VA Healthcare system.  No, this is not generally the case; the veteran is not protesting; they are fed up with the fight to be respected, noticed, and receive assistance from people who have pledged to fulfill the Department of Veterans Affairs Mission Statement.  To fulfill President Lincoln’s 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.”

DutyI demand to know where are the legislative branches of government in scrutinizing the operations at the VA?  Why are suicide rates allowed to climb without significant input from the legislative branch?  Why are veterans, directly after an encounter with the VA bureaucracy, committing suicide without in-depth investigations where heads roll for failing to perform the most basic customer service in fulfilling the VA’s Mission Statement?

While an employee of the VA, to get to the directors of the hospital’s offices, I had to walk past this mission statement that hung on brass letters, and all my attempts to aid in change fell on brass ears and plastic lips!  Every time the VA-OIG reports another death by suicide, death by negligence, with ties directly to VA employees not performing their jobs, I want to scream in frustration!  Veteran suicide rates are egregiously high, and for veterans to commit suicide within 96 hours of a visit to the VA is 100% unacceptable!  Why 96 hours; because to date, this is the longest time between actions by the VAMC and the death by suicide the VA-OIG has reported where VA employees should have been held accountable for their refusals to act in a manner to prevent a veteran from committing suicide.

Millstone of Designed IncompetenceAfter over a decade of reading and reporting VA-OIG reports and investigations, the deaths by suicide and negligence are the ones that raise my ire the most!  I would see the VA improve, but until the VA admits, or is forced by elected representatives to admit, they have a problem, nothing will change.  But the horror in that sentence is that veterans will continue to commit suicide and die through VA Employee negligence, and their deaths are as unremarked as if these heroes were common criminals who died in a prison brawl.  This remains an abysmal testimony to the incompetence and uncaring bureaucrat found in the VA’s vaunted halls!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

August VA-OIG Updates: More SHAMEFUL VA Conduct.

I-CareDue to personal issues with the Department of Veterans Affairs (VA), specifically the Carl T. Hayden VA Medical Center (VAMC) in Phoenix, AZ I fell a little behind in June/July/August of 2020.  As I work to clear the backlog of completed Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports from August, please keep in mind solutions to these problems are available. The failure of leadership to be held accountable, by the elected officials is staggering, and the lack of accountability and responsibility boggles the mind.  Without exception, I know the VA can be improved, developed, and saved.

August 2020 begins with an individual employee making a decision regarding healthcare decisions for a veteran at the Robley Rex VAMC in Louisville, Kentucky.  The VA has a process where individuals can be allowed to be surrogate decision-makers for a veteran who needs additional assistance.  This process works is legal and is a great tool for family and friends of veterans to play a significant role in the healthcare process of the veteran.  In this instance, the process failed, not because the process was bad, but because people did not do their jobs properly.

The VA-OIG assessed an allegation that providers permitted an individual with no legal authority to make medical decisions on behalf of a patient, and a host of other patient rights were trampled as documented.  “The patient experienced a three-week medical and mental health hospitalization with repeated episodes of confusion, agitation, and combative behavior. The patient was transferred to hospice care and died five days later.  The VA-OIG found that facility staff did not take the required appropriate steps to identify and confirm the eligibility of this surrogate.  The VA-OIG determined records did not contain sufficient documentation of physicians’ clinical assessments to support diagnoses and treatment decisions. Clinical communication and collaboration were inconsistent, insufficient, and negatively impacted the patient’s continuity and quality of care. Providers did not consistently document medication monitoring and oversight activities to ensure safe patient care. The patient’s transfer to hospice was completed without fully pursuing other diagnoses and treatment options and staff did not ensure the patient’s rights were upheld regarding involuntary admission and behavioral restraints. Facility leaders did not complete a thorough quality of care review to understand the reasons for the patient’s atypical hospital course and outcome” [Emphasis Mine].

Many times, the VA-OIG reports do not clarify all root causes due to employee privacy; however, from the report, the employees who repeatedly allowed the neighbor to make healthcare decisions were exceeding their legal bounds and made decisions that harmed the patient.  This veteran died and from the report, it is clear the veteran died confused, possibly due to medication changes, and the family was not notified in a timely manner because the neighbor, without legal and written authority, was allowed to make healthcare decisions for the veteran, even though there was written healthcare directives on file for a family member to make these decisions.  Utterly shameful behavior!

PatriotismThe Veteran Integrated Service Network (VISN), is a geographical grouping of VA Healthcare Systems, e.g. hospitals and clinics, under a combined leadership plan.  One of the tools the VA-OIG uses to monitor the quality of patient care inside VISN’s is called a “Comprehensive Healthcare Inspection Program (CHIP).  CHIP covers selected clinical and administrative processes all of which are deemed consistent with promoting quality patient care.  The CHIP occurs on a rotational 3-year periodicity and the focus is shifted slightly each 3-year cycle to, theoretically, encompass all administrative processes over time.  The VA reports the following are the specific areas that lead to quality patient care through administrative practices:

  1. Quality, safety, and value;
  2. Medical staff privileging;
  3. The environment of care;
  4. Medication management (specifically the controlled substances inspection program);
  5. Mental health (focusing on military sexual trauma follow-up and staff training);
  6. Geriatric care (spotlighting antidepressant use for elderly veterans);
  7. Women’s health (particularly abnormal cervical pathology result notification and follow-up); and
  8. High-risk processes (specifically the emergency department and urgent care center operations and management).

All of which is mentioned as an explanation providing details for the following VA-OIG inspection reports of CHIP received in August 2020.  A total of seven CHIP reports were received in August recording performance from inspections carried out.  These reports, while somewhat individualized for the specific VAHCS, reads like a carbon copy.  Repeatedly written procedures for standard operation are missing, staff training is inadequate or antiquated, risk analysis is not able to be competently and correctly conducted, patient safety issues abound, and the proper utilization of management processes remains glaring!

Root Cause AnalysisThe CHIP reports are so repetitive in nature, the VA-OIG recommendations are grouped, conveniently, into the eight administrative areas listed above.  According to proper management techniques, the VA-OIG then “encourages” the leadership team to select one or two areas for improvement and focus their efforts on leading change in those areas.  For example, if the VAHCS wants to improve in risk analysis, the leaders can begin by promoting training on properly conducting risk analysis online, hold meetings to review risk analysis procedures and begin to train and develop staff on improving n this area.

However, here is where reality meets theory, without written standard operating procedures risk analysis cannot be completed properly.  The bureaucracy protects itself and will thwart the implementation of written standard operating procedures as this removes designed incompetence that keeps the bureaucrat in power at the VA.  Thus, the root cause of improving root cause analysis is the lack of written procedures that measure performance against a single written standard.

CHIP Report after CHIP Report the same issues arise, are noted, recommendations from the VA-OIG are documented, and the same response is supplied; this represents the epitome of designed incompetence and the root of the problem the VA is facing.  Recommendations for improvement have been repeatedly provided and change can occur; but, not without dedicated leadership, not management, to thwart the bureaucratic quagmire that the VA has fallen into.

Leadership CartoonAnother regular entry on the CHIP reports is the following: “Employee satisfaction scores revealed opportunities for the Associate Director for Patient Care Services to improve employee attitudes towards senior leaders.”  Here is the problem, how many of the “senior leaders” are less than managers, promoted beyond their maximum level of incompetence, solely because they were the next warm body in line; too many!  When staff training is a repeated issue on CHIP reports, one must ask how employees are being measured?  Where are the written scorecards that reflect a process that was used to measure employee performance fairly and equitably?  Was the employee trained on how to perform their role according to the standards published?  Do the scorecards reflect that all employees have been trained, measured, and reported equally?

Guess what, since staff training remains a consistent problem, the staff leaders are the problem!  A major part of “Quality, Safety, and Value” is “Leadership and Organizational Risks.”  A lack of training in properly, timely, and correctly performing one’s role as hired is both a leadership and an organizational risk.  Failing to train employees is the absolute worst comment a leader should be informed of by a third-party inspection team.  Yet, the training of staff is consistently the root cause after a lack of standardized operating procedures.  Every mid-level supervisor, trainer, manager, director, etc. titled individual at the VA should be embarrassed when told their staff is untrained; but, it appears these same leaders do not care!

The Duty of AmericansHow can a person draw the conclusions that the VA appears to not care about improvement, or that the lack of caring is rampant across the entire VA structure; look no further than the site visit VA-OIG inspection report of the Department of Veterans Affairs – Veterans Benefits Administration (VBA).  The deputy undersecretary for field operations expected regional office managers to be aware of issues raised in other regional office site visit reports, but there was no written policy for addressing frequently identified errors.  So, the mid-level regional office managers must be told to investigate internal websites to gather lessons learned and apply those lessons in their regional offices.  What an incredibly inept excuse; shameful conduct by a senior leader, and how much worse does this attitude become as it filters down to the troops?  The behavior that claims a new policy is needed to improve performance is utterly bereft of logic and demonstrates the lackadaisical attitude being discussed.  Then these same leaders wonder why their staff is disengaged, disconnected, and distrusting of leadership; unbelievable!

One of the first lessons I learned in becoming a business professional was, “If you have to write your ethics down, you have already lost.”  The VA policies on ethics, ethical conduct, and ethical behavior are voluminous, trying to cover every detail, every loophole, every issue, and mostly the VA-OIG reports on ethical breaches reflect individual poor judgment at best, and designed incompetence at worst.  Yet, still, the VA tries to implement ethics without a source, moral behavior without a purpose, and the individual employee is left with plenty of excuses for not behaving in a properly ethical manner.  This is the topic of another article; but it must be made clear here and now, ethical lapses continue to abound at the VA.  From the nurse not giving drugs to patients and selling the drugs on the street, to hospital directors not disclosing what appears to be a conflict of interest, the VA remains afloat on a sea of ethical violations.

The remaining reports in August reflected an investigation that the VA-OIG was unable to substantiate due to a lack of reports filed in a timely and proper manner.  More designed incompetence on the part of the VA.  Also included in these final reports were more repetitions of issues discussed where staff training was the root cause for ethical violations, failure to properly perform duties as hired, and staff training was the problem with adherence and compliance issues.

The disconnect is obvious, and the direction forward is clear.  Hospital Directors, write the standard operating procedures, using the resources of how the work is performed currently as the baseline.  Then begin correcting and amending the written procedures over the following year to improve performance to a written standard.  Once the written standard is completed, e.g. the baseline, begin training of staff.  You cannot measure individual performance without standards, and standards cannot be followed without written operating procedures for conducting business.

Behavior-Change© 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.

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