I 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.
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.
Because 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.
Boats 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!
Consider 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?
Boats 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.
Where 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.
VA 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.
Mr. 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.
The VA-OIG reports, “when contracting officers violate federal regulation by failing to obtain the required approval for sole-source contracts, they exceed their contracting authority.” Contracting officers work with the approving authority, how can they not “know” who they work for and how to obtain proper authorization? The excuses are weak and inexcusable; as an operation professional, the first step in getting to know the business is to know who answers the questions, who has the authority, and where that person is located. For contracting officers, the approving authority is the boss, either the employees do not know who they are working for, or there are significant issues in lines of authority, and both situations speak of phenomenal incompetence and failure of leadership.
Speaking of “phenomenal incompetence and failure of leadership.” Please allow me to prepare the groundwork for the subsequent VA-OIG investigation. To be a supervisor in the VHA, VBA, or National Cemetery, you first must work in the positions you will be supervising. This information was passed during a job-interview by the hiring authority and confirmed by several VA directors since. From the VA-OIG Report, we find, “a supervisor at the VA regional office in Boston, Massachusetts, incorrectly processed system-generated messages known as “work items.” The supervisor, “incorrectly canceled 33 of 55 work items out of 110 reviewed (that’s a less than 50% accuracy), and improperly cleared another nine work items from the electronic record. Because of these incorrectly processed cases, VA made about $117,300 in improper payments to veterans or other beneficiaries, along with about $8,600 in delayed payments.” Best of all, the supervisor claimed these work items were improperly handled because, “he did not intentionally process the work items incorrectly, and the errors were the result of working too quickly and misunderstanding procedures.” You are the supervisor, you are in charge, you should know who to approach for guidance and clarification, you have caused significant harm to veterans who either are not being paid or now must repay funds improperly provided. There is an obvious question here, “If the supervisor is less than 50% accurate, what is the accuracy of the supervisor’s team?” While the VA-OIG cannot investigate this question, is the director investigating this question?
From the files of “Not Enough,” comes another egregious example. A patient in a psychological ward in the Philadelphia Pennsylvania VA Medical Center was killed because of a drug-to-drug interaction, were due to insufficient observation, insufficient monitoring, and inadequate action when the patient coded, and a veteran died at the hands of caregivers. When a patient in a hospital ward, which is monitored electronically and physically, commits suicide, I become very agitated. When any patient dies at the hands of the healthcare provider, I have officially lost my “cherub-like demeanor” and begin resembling a grizzly bear with a bum tooth, hemorrhoids, and woken too soon from my winter nap. The VA-OIG Report states the following, “… providers did not monitor the patient for electrocardiogram changes or drug-on-drug interactions. Staff and providers documented signs consistent with over-sedation but did not intervene, communicate directly with each other, or add team members on as additional signers to the electronic health record. The facility did not comply with the Veterans Health Administration requirements for issue briefs, root cause analyses, and peer reviews. The staff did not follow the facility’s observation policy. Facility providers did not adhere to policies requiring discussion, documentation, and patient signed informed consents prior to initiating methadone treatment.” The providers knew they had a problem, before the patient got into trouble, and did nothing! In any civilian hospital, this is called malpractice; but in the VA Hospital system, “this is an unfortunate incident.” While I am undoubtedly glad leadership acted to remedy this situation in the future; I am very displeased to note it ever occurred. With all the publicity over the power of methadone as an opioid, with the technology to remedy these problems before the patient dies, I cannot accept this situation could occur in the first place! This veteran’s death should never have happened and the fact that this veteran died at the hands of providers from over-sedation, is a testament to the incompetence designed into the VA processes that excuses accountability and rewards malfeasance.
I would like to take a moment and thank the VA-OIG for stepping up to the plate and correcting pre-award contract pricing to save the American taxpayer $515 million because the contracting officer on 16 of 22 proposed pharmaceutical contracts was improperly priced. In case you are wondering, the accuracy of the contracting officers was less than 75%. I know of no industry, business, or service organization that can have a 75% or less accuracy rate and remains in business. As a business operation and purchasing professional, these numbers appear to suggest that the contract officers are either intentionally neglectful, or they are counting on pre-award review to protect them from price gouging; both situations are inexcusable for a contracting officer for the Federal Government.
As the Los Angeles Vocational Rehabilitation and Employment program (LA VOCREHAB) was recently featured in an article, I am pleased to see that hiring additional staff has improved performance, per the findings of the VA-OIG. The VA-OIG Report found accuracy in spending money had increased, compliance, and helping veterans to gain employment had all increased since the damning report from the VA-OIG; thus, congratulations to the LA VOCREHAB program!
DNC-Consulting 