“That’s Crazy!!!” – More Chronicles From The VA

Bobblehead DollThe week of 27 September 2021 started funkily and has gone downhill rapidly!  I reported Monday being refused medical service for not wearing a mask.  On Tuesday, I visibly struggled for breath, standing in the VA pulmonologist’s office in front of the pulmonologist who was holding my pulmonology function test results.  I am holding a letter showing I cannot wear a mask, wearing a face shield, and being told by the doctor, “I do NOT care, he needs to WEAR A MASK, or I AM NOT SEEING HIM” [emphasis his].  Eventually, the doctor agrees to see me, provided I remain more than 6 feet from him, and he does not have to touch me.  The doctor then proceeds to lecture me about getting the vaccine, wearing a mask, and of course, breathing through my breathing difficulties.

As they say on the Home Shopping Network, “But wait, there’s more!”  Crazy has only just begun, unfortunately!

A patient with iron-deficiency anemia died at the hands of VA Doctors at the San Juan Puerto Rico VAHCS (2017), and the VA-OIG is just completing and reporting on their death in 2021.  The patient who came in for a colonoscopy developed rectal bleeding, which required an anticoagulant, and the patient subsequently died.  A tragic set of dominoes was set up and knocked down in this patient’s case, and the VA is entirely at fault for the patient’s death.  How badly the patient’s family must feel with this report in hand and knowing they can do absolutely nothing!VA 3

100% crazy indeed; but wait, there’s more!

Justice was served cold and raw, and while I was hoping for a harsher sentence by far, I am still hoping his victims can recoup some of their losses and obtain retraining.  “Jonathan Dean Davis, the owner of Retail Ready Career Center in Texas, was sentenced for deceiving the VA of $72 million. Beginning in 2014, he offered six-week heating, ventilation, and air conditioning course, promising to prepare veterans for careers in the HVAC industry. However, upon entering the workforce, many of these veterans discovered that the course had failed to teach them many of the basic skills necessary for entry-level technician jobs. Davis was also ordered to pay $65.2 million in restitution and forfeit $72.5 million to the federal government.”

It is very hard to describe what goes into the GI Bill besides money and time in service.  It is even tougher to explain how cheated you feel when the benefit is cut by the government, stolen by school administrators, and reduced by petty rules and regulations.  To see your benefits stolen through shoddy training and see your hopes and dreams dashed, as well as your benefit, turned into useless paper, the heartbreak is incredible!  The punishment for all involved should have been greater, and some federal employees should have shared the blame for failing to do their jobs!I-Care

Hold onto your seat, folks; the insanity has not even reached its peak yet; there’s more!

The VA Office of Inspector General (OIG) inspected the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (CLC), of failure to observe infection control practices, failure to minimize the risk of exposure to COVID-19, inconsistent ongoing testing, and failure to notify residents, families, and staff of positive test results. During the inspection, the OIG identified concerns related to leaders’ post-outbreak actions.  The VA-OIG substantiated a failure to observe general infection control practices, including in the following areas:

    • Leaders failed to minimize the risk of exposure to COVID-19.
    • Leaders did not respond adequately to staff exposure.
    • Leaders did not have a plan for the transfer and isolation of residents.
    • Leaders did not implement recommended infection control measures when performing aerosol-generating procedures and continued to hold group therapies.

The VA-OIG substantiated the lack of a post-baseline testing plan and a failure to test CLC staff after potential exposure.  The OIG identified actions taken by leaders following the CLC outbreak that lacked input from frontline staff to identify corrective actions and opportunities for improvement.”  This is the politically correct way of saying that the community living center leaders are thoroughly incompetent and should not be trusted in their current positions.

Leadership failure in spades, employees, patients, families all placed at risk because of incompetence and politics of the facility leaders, and the VA-OIG does not have the teeth needed to FIRE and REPLACE the leaders who are clearly out of their depth and ability!  For months the media and political leaders have been harping and preaching how dangerous COVID as a viral infection is.  Yet, the leaders in the Illiana VAHCS seem to be operating to a different set of rules and policies.  Will any elected leader be asking why?  Insanity runs deep in Illinois!VA 3

On the topic of COVID-19, and the failures of VA providers to do their jobs, we find another dead veteran due to what in the private sector would be a classic case of malpractice!  Yet, care at the VA is protected from malpractice, and the providers are safe from responsibility and accountability for their failures.  While the following is specific to North Carolina, similar examples are found across the United States.  Insanity thy name is represented in spades at the VA!Angry Wet Chicken

The VA OIG conducted a healthcare inspection at the Fayetteville VA Coastal Health Care System in North Carolina to assess concerns related to the quality, coordination, and timeliness of care, and the impact of COVID-19 on a patient with unintentional weight loss who was later diagnosed with oral cancer and died at another VA medical center.”

    • The VA-OIG substantiated that the primary care provider and dietitians did not provide quality care to the patient.
    • The VA-OIG substantiated that dietitians conducted incomplete nutritional assessments.
    • The VA-OIG substantiated that the patient’s PACT nurse and dietitians failed to coordinate care by not communicating the family’s request for a face-to-face appointment and the patient’s declining nutritional status to the primary care provider.
    • The VA-OIG found that incorrect scheduling resulted in the patient not being seen by a dietitian for a follow-up appointment and a delay in scheduling a non-VA dental appointment.

The VA-OIG concluded that COVID-19 impacted the care provided by dietitians because of the use of telephone visits, which did not allow dietitians to visually assess the patient’s physical characteristics caused by a declining nutritional status.”

Blaming a viral disease for the failure of people to do their jobs is the height of skullduggery, showing pusillanimous disregard for the patient and a timid weak-kneed, and yellow-bellied timorous approach to medicine.  None of you deserve to be in the medical field if you cannot properly take personal protection and see patients who need to be physically seen!  Now, let’s call a spade a spade and call out your wimpy, limp-wristed, lily-livered weakling leaders who refuse to act like leaders in a hospital and prefer to act like scared amoebas in a petri dish!  There is NO EXCUSE for your paltry excuses, your shady practices, and your hiding in offices and behind the disruptive behavioral committees when your policies and procedures FAIL when YOUR training plans fall apart, and when reality bites hard enough to disrupt hospital operations and your policies are the problem endangering patients!VA 3

Crazy…  Thy name is abused in the VA, and the leaders are failing to understand sanity!  But … wait, there’s more!

There are times when I describe the insanity at the VHA, VBA, National Cemeteries, and the Department of Veterans Affairs (VA) as designed incompetence.  The following is the purest example of designed incompetence witnessed to date.  Consider with me the following:

?u=http3.bp.blogspot.com-CIl2VSm-mmgTZ0wMvH5UGIAAAAAAAAB20QA9_IiyVhYss1600showme_board3.jpg&f=1&nofb=1Blue Water Navy Outreach requirements were met, but processing and procedures remain lacking and need improvement.  The VBA was legislatively mandated to extend veteran benefits to a classification of sailors who operated in blue water conditions off Vietnam or within 12 Nautical Miles of Vietnam.  The VBA went forward and established the computers, the records, the systems, etc., to handle these claims.  The results, a complete farrago!

The VA-OIG substantiated that the VBA has not established procedures for its employees to follow when the computer search tool they use to determine ship locations during claimant service dates returns unlikely results (for example, providing an inland location in a search for an aircraft carrier). In addition, VBA employees inaccurately decided approximately 46 percent of veterans’ claims (2,100 of 4,600) from April through June 2020, which led to about $37.2 million in improper payments to veterans ($25.2 million in overpayments and $12 million in underpayments) during that period. About 95 percent of these errors resulted from VBA employees deviating from policies governing disability-rating decisions.”

Did you catch that the VBA intentionally designed a system that failed to perform the task because humans and computers were lenient to deviate?  Nobody is held accountable for the continued loss of benefits, treatment, and wasted resources of the government and the veterans involved!  Here’s the rub, this is NOT the first time this has happened!  The VBA is notorious for failures like this and never held accountable by the elected officials hired to scrutinize the government!  Name a military excursion where benefits had to be carved out by legislative order, and you will find foot-dragging, designed incompetence, inconsistencies in decision making, and piss-poor performance at every level of the VBA.  Why?LinkedIn VA Image

Let’s imagine you hold a job that has a reporting requirement to an authorizing body that can shut you down.  You arbitrarily change language in metrics and reporting, do not tell the authority but still expect the authority to license you and your efforts.  How likely do you think the governing body will look favorably upon your changes?  The VA is legislatively mandated to report to Congress on its capacity in five areas, spinal cord injuries, traumatic brain injuries, blind rehabilitation, prosthetics and sensory aids, and mental health.  But, by changing the language, metrics, and methods of talking about injuries, the VA can hide, misreport, underreport, overreport, and play reporting games with the report to Congress and the VA-OIG second look get away with the deception.  Never forget, the maskirovka comes with veteran patient abuse!Angry Grizzly Bear

The VA-OIG has reported continuously to Congress, to deaf ears and plastic lips, the following, “… VA cannot compare its current mental health capacity with its 1996 capacity because of changes in diagnosis and treatment, service provision, and data collection. For example, VA must report on the number of veterans with “serious mental illness,” but VA no longer uses that term. And non-VA care, which veterans increasingly seek, must be excluded from reports on VA’s capacity to provide care. The OIG believes that by modernizing the reporting metrics, Congress would be better positioned to assess VA’s capacity to provide care for today’s disabled veterans.”

Congress continues NOT to push the VA to adopt 1996 language and metrics for reporting, or change the law to update the language and metrics to capture the data more accurately, thus allowing the lies and deceptions to continue.  Will anyone in the media EVER ask Congress WHY?VA 3

What kills me, the insanity discussed in this summation of VA-OIG reports does not even scrape the iceberg.  In my email inbox, I have to select between continued financial failures by leaders, veteran suicide during an inpatient residency, and the continued moral distress of employees by facility leaders.  I have twenty more VA-OIG reports sitting awaiting summation because the insanity has blossomed, and the VA-OIG is working hard to clear their reports for the end of the calendar year.  Each and every one of these reports deserve analysis, discussion, and mega-doses of sunshine disinfectant.  The sheer enormity of the insanity means that timely discussion physically cannot occur.  By overloading the system, the perpetrators of veteran abuse can escape sunshine disinfectant, and that is a sore injustice!Satire? Obama ISIS Speech Depresses Nation | Hooper's War - Peter Van Buren

Pray for the families of those who have died at the hands of the VA providers and for those currently dying under the hands of VA providers.  Congress needs to act, and we, the electorate, must hold their feet to the fire until they are consumed, or they stand and do their jobs!  There are no excuses for the insanity contained in these VA-OIG reports!

© 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.

Chronicling the VA, One Ignominious Story at a Time!

I-CareAs we catalog the VA, occasionally, local services providers must be recognized for their service or their deficiencies.  In the spirit of fairness and transparency, it is time to discuss one of those community providers, Advanced Neurology Epilepsy & Sleep Center (ANESC), Dr. Aamr A. Herekar M.D.  Also, in the spirit of fairness and complete transparency, I have tried to settle my problems through the VA Community Services Offices and an appeal to the management and doctor of ANESC, all to no avail!  Regular readers know I have been in a multi-year battle with the VA over arresting me for not wearing a mask because when I wear a mask, I become a medical emergency.

I possess a note from my doctor, a VA Primary Care Provider, written to my employer on VA Letterhead with a wet signature, declaring my inability to wear a mask.  The VA did not accept this letter and arrested me three times.  Well, Dr. Herekar’s office was presented the same letter, and hassled me before both appointments for not wearing a mask, became hostile, argumentative, and a nuisance over the mask issue, even after I complied with putting on a face shield.  Today (23 September 2021), over Facebook messenger, I was informed that I would be invited to find a different provider due to my refusal to wear a mask.VA 3

Imagine that; Facebook Messenger has become the medium of choice for ending a patient relationship with a medical provider.  How very inappropriate!  How very unprofessional!  How very typical of some of the providers I have been sent to in the community by the VA.  Apparently, the abuse of veterans is spreading from the VA providers to the community providers.  If you are in the El Paso area and receive a referral to Dr. Herekar, please be cautious of his staff.  I have no idea of the efficacy and quality of the doctor, but his staff is absolutely third-rate or less!  The shame of the entire episode, the taxpayer is on the hook for my being abused by the staff.  How deplorable!Foghorn Leghorn - Medication

In reviewing different results reported from the Department of Veterans Affairs (VA) – Office of Inspector General (OIG) comprehensive healthcare inspection (CHIp) of VAMC’s, I am finding some interesting trends.

      1. Why the sudden, as of July 2021, focus on attendance and staffing in behavioral committees? More to the point, why are the behavioral committee’s processes and procedures so draconian?  More specifically, the following is a unique passage too often see in CHIps.
          • High-Risk Processes
            • Disruptive behavior reporting and tracking
            • Disruptive Behavior Reporting System
            • Order of Behavioral Restriction and patient notification documentation
            • Staff training – Isn’t this interesting, staff training is a “High-Risk Process?”
      1. When reporting that patient experience scores are similar to “VHA Averages,” isn’t this like saying a VAMC is as good as another pig in a pile of slop? Why accept averages that are comparable to other VAMC’s?  The leadership at the VAMC’s across the country is failing the veterans, yet the VA-OIG is accepting average performance compared with other VAMC’s.  It sounds like pathetic designed incompetence, wrapped in weak excuses, and deep-fried in a pity party!
      2. Training continues to be a fundamental excuse for failing, and even the VA-OIG seems to have given up and thrown in the towel.VA 3

An example of how training continues to be a fundamental excuse for failing and designed incompetence lies in another CHIp, specifically reporting reusable medical equipment (RME) and sterile processing services (SPS).  The VA-OIG reported the following weaknesses:

      • Standard operating procedures not aligning with manufacturers’ guidelines.
      • Annual risk analysis reporting to the VISN SPS Management Board.
      • SPS chiefs developing, implementing, and enforcing a daily cleaning schedule for all SPS areas
      • Equipment storage, cleaning, and usability.
      • Completion of Level 1 training within 90 days of hire, competency assessments for RME, and monthly continuing education for SPS staff.

All this after the VHA has already been caught with poor cleaning of reusable medical equipment on multiple occasions, where the training of cleaning staff was the primary reason for failing the CHIp from the VA-OIG.  The cycle continues unabated, and training is central to correcting and ending the process.  Yet, even the VA-OIG refuses to address the leadership failures and be part of the training corrective action behaviors.VA 3

In other CHIp reports, we find that completion of training is a high-risk process.  Leading to interesting questions about why and what is involved in staff training to make training high-risk.  What boggles my mind, much of last year, the CHIp reports found moral distress from leadership, this year, nothing; why?  Did the VA-OIG stop asking about this issue?  Certainly, the VA has not corrected this problem.  Am I merely suspicious, or is there a correlation between less focus on employees feeling morally distressed at work and increased focus on patient disruptive behavioral committees?

From other CHIp reports, we find more questions and logic that make no sense.  For example, how can patients be receiving care that meets VHA averages in acceptable care, but the employees reflect severe moral distress?  Does this not indicate that the averages for patient care are set too low?  Would not this be an indicator that leadership is not held to a sufficiently high enough standard of performance?  Worse, on these CHIp reports, we find greater mention of disruptive behavior committee actions, paperwork, training, and actions taken.  Thus, there appears to be a correlational data relationship between disruptive patients, moral distress in employees, failing leadership, and the abuse of the disruptive behavior committee process.  Where are the elected officials asking questions and drawing substantive conclusions regarding the data presented by the VA-OIG?  Heck, where are the VA-OIG data analysts raising alarms and red flags over correlational data points for investigators to act upon?VA 3

As a person who has been fallaciously labeled and erroneously called “disruptive,” this particular topic strikes home.  The system is ripe for abuse by egotistical leaders hell-bent on power-tripping!  When I asked how do you appeal the decisions, I was told lies, given wrong information, and forced to pay fines that I should not have had to pay.  Worse, the Federal Marshals at the courthouse remarked that there had been a significant uptick in veterans in the same situation as mine being fined erroneously by the VA.  Thus, the abuse of the veterans is both widespread and decidedly egregious!

Another recurring issue from the CHIp reports is remarkable from recent VA-OIG investigations, especially since multiple veterans have recently died over the issue, care coordination.  Care coordination includes completing paperwork, filling out the electronic health record, and signing the electronic health record, so the notes are available for other providers to use for follow-on patient treatment, nurse-to-nurse communication, and medication transmission, but most importantly, monitoring and tracking patient whereabouts on the facility’s grounds.  Yet, even with dead veterans with these issues as root causes, the VHA continues to fail in care coordination.  How do you define appalling, detestable, and disgraceful?  Where are the elected officials?  Where are the veteran service organizations in raising rhubarbs about the abuse of veterans at the hands of the VHA?VA 3

Finally, the most astounding and absurd continuous hit point from CHIp to CHIp report is found under the heading of “Quality, Safety, and Value.”  Under this heading falls a lot of topics, but imperative to improvement is the leadership failure to hold meetings attended by the primary audience.  Tell me, in the private sector; your boss calls a meeting of all department heads and their number two person.  If these people are no-shows, how long will they keep their jobs?  Yet, the VA-OIG finds repetitive missed meetings, no follow-up, no remediation, no punitive measures, no corrective actions, and these people are still employed!

Knowledge Check!One of the most bothersome things about reading three weeks’ worth of CHIp reports has been the consistency of the reports.  Too often, the reports read like they were copied.  Maybe this is due to the consistency of failed leadership; perhaps this is due to the lack of originality in thinking in the VHA, VBA, and the VA in general.  Regardless, the CHIp reports raise some concerning issues, specifically around the potential for abuses found in the disruptive behavior committee process and what disruptive behavior is at the VHA and VBA.  For example, if a patient is throwing furniture, this is obviously disruptive.  But, if a patient disagrees with a policy and is politely asking to speak to administration, this is not disruptive, but the patient is treated as disruptive, and that is abusive of the disruptive patient policies.

© 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.

More Repugnant VA Chronicles! – When will this Insanity END?

I-CareMonday and Tuesday this week, 28 and 29 June 2021, the Department of Veterans Affairs – Office of Inspector General (VA-OIG) returned three more investigations, inspections, or criminal reports.  While no veteran is dead in this batch of reports (Thankfully!), the behavior exhibited remains egregious and blatantly criminal, and the bureaucrats and bureaucracy remain intact to continue to commit malfeasance, misfeasance, and malpractice!

Before getting into the VA-OIG reports, I want to hand out some praise.  The El Paso VAHCS was the focus of a major problem just a couple of years ago when the VA Police attacked a veteran and ended up pulling his arm out of his shoulder socket.  I am now a patient at the El Paso VAHCS, being seen at the VA Out-Patient Clinics instead of the Las Cruces Community Based Outpatient Clinic (CBOC).  While the fallacious claims of the Phoenix VAMC continue to dog me, I am very happy to report that the VA Police in El Paso were professional, polite, and the customer service displayed was top-notch.  Growth has occurred since the veteran incident mentioned, and I, for one, am grateful!VA 3

The VA-OIG has announced that Dr. Kenneth C. Ramdat has received one year of probation after being allowed to “plead guilty” to touching two women’s breasts without permission.  When the VA is compared to a criminal syndicate, where the administrators are actively against the employees and the patients, I can see the connection!  What else happened at the Louis A. Johnson VA Hospital in Clarksburg, West Virginia, while this doctor was on staff and is not included in the criminal trial?  West Virginia keeps coming up as another morally distressed VA Health Care System; what is the VISN doing to improve the environment for illegal activity?  If Phoenix and VISN 22 are an example, nothing, which is negligence worthy of criminal investigations!VA 3

How can employees trust each other when plea deals are allowed, and behavior worthy of criminal punishment exists?  I was physically attacked, as an employee, by another employee, and the administration swept the incident under the rug.  After being discharged during probation, I learned that the employee who attacked me had done this previously with no punishment and the revelation that the administration was gunning for my removal for reporting the attack.  How many VA Employees lost their jobs before Dr. Ramdat was finally forced to be held accountable for sexual assault?  Why the plea deal?  Doesn’t this plea deal re-injure the victims, the perpetrator got off, essentially?

Sexual assault pled down to simple assault with probation – criminal syndicate indeed!Plato 2

Kristopher M. Voyles’s trial ended with a sentence of 27-months in prison, 3-years supervised release, and restitution of $20,502.  While this is a good sentence for theft of medical treatment, Mr. Voyles was never charged and investigated for the actual crime, identity theft of a veteran!  Mr. Voyles stole the name, date of birth, and social security number of a veteran fraudulently created documents, and then obtained care.  Thus, theft of medical care was criminal activity.  Until we read, “Subsequent investigation revealed that Voyles had previously been prosecuted by Atlanta, Georgia authorities for using the same veteran’s identity to obtain prescription drugs from the VA Medical Center in Atlanta.”VA 3

Do the veterans targeted know that Mr. Voyles stole their ID and used it fraudulently?  How did Mr. Voyles repeatedly target and steal the identities of veterans?  Is the ID Theft related to any VA data breaches, losses of veteran identities, or IT problems consistently occurring at the VA?  Were any of these questions asked during the “subsequent investigations?”  If so, where are those VA-OIG reports?  This criminal intentionally targeted veterans, stole identities, used those identities; how many other veterans’ identities does he have or have access to?  The Department of Veterans created the problem of ID Theft; when will they be held accountable for the loss of ID?  Better still, when will the data theft from the VA end?

Knowledge Check!Our final example (today) for the repugnant and criminal behavior of VA Employees needs a little background to be fully understood for those outside the military and government employment.  In government, contracting officers liaison between the facility receiving goods and services, the government paying for goods and services, and the third-party hired to provide goods or services.  Some third-party contractors receive government-issued identification cards similar to an employee identification card, both of which are called a “Personal Identity Verification” (PIV) card.  These cards act as keys to the facility, prove identification and authorize the contractor to be doing what they are doing.  The contracting officers are the end-all in the responsible party for that third-party contracted vendor.

VA SealContracting officers and third-party contractors act under Federal Regulation called “Federal Acquisition Regulation (FAR).  FAR is like the Bible; it has everything in it outlining duties, responsibilities, and authorities.  Contracting officers are supposed to know the regulations before contracting goods and services, and they teach the contractor their responsibilities.  Especially where a PIV has been issued, the contracting officer, as the liaison, IS THE Responsible Party, not the contractor.

Now, gauge the following VA-OIG report with these facts in mind.

The VA-OIG “… examined a random sample of 46 professional service and healthcare resource contracts. None of the reviewed contracts had adequate evidence to demonstrate FAR requirements were met. VHA contracting officers’ noncompliance with PIV card requirements occurred because they were unaware of their responsibilities and the requirements. In addition, VHA did not have policies or procedures detailing supervisory oversight of contracting officers’ duties regarding PIV cards, the internal audit office did not review compliance, and there was no automated tool for continuous tracking and monitoring of PIV cards issued; to contractors’ personnel.”VA 3

Did you catch that; a 100% failure in a random sample of contracts, contracting officers, and oversight supervisors were unaware of their roles and responsibilities.  How long has this failure been occurring?  How many government PIVs are available granting access to facilities where the contract has concluded?  This is not the first time the government contracting officers and offices have utterly failed to perform their roles and responsibilities; yet, this is one of the most dangerous to the PIV system’s security, safety, and reliability.  This is just an investigation from the VA, how bad is this problem across the entire government contracting establishment?

QuestionI cannot understand how a contracting officer, with all the training, re-training, and refresher training that is mandated, could use the excuse, “I didn’t know that was part of my job!”  As a person who has worked around contracting officers, I knew this was their job, and I am not a contracting officer.  It is simply common sense; if you facilitate obtaining identification, keys, and access codes, you are responsible for getting these things back!

While the behavior of the contracting officers is part of the problem, the culture of passing the buck and dodging responsibility is readily apparent in the following statement from the VA-OIG list of recommendations.  “The OIG also recommended VHA assess whether the existing and planned information systems could have the functionality to allow effective and routine monitoring of contractors’ PIV cards or a new system is needed.”  Designed incompetence will allow the IT failure to be the problem, to finagle more money from Congress for IT infrastructure upgrades and new systems, as the legacy systems were purposefully designed not to accommodate regular, daily, routine activities!VA 3

I refuse to believe the VA has ever designed a system that works, is cost-effective, does its job, and can be useful.  Why; because, having worked at the VA, been a patient at VAMC’s across the country, and reading the VA-OIG reports, the VA has proven their utter incompetence!  If a local hospital allowed this type of failure in their contracting department, heads would roll, and Congress would be demanding investigations to ensure HIPAA was not breached.  Yet, the VA can get away with murder, and Congress cannot even care, let alone issue a mild rebuke or increase scrutinization.

Angry Wet ChickenThus, I call upon every American to share my disgust and demand action!  Stop allowing this detestable behavior, paid for by taxpayers, to thrive.  End the abuse!  Not just for veterans harmed by the VA bureaucracy, but for your hard-earned tax dollars and the disrespect the elected officials display towards you, the boss!  Tell me, if your employees displayed the same behavior witnessed by elected officials and bureaucrats of all stripes, how long would they keep their jobs?  If your boss showed you the same disrespect, how fast would you be looking for new employment and telling everyone not to apply there?  Now, answer this question, “Why do we accept this abuse by government officials and elected representatives?”

© 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: Memorial Day 2021 – Are you sure this is “proper” remembering?

Knowledge Check!It is no secret that the Department of Veterans Affairs (VA) is a sick and twisted organization.  It is no secret that the Department of Veterans Affairs – Office of Inspector General (VA-OIG) tries to recommend how the VA should be operating in accordance with currently established procedures, methods, and policies for the benefit of the veteran community.  It is no secret that I continue to write about the VA in the hopes of sparking interest in communities and obtaining more fair, honest, transparent, and humane treatment for veterans by the Government agency tasked with caring for veterans.

On this Memorial Day, as you sit down to barbecue, family, friends, sports, I would ask that you take a moment and consider if this were how you would like to be remembered?  Are the actions described proper for remembering those who sacrificed and came home?  Are these actions, which are adding to veteran funerals, an appropriate way for veterans to be leaving this world?  If the answer is no, I ask for your help changing the Federal Government by electing people who will scrutinize the government more stringently and demand change in all government agencies.  If you deem this behavior acceptable, please leave a comment detailing why you think so.  I want to hear your thoughts.Image - Eagle & Flag

From a VA-OIG report published on Wednesday 26 May 2021, we find the following announcement:

Phillip Hill, a former VA program analyst, was sentenced to 46 months in prison for stealing personal information from veterans and VA employees while employed at the Central Arkansas Veterans Healthcare System. The investigation revealed that Hill contacted another individual and attempted to sell personal identifying information to a buyer for approximately $100,000.”

Now, I am thrilled this guy was caught.  I am glad he will do time behind bars.  Yet, why did Assistant US Attorney Jana Harris allow a plea deal?  Where are the VA supervisors who should have been monitoring this employee’s work and behavior?  What are the details of the deal?  The VA continues to have nothing but IT/IS security, and these problems are decades old.  Still, the elected representatives allow the criminal behavior to exist until the criminal is caught, and then the elected representative’s crow about cleaning the swamp.  Is this how you correctly remember veterans, their sacrifice, and their memories?VA 3

I suppose the following VA-OIG report, released 27 May 2021, should begin with congratulations.  The Department of Veteran Affairs – Veterans Benefits Administration (VBA) mostly processed monetary proceeds records accurately.  However, the following continues to astound and amaze me:

Service and pension center staff do not have timeliness measures for proceeds incorporated in their performance standards. Setting a timeliness standard would help encourage the closing of these proceeds. The OIG also found that ineffective monitoring contributed to delays in handling proceeds. The Debt Management Center had only limited internal monitoring but instituted new practices for monitoring proceeds in February 2020, shortly after this audit began” [emphasis mine].VA 3

Why are government employees not held to a productivity and quality standard?  Being a veteran with regular concerns involving the VBA, I cannot help but wonder why quality and productivity are not required?  As an industrial and organizational psychologist, the first step in improving responsiveness to customers is to increase productivity and implement quality measures.  I know the Federal Government’s legislative branch, e.g., Congress, has insisted on developing quality measures.  Yet, the same tired excuses built upon designed incompetence are allowed to survive, and all the VA-OIG can do is issue more recommendations.  Consider something; proceeds include payments to dead veterans.  How much financial hardship occurs at the passing of a loved one?  How much more difficult can that death become when months down the road, money spent is suddenly being demanded back because some incompetent bureaucrat failed to do their job in a timely manner?

QuestionIs this properly honoring and remembering the veterans and their sacrifice?  Is this behavior acceptable in your workplace?  Why do we allow this behavior from government workers?

While never having been a patient at the Chillicothe VAMC in Ohio, I have friends who are patients.  The stories they tell about care there would shock and amaze many.  What infuriates me, the VA-OIG just published their report of a comprehensive inspection of this VAMC, and the results are as tragic as a veteran’s death!  The information was released to the public on 27 May 2021.  Never forget, the Chillicothe VAMC in Ohio was recently investigated for improper cleaning and sterilization procedures, as well as employee monitoring for compliance for medically reusable equipment, which for this case refers to endoscopes.  With this fact in mind, let us review the comprehensive inspection report.

Limitations on findings:

      • The VA-OIG held interviews and reviewed clinical and administrative processes related to specific areas of focus that affect patient outcomes. Although the VA-OIG reviewed a broad spectrum of processes, the sheer complexity of VA medical facilities limits inspectors’ ability to assess all areas of clinical risk” [emphasis mine].

VA 3The statement provided here is pretty standard and represents the first limitation to the scope of the investigation; complexity limits inspector ability.  Yet, who made the VAMC so complex, the VA.  Who has allowed the complexity to grow as designed incompetence, the VA? Why is the VA allowed to cheat their inspector general through complex operations which limit inspector ability and increase patient risk?

The Focus of Inspection (Investigation Scope):

      • The VA-OIG team looks at leadership and organizational risks, and at the time of the inspection, focused on the following additional areas:

WhyLong have I wondered why the second item in the comprehensive inspection is “Quality, Safety, and Value.”  When the VA continues to present the bare minimum of quality, disregards patient safety, and due to complexity, offers less value than a broken wrench to a mechanic, but I digress.

Finding One:  The VA-OIG issues 12 recommendations to the leadership team, and “selected results showed respondents were generally favorable the national VHA results.”  I have been accused of being cynical, which generally is wrong.  However, when I see words like “selected results” in an investigation into patient care and concerns, I have to ask, “How hard did the VA-OIG have to dig to find favorable results?”VA 3

Finding Two:  Strategic Analytics for Improvement and Learning (SAIL) represents a value model to help define performance expectations within VA.  This is the standard language for comprehensive inspections.  “In individual interviews, the executive leadership team members were able to speak in-depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences.”  If we accept this as a true statement.  How was an employee able to fake documents, fail to clean reusable equipment properly, and repeatedly get away with this abysmal behavior at this VA?

VA 3Finding Three:  Under Quality, Safety, and Value, we find the following tidbit:

The VA-OIG noted concerns with protected peer reviews, utilization management, and root cause analyses.”

Essentially meaning there are problems with whistleblowers, privacy protection, retaliation against whistleblowers, proper utilization of policies and procedures, and the leadership could not find a problem using root cause analysis if their lives depended upon it.  The source for my interpretation of the VA-OIG results arrives from the following:

VHA Directive 1117, Utilization Management Program, 8 October 2020. Utilization management involves the assessment of the “appropriateness, medical necessity, and the efficiency of health care services, according to evidence-based criteria” [emphasis in the original report].

I have to ask the VA-OIG whether these findings were before or after the employee who endangered patient lives through improper cleaning and sterilization of reusable medical equipment were discovered?

VA 3Finding Four:  Under medication management, we find the following:

The VA-OIG team observed compliance with many elements of expected performance, including pain screening, aberrant behavior risk assessment, and documented justification for concurrent therapy with benzodiazepines. However, the VA-OIG identified opportunities for improvement with urine drug testing, informed consent, patient follow-up after therapy initiation, and quality measure monitoring” [emphasis mine].

VaccineIf you read any of the comprehensive inspection reports, you will see this is a common and recurring theme at the VA.  Some of the medication policies are being followed, but the same problem with drug testing, informed consent, patient follow-up, and quality measuring monitoring always remain a problem.  It is almost as if the SAIL learning matrices do not even exist as a quality improvement tool.

Finding Five:  Under High-Risk Processes, the VA-OIG report claims the following:

The medical center met the requirements for quality assurance monitoring and monthly continuing education. However, the VA-OIG identified deficiencies with standard operating procedures, an airflow directional device, and staff training and competency” [emphasis mine].

Are the SAIL metrics even accurate?  Where is the value in the “monthly training and monitoring if there are issues in following standard operating procedures, problems in staff training, as well as staff competency?  Do you get it?  The training sucks at the VA, and the SAIL metrics do nothing to fix the problem, address the deficiencies, or even improve competency?  The same question arises here, from quality, safety, and value; how was an employee able to successfully pencil-whip the paperwork while not doing their job in properly cleaning and sterilizing reusable medical equipment?  Where are the SAIL documents that should have identified a problem?  Where are the SAIL metrics in aiding in finding root causes for derelict employees?VA 3

Honestly, do you, the taxpayer, consider the Department of Veterans Affairs, which covers the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries adequate to remember the veteran correctly?  Do you, the taxpayer find value in the leadership and investigative arms of the VA to correct and improve performance?  Do you, the taxpayer find that the VA employees are doing their level best to honor, remember, and pass on the legacy of veterans?

Image - Eagle & FlagOn this Memorial Day weekend, please consider the data in this and the other VA-OIG reports regularly relayed on this blog, and ask yourself, are you doing enough to help veterans?  I love Memorial Day, and I love my country, but America has some serious problems, and only when the electorate awakens to the issues can real change begin to be implemented.  We, the veteran community, need you!  We need your voice as we struggle against the incessant attacks from the VA.  We need your votes for the elected representative’s intent on scrutinizing the government and demanding action.  We need you!  Please help us!

© 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.

Weep America! – The VA Leadership is Becoming Worse! – Part 2

Angry Wet ChickenOne of the first rules in overseeing junior people working is to make available someone to answer questions, immediately, and render support if needed.  I have had the pleasure of training junior people in a myriad of tasks over the years.  When I read this Department of Veterans Affairs – Office of Inspector General (VA-OIG) report, a plethora of questions arise, and I deeply question the professionalism and competence of the doctor overseeing the work of residents in a VA Hospital who are performing procedures.

  • Ophthalmology Resident Supervision – Important to note, the patient did not experience any long-term loss of sight over this issue. Congratulations to the resident and the other ophthalmology doctors present!  From the VA-OIG report we find the following:

“… The subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case.”  Essentially, the doctor charged with overseeing residents was AWOL, and then compounded his error by falsifying patient records.  The VA-OIG report continues by claiming this falsification was the result of an oversight when using pre-recorded notes for patient files.

Draw your own conclusions.  Personally, I think this doctor needs to be released of all duties where overseeing residents is concerned.  I would also question his ethics and morals for falsifying patient records.  You hold a double position of trust, first as a doctor, second as a teacher and leader of residents, and the behavior witnessed should come with steep repercussions professionally!VA 3

Knowledge Check!On the topic of professional duties, and steep repercussions, drug interactions killed a veteran at the Marion VAMC in Illinois.  Before launching into the VA-OIG’s report, please allow me a moment of your attention.  Drug interactions can arise due to vitamin usage, over-the-counter medications, and from illegal and legal but illicit drug use.  Often, I have claimed that people are walking chemistry experiments, and even vaccines need to be carefully evaluated for drug interaction potential.  Foods can cause drug interactions due to the chemicals in the food.  Drug interactions are a growing problem and every medical professional I have spoken to admits drug interactions are becoming worse by the day.  I do not say this lightly, but I do not hold the medical professionals as fully competent in fighting the drug interaction problem due to the amount of chemicals the average person interacts with daily.  The problem is Big-Parma and the continual push towards more specialized medicines, we are going to see more drug interaction issues.  Unfortunately, drug interaction issues come with the risk of death!

From the VA-OIG report we find the following:

The VA-OIG substantiated that high cholesterol contributed to the patient’s death; however, the death certificate indicated that the primary cause of death was accidental acute multi-drug intoxication. The psychiatrist and staff failed to document providing the patient with education during a telephone encounter regarding potential side effects or adverse drug-drug interactions of medication changes. Contrary to clinical guidance, the psychiatrist prescribed long-term benzodiazepine use for a patient diagnosed with posttraumatic stress disorder. The psychiatrist also failed to address the patient’s two negative urine drug screens for a prescribed medication and failed to address a positive urine drug screen for cannabis. Due to COVID-19, the facility failed to launch the Psychotropic Drug Safety Initiative Phase Four Plan. The primary care provider did not comply with facility policy by failing to enter a return-to-clinic order following an appointment but could not determine if this affected the patient. Primary care and behavioral health staff did not comply with facility policy to telephone the patient or send a letter after the patient missed appointments” [emphasis mine].

The lack of staff to follow procedures and do their job, I will certainly hold them accountable for, especially since Cannabis is involved!  Please do not believe that Cannabis is a non-toxic drug, especially when mixed with other drugs, it can be the fatal trigger in a multi-drug intoxication!VA 3

At 18, low those many years ago, I took the EMT-Basic class, but left for US Army Basic Training before I could certify.  Since then, I have received certification as a combat medic and a Journeyman Firefighter (Any industry) which required a lot of hours studying emergency medicine.  I am experienced in drawing blood, starting IVs in difficult circumstances, and handling a myriad of injuries.  I am not a medical professional by any stretch of the imagination, I simply have a healthy desire to learn, and emergency medicine is a fascinating topic I regularly pursue.  I am not a chemist; I rely upon peer reviewed resources and legal and medical websites to stay current on a host of topics.  With this as my qualifier I am going to make several statements and you can judge their merit.  Feel free to comment.

      1. The first rule of medicine is document everything! My first lesson, first day of EMT training, this point was driven home.  If you do not write it down, it never happened!  Yet, what does the VA-OIG find time after time in reviewing cases at the VHA, lack of documentation of steps taken!  Can you say, “Asinine and abysmal behavior by credentialed professionals?” I know I can!
      2. Aspirin and Alcohol can cause a drug interaction that can be deadly. Both chemicals are readily available in the home and over the counter.  Why is spray paint now requiring proper ID, because people are huffing the stuff and getting a multi-drug intoxication.  Oven cleaner and spray pain can cause serious breathing issues and when mixed together can cause a cheap high, as well as a multi-chemical intoxication leading to breathing paralysis and death!
      3. Cannabis continues to be modified, changed, enhanced, and designed to trigger different chemical reactions in the body. Continuing work that began in earnest in the 1960s for the pot-smokers who wanted a more serious high.  Guess what, cannabis and aspirin along with vitamins can cause multi-drug intoxication problems leading to death!
      4. Vitamin D and Vitamin C have both caused serious drug intoxications during COVID-19. People became frightened and took too many of both or just one and wound up in the ER with life-threatening health problems from toxicity of these vitamins.  India has reported a spike in black mould that has caused serious long-term health problems for diabetics after recovering from COVID.  It is currently presumed that the chemicals used to fight COVID allowed for a natural mould to grow in the body, and that became life-threatening.

The VA-OIG conducted another virtual comprehensive healthcare inspection, and found the same problems continue at another VAMC.  Do you know how tired I am of reading these “comprehensive inspection” results and finding the same problems time after time?  When will the VA actually start enforcing some of these VA-OIG recommendations to effect change?  Better, when will the politicians who are charged with scrutinizing the government tire of seeing the same recommendations and not seeing any change?  Bloody frustrating reading these reports and not seeing improvement!VA 3

Broken RobotFinally, we come to what I was hoping to be a great report, where the politician’s heads were going to explode at the inefficiencies, the detestable behavior, and the horrendous responses to legally mandated IT infrastructure changes, and why those changes are not happening at the VA.  I was not disappointed; I was thoroughly disgusted that his report fell on plastic ears speaking plastic words from wax lips!  Statement of Michael Bowman, Office of Inspector General, Department of Veterans Affairs, Director of IT and Security Audits Division, Before the Subcommittee on Technology Modernization, Committee on Veterans’ Affairs, U.S. House of Representatives, Hearing on Cybersecurity and Risk Management at VA: Addressing Ongoing Challenges and Moving Forward May 20, 2021.  Notice something, the failures at the VA in the IT Department are being called “ongoing challenges.”

Millstone of Designed IncompetenceLet me remind you, FISMA was released on 29 April 2021, and I wrote about the abysmal findings of the VA-OIG.  This report is the accountability statement to the Congressional representatives who should have skewered this bureaucrat and roasted him on a spit with onions and peppers, then served him up for public ridicule after firing him!  For the Director of IT and Security Audits Division to make the following statement is flat out beyond comprehension, “The OIG’s conclusions in the FY 2020 FISMA audit are not new or revelatory—rather, they repeat many of the same concerns with VA’s IT security that the OIG has found for many years.”  What incredible chutzpah to make this comment after that scathing report showed just how deplorable the leadership of the IT and Security Audits Division revealed!  Director Bowman then goes on to downplay the band-aid solutions implemented while decrying the time for improvement is too short and there is not enough money.  Do not forget, “Of the 26 recommendations, 21 have been included in every FISMA audit dating back to at least 2017.”  With at least 15 of these recommendations dating back even further.  Want a full list, as well as how old these recommendations are; you will not find it in the Director’s report to Congress!  Is anybody incensed enough to demand a full accounting of just how old these IT recommendations are?

Detective 4The gall of this director to continue to blame legacy systems that were legislated to have been scrapped between 2000 and 2010 continues to highlight the incompetence of the director in conducting business and holding people accountable for failed projects and overspending of taxpayer monies!  The director went further and stated the following, at which time, every single Congressional Representative should have stood and demanded his head.  The “VA does not properly manage and secure their IT investments.”  Tell me director, why should you remain employed if the VA does not properly manage and secure their IT investments?  Is the failure to manage and secure IT investments the root cause for veterans to continue to suffer identity theft from the VA losing their identity?

The director’s next statement puts his other outrageous comments to sleep.  “Security failures also undermine the trust veterans put in VA to protect their sensitive information and can affect their engagement with programs and services” [emphasis mine].  Talk about such an obvious statement, it’s like the sun coming up on a cloudy day, you just cannot miss that sun rise; you also cannot miss the absurdity of making this statement!  Did some intern write his speech?  You are the director of IT Security and you make this type of comment, did you make this comment with a straight face?  I cannot find the video-record of this Congressional hearing so I can only guess he delivered his lines with a straight face!  Most detestable of all, he continued to make outrageous comments, his plan to move the IT security program at the VA forward is weak, lacking firm deadlines, and continues to allow him and his staff to escape accountability and responsibility.VA 3

Angry Grizzly BearAmerica, with these bureaucrats in charge, why shouldn’t we be weeping and wailing, and gnashing our teeth in frustration?  When will we, the owners of this atrocious government, finally scream ENOUGH and demand a full change of heads at the ballot box?  For until the elected representatives are forced out, the bureaucrats abusing us, will only continue!  The VA is sick, but the problem lies in the bureaucrats, administrators, and directors leading the VA at the Federal and VISN levels.  So many other government agencies are just as sick, or worse, and the same problem arises, the leadership refuses to act, but still expects a big titanium parachute when they leave office!  I say it is time to tell them NO!

© 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: Revisiting the VBA and Spinal Claims Issues

VA SealOne of the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports I wrote about in 2019 was how the Department of Veterans Affairs – Veterans Benefits Administration (VBA) was inaccurately deciding spinal claims for veterans.  Apparently, the complexity of primary injuries and secondary problems was causing confusion at the VBA, and when the VA-OIG came around to investigate, 100% of the claims from 01 January to 30 June 2018 were inaccurate in some way, shape, or form.  The VA-OIG reviewed 62,5000 spinal injury claims in the designated window; 34,700 were incorrectly processed, with approximately 5000 receiving inaccurate decisions resulting in over or underpayments totaling $5.9 Million.  Thus, each of the 5000 veterans had about an over or underpayment of $1180; whether this is monthly or in total is not detailed.

Something to think about those 5000 veterans mentioned does not include the 29,800 veterans’ claims which contained processing errors that could have had a monetary effect on veterans.  The VA-OIG could not determine monetary over or underpayments on these 29,800 claims.  Hence, $35,164,000 in possible over or underpayments was still in question if the average per person holds from the 5000 mentioned above.VA 3

More details on the other 34,700 veteran claims incorrectly processed for these claims with processing errors, VBA staff decided on the claims before completing all required evaluation steps.  The Department of Veterans Affairs (VA) conveniently designs its processes to fail, and this is referred to as designed incompetence.  Think I am wrong; check out what the VA-OIG discovered as the root cause of incorrect spinal claims processing.

The OIG found that all incorrectly decided veteran claims resulted from VBA’s inadequate process for ensuring accurate and complete evaluation. The disability rating schedule—the primary criteria for evaluating disability—contains minimal guidance on neurological and peripheral nerves. A procedures manual detailing the rating schedule is too subjective about peripheral nerve disability evaluations, which can lead to an inconsistent evaluation for a secondary service-connected condition” [emphasis mine].

Angry Wet ChickenThe manuals, designed and published by the VBA, are inadequate to decide spinal claims consistently.  The VBA created these books to be a ready-made excuse for cheating veterans with improperly decided claims on spinal injuries.  Why is this such an issue for me; I have been fighting chronic pain in my spine since 2002.  I fell multiple times onboard the ship after being pushed by a First-Class Petty Officer while carrying a load of D Cell batteries.  I experienced weakness and shortness of breath on the boat, went to medical; none of those records exist anymore.  The Chief made Senior Chief and was “encouraged” to retire shortly after I left the ship. After leaving the service, I discovered that the Independent Duty Corpsman, a US Navy Chief, was consistently sinking medical records for the Engineering Department to Davey Jones’ Locker.

Angry Wet Chicken 2Today, 10 May 2010, I had a Compensation and Pension appointment with LHI.  I discovered the VBA had edited my claim, and my C-Spine information again was missing from the evaluation.  Since my spine was inappropriately decided in 2014, I could not add the C-Spine problems into today’s appointment.  I was sent back to the VA to file a supplemental claim, using the VA-OIG report from 05 September 2019, as “New and Material Evidence” to have my 2014 claim reopened.  That 2014 claim, called bulging disks in C-Spine, bulging disks in L-Spine, and a trauma-induced S-Curve in my T-Spine as “lumbar strain with chronic pain.”  Today, I was asked how the peripheral nerve problems in my right arm were connected to my lumbar spine!  Not joking, a Nurse Practitioner asked me to explain the connection, without mentioning the C-Spine, the fact that my Right Shoulder is 1-1/2 -2” shorter than my left shoulder, not to mention the headaches at C-0, but all this has something magical to do with my lumbar spine.  After all the tedious bureaucratism I have experienced with the VA, I was not surprised; other adjectives fit, but not surprise!

Upon returning home, I filed a supplemental claim, as advised by a customer service representative at the VBA.  Best of all, the customer service representative confirmed I could use the VA-OIG report as my “New and Material Evidence.”  This is good because none of the MRIs since 2014 are allowed as “New and Material Evidence,” the neurological decision claiming I have an unknown neurological disease is not permitted. All the lost jobs, employer letters claiming a need for ADA Accommodation, or physical therapy notes are also not allowed as “New and Material Evidence.”  All because of those published books the VBA uses to make determinations, which continue to fail to accurately and consistently aid in deciding spinal claims for the VBA and for the VHA to treat.VA 3

The VA-OIG Report has the following to report, which also played a significant role in confusing the nurse practitioner interviewing me today.

“… The medical examiners did not always choose disability levels that were consistent with documented symptom details from the exam. Examiners told the review team that VBA did not provide any guidance on the definition of these disability levels. In addition, they are VBA terms, not medical ones, and there are no standardized criteria for the examiners to determine severity.”

The nurse practitioner could not explain the difference between mild, moderate, and severe.  The VHA uses a pain scale from 1-10; thus, confusion reigned during the LHI compensation and pension evaluation.  Imagine that; the VBA cannot train a third-party contractor on VBA-specific terms designed to create confusion between the language used in the VHA and the language used in the VBA.  Color me shocked; NOT!  VA 3

There have been no changes to these terms, and the confusion generated since the VA-OIG called out the VBA on their inability to communicate and accurately decide veterans claims.  Imagine my surprise when a reader claimed I was too harsh on the VA Administrators and their failures to lead, correct, and design anything that fundamentally fixes the VA.  The VA-OIG issues “recommendations,” the VBA, The VHA, and the National Cemetery ignore the recommendations and continue with business as usual.  Hey taxpayer, how would you rate the VA and evaluate their job in not wasting your tax dollars?

What blows my mind is that this is what the marketing department for the VA calls “Defining Excellence” in VA Healthcare!  The VA-OIG report continued claiming:

The same form also asks medical examiners to provide an opinion about whether the veteran’s range of motion is limited during flare-ups or after repeated use. The medical examiner can decline to provide an opinion, but a sufficient explanation is required if the medical examiner takes that route.  The VBA manual states the opinion may be insufficient if the conclusion is not adequately justified or implies a general lack of knowledge or an aversion to offering this statement on issues not directly observed.  Most of the errors the OIG team identified did not have the required and sufficient explanation about why the examiner could not express an opinion.”

Recognize a problem here; if I replicate a movement that causes me severe pain, I fall to the floor, insensate, and become an ER issue.  For the last spinal compensation and pension evaluation, the evaluator collapsed my legs four times in her office by placing her hand on my L-Spine where the disks are known to be bulging.  What did the VBA call this? Insufficient evidence for a secondary peripheral nerve problem.  I had to report to the Albuquerque ER for a shot of morphine and a shot of Toradol. Missing the next three days of work due to pain in my spine where the medication was insufficient to the task of relieving the suffering.  Those days missed directly led to my being dismissed from VA employment and spending the majority of the next two years unemployed!VA 3

So, not the VBA cannot communicate using medically acceptable terms.  They cannot understand when nerves have a primary, secondary, and tertiary issue causing a veteran loss of employment, severe pain, repetitive injuries.  Then the VBA has the gall to refuse to accept all VHA medical records as “New and Material Evidence.”  Do you know how hard it is to replicate a secondary or tertiary problem when it occurs intermittently on one side of the body but is a regular 24/7 injury on the other side of the body?  My right side is neurologically worse than the left side, but how do you communicate that to the interviewer?  How do they properly communicate that to the VBA when the VBA does not use medically recognized terminology?

LinkedIn VA ImageWorse, all the problems have a root cause in the technology forced upon the medical reviewer. There is an insufficient explanation to describe to a veteran what the VBA is asking for, so the veteran can answer the questions correctly.  The person who made my spinal claim originally had been writing VBA claims for 20+ years.  She was still disregarded by the VBA because the Veterans Service Representative reviewing the claim could not, or would not, interpret the doctor’s note correctly for an accurate decision.  Any fourth-grade biology student can tell you that the T-Spine is different from the L-Spine, and damage in one does not mean damage can be added to the other, and all the damage can be lumped together!  Yet, that is precisely the asinine decision I was handed and have been fighting!VA 3

If you want more details on this egregious example of leadership failure and VBA insanity, the whole report can be read here.  I am not joking, and adjectives are expended describing how deplorable the VBA processes are and the problems these decisions place the veteran into!  The rules are ineptitude hiding behind designed incompetence to the Nth degree, and that is an absolute disgrace!Apathy

I believe in the little rocks that start landslides.  I know the power of tiny snowflakes that create an avalanche.  I know that if enough veterans, their families, friends, and communities rise up, the elected politicians responsible for scrutinizing the government will be forced to make veteran safety and health at the VA a priority, and blessed change will finally arrive in the VA Administration and administrators.  Imagine how you would feel about learning a close friend or family member was being refused treatment at the VA because their claim was inaccurately decided.  Please respond accordingly!

© 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: Calling Out Politicians – The Rep. Greg Stanton (D) AZ09 Edition

Foghorn Leghorn - MedicationWhile Rep. Greg Stanton (D)’s staff did respond, and this is a good thing, neither senator from Arizona Sen. Kyrsten Sinema (D) or Sen. Mark Kelly (D) cared enough about my concerns to respond.  Frankly, this speaks volumes about how little the senators representing Arizona care about their constituents or veterans.  Hence when re-election arrives, remember well the treatment and vote for anyone else!

Now, getting back to Rep. Greg Stanton (D).  I contacted his office initially in December 2020; by early January 2021, I received a response from the director of constituent services and was told to allow the VA 45-days to respond to my complaint.  Remember, this is my seventh attempt at contacting any of the federal elected representatives to no avail.  I was 6-months into being discriminated against by the Carl T. Hayden VAMC for my medically approved breathing problems that preclude wearing a mask.  I have sent letters to the hospital director, the VISN Director, and Secretary Wilkie to no avail.  I have sent emails to the patient advocate and gotten misleading information, at best.  My Primary Care Provider (PCP), at the Carl T. Hayden VAMC, refuses to diagnose over the phone or through distant means and has invited me to find another PCP.  I have been arrested, injured, and cited three times by VA Police, who have no say in writing policy.  The policy they are enforcing is causing me both injuries at their hands and refusal of emergency care illegal under EMTALA.  Not to mention the continuous HIPAA violations as they joke about my medications, mental diagnoses, and physical diagnoses.

PatriotismI explain this by phone at least three times to the director of constituent services for Rep. Greg Stanton (D), who called me multiple times while responding to my numerous requests for assistance since the election occurred in Nov 2020.  Not having heard anything from Jan 2021 to 25 April 2021, I sent the following message via email to the director of constituent services:

“Good Morning XXXX,

Has it been sufficient time for the VA to address my concerns and return a response to your office? The governor of AZ has made mask mandates unenforceable since 25 March, and the VA continues to push masks as mandatory and deny me access.  This includes refusing to schedule blood work through the community while insisting that I needed blood work to be conducted before I could get a prescription refilled.  I went more than 2-weeks without diabetes medication because my primary care provider refused to alert me in early February that a refill of Metformin would need blood work.  I did not discover the need for blood work was required to refill until after I had been without Metformin for a week!

Mask discrimination at the VA is real and dangerous to veterans’ health and safety, and I, for one, am sick and tired of the BS the VA keeps serving as excuses to deny service.  I am not a behavioral problem, as the Carl T. Hayden VAMC continues to claim.  I do stand up for my rights against all enemies, foreign and domestic!  I have paid my fines.  If the US Marshals at the Federal Courthouse can have situational empowerment to not press the mask issue for those of us with qualifying medical conditions, the same should occur inside the VA with the VA Police.

The mask mandate is a policy issue threatening my health, safety, and well-being, as well as thousands of other veterans with breathing problems.  Just what, if anything, has been done since January on this issue?

Sincerely,
Dave Salisbury”

I realize that the AZ State Governor does not have anything to do with the Federal Policies; I mentioned the governor’s action solely as an indicator that change in the state of AZ has come (finally), where mask mandates are concerned!  The VA claims their mask policy is “constantly changing,” but the only changes I have witnessed are moving from draconian to oppressive, then to ruthless and punitive!  The mask policy is wrong, has never been printed as a work standard, and has never been published for veterans to abide by.  The best a person has is a sign claiming masks are mandatory and a bunch of emotionally charged employees acting like snowflake Nazi Storm Troopers on a 6-day pass from hell!

The Duty of AmericansToday, 28 April 2021, I reached out to the director of constituent services as I had not received any additional information.  Sending the following email:

“I blog, I have a pretty good following, here is my latest: https://dnc-consulting.com/2021/04/28/no-more-bs-speaking-of-administration-bureaucrats-in-government/

Please note, I have not mentioned Rep. Stanton (D) by name, yet, as a politician, I am begging to perform his job of scrutinizing the government, but the temptation is real!  I have to be able to access the VA Healthcare system ASAP safely!  Where is this issue in being resolved?  Feel free to explore the other VA Articles I write on my blog.  You will find every single one of the letters to the VA, you will find other veterans having similar problems, and you will find I do not hesitate to name names and point fingers.

I am still waiting patiently, but patience does wear thin when information is lacking!

Sincerely,
Dave Salisbury”

Anton EgoWithin 3 hours of this email, I received the following:

“Dr. Salisbury,

Thanks so much for sharing! Apologies for the delayed response. I am following up with the Phoenix VA Medical Center and determine the status of the inquiry.”

Why am I writing this article?

Angry Grizzly BearFrankly, I am through!  I am done with the foot-dragging administration at the Carl T. Hayden VAMC, and Alyshia Smith, the director who has dodged, balked, and refused to engage.  I am through with the VISN 22 Director Michael Fisher being able to remain silent and unresponsive in this farrago.  I am sick to death of being ignored by the VA Secretary, Secretary’s Wilkie and McDonough and their respective staff, while many other veterans across this country and I are physically harmed by a mask policy that doesn’t have enough sense to include “except for medically acceptable conditions,” and was never a policy, just some bloody marketing signs.  I am beyond insane about having to go to court for being arrested at the VA three times, kicked off property two additional times, and harassed more than 15 times, for being short of breath, denied emergency care, and then had jokes made by the VA Police about my HIPAA controlled data!

The US Marshals have situational authority to assess and bend the mask policy; why does the VA Police not have this ability?  Simple, easy, direct policy question that everyone in the VA refuses to address as having received, let alone answer.  Why are the elected officials SILENT about this problem that is harming the safety and well-being of their constituents?  Why can a congressional inquiry not DEMAND a prompt and timely response from bureaucrats hiding from the public in their offices?

DutyRep. Greg Stanton (D), why are you not more involved personally in DEMANDING the VA to correct their errors?  Do you not realize how many veterans are in your district?  Do you think you can abuse us and through us our families and hope to be re-elected?  You, sir, are in desperate need of correcting your attitude and behavior before your re-election chances are forever harmed.  I promise this article will survive to your utter shame if a prompt and immediate response is not taken!

Dont Tread On MeI have reached the point where I no longer possess anything “cherubic” in my demeanor on this issue!  You cost me time, money, and physical health.  You cost other veterans in the AZ09 Congressional  District the same.  I will find more veterans suffering as I have, as the US Marshals reported that they had seen a massive uptick in veterans being arrested and cited for mask policy violations at the Carl T. Hayden VAMC.  The VAMC, coincidentally located in your Congressional District, is harming veterans. You cannot appear to care, let alone act in a manner befitting your office as a Congressional Representative!  Immediately come out in support and show yourself a true representative worthy of the title of your office, or leave office immediately, there is no third option!

Your need to change; its mandatory!

© 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: 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.

Thank you, for your service!

Thank you!(I claim no rights or own this picture.)

As a dual service (Army/Navy) veteran and guardsman, I have heard this statement and I appreciate the sentiment behind the words. As a former military dependent and as someone who has seen first hand the plight of military spouses, I want to raise some awareness. My wife served as a geographical bachelorette while I was sailing in the US Navy. She spent a significant amount of time fighting plumbing, home, budgeting, and health problems all while I was engaged in military duties. Now, as the spouse of a disabled veteran, she continues to serve. Since many times the service of military dependents and spouses goes unnoticed, from a grateful veteran, Thank You!

Often I have told military spouses that your service is the more difficult service. Your worries often leave premature grey, stretch thin resources for child rearing, and can include some of the most frustrating moments of your life. Your service should be called the “Silent Service” as too often the parade includes your spouse but not you. You get less recognition than you deserve, and your service does not end with a contract date. Your enlistment seems to take everything from you but dignity; and the grace found in the company of military spouses is very difficult to describe. Please know, even when we forget to say it often enough, your sacrifice and services are appreciated. Thank You!

To the kids who sacrifice time with their mothers and fathers, sacrificing special events, such as birthdays, holidays, and other important occasions, Thank You! Your service and sacrifice is also appreciated. Often times you get the blunt end of the stick when you want or need a parent and cannot find one because one parent is in the military and the other is working to make ends meet. Yet, when the military parents’ service is completed, you still serve. The emotional upheaval found in a returning military parent can often be frustrating, difficult, and sometimes you feel lonely while in the same room with your parent. Sometimes your sacrifice includes a disabled parent or worse the loss of a parent and the additional loss of friends as you move from military bases to a different home often far away. You sacrifice so much and many times it seems your sacrifice never ends or is not completely understood leaving frustration, anger, and resentment. Your service and sacrifices are appreciated; please know it is noticed.

To the extended family of military members who answer the 0300 call for help with frozen pipes, acting as sounding boards, holding the hands of military dependents as they get hard news about a loved one, Thank You! Many times as a deploying service member, knowing the extended family was still going to be active and engaged helped me leave those troubles behind and focus on the task of military service. Thank you for being there, for being willing, for reaching out, and for understanding and enduring the expected and unexpected of military life, commitment, and responsibility. It is very hard to be extended family of a military service member, and your sacrifices are appreciated. Too often, you have to learn another language just to have a conversation. Many times you experience concern about what now when the phone rings, and when family ties stretch to the far flung battle lines and your loved ones are away. The worries can be an added weight that many times feels like it can swamp you; yet, for all this you remain engaged, Thank You!

A volunteer military is very hard on communities, harder still on families, and yet even harder still on the military member. Yes, it takes a village to support a military member. To the friends of military members, who pitch in to move a family, answering emergency calls for help, and providing support, Thank You! You in the community do a lot; your words and kindness, your time, your discounts, and your understanding are appreciated. For those communities with a larger share of National Guard and Reserve military members, you spend a lot of additional time adjusting to changing labor pools, tax pools, and often these changes come last minute as a reservists or guardsman is called upon to fulfill a different duty and you are left with the responsibility and making the changes. Employers, who have to make an emergency reshuffle, then shuffle again when the reservists or guardsman returns; your sacrifice is also appreciated.

This article is not to reduce in anyway the sacrifices of the military member. I know how hard it is to leave loved ones for deployments and daily activities with prolonged hours to do the assigned military duties. I know the time, emotional, physical, and monetary sacrifices (amongst so many others) of the military members. As a community member who supports the reservists and guard members, as a fellow veteran, as a previous dependent, I have seen and experienced much, but the support group of extended family, communities, children, and spouses need recognition. The service of families, especially spouses and children, needs spoken to, honored, and gratitude provided. For even after we, the service members return physically, too often we continue to struggle and these members continue to sacrifice and serve.

From this veteran to fellow veterans, to those who have passed on ahead and those currently serving, to their wives and children, to extended families, to friends and communities, Thank you! You stand tall with the dignity of a country that is known for having the greatest military in the history of the world. Our military is great because of you. Your sacrifices, dedication, and service makes being a military member a little easier, Thank you! When your military loved one passes and I leave a Thank You, this signifies my gratitude not just for your sacrifice and your support for the military member, it recognizes that you shared and lost something precious, and I am grateful for both the service provided and the sacrifice rendered by your military member and you, Thank You.

© 2015 M. Dave Salisbury

All Rights Reserved

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