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.

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: Putting Shame in the Right Place at the VA – Administration

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

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

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

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

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

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

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

LinkedIn VA ImageBoats has serious problems.  The legacy of the VA is to kill him instead of fixing their administrative problems.  But, the VA’s mission statement is still, “To fulfill President Lincoln’s promise: “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.
“Our department remains fully committed to fulfilling the sacred obligation that we have to those who serve in uniform.” ~VA Secretary Denis McDonough.

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

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

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

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

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

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

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

NO MORE BS: Responsibility

LookDale Renlund made a powerful point:

“… Blaming others, even if justified, allows us to excuse our behavior.  By so doing, we shift responsibility for our actions to others.  When the responsibility is shifted, we diminish both the need and our ability to act.  We turn ourselves into hapless victims rather than agents capable of independent action.”

Consider this statement with me as we observe and review recent events in America and the world.

  1. The Department of Veterans Affairs – Office of Inspector General (VA-OIG) reviewed the administration of spina bifida benefits for children born to Vietnam veterans, found internal communication and data sharing were the root cause of administering the benefits program incorrectly. The Department of Veterans Affairs – Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA) blamed each other for administration failure.  Applying Renlund’s point, we find that blaming each other equally provided the excuse for neither bureaucratic administration to accept responsibility.  Blocking movement towards action in correcting the problem, and ultimately the victims will continue to be children born of Vietnam veterans who deserve better and cannot cut the red tape to reach help desperately needed.  Worse, the blaming has turned the VBA and VHA from independent administrations into victims who deserve pity, instead of a boot kicking for their customers’ abuse!
  2. The VA-OIG, in another inspection, found COVID to be the root cause for shortages and outages of personal protective equipment (PPE). Except none of the 42 facilities surveyed ran out of anything.  Stocks dipped low, but outages of supply never occurred.  The blame for the low stock was also found on data and lack of reporting data correctly.  While people were praised for acting to “shift supplies, create new processes, and order supplies promptly,” the people could not be blamed for the low stock levels and were made into victims of COVID and data mismanagement.

Detective 4Please allow me a brief public service announcement: in business, one finds Juran’s Rule.  Juran’s Rule states that when there is a problem, 80-90% of the time, the processes are blamed, not the people.  The processes, or the written (supposedly) directions to perform a task, are so convoluted in government that Juran’s Rule could slide into 98% of the problem and still not run out of process convolution before people can be blamed.  Yet, the leadership of the VBA, VHA, and every other government agency refuse to look at the processes and eliminate, change, correct or even take action to review the processes.

Thus, Renlund’s point steals potential from people, as people become hapless victims to processes and procedures, instead of the commander of their duties and roles as hired.  The shift of responsibility from people to processes is the danger found in Juran’s Rule, not the truth in Juran’s Rule.  Thus, action to correct is diminished because responsibility has been shifted from leaders to the processes they are already responsible for monitoring.  Hence, when I see the VA-OIG allowing data or business processes to be blamed for the failure of people to act, according to the roles they have been hired to fill, I doubt the ability to fix the right problem.

  1. Using Renlund’s point, here is a typical VA-OIG inspection summary. See if you can spot the responsibility shifting, the inaction, and the problems.
      • The Department of Veterans Affairs – Office of Inspector General (VA-OIG) examined whether the VHA had effective procedures for (1) purchasing, (2) inventorying, and (3) tracking biologic implants such as skin substitutes and corneal or dental implants. The VA-OIG found deficiencies in all three areas at four medical facilities it visited. The audit team determined that purchasing agents did not always record implant purchases correctly or use the appropriate funds. The purchasing agents did not register 2,931 of 10,305 purchased biologic implants in the proper system [emphasis mine]. Instead, agents documented the implants in various local spreadsheets, databases, and third-party systems. Purchasing agents improperly used logistics funds instead of prosthetic funds, making it difficult for VHA to account for biologic implant spending fully and effectively budget or use funds for other purposes. Due to inadequate guidance, the OIG found that the facilities visited had an inaccurate inventory of biologic implants, did not use a standardized system, and did not consistently review stock on hand. The staff could not locate 714 biologic implants in inventory at the four facilities visited, valued at almost $1.1 million [emphasis mine]. The audit team also found 288 additional unrecorded items, valued at nearly $433,000, in storage locations [emphasis mine]. Poor inventory management can jeopardize prompt care, as medical providers may need to delay or cancel procedures if implants are unavailable. The facilities visited failed to track at least 45 percent of implants reported as used from October 2017 through March 2019 [emphasis mine]. VHA did not designate responsibility for overseeing tracking, develop a national policy on how facilities should track biologic implants, or have a standard tracking system that meets accreditation requirements. Effective tracking is needed for facilities to notify veterans if the manufacturers recall their implants.
      • Are the problems of shifting responsibility and the magnitude of the problem more understandable? Feel free to use the comments to discuss this example.LinkedIn VA Image
  2. In the final example, we find another common problem at the VHA, the refusal to alert patients promptly about test results, with the same worn out and tired excuses, time, and refusal to employ and document according to standards. People did not do their jobs, and it took “several concerned members of Congress” to initiate a VA-OIG investigation to certify there was a problem. Still, the solution by the VA-OIG remains tepid at best!  Leading to questions for Congress to allow these problems to thrive and advance the issues that VHA hospital leadership intentionally designs incompetence into their processes and procedures, then dares the patients seeking care to find a solution to force the administration to do their jobs.  Irony strikes again in the VA-OIG reports; the same issue was investigated and reported with the same “recommendations” almost every month throughout the last two-years.  Why aren’t the VHA local leaders being held accountable by their VISN leadership teams for failure to act to fix their problems proactively?

DetectiveToo often, the pattern at the VA, is exemplified in every other government agency for the keen observer to witness; act in a manner unacceptable, hide behind broken processes intentionally designed to hide purposefully designed incompetence, and escape responsibility but retain their jobs into retirement.  Essentially, the leaders of government agencies have employed the pattern discussed by Renlund for personal gain at the expense of the frustrated taxpayer.

When responsibility has been dodged, the answer is not to allow retirement, but to demand correction, holding people accountable, and set performance standards that include penalties for failure.  Training will have to occur, but cannot happen until written directives, policies, and procedures appear, that form the standard for employees’ behavior not responsible for the designed incompetence created by leadership.

In a “Liberty First Culture,” the adults looking to demand change take the pattern offered by Renlund and recognize the behavioral issues that will need correcting.

“… Blaming others, even if justified, allows us to excuse our behavior.  By so doing, we shift responsibility for our actions to others.  When the responsibility is shifted, we diminish both the need and our ability to act.  We turn ourselves into hapless victims rather than agents capable of independent action.”

Gadsden FlagAmericans [A(h)-ME-I-CAN] are not hapless victims; we stare responsibility in the eye, accepting the responsibility, and choose to act in a manner that shows we have learned the lessons and are prepared to improve.  The time to correct the government that represents us is Right Now!  We must act, recognize the designers of incompetence for the traitors they are, and remove them from employment in government, promptly!

© 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.

Department of Veterans Affairs Chronicles of Shame

I-CareAs a veteran who struggles with post-traumatic stress disorder (PTSD), stemming from military sexual trauma (MST), where a first-class petty officer jumped on my back and tried to rape me.  When I see the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports on PTSD from MST, I pay close attention.  Since the Department of Veterans Affairs (VA) continues to deny my MST claim because MST does not happen to men, I get agitated when I see these VA-OIG reports repeating year-over-year with the same excuses and designed incompetence.  Designed incompetence is all about creating ready-made excuses for failing to perform correctly the role one has been hired or promoted to perform.  Consider the following:

“In 2018, the VA Office of Inspector General (OIG) reported that nearly half of disability benefit claims that were denied service connection for post-traumatic stress disorder (PTSD) and were related to military sexual trauma were not processed properly.”

That is the first sentence of the VA-OIG report released on 08 December 2020 declaring that the improvements suggested by the VA-OIG in 2018 had not occurred.  The following statistics come directly from the report issued.

      • 18,300 claims or approximately 16% were processed incorrectly in Fiscal Year 2019
      • 118,000 claims were submitted

Why were the claims processed incorrectly; because of designed incompetence by the Department of Veterans Affairs – Veterans Benefits Administration (VBA).  From the report, we find the following five root causes, or excuses: emphasis mine.

    1. Most errors occurred because claims processors did not verify or ask veterans to provide the disorder’s cause, known as an in-service stressor.
    2. In other cases, claims processors did not request a medical examination, medical opinion, or clarification of inconsistencies in the examination as required.
    3. Claims processors made these errors because they did not fully understand PTSD stressor types and the stressor verification process.
    4. VBA’s Compensation Service did not mandate any national training for claims processors on these subjects except during the first year in the position.
    5. In addition, VBA’s procedures manual was not effectively organized to allow staff to locate this information and lacked specific guidance for some aspects of PTSD claim processing.

VA SealWhy are the causes of the problems considered designed incompetence, because they never change!  At the VBA, the processors all need constant training to remain current in their positions; but never receive the training.  The VBA never holds value-added training sufficient to train the employees on their jobs, but this remains the number one excuse to justify poor performance in VA-OIG inspections.  Failure to perform the job is also not a new excuse, where the VA-OIG reports are concerned.  Not understanding how to ask for help is also not new, and frankly astounds and mystifies observers that those hired remain employed when their performance clearly remains insufficient to the job expectations.  While it is unique to the VA to see a procedure manual, it is only natural and expected that the manual is poorly organized, poorly executed, hard to follow, difficult to find, and generally useless.  The VA is famous for this designed incompetence trick.

You say, “Big Deal;” everyone knows the VA is messed up, full of failures, and is generally known for poor performance.  Why this is a “Big Deal” stems primarily from the costs associated with poor performance.  An annual salary is paid for the processors, the adjudicator, and the entire chain of command, totaling in the hundreds of millions of dollars.  The veteran has to pay for lawyers and other services to appeal the original decisions, which take time.  The veteran has to pay for a third-party Nexus Letter to accompany the claim to declare the original claim was faulty.  All of this requires substantial time investments and other resources, all because the original work has to be duplicated.  How many times the claim is duplicated depends upon the processors’ abilities to do the job they were hired to perform.

Your car breaks down; the tow truck driver only secures your vehicle 84% before driving to the auto repair facility, is this satisfactory performance?  Your surgeon has an 84% success rate where his patients will live after surgery for tonsil removal, is this satisfactory performance?  You are in hospital; your nurse only gets your pain medication to you 84% of the time or is only 84% accurate in providing the right patient the proper medication; is this satisfactory performance?  Of course not, but for government employees, this level of performance is “award-winning.”

Military CrestsCongress mandates VBA claim error rates; there is supposed to be a quality assurance check to reduce the error rates.  Yet, with all the checks, the balances, and the quality assurance programs, the VBA continues to surpass the error rates and physically harms veterans due to their inefficiencies.  Yes; a failure rate of 16% is a “Big Deal!”

Want to know how bad the VA is managing your taxpayer monies; read the audit released 14 December 2020.  In that audit, you will find comments like the following:

      • The material weakness involving information technology security controls has been reported for more than 10 years.
      • VA did not substantially comply with federal financial management systems requirements and the United States Standard General Ledger at the transaction level, as required by the Federal Financial Management Improvement Act.
      • [The] VA’s complex, disjointed, and legacy financial management system architecture no longer supports stringent and demanding financial management and reporting requirements.
      • VA continued to be challenged [with] consistently enforcing established policies and procedures throughout its geographically dispersed portfolio of outdated applications and systems.

In light of the recent computer hacking issues the Federal Government is experiencing, knowing that the VA has dumped hundreds of millions of taxpayer dollars to patch and repair, and sometimes replace (sort of), legacy (old, expired, useless, insecure, unreliable, etc.) technology over the last 20-years, how is the VA able to keep getting away with these designed incompetence excuses?  Congress, when will you hold the administrator’s feet to the fire for making progress on these glaring issues?  Congress receives these VA-OIG reports and audits before they are made public, yet the elected representatives cannot take a moment to check this poor behavior.  Why not?

Police and Government Lines of CongruenceFor the first time in more than a decade of chronicling the VA-OIG reports, I am mentioning a monthly highlight (lowlight) condensed report.  This report is unique due to the insanity of criminal investigations mentioned, the results of audits, and the healthcare inspections.  When you have 18 defendants in a bribery scheme, where 15 plead guilty, who defrauded untold Millions of dollars in Florida, the problem is not so much with the employees, but the organization that allowed this to occur since 2009!  A noteworthy criminal investigation indeed.

The highlights (lowlights) of November 2020 also include a VA physician from West Virginia being indicted for abusive sexual contact and simple assault and a surgical supervisor in Northern Ohio who defrauded the VAMC of approximately $3.2 Million in two separate schemes.  Regarding financial audits and the importance of improving that ancient technology, a VA Fiduciary has been indicted for misappropriating government funds from Pennsylvania to the tune of more than $155,000.  Best of all, a husband and wife team from California, technical school owners, bilked the GI-Bill of more than $29 Million since 2015.

The criminal issues the VA is facing regularly are not a one-off issue, but an organizational design problem as the frauds, thefts, and malfeasance reported is ever only the very top 1% of the problem that is ongoing and systemic in the Department of Veterans Affairs!  The November 2020 report discussed an incredible number of canceled patient appointments because veterans and COVID mask mandates do not play well together.  Yet, the VA Federal Police cannot stop persecuting veterans for their physical inabilities to wear a mask.

Thus, where are the elected officials from the legislative bodies who possess oversight and funding responsibilities?  Where is the executive branch of government in correcting and demanding specific action from the legislative branch?  Where are the administrators at the Federal, VISN, and Local levels in performing their jobs?  The designed incompetence must cease forthwith to allow for practical changes to be made and the organizational design to be corrected.  For the VA-OIG to be forced to accept the same tired, lame, and detestable excuses, year-over-year is the epitome of abuse to the taxpayer and veteran alike!

The Duty of AmericansWorst of all, this condensed version did not even scratch the surface of the issues reported in just three VA-OIG reports.  Shame!  Shame! Shame!  Shame on the elected officials, Republican, Independent, and Democrat, who have allowed this problem to grow and done nothing!  Shame on the myriad of presidents who have done nothing but throw good money after bad, without demanding progress and holding real people responsible for real results!  Shame on every single VA employee who shirks their job for easiness to the pain and suffering of a veteran, dependent, or spouse!

© Copyright 2020 – M. Dave Salisbury
The author holds no claims for the art used herein. The pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.
All rights reserved. For copies, reprints, or sharing, please contact through LinkedIn:
https://www.linkedin.com/in/davesalisbury/

Uncomfortable Truths: Department of Veterans Affairs, are you listening?

It was surprising that the Department of Veterans Affairs will automatically share health information with third parties without the veterans written consent unless the veteran opts-out in writing or submit a revocation in writing submitted in person or by US mail.  Especially surprising is that the official form for opting-out is not legally active until October 2019, and the deadline for opting-out, in writing, is 30 September 2019.  While this news if significantly troubling, let us define the full problem, courtesy of the Department of Veterans Office of Inspector General (VA-OIG).

I-CareOn 12 September 2019, the VA-OIG completed their investigation into the Beneficiary Fiduciary Field system (BFFS), who handle benefits payments for veterans and other beneficiaries who, due to injury, disease, or age, are unable to manage their financial affairs and are thus vulnerable to fraud or abuse.  The veterans affected are those who are the most susceptible in the veteran population, and the government agency charged with protecting, helping, and supporting these veterans is vulnerable to fraud and misuse.  In fact, the VA-OIG found that the BFFS, “… lacked sufficient controls to ensure the privacy of sensitive data and prevent fraud and misuse. Specifically, finding the VA’s Office of Information and Technology inappropriately set the security risk level for BFFS at moderate instead of high. Risk managers did not follow established standards and did not consider whether information for beneficiaries and fiduciaries stored in the system’s database was sufficiently protected.”

Yet, the VA is now making available to third-parties, the health records of veterans.  Does anyone else see a problem?  Previously I have written about the continuing risk of veteran’s files from being accessed by persons unknown, and how this problem does not slow, simply how the VA has stopped reporting how bad the problem continues to be.  Personally, I have been a victim of ID Theft from VA Data breaches three times.  I have had VA Employees surf my medical records and then use this data to discriminate against me.  I have witnessed blatant HIPAA violations by VA Employees without hospital leaders taking any action.  Now, the VA is going to “share” my medical record access with “interested parties.”  I have some concerns!

Just in case your attention was drifting due to fallacious impeachment proceedings, the VA inappropriately sole-sourced contracts for ambulance services in three separate Veteran Health Administration Regional Procurement Offices (RPO).  The significance of this event is evidenced in the lack of competition for government contracts.  Designed incompetence was the origination of this issue, the contracting officer claimed, “I didn’t know.”  The contracting officer, who must go to school to obtain authority to enter into contracts for the Federal Government, somehow “didn’t know” about the regulations and rules for sole-sourcing a contract.  I have some doubts!

In further news from VA-OIG investigations, we find another contracting officer who claims, “I don’t know,” to hide behind designed incompetence in sole-sourcing contracts.  From the VA-OIG inspection report, “15 sole-source contracts awarded by RPO West with a total value of about $19 million, were inspected to determine whether they were properly justified and approved, and found that this was not done for five contracts worth about $6 million.”  The contracting officers in RPO West, who “misunderstood who the proper approval authority was.”  Are you kidding me?

Blue Money BurningThe VA-OIG reports, “when contracting officers violate federal regulation by failing to obtain the required approval for sole-source contracts, they exceed their contracting authority.”  Contracting officers work with the approving authority, how can they not “know” who they work for and how to obtain proper authorization?  The excuses are weak and inexcusable; as an operation professional, the first step in getting to know the business is to know who answers the questions, who has the authority, and where that person is located.  For contracting officers, the approving authority is the boss, either the employees do not know who they are working for, or there are significant issues in lines of authority, and both situations speak of phenomenal incompetence and failure of leadership.

Just like the Home Shopping Network is always claiming, “But wait, there’s more!”  RPO East, not to be outdone by RPO West, had the VA-OIG inspect “20 sole-source contracts awarded by RPO East totaling $41.4 million. The OIG found RPO East contracting officers did not obtain required approval before awarding 10 contracts worth about $14.2 million.”  The reason these contracts were not appropriately sole-sourced, “because officials did not follow the proper approval process, did not receive the correct guidance, and misinterpreted regulations.”  If RPO West is suffering from “phenomenal incompetence and failure of leadership,” then RPO East is beyond saving under the current leadership, and I call upon Secretary Wilkie and his team to scrub RPO East leadership and start over under strict quality review teams to ensure compliance and correction.  I repeat, only for emphasis, this situation is inexcusable.  The contracting officers must attend school, must know the regulations, and must not “individually interpret” the purchasing rules, and they know this from the first second on the job.  I was made aware of sole-source contracting regulations, and I was not a contracting officer.

RPO West has the follow-through needed to boil someone’s blood.  “The VA-OIG reviewed 15 sole-source contracts awarded by RPO West with a total value of about $19 million to determine whether they were properly justified and approved, and found that this was not done for five contracts worth about $6 million.”  The reason these contracts were not appropriately sole-sourced, “because officials did not follow the proper approval process, did not receive the correct guidance, and misinterpreted regulations.”  I rescind my earlier comments about the ability to save RPO West, I call upon Secretary Wilkie to personally ax the leadership at both RPO East and West, to start on a clean slate the contracting officers, leadership, and then strictly observe and implement a quality control mechanism to protect the taxpayer.

People ProcessesSpeaking of “phenomenal incompetence and failure of leadership.”  Please allow me to prepare the groundwork for the subsequent VA-OIG investigation.  To be a supervisor in the VHA, VBA, or National Cemetery, you first must work in the positions you will be supervising.  This information was passed during a job-interview by the hiring authority and confirmed by several VA directors since.  From the VA-OIG Report, we find, “a supervisor at the VA regional office in Boston, Massachusetts, incorrectly processed system-generated messages known as “work items.”  The supervisor, “incorrectly canceled 33 of 55 work items out of 110 reviewed (that’s a less than 50% accuracy), and improperly cleared another nine work items from the electronic record. Because of these incorrectly processed cases, VA made about $117,300 in improper payments to veterans or other beneficiaries, along with about $8,600 in delayed payments.”  Best of all, the supervisor claimed these work items were improperly handled because, “he did not intentionally process the work items incorrectly, and the errors were the result of working too quickly and misunderstanding procedures.”  You are the supervisor, you are in charge, you should know who to approach for guidance and clarification, you have caused significant harm to veterans who either are not being paid or now must repay funds improperly provided.  There is an obvious question here, “If the supervisor is less than 50% accurate, what is the accuracy of the supervisor’s team?”  While the VA-OIG cannot investigate this question, is the director investigating this question?

If the accuracy of claims handling personnel is less than 50%, how can any veteran be sure their claim has been handled properly?  Having been forced to repay funds to the VA, I can attest to the financial impact these over and underpayments cause for veterans.  When will these decision-making officers be held personally accountable for improper decisions?  Senators, members of the House of Representatives, what are you doing to support improving the VA, in conjunction with Secretary Wilkie?  From what I witness, not enough!

You're FiredFrom the files of “Not Enough,” comes another egregious example.  A patient in a psychological ward in the Philadelphia Pennsylvania VA Medical Center was killed because of a drug-to-drug interaction, were due to insufficient observation, insufficient monitoring, and inadequate action when the patient coded, and a veteran died at the hands of caregivers.  When a patient in a hospital ward, which is monitored electronically and physically, commits suicide, I become very agitated.  When any patient dies at the hands of the healthcare provider, I have officially lost my “cherub-like demeanor” and begin resembling a grizzly bear with a bum tooth, hemorrhoids, and woken too soon from my winter nap.  The VA-OIG Report states the following, “… providers did not monitor the patient for electrocardiogram changes or drug-on-drug interactions.  Staff and providers documented signs consistent with over-sedation but did not intervene, communicate directly with each other, or add team members on as additional signers to the electronic health record.  The facility did not comply with the Veterans Health Administration requirements for issue briefs, root cause analyses, and peer reviews.  The staff did not follow the facility’s observation policy.  Facility providers did not adhere to policies requiring discussion, documentation, and patient signed informed consents prior to initiating methadone treatment.”  The providers knew they had a problem, before the patient got into trouble, and did nothing!  In any civilian hospital, this is called malpractice; but in the VA Hospital system, “this is an unfortunate incident.”  While I am undoubtedly glad leadership acted to remedy this situation in the future; I am very displeased to note it ever occurred.  With all the publicity over the power of methadone as an opioid, with the technology to remedy these problems before the patient dies, I cannot accept this situation could occur in the first place!  This veteran’s death should never have happened and the fact that this veteran died at the hands of providers from over-sedation, is a testament to the incompetence designed into the VA processes that excuses accountability and rewards malfeasance.

Speaking of opioid medication problems, the VA-OIG inspected 779,000 VA patients prescribed opioids, and for 73% (568,670) of those patients there was an insufficient investigation by the primary care providers in consulting the state-operated prescription drug monitoring programs (PDMPs) to ensure over-medication did not occur.  The VA-OIG estimated that 19% of those files improperly handled placed patients at risk because of medications prescribed outside the VA Medical System.  With the constant harangue from the mainstream media over opioid addiction and deaths from opioids, a person might ask, where is the concern?  Why isn’t this a talking point in a Congressional Investigation to understand why, and then begin to implement changes to ensure the VA is not stained with more veteran deaths over opioids.  Finally, with an accuracy rate of less than 25%, it appears to me this problem needs immediate rectification using technology and quality control measures at the local level to improve adherence.

blue-moneyI would like to take a moment and thank the VA-OIG for stepping up to the plate and correcting pre-award contract pricing to save the American taxpayer $515 million because the contracting officer on 16 of 22 proposed pharmaceutical contracts was improperly priced.  In case you are wondering, the accuracy of the contracting officers was less than 75%.  I know of no industry, business, or service organization that can have a 75% or less accuracy rate and remains in business.  As a business operation and purchasing professional, these numbers appear to suggest that the contract officers are either intentionally neglectful, or they are counting on pre-award review to protect them from price gouging; both situations are inexcusable for a contracting officer for the Federal Government.

Thank you!As the Los Angeles Vocational Rehabilitation and Employment program (LA VOCREHAB) was recently featured in an article, I am pleased to see that hiring additional staff has improved performance, per the findings of the VA-OIG.  The VA-OIG Report found accuracy in spending money had increased, compliance, and helping veterans to gain employment had all increased since the damning report from the VA-OIG; thus, congratulations to the LA VOCREHAB program!

© 2019 M. Dave Salisbury

All Rights Reserved

The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

 

Uncomfortable Truths – Where is the Accountability for Designed Incompetence?

I-CareThe Department of Veterans Affairs Office of the Inspector General (VA-OIG) conducted a review and sent the following report on their findings, “… the Veterans Benefits Administration (VBA) incorrectly processed more than half of the 62,500 claims decided in the first six months of 2018.”  A less than 50% accuracy rate is unacceptable in every business, organization, and school; yet, the VBA gets a pass on designed incompetence?  Why?  Already veterans must scrounge, dig, and provide endless reams of supporting proof, or new and material evidence, to obtain a “service-connected rating” for injuries and disabilities stemming from military service.  For the most part, the veteran accepts this as the cost of receiving treatment, and for the VBA to incorrectly process less than 50% of the claims, where spines are concerned, is deplorable performance.

In support of the claim that this is designed incompetence, the following is quoted from the VA-OIG report, “… incorrectly decided claims resulted from VBA’s inadequate process for ensuring accurate and complete evaluation. VBA’s primary means of evaluating disability contains minimal guidance, and a procedure manual is too subjective in key areas, which can lead to an inconsistent evaluation for related conditions stemming from the primary disability.”  The VA designed the processes for the VBA to follow.  Hence the incompetence is designed into the system to create additional problems, issues, and pain for the veteran.  Leading to a question for the elected officials in Federal Service, “Why are you allowing this nightmare to continue?”

Spine AnatomyAs a business consultant and industrial-organizational psychologist, I counsel those hiring me to never allow a process to reach a second birthday without a full and complete review.  When training deficiencies are found, immediate action is required, and that action must be documented.  Why is the VBA getting a pass on not training, not designing competent and reliable working processes, and not held accountable for performance that meets a passing score?  Not mentioned in this VA-OIG report, due to being outside the scope of the investigation, is the longevity of this single issue.  Why is a Congressional Blue-Ribbon panel not demanding historical information, and detailing for the American Taxpayer, especially the veterans involved, the significance of the rating problems and holding accountable those who designed the incompetence into the process?  By the time the VA-OIG reports are released for public distribution, there is supposed to be an alert to the Congressional Committees overseeing these government agencies.  The media is often alerted at the same time the Congressional Committees are informed; yet, a failing score in rating the “Spinal conditions [accounting] for two of VA’s top 10 service-connected disabilities, doesn’t even merit crickets.  Media why not stop reporting junk, and start reporting problems needing rectification?

If you want the full report, use the following link.  The full report is design incompetence of the greatest magnitude.  Elected officials, it is past time for action on the issue of design incompetence that allows substandard performance in government service!

Where designed incompetence continues to be the applicable excuse for poor performance, look no further than the Veterans Health Administration (VHA).  The VA-OIG report on Hospice and Palliative Care (HPC) is a full-on description of design incompetence to rival the VBA and maintain their lead on abusing veterans for personal power.  Consider the following, “… The OIG determined that 10.3 percent of the reviewed patients had a formal HPC consult or an HPC-related interaction/conversation without a designated HPC consult or stop code.”  Of those records, the 10.3% who were appropriately handled, and the 87.3% handled improperly, 100% of the patients reviewed experienced issues where “… administrative data did not reflect all HPC services provided by VHA. Inaccurate administrative data indicate that VHA has an incomplete understanding of how much HPC service it is providing or how much is needed, which could affect [the] allocation of resources and planning.”  Design incompetence allowed for every patient to have problems with information related, services the HPC provided, and the “VHA has opportunities to ensure that HPC consults are documented and coded accurately to account for HPC services.”  “Opportunities,” 100% of the records had administrative issues, 89.7% were improperly handled, “opportunities” might be a slight understatement.  Show me a successful business where 89% of the customers are mishandled, and 100% of the customers are provided inaccurate information when contacting the company for answers, and I will show you the floating mountains of Pandora in reality!

Secretary Wilkie has his hands full, and entirely tied, by the bureaucracy, employee inertia, and the uphill battle with intentional design incompetence that allows people who have been in their jobs since Adam and Eve left the Garden of Eden, to still not know how to perform their job.  Federally elected officials, I must ask, “How can a VA employee qualify for retirement or continued employment, without knowing the job, or doing, the job they were hired or promoted for?”  Like fingers on a hand, the Federally Elected Officials have employees placed in leadership positions doing the business of the elected officials, if those employees cannot honorably do the jobs, they do not need to remain in your service, as you serve those who chose you on the ballot.  Is this pattern clear?  The voters hold you responsible for how well the government works, why are you not holding those in your service accountable and responsible for their inaction and their designed incompetence that promotes a ready-made excuse for dismal performance?

From personal experience, design incompetence is the only excuse many VA employees have, and the excuse is worthless.  There is a director of a major department of a statewide VA Health Care System, who refuses to write things down for fear of being held accountable.  Hence, every employee under this director’s leadership has adopted the same philosophy, no written guidance, written policy, no written procedures, and this situation is considered acceptable direction to this directors’ superiors.  Design incompetence is fought by holding individuals personally accountable, training, and using the performance management process to improve adherence and compliance.  For the VBA and the VHA to continue to allow design incompetence to excuse the inexcusable is a leadership issue which needs immediate Federal Elected Official intervention in support of Secretary Wilkie.  Please give him the tools needed to clean house, correct deficiencies, and establish sound policies to move the VA forward successfully!  The tools include a muzzle on the union, improved hiring, and support for eliminating thugs, criminals, and incompetence at every level of the VA hierarchy.

© 2019 M. Dave Salisbury

All Rights Reserved

The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

 

Tragedies, Travesties, and Uncomfortable Truths – Shifting the Paradigm at the Department of Veterans Affairs

For the uninitiated, the Department of Veterans Affairs (VA) has three chief administrations the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemetery (NC).  The majority of the problems a veteran is going to experience originates in decisions from the VBA, which then influence care with the VHA.

I believe in giving credit where, and when credit is due; thus, please join me in congratulating the VBA for meeting a significant milestone.  From the VBA press release we find the following:

“On August 11th, VA updated portions of the rating schedule that evaluate infectious diseases, immune disorders and nutritional deficiencies. By updating the rating schedule, Veterans now receive decisions based on the most current medical knowledge of their condition.”

The reason this is good news stems from so many veterans leaving the military with problems caused in the service where the VBA has dictated there is no injury due to the rating scales, forcing the VHA into a treatment problem where the patient is concerned.  More on the rating scales issue momentarily.

I-CarePlease join me in mourning another death at the hands of the VHA, which is labeled by the Department of Veterans Affairs Office of Inspector General (VA-OIG) as “largely preventable.”  A patient in the West Palm Beach VA Medical Center was in a mental health unit and committed suicide.  Largely preventable is a vast understatement when hospital leaders only begin caring about the veteran committing suicide after the suicide, where training and policy adherence was not mandated prior to the suicide, and the lack of cameras and staff monitoring allowed for a patient, already having trouble and this trouble is known to the hospital providing treatment, to take their own life.  No staff monitoring every 15-minutes was occurring; why?  Why were the cameras non-functioning?  How long had these problems been known and nothing was being done to correct these discrepancies.

Let me emphasize a truth about suicide.  A person expressing desire to suicide is not weak or lazy, and they will not “find a way.”  Having had depression sufficient to consider suicide in the past, I can tell you from personal experience that friends help, talking openly and honestly helps, and the emotional burdens placed upon a family when a suicide is successful are tremendous, as well as the guilt the surviving family must overcome.  This veteran did not have to die, their death was “largely preventable,” and for their death to occur on VA property, in a mental health ward, remains a tragedy.  That the VHA dropped the ball and allowed, through leadership failures, non-working technical means, and training deficiencies, this veteran to die is disgraceful!

The VBA is committing travesties of justice every day.  Consider the following, in the past 15+ years since I left the US Navy, I have had discussions with veteran service officers (VSO’s) across the continental United States on my own claim, and while supporting other veterans with their claims.  A recent example serves to illustrate the problem.  A Spine Anatomyveteran has bulging disks in the cervical spine.  The MRI shows disk degeneration, stenosis, and other problems in the cervical spine.  The veteran has an “S-Curve” in the thoracic spine caused by carrying bottled gas containers from the pier into the ship.  There is stenosis and disk degeneration in the thoracic spine.  The lumbar spine has bulging disks, degeneration, and stenosis.  Three separate areas of the spine, three distinct injured areas, yet, the VBA calls the spine issues, “Lumbar strain.”

Any person who has taken human biology in K-12 education can tell that spine issues in cervical and thoracic are not “lumbar strain” and would not need “new and material evidence” to understand that the first decision was flawed.  Yet, for the veteran to obtain a rating for their spinal issues, they must find an orthopedic spinal specialist, not affiliated with the VHA, and get a letter of diagnosis detailing why these separate areas of the spine are not “lumbar strain.”  The current corporate medicine world, finding an orthopedic specialist will require a non-VHA doctor as a primary care provider (PCP) to refer the veteran to a specialist.  Without a significant cash investment, time investment, and replication of VHA completed tests, x-rays, and MRI’s, the veteran will not be able to obtain a letter detailing the issues sufficient to sway the VBA in correcting their initial judgment.

The veteran will be stuck between three bureaucracies, the VBA who is denying the claim for spinal injury, the VHA who cannot diagnose and document a problem sufficient to meet the VBA standards, and the corporate medicine outside the VHA.  Yet, anyone with a passing understanding of human anatomy and biology can logically make the leap that the spinal issues cannot all be lumped under “lumbar strain.”

I continue to ask, “What is a veteran to do?”  Many times, the veterans in this position are either unemployed or employed below their skill level because they are in pain, they have medical issues requiring treatment, and they cannot obtain the treatment needed because the VBA has not allowed a military service claim to be placed upon the medical records for the VHA to treat.  To chain medical professionals to a rigid and dead bureaucracy, by refusing their ability to diagnose a problem for another VA administration is, without a doubt, a terrible decision, and dangerous practice.  To refuse to investigate a medical problem, restricted breathing with chest pain because the pain is not related to heart and lungs remains a travesty and an abuse of the patient.

To the elected Federal officials, why are you not demanding improvement to the VHA and the VBA?  Why do veterans have to die in the care of the VHA before any improvement is made to the bureaucracy you created?  Where does a veteran go to obtain relief from the bureaucratic nightmare where the VBA and the VHA are refusing to help the veteran?  The tragedy in this entire article is that the VA cannot enforce policy adherence, controlling the risks to avoid incidents like those detailed, and demand better performance from the people and the systems that are supposed to help the veterans.  The travesty in this article is the policymakers between Secretary Wilkie and the front-line employees; who is helping the veteran navigate these rocky shoals and dangerous waters of government policy?

I have met some great VSO’s, employees of the VBA and VHA, and interviewed with phenomenal people working in the National Cemetery; yet, they all have the same problem, the millstone around their necks is the regulations, policies, procedures, and red-tape of the VA that has been designed to refuse help as the first response to every question posed.  Thus, as I have asked Senator Udall (D-NM) and Representative Haaland (D-NM), as well as countless other Federally elected officials between 1997 and the present, what is a veteran to do to obtain the help they need from the VA?  Who would the veterans approach for guidance and support?  When the VBA is demanding “new and material evidence” before acting to support a veteran, how does a veteran obtain this evidence?

I know of hundreds of veterans who were affected by an independent duty corpsman in the US Navy who threw records over the side of the ship to avoid being held accountable for bad decisions and patient abuse.  Because these records are not in the medical files, injuries sustained in the service are not documented, and the VBA will use this as an excuse to deny claims.  What is a veteran to do?  Where does the veteran go?  How does a veteran correct something that occurred beyond their control to obtain treatment for decades-old injuries?  You the elected officials allowed the bureaucracy to be built, you are responsible for correcting these issues experienced, what are you doing to affect change and support Secretary Wilkie in fixing the VA, and by extension the VBA, the VHA, and the NC?

The American people are watching how you treat veterans, and we are not pleased!

 

© 2019 M. Dave Salisbury

All Rights Reserved

The images used herein were obtained in the public domain; this author holds no copyright to the photos displayed.