NO MORE BS: Come, Let us Reason Together

Knowledge Check!In physics, for every action, there is an equal and opposite reaction.  I am not a fan of the word reaction, for a reaction places all the control of the action into the control of the original actor, and nature does not work like that.  But, to reason, we sometimes must use language common to all to understand each other; thus, it is sufficient to my purposes to use the term reaction in this discussion.  A similar law applies to psychology; a human chooses to act, natural consequences follow.  The ability to as, agency, and the person being acted upon, the actor, play a significant role in how and why businesses succeed and fail.

Plato 2Societies, cultures, governments, and countries all rise and fall on the moral agency of the individuals in power, the common citizen, and the collective leaders of those groups of people.  I have always liked the movie “The Fiddler on the Roof,” Tevye makes a statement about how without tradition, they would be as shaky as a fiddler on the roof.  Bringing a mental image of a fiddler, balancing upon a roof, and having two options, climb down and resume playing, or learn to balance on the roof while playing.  Both choices offer natural consequences that are easily understood, especially if you have ever worked on a roof.

Detective 4I have consistently written about VA Leadership failures for several weeks, rightly calling out the administrators at the local VAHCS and VAMC, the VISN, and the Federal levels.  Hospital leadership is not so different than leadership in any other industry, even though the VA has tried to make hospital leadership distinct.  Herein lay the problem, an employee, a nursing assistant, has just been sentenced to 7 consecutive life sentences for second-degree murder.

“Mays was employed as a nursing assistant at the VAMC, working the night shift during the same period of time that the veterans in her care died of hypoglycemia while being treated at the hospital. Nursing assistants at the VAMC are not qualified or authorized to administer any medication to patients, including insulin. Mays would sit one-on-one with patients. She admitted to administering insulin to several patients with the intent to cause their deaths” [emphasis mine].VA 3

We have an affect, but what was the cause?

“While responsibility for these heinous criminal acts lies with Reta Mays, an extensive healthcare inspection by our office found the facility had serious and pervasive clinical and administrative failures that contributed to them going undetected,” said VA Inspector General Michael J. Missal” [emphasis mine].VA 3

Regardless of her intention, an employee was allowed to commit murder because of the “pervasive clinical and administrative failures” of the VAMC leadership.  Now, two days prior to receiving the results of Reta Mays’ court proceedings, I received the Department of Veterans Affairs – Office of Inspector General report on the clinical leadership failures.  I have not witnessed a more despicable and damnable report of leadership failures in the decade-plus; I have been following and writing about the Department of Veterans Affairs or any other government agency!

“In June 2018, facility leaders identified nine patients with profound and concerning hypoglycemic events dating from November 2017 to June 2018” [emphasis mine].VA 3

The scope of the administrative investigation is as follows.  Staff from the VA-OIG’s Office of Healthcare Inspections (OHI) assessed the following areas, in parentheses is who owns the problem raised in the investigation:

      • Mays’s hiring and performance (Human Resources)
      • Medication management and security (Pharmacy and Security)
      • Clinical evaluations of unexplained hypoglycemic events (Nursing and Doctoral Staff)
      • Reporting of and responding to the events (Facility Leadership)
      • Quality programs and oversight activities (Facility Leadership)
      • Facility, Veterans Integrated Service Network (VISN), and VHA leaders’ responses and corrective actions (Local and area-wide administrators)
      • During the course of this review (investigation), the OIG also noted areas of concern regarding hospice and palliative care practices and nursing policies and practices (Nursing, Patient Care and Safety, and Hospital Administrators)VA 3

Just as logic tells the fiddler on the roof that he has two choices to live a long and musically fruitful life, the investigation reveals that the VAMC leadership had choices and made both poor and potentially criminal choices in this investigation of Mays’ conduct.

Ultimately, quality health care is dependent on leaders who promote a culture of safety that reduces or eliminates those risks whenever possible. Providing high-quality health care to a diverse and complex patient population demands the support of, and adherence to, an organization-wide culture of safety. When this occurs, a patient-centric environment becomes the “norm.” Conversely, systemic weaknesses in a facility’s culture of safety can have devastating consequences. The OIG found that the facility had serious, pervasive, and deep-rooted clinical and administrative failures that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier. The failures occurred in virtually all the critical functions and areas required to promote patient safety and prevent avoidable adverse events at the facility” (pg ii) [emphasis mine].VA 3

Before we go further into the report, it must be made clear; the investigation team found the leadership, the hospital administrators responsible for allowing Mays to kill seven patients.  Attack another patient with the intent to kill and a potential additional hypoglycemic patient who died under her care but could not be directly linked to Mays.  A question arises, how did Mays gain employment with the VA; the answer, a former HR employee, failed to do their job in conducting “… background investigation file and determining her suitability for employment!”  In a previous article, I wrote about the hazards the VA was purposefully opening themselves to by using “COVID” as an excuse to delay proper investigations into backgrounds when hiring.  Here is a classic case where “COVID” is not related, and failing to investigate a background led to people dying!Plato 3

The VA-OIG last year reported that hiring practices had been relaxed due to COVID and background checks delayed for employees being hired during a pandemic.  Yet, when will those background checks be completed?  If someone is found unfit due to background checks, will they be forced to return all their wages for lying on a government form?  If there is a testament to the need for comprehensive background checks on employees, the seven (7) dead patients who died at the hands of Reta Mays!  How many times will this story replicate because the hiring managers are not doing their jobs?VA 3

Let us reason together, is the VA administrators the problem with the VA?  Does the VA leadership require immediate and total removal?  How would you resolve the issues without breaking the system and further endangering the lives of veterans?  Please let me know in the comments section.

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

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

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

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

© 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: VA Leadership IS the Problem!!!

Angry Grizzly BearPSA:  If you have a weak stomach, please feel free to not read this report.  This article is discussing the ongoing and continual problems of the VA leadership to ensure clean medically reusable equipment is available for practitioners use.  While the YUCK factor is high, the issue remains a leadership failure, and worse, it was purposefully designed into the VA organization to spread infectious diseases between veterans!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) conducted an investigation and reported its findings 16 June 2009.  While still not the first-time endoscopes and colonoscopes being dirty have caused patience significant risks, this report clearly details the failure of VA Leadership as an organizational design flaw.  From page i of the report, we find the following:

Facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans. Reprocessing of endoscopes requires a standardized, monitored approach to ensure that these instruments are safe for use in patient care. The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure” [emphasis mine].VA 3

Also, from page i the scope of the investigation and those requesting the investigation are detailed:

The VA Office of Inspector General received requests from the Secretary, Chairmen and Ranking Members of VA oversight committees, along with individual members of Congress, regarding the reprocessing of endoscopic equipment at several specific VA medical centers (VAMCs), and to assess the extent of related problems throughout the Veterans Health Administration (VHA). The purpose of the review is to describe the pertinent events at VAMCs where problems were reported, assess VHA’s response to the events, and conduct a system-wide evaluation of current reprocessing practices” [emphasis mine].VA 3

Let us be perfectly clear, since 2009, the VA Federal Officers have been informed and kept abreast of the problems with properly cleaning, sanitizing, and documenting reusable medical equipment, specifically endoscopes and colonoscopes, and have done nothing to fundamentally correct the direction of the VA, the VHA, or the offending VAMC’s.  What good is a memo when it is not applied as a standard operating procedure, where consequences are involved?  How is a memo going to be effective against a culture trained to not do their jobs, no matter the cost to patient safety?  To fully comprehend the problem with reusable medical equipment not being properly cleaned and sterilized (repurposed) see pages seven and eight of the following report linked.  There are a lot of acronyms, but the general sentiment is clear, the VA has an enormous problem with properly cleaning reusable medical equipment!

In a VA-OIG report dated 06 May 2021, we find an employee, after having been caught once, still not being properly supervised, not doing their job, and remaining employed.  This employee was caught falsifying legal documents on the cleanliness of endoscopes, and dirty equipment was used on multiple patients.  The facility conducted an investigation, the VISN conducted another investigation, neither investigation led to any type of fundamental organizational change to protect the patient.  Even the VA-OIG investigation has not led to fundamental organizational changes and improvements in cleaning and sterilizing reusable medical equipment.  Frankly, this should scare the daylights out of every veteran going in for any type of care at the VA.VA 3

Trust is hard won and easily lost.  Right now, can any provider at the VA assure any patient that the reusable medical equipment has been properly cleaned and sterilized before being used on that patient?  Since the VA-OIG report in 2009, the direct answer to this question is a resounding NO!  Again, I ask only for emphasis, if a non-VA hospital, clinic, or provider’s office was caught not properly cleaning, sterilizing, and documenting medically reusable equipment, how could they remain in operation?  The short answer is, they could not; unless they are an abortion clinic, but that’s and entirely different subject.  The Federal Government and the lawyers would descend en masse to shut down the facility, hold the administration accountable, and demand retribution for the patients involved.  Why is the VA Administration and VHA Administration, and the VAMC and VISN Administrations able to escape culpability in risking a patient’s health with dirty medical equipment?

Angry Wet ChickenEvery single Federally elected politician should be up in arms about the double standards between VA hospitals and non-VA hospitals.  If a non-VA hospital is caught with dirty medically reusable equipment, can they use the VA as an example in court as a defense?  NO!  Yet, here is a legal double-standard and precedence that opens the door to more questions.

Returning to the 2009 VA-OIG report, we find how the investigation was methodologically carried out.  The methodology reveals just how widespread and in-depth the investigation is, and how deeply this problem is organizationally wide for the VA.

We visited the facilities which had been the subject of considerable media attention: the Bruce W. Carter VAMC (Miami) in Miami, FL; the Tennessee Valley Healthcare System-Murfreesboro campus (Murfreesboro); and the Charlie Norwood VA Medical Center (Augusta) in Augusta, GA. We reviewed applicable regulations, policies, procedures, and guidelines. Furthermore, 26 inspectors conducted unannounced onsite visits for the total of 42 probability-based randomly selected VHA facilities to examine pertinent endoscope reprocessing documentation.

Because of the unannounced nature of the inspections and for cost-efficiency, a stratified clustering sample design was employed to maximize the number of facilities that could be inspected in a single day. Two probability-based random samples of VHA endoscope reprocessing facilities were selected from the study populations for the unannounced onsite inspection: one for colonoscope reprocessing and another for ENT endoscope reprocessing. With probability sampling, each unit in the study population has a known positive probability of selection. This property of probability sampling avoids selection bias and allows use of statistical theory to make valid inferences from the sample to the study population.”VA 3

Back in 2009, the media was very cognizant of VA issues, then the dead veteran scandal of 2012 and 2017, turned the media’s attention away from how the VA conducts business.  Let me direct your attention to the final sentence of the quoted material above.  As a researcher, this is a gold standard methodology statement for researching a complex organization like the VA, to pick proper probability samples, and to reduce individual inspector bias in the combined report of findings.  Thus, from this quoted material we can presume both that the methods of conducting the research were sound and conclude that the egregious behavior by administrators is VA wide!VA 3

If dirty medical equipment is how the VA defines excellence in the 21st Century, America’s veterans are in trouble deep!  I am now in my eleventh year of writing about the behavior of the VA and how they intentionally treat veterans.  I have witnessed detestable behavior by providers as an employee, and brought this behavior to the administrator’s attention, for which I was discharged without cause!  I have written about instances of negligence so terrible that there should have been a Congressional Blue-Ribbon panel assigned to demand correction and conduct and investigation, but nothing ever transpired.  I have personally experienced providers so inept, their qualifications should be questioned.  I have observed VA employees abuse, harass, threaten, and intentionally hinder treatment.  The behavior of the VA Administration where reusable medical equipment is concerned is so far beyond the pale, words escape me to describe.

Dont Tread On MeI 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 to learn a close friend or family member caught an infectious disease during treatment at the VA.  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: VA Administrators – Heaping More Shame

Angry Wet ChickenI believe in public shaming; I am an equal opportunity shamer.  Where the VA is concerned, well, I tend to be more motivated to pass out shame than any other government entity.  Not that I won’t pass along shame, or congratulations, when warranted, the administration of the VA deserves a few more scoops from the shame bucket today!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) passed along two issues today, and I have to weigh in on serving more shame, cold, hard, and well deserved.  Long have I maintained that the administration and administrators of the VA are the problems in the Department of Veterans Affairs (VA).  Today’s VA-OIG reports provide more justification for demanding cleaning of the house for administration officials at all levels in the VA.

      • Rita Copeland, 59, of Portsmouth, Virginia, pleaded guilty today to wire fraud and aggravated identity theft in connection with a scheme to defraud veterans. Copeland operated an entity known as Veteran Services of the Commonwealth and purported to provide various services to veterans from 2016 through 2020. She caused a number of victims to apply for VA home improvement grants and then used a portion of the grant payments to her own benefit instead of performing the promised work.”
      • Sophia J. Quill, 60, was charged with defrauding the VA and the Michigan Department of Treasury out of $470,000. Quill and her co-conspirator Melissa Flores, who was arraigned last year, allegedly created aliases and obtained or created fraudulent documents to make it appear that they were heirs to various individuals who died.”

VA 3If this is VA Excellence in action, we all need to be concerned!  Do you notice anything missing from these reports?  Let me help; where are the approving officials expected to do due diligence in being held culpable for allowing the fraud to thrive?  I fully admit I have limited experience being a document reviewer and approving authority.  I cannot help but ask about these approving officials who have been trained and gathered experience for their employment role.

ApathyI submit documents to the VA all the time, and every time I have to submit anything, the intake “officer” has to certify the document’s validity.  Heck, the VA had my NGB Form 22 and both DD 214’s, and I still had to submit valid copies to ensure I was not defrauding the government.  Forget innocent until proven guilty; submit forms to the VA, and you are guilty until they begrudgingly claim you are innocent.  Submit documents to Social Security for a claim, same thing, same process, same everything.  Yet, somehow three different people were able to defraud the government, stealing money, and are now hosts of the government.

Detective 4Now, returning to the VA-OIG reports, who authorized accepting the fraudulent documents?  Where were the inspectors?  How many veterans had to complain they were being cheated before anyone took notice of Copeland’s crimes?  How many congressional members were contacted for help that never arrived?  How many letters to administrators were written that were never answered?  How long did veterans suffer before the VA took action, especially in Copeland’s case?  How many evidence intake specialists lost their jobs in either case?  Were any held accountable for failing to do their jobs?

Congress, you have two straightforward jobs, write laws that are constitutional and scrutinize the legislative branch to protect the citizen from runaway government.  After the last two weeks, I have to ask, where are you in performing either role?  Passing District of Columbia Statehood for the “umpteenth time” is unconstitutional!  Overlooking the scrutinizing of the legislative branch is unconstitutional and criminal negligence of your sworn duties.

The administration of the Department of Veterans Affairs is rotten to the core!  Yet, even when directly responsible for fraud, negligence, and dead veterans, the administrators are given a “Get out of Jail Free Card.”  Wasn’t Speaker Pelosi pretty upset with CEOs and “Golden Parachutes?”  Yet, the VA Administration has precisely this and more, and the veterans and taxpayers cannot even get your attention for a second of work!  Where is the corporate media taking the politicians and the VA administration to task for criminal negligence and failure to protect the citizen?  It seems to me we can add a culpable third party to the needs a dish of shame, the media, who are also criminally negligent in performing their duties.The Duty of Americans

Where are the lawyers?  Copeland’s case undoubtedly deserves a Class-Action Lawsuit to help those defrauded get the money they need.  Where are the lawyers, hungry to see change and willing to risk becoming known for taking on the VA and winning?  The actions of the VA Administrators need to be corrected.  If Congress refuses to scrutinize appropriately, the lawyers need to begin processes in all 50-states and US Territories and Districts to demand the VA get fixed!

Bird of PreyThe time for kid-glove treatment and soft-shoe approaches is past and dead; more positive and forceful measures are required.  Where are the lawyers?

© 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: The VA Chronicles of Shame Continue

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NO MORE BS: What Would The Founders Do – Privacy of Individuals

Angry Wet ChickenPrivacy is the paramount right of individuals.  To be free inside their own homes, their papers (business), and their actions.  Except, from every front, an individuals’ privacy is being stolen through technology, government edict, and the courts’ power.  Do you even realize how much of your privacy is being subverted for the gain of others?  The more I research privacy, the madder I get!

Here is the foundational statement by the Founding Fathers of America on an individuals privacy from the US Bill of Rights and US Constitution as amended:

      • Amendment I
        (Privacy of Beliefs)
        Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble and petition the government for a redress of grievances.
      • Amendment III
        (Privacy of the Home)
        No Soldier shall, in time of peace be quartered in any house, without the consent of the Owner, nor in time of war, but in a manner to be prescribed by law.
      • Amendment IV
        (Privacy of the Person and Possessions)
        The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.
      • Amendment IX
        (More General Protection for Privacy?)
        The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.
      • Liberty Clause of the Fourteenth Amendment
        No state shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any state deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.

Apathy1961, Griswold v. Connecticut Justice William O. Douglas declared there are “zones of privacy” that allowed Griswold to purchase contraceptives against the State of Connecticut’s desires.  Except, in ruling this way, the “zones of privacy” became the black hole sucking in all the abuses of privacy by technology companies, by the government, and by the courts.  Under the “zones of privacy,” abortion has been made legal along with gay sex, both of which fall into the founder’s old legal phrase, “The privacy of families.”

Millstone of Designed IncompetenceThe statute of “The Privacy of Families” stretches back into history and means exactly as it states, the government, the lawyers, and society have no business sticking their noses into “The Privacy of Families.”  Only to violate individuals’ privacy and intrude into an individual or family’s business, “Privacy of Families” has been used as a legal excuse for violating privacy and destroying individuals.  Consider the sale of educational research data from K-12 students, the sale of HIPAA data for research purposes.  If you live in a socialized medicine country, you have even less protection for your private medical data.  The business of buying and selling data for research purposes is vast, and anyone who can create an excuse can meet the legal standards of violating your privacy for “science.”

Is the problem a little more explicit; what started as a good thing, “zones of privacy” and “The Privacy of Families,” has morphed into the legal nooses of red tape hanging an individual and family over an ethical morass while some bureaucrat is chopping on the rope.  In a legal twist of irony, Alexander Hamilton had to admit he committed adultery and was bribed, over a honey trap created by a married couple, to beat a charge of worse behavior to his social reputation.  Hence, the citizenry needs to understand how far the government will stretch to breach an individual’s privacy.

Broken RobotDoesn’t America have laws like FERPA and HIPAA and other privacy legal requirements; absolutely, but are you going to trust the government to protect your records?  Were you affected by the OPM Federal Government data breach (2015), the multiple VA data breaches since the loss of 26.5 million unencrypted veterans records (2006), or been a victim of the DMV selling your personal data?  I guarantee you have been affected either as a primary, secondary, or tertiary victim of a data hack.  Yet, the FISA courts and the “Patriot Act” were explicitly invented to destroy individual and family privacy as unconstitutional actions by a legally elected government.

Reality check, what does the government hold as records?

The stolen VA data has included the names, Social Security numbers, dates of births, and disability ratings for 26.5 million veterans and spouses, on an unencrypted laptop hard drive.  Since this first data breach in 2006, the VA has regularly lost additional private medical records, emergency contact information, children records, and other data.  I have regularly received a letter from the VA that my data was included in a data breach.  I have written about how the VA brags that the flow of data from the VA into nefarious hands slowed a tenth of a percentage point and is to be applauded.  Not ended, not stopped, slowed a tenth of a percentage point, as if that was progress.

Angry Grizzly BearIf you believe the hype, the VA congratulates themselves for not losing any financial data, like account numbers, credit card numbers, and bank information.  Except if you lose someone’s full legal name, date of birth, Social Security number, that person WILL take a financial hit!  My identity has been stolen, cost me almost $5k in bank fees, overdraft fees, and other charges.  The day after I closed my bank account in Phoenix, AZ., a person with my identity walked into the bank branch in Janesville, WI., presenting a check for cash for $500.00.  I had spent from January to July complaining that my data had been hacked; the Janesville bank branch did not even bother to call the police.

The Office of Personnel Management data breach, June 2015 (you want to click that link) is as egregious a loss as humanly possible for several reasons:

      1. Nobody knows how long the tap was leaking data. If you believe the media, the tap was only open for a few short months.  If you believe the industry investigators, the tap had been in place for years.
      2. The data lost included everything on an SF-86 form for background checks and security clearances. My first SF-86 was completed over five days with a military recruiter.  It included all my brothers and sister private data, the names and addresses of friends and close associates, and extended family members.  My Navy SF-86 was longer as I had previously held security clearances, and a deeper check was ordered.
      3. Have you ever applied for a security clearance or applied for employment with the Federal Government? Do you have relatives or friends who work for the Federal Government?  Guess what; you are either a secondary or tertiary victim of the OPM Data Hack, and nobody has been held accountable, nor has a full accounting of the problem ever been made known to the public.

Dont Tread On MeHence, the next time you hear about the government “working hard to protect your privacy,” ask them about those data centers in Utah’s desert that hold private data for the government alphabet agencies.  Ask about the OPM and VA data hacks.  Better still, ask about the IRS data hack in the spring of 2015.  While the IRS claims “only 104,000 taxpayers were involved, the reality is much higher, and politicians play games with the truth.  Eventually, the game of political hot-potato will end, and that will indeed be a great and dreadful day!

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

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

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

What is bureaucratic fiat?

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

LinkedIn VA ImageVeteran Suicide!

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

Scrutinizing the Government!

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

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

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

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

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

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

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

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

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

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

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

The Perils of a Toxic and Inert Workplace Culture

DutyDandira (2012), in an epic discussion on the origins of organizational cancer, discussed how communication, among other things, breeds organizational cancer.  The author stated what should be obvious, but the government remains oblivious to government agencies and the body’s organizational cancer.  “Responsibility and authority: (the CEO/Executive Chief) he should have the power to hire and fire, especially those who continue to follow the old system of playing political games at the expense of the organization” (Dandira, 2012, p. 191).  Again, while the following is using the Department of Veterans Affairs (VA), the examples spread like thick peanut butter, or bathtub scum, across all government agencies and NGOs.

Wasting TimeFrom the Department of Veterans Affairs – Office of Inspector of General (VA-OIG) reports, we find:

Michael Wibracht of San Antonio, Texas, the former owner of several construction companies, defrauded the United States by obtaining government contracts under programs administered by the Small Business Administration for which neither his nor his co-conspirators’ companies were eligible. One co-conspirator, Ruben Villarreal, also of San Antonio, pleaded guilty on Nov. 20, 2020, to participating in the same conspiracy. “The defendants conspired to fraudulently obtain multi-million dollar government contracts under a program designed to benefit service-disabled veterans,” said VA Inspector General Michael J. Missal. “These guilty pleas send a clear message that individuals and companies who defraud the government contracting process for service-disabled veterans will be held accountable.”

VA Inspector General Michael J. Missal, you are 100% incorrect!  Holding third-party contractors responsible for defrauding the VA does not “send a clear message,” nor will any of the actual problems be addressed; hence the fraud will continue, and the taxpayer and veterans will continue to suffer.  A little research into this story reflects that no VA Employees, who had to have been aware of the schemes and aided and abetted the schemes, have been held accountable for dereliction of duty.  Thus, the fraud will continue, and frankly, I wish you would learn this particular lesson!

VA SealDandira’s (2012) point is the hinge upon which fraud will or will not continue, does the executive heads at the hospital, VISN, and D.C. levels have the power and authority to act?  No; they do not, because Congress refuses to grant this power, while also refusing to scrutinize the government properly!  A convoluted mess that should have already been resolved, but the bureaucrats prefer designed incompetence and inertia to perform any work to improve the culture and accountability to the American Citizen and veterans.

Speaking of a culture needing work, the VA-OIG reports:

Matthew Pizarro, 32, of Stoughton, Massachusetts, was sentenced to 10 years in prison and eight years of supervised release for distribution of fentanyl, one count of distribution of 40 grams or more of fentanyl, and one count of possession with intent to distribute 28 grams or more of crack cocaine. Pizarro was indicted in October 2018 and has been in custody since his arrest in August 2018.”

LookSpeaking to the cultural problems allowing for criminal behavior to be accepted as part of the VA’s normal daily operations, consider visiting the following link.  That link will take you to incidents of failure to correct the criminal and toxic culture at the VA starting from 2013.  Not that the culture began in 2013, but that is as far back as the VA is willing to admit the culture extends from.  For example:

Lisa M. Hoffman, 48, a former pharmacy technician at East Orange VA Medical Center in New Jersey, was charged with stealing more than $8.2 million worth of HIV medication. Hoffman used her position to order, then steal, large amounts of HIV medication, which she later sold to an associate for cash.”

Detective 3While the last two examples of toxic culture include individuals, I am always impressed with the lack of integrity and the language games to spin a VA-OIG investigation report to more favorably report a Charlie-Foxtrot!  The VA-OIG investigated the use of virtual appointments for primary care during the COVID Pandemic.  Here’s the issue, before the pandemic, the only people regularly using virtual appointments were the psychologists treating individual patients who had the technology.  My Primary Care Provider (PCP) refused to use virtual appointments until last March.  Even then, my current PCP refuses to diagnose, treat, or even answer general health questions using virtual appointments.  The last three appointments using virtual technology have been technological disasters where the sound cut off and on, the picture cut off and on, random noise was broadcast, and nobody can explain how secure the technology is and how it meets HIPAA requirements.  The VA-OIG is crowing and magnanimous about the growth of virtual care appointments using VA Video Connect (VVC) in the VA.

Worse, the virtual appointments using the VVC technology do not come with technical support, so the veteran is left trying to fix connection issues without guidance and assistance.  Training for the VVC technology is either missing or obsolete, and frustration is the only regular VVC technology product.  Go ahead and crow VA-OIG; the veterans stuck using this garbage should have been part of your survey, and the fact that you refused to obtain the veterans’ input tells much about how respectful the VA is about their patients!

InertiaHere is a real-life example of a toxic culture with inert actors in action. It is reminding me of those “Priceless” MasterCard commercials from a few years back!

This management advisory memo identifies potential risks associated with the Veterans Health Administration’s (VHA) efforts to expedite adding new staff to meet increased demand caused by the COVID-19 pandemic. The VA Office of Inspector General (OIG) recognizes the tremendous pressure to hire staff to meet unprecedented needs quickly. To achieve VHA’s goal of bringing all new employees on duty within three days of making a tentative offer, VHA has modified or deferred tasks such as fingerprinting, background investigations, drug testing, credentialing, and preplacement physicals. The potential risks identified by the OIG may threaten VHA’s ability to safeguard veterans’ sensitive information and ensure its workforce is suitable for serving patients at VA medical facilities. The OIG organized these potential risks into three categories: (1) employees who do not have a completed fingerprint-based criminal history check may gain access to sensitive information and controlled substances; (2) delays in processing fingerprints add to a backlog of investigations; (3) onboarding tasks are deferred—such as drug testing and credentialing—that is not being centrally monitored to ensure completion. If realized, these risks could damage the trust veterans have in VA, keeping their information secure and meeting employee suitability standards; this memorandum raises issues for VHA to consider in determining whether vulnerabilities and related processes warrant further review. These include possible changes to centralize governance of deferred actions to improve oversight.”

Scared Eyes!Who says the veterans trust the VA to keep their data secure?  I am amongst thousands of veterans who annually have to track our identity because the VA continues to lose data through the most elementary methods.  Worse, the government is a sieve of escaping personal data from the VA to the OPM; the government keeps losing data.  These VA articles keep mentioning designed incompetence, want to see designed incompetence in action, “VHA has modified or deferred tasks such as fingerprinting, background investigations, drug testing, credentialing, and preplacement physicals… which is not being centrally monitored to ensure completion.”  Change processes, probably never even wrote down the procedures, and then refuse to monitor for completion.  Whiskey-Tango-Foxtrot on that Charlie Foxtrot, over!  Please excuse the military axiom; I am mentally blown away that this was approved, put into operation, and then left alone to fester!  When it is discovered that more criminals and nefarious people were hired, who gets the blame; nobody!  It will be COVID-19’s fault, not a mindless and spineless drone!

Detective 4I am personally aware and have reported both on this blog and to the proper authorities (not that they ever cared or did anything), the HIPAA, EMTALA, and other legal abuses of veterans in several VA Hospitals.  Without improvements in operations and providing authority to clean house for those in leadership positions, the VA’s problems will only worsen.  Please be aware; it is not for the lack of money or technology to pinpoint abuses and problems with employees; it is all the inertia of the leadership towards action and the toxic culture which allows and encourages pushing the boundaries that are killing the VA.  The VA requires a cancer operation, where the potential killing growths are removed and the body allowed to heal—healing through better leaders, better-written procedures and policies, and improved communication chains that promote catching the problems before the VA-OIG!

Reference

Dandira, M. (2012). Dysfunctional leadership: Organizational cancer. Business Strategy Series, 13(4), 187-192. doi: http://dx.doi.org/10.1108/17515631211246267

© 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: Government Customer Service

Duty 3As a subject matter expert on customer service, as a professional customer service provider, and as a concerned American, I have to state for the record, the government’s abuse of the taxpaying customer is beyond atrocious, ridiculous, and craven!  I am sick to death of being treated like cat vomit; when I seek customer support from the government, I pay such incredible sums to fund.  Worse, I am fed up with the bureaucratic mindset that places the customer in the wrong, the customer as a pain, and the customer as a nuisance to be endured instead of assisted professionally.

ProblemsMy local Post Office here in Phoenix was visited yesterday (03 March 2021).  The Post Office does not deliver packages to the apartment complex we live in, so the standard procedure is for the USPS delivery person (mailman) to place a card notifying the customer of a package on a 10-day hold in the customer’s mailbox.  Since we moved in, we have not gotten these indicators, and Monday, my wife was notified a package she needs was returned by USPS.  It was delivered Monday to the Post Office and returned to sender as “customer refused delivery” the same day.

I went to the Post Office seeking answers.  The counter-working postal representative was the epitome of rude, obnoxious, and downright unfriendly.  It took more than an hour for a supervisor to arrive, and upon discussing the problem, I was told, “Lots of your neighbors have been complaining about this issue.”  Are you kidding me?!?!?!  You have two 500+ Apartment complexes across the street from each other, multiple people from both complexes are complaining about package delivery failures, and with a smile, you can tell me this is a known issue.

Theres moreAsk yourself the following question, if you had upwards of 100 customers complaining about your work, how long would you remain employed?  Frankly, I am still stunned 24+ hours after the interaction with this supervisor.  My visit was the sixth time I had been to the Post Office complaining about not getting package notifications and having trouble with packages sitting around the post office taking up space.  One of these visits included speaking to the Post Office’s head, general, whatever, the top person in charge of a local post office is titled.  Still, the employee has maintained their job, kept the same route, and the customers continue to be abused.

After I wrote a formal complaint, I was assured that action would be taken, and the employee talked to about this oversight in their duties.  Seriously, that was exactly what the supervisor said, “the employee will be talked to.”  I understand the human resources processes, understand and have designed human resource processes, and possess a Doctor of Psychology title specializing in industrial and organizational psychology.  But, I do not know how 100+ complaints can arrive at the post office weekly, and the same mailman is only on their verbal reprimand for failure to perform their duties.  We have been complaining about this issue for a year now, and in speaking with several neighbors, they have been complaining for longer than a year about this failure.  I have some doubts that this issue will be resolved, ever!

Detective 4But hey, the Post Office is only one of the government agencies exhibiting a race to the bottom where customer abuse and customer disservice are concerned.  The Department of Motor Vehicles (DMV), a state-run agency, is always in this race, and they take hostile customer service to new heights, or depths, depending upon how you look at their performance.  The last visit to the DMV ended with screaming for several minutes in my car before possessing the proper mindset to drive away safely.  The DMV is comparable to a dentist drilling before anesthesia starts and doing a poor job on an infected tooth; you just know you will have a bad day when a visit to the DMV is scheduled!

Yet, in discussing the race to the bottom, the Department of Veterans Affairs (VA) is also a constant competitor in asinine customer service practices, customer abuse, and inept inertia.  I do not think the VA could even get bureaucratic inertia correct if someone had not taught them how.  The Department of Veterans Affairs – Office of Inspector General (VA-OIG) investigated a surgical supply program for abuses and found:

VA controls were not sufficient to ensure VA medical facility staff accurately reviewed, verified, or certified distribution fee invoices for the program. VA also did not ensure staff at medical facilities accurately established and applied the on-site representative rates and paid fees based on annual facility purchases. The pricing schedule establishes fee rates for on-site representatives based on annual facility purchase amounts.”

The amount of money involved is staggering ($4.6 Billion). The fact that the VA cannot correctly oversee a supply program, check invoices, monitor stock levels, and pay invoices properly does not bode well for integrity in customer service.

LinkedIn VA ImageThe VA is to be congratulated, the colonoscope, which is used on multiple patients for a colonoscopy, is being cleaned properly and to standard, which means that infections from one patient are less likely to occur in another patient transferred from the colonoscope.  However, the training program, certification program, and training documentation remain under considerable scrutiny for continual failure, as discovered by a VA-OIG investigation of 10 different clinics!  Training, certification of training, and documenting and tracking training are internal customer service actions that the entire VA continues to fail.  Whoever is in charge of adult education and training at the VA is not performing their jobs, and this is witnessed every couple of weeks in the VA-OIG investigation results across the entire VA.  Designed incompetence leading to customer service failures, absolutely ridiculous!

I-CareThe VA-OIG conducted a lengthy investigation at the Veterans Benefits Administration (VBA) Chicago VA Regional Benefits office in Illinois.

The OIG found claims processors did not properly correct administrative errors in 88 percent of cases reviewed. Errors resulted in improper underpayments of about $59,100 to six veterans, improper overpayments of $18,900 to two veterans, and $5,900 in debts VA had inappropriately collected from eight veterans through January 2020.”

Revisiting the Post Office example above, if you had an 88% error rate in your job, how long would you expect to keep your job?  Training and certification of claims processing personnel remains a failure of internal customer service and is mentioned in every VBA investigation by the VA-OIG.  As a point of fact, the failures of training and training certification were recently cited as a significant deficiency, where in 2018, no certification and training occurred due to internal technical problems with the intranet.  Yet, even with all this evidence that training is failing, certification is not occurring, and claims processors continue to abuse veterans through clerical, system, procedural, and process errors on claims, they maintain their positions.  Cited in this latest VBA investigation was the claims processors’ continual failure to communicate with the veteran.

Boris & NatashaConsider the following analogy.  A 100% disabled veteran gets paid once a month and budgets those monies very carefully to last the entire month.  A claims decision is made, and without any communication for why, the amount the veteran is expecting to live is cut in half.  The veteran is then responsible for wading through the various call centers to find why, how the decisions were made, and what to do, which takes time, lots, and lots of time on the phone.  While bills go unpaid, food goes unpurchased, financial difficulties mount, and correcting the situation takes more time.  Sure, the VA will pay back pay, but that is never sufficient to cover all the accruing costs and losses experienced.

Hostile customer service by the government is the most inexcusable example of customer disservice imaginable.  Why; because there is no competitor to move your business.  There are no pathways for holding customer service representatives accountable when even talking to a supervisor is not worth the time and effort.  I spent four hours on the phone chasing a claims processing error; at one point, I finally got so mad I demanded a supervisor.  I waited on hold for just under 120-minutes for the supervisor, who said had I worked better with the agent, I would not have had to wait, and the problem could have been resolved, as their opening statement!

Survived the VABy this time, I had worked with four separate agents who were confused or refused the call by hanging up.  I had been sworn at, I had been told I was a liar, and I was told my office could not handle your request.  Each call required anywhere between 30 and 50 minutes of hold time waiting for an agent.  As the supervisor reviewed the problem, they discovered that their agents could not have handled the situation, and a specialist was required.  But, I never got an apology from the supervisor for the waste of my time, the issues experienced with previous agents, nor the loss of my time and resources it took to handle the problem.

Gadsden FlagGovernment employees beware; how you treat customers is a problem, and you need to be held to task for your insolence, depravity, ineptitude, inertia, and uncaring attitudes!  When discussing the BS of government, the customer service issue is the most egregious.  I will call you out publicly every time you abuse a customer.  I am done being abused!

© 2021 M. Dave Salisbury
All Rights Reserved
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