Leadership and the Department of Veterans Affairs – Shifting the Paradigm on Killing Veterans

Since the beginning of 2019, a running theme in the Department of Veterans Affairs Office of Inspector General (VA-OIG) reports, that I have delivered via email, has been the lack of leadership. Today’s VA-OIG report is a perfect example of discussion and remains significant due to a veteran being killed by the Spinal Cord Unit in San Diego, CA. I fully submit that VA Secretary Wilkie is trying to reform the Department of Veterans Affairs. I fully offer that the nurses and providers, as well as other front-level employees at the Department of Veterans Affairs, are trying to do a difficult job in a bureaucratic nightmare. I contend that the mid-level managers between the supervisors and Secretary Wilkie need removed and processes redesigned.

Using today’s VA-OIG report, we find causation for removing mid-level managers to streamline leadership effectiveness and positively contribute to saving patients. The VA-OIG claimed, “At the time of the patient’s death, the SCI unit used an outdated nurse call system that required the use of a splitter to connect the ventilator to the call system, none of the respiratory therapy staff had training or competency assessments related to PMV use, staff failed to report the patient’s ventilator tubing disconnections through the Patient Safety reporting system, and SCI leaders failed to follow the standard operating procedure for the management of clinical alarms.” [Are you kidding me?!?!]

Outdated technology is inexcusable, especially for all the money continually pumped into the Department of Veterans Affairs to update technology. Who are the mid-level managers in charge of procurement that have failed to do their job and improve technology effectively? VA-OIG, was the role of technology procurement included in this investigation? If not, why? If so, where is that report? I have personally witnessed 10+-year-old technology used for patient care due to inadequate leadership efforts and procurement people wasting time, as well as other resources. If a root cause in a patient dying is old technology, why are we not holding those in procurement an IT accountable?

Training at the Department of Veterans Affairs is a colossal joke; either the training is bloated, and the user cannot identify which parts are valuable to their job duties specifically, or the training is so shallow that the topics are considered a waste of time. But, there is also a third option for training; training only applies to managers due to the labor union collective bargaining agreement. Thus, the front-line worker could use the knowledge, but the union is preventing that knowledge from spreading as that policy has not been approved on a national level. The leaders in charge of training cannot answer basic questions regarding applicability, usefulness, or point to policies and procedures that govern why certain topics are required to specific audiences. The lines of communication breakdown in training have reached monumental proportions, and as witnessed, is killing patients. Worse, the training at the VA is governed by third-party LMS software that can quickly be completed without ever influencing the actions of the individual. Classroom training is a rehash of the LMS training and does not cover the gaps or explain why. Front-line supervisors cannot answer basic questions about the why behind a process or procedure, nor can they point to a resource where the information can be discovered; yet, training is a causal variable in deaths of patients, cost overruns in construction, criminal activity, and more in the majority of VA-OIG reports.

The VA-OIG noted a root cause in their investigation, “The OIG could not determine what the ventilator settings were at the time of the patient’s death, because facility staff who inspected the ventilator immediately thereafter changed the settings to check whether alarms were functional and then reportedly returned the settings to the previous levels.” If the setting on a piece of equipment is required for a patient safety report, why are there not digital pictures taken? I find the VA-OIG being unable to ascertain equipment settings to be a complete failure of current technology. How many smartphones are possessed by patients, staff, providers, etc. that could snap a picture of a piece of equipment for an official record? Did the VA cease issuing smartphones to mid-level managers?

One of the most egregious problems at the VA is designed incompetence to allow a malefactor the ability to hide behind bureaucracy to avoid accountability and responsibility. Designed incompetence is the problem and I do not see any of the mid-level managers, leaders, supervisors, trainers, etc. acting to eliminate designed incompetence to the improvement of the Department of Veterans Affairs. Consider for a moment the hundreds of millions of dollars lost in bloated construction projects. The project leader has vague, inaccurate, old, etc. processes and procedures to blame the failures upon; this is an example of systemic designed incompetence, that protects a lazy employee and costs the taxpayers resources, and the Department of Veterans Affairs reputation.

The VA-OIG reported more root causes in the death of a patient to include, “… the facility did not implement risk mitigation strategies, ... did not have a backup monitoring plan when the ventilator alarms were off, patient criteria to determine when the valve should be removed, policies for facility staff and patient/family education on the use of the PMV, policies or procedures for monitoring and documenting ventilator and alarm settings while using the PMV, or a policy to use anti-disconnect devices.” Risk mitigation is everyone’s job in a VA Medical Center. Risk mitigation is a facet of every post and included in the third-party software training programs for providers, nursing staff, and clerical staff. Why did this patient die from a lack of risk mitigation? What are the tactical risk mitigation actions that support risk reduction strategies? I have asked this exact question, as an employee and a patient, in two separate VA Medical Facilities and never received an answer beyond simple platitudes. A root cause in a patient dying was risk mitigation strategies; VA-OIG, there is a bigger problem here that merely making a recommendation to leadership can resolve. If a strategy is not supported with tactical action, there are no strategies; simply wishful thinking and hope statements. Are the mid-level managers going to be held accountable for dropping the tactical ball here and letting a patient die from systemic designed incompetence?

The US Military believes in redundancy; every mechanical system has a backup, that backup has a backup, and there is a manual backup for when all else fails. How can the Department of Veterans Affairs claim to serve America’s military veterans without redundancies? Without training on redundancies? Without education and real-life training scenarios, to prod thinking before an emergency occurs? The simple answer, the VA cannot represent, serve, or support America’s veterans without these core competencies built into the processes and procedures that power a learning organization.

I am sick and tired of seeing veterans harmed, abused, and killed at the hands of bureaucratic ineptitude and systemic incompetence that protects the lazy and useless at the expense of veterans. I am beyond disgusted that mid-level managers, supervisors, directors, etc. have the power to arbitrarily pick winners and losers based solely upon the worship that employee does to the boss when the employee cannot do the job they were hired to accomplish. It is beyond inexcusable to see no job-specific duties, processes, and procedures that provide tactical action for strategic aims at every workstation where training is held daily to meet the strategic goals of the medical facility. The Department of Veterans Affairs needs to begin cleaning house of the criminals, the incompetent, and the lazy that are supporting a reputation of killing veterans through designed incompetence, as they masquerade as supervisors, directors, managers, etc.; there is no excuse for killing another veteran!

? 2019 M. Dave Salisbury

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