Realities and Uncertainties – The Paradigm at the VA

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports they are returning to a more regular schedule of release for the inspection reports with the Department of Veterans Affairs (VA) recovering from COVID-19. Congratulations are in order, to the VA, as they begin returning to normal operations and procedures. The reality is that standard operating procedures (SOP) are regularly missing at the VA, this absence causes uncertainty, and forms the crux of this report. A question for the VA-OIG, “How can you assess employee competency without SOPs?” To the VA VISN leaders, “How can your directors and supervisors, conduct employee evaluations without written SOPs?” The short answer is you cannot!

Congratulations are in order, for the Marion VA Medical Center (VAMC) in Illinois. The Marion VAMC experienced a “comprehensive healthcare inspection” and were generally praised for the excellent work being conducted, the happiness of the patients, and the overall condition of the facilities. While there were recommendations made by the VA-OIG (29 in 8 different areas), the overall report was satisfactory, and this is mentionable. Hence, my heartfelt congratulations for your success in this inspection.

The Marion VAMC VA-OIG report raises a common theme, and this is a reality the VA appears to be incapable of addressing training and two-directional communication. From the hospital director to the patient-facing staff, training always appears as a significant issue in VA operations. Having experienced the training provided by the VA for employees, and as an adult educator, I know the uselessness of the training program and have several suggestions. Perhaps the problem would be best addressed if more evidence was provided of a systemic failure in training employees at the VA.

In 2017 Congress mandated a change in research operations for the VA, specifically where canine research was concerned.

“The OIG found VHA conducted eight studies without the former or current Secretary’s direct approval, resulting in the unauthorized use of $393,606 in appropriated funds.VA continued research using canines after the passage of the funding restrictions, in part, because VHA executives perceived that then VA Secretary David Shulkin had approved the continuation of the studies before his departure.”

The cause of the problem, the VA-OIG discovered was, “Unclear communication, inadequate recordkeeping, and failure to ensure approval decisions were accurately recorded and verified all contributing to VHA’s noncompliance.” The researchers and executives relied upon two leading causes for not following regulations, designed incompetence, and a lack of training through clear and concise communications.

Congress mandated the documentation to assure approval was obtained before research commenced; yet, the researchers and administrative staff collectively failed to do their jobs and were able to hide behind the bureaucracy they established to excuse their poor behavior. Loopholes for designed incompetence and lack of training need closed; but, two incidents do not clearly illustrate the reality of the problem.

The VA Southern Nevada Healthcare System in North Las Vegas, in response to a referral from the U.S. Office of Special Counsel (OSC), was investigated by the VA-OIG after a community healthcare worker was attacked. The VA-OIG findings are appalling, but the reasons for the problem are worse.

“The OIG determined that facility managers failed to timely respond after the social worker reported an assault during a home visit and did not address the social worker’s health needs after the assault. The social worker’s supervisor failed to immediately report the incident to the community and VA police. The facility’s policies lacked specific guidance regarding employee emotional and mental health injuries. Further, the OIG substantiated that the social worker was not informed by a supervisor of a homicidal threat, occurring subsequent to the assault, until two weeks after facility leaders became aware of the threat.”

The facility leaders knew there was a problem, yet did nothing before or after the event, that could have cost this healthcare worker their life! VA-OIG recommendations boil down to a need for clear communication and staff training. The recommendations highlighted another issue entirely that forms the reality and creates uncertainty at the VA, communication is not a two-directional opportunity to share information. Single directional communication is useless, and those leaders supporting the bureaucracy to only allow communication to flow in, need immediate removal from the VA. During my time at the VA as an employee on the front-lines, facing patients, I regularly experienced the lack of communication, and this issue is systemic to the entire VA as witnessed and observed at VA Medical Centers across the United States.

The Nevada incident is deplorable, reprehensible, and the potential for loss of life cannot be overlooked by VA leadership in Washington, at the VISN, or at the Medical Center any longer! The problems of communication cannot explain this incident, and failure for training cannot excuse this behavior! Since the OSC initiated the complaint, I am left to wonder, did the employee reporting this incident get fired and needed to appeal to the OSC for remediation? I ask because the knee-jerk reaction to problems at the VA is to fire the person reporting the issue, as previously observed and personally experienced, and as described to Congressional representatives during televised hearings. A more thorough investigation into causation needs to be concluded and reported to Congress for this incident reeks of politics and CYA.

The Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri, and multiple outpatient clinics was recently provided a comprehensive healthcare inspection, and the leadership team provided 14 recommendations in 7 different areas for improvement. While congratulations are in order, for the patient scores, the employee scores, and the overall conditions discovered. Yet, again staff competency, e.g., training and communication, remain critical articles requiring targeted improvement. Is the pattern emerging discernable; in Nevada, an employee is assaulted and training and communication are blamed, comprehensive healthcare inspections are conducted in three different geographic areas and the same causation factors discovered; training and communication are systemically failing at the VA. But, the evidence continues.

The John J. Pershing VA Medical Center in Poplar Bluff, Missouri, recently underwent a comprehensive healthcare inspection. The VA-OIG issued 17 recommendations in 6 fundamental areas, including staff competency assessments, e.g., training and communication, as well as the inadequate written standard operating procedures. When discussing designed incompetence, the first step to correcting this problem is writing down the standards, operating methods, and procedures. Then the medical center leaders can begin training to those standards. Barring written instructions and published standards, employees are left to ask, “What is my job? and “How do I perform my job to a standard?”

The Oscar G. Johnson VA medical center, and multiple outpatient clinics in Michigan and Wisconsin recently underwent a comprehensive healthcare inspection, 11 recommendations in 3 critical areas. As did the Tomah VA Medical Center and multiple outpatient clinics in Wisconsin, 4 recommendations in 3 crucial areas. Both facilities are to be congratulated for their continual improvement and their success during the inspections. In case you were wondering, staff competency assessments, e.g. training and communication, are vital findings and variables in improving further for both facilities.

The VA has what it calls “S.A.I.L” metrics that form the core standard for performance. S.A.I.L. stands for Strategic Analytic (sic) for Improvement and Learning. Learning is a critical component in how the facility is measured and yet remains a constant theme in the struggles for improvement. Thus, not only is two-directional communication a systemic failure, but so is the poor training results found on all the comprehensive healthcare inspections performed by the VA-OIG. Poor communication almost cost a healthcare worker their life, and staff training was a key component for recovering from this incident in Nevada. How can the VA consistently fail at two-directional communication and training, designed incompetence? Those in charge require an excuse for not doing their jobs, and the most common excuse provided is a lack of training and poor communication.

It is time for these petulant and puerile excuses to be banished and extinguished. The following are suggestions to beginning to address the problems.

1. Easy listening is a musical style, not an action in communication. By this, it is meant that the VA needs to stop faking active listening and engage reflective listening. Reflective listening requires reaching a mutual understanding and is critical to two-directional communications. In the world of technology, not responding to email, not responding to text messages, and untimely responses to staff communication are inexcusable on the part of the leaders.
2. Staff training remains a core concept, but before staff can be properly and adequately trained, standards for performance, operational guidelines, and procedural actions must be clearly written down. The first question I asked upon hire was, “Where are the SOPs for this position?” I was told, “Do not mention SOPs as the director hates them and prefers to work without them.” Do you know why that director preferred to work at the VA without SOPs because she used it as an excuse to get out of trouble, to fire those she deemed trouble makers, and to escape with her pension and cushy job to another VA medical center? A repeatable pattern for poor leaders to spread their infamy. Shame on the VA Leaders for promoting this director to a level beyond her incompetence. Worse, shame on you for creating an environment where many like her have excelled and done damage to the VA reputation, mission, and patients, including killing them while they awaited care.
3. From the VA Secretary to the front-line patient-facing employee, cease accepting excuses. The private sector cannot hide behind immunity from litigation and act in a more responsible manner. Thus, the VA needs to benchmark what private hospitals do where staff training and SOP’s are concerned. Benchmark from the best and the worst hospitals for an average, then implement that average as the standard. One thing discovered in writing SOPs for the NMVAMC, the committee for approving SOPs, and the process for writing SOPs were so convoluted and time-intensive that the SOP was outdated by the time it could be implemented. Shame on you VA leadership for creating this environment!
4. Training should be an extension of an organizational effort and university. The VA is not properly training the next generation of leaders; thus, the problems multiply and exponentially grow from generation to generation. Launch the VA Learning University concept, staff that university with adult educators, and allow lessons learned from the university to trickle into operational excellence.
5. Form an independent tiger team in the VA Secretary’s Office who has the authority to travel anywhere in the VA System to conduct investigations with the ability to enact change and demand obeisance. The Nevada incident was a failure of leadership and needs a thorough reporting and cleansing of the bad actors who allowed that situation to occur. Worse, in my travels, I have heard many similar stories. I heard of a patient getting their ear chopped off when a veteran assaulted another veteran after becoming irate at waiting times in the VA ER. I have heard and witnessed multiple incidents of furniture being thrown, employees being assaulted, employees harassing and assaulting patients, staff property trashed, and so much more. These incidents need direct intervention and investigation by a party not affiliated with that affected VAMC and the leadership’s political policies.

04 October 2016, the VA-OIG released a report on dead veterans after the comprehensive investigation into the Carl T. Hayden VAMC in Phoenix, Arizona. The same event occurred in 2014, at the same hospital, with the same causes and the same conclusions. The core causes for the dead veterans, no written procedures, poor to no training, and reprehensible communication practices. The Phoenix VAMC went out of their way to fire all the employees who reported problems at the Phoenix VAMC before the veterans began dying in 2014, I can only speculate that the same occurred in 2016. Staff was frightened in 2014; they are demoralized in 2020. Nothing has changed at the Carl T. Hayden VAMC in Phoenix, Arizona, after two successive hospital directors, if anything the problems have worsened. The problems worsened because leadership failed to act, failed to write down SOPs, failed to communicate, and failed to train. The hospital directors since 2014 have been appointed from the same pool of candidates who created dead veterans in the first place, and that is a central failure of the VA Secretary and Congressionally elected representatives’ failure to act!

How many more veterans or staff must die before the VA is willing to act?

? Copyright 2020 – M. Dave Salisbury

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