Structured Incompetence – The Department of Veterans Affairs and Congress

The Department of Veterans Affairs (VA) is allowed the ability to govern themselves, provided they meet specific guidelines and legislated goals and directions. The Department of Veterans Affairs – Office of Inspector General (VA-OIG) was established to provide legislators and the VA with tools and processes to improve, as well as to investigate root causes, and make recommendations for improvement. But, here is the rub, the VA-OIG has no teeth to help their recommendations hold the attention of those in charge to make changes.

In December 2014, the Federal Information Technology Acquisition Reform Act (FITARA), passed Congress and was signed into law by the president; FITARA is a historic law that represents the first major overhaul of Federal information technology (IT) in almost 20 years. Since FITARA’s enactment, OMB published guidance to agencies to ensure that this law is applied consistently governmentwide in a way that is both workable and effective. 2014 saw the VA slow the loss of private data from the VA, the Office of Personnel Management (OPM) Data Breach is gaining momentum and will crest in 2015, and in case memory has failed 2014 saw an explosion in VA malfeasance get uncovered starting with the Carl T. Hayden VA Hospital in Phoenix, AZ.

December 2020 will mark the sixth anniversary of FITARA, and President Trump signed a five-year FITARA bill in May 2018. The VA-OIG in reporting progress on FITARA at the VA has this to report,

“… The audit team evaluated two groups of requirements involving the role of the VA chief information officer during fiscal year 2018. They related to the CIO (1) reviewing and approving all information technology (IT) asset and service acquisitions across the VA enterprise and (2) planning, programming, budgeting, and executing the functions for IT, including governance, oversight, and reporting. The audit team found that VA did not meet FITARA requirements and identified several causes.”

The number one reason for non-compliance after almost six-years was, “VA policies and processes that limited the chief information officer’s (sic) review of IT investments and the oversight of IT resources.” Not mentioned in the VA-OIG report is how many of these processes and policies had been enacted since 2014. The VA’s own processes and policies reflect more structured incompetence, making a ready excuse to be out of legal compliance with legislated obligations. If this was a private business, and the legislated obligations were not being followed exactly, no excuse could keep the leadership team out of jail and the business in operation. Hence, Congress why do you allow this egregious behavior by public servants?

On the topic of structured incompetence, foot-dragging, and legislated obedience, the VA-OIG issued a glowing report of compliance because the VA was found to be in compliance with three of the five recommendations from a VA-OIG inspection on Mission Act from June 2019. The progress made was on all aspects of the Mission Act except mandatory disclosure. Why does this not surprise me; of course, the VA has had, and continues to suffer from, a case of refusing to report, disclose, and communicate without severe prodding and legislated mandates. Thus, I congratulate the VA on being in compliance with the Mission Act for the last three consecutive quarters on a total of three recommendations from the VA-OIG; this is a good beginning, when can we expect improvement on mandatory disclosure? Structured incompetence relies upon disclosure malfeasance, collective misfeasance, and leadership shenanigans.

On the topic of structured incompetence, the VA-OIG reported that the Northport VA Medical Center in Northport, New York, prior medical center leaders did not plan effectively to address deficiencies in aging infrastructure. Which is the polite way of saying, the buildings are old and maintenance has been creatively haphazard, so when steam erupts from fittings and contaminates patient treatment rooms with asbestos, lead paint, live steam, and other construction debris, a small problem becomes a multi-month catastrophe. Thankfully, the VA-OIG reported no harm to the patients or patient care restrictions from this episode. Unfortunately, the VA-OIG cannot hold the managers and directors of engineering services responsible. Having worked in several capacities in engineering I am astounded at the following recommendation from the VA-OIG, and covered under creatively structured incompetence:

“… The OIG recommended that the medical center director develop processes and procedures for submitting work orders—including for notifications when work orders are assigned and reviewed for accuracy and consistency—to help the center’s engineering service prioritize work and manage resource.”

Will the VA-OIG please answer the following questions, “Why is this the hospital directors’ job?” You have an entire engineering plant, with a supposedly competent director to oversee engineering operations, why and how should the hospital director be focusing such extensive amounts of time on the job that rightly belongs to the engineering plant director? There are several technology-based programs and options that can perform this work, and form reports automatically based upon performance by engineering staff in completing work orders. Why is the VA-OIG recommendation not including an automated process to improve performance? The lack of oversight in the engineering department is both creatively and structured incompetence, because the VA-OIG report recommended following the master plan, reporting progress to the master plan, and suggested that the director of the engineering plant needs to be doing the job they are collecting a wage to perform.

On the topic of creatively structured incompetence, we find the following from the Department of Veterans Affairs – Veterans Benefits Administration (VBA). A veteran patient that spends more than 21-days in hospital for treatment is supposed to be placed on 100% disability, and be paid at the higher disability amount. Those veterans with mental health concerns are supposed to have additional support to aid them in managing their benefits from the VA.

“The VA-OIG estimated VA Regional Office employees did not adjust or incorrectly adjusted disability compensation benefits in about 2,500 of the estimated 5,800 cases eligible for adjustments, creating an estimated $8 million in improper payments in the calendar year 2018. The OIG estimated 1,900 cases did not have competency determinations documented for service-connected mental health conditions.”

Why is this another case of creatively structured incompetence, because every time the VBA gets caught not doing their job, the reason is training, reports not properly filed, and lack of managerial oversight. I could have predicted these reasons for structured incompetence before the investigation began. That managerial oversight, employees not filing proper and timely reports, and training not occurring for employees has been an ongoing and repeated theme in VBA incompetence since early 2000 when magically the VBA was behind in processing veteran claims for disability. This theme stretches to the VBA inappropriately deciding claims for spine issues. The same theme was reported in the VBA improperly paying benefits. The list of offenses by the VBA is long, and the excuse is tiresome. The VA-OIG reported:

“Employees who processed benefit adjustments also lacked proficiency. They lacked sufficient ongoing experience and training to maintain requisite knowledge. This is also why employees were unclear on the requirement to document the relevant competency of veterans admitted for service-connected mental health conditions.”

 How ironic that the root causes of a VA-OIG inspection find people being paid to perform a job, but are not actually doing the job because they lack proficiency, training, managerial oversight, and are unclear on what they are expected to do in their jobs.

 To the elected officials of the US House of Representatives and the Senate, the following are posed:

1.     If you hired a carpenter to enter your home, perform work, and you discover that the carpenter does not know the job they were hired and contracted to perform, what would be your response? If your answer is to keep that non-working carpenter in that position, in your home, I must wonder about your intellect.

2.    How can you allow this structured incompetence to live from one VA-OIG report to the next? How can you justify this behavior at the VA? How many other offices of inspectors general reports are reporting the same structured incompetence in Federal Employment and you are not taking immediate action to correct these deficiencies?

3.    Why should anyone re-elect you; when we the taxpayers endure this incompetence, paying you and them to abuse us. You were elected to oversee and manage that which we cannot; yet, you continually strive to perform everything but this essential role. Why should we re-elect you to public office?

 The following suggestions are offered as starting points to curb structured incompetence, improve performance, and effect positive change at the Department of Veterans Affairs, which includes the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries.

A.  Implement ISO as a quality control system where processes, procedures, and policies are written down. The lack of written policies and procedures feeds structured incompetence and allows for creativity in being out of compliance with legislated mandates.

B.   Eliminate labor union protection. Government employees have negotiated plentiful benefits, working conditions, and pay without union representation, and the ability for the union to get criminal complaints dropped and worthless people their jobs back is an ultimate disgrace upon the Magna Charta of this The United States of America generally, and upon the seal of the Department of Veterans Affairs specifically.

C.   Give the VA-OIG power to enact change when cause and effect analysis shows a person is the problem specifically. Right now, the office of inspector general has the power to make recommendations, that are generally, sometimes, potentially, considered, and possible remediations adopted, maybe at some future point in time, provided a different course of action is not discovered. This insipid flim-flam charade must end. People need to be held liable and accountable for how they perform their duties!

D.  Launch a VA University for employees and prospective employees to attend to gain the skills, education, and practical experience needed to be effective in their role. I know from sad experience just how worthless the training provided to new hire employees is and this is a critical issue. You cannot hold front-line employees liable until it can be proven they know their job. Employee training cannot occur and be effective without leadership dedicated to learning the job the right way and then performing that job in absolute compliance to the laws, policies, and procedures governing that role. Training is a leadership function; how can supervisors be promoted and not know the role they are overseeing; a process which is too frequent in government employment.

I – Care about the VA!

When will you the elected officials show you care and begin to assist in improving the plight of veterans, their dependents, and their families?

? Copyright 2020 – M. Dave Salisbury

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