Remember back to yesteryear when we had Operational Readiness Inspections? A pack of chuckle heads with clipboards would spill out of a C-47 on the laterite in crisp 1505 Khakis with spit-shined shoes and begin what seriously reminded me of the Keystone Kops vignettes. Everything was loud and all answers carried 200 yds. in the wind. Baggage was shuffled until it was organized-in a word- a union job. Fifteen guys to do what 4 could.
After a lot of questions, observation and getting in the way, they would determine things weren’t that bad but could be done better. Thus was born the traveling Dog and Pony Show. The ORI team would show up and everyone bowed and scraped their hats. Amenities were observed and everyone performed their dance. Afterwards the signatories would meet and promise to look into certain “problem” areas that needed improvement.
More bowing and scraping occurred and the ORI team was returned to the C-47 from whence they came. And then? Business as usual. The napalm, which had been hidden over on Air America’s PSP parking apron, would be forklifted over to the bomb dump alongside our parking apron. Smoking would resume within 50 feet of the fuel wagon and life would proceed as if nothing out of the ordinary had transpired. Fast forward to 2012 and the VA…
Specifically, the complainant alleged that a patient presented to the Emergency Department (ED) with suicidal ideation and had to wait in the triage holding area for over 4.5 hours prior to being seen by a psychiatrist. The psychiatrist told the patient that admission was not indicated. The patient had a panic attack, and the police were called to escort the patient out of the facility as the patient was upsetting the staff. We did not substantiate that a suicidal patient was denied admission for inpatient treatment.
Nothing has changed. Their ORI team descends unawares and rolls into town-albeit via commercial air. They aren’t adroit at sneaking up on the medical facility but that is immaterial. They announce themselves and give everyone time to move the napalm and foo gas out of sight. Feast your eyes on what didn’t happen here. Read about what was not discovered or substantiated. Contemplate the fact that the records did not concur on the patient’s claim of suicidal ideation.
Although the patient’s electronic health record documented the patient was hopeless and depressed, it also documented that the patient denied suicidal ideation.
We determined that there was no facility policy or standard operating procedure written to describe the process for patient evaluations in the ED; therefore, there was no training on such a policy or procedure for anyone working in the ED. This may have contributed to the long ED visit for the patient and influenced the patient’s decision to leave against medical advice.
Gee. Ya think? I thought they said they frog-marched him out for upsetting the staff watching a rerun of House, M.D. Fortunately for Vets in Dallas, all concerned agreed that a better outcome would have been preferable and that the Great Strides Forward Program (GSFP) has been instituted to insure that this unfortunate debacle never happens again (in Dallas- mind you -but they’ll have to visit every other VA ER in America to make similar assessments). A working memorandum was signed admitting a wee bit of guilt and sack cloth and ashes were distributed. Mea culpas were deemed optional and bonuses were handed out to all involved.
Ahhh!. America. How sweet the sound of wasted money. Now, multiply that by about 200 Emergency Departments. As Senator Barry Goldwater remarked once ” A million here, a million there and pretty soon you’re talking some serious money”. He had no idea anyone at the VA would have the gall to plan an extravaganza like Orlando. He might have died of apoplectia.
I don’t make this stuff up. I don’t have to. VA does it for me and now I’m on their mailing list to make it even easier to learn about. Thank goodness they feel the need to crow about their achievements so much that they publish it on the web. How many Vets lose out on compensation to pay for this boondoggle?
asknod
Bethanie Spangenberg
kcraveiro
robinhoodesqvetsatty
Wesley McCauley
