An uncovered official VA letter reveals an elaborate and apparently ineffective VA ethics program for agency hospitals that amounts to little more than an elaborate behavior modification scheme through numerous programs. While some may find the VA letter to be innocuous, it provides a list of programs worth exploring including behavior modification programs without any explanation of how VA gains “informed consent” from those who are tracked.
Titled, Intimidating and Disruptive Behaviors that Undermine a Culture of Patient Safety, the VA Information Letter reveals a myriad of data the agency gathers that is basically a behavior control program that teaches employees how to modify behavior of other employees and veterans.
[Download VA Information Letter here]
Under the guise of “ethics”, the programs outlined within the document reveal numerous failing programs that cost taxpayers millions to set up such as its IntegratedEthics program. This program integrates metrics within VA ethics rules to encourage behavior changes through incentives tied to behavior changes, which clearly was ineffective in preventing the illegal behavior of staff at Phoenix VA and elsewhere.
Based on the current scandal, is IntegratedEthics truly about changing workplaces for the better or is it more about tracking and research?
Another program actually focuses on behavior prediction and behavior modification. It is referenced in the document as the controversial Disruptive Behavior Program, which is a bi-product of the curious VHA Behavior Threat Management Program run by Dr. Lynn Van Male at Portland VA and Oregon Health & Science University. This “evidence based” program is used in part to predict and influence veteran predatory acts and those of employees. The implications of using such data are vast since VA is tracking both veterans and employees for the purpose creating more accurate predictive human management schemes.
Is this just what the doctor ordered to help VA manage its facilities or is it a surprising overreach with questionable implications? VA recently started a collaboration with Kaiser Permanente to study best practices in “population management” and genomics. Programs like these tend to benefit big business more than veterans, so will the intellectual property and data gleaned from the Behavior Threat Management Program really help vets or big business in this instance?
Since the Phoenix VA scandal was exposed, unethical actions by VA employees were revealed to be at the root of numerous veteran deaths. Last week’s VA OIG report showed widespread unethical and outrageous behavior by VA employees – so much so that America and its veterans did not think VA even had a functional ethics program.
Yet, according to the VA Information Letter we uncovered yesterday, our presumption that VA has no ethics program at all was sorely mistaken. In fact, the health care arm of VA has a very robust and obviously ineffective program that supposedly polices veterans, VA employees and their actions toward each other.
But since VA has epically failed in adhering to any ethics rules, what exactly are these behavior management programs really doing?
Here is what I think. It is helping VA gather data about veterans to analyze and study how high we jump when they ask us to jump — It will tell them how quickly they can turn up the metaphoric heat of the water before we notice we are being boiled. It seems likely this data will be used by “partners” of VA wherein corporations will profit and veterans will endure needless processes to get care that would never be required at a non-VA facility. Those corporations will benefit from our frustration by not incurring the expense of conducting the research on their own.
The Information Letter, which includes numerous broken links to other VA documents, indicates VA uses potential behavior control techniques designed to control threatening veterans to also influence behaviors of certain co-workers. VA received a lot of pressure this summer when abuses of authority within Disruptive Behavior Committees across the country that were linked to the patient flag program. Apparently, the techniques VA uses to control agitated veterans are also effective on their own employees.
Here are some examples from The Joint Commission Report on improving patient and worker safety regarding reasons VA flagged someone within that behavior management program:
Have you ever raised your eyebrows when a VA employee who was misstating the law to you or the facts of your case?
Take a look at it below. The bolding was added for emphasis:
January 13, 2010
DEPARTMENT OF VETERANS AFFAIRS
Veterans Health Administration Washington DC 20420
In Reply Refer To: 10E
UNDER SECRETARY FOR HEALTH’S INFORMATION LETTER
INTIMIDATING AND DISRUPTIVE BEHAVIORS THAT UNDERMINE A CULTURE OF PATIENT SAFETY
1. This Veterans Health Administration (VHA) Information Letter (IL) provides Department of Veterans Affairs (VA) medical center leaders and staff with information about the new Joint Commission Leadership Standard on intimidating and disruptive behaviors. This IL identifies resources within VHA that meet The Joint Commission (TJC) standard by promoting a culture of civility and discouraging behaviors that undermine effective teamwork and patient safety.
2. TJC has a Leadership Standard (LD.03.01.01), effective January 1, 2009, for all accreditation programs, which addresses disruptive and inappropriate behaviors in two of its Elements of Performance (EP):
a. EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.
b. EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors.
3. In addition, standards in TJC Medical Staff chapter include interpersonal skills and professionalism as core competencies to be addressed in the credentialing process.
a. In regard to standards on interpersonal and communication skills, “Practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams.”
b. Regarding standards on professionalism, “Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society.”
4. The intent of these standards is to promote communication and a collaborative work environment based on civility, respect, engagement, and professionalism and to do so by ensuring that health care organizations address problem behaviors that threaten the performance of the health care team (see subpar. 8a).
Work done at VHA’s National Center for Organizational Development (NCOD) has identified strong correlations between perceptions of civil behavior among staff and economic benefits, patient satisfaction, and quality of care measures (see subpar. 8b). In addition, some of the behaviors defined as uncivil or unprofessional in fact cross the line to explicit aggression, assault, and battery from a legal perspective. Emotional abuse as well as “bullying” at work can also cause intimidation. The National Science Foundation-funded VA Workplace Stress and Aggression Project (see subpar. 8d) identified work stress in health care as one of the major drivers for employee dissatisfaction in VHA. Understanding the confluence of the setting, the initiator/perpetrator, the victim, and stress (in the workplace and in the home environment) is critical at the individual level. Understanding local resources for intervention is equally critical.
5. TJC standard specifically refers to a “code of conduct.” However, TJC surveyors should be told that there is only one “code of conduct” for Federal agencies, Standards of Ethical Conduct for Employees of the Executive Branch (Title 5 Code of Federal Regulations (CFR) Part 2635). Although these general standards do not necessarily encompass the requirements placed on individuals by virtue of their unique role as health care professionals, VHA has determined that there is no need for special facility policy because the following VA and VHA resources encompass policy, procedure, and guidance regarding expectations for performance that are included in TJC standard. Surveyors can be referred to these resources in any review of compliance with the standard on intimidating and disruptive behaviors.
6. VHA expects VA medical center leaders and managers to make use of these and other resources to communicate expectations to clinicians and other staff that disruptive, inappropriate, intimidating, and uncivil behavior can compromise VHA’s mission of high quality health care service to Veterans. VA staff who experience or witness such behavior are encouraged to advise an appropriate supervisor, Patient Safety Officer, or other individual as described in the following Agency resources.
a. Civility, Respect, Engagement in the Workforce (CREW) Initiative. CREW is a VHA- wide program to increase workplace civility as assessed by employee perceptions of specific behaviors in the workplace, such as diversity acceptance, coworker support, conflict resolution. Almost 350 CREW interventions at the workgroup level, involving thousands of individuals, have occurred, with dramatic improvements in employee satisfaction scores. In addition, VHA established the Office of Organizational Health to assist in the coordination of healthy workplace efforts across the organization. NOTE: The Internet link for this item is http://10.190.0.50/succession/Templates/Master.aspx?pid=2971.
This is an internal VA Web site and is not available to the public.
b. Measuring and Assessing Workplace Civility. Based on data from the VHA All Employee Survey, findings demonstrate that civility can be measured reliably and that it is positively associated with several organizational assessment perceptions and independently measured patient satisfaction scores. Civility is related to lower incidences of Equal Employment Opportunity (EEO) complaints, turnover rates, job strain, and sick leave usage. NOTE: The link for this item is http://organizationalhealth.vssc.med.va.gov/Pages/Default.aspx .
This is an internal VA Web site and is not available to the public.
c. Prevention and Management of Disruptive Behavior Program. This program is designed to prevent aggressive behaviors within VHA, including violence related to patient assaults. One major element, as a core skill, is a segment on de-escalation training, a crucial intervention skill equally applicable to co-workers. NOTE: The Internet link for this item is http://www1.va.gov/vasafety/page.cfm?pg=541.
d. IntegratedEthics. IntegratedEthics is a VHA-wide program that includes identified personnel at each VISN and VA medical center, and assists leaders to create, sustain, and change their organization’s culture through their own behavior and the program in order to create an ethical environment, i.e., an environment in which employees recognize and discuss ethical concerns, seek consultation on ethics cases when needed, work to resolve ethics issues on a systems level, and feel empowered to behave ethically. NOTE: The Internet link for this item is http://www.ethics.va.gov/integratedethics/index.asp.
e. VHA HANDBOOK 1050.01, National Patient Safety Improvement. VHA Handbook
1050.01 provides policy and procedure for preventing harm to patients, visitors, and personnel, including root cause analysis of the system dimensions of adverse events. NOTE: The Internet link for this item is http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1695.
f. The National Patient Safety Medical Team Training Program. The National Patient Safety Medical Team Training Program improves outcomes of patient care by implementing Crew Resource Management (CRM) communication techniques in the clinical workplace. CRM was developed and applied in the aviation industry to address communication failure. NOTE: The Internet link for this item is http://www.patientsafety.gov/MTT/index.html.
g. VHA DIRECTIVE 2008-018. The Prevention of Sexual Harassment. VHA Directive 2008-018 provides policy establishing that VHA leaders and staff must maintain a work environment free from intimidation and abuse of a sexual nature. NOTE: The Internet link for this item is http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1673.
h. VA DIRECTIVE 5978, Alternative Dispute Resolution (ADR). VHA Directive 5978 contains policy regarding VA’s use of ADR, particularly mediation, to help resolve workplace conflicts and disputes.
NOTE: The internet link for this item is http://www1.va.gov/adr/page.cfm?pg=10
i. VA DIRECTIVE 5021, Employee/Management Relations. VA Directive 5021, Part II, Appendix A. Includes a Table of Penalties that should be used as a guide to identify the range of penalties that may be prescribed for types of offenses. The broad list of offenses is not intended to be exhaustive but includes the range of penalties for such offenses as “Disrespectful conduct, use of insulting abusive or obscene language to or about other personnel.”
NOTE: The Internet links for these items are: http://vaww1.va.gov/ohrm/Directives Handbooks/Documents/5021.doc and http://vaww1.va.gov/ohrm/EmployeeRelations/ConductTopics/TableT38.htm
These are internal VA Web sites and are not available to the public.
j. VA EMPLOYEE HANDBOOK. The VA Employee Handbook outlines employee responsibilities including the following: “The responsibility to serve diligently, loyally, and cooperatively… to avoid misconduct and other activities that conflict with your employment; exercise courtesy and dignity; and otherwise conduct yourself, both on and off duty, in a manner that reflects positively upon yourself and VA. You must not discriminate on the basis of race, age, color, sex, religion, national origin, politics, marital status, or disability in any employment matter or in providing benefits under any law administered by VA.”
NOTE: The Internet link for this item is http://www1.va.gov/ohrm/hrlibrary/Archives/VAhandbook/Employee_Handbook_Cover.pdf
k. VA HANDBOOK 5013, Performance Management Systems. VA Handbook 5013 contains policy and procedures on employee performance appraisal including procedures regarding Notification of Unacceptable Performance/Opportunity to Improve.
NOTE: The Internet link for this item is http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=214&FType=2 .
l. VA Office of Security and Law Enforcement. VA Police Officers, while fully sworn and trained as law enforcement officers, also receive specialized training to help them to function within the VHA culture. For any employee who believes that he or she is the target of verbal abuse, threats, intimidation, or bullying, one option is to contact VA Police. Doing so can put into motion an investigation and possibly even an arrest or citation if it is found by VA Police that a crime (e.g., ‘simple assault’ – verbal threat) has been committed. The VA Police will also be in a position to assess the presence of other violence risk factors in the situation. Even without criminal charges, however, becoming the subject of a police investigation can often be a very sobering message to the alleged perpetrator. NOTE: The Internet link for this item is http://www1.va.gov/OSLE/ .
m. VA Office of the Inspector General (OIG). OIG conducts independent investigation, audit, and oversight of activities affecting the programs and operations of VA including violations of ethical conduct and abuse of authority. NOTE: The Internet link for this item is http://www.va.gov/oig/ .
n. Office of the Medical Inspector (OMI). OMI independently investigates complaints and health care issues, including concerns about unprofessional conduct, raised by Veterans and other stakeholders to monitor and improve the quality of care provided by VHA. NOTE: The Internet link for this item is http://www.omi.cio.med.va.gov/.
8. ADDITIONAL REFERENCES
a. The Joint Commission Sentinel Event Alert Issue 40, July 9, 2008: Behaviors that undermine a culture of safety. Available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm .
b. Osatuke, K., & Dyrenforth, S. (2006). Civility in VA hospitals relates to costs and performance indicators. Paper presented at the 114 Annual Convention of the American Psychological Association, New Orleans, LA, August 10, 2006.
c. Mohr D., Meterko M., Charns M., Dyrenforth S., & Osatuke K. (2007) Workplace factors that increase employee’s satisfaction and performance. Paper presented at the Academy of Health Annual Meeting, Orlando, FL, June 13, 2007.
d. Kowalski R, Harmon J, Yorks L, Kowalski D. Reducing workplace stress and aggression: An action research project at the U.S. Department of Veterans Affairs. Human Resource Planning. 2003; 23(2):39-53.
e. Leape LL, Fromson JA. Problem Doctors: Is There a System-Level Solution? Annals of Internal Medicine 2006;144:107-115.
Gerald M. Cross, MD, FAAFP
Acting Under Secretary for Health
DISTRIBUTION: E-mailed to the VHA Publication Distribution List 1/19/10
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