VA OIG: VHA Failed To Adequately Support VA Employees

A VA OIG report released this week revealed the agency failed to take appropriate steps to support VA employees serving veterans during the pandemic.

Importantly, IG noted VA employees reported a “perception of inadequate support and responsiveness from leadership.” Sometimes perception is reality.

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Given testimony from EHR implementation lead Dr. Terry Adirim (former DOD leadership), it appears VA leadership is ready to throw its frontline workers under the bus to avoid stalling the Cerner Millennium EHR rollout despite the system not being ready.

It’s just a hunch, maybe even a stretch, but VA leadership appears to be detaching from their prior steadfast connection with frontline employees in subconscious anticipation of a wedge forming. Perhaps the negligence to properly tend to the needs of care for frontline workers during the pandemic is not connected, but I wonder.

Remember, veterans first, except when the contract is over $10 billion.

Then it’s Lord of the Flies.

VA OIG Report

This excerpt is the VA OIG report 21-00533-157 executive summary. It is quoted directly, below:

The VA Office of Inspector General (OIG) conducted a review to assess how the Veterans Health Administration (VHA) addressed the emotional well-being of employees during the novel coronavirus disease (COVID-19) pandemic. The OIG also conducted an overview of VHA programs, including what specialized programs, if any, were developed and deployed in response to the unique psychological challenges created by the COVID-19 pandemic for VHA’s staff.

Mental health needs generally surge during and after disasters, including pandemics. In March 2020, after declaring COVID-19 a pandemic, the World Health Organization highlighted the importance of maintaining the mental health and emotional well-being of healthcare workers caring for COVID-19 patients.

On March 23, 2020, the VHA Office of Emergency Management issued the initial COVID-19 Response Plan with its four-phase approach and a second, updated version on August 7, 2020. The August 2020 response plan update included language allowing VHA to delegate responsibility to program offices to develop resources for response plan strategies. With that delegated authority, the National Center for Organization Development created and maintained resources for leaders and the VHA Organizational Health Council created and maintained resources for employees and took responsibility for collaboration and coordination of efforts across multiple program offices.

The OIG initiated the review on November 30, 2020, and conducted virtual interviews with VA and VHA leaders in multiple offices. The OIG developed a series of survey questions about VHA guidance regarding employees’ emotional well-being during the pandemic, available resources, monitoring of available support programs, and employee engagement with available support programs.

The National Center for Organization Development created a COVID-19 rapid response consultation process for VHA leaders who were in a supervisory role. This rapid response consult provided counseling about leadership skills in a virtual environment, communication, and employee support needs. The Organizational Health Council’s VHA Social Work COVID19 Tiger Team coordinated with multiple VHA program offices to create a COVID-19 Employee Support Toolkit and other resources, including a SharePoint website. Additionally, several VHA offices independently created and disseminated employee well-being resources specific to the COVID-19 pandemic, including the National Center for Organization Development, Patient Centered Care & Cultural Transformation, Chaplain Service, and the Office of Mental Health and Suicide Prevention.

Through a survey of selected Veterans Integrated Service Networks, facility, and clinical and non-clinical staff, the OIG identified areas of concern related to employee emotional well-being: mainly a generally diminishing awareness of supports in relation to organizational hierarchy, low utilization of support resources by leadership and frontline employees, as well as employee perception of inadequate support and responsiveness from leadership.

Awareness of Support Resources

Of the individuals who chose to participate in the OIG survey, 81 percent (17 of 21) of Veterans Integrated Service Network respondents, 91 percent (41 of 45) of facility leader respondents, 60 percent (332 of 557) of facility service line leader respondents, 40 percent (1,962 of 4,909) of clinical staff respondents, and 47 percent (1,149 of 2,461) of non-clinical staff respondents reported they were aware of VHA’s guidance for efforts to provide emotional support resources for employees (see figure 1).

Utilizing Support Resources

Only about one-quarter of frontline staff respondents reported utilizing support resources with personal protective equipment and virtual resources most frequently accessed. The OIG asked survey respondents who had used the support resources, “Have you found your facility, unit, or group’s COVID-19 related resources helpful?” Seventy-nine percent of clinical staff respondents and 82 percent of non-clinical staff found the resources they used to be helpful.

Emotional Support Adequacy

Thirty-eight percent of clinical staff respondents and 31 percent of non-clinical staff respondents said their leaders were not responsive. Additionally, 51 percent of clinical staff respondents and 41 percent of non-clinical staff respondents expressed that they did not feel adequately emotionally supported during the pandemic.

The OIG concluded that greater leaders’ and employees’ awareness and encouragement could lead to increased utilization of resources, a better sense of facility support for employees experiencing distress, and improved organizational resilience.

The OIG made one recommendation to the Under Secretary for Health to review the processes by which COVID-19 emotional well-being resources were developed and disseminated and to take action as needed to increase and ensure Veterans Integrated Service Networks and facility leadership as well as facility staff’s awareness of available resources about the potential risks and signs of burnout.

VA Comments and OIG Response

The Deputy Under Secretary for Health, performing the delegable duties of the Under Secretary for Health, concurred with the findings and recommendations and provided an acceptable action plan. See Appendix E, pages 32–33, for the Deputy Under Secretary’s comments and pages 34– 35 for the action plan. The OIG will follow up on the planned actions until they are completed.


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  1. Ben, when trying to utilize the new Mhhealthevet sign in today, this is the message that appears:

    “You may have trouble signing in right now
    We’re sorry. If you’re using the Safari browser or an Apple mobile device, you may have trouble signing in right now. We’re working to fix this problem as fast as we can.”

    I have yet to be successful in utilizing the new sign in because of this problem.

    The Roseburg VA will be switching over to the new EHR on June 11th and will also switch to the new Myhealthevet.

    Chicago Mike

    1. The first dumbass mistake was calling the new system/platform “MyVAHealth”, as opposed to MyHealthEVet. WTF?

      What I saw online was that the new system doesn’t yet support anything but Chrome or MS. It’s certainly rejecting my Anrdoid device.

      I can hardly wait

      1. Of course Chrome and MS provides the big brother to gather more info on whoever uses it than if the Veteran used a more restrictive operating system and software Of the VA, By the Va, For the VA;
        F**K the veteran

      2. UPDATE: this afternoon I received aN email alerting to a new message but am now forced to use the My VA Health sign in. which I was auto directed to and an email was sent to me to verify my email and a verification code was sent to me via email which was no-good but the code texted to m was good but takes you in a circle from this screen: “New: Portions of My HealtheVet Transitioning to My VA Health
        Your VA health record or portions of it may be managed on My VA Health. Learn more about the steps you may need to complete in your My HealtheVet account, such as communicating with your VA health care team.”

        And then to this screen: “We’re sorry. We couldn’t connect to your health record.

        Please try again later.

        Questions about using your My VA Health patient portal? Contact support anytime at 888-444-MYVA (888-444-6982).

        Agreement Status
        Medical Center: (531)
        Medical Center: (648)
        Medical Center: (663)
        Medical Center: (578)
        Medical Center: (692)
        Medical Center: (556)
        Medical Center: (537)
        Medical Center: (653)
        Medical Center: (553)
        Medical Center: (200) ”

        While I was able to get to the secure message screen when I tried to open the inbox I was shown the first message above.

        I am currently locked out of myhealthevet and My VA Health.
        Chicago Mike

    2. UPDATE: this afternoon I received aN email alerting to a new message but am now forced to use the My VA Health sign in. which I was auto directed to and an email was sent to me to verify my email and a verification code was sent to me via email which was no-good but the code texted to m was good but takes you in a circle from this screen: “New: Portions of My HealtheVet Transitioning to My VA Health
      Your VA health record or portions of it may be managed on My VA Health. Learn more about the steps you may need to complete in your My HealtheVet account, such as communicating with your VA health care team.”

      And then to this screen: “We’re sorry. We couldn’t connect to your health record.

      Please try again later.

      Questions about using your My VA Health patient portal? Contact support anytime at 888-444-MYVA (888-444-6982).

      Agreement Status
      Medical Center: (531)
      Medical Center: (648)
      Medical Center: (663)
      Medical Center: (578)
      Medical Center: (692)
      Medical Center: (556)
      Medical Center: (537)
      Medical Center: (653)
      Medical Center: (553)
      Medical Center: (200) ”

      While I was able to get to the secure message screen when I tried to open the inbox I was shown the first message above.

      I am currently locked out of myhealthevet and My VA Health.
      Chicago Mike

  2. Benjamin here is what needs to happen in this agency. There is already a disconnect between the leadership and the employees. Many times the employees are directed by the leadership about what to do in actual procedures. Ben most of the leadership are not physicians at all. The system is a population control system. This system is Socialism and Communism. This is not healthcare at all. Back in the day the VA did truly use to invest in veterans more than they do now. Now I believe many of the errors are intentional. Because the more veterans they keep down the more money they believe they will receive. Anyway, since the leadership is so disconnected from the employees, I believe the agency should be broken up similar to Tricare and Medicare. Have the medical providers to themselves. This would allow more freedom of decisions when they are and if they are trying to assist the veteran patients. Leadership should be in an administrative facility to themselves.
    By separating the two, accountability could become more involved. The smaller the easier to deal with and get things done in more efficient ways. When it comes to licensure, they do not care if their medical providers are credible or not. All about status is what this hold country has become. The current status quo is to do away with merit. VHA needs to be broken up.

    1. Sir before they did not invest in Vets. In the history I have used VA since 1986. The leadership has always not really do what was write to the Vets. They protected top management And treating workers and vets with total disrespect. I have written letters to director of Dallas hospital of doctors lying on the entries doctors have entered in my medical records and there response they can not help me on my disability claim. I had no claim and this was about ankle scope. They messed ho and have proof and was having allot of pain but what I was told by the doctor was I should not go back to work till my ankle fully healed. That was never written in my record but I was released to go back to work. I was an aircraft mech. This is one time of 5 times. I had talk to other vets and same things happen to them also.

      1. I am referring to Chapter 31 Vocational Rehabilitation success stories back before the middle 2000s. I was not referring to care or disability decisions or GI Bills either. I was not referring to me either. I was referring to the resources around me and what was happening to many veterans around me. Trust me I have been hammered.

    2. When they speak about lack of emotional support, in that type of system emotional support is always lacking. Here is why. The direct tyrannical approach contributes to detachment which in turn produces the disconnect. Abuse of authority eliminates any type of emotional support. Also it is the detachment that that can contribute to the disregard for life. A person cannot care about another human being without an emotional connection. This would be the same as VA providers providing services to veteran patients. Most connections between veterans and providers are about just information gathering in recent years. All the malpractice and medical errors mainly have happened because of the detachment produced by the authoritative system.
      The disconnection removes the morality from the VA providers and the VA leadership. I am saying probably many but not all. Also the Socialistic system or the single payer system emotionally sabotages both the employees and the veteran patients. I bet VA employees have not noticed. Although they may have noticed and have not bucked the system because they need jobs. The lack of emotional support stems from the individuality that is missing from the people who work in the VA. Positive emotional healthy connection only happens if individuality is allowed. Group think or herd mentality blocks the emotional supportive connection. Because the tyrannical system or single payer system only allows superficial connection. The emotional supportive experiences are only experienced in what one would say the sixth dimension.
      “Hope is the companion of power, and the mother of success; for who so hopes, strongly has within him the gift of miracles.” Samuel Smiles.
      Hope is stepping beyond all one knows in expectation that a need will be met.
      Benjamin when people are wounded the only way the body heals is in the sixth dimension. The only way people heal is through the healing process that occurs both with the mind and the body connected. Only happens in supportive environments. Single payer is Socialism and Communism and abuse of powers. Employees and veteran patients will never experience increased emotional support in this system. Benjamin they claim to have online help for mental health. This does nothing in the way towards helping veterans heal wounds. What I have mentioned is important. This is the reason for most veteran suicides and for what the VA employees reported to the VA OIG in the survey on.
      Of course I am not an expert. I am just speaking from my own insights.

      1. When they have had any type of support that sets the stage for positive emotional support and healing, they seem to eliminate it real fast. Oh yes….witnessed it. Ben in my opinion this is why they are always changing to this or that. Of course the money too.

    3. Benjamin let me add this if I still can.
      What has been happening is the corporate has been emerging with the state against the citizens. Managerial class vs the regular citizens. Government getting their hands into the private sector pretending that it is Capitalism. Subsidizing everything is not free market anything. This is crony capitalism. The corporations CANNOT exist as part of government. They can’t but they are trying to force it. There are boundaries and they both have different functions. Just like the separation of powers between the different branches of government. Ben apples cannot become oranges. And one entity cannot assume all roles of functioning. Uniformity is not Reality. It cannot happen. Make believe through deception but even then this is just nothing. We live in a world where all of of it is Chemistry at all levels. They cannot exist in a non existent world.

      1. I do not have to prove anything to anyone or any agency or any company.

        We do not.

        They are the ones who are forcing the deception.

  3. VA is garbage healthcare for the down & out. But if you’re homeless, drug/alcohol addicted, and got mental illness then it’s better than nothing. If you have private insurance and a choice, then choose something better.

  4. April 2020, at the start of the pandemic, the headlines: Roseburg VA director leads coronavirus dance party without social distancing, face masks.

    Here is just one link but there are many: “”

    this was an internal Roseburg VA video, several of his employs turned him in. Many employees spoke out about under conditions of anonymity fearful of reprisals/retaliation. The previous two directors, Dave Whitmer resigned from the VA after being disciplined twice for whistleblower retaliation amid allegations he falsified testimony in an EEOC case but this was after had already left Roseburg.

    Doug Paxton was known for his retaliation against whistleblowers, DeFazio even spoke about the toxic management at the Roseburg VA from the House floor on October 12, 2017 (posted on you tube)

    With regards to Medical Records, I just discovered in a recent ROI/FOIA request that another veterans medical records “Lance Badger” was mixed in with my medical records. Roseburg VA Privacy Officer is investigating.

    Don’t have time to go through the whole list of systemic problems which includes denying Veterans Medical Screenings and failure to inform Veterans of the Clinical Appeal Process or post or provide handout regarding Veterans Healthcare patient rights. The current available info pertains to Veterans and family members rights who reside in Community Living Centers from January 15, 2013.

    Can’t find VA healthcare Facilities patient rights on the internet and VA could not provide. Any of you have anything more current?

    Clinical decisions are not BVA appealable per the VHA clinical appeal directives dated 2016 and 2020. Clinical appeals are another tool for VSOs to help Veterans. see VHA directive titled Patient Advocacy which reads in part: “h. Patient Advocate. A patient advocate is one who pleads the cause, is the voice for and advocates for Veterans’ rights consistent with law, policy and professional standards. The advocate protects the Veteran’s health and health care rights and provides assistance in asserting those rights if the need arises. Advocates within VHA have numerous duties and responsibilities, to include educating the Veteran on the Patient Advocacy program and their appeal rights.”

    does anyone know if the VA is required to participate in the 21st century “CURES Act”? this is intended to prevent “Information Blocking” and give patients the opportunity to be more engaged intheircare through improved access to their health information via electronic health records.

    My available records on myhealthe vet are grossly incomplete.

    thanks for the replies, let me know what you find out.

    thanks, Chicago Mike

    1. Chicago Mike,
      thank you for your in-depth comment. Mike, in order to clean any of this up legal system has got to become more in line with following the laws. In regards to preventing information blocking, I do not believe the VA is honoring any aspect of that because they still have shutdown veterans. These are two different types of issues and of course this one would not apply to healthcare. The first one that comes to mind is VA providers trying to dictate who the veteran votes for. The other issue is veterans can rarely move claims forward in the system. The lower personnel block it.
      And when issues come up out here to be handled the veteran cannot stand up to the VA because the veterans are out here. Dealing with this system was a full time job. They spin everything. Chicago Mike, you mentioned about another veterans information being in your records. Well that happened to me. The VA had me going out of state for a liver transplant. They were arranging the travel. I questioned them? This happened when I started getting more of my stability back. I knew I did not warrant a liver transplant. I knew. Sure enough they had entered another veteran’s information into my record. As for my FOIA, I have no idea. For the last few years my life has revolved around cleaning up situations and correcting situations out here. All had to do with companies and the VA. As for my records and what has happened, I know what should be there and what shouldn’t be there. I have my paper records too. I am a Gulf War Era veteran. Along with me, people have been in the know. I mean people who have been on the course with me. Whatever is in the FOIA could pertain to why this VISN 8 has been blocking me and or slamming me. But then the information may be correct in the FOIA. Because it is normal conduct for the VA to deny and kick down the road. So I really do not know what they have put into my records. I know the path that I have walked and others know too. I know what information I have in my own hands. Furthermore the government as a whole is a disaster. I have tried to use service officers in VISN 8. They all blew me off and shut me down or just would not engage for whatever reason. I originated out of the Northeast. Two DAV handled my situation. One reviewed service records while still on active duty prior to being retired and the other one a year later. After the Georgia Department of Veterans Affairs submitted additional document. First DAV became ill with cancer. I still have their cards too. Navy documented accommodations prior to TDRL and PDRL. Of course none of this mattered then because I could not function to do anything. People were helping me. VA tried back then to put me into assisted living but I could not handle that. It never happened. I lived in a room in a boarding house with people from the community helping me. Anyway, I speak today how I was and people today cannot fathom it. This is why the system has got to be fixed. Many of the people or some of the people in the state mental hospitals can be given a hand up. But the government will not do that. The federal government and all governments hold them down by continuing to overmedicate to where there is no coming back. I see through all of this. Big pharma removing molecules from the molecular structure in drugs for the purpose of profits. And these drugs were actually quality and helping people. Oh no big pharma could not stand for that so here they come. Dismantling successes just like the VA does should they ever have any.

      1. Thanks for the reply A,
        There is no accountability for VA facility or VISN Leadership. The VA looks great on paper when you read the VHA Directives Governing Veterans Healthcare. The stated “purpose” in these Directives is to satisfy the requirements of Title 38.

        a lot of Veterans problems/issues would would have never occurred or would be resolved if the VA would jut follow the Law aka VHA Directives.

        I would agree with you that the system is needs to be fixed, unfortunately the incompetence/wrongful denials of healthcare will continue.

        The VA, even our senators and congressman may fix problems for Veterans on an individual basis, the root cause of the problems remain so the next Joe that experiences the same problems must re-invent the wheel al over again.

        There is a built in system that is designed to correct VA Problems when they are reported to the Patient Advocate and entered into the Patient Advocate Tracking System (PATS) nationally. when there are enough similar problems corrective action to address the root cause is supposed to be taken. this does not happen. but this is just one of the many problems.

        I have requested the PATS reports that were filed at the Roseburg VA an tried to address this problem.

        Patient Advocate/VEO Sarah Cranston admitted in writing that VHA directives are not followed at the Roseburg VA!

        this is just one of the numerous examples of the failures that continue to plague Veterans seeing healthcare/treatment.

        Thanks for the reply A. your testimony, here, like most of the Veterans who write here continues to underscore the numerous failures of VA healthcare.

        with 65% of Veterans that utilize the VA system now being over 65 years of age, the problems will not be fixed. Delay, Deny, Lie until you die will continue to be the modus operandi of the VA.


  5. Please read OIG report 21-02492-77 dated February 9th 2022 lack of care and coordination and hepatocellular carcinoma surveillance of a patient at the VA Eastern Colorado Health Care system in Aurora. And you can see what the VA did to me five Primary Care Providers left me behind so now I need a liver transplant due to rupture and also see that they left other veterans behind as well. A systemic problem.

  6. Agree with most comments. Unfortunately policy set forth by former administration was rescinded by current administration that would have gotten rid of the lazy, institutionalized VA employees. As a veteran of Desert Storm I have encountered lazy people and was told “we are trying to replace that person, but the union is involved”. VA also has changed the way veterans are compensated.

  7. The VA OIG, this agency is a BAD JOKE, I contacted this group regarding six Federal Law violations done by employees of Ft Harrison VA, after 57 pages of documentation there answer is we do not have the resources available to do anything about your complaint. Yet, they have time and money to investigate under utilization of resources and employee protection, Have you ever tried to enter the VA Hospital, you have a better chance of entering the Kemlin than the VA, they treat the Veteran that served and protected them like they are the enemy instead of the patient, The VA is OF, BY and FOR the Employees that are the problem causers of the poor VA medical care for the Veterans that served and simply now trying to survive in the Hostile VA staff need to be fired and replaced with competent people not just employees that feel they have a job for life while mistreating us Veterans

    1. Agree with you John.
      Though it is not all about the employees a lot of the problems stem from the over regulation, the dinosaur agency, and just tyranny applied through in and through out. Healthcare is NOT supposed to be Cognitive Warfare and Physical Warfare. The whole healthcare system in and out of the VA is being used as a prison or a firing squad almost. Just look at the people harmed. The whole system is unacceptable in my opinion. It does not deliver in the way of health and recovery.
      People are better off seeing about themselves in some situations.

  8. Well, well, well, VA employees are finally getting a taste of what they’ve been doing to veterans for decades!
    Most of them are cry babies anyway!

    1. Crazy Elf
      you are correct.
      However, the VA leadership have always stepped on the employees though.
      A one and only one VA physician of VISN 8 excluding the Lake City VA did act in my best interest a few years ago. From that point on I was slammed to such a degree that I left.
      Came from the VA leadership. All the healthcare is politicized and it should not be. Most VA employees do as they are told. This is the problem. Many physicians and nurses go into the VA to make a difference but this rarely happens. The new VA employees get taken over by the group think. The group think deteriorates skills. Herd mentality reduces efficiency. Also they get taken over by the Compartmentalization which also contributes to inefficiency. All compartmentalization does is keep the VA employees protected under the AFGE union. Although in these instances big pharma companies could not be held accountable for deaths and harm from the vaccines. Recently the CDC finally admitted they were wrong about the vaccines. As for the mental health resources and or other resources, people have to already have developed their inner strengths to be able to hold up. When people are strapped into having to do under extreme situations, the extreme situations override the people if the inner strengths are limited. In order to practice the resources or to do the list of supports provided by OIG or whomever, one has to have the time to engage them. Then it comes down to survival, if the environment and or the responsibilities do not permit the time for the employees to engage, then they have to have already developed such internal strength in order to be able to survive and in order to treat veterans. All that is going on is for money at the expense of many lives. Morally wrong and inhumane. Some of the VA employees are good seeds among some bad seeds. Companies using Americans as experiments is both unethical and against the law. Companies should have not been given free reign. Accountability is important for everything. Lawlessness took over. I will say there is a big disconnect between the VA leadership and the VA employees. All people deserve respect regardless.

  9. The support for Veterans is so bad at the Cheyenne VAMC that the employees will NOT answer the phone so a Veteran can NOT get the help they need.

    I am still waiting to get paid travel from last October!!!!! The travel clerk said the system is backlogged 7 fricking months.

    In the new MISSION Act, it specifically has a paragraph devoted to travel. Goes something like this: ‘Pay faster and come to grips with reality and pay what the economy is rated at CURRENTLY not 1964!!!!!!!’

    Nuf sed.

    1. It’s the way the VA operates. Make it steadfastly difficult for veterans to receive travel pay in order to make them give up on applying for it. That’s the way they save money on treating veterans and produce more money in their bonus till.

  10. One thing to consider is that this covid, although real, has been a scam perpetuated on the entirety of the human race. If I don’t get vaccinated I’m 99% not going to die and 100% not going to suffer the 9 pages of side effects. So they took a non issue and created a pandemic causing all of us to suffer.

    1. C Fore you are right:
      The Covid 19 was a propaganda convincing brain washing of the public, it was also a tools to see how far they could create conditioning and fear so they just “say oh my government my government how great thou art. More people have DIED from the JAB than from the actual virus which is and was nothing more than the common flu ( the common flu kill over 58,000 people each year.) 126, 000 died from the JAB 84,000 from the associated virus effects not to mention the numbers of died and lame people from the side effects

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