Blickwedel, Ted W.. - From: Blickwedel, Ted W.. Sent: Friday, January 26, 2018 3:06 PM To: Fisher, Michael RCS Deputy Directors; RCS District Directors; VHA 10RCS Action; VHA RCS District 1 Vet Center Directors; VHA RCS District 1 Zone 2 Counselors; VHA RCS District 1 Zone 3 Counselors; VHA RCS District 1 Zone 4 Counselors; VHA RCS District 1 Zone 1 Counselors; VHA RCS District 2 Zone 1 Counselors; VHA RCS District 2 Zone 1 Vet Center Directors; VHA RCS District 2 Zone 2 Counselors; VHA RCS District 2 Zone 2 Vet Center Directors; VHA RCS District 3 Counselors; VHA RCS District 3 Vet Center Directors; VHA RCS District 4 Counselors; VHA RCS District 4 Vet Center Directors; VHA RCS District 5 Counselors; VHA RCS District 5 Vet Center Directors Cc: VHA 10RCS Action Subject: RE: CHANGE NEEDED IN RCS QUANTITATIVE CLINICAL PERFORMANCE EXPECTATIONS Mike, In all due respect email is one of the best ways to continue this conversation. Not everyone is able be involved in town hall meetings and conference calls because of their over-demanding schedules, which is driven by the expectation to meet the RC5 clinical production numbers that is burning out counselors and therapists. have already received a multitude of responses from clinical staff all over the country who are stressed out and hurting on a number of levels due the productivity level expectations. It is unreasonable and unrealistic for clinicians to continue operating like this and still be able to stay healthy and have the adequate time they need to provide the best quality services that our veterans deserve. was literally in tears when reading some of the responses I received regarding how RCS counselors are being effected by the extreme duress they are experiencing because ofthe productivity standards FMLA leave, depression, burnout, medication protocols, looking for other employment, retiring early, etc.). So, I don?t think you really understand the magnitude of this problem. The production expectations need to change or else clinical staff are going to continue being adversely impacted which will ultimately result in our veterans not getting the kind of quality care they should. So, as you mentioned, ?improving how we explain the standards and why these standards exist? or ?finding new ways to discuss the how any why behind these standards? is not going to resolve this issue. Further, you indicated below about ?the problems that can occur when policies are implemented without having a graSp on the capacity of an organization, and that we must do our best to ensure nothing similar ever occurs in Well, it is already happening in RCS due to the new productivity and administrative standards and policies that have been promulgated over the last couple years, which has negatively impacted RCS counselors the way it has. Additionally, the feedback I am getting so far also indicates that clinical staff feels that the leadership does not care about them and their well?being because of all this, and that their concerns are not being genuinely addressed. Whoever is coming up with these production standards is seriously out of touch with what is happening in the field and how it is adversely impacting those of us who are doing the day?to?day therapeutic work. Consequently, there needs to be more than just talk about this. There needs to be action to make the actual changes that are necessary for the sake of RCS counselors and their well-being, which will give them the capacity to carry out the RC5 mission at an optimal level. The bottom line is the productivity expectations need to be reduced to a fair and reasonable level so this can be accomplished. 1 Istrongly encourage everyone to speak up and respond ?reply all? with your comments so your voices are heard. The enormity of this issue and its impact needs to be fully understand by all. This won?t happen if we 7 don?t share our concerns. This is a perfect opportunity to do so. Everyone needs to truly come together, both staff and leadership, so we can finally get real solutions. Hopefully, this will occur soon so this matter does not have to be elevated to the next level. Sincerely, Ted Blickwedel, LICSW Providence VET Center 2038 Warwick Avenue Warwick, RI 02889 401?739?0167 From: Fisher, Michael (10RCS) Sent: Friday, January 26, 2018 1:00 PM To: Blickwedel, Ted RCS Deputy Directors; RCS District Directors; VHA 10RCS Action; VHA RCS District 1 Vet Center Directors; VHA RCS District 1 Zone 2 Counselors; VHA RCS District 1 Zone 3 Counselors; VHA RCS District 1 Zone 4 Counselors; VHA RCS District 1 Zone 1 Counselors; VHA RCS District 2 Zone 1 Counselors; VHA RCS District 2 Zone 1 Vet Center Directors; VHA RCS District 2 Zone 2 Counselors; VHA RCS District 2 Zone 2 Vet Center Directors; VHA RCS District 3 Counselors; VHA RCS District 3 Vet Center Directors; VHA RCS District 4 Counselors; VHA RCS District 4 Vet Center Directors; VHA RCS District 5 Counselors; VHA RCS District 5 Vet Center Directors Cc: VHA 10RCS Action Subject: RE: CHANGE NEEDED IN RCS QUANTITATIVE CLINICAL PERFORMANCE EXPECTATIONS You bring up an important point in that we all need to find more ways to talk to each other, bring up and discuss issues, and most importantly find solutions. This was the one of the main reasons why we started and are continuing with National Virtual Town hall meetings every month where staff can ask any question they want. Data and productivity questions do come up every time I meet with Vet Center staff. It is something that I believe will always be evolving as we try new things, interpret data in different ways, or the environment of Veteran?s need changes. I recognize that there is concerns over productivity and we need to improve how we explain the standards and why these standards exist. We will start with getting rid of the color coding and find new ways to discuss the how and why behind these standards as we continue to review for improvements. We learned all too well in Phoenix several years ago the problems that can occur when policies are implemented without having a grasp on the capacity of an organization. We must all do our best to ensure nothing similar ever occurs in RCS. Also brought up in the letter was training. I agree that is this a priority that we cannot ignore. At the beginning of the fiscal year, we required all Districts to develop face to face training opportunities for all positions to be ready to implement when the final budget is approved by the President. We also required the Districts to increase training through technology (VTel, etc.). While we believe that we will get an increase in the final budget for FY18 we cannot bank on that and need to prepare for a possibility of not receiving additional funding. With that in mind, we have asked all Districts to tighten A the belt and only spend money on things that are absolutely required so we can focus resources to training staff. Moving forward, email is not the best way of continuing this conversation and this conversation must continue. RCS Leadership is currently setting up a National Readjustment Counseling Service VAPulse page. We will send out the login information for everyone to join in the next week and will continue this discussion. I look fonNard to hearing your continued thoughts on VAPulse. Thank you for the message and most importantly thank you all for what you do every day for Veterans, Service members, and theirfamilies. Michael Fisher Chief Officer Readjustment Counseling Service (1 ORCS) 202-461-6525 202-495-6206 Fax Michael.fisher6@va.qov From: Blickwedel, Ted W.. Sent: Thursday, January 25, 2018 12:24 PM To: RCS Deputy Directors; RCS District Directors; VHA 10RCS Action; VHA RCS District 1 Vet Center Directors; VHA RCS District 1 Zone 2 Counselors; VHA RCS District 1 Zone 3 Counselors; VHA RCS District 1 Zone 4 Counselors; VHA RCS District 1 Zone 1 Counselors; VHA RCS District 2 Zone 1 Counselors; VHA RCS District 2 Zone 1 Vet Center Directors; VHA RCS District 2 Zone 2 Counselors; VHA RCS District 2 Zone 2 Vet Center Directors; VHA RCS District 3 Counselors; VHA RCS District 3 Vet Center Directors; VHA RCS District 4 Counselors; VHA RCS District 4 Vet Center Directors; VHA RCS District 5 Counselors; VHA RCS District 5 Vet Center Directors Subject: CHANGE NEEDED IN RCS QUANTITATIVE CLINICAL PERFORMANCE EXPECTATIONS To All RCS Counselors Therapists, On January 18th I sent the message enclosed below to the RC5 Chief regarding the negative impact that quantitative clinical performance expectations have had on RCS clinicians stress, health, morale, burnout, etc.). This issue has already been addressed through the proper chain of command by a number of VET Centers in District 1, Zone 1; especially during the past several months and longer in some cases. However, the leadership has not responded to these concerns; which is imperative for the care and support of RCS counselors and therapists, as well as their ability under this current duress to continue being able to provide quality counseling and therapeutic services to our veterans at an optimal level. Consequently, since this does not appear to be getting resolved after going through the appropriate channels, I have decided on my own accord to further illuminate this issue in an open forum to all concerned in the hope that everyone at all levels can work together to rectify this in a positive and compassionate manner. The correspondence to the RC5 Chief below describes the issue in more detail and offers suggestions on how to remedy this. I also encourage you to express any concerns and provide any constructive solutions you might have to your VET Center Directors, Deputy and District Directors, and the RC5 Chief if this is relevant to your experience. Hopefully, this will be addressed by the leadership so there can be a healthy balance between quantitative measures at a reasonable level and the welfare of clinical staff. Sincerely, Ted Blickwedel, Providence VET Center 2038 Warwick Avenue Warwick, RI 02889 ?401?739?0167 From: Blickwedel, Ted W.. Sent: Thursday, January 18, 2018 4:46 PM To: Fisher, Michael (10RCS) Cc: Moreno, Debra M. Willis, Dale Miller, Allison B. Fortin, Rochelle LICSW, Furtado, Bernadette; DiCandia, :larisse Tarducci, Heather Curran, James Santilli, Paul Sherman, Jeanne Medina, Jose; Witherell, Holly Subject: FEEDBACK ON RCS CLINICAL PROCEDURES Mike, lam a retired Marine and combat veteran who has worked as a counselor at the Providence VET Center in Warwick, RI since January 2009. I have decided to retire early from RCS since the bureaucracy has degraded the ability of clinicians to properly perform their duties as counselors and therapists, which has negatively impacted the morale and welfare of VET Center staff. These concerns were addressed by our staff to Dale Willis who conducted a clinical site visit at our VET Center in September 2017. Dale even acknowledged that he consistently heard the same concerns from other VET Centers he had been to. So, this is something that is a widespread problem and not limited to just a handful of employees. However, it appears that none of the issues discussed have been attended to, which is critical for the well- being of clinical staff and ultimately the veterans we are here to serve. Consequently, I would like to offer feedback about this, as well as suggestions on how this might be resolved. The biggest issue is productivity expectations for counselors. It used to be 50% for overall productivity and 40% for direct service. This seemed to be a reasonable number; especially considering the time that is necessary for consultation, progress notes, treatment plans, assessments, dealing with emergencies and crises, ROI correspondence, and other administrative duties. Subsequently, a few years ago, the expectation increased to 60% and 50% respectively which was feasible, but pushing the upper limit. However, when the visit count number was added to the production expectation (86%?100% in percentage terms), that is when the difficulty for clinicians really began, especially due to the threats of negative action being taken for those who did not meet these expectations. Not only was it not possible for some counselors to attain, it has come at great cost for those that have. I personally have struggled on a number of .evels because of this, and have witnessed my peers? frustration and burnout. Some clinicians have even started a medication protocol to cope with their anxiety. This has resulted in an ethical dilemma with having to choose between focusing on the numbers the leadership wants or providing quality services to our veterans which we are primarily here for. These expectations force us to schedule appointments back to back on the hour every hour, having to account for cancelations and no-shows, which does not allow for adequate time to perform other duties mentioned above that are also expected. Further, this is not conducive to conducting appropriate trauma treatment that often requires 80-90 minute sessions to properly execute. Ultimately, the veterans suffer since they cannot be given the best care they deserve under these circumstances. This is compounded by the leadership continuing to increase our administrative duties that often times is redundant and unnecessary reconciling RCS visits against appointment schedules, adding more content to closing notes that is already contained in previous progress notes, filling out an extra checklist in the course of doing record audits when this information is already available in the electronic audit, etc.). So, we are either counselors or administrators. We cannot do both to extremes. There needs to be a healthy balance. Someone seriously needs to rectify this. Additionally, there is the issue of taking care of our clinical staff, which is deplorable. Counselors have been and continue to be negatively impacted by what has been previously described. All we see is lip service being given to this by the leadership without any action. We predominantly only hear about numbers, numbers, numbers, production, production, production; and hardly anything regarding quality services, cutting edge trauma treatment, self-care, etc. The only person I have seen try to do anything about this is Allison Miller who is the Associate District Director Counseling for District 1, Zone 1. She coordinated and conducted a self-care seminar via the teIe?conference network for clinical staff approximately a year-and?a-half ago because of concerns she had about the well?being of counselors. Also, it is amazing after the national Team Leader (Director) conference in Washington about two-and-a? half years ago that nothing has been done about the care and well-being of clinical staff from an institutional 4 standpoint; especially since there were apparently numerous accounts of VET Center Team Leaders during the conference who expressed being depressed, and some with suicidal ideation. Overall, this sends a message that the leadership does not care about RCS staff. It is both unacceptable and negligent, and needs to be resolved for the sake of all concerned. I am sure the leadership genuinely wants RCS to provide the best possible services to our veterans. However, it appears the priorities are currently misguided and backwards since there seems to be more emphasis on servicing the bureaucracy rather than the veterans and staff. I know you and the rest of the leadership are dealing with organizational politics and mandates which are most likely shaping the decisions you have to make. Part of the problem is that we at the lower echelons are not privy to what is driving RCS policies and guidelines, which gives us the appearance when left in a vacuum that the leadership is incompetent because of decisions which are made that are contrary to the common sense of what is needed to effectively perform our clinical functions while taking care of RCS counselors. We desperately need a course correction to fix all this, in order to enhance the well-being of clinical staff so thev can provide optimal care for the veterans who deserve the best services we can give them. What I have explained here is also the opinion of the vast majority of RC5 counselors I work with and who know in other VET Centers. Many of them are reluctant to voice their concerns about this due to a fear of adverse repercussions they might experience if they do so. I personally have lost faith in the system and its leadership at this juncture, and consequently, have decided that it is in my best interest to retire and possibly be involved in this line of work in another venue that truly fosters an environment where one can provide the best PTSD-related trauma treatment, and that actually demonstrates a sincere interest in the self-care of counselors. Hopefully, for all my colleagues and the veterans that RCS serves, the leadership will wake up and do what is necessary to appropriately resolve this situation. Otherwise, they have failed their clinicians and the veterans they are here to help. I thought long and hard about who I should include on this correspondence; especially since these concerns have been brought up before, but have apparently fallen on deaf ears without any response or resolution. Enough is Enough. The time for action is NOW. I have considered addressing this with Secretary Shulkin himself, as well as going to the media and/or sending this to all RCS Employees. I have not yet ruled that out, depending on how the RC5 leadership handles this. However, I have decided for the time being to give you the benefit of the doubt. So, I will be watching, waiting and listening to see how this goes. In conclusion, I recommend the following suggestions be considered by RCS to rectify these issues: 1. Modify the performance expectations to a reasonable level in order to minimize the stress of clinical staff and maximize their ?quality? performance eliminate or reduce the visit count to a feasible amount, go back to 50% for overall production 40% for direct service). 2. Have more emphasis on the care and well?being of clinical staff, to include creating a committee if needed to establish guidelines to ensure this is occurring. This could even include half or full day retreats for clinical staff on or off site at determined intervals. 3. Advocating for necessary appropriations to fund adequate training for counselors, which had significantly declined a few years ago. This also includes granting AA to attend training, which has become more difficult over the last 3-4 years. None of this should be contingent on ?quantity? of performance for liability reasons, as well as to enhance the professional development of all clinicians which ultimately benefits the veterans we serve. 4. Get feedback from the field before implementing any new policies or procedures which might adversely affect clinical services or the well-being of clinical staff. This would help optimize clinical performance and enhance the health and welfare of RCS counselors. Further, it will empower everyone to be vested and have a voice in the decision process which will boost morale. 5. In the future, hire only managerial staff at the District Level and above who have a clinical background and adequate clinical experience within the RC5 system, in order to preserve the proper VET Center culture and to ensure appropriate clinical functions can be performed which are not impeded by someone without a clinical background who might establish policies that have a negative impact on clinical operations. 5 Sincerely, Ted Blickwedel, LICSW Providence VET Center 2038 Warwick Avenue Warwick, RI 02889 401-739?0167