Last week Massachusetts officials published a report about one of the worst failures of our state’s Covid-19 response so far: the deaths of dozens of elderly veterans at the Soldiers’ Home in Holyoke, Mass. in late March and early April, at the height of our coronavirus outbreak here. 

The report is worth compliance and audit professionals’ attention, because it explores a critical issue to corporate governance today. How does an organization fail to respond to changing risks, and consequently invite disaster? 

We can begin with Bennett Walsh, director of the Soldier’s Home from 2016 until he was suspended from that role on March 30. Walsh was a retired lieutenant colonel from the Marines. He had no experience in healthcare administration when he took the job. Rather, he was a political hire, with family and friends who had deep ties to Western Massachusetts politics.

leadership

Walsh

Walsh’s tenure was tumultuous. The home’s senior management team resigned during his four years there, including several successor hires who had replaced the first wave of departures. Walsh also left vacant the deputy superintendent’s job — a critical role that even Walsh himself said was responsible for day-to-day management of the home — from last summer clear through the Covid-19 crisis this spring. 

The independent investigation found numerous safety lapses among the staff, too. For example, even as patients and staff started testing positive for the virus, staff were still allowed to “float” among various wards at the home, increasing the risk of contagion. Nor did the staff move in a timely manner to close common spaces such as recreation rooms.

One egregious step happened on March 27, when the chief nursing officer decided to consolidate two wards of dementia patients. Each ward had some patients sick with Covid-19, others not. Rather than isolate all the covid-positive patients, however, the staff put infected and healthy alike into one crowded space. So instead of reducing infection risk, the staff increased it.  

The investigation also found incomplete documentation and record-keeping, which began long before coronavirus arrived. So even if staff had wanted to, say, transfer critically ill patients to a local hospital, or not intubate someone who had signed a do-not-resuscitate order, they lacked the data to take such steps quickly.

The report has plenty more details like that, and for people working in long-term care, reading all 174 pages might be worthwhile. The rest of us can already see the looming question here. 

What is the connection between poor organizational oversight and the inability to change procedures as a risk gets worse?

Because that’s a threat that could affect any organization at all. 

The Role of the Leader

What struck me most as I read the report was the game of hot potato that so many Soldiers’ Home executives seemed to play when asked about decisions that, in hindsight, seem terrible. Everyone was not involved, not consulted, not aware — and yet, clearly those terrible decisions were made, because they happened. So how were such terrible decisions allowed to stand? 

Holyoke home

The Soldiers’ Home in Holyoke, Mass.

I can appreciate that some Soldiers’ Home executives might want to be evasive in their answers; the report accuses Walsh himself of making false statements to investigators. I also appreciate that chronic staffing shortages make the management of nursing homes worse. 

But something deeper is amiss here. The report depicts a culture of dysfunction. Indirectly, that says a lot about the role of the leader to prevent a culture of dysfunction. 

To my thinking, one sentence on Page 15 of the report captures the mess perfectly: “The clinical staff made the wrong clinical decisions, and Walsh failed in his duty to oversee them and ensure a robust decision-making process.”

Ensure a robust decision-making process — that’s the whole ballgame, right there. Walsh failed at the task. Many senior executives do. 

Several things need to exist for a robust decision-making process. They are:

  • Complete and accurate data for the question you’re considering
  • Personnel trained and competent in their judgment
  • A cohesive corporate culture where employees speak up about things at risk
  • A structured, rigorous process executives use to make actual decisions

Without those four elements, an organization makes bad decisions. Many people within the enterprise might even be trying to make the right decisions — for example, I bet that chief nursing officer believed she was doing her best when she consolidated the two dementia wards — but at best, those good decisions will be scattershot moments of luck. Any organization that lacks the four elements above will, over time, see its decision-making ability degrade. 

That’s all the more true in environments such as we see today, where Covid-19 is scrambling our standard risk scenarios radically. What becomes paramount in those situations is trust among the team, openness to hearing new information, wisdom when making judgment, and a methodical process for doing so.

Will having those four elements mean a company can glide through the Covid-19 crisis unscathed? No. Many organizations will have a wise leader who cultivates these four elements and they’ll still suffer, and perhaps fail. But your odds of finding a better solution to these times — a sustainable process to weather our unpredictability — will go up dramatically. 

Back to Compliance, Audit, and Risk

So when I read in the report that Walsh drove away experienced clinical staff who should have been his lieutenants, I winced. When I read about staffers’ fears of retaliation for speaking up, and Walsh’s habit of petty slights and inattention to detail, I winced. Walsh was utterly out of his depth as leader for the Soldiers’ Home, and dozens of veterans died as a result.

Again: How was that situation allowed to linger for so long?

Lack of oversight, time and again. That’s what let Walsh linger in a role he never should have had, and the organization underneath him went to rot.

This is where audit and compliance executives can start to see the role they can play in your own organizations, to avoid the disaster that happened at the Soldiers’ Home. What corporate enterprises need is effective oversight, at multiple levels, all the time. 

Urena

The chief nursing officer consolidated the two dementia units because Walsh failed to question the wisdom of that decision. Walsh let the corporate culture and competency at the Soldiers’ Home fall apart because his boss, Massachusetts secretary of veterans services Francisco Urena, failed to oversee him. (Gov. Charlie Baker ousted Urena last week, one day before the Soldiers’ Home report was published.) 

Just as bad, in 2016 the state established a new role, executive director of veterans homes, to be led by somebody who had at least five years’ experience in healthcare management. That person was supposed to be a resource to help hapless leaders like Walsh, or at least investigate them and raise alarms about mistreatment. 

Except, Urena decided state lawmakers didn’t appropriate enough funding to fill that role, so nobody has ever held it. 

So one lesson is that compliance and audit executives can identify “oversight deficit” in your own organizations, and raise alarms as necessary. This might be a task best suited to audit executives, since you report to the audit committee, but you see my broader point here. 

Compliance and audit professionals can be a bridge between employees who toil under poor leadership and the overseers who, ideally, care about removing poor leaders. All the work you do to assess internal controls, policies and procedures, corporate culture — that’s supporting evidence for the arguments you might someday need to make. 

The good news is that most CEOs recoil at a leader with Walsh’s shortcomings; he represents everything good leaders dread and want not to be. Those good leaders will want a strong audit or compliance function that can help them avoid that fate. 

The bad news is that CEOs like Walsh do still exist. And the worst news is that here in Massachusetts, we didn’t wake up to the threat until it was already too late for veterans who died a death they didn’t deserve.

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