A recent investigation confirmed that Washington DC VA Medical Center officials knew about issues affecting patient health for years, yet did nothing. On Wednesday, the US Office of Inspector General (“OIG”) released a report detailing the DC VA facilities appalling conditions, citing a dangerous lack of supplies, wasted funds and threats to patient privacy.
OIG Michael Missal blames “failed leadership” and a “climate of complacency” during VA Secretary David Shulkin’s service as Under Secretary of Veterans Affairs for Health. Shulkin claims he never knew any issues existed.
As Shulkin clamors to hold on to his job, he is quickly replacing senior leaders in VA hospitals across the US. For the sake of our valued veterans, an immediate and complete overhaul is in order.
Report Details Dangerous DC VA Med Center Practices
In March 2017, an anonymous complaint prompted the OIG to inspect the Washington DC VA Medical Center, a hospital and four clinics that serves around 100,000 veterans (including Congress members).
Three weeks later, the OIG released a preliminary report on the investigation, describing “serious conditions that put both patients and federal government assets at risk.”
The April 2017 interim report outlined several unacceptable deficiencies at the DC VA Medical Center, including a critical lack of patient care supplies and equipment, unsanitary surgical supplies causing avoidable hospitalizations, and millions of dollars spent on supplies and equipment that were nowhere to be found.
Now, the OIG has released the final 158-page report detailing dangerous issues that affected hundreds of veterans between 2014 and the fall of 2017.
Top Four Findings from Latest VA Watchdog Report
#1. Leadership Failures Caused Severe System Deficiencies
Between 2015 and 2016, at least three VA program offices (Office of Network Support, National Program Office of Sterile Processing, and VHA Procurement and Logistics Office) knew of “serious, persistent deficiencies” that could affect patient care.
Several vital leadership positions in departments like Environmental Management Services, Logistics, Sterile Processing, and Prosthetics remained vacant for months to years. As of March 31, 2017, over 10,000 veterans were waiting for artificial limbs and hearing aids – some waiting months.
The OIG report found an “unwillingness or inability of leaders to take responsibility for the effectiveness of their programs and operations.”
The report states that at the time DC VA Medical Center Director, Brian Hawkins, failed to address problems and led the facility with a management style described as “exclusionary, nonresponsive, resistant and/or intimidating.”
In addition, according to communication policies, Shulkin should have learned of the Medical Center’s deficiencies. Yet, he claims he heard nothing about it.
#2. Absent Supplies, Sterile Instruments Endangered Patient Health
In at least 375 cases between 2014 and 2016, surgical suites consistently lacked the necessary supplies, sterile instruments, and equipment. This caused “prolonged or unnecessary anesthesia,” surgery cancellations (sometimes mid-surgery, after administering anesthesia), and extended hospital stays.
Doctors would occasionally rush over to nearby hospitals to borrow supplies mid-procedure. Half of the 375 supply problem incidents were never recorded in the VA patient incident tracking database.
#3. Poor Asset Control Wasted Millions
Poor internal controls and dysfunctional accounting systems allowed the DC VA Medical Center to spend $92 million in taxpayer dollars on overpriced supplies and equipment, paying no mind to whether the purchases were economical, necessary, or bought through prime vendor contracts.
Meanwhile, over 500,000 medical items (including 185 hospital beds, $25,000 in blood pressure cuffs, and $80,000 of refrigerators) sat uninventoried in an unlocked warehouse for years, allowing for duplicate purchases and more wasted dollars.
#4. Mishandled Records Jeopardized Patient Privacy
Investigators found 1,307 boxes of patient records in a dumpster and an unlocked off-site warehouse that contained sensitive patient-protected health information. Storing confidential patient information in unsecured locations is against policy and placed veterans at significant risk for identity theft and other potential abuse.
Shulkin Says “I Didn’t Know”
DC VA Medical Center officials knew about the issues for years. So, why was nothing done? VA Secretary Shulkin claims no one ever brought the problems to his attention.
As VA Under Secretary from March 2015 to February 2017, Shulkin should have received all local and regional complaints about operational issues or problems involving patient harm.
But Shulkin claims he “does not recall senior leaders’ bringing issues at the DC VA Medical Center relating to supplies, instruments, and equipment to his attention.”
Shulkin says the watchdog report’s findings are “a failure of every level,” and that similar problems “are happening at VAs across the country.” He thanked inspector general Michael Missal for bringing the issues to his attention last April and says he is acting immediately to repair the damage.
VA Senior Leaders Reassigned, Retired, Replaced
As his first priority, Shulkin says he is replacing leaders in Virginia, Maryland, New Hampshire, Washington, Phoenix, and California medical facilities. He has brought in 24 new directors over the last year.
Shulkin reassigned Joseph Williams, the Director for VA hospitals in Maryland, West Virginia and Washington. Both Marie Wheldon, Director of New Mexico, Arizona and California VA hospitals, and Michael Mayo-Smith, Director for the VA New England Healthcare System, retired.
Last April, Shulkin replaced DC VA Medical Center Director, Brian Hawkins, with Lawrence Connell, and hired over 50 new medical personnel.
Shulkin has also ordered:
- Immediate Washington VA headquarters restructuring
- Surprise audits of over 1,700 medical facilities
- Communication policy overhaul
- Immediate hiring for leadership vacancies
VA Secretary Fights to Keep His Job
Wednesday’s report is far from the first list of VA shortcomings occurring under the leadership of Shulkin.
In January, Shulkin caught slack when he announced plans to end the VA’s homeless veteran’s program and reallocate the program’s $460 million to other projects. Fortunately, diligent veterans’ advocates succeeded in convincing the VA to keep the HUD-VASH program.
Last March, Iowa Republican Senator Chuck Grassley busted VA officials for lying about Iowa VA hospital patient wait times.
Upon a showing that over 1,500 veterans were waiting more than 90 days for an appointment (537 waiting between 91 and 180 days), Shulkin replied, “I assure you that was not our intent and believe this was a case of misunderstanding between VA and committee staff.”
Just last month, an inspector general report claimed Shulkin improperly accepted Wimbledon tickets and used taxpayer funds to cover a $122,000 European trip. The report claimed Shulkin’s Chief of Staff, Viveca Wright Simpson, altered documents to show Shulkin’s wife was an ‘invitational traveler,’ authorizing taxpayer dollars to fund her $4,000 travel costs.
OIG Missal Blames Senior Leaders’ Complacency
“Failed leadership at multiple levels within VA put patients and assets at the DC VA Medical Center at unnecessary risk and resulted in a breakdown of core services,” Missal said. “It created a climate of complacency … That there was no finding of patient harm was largely due to the efforts of many dedicated health care providers that overcame service deficiencies to ensure patients received needed care.”
“It was difficult to pinpoint precisely how the conditions described in this report could have persisted at the medical center for so many years,” Missal said, adding “Senior leaders at all levels had a responsibility to ensure that patients were not placed at risk.”
As American taxpayers, we pay our hard-earned dollars to ensure that our military men and women are guaranteed quality medical care. The disgraceful wait times, dangerous hospital conditions and inexcusable carelessness regarding patient privacy are completely unacceptable.
Our nation’s veterans deserve prompt, high-quality care. We certainly hope to see some serious improvements in the very near future.