VA inspector general warns: DC Medical Center patients "at unnecessary risk"

At least this time veterans got a warning — some veterans, anyway. According to USA Today, the inspector general has reported that those veterans already at the Washington DC VA Medical Center are in “imminent danger” due to substandard care and facilities. The situation is so dire that Michael Missal felt it necessary to issue the warning before his inspection was complete:

Conditions are so dangerous at the Department of Veterans Affairs Medical Center in Washington, D.C., that the agency’s chief watchdog issued a rare preliminary report Wednesday to alert patients and other members of the public. …

His investigation, which stemmed from an anonymous complaint on March 21, found that during the past three years, there have been 194 reports that patient safety has been compromised because of insufficient equipment.

In fact, the team is still on site today as they issued this warning. The report itself does not use the words “imminent” or “danger,” but it makes the issue plain enough otherwise. “OIG has preliminarily identified a number of serious and troubling deficiencies at the Medical
Center that place patients at unnecessary risk,” the report states at the outset, while noting that they have yet to find specific “adverse patient outcomes.”

So what are the specific risks found by the IG? For one thing, 18 of the 25 supposedly sterile satellite storage areas for supplies are dirty, which seems like a pretty big risk. Five of these areas had mixed sterile equipment and supplies with dirty stock, and eight of them were improperly configured to prevent contamination from the floor. Nor was that all. Their dialysis unit ran out of dialyzer bloodlines on two different days last month, and had to borrow lines from a private dialysis provider to complete their work. USA Today perused the report and found more notable failures:

• In February 2016, a tray used in repairing jaw fractures was removed from the hospital because of an outstanding invoice to a vendor.

• In April 2016, four prostate biopsies had to be canceled because there were no tools to extract the tissue sample.

• In June 2016, the hospital found one of its surgeons had used expired equipment during a procedure

• In March 2017, the facility found chemical strips used to verify equipment sterilization had expired a month earlier, so tests performed on nearly 400 items were not reliable

Even when the VA facility in DC had appropriate supply levels, they had no mechanism to ensure that they were not expired or recalled. “In a VA facility with an approved inventory management system, reliable controls exist that can be used to determine whether the facility’s stock includes any recalled items and where such items are located,” the IG notes in the report, adding, “The DC Medical Center has no such system.” Why? Shouldn’t the central control within the VA help ensure that practices and procedures are used across the system?

The report indirectly answers that question by noting that current management has known of these issues, but has done little to nothing to correct them — even while the OIG team was on site:

The OIG determined that a site visit team from VA Central Office knew of the Medical Center’s deficiencies in medical supply and equipment management since at least January 2017. While Logistics personnel from the Veterans Integrated Service Network (VISN) and another facility were onsite when the OIG arrived at the facility on March 29, significant equipment and supply shortages continued, placing patients at risk.

After the OIG notified VHA of its preliminary observations and findings on March 30, VHA took additional actions, which included establishing an incident command center1
(now deactivated) and temporarily assigning an additional logistics chief, technicians, and VISN staff to the facility on a temporary basis. These actions are short term and potentially insufficient to guarantee the implementation of an effective inventory management system and address the other issues identified. Further, shortages of medical equipment and supplies continued to occur while the OIG was onsite, confirming that problems persisted despite these measures.

We are now rapidly approaching the four-year anniversary of the VA scandal that forced Secretary Eric Shinseki out, and it seems as though nothing much has changed at all in the single-payer VA system. David Shulkin just took over the VA in February, but he worked under former Secretary Robert McDonald long enough to have responsibility over this sorry state of affairs. And if conditions are this bad in the Washington DC VA facility, under the very noses of Shulkin and Congress, one has to wonder just how bad it gets in other facilities further from scrutiny.