Inspector General confirms: VA center in DC has chronic "failures to consistently deliver timely and quality patient care"

Plus ça change, plus c’est la même chose. The VA’s inspector general has released a final report on the status of the system’s center in the nation’s capital after having first issued an interim report nearly a year ago. Nothing much has changed since, according to the IG:

A report from the Department of Veterans’ Affairs inspector general found that the Washington DC VA Medical Center has for years “suffered a series of systemic and programmatic failures to consistently deliver timely and quality patient care,” and heightening the potential for waste, fraud and abuse of government resources.

The report released Wednesday found that the main health care facility for veterans in Washington lacked consistently clean areas for medical supplies, had staffing issues across multiple departments and that approximately $92 million in supplies and equipment were purchased over a two-year period without “proper controls to ensure the purchases were necessary and cost-effective.” …

In the report detailing the troubling conditions at the VA hospital, Missal faults “failed leadership at multiple levels within VA that put patients and assets … at unnecessary risk.”

These problems existed at the most visible VA facility in the nation without any significant action taken to deal with them despite years of warnings, the IG found. For a significant part of that time, current VA Secretary held the #2 position in the department, but told the IG that he’d never heard about the problems at the facility closest to his office. The IG sounds skeptical about that claim:

With respect to the managerial and administrative deficiencies at the Medical Center outlined in this report, at least three Program Offices—the Office of Network Support,157 NPOSP, and the VHA Procurement and Logistics Office—had information sufficient to inform the Under Secretary for Health (USH) that serious, persistent deficiencies existed within the Medical Center that could potentially impact patient care. In a 2017 interview with OIG staff, VA Secretary David Shulkin indicated that when he was the USH from March 2015 to February 2017, he expected significant issues involving patient harm or operational deficiencies to be raised through the “usual” communication process.158 Secretary Shulkin told interviewers he does not recall senior leaders’ bringing issues at the Medical Center relating to supplies, instruments, and equipment to his attention while he was the USH.

In other words, despite his appointment in March 2015 to a department beset with scandal and failures, Shulkin apparently never bothered to ask whether performance was improving. Instead, he just expected the same bureaucracy that had committed fraud and malfeasance to self-report its failures. That’s an astounding statement, perhaps one of the more brazen attempts to pass the buck one can imagine — especially given this center’s proximity to Shulkin’s office. Wasn’t he at least curious enough to visit the center and ask its employees how things were going?

Since Shulkin wasn’t terribly curious about the performance at the DC VA, the OIG report brings him up to date on what he missed:

The OIG found widespread and formidable inadequacies in many essential functions at the Medical Center that contributed to the deficiencies described in this report, including

  • The inability to consistently provide supplies, equipment, and instruments to patient care areas when needed;
  • Ineffective sterile processing contributing to delays or postponements of procedures due to unavailable usable instruments;
  • The lack of consistently clean storage areas for medical supplies and equipment;
  • The failure to accurately and consistently track and trend patient safety events;
  • Excessive vacancies in leadership positions and other pervasive staffing issues across multiple departments, including Logistics, Prosthetics, Sterile Processing, and Environmental Management Services;
  • More than 10,000 open and pending prosthetic and sensory aid consults as of March 31, 2017, causing some patients to wait months for needed items;
  • Financial and inventory systems producing inadequate data, lacking effective internal controls, and yielding no assurances that funds were appropriately expended;
  • Approximately $92 million in supplies and equipment being charged to purchase cards over a two-year period without proper controls to ensure the purchases were necessary and cost-effective;
  • Underutilization of the prime vendor contract that was designed to purchase supplies at more favorable prices;
  • More than 500,000 non-inventoried items maintained in an inadequately secured warehouse; and
  • Patient protected health information (PHI) and personally identifiable information(PII) stored in unsecured areas.

The dollar figure on unauthorized purchases leaps out from this list. One center spent $92 million on supplies and equipment over two years — on a credit card? How did Shulkin miss that while serving as the VA’s second in charge? Put together, this list paints a portrait of a medical center offering substandard care and an executive team that couldn’t be bothered to find out about it.

The advocacy group Concerned Veterans for America blasted the VA for its failures and inaction, renewing its call for full choice of care for veterans:

“This is yet another disgraceful instance of a VA medial center not only failing to provide safe, reliable care to patients, but also failing to address it for months and years on end. As in other cases, staff on the ground also failed to report many of the safety lapses or tried to downplay. Worse, VA officials received reports of these lapses and did nothing for years.

“This case is exactly why we our grassroots army is working every day to pass legislation to expand health care choices for veterans.”

It also demonstrates that the current leadership at the VA will never be part of the solution. Shulkin has other issues, too, but his casual “no one told me about it” attitude should be grounds for immediate disqualification alone. Donald Trump has to make a choice between veterans and an Obama holdover that should have been shown the door a year ago. Let’s hope he gets it right this time.