Debacle at the VA

“It was difficult to pinpoint precisely how the conditions described in this report could have persisted at the Medical Center for so many years.”

Thus begins the conclusion to the full report issued by the Department of Veterans Affairs’ investigative office, the follow-up to a scathing interim report issued one year ago about deficiencies at the Washington, D.C. VA Medical Center.

The interim report — issued quickly because of the dire situation — detailed dirty clean/ sterile storerooms, millions of dollars in supplies that hadn’t been inventoried sitting in a dirty warehouse with a parade of people wandering through, missing equipment, having to borrow surgical equipment at the last minute from other hospitals or cancel the surgery (sometimes after the patient had already been put under), lack of safety recall procedures that left expired items on the shelves, and much more. Now the full investigation has been completed.

VA Secretary David Shulkin quickly issued a press release itemizing all the great improvements made on problems in the interim report. They include establishing a new process for identifying potential supply shortages and a 24-hour hotline to procure those items. A sterile processing center will be completed in March 2019. Access to equipment and supplies in a warehouse now is restricted.

How, one wonders, does a surgical unit run out of the staplers that close an incision? How does a hospital emergency room run out of the thin tubes that deliver oxygen to the nose? How could outages in crucial supplies continue, six months after the interim report came out? And how, as recently as four months ago, could rusted instruments still be on hand?

So, do I trust the press release issued by the VA on the heels of the complete Office of the Inspector General report? No.

The annual budget for the VA OIG should be doubled. To review the whole 158-page report, go to www.va.gov/oig/pubs/VAOIG-17-02644-130.pdf.