VA failures persist after three secretaries
Administrations change, suffering stays the same
On the front lines at the Department of Veterans Affairs — in the agency’s 1,240 hospitals and clinics — it doesn’t much matter who holds the secretary’s job in Washington.
David Shulkin, who was fired Wednesday, was the third VA secretary in four years. If President Trump’s nominee to lead the agency, Navy Rear Adm. Ronny Jackson, is confirmed, he will be the fourth.
Each leader sought to fix the department, laying out visions and priorities — Shulkin’s top priority was “access,” making sure veterans got appointments when they needed them. His predecessor, former Procter and Gam-
ble CEO Bob McDonald, focused on staffing, training and veteran-centered customer service.
Year after year, critical deficiencies remain, and veterans bear the brunt of the failures. Here are some shortfalls that plague the system:
❚ Veterans are still waiting: In 2014, whistle-blowers in Arizona divulged that thousands of patients were backlogged at the Phoenix veterans hospital, and some of them died awaiting care. VA investigators determined that medical center administrators knew about the crisis, yet put out fraudulent waittime data to collect bonus pay.
A USA TODAY investigation in 2016 found supervisors instructed employees to falsify patient wait times at VA medical facilities in at least seven states.
A few weeks after Shulkin was sworn in last year, the VA inspector general released a report finding widespread inaccuracies in scheduling records at a dozen hospitals in North Carolina and Virginia. The records vastly understated how long veterans waited for appointments and prevented as many as 13,000 from getting VA-funded care in the private sector.
❚ Quality of care: The VA’s lowestperforming hospitals remained at the bottom of the pack on the agency’s internal quality measures for two years in a row. The VA regularly scores its medical centers based on dozens of quality factors, including death and infection rates, instances of avoidable complications and wait times. The agency uses a five-star scale.
Among the facilities that received only one star in 2015 and 2016 were VA hospitals in Phoenix and Memphis. One Memphis employee dubbed the facility a “house of horrors” when USA TODAY obtained internal documents revealing reported threats to patient safety soared in recent years from 700 to more than 1,000.
One veteran had to have his leg amputated after a VA provider left a piece of plastic tubing in a critical blood vessel during a procedure.
❚ Bureaucratic breakdowns: In Washington, the VA inspector general issued a rare emergency report last year saying patients were in imminent danger at the hospital. The facility had dirty sterile storage areas and regularly ran out of critical supplies needed for surgeries and other procedures, including patches to seal blood vessels and tubes for kidney dialysis.
Shulkin removed the hospital director and sent teams to try to fix the problems. An inspector general report released this month found that VA officials at every level — local, regional and national — knew about the problems for years but didn’t fix them.
Investigators found “a culture of complacency and a sense of futility pervaded offices at multiple levels.”
The inspector general singled out front-line workers at the Washington hospital, saying they went to great lengths to make do, and they may be the only reason no patients were harmed.
❚ Vetting failures: The VA has had persistent difficulties recruiting and keeping enough medical care providers to meet veterans’ needs.
In 2015, critical VA jobs, such as intake workers, doctors, nurses and assistants, went unfilled, a USA TODAY investigation found. Though the agency has made headway, there are still shortfalls. In some cases, that has created an incentive to hire medical care providers with problem records that may have prevented them from getting jobs in the private sector.
A VA hospital in Oklahoma knowingly hired a psychiatrist sanctioned for sexual misconduct who went on to sleep with a VA patient, according to internal documents obtained by USA TODAY. A Louisiana VA clinic hired a psychologist with felony convictions. The VA fired him after it determined he was a “direct threat to others” and the VA’s mission.
In a report released Monday, the inspector general found vetting failures go beyond medical providers. Investigators determined that the VA did not conduct required background checks on more than 6,000 employees, and managers failed to properly document and oversee background checks.
❚ Hiding shoddy care: A USA TODAY investigation found that the VA didn’t report to a national database a podiatrist who harmed 88 patients and took years to report him to state boards. By the time the VA told his patients, one of them, Army veteran April Wood, had decided to have her leg amputated after two failed surgeries by the podiatrist.