VA staff plea: ‘Stop this ... incompetence’
Despite assurances, DC hospital still in decline
WASHINGTON – Employees at the Veterans Affairs hospital in Washington pleaded with the new VA secretary to take action as conditions at the facility have continued to deteriorate even after national leaders swept in more than a year ago, removed the hospital director and sent in patientcare experts to help.
Infection rates in veterans’ bloodstreams and in their urinary tracts went up instead of down. Patient satisfaction went down instead of up. Employee satisfaction tanked.
The hospital declined so much that a senior VA health executive put local and regional officials on notice last month that the situation is under investigation and more “leadership changes” could be in store, according to internal documents obtained by USA TODAY.
The group of anonymous employees showed little faith in the effort. They wrote to newly minted VA Secretary Robert Wilkie this week asking him to step in and finally fix the hospital that serves tens of thousands of veterans in the nation’s capital.
They noted an investigation concluded this year that VA managers at every level – local, regional and national – knew for years about dangerous conditions at the hospital but didn’t fix them. The VA inspector general found “a culture of complacency and a sense of futility pervaded offices at multiple levels.”
When the results were announced in March, VA officials said “significant improvement” had been made even as key quality indicators deteriorated, including rates of ventilator complications and patient safety scores.
“We ask you, our respected leaders, to stop this coverup and incompetence, to really care and live up to America’s promise to its Heroes,” the employees wrote to Wilkie and other top VA officials. “Enough is enough.”
The VA replied in an email Monday, saying the secretary forwarded their concerns to top VA health officials for consideration: “Thank you for your communication.”
Fearing the problems would be swept aside, the employees provided a copy of the correspondence to USA TODAY on the condition they not be identified because they fear retaliation.
VA spokesman Curt Cashour declined to answer questions about why the hospital has deteriorated but said VA officials are “taking additional measures to support the facility.”
“VA appreciates the employees’ concerns and will look into them right away,” he wrote in a prepared statement. “Veterans deserve only the best when it comes to their health care, and that’s why VA is focusing on improving its facilities in Washington and nationwide.”
The Washington VA hospital made national headlines in April 2017 when the agency’s inspector general issued a rare emergency report because conditions at the medical center put veteran patients in imminent danger and VA managers who knew about the problems hadn’t fixed them.
The operating room repeatedly ran out of equipment, including vascular patches to seal blood vessels and ultrasound probes to map blood flow. The facility had to borrow bone material for knee replacement surgeries. Investigators found that most of two dozen sterile storage areas were dirty.
Top VA leaders quickly removed the hospital’s director, set up an incident command post and sent teams of experts to help the facility.
But problems continued.
In June, the inspector general again found sterile storerooms that did not meet infection prevention or cleanliness criteria. In August, hospital staff reported running out of tubing for blood transfusions and oxygen. In September, the facility didn’t have staplers to close incisions for days.
In November, specialists from VA headquarters found stained and rusty medical instruments and bacteria in water used to disinfect them. The hospital repeatedly ran out of sterilization supplies and had to borrow them from a neighboring private-sector hospital, according to an internal report obtained by USA TODAY.
In January, the specialists found nearly a dozen “repeat findings,” including failures in surgical instrument tracking and quality assurance monitoring, another internal report shows.
The inspector general’s investigation concluded in March that local, regional and national VA officials had received 10 reports dating as far back as 2013 about sterilization and supply problems but hadn’t fixed them. “In interviews, leaders frequently abrogated individual responsibility and deflected blame to others,” the report said.
VA officials have asserted publicly for more than a year that things are being fixed. In May, the top health official at the time, Carolyn Clancy, testified at a congressional hearing that “substantial progress has been made.”
Clancy is the same official who wrote to leaders at the facility last month noting “continued deterioration in overall quality” at the hospital and “significant gaps causing concern.”