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REPUBLICAN PRESS RELEASE

April 19, 2007

VA medical center’s problems offer lessons for VA-wide improvement

By Jeff Phillips, for more information contact (202) 225-3527

Washington, D.C. — Responding to reports of inadequacies in surgical services at a North Carolina Veterans Affairs (VA) Medical Center , a Subcommittee on Oversight and Investigations oversight hearing today found systemic procedural problems in patient safety and other components of health care management. Many of these problems have since been corrected; others are still a matter of concern.

“Whenever there are concerns over patient safety, Congress has an obligation to conduct oversight,” subcommittee Ranking Member Ginny Brown-Waite (R-Fla.) said. “I would expect that every VA facility interpret today’s hearing as a call for stronger medical safety procedures up front, rather than forcing action by Congress when systemic problems come to light. Quality of care for our veterans everywhere is my goal, and I am confident that the lessons learned at Salisbury will translate into better medical services in the future.”

In September 2004, VA’s Office of Inspector General (IG), because it was working at full capacity, asked the department’s Office of the Medical Inspector (OMI) to investigate an allegation of suspicious deaths in the surgical service at the Hefner VA Medical Center in Salisbury, N.C. The allegations, made on VA’s hotline that August, alleged that more than 12 deaths of surgical patients had occurred in the last two years.

The OMI issued its report in March 2005, finding serious mishandling of numerous cases and a litany of medical issues not addressed or solutions implemented. The OMI report made 18 recommendations, all accepted by VA’s health under secretary.

In September 2006, the department’s assistant inspector general, Dr. John Daigh, issued a combined assessment program review of Salisbury , but the team doing the review wasn’t aware of the 2005 OMI report, reducing its effectiveness. Daigh found that improvements had been made, a conclusion shared by Melvin Watt (D-N.C.) the congressman whose district includes the Salisbury medical center. (Daigh has since ensured that IG staff have full access to OMI reports and refer to them.)

Yet, while the problems at Salisbury, largely attributed by both Watt and Salisbury ’s current chief of staff to former facility management, have been largely corrected, systemic problems persist. Veterans’ Committee Chairman Bob Filner (D-Calif.) pointedly asked witnesses how VA employees are held accountable. “We’re talking about the deaths of human beings,” he said, decrying a bureaucratic system that impedes critical information from reaching those who have a right to know, such as patient family members, and those who can implement remedies.

Aggravating the problem, VA’s “peer review” system, which is supposed to facilitate the critique of clinicians by their peers, seems to be hobbled by fear. When asked by Brown-Waite if nurses feared that revealing problems with the performance of doctors could cost them their jobs, Daigh admitted the existence of such problems in some VA locations.

“While I was pleased that the Veterans Affairs Committee held this hearing to ensure that men and women get the best possible care at the Salisbury facility, the discussion of the hearing raised more questions for me,” said Robin Hayes (R-N.C), whose constituents include veterans using the Salisbury facility. I am concerned about some of the staffing and disciplinary policies currently practiced in Salisbury . It also took entirely too long to investigate these serious complaints. I look forward to working with the committee and the VA to address these issues.”

The lack of information to patients and to the general public in the wake of such reviews appears to be a systemic weakness within the department. Subcommittee member Brian Bilbray (R-Calif.), expressing concern shared by many in the subcommittee, urged VA to do a better job of providing information as quickly as possible.

“When it comes to our veterans, all gave some and some gave all and each and every one of our veterans deserve nothing but the very best quality of care,” Bilbray said. “Public reviews of our VA facilities must be 100-percent transparent so that we can get to the root of the problems and resolve them swiftly and effectively. Our veterans are the ones who suffer the most when the bureaucracy within the VA prevents an open and honest public review. I look forward to working with my colleagues to see to it that these weaknesses within the department are addressed, so that the men and woman who served our country will have the quality of care worthy of the sacrifices they have made.”

“Those of us in Congress are committed to ensuring that our veterans receive first class care and treatment,” said Howard Coble (R-N.C.), whose constituents include veterans using the Salisbury facility. “Today's hearing is an important first step to making sure that we care for those who have sacrificed so much for our country.”

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Larry Scott

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