Hospital director removed but will continue career with VA. Quality Management team arrives Thursday for further investigation.

NOTE from Larry Scott, VA Watchdog dot Org ... Yesterday we brought you the latest about the ongoing problems at the Marion, Ill. VA hospital.  That story here ...
http://www.vawatchdog.org/09/nf09/nfnov09/nf110309-3.htm

As the man on TV says:  But, wait!  There's more!

Now we learn that the hospital director has been removed ... but will continue his career at the VA (something wrong, here).  Also, a VA Quality Management (QM) team is moving in for further investigation.  And, VA Secretary Shinseki will have a face-to-face with concerned members of the Ohio Congressional Delegation (I would just love to be there and hear Sen. Dick Durbin go off on the Secretary).

We have three pieces of information.  First is an internal VA email explaining much of this (including praise for the outgoing director).  Then, two news stories.

Use our search engine for a complete background on the host of problems unearthed at the Marion VA ... here ...
http://www.yourvabenefits.org/sessearch.php?q=marion&op=and

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EDITOR'S NOTE:  This VA email came to me from a VA employee.

To: VHAMRNALLMRN; VHAMRNALLCBOC; VHAMRNALLEOPC; VHAMRNALLVAMCSTAFF

Subject: Message to all employees from the VISN 15 Director

As the VISN 15 Director, I want to inform you of some actions that will be taking place at Marion VAMC. Let me first say that I know that Marion VAMC is committed to the highest standards of care and professionalism, and to its mission of providing Veterans with quality health care in a safe and caring environment.

Recently the Office of Inspector General Combined Assessment Program (OIG CAP) review identified several recommendations with processes, but no questions regarding patient outcomes. The report included 10 recommendations with several focusing on quality management processes.

The Marion VAMC has made many quality improvements since August 2007, and I am committed to ensuring that this progress continues.

Mr. Warren Hill who has served as Director at Marion for the past 18 months has accepted and been approved for a new assignment within VHA. This assignment is very important to his professional development and his personal commitment to serving our Nation’s Veterans. Mr. Hill will remain at Marion to ensure a smooth transition to the new leadership. I am personally very grateful for Mr. Hill’s leadership and accomplishments at Marion during the last 18 months.

To assure leadership continuity, I have immediately secured and appointed a new medical center director to lead the Marion VAMC’s continuing efforts to enhance the quality of patient care.

James Roseborough, will lead the effort. Roseborough is returning to VA after retiring in 2008 as network director of the VA Great Lakes Health Care System. He previously served as director of VA medical centers in Ann Arbor Michigan, and Poplar Bluff, Missouri. He will arrive tomorrow.

A quality management team will arrive in Marion, Thursday, November 5. It will be lead by Dr. Luke Stapleton, Chief Medical Officer of Veterans Integrated Service Network (VISN) 7.

Thank you for your dedication to meeting the needs of our Veterans we are privileged to serve.

James R. Floyd

DIRECTOR, VISN 15

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Lawmakers want VA suspensions

BY BECKY MALKOVICH, THE SOUTHERN

http://www.thesouthern.com/news/local/article_d
bdbbfb4-c83a-11de-948c-001cc4c03286.html

MARION - Illinois lawmakers called for the immediate suspension of those "in the direct line of command" of VA Medical Center in Marion after a report critical of the facility was released Monday.

The report released by the Department of Veterans Affairs' Office of the Inspector General indicates ongoing issues with patient safety and quality care management at the hospital where the 2007 deaths of nine veterans were allegedly the result of surgical malfeasance resulting from poor leadership and communication.

"The Inspector General's report indicates that patient safety and quality care management at the Marion VAMC once again has fallen short of VA standards and guidelines. Simply put, we find this situation appalling," U.S. Sens. Dick Durbin and Roland Burris and U.S. Reps. John Shimkus and Jerry Costello said in a letter to the Secretary of Veterans Affairs.

"We would like to meet with you as soon as possible to discuss how to dramatically change course and return the quality of care at Marion to the highest standards. In the meantime, it is clear that those in the direct line of command in VISN (Veterans Integrated Service Network) and at the Marion facility have again violated the public's trust and should be relieved of their duties until serious questions over management can be answered."

The Inspector General's review covered five operational activities at the medical center, making compliance recommendations in four of those areas including quality management, physician credentialing and privileging, environment of care and medication management.

The center complied with selected standards in the fifth activity, which was coordination of care.

According to the report, the center had continued problems with mortality assessment, a patient safety program, outdated staff training, patient data analysis and peer review.

For example, three sets of documents showed three different death totals for April 2009.

Some of the findings are repeated from previous evaluations, although VA officials said steps have already been taken or are under way to make improvements at the hospital.

James Floyd, VA regional network director, spoke at a news conference in Marion shortly before the report was released to the public.

He said of the report's 10 findings, eight were already remedied, while the other two would be within the next two weeks.

He also announced the imminent departure of Marion director Warren Hill, who has taken a position in Wisconsin.

Hill has overseen operations at the Marion facility for the past 18 months and did "a terrific job here," Floyd said.

Retired VA employee James Roseborough will act as director for a period of one year, Floyd said, while a search for a long-term director is conducted.

Changes at the facility can't come fast enough for the lawmakers, who said care of the nation's veterans is a health care priority.

"This report from the VA Inspector General is shocking and must be addressed immediately," Costello said. "It is absolutely unacceptable that many of the quality management issues we learned about over two years ago have not been addressed. Particularly troubling to me is the fact that the VISN does not appear to be aware of what is going on at the facility. We need to know what the VA is going to do to solve these problems and restore the confidence of our veterans; it is not enough to simply say the VISN Director needs to ensure compliance, as this hasn't worked to this point. This situation needs to have the full attention of VA leadership - that is why we are asking for a response directly from Secretary Shinseki - and additional senior staff changes at Marion must occur. Obviously, this must be the top priority of the new facility director."

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Marion VA hospital issues to be aired in Congress

By Jacob Carpenter
Post-Dispatch Washington Bureau

http://www.stltoday.com/blogzone/political-fix/political-fix/200
9/11/marion-va-hospital-issues-to-be-aired-in-congress/

WASHINGTON — Veterans’ Affairs Secretary Eric Shinseki will walk into a room of angry Illinois members of Congress Wednesday morning.

Shinseki will meet with Sen. Dick Durbin, D-Ill., and other livid Illinois elected officials in Washington to address persistent problems at the Marion Veterans’ Affairs Medical Center, which were brought back to light by a VA’s inspector general report issued this week.

While the report isn’t quite as harsh as the findings of a January 2008 report — which found 10 examples of poor patient care given to patients who died, among other serious issues — investigators continue to find areas of inadequate care and protocol. The most glaring problems include:

– Two procedures done by employees lacking the proper credentials;

– Record-keeping inconsistencies about the hospital’s number of deaths;

– Inadequate documentation and review of patient cases;

– Inability to implement changes suggested in January 2008 report.

The 2008 report led to the removal of the hospital’s director, chief of staff, chief of surgery and anesthesiologist. The hospital still doesn’t perform major surgical procedures.

In a letter to Shinseki sent Monday, Durbin, fellow Illinois Democrats Sen. Roland Burris and Rep. Jerry Costello, as well as Illinois Republican Rep. John Shimkus, called the VA’s lapses “simply appalling.”

The four congressmen wrote that Marion VA hospital officials have “violated the public’s trust and should be relieved of their duties until serious questions over management can be answered.”

The VA inspector general’s report lists 10 recommendations for changes at the hospital. In a letter responding to the report, the hospital’s interim director, Warren E. Hill, agreed with every recommendation and said those changes would all be put in place by the end of November.

“VA Medical Center management had identified areas of improvement in most of these areas and was taking action to strengthen these programs,” Hill wrote. “We concur that these programs could be further enhanced through additional improvements.”

Shimkus sought to tie the problems in Marion to the debate over a public option in health insurance reform bills.

“It does speak to government-run,” Shimkus told reporters. “Everybody says government-run health care is great. The problems we’ve had with the VA are disastrous.”

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TOPICS: veterans, veterans' benefits, VA, Department of Veterans' Affairs, Marion, Ill.