Over the course of 158 pages, the Department of Veterans Affairs Office of Inspector General detailed “critical deficiencies” at a District of Columbia VA hospital that it called “pervasive and persistent” and which leaders failed to address.
The OIG, which conducted an investigation into the hospital, released a searing final report yesterday that said deficiencies often spanned many years but were not remediated by leaders at multiple levels within the VA.
The report detailed failures that included ensuring healthcare professionals had supplies and equipment when caring for patients, processing and sterilizing instruments, maintaining cleanliness, providing prosthetic devices and properly reporting patient safety events.
Despite all those problems, the investigation did not find evidence of adverse clinical outcomes, which it said was largely due to front-line providers who were committed to provide the best possible care to patients. They did so by borrowing supplies, improvising or personally ensuring patients received what they needed, the report said. The OIG made 40 recommendations for improvement, which the VA concurred with.
OIG issued Critical Deficiencies at the Washington DC VA Medical Center - Final report details findings of OIG inspection at the DC VA Medical Center following allegations that patients and assets were at risk https://t.co/Yl6QWbOm1c pic.twitter.com/b77mOmibdL— Veterans Affairs OIG (@VetAffairsOIG) March 7, 2018
The OIG released a preliminary report last April that said the hospital engaged in practice that put patients at unnecessary risk. In response, the VA removed the hospital's medical director, Brian A. Hawkins, from the position.
Yesterday, the Secretary of Veterans Affairs David J. Shulkin announced further leadership changes including a move by Bryan Gamble, M.D., who helped lead the Orlando, Florida, VA, to Washington to oversee a significant restructuring effort at three VA networks, including the one of which the D.C. hospital is a part. Shulkin also tasked independent healthcare management experts to conduct onsite, unannounced inspections of VA hospitals nationwide.
VA’s @SecShulkin outlined a series of major improvements undertaken at the @DCVAMC in the 11 months following a @VetAffairsOIG interim report that was critical of the medical center. https://t.co/UExmOxeZyw via #VAntagePoint pic.twitter.com/Kr0mDdxQQp— Veterans Affairs (@DeptVetAffairs) March 7, 2018
Among the findings by investigators revealed in yesterday’s report:
- Leaders failed to respond to warnings and ongoing indicators of serious problems that included sterilization lapses and equipment shortfalls at the medical center. Investigators described “a culture of complacency and a sense of futility [that] pervaded offices at multiple levels.”
- Clinicians put patients under anesthesia before realizing they didn’t have needed equipment. In some cases, they canceled procedures. In others, staff went to a nearby private hospital to borrow supplies.
- More than 1,000 boxes of unsecured documents that contained veterans’ information, including medical records, were uncovered in storage facilities, the basement and a dumpster.
The VA’s health system has been under a microscope since 2014, when news broke that patients in the system faced unacceptably long wait times for care. Investigations found that the VA’s method for recording wait times often underestimates how long patients wait for care In response, this week the VA launched a new site that allows patients to look up average wait times for appointments at VA hospitals in their area.