Mismanagement inside the department of veterans affairs

[boardman]

Mismanagement inside the department of veterans affairs
According to a March 25, 2013 Department of Veterans Affairs (DVA) Memorandum (Subject – Allegations of Mismanagement of the GI Clinic, Dorn VAMC Columbia, South Carolina) from an Administrative Investigation Board (AIB) to the Deputy Under Secretary for Health for Operations and Management:

Background – during the summer of 2012, VHA Central Office became aware of a facility disclosure concerning a cancer patient whose treatment was delayed due to a backlog in Gastroenterology (GI) Clinic appointments.

In response to the issue identified above, the AIB conducted a site visit at the facility and interviewed 22 witnesses. Five specific questions were posed and based on the facts conclusions were drawn and recommendations made by the AIB.

For a copy of this report go to i2.cdn.turner.com/cnn/2013/images/11/20/aibreport.pdf or contact Fred Elliott at felliott@rochester.rr.com


On September 6, 2013 the DVA Office of Inspector General issued Report No. 12-04631-313, Healthcare Inspection, Gastroenterology Consult Delays William Jennings Bryan Dorn VA Medical Center Columbia, South Carolina.

Executive Summary: The VA Office of Inspector General Office of Healthcare Inspections conducted a review to evaluate policies and practices related to gastroenterology (GI) consult and resource management at the William Jennings Bryan (WJB) Dorn VA Medical Center (the facility) in Columbia, SC. The purpose of the review was to determine whether deficient practices contributed to or caused delays in care, and whether facility leaders appropriately addressed clinical managers’ concerns.

We substantiated the allegations and found additional factors that contributed to the events. Veterans Integrated Service Network (VISN) and facility leaders became aware of the GI consult backlog in July 2011 involving 2,500 delayed consults, 700 of them “critical.” A funding request was made at that time and the VISN awarded the facility $1.02M for fee colonoscopies in September 2011. However, facility leaders did not assure that a structure for tracking and accountability was in place and by December, the backlog stood at 3,800 delayed GI consults. The facility developed an action plan in January 2012 but had difficulty making progress in reducing the backlog. An adverse event in May 2012 prompted facility leaders to re-evaluate the GI situation, and facility, VISN, and Veterans Health Administration leaders aggressively pursued elimination of the backlog. This was essentially accomplished by late October 2012. However, during the review “look-back: period, 280 patients were diagnosed with GI malignancies, 52 of which had been associated with a delay in diagnosis and treatment. The facility completed 19 institutional disclosures and 3 second-level reviews are still pending. As of May 2013, nine patients and/or their families had filed lawsuits.

A confluence of factors contributed to the GI delays and hampered efforts to improve the condition. Specifically, the facility’s Planning Council did not have a supportive structure; Nursing Service did not hire GI nurses timely; the availability of Fee Basis care had been reduced; low-risk patients were being referred for screening colonoscopies, thus increasing demand; staff members did not consistently and correctly use the consult management reporting and tracking systems; critical VISN and facility leadership positions were filled by a series of managers who often had collateral duties and differing priorities; and Quality Management was not included in discussions about the GI backlogs.

The GI consult backlog has been the subject of multiple reviews and recommendations, and overall, the conditions have improved and the GI backlog has resolved. However, continued vigilance is needed to ensure that the conditions do not recur. We recommend that the VISN, in accordance with the Administrative Investigative Board conclusions and recommendations, take appropriate action in relationship to facility leadership deficits contributing to the GI consult backlog. The VISN Director concurred with our recommendations and provided an acceptable action plan. We will follow up on the planned actions until they are completed.

For a copy of the full report go to i2.cdn.turner.com/cnn/2013/images/11/20/dornscigreport.pdf or contact Fred Elliott at felliott@rochester.rr.com
Mismanagement (continued)

Less than three months after the IG report was issued, CNN Investigations reported the following:

Because of long waits and delayed care, military veterans are dying needlessly. According to documents obtained by CNN and interviews with numerous medical experts, the DVA is aware of the problems and has done almost nothing to effectively prevent veterans from dying from delays in care. At the Dorn VAMC in South Carolina, veterans waiting for simple GI procedures have been dying because their cancers are not caught in time. The VA has confirmed six (6) deaths at Dorn due to delays. However, that number could be twenty or more according to sources close to the investigation.

A million dollars in taxpayer money was appropriated to Dorn to correct the problems but only a third of those funds were used to pay for care for veterans on a waiting list.

In a statement to CNN the VA said, “The Department of Veterans Affairs is committed to providing the best quality, safe and effective health care our Veterans have earned and deserve. We take seriously any issue that occurs at one of the more than 1,700 health care facilities across the country. The consult delay at Dorn VAMC has been resolved.”

The full CNN article can be read at www.cnn.com/2013/11/19/health/veterans- ... index.html or by contacting Fred Elliott at felliott@rochester.rr.com


On November 22, 2013, two days after the above CNN Investigations report, CNN Investigations reported a public apology by Robert Hamilton, the director of the Charlie Norwood VAMC in Augusta, Georgia. The VA confirmed that three veterans died as a result of delayed care. Internal documents at that facility showed a waiting list of 4,500 patients.

Director Hamilton told CNN, “We reviewed a total of 80 cases and after careful review of both internally and externally into our organization we found that seven were related to a delay in care.” When CNN asked if more veterans might be dead or dying due to delays of care at Norwood, Director Hamilton said, “We’ve had no additional fatalities at this point, and we are not aware of any additional requirements for any institutionalized disclosures based on the evidence.”

The full CNN article can be read at www.cnn.com/2013/11/22/health/veterans- ... index.html or by contacting Fred Elliott at felliott@rochester.rr.com


In a January 2014, CNN reported that members of Congress visited the Dorn VAMC in South Carolina and the Norwood VAMC in Georgia to demand answers about the veterans who died at those facilities. The delegation was led by House Veterans Affairs Committee Chair, Jeff Miller of Florida. Representative John Barrow of Georgia stated that, “Our goal here today is to try to get to the bottom of what happened and to prevent this from ever happening again. What’s important (is for) folks to understand this is just one step of a multistage affair to get to the bottom of what happened and to hold accountable those who were responsible”.

The Veterans Affairs Committee has been looking into problems at VA medical centers for the past year and says the VA administration continues to stonewall and withhold information the congressmen believe is critical to understanding why the VA appears to be run so poorly. The VA has also refused CNN’s repeated requests to interview Secretary of Veterans Affairs Eric Shinseki or any other VA official on camera.

Chairman Miller said the practice at VA seems to be to hold no one accountable for errors, and instead transfer poorly performing executives and employees to other facilities instead of firing them.

The full CNN article can be read at www.cnn.com/2014/01/07/health/congress- ... index.html or by contacting Fred Elliott at felliott@rochester.rr.com
Mismanagement (continued)

CNN reported on January 30, 2014 that the VA did issue a written statement from Dr. Robert Petzel, the Under Secretary for Health at the Department of Veterans Affairs. In part, Dr. Petzel stated, “As a result of the consult delay VA discovered at two of our medical centers, the Veterans Health Administration (VHA) conducted a national review of consults across the system. We have redesigned the consult process to better monitor consult timeliness. We continue to take action to strengthen oversight mechanisms and prevent a similar delay at another VA medical center. We take any issue of this nature extremely seriously and offer our sincerest condolences to families and individuals who have been affected and lost a loved one.”

The full CNN article can be read at www.cnn.com/2014/01/30/health/veterans- ... re-delays/ or by contacting Fred Elliott at felliott@rochester.rr.com


On February 3, 2014, the House of Representatives passed H.R. 357, the G.I. Bill Tuition Fairness Act of 2013. This bipartisan bill would, in addition to improving veterans’ educational benefits, provide for some accountability at VA. The bill will, among other things, create a five year ban on performance bonuses for VA Senior Executive Service employees and establish more comprehensive reporting requirements for VA employees traveling abroad.

The Senate companion bill, S. 257, sits with the Senate Committee on Veterans Affairs.

To read the full text of either bill, Google H.R. 357, S. 257, or “The G.I. Bill Tuition Fairness Act of 2013.


The Department of Veterans Affairs Management Accountability Act of 2014 was introduced in both the House and Senate on February 11, 2014. Representative Jeff Miller of Florida introduced the bill in the House (H.R. 4031) and Senator Marco Rubio of Florida introduced the companion bill in the Senate (S. 2013).

These bills are important because DVA senior executives who presided over negligence and mismanagement are more likely to have received a bonus or glowing performance review than any sort of punishment. Despite the fact that multiple VA Inspector General reports have linked many VA patient care problems to widespread mismanagement within VA facilities, and GAO findings that VA bonus pay has no clear link to performance, the Department has consistently defended its celebration of senior executives who presided over these events, all the while giving them glowing performance reviews and cash bonuses of up to $63,000.

H.R. 4031 / S. 2013 will amend Title 38 United States Code (U.S.C.) and give the Secretary of the DVA authority to remove employees of the Senior Executive Service, whose performance the Secretary believes warrants removal, from the government service completely or transfer them to a General service position within the current civil service program.


Officials of the American Legion met with Thomas G. Lynch, M.D., VA’s assistant deputy under secretary for health and clinical operations on April 24th. In response to questions posed by attendees, Dr. Lynch provided no useful answers. When asked about the Phoenix facility’s secret list, he said it was created because some VA employees didn’t use electronic wait-list software correctly.







Mismanagement (continued)

It is these types of responses from the leadership at VA that erode veterans’ confidence in the system. But, no worries, Congress is going to hold hearings to resolve these issues. When you ask, why as soon as VA’s Office of Inspector General completes its latest investigation which is now under way. I don’t know about you, but I don’t expect any changes or fixes until after the November elections, if then. Cynical ? Maybe, but I think it’s a realistic attitude given VA’s and Congress’s track records.

What can we do ? We can send letters/emails to VA Secretary Shinseki at…no wait, he’s part of the problem and will likely only spout the “company line”. So let’s skip him.

Instead we can send letters/emails to Senators Schumer and Gillibrand. Senator Schumer can be reached electronically at www.schumer.senate.gov/Contact/contact_chuck.cfm ; Senator Gillibrand can be electronically contacted at www.gillibrand.senate.gov/contact/

Our representatives are either Dan Maffei (24th District – Wayne County) at https://maffei.house.gov ; Louise Slaughter (25th District – Monroe County) at www.louise.house.gov ; or Chris Collins (27th District – Genesee, Livingston, Ontario, Orleans, and Wyoming Counties) at https://chriscollins.house.gov

When you contact your Senators, ask them to support senate bill S.257 – G.I. Bill Tuition Fairness Act of 2013 and S.2013 – The Department of Veterans Affairs Management Accountability Act of 2014. Tell them why you feel they should support those bills; let them know that you are a U.S. Military veteran; and be polite but firm.

Once you have determined which Congressional District you live in, contact your Representative and ask him to support house bill H.R.357 – G.I. Bill Tuition Fairness Act of 2013 and H.R. 4031 – The Department of Veterans Affairs Accountability Act of 2014. Tell them why you feel they should support those bills; let them know you are a U.S. Military veteran; and be polite but firm.

SAMPLE LETTER/EMAIL

Dear Senator/Representative ________,

I am requesting you to add your support to Senate/House Bill S.257/H.R.357 the G.I. Bill Tuition Fairness Act of 2013. Passage of this bill and its companion in the Senate/House will be a major step towards accountability at the Department of Veterans Affairs. The bill seeks to place a five year ban on bonuses for VA Senior Executive Service employees and to require more comprehensive reporting requirements for VA employees traveling abroad. In light of the recently discovered “secret list” at the Phoenix VAMC and the delays in consults that led to the deaths of some 40 veteran patients and the deaths at other VA facilities, it is important to stop these bonuses that have no connection to performance.

Additionally, I am requesting you support Senate Bill S.2013/House Bill H.R.4031, The Department of Veterans Affairs Management Accountability Act of 2014. Passage of this Bill and its companion bill in the Senate/House will amend Title 38 U.S.C. and give the Secretary of the DVA authority to remove employees of the Senior Executive Service whose performance the Secretary believes warrants removal.

These bills are important because DVA senior executives who presided over negligence and mismanagement are more likely to have received a bonus or glowing performance review than any sort of punishment. Despite the fact that multiple VA Inspector General reports have linked many VA patient care problems to widespread mismanagement within VA facilities, and GAO findings that VA bonus pay has no clear link to performance, the DVA has consistently defended its celebration of senior executives who presided over these events.

Your Name
U.S. Armed Forces Veteran

[boardman]

Department of Veterans Affairs Under Secretary for Health submits resignation

VA Department of Veterans Affairs
Office of Public Affairs
Media Relations
Washington, DC 20420
(202) 461-7600


WASHINGTON (May 16, 2014) -- Secretary of Veterans Affairs Eric K. Shinseki made the following statement:

"Today, I accepted the resignation of Dr. Robert Petzel, Under Secretary for Health in the Department of Veterans Affairs.

As we know from the Veteran community, most Veterans are satisfied with the quality of their VA health care, but we must do more to improve timely access to that care.

I am committed to strengthening Veterans' trust and confidence in their VA healthcare system.

I thank Dr. Petzel for his four decades of service to Veterans."