From Military.com:
“Leadership Hasn’t Done Enough
to Protect Patients at the VA, Watchdog Says”
Last summer, a veteran in Las
Vegas died by suicide two hours after he was discharged from a Department of
Veterans Affairs inpatient mental health facility, despite having told a family
member while he was hospitalized that maybe he "should just die."
An investigation found that the
facility failed to address the patient's complaints and didn't flag him as high
risk. Furthermore, the facility didn't fully examine the circumstances that led
to the death and never listed it as a "sentinel event" -- in effect,
hiding the death from scrutiny up the leadership chain, according to the VA's
Office of Inspector General.
In the past five years, the
Veterans Health Administration has grappled with several high-profile patient
safety issues, including the murder of seven veterans at a Clarksburg, West
Virginia, VA hospital; an alcoholic pathologist who went unchallenged on his
job, resulting in 3,000 diagnostic errors; and a VA gynecologist who made
graphic and lewd comments to patients while conducting pelvic examinations. While
these cases center on errors or malfeasance by individuals, they demonstrate a
systemic failure of leadership and indicate a need to accelerate the VA's
efforts to overhaul its health care culture, according to the top watchdogs for
the VA and the federal government.
Dr. Julie Kroviak, deputy
assistant inspector general for health care inspections in the VA's Office of
the Inspector General, told members of the House Veterans Affairs Subcommittee
on Health on Wednesday that while the department has undertaken initiatives to
improve its reliability, the effort is still in its infancy and mistakes
continue. "OIG oversight work has shown that these missed opportunities
were nearly always due in large part to the actions and, even more often,
inactions, of leaders," Kroviak said. "Changes to [Veterans Health
Affairs'] patient safety approaches are necessary and overdue, but impossible
without the dedication of strong leaders who recognize that a cultural
transformation is required to support meaningful and sustainable change."
Sharon Silas, director of the
health care team at the Government Accountability Office, noted that VA health
care, which has been on the GAO's "high-risk list" since 2015 -- a
designation that means the department requires transformation or is vulnerable
to waste, fraud, abuse or mismanagement -- has failed on several accounts to
improve its standing. Silas noted that the VA lacks the capacity, including
personnel and resources, to effectively institute changes to reduce risk to
patients; has not developed a comprehensive plan to improve performance; and
has failed to demonstrate progress. She added that the VA also lacks leadership
commitment across the board -- a lapse most notable in its failure to name a
permanent head of the Veterans Health Administration, a position that has not
had a Senate-confirmed leader for nearly five years. "The number and
repetition of recommendations we have made to address deficiencies in oversight
and accountability are symptomatic of deeper issues underlying these efforts to
oversee [VA's] delivery at health care," Silas said.
VA officials noted that the
department has undertaken steps to improve the entire health system. They say
the department has introduced and will expand its "high reliability"
patient training initiative to improve treatment and care. It has reorganized
the Veterans Health Administration's headquarters to better support medical
centers. And it has revised its action plan to address shortcomings identified
by the GAO this year. "In our ongoing efforts to identify which processes
work and which do not, VA continues to examine how our [medical centers] are
designed and functioning and how processes can be configured to function in a
manner that ensures the highest-quality and safest care possible," said
Renee Oshinski, assistant health under secretary for operations.
Lawmakers expressed skepticism
over the VA officials' pledges that a culture change is underway. Subcommittee
Chairwoman Rep. Julia Brownley, D-Calif., began the hearing noting that the
Veterans Health Administration "needed to change." "The tone of
the testimony seems to be one of defensiveness, not an organization that has
taken a hard look at itself and embraced the kind of humility and individual
accountability it is seeking from its frontline employees," Brownley said.
"The testimony is quite frankly damning," said Michigan Rep. Jack
Bergman, the top Republican on the subcommittee. "I have said before that
many of VA's problems are the result of lapses of leadership. This is as true
today as it ever was." Subcommittee members urged VA Secretary Denis
McDonough to fix what Kroviak called a "broken culture" at the VA and
promised additional oversight in the coming months on patient safety and the
under secretary search. VA officials pledged that the work is underway. "One
bad outcome is too many," Oshinskii said.
^ Sadly, the VA is still broken
from the top-down and that means Veterans are the ones to continue to suffer. ^
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