'Culture of complacency': DC veterans hospital plagued by problems despite claims of progress
By NIKKI WENTLING | STARS AND STRIPES Published: April 5, 2018
WASHINGTON — A broken refrigerator in the blood bank. Dirty syringe bottles. Critical staff and supply shortages that led to canceled procedures. Unsanitary equipment and rooms in disarray.
All were found in the Department of Veterans Affairs hospital in Washington nearly one year after VA leaders at all levels were warned of safety risks that required immediate action.
According to multiple inspection reports obtained by Stars and Stripes, many of the problems that existed in April 2017 remain unresolved, despite public reassurance that real progress had been made.
As recently as March 5, the Food and Drug Administration censured the hospital’s blood bank. A separate inspection at the end of January concluded the facility still posed a risk to patient safety.
Michael Mann, a professor of surgery in San Francisco who has worked at three VA hospitals, said the situation exemplifies a “box-checking culture” that exists across the VA system.
“The most common response to any problem is to make things appear to have improved or to be acceptable when, in fact, they are not.”
With former VA Secretary David Shulkin’s contentious dismissal last week, the pressure to fix the D.C. hospital will be on his replacement. Add that to the list of critical issues he will have to address across the VA network of more than 170 facilities, many with their own challenges.
‘Culture of complacency’
In April 2017, investigators with the VA Inspector General’s Office had just started a review of the DC hospital and found enough wrong with the facility that they stopped their work and immediately intervened. Shulkin responded by firing the hospital director, Brian Hawkins, and replacing him with retired Army Col. Larry Connell.
The IG’s office released its full report March 7, almost a year later.
In more than 150 pages, it detailed problems found during multiple site visits in 2017 and blamed a “culture of complacency” for widespread failures.
“This hospital is a different hospital today than it was back in April,” Connell told reporters after the release of the report, suggesting that the problems had been addressed.
In an official response to the IG, Acting Undersecretary of Health Carolyn Clancy wrote that “substantial progress” had been made at the hospital since the interim report in April.
Clancy wrote that staff positions had been filled and millions of dollars’ worth of supplies had been ordered. Connell said the facility had been scrubbed clean and that he often heard compliments about its cleanliness.
“This is a great hospital for veterans to receive their health care,” he said. “I am so confident in the quality and safety of care at this facility, I enrolled here with my health care.”
In May 2017, just one month after he was first notified of the problems, Shulkin told senators the hospital was a “high-quality environment” and said at a public hearing that there were no more patient-safety concerns.
Despite those claims, the VA Inspector General’s Office said the eight early recommendations it made in April 2017 to fix the DC hospital — which it said should be carried out “immediately”— had not been completed as of this week. The IG asked the VA to ensure that supplies were available, create a working inventory system and hire key staff, among other recommendations.
Multiple problems the IG discovered last April were echoed in a January 2018 report from the VA’s National Program Office for Sterile Processing.
During an unannounced visit Jan. 22 to 26, the National Program Office found key staff vacancies. A supervisor and educator in the department responsible for sterilizing equipment had been reassigned because of an investigation by the VA’s Administrative Investigative Board. Those spots remained unfilled.
An inventory of medical instruments was “not adequate to meet current clinical/surgical workload,” the report states. Inspectors with the National Program Office also found a fluid leak, mold and a cockroach inside a decontamination area. Two utility rooms were in “disarray.”
When inspectors found dirty syringe bottles, they stopped their work to hold an immediate meeting with hospital leadership about the risk to patient safety.
The January report labeled the findings that existed during previous inspections. A few issues went as far back as April 2017. Others were discovered in July, September and November.
The hospital was still putting veterans at risk, the report states, though it notes the risk was “minimal.”
VA Press Secretary Curt Cashour said that since the January inspection, the hospital has changed leadership of its sterile processing team and hired more staff. The facility is implementing an inventory tracking system, to be in place by June 30, he said.
The DC hospital “has been aggressively addressing a number of identified concerns, but the facility’s problems didn’t emerge overnight and they won’t be solved overnight,” he said.
The VA contends the last procedure canceled due to supply shortages occurred in January. The agency blamed delays at the Federal Express sorting station, and the veteran underwent the procedure two weeks later.
Even more recently, a FDA inspector in March found the hospital’s blood bank was keeping blood at room temperature because of a nonworking refrigerator, and workers weren’t always recording the temperature of blood when it was transported to the Children’s National Medical Center next door. On March 5, the FDA ordered the VA to resolve the issues.
Cashour said the FDA’s findings were routine and had “zero impact on patient safety,” nor did they create interruptions in operation at the blood bank. He said the hospital corrected the problems within three days of the inspection.
Lawmakers on the House Committee on Veterans’ Affairs have heard numerous reassurances from VA leaders over the past year, but they say they are still concerned. The committee is conducting an investigation, looking into dirty storage conditions and procedures being canceled due to supply shortages. It's planning an oversight hearing on the DC hospital in May, said Tiffany Haverly, the committee’s communications director.
“While the medical center has taken steps in recent months to reform itself, there is still a lot of work to be done,” Rep. Tim Walz, D-Minn., said Tuesday. Walz is the ranking Democrat on the committee. “There is absolutely no reason any veteran should have to grow accustomed to deficiencies in care or failures in leadership as a prerequisite for receiving care.”
Problems go back years
Issues at the DC hospital have been documented as far back as 2013.
That year, the VA commissioned an analysis of the facility by the consulting firm Booz Allen Hamilton. Few aspects of the hospital’s operation met minimum requirements, the report shows. Consultants flagged 11 areas of hospital management as “needs attention.”
In an email obtained by Stars and Stripes, Maura Catano, the VA’s acting executive director of the Office of Strategic Integration, wrote to VA Deputy Undersecretary for Health Steve Young that it would “cause a whole new set of problems” if the public was made aware of the 2013 Booz Allen Hamilton report. Catano’s email was dated April 20, 2017, after the IG’s office shared its early findings from the DC hospital with VA leaders.
“The assessment had similar findings to the recent IG report, yet it is not apparent if any corrective action was ever taken,” she wrote about the 4-year-old analysis.
The IG report in March said local and regional leaders of the DC hospital were given “many warnings” since 2013 that problems existed.
Shulkin began working with the VA in 2015 as chief of the Veterans Health Administration. He said he was unaware of any problems at the DC facility until Inspector General Michael Missal shared the early findings in April.
“I was not aware of those issues,” Shulkin said. “I was not aware until Mr. Missal picked up the phone.”
Cashour said the VA has “taken ownership of the oversight failures” that occurred after the 2013 report “and as a result has instituted a number of new policies designed to prevent similar problems from occurring in the future.”
VA leaders were required to respond to the IG report with a plan of action. They listed numerous improvements they would make to the DC hospital that would be completed this year or in 2019.
Connell said he would initiate renovations to parking, an in-patient mental health area, the emergency department and a community living center. The VA filled some vacant logistics jobs, and it has awarded a nearly $9 million contract to construct a 14,200-square-foot sterile processing space at the DC hospital that will be completed in 2019, Clancy said.
After the blood bank inspection, the DC hospital’s chief of pathology and laboratory services began to correct the problems. The VA planned to get a new refrigerator and have a temperature sensor installed in the blood bank room.
“This year is going to be an exciting year,” Connell said in March. “We’re not standing still; we’re moving out to make this facility better than it even is.”
But it has recently been thrown into question whether Connell will be around to see through the improvements.
CNN reported in late March that correct hiring processes might not have been followed when Shulkin named Connell to lead the hospital. A memo from the Office of Personnel Management showed multiple protocols were possibly violated when Connell was appointed, CNN reported.
The memo stated that political influence could have had a role in his selection. Connell worked on Trump’s transition team and was later a special adviser to Shulkin.
Cashour said the VA Office of Accountability and Whistleblower Protection is investigating.
Last week’s firing of Shulkin adds to the uncertainty in VA leadership.
Trump’s unexpected nominee for VA secretary, Rear Adm. Ronny Jackson, must go through the confirmation process, which is likely to be arduous and could take weeks, if not longer. Critics worry the White House doctor doesn’t have the experience to run the largest health care system in the U.S.
Trump’s designated acting secretary, Robert Wilkie, was the undersecretary of personnel and readiness for the Defense Department. A question has been raised whether Trump had the legal authority to put him in that position, and at least one major veterans organization had raised doubts as of Thursday about his qualifications for the job.