VA boss says agency aggressively responds to problems
By JOE DAVIDSON | The Washington Post | Published: May 30, 2017
Was it a hospital or a roach motel?
A new report makes the Department of Veteran Affairs (VA) hospital in Hines, Illinois, sound like it was a place where the bugs were well fed, much to the disgust of patients who didn't want to eat after creepy critters.
The VA Office of Inspector General report issued last week is one in a series in recent weeks that demonstrate problems related to veterans' health services, even as the care they receive generally is good.
But wait. VA Secretary David Shulkin says the reports, including one about the suicide crisis line and another concerning unsanitary conditions at the District's VA hospital, ultimately represent good news about how the department responds to problems.
He readily admitted, during a telephone interview, the VA has its troubles. He vigorously insisted, however, that the department is moving aggressively to correct what is wrong, despite a "constant drumbeat of negativity."
"I want people to understand," Shulkin said, adamantly, "that this is a VA that is willing to acknowledge it has problems and to make decisions quickly and is getting the results."
That was the case, Shulkin added, following an OIG report last month about dirty "sterile" storage areas and supply problems at the VA Medical Center in the District of Columbia. He replaced the director within hours of the report's release and visited the hospital the next day.
Shulkin pointed out that the Hines report, though issued last week, is based on a site visit last year. Since then an outside report by a pest-control company gave the facility high grades.
The title of the inspector general's report is government bland - "Nutrition and Food Service Environment of Care Concerns Edward Hines, Jr. VA Hospital Hines, Illinois." But the findings are shocking:
--"Several patients received food trays with cockroaches on them"
--"Nursing staff and several patients witnessed cockroaches on transportation carts"
--Inspectors "observed conditions favorable to pest infestation."
"In the main kitchen," the report added, "we found open cardboard boxes with dry food products exposed, food items in open cardboard boxes that were stored less than 6 inches from the floor, several cracks in the flooring, water infiltration around the floor drains, and trash receptacles without lids."
To make matters worse, the hospital's leadership did not move aggressively to correct the problem.
Reports of cockroaches on patient food trays were submitted to the hospital leaders six times between March 2011 and December 2015, but they "had not successfully resolved the problem," the inspectors found. "Facility leadership relied on its pest control program and did not take additional action to control the problem."
Patients took action and in at least one instance would not accept hospital meals. Pizza was ordered, the report said, "because patients were upset and refused to eat the food delivered via transportation carts."
In response, James Hutton, a VA spokesman said there have been "outside re-inspections of the kitchen since the OIG report and none of them have shown findings of roaches.
"In fact, a board-certified entomologist from Orkin inspected the main kitchen at Hines less than three weeks ago on May 11 and reported, 'your kitchen is very clean, nearly perfectly repaired, and your staff are pursuing recommendations aggressively.' The Orkin inspector noted 'You are now outperforming the wide majority of commercial kitchens out there in regards to pest proofing and management.'"
That's good news, but sometimes news from the VA is not as good as it seems.
A March 21 VA news release headline said "VA fixes Veterans Crisis Line." That followed an inspector general's report about "significant obstacles providing suicide prevention and crisis intervention services to veterans, service members, and their families."
Fixed? That was a surprise to Inspector General Michael Missal, because so many items weren't.
"I didn't understand how it could be seen as fixed when we had 23 open recommendations," Missal said by telephone.
Shulkin said the one issue that matters is getting calls to the crisis line answered quickly.
Now, 95 percent of calls are answered within 20 seconds and just 1 percent are rolled over to another suicide-prevention service, Shulkin said. He's hired new crisis line leadership and 200 new crisis line staffers to answer calls.
Note - My test call to the line was promptly answered Tuesday afternoon. After a few words, I hung up, not wanting to get in the way of someone who actually needed help. Then, someone called back just to make sure I was not in distress. That's good service.
"It is working. It has improved, but it is not perfect," said Jim Tuorila, a psychologist and surgeon general of the Veterans of Foreign Wars. Some callers, he added, remain "on hold for longer periods of time than they should be."
Considering the continuous, and often justified, beating the VA has taken since the scandal over the cover-up of long wait times erupted in 2014, it's worth noting that veterans generally praise the department's health care, once it's delivered. In July, a Journal of General Internal Medicine literature review found "the VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care."
That's very good. But it only takes one roach to ruin a reputation.