Management failures at multiple levels led to critical equipment shortages, overspending and “pervasive staffing issues” that put patients at Veterans Affairs’ flagship medical center in Washington at risk for years, a searing investigation released Wednesday by the agency’s watchdog found.
Despite repeated warnings of systemic failures going back to 2013, leaders at the medical center and its oversight divisions up to senior managers at the Veterans Health Administration largely ignored the problems, Inspector General Michael J. Missal found.
“The dysfunctions … were prevalent and deeply intertwined,” Missal wrote in a 142-page report. “The [inspector general] encountered a culture of complacency among VA and Veterans Health Administration leaders at multiple levels who failed to address previously identified serious issues with a sense of urgency or purpose.”
“At the core,” Missal wrote, investigators found “an unwillingness or inability of leaders to take responsibility for the effectiveness of their programs and operations.”
He called the “repeated exposure of patients to risk of an adverse clinical outcome,” wasted money and management failures at the medical center “unacceptable.”
VA Secretary David Shulkin on Wednesday called the findings “a failure of every level. It’s unacceptable to me. Fortunately this has not led to any known patient harm.”
He said he is installing new leaders not just at the D.C. hospital but in Maryland, New England, Phoenix and Virginia. He described the moves as “the start of a restructuring of VA affairs” and said his staff has identified 15 low-performing medical centers across the country. “We will have an entire new leadership here in D.C., to make sure this is an environment that is safe for the 93,000 veterans we serve,” Shulkin said.
Last April, after the inspector general’s office issued a rare alert as investigators began uncovering safety problems at the facility, Shulkin removed the medical center’s director, Brian Hawkins, and installed a deputy in his place. Shulkin also served in the Obama administration as undersecretary of health for 18 months from 2015-2016.
The hospital and three clinics that make up the Washington Medical Center are among the largest and most complex in the VA’s sprawling health care system. Despite the risks to patients of years of dysfunction, no one died, Missal wrote, a lucky outcome that he attributed to actions by some dedicated medical staff, who conducted their own inventories, raced to nearby hospitals to borrow supplies — including during surgeries — and other efforts. The stopgap measures “are not in accordance with an effectively managed health care facility,” he wrote.
The report is the result of a yearlong review after a confidential complaint led investigators to conduct an inspection in March 2017 and issue their alert three weeks later.
The report describes “widespread and formidable inadequacies” in many of the essential functions that are needed to operate a hospital.
Patients were hospitalized needlessly — at great medical risk — when procedures had to be canceled following their admission because equipment could not be accessed for surgeries. Some patients received unnecessary anesthesia. Surgeons had to rely on outdated medical instruments. Discolored and broken instruments reached clinical areas because the hospital’s sterile processing operation was broken down.
Investigators also found dirty storage areas for medical supplies and equipment.
Missal noted some improvements under the new leadership. The wait for prosthetics has decreased, and storage rooms are now clean. But the report said that problems persist.