During the COVID-19 pandemic, I have been trying to give the benefit of the doubt to the VA; I was wrong to extend this kindness. The Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin, was investigated by the Department of Veterans Affairs-Office of the Inspector General (VA-OIG) due to reports of leadership failure and manipulation of radiology reports. The VA-OIG found gross errors in treatment delays, misleading reporting in records, and the leadership both knew and were tolerating this behavior. From the report, we find that the VA-OIG, “… found evidence of manipulation and vulnerability of the electronic health record and mismanagement of the Medical Imaging Service. Facility leaders failed to successfully manage or address the impact of interpersonal conflicts within the Medical Imaging Service that included intimidation of staff radiologists.”
Sadly, I am not surprised at the findings in this investigation; for a considerable time now, the VA has suffered from leadership irregularities, poor leadership, mismanagement, and over management in the majority of the local hospitals. This situation remains highly frustrating to the veterans cursed with needing the VA’s services, and this madness must cease! If it were not for another VA-OIG report declaring follies and leadership failure specifically in the radiological department, the dire situation would not have been so egregious.
The VA-OIG began their report of the VA Illiana Health Care System in Danville, Illinois, stating the following:
“This report is compelling because it discusses significant patient safety issues including a radiologist’s error rate, the facility’s radiology quality assurance program, and a recommendation to the Under Secretary for Health regarding adopting national radiology guidelines.”
The VA-OIG inspection began due to radiological concerns and a high error rate. The VA-OIG discovered such a poor error rate, a second investigation was required to expand upon the issues found in the first investigation. A radiologist had an incredibly high error rate, and the facility leaders did nothing. Does this not initiate a leadership cleaning of the house to remove the rot and begin to build community trust; if not, why?
To be clear, both the local hospital leaders and the Veterans Integrated Service Network (VISN) leaders are at fault for poor leadership decisions. From the VA-OIG report, we find, “Veterans Integrated Service Network and facility leaders failed to conduct a thorough and impartial review related to the OIG request to evaluate the original allegations.” Leading to another question, actually repeated now for multiple years, why are the local leaders, who created the problems, “conducting a review” during the VA-OIG investigation? Isn’t this akin to placing a bank robber in charge of the criminal investigation into the bank robbery?
The primary care doctor, emergency room doctors, and more all depend upon the radiologist report as the VA doctors no longer read x-rays, MRI’s, CT Scans, due to the complexity of the imaging. Thus, any error in the radiological report causes significant patient care delays, harm, or death. Yet, at two geographically separate VISN’s and Hospitals, the VA-OIG is reporting poor QA and high error rates in radiological reporting. Compounded by leadership failure at both the local hospital and the VISN level. The VA-OIG reports do not relate that anyone was fired, forced to change jobs, or other remedial actions taken beyond making “suggestions” for improvement at the federal, VISN, and local hospital levels. What significantly increases the problem, these same radiological records form the backbone of the compensation and pension decisions. Downstream issues were not in the scope of either radiological investigation. Still, every error in the VA bureaucracy has a significant downstream impact that always seems to be forgotten or overlooked.
Secretary Wilkie, lacking a downstream review from the VA-OIG investigations, places patients at significant risk and incredible harm. Consider the following; the VA-OIG reported last year (2019) that radiological reports on spinal problems were not adjudicated correctly in compensation and pension claims from 2002-2006 roughly. No downstream review occurred, and thousands of veterans’ claims are locked in the appeals process for decisions that should have triggered an automatic analysis and new radiological reports ordered immediately upon the conclusion of the VA-OIG’s investigation. Where is the culpability and responsibility to the veterans harmed and suffering all because the VA did not do their collective job?
Now, at least two VA facilities are hindered by radiological errors and poor leadership at the hospital and VISN level. Thus, the veterans need to know, can any radiological reporting be trusted with this blemish on the VA record? Quality assurance (QA) is the backbone of the radiological imaging and reporting processes to assure the patient that proper diagnosing is happening. Yet, QA is the problem in two different VA-OIG investigations of the radiological departments, and how many other VA Medical Centers have the same problem but have not been caught? Where is the accountability for preventing these issues in other VA Medical Centers?
Here are five suggestions for rebuilding the reputation in the community, and in the VA Health Care System (VHA):
- Downstream investigations are critical and need initiation upon discovery by the VA-OIG of wrongdoing. Downstream investigating includes compensation and pension decisions, patient medical record discovery, and fixing the problems in the healthcare record. Build an internal team of various professionals who can investigate and initiate these reviews. Doing so will build trust, save millions of dollars in wrongly adjudicated compensation and pension claims, and saves lives in the VHA.
- Since the leadership failures are so common, so prevalent, and creating such an incredible talent drain, all while risking patient health, it is time for the VA to begin growing leaders through a VA University program. Do not allow leadership currently working for the VA to apply without good reasons; allow open applications where students can learn, can graduate with a degree, and can work in VA leadership roles as they gain a formal education.
- Begin weeding the leadership for the most disingenuous, detestable, and despicable leaders, replacing them with people who have never worked for the VA but are capable and willing from other industries. The VA needs new ideas, new leaders, and new methods if they are to fix the current problems.
- Put teeth into the VA-OIG investigations. These problems as so egregious and widespread that the VA-OIG needs tools to demand compliance and insist upon remediation. In three VA Medical Centers in Albuquerque, NM., Salt Lake City, UT., and a VA Clinic in Ashtabula, OH., I have heard the following, or something similar, from employees regarding VA-OIG investigations, “Don’t worry.” Never again should any VA Employee not worry about being investigated by the VA-OIG.
- Start using an ISO 9001 for healthcare as a QA program where processes and procedures are written down and followed. QA should be a program that fits holistically and improves people. Quality assurance should be a constant learning evaluation that never ends. Yet, somehow the VA, including the VBA, the VHA, and the National Cemeteries, always seem to not have a quality program. Implement the ISO 9001 one VA Medical Center at a time until a whole VISN is working under the ISO program. This allows the VA to learn and use these learning moments to build anew that which has fallen into disrepute.
Secretary Wilkie, some will suggest these ideas are expensive, but how expensive has the revolving door in human resources been for talent drain? How costly has failed training programs been? How expensive is the appeals process to compensation and pension decisions both in green and blue money? The short answer, too bloody expensive. Thus, it is time to begin looking for innovative ideas, using new ideas, employing new talent, and demanding higher returns for the taxpayer investment in the Department of Veterans Affairs.
©Copyright 2020 – M. Dave Salisbury
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