PSA: If you have a weak stomach, please feel free to not read this report. This article is discussing the ongoing and continual problems of the VA leadership to ensure clean medically reusable equipment is available for practitioners use. While the YUCK factor is high, the issue remains a leadership failure, and worse, it was purposefully designed into the VA organization to spread infectious diseases between veterans!
The Department of Veterans Affairs – Office of Inspector General (VA-OIG) conducted an investigation and reported its findings 16 June 2009. While still not the first-time endoscopes and colonoscopes being dirty have caused patience significant risks, this report clearly details the failure of VA Leadership as an organizational design flaw. From page i of the report, we find the following:
“Facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans. Reprocessing of endoscopes requires a standardized, monitored approach to ensure that these instruments are safe for use in patient care. The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure” [emphasis mine].
Also, from page i the scope of the investigation and those requesting the investigation are detailed:
“The VA Office of Inspector General received requests from the Secretary, Chairmen and Ranking Members of VA oversight committees, along with individual members of Congress, regarding the reprocessing of endoscopic equipment at several specific VA medical centers (VAMCs), and to assess the extent of related problems throughout the Veterans Health Administration (VHA). The purpose of the review is to describe the pertinent events at VAMCs where problems were reported, assess VHA’s response to the events, and conduct a system-wide evaluation of current reprocessing practices” [emphasis mine].
Let us be perfectly clear, since 2009, the VA Federal Officers have been informed and kept abreast of the problems with properly cleaning, sanitizing, and documenting reusable medical equipment, specifically endoscopes and colonoscopes, and have done nothing to fundamentally correct the direction of the VA, the VHA, or the offending VAMC’s. What good is a memo when it is not applied as a standard operating procedure, where consequences are involved? How is a memo going to be effective against a culture trained to not do their jobs, no matter the cost to patient safety? To fully comprehend the problem with reusable medical equipment not being properly cleaned and sterilized (repurposed) see pages seven and eight of the following report linked. There are a lot of acronyms, but the general sentiment is clear, the VA has an enormous problem with properly cleaning reusable medical equipment!
In a VA-OIG report dated 06 May 2021, we find an employee, after having been caught once, still not being properly supervised, not doing their job, and remaining employed. This employee was caught falsifying legal documents on the cleanliness of endoscopes, and dirty equipment was used on multiple patients. The facility conducted an investigation, the VISN conducted another investigation, neither investigation led to any type of fundamental organizational change to protect the patient. Even the VA-OIG investigation has not led to fundamental organizational changes and improvements in cleaning and sterilizing reusable medical equipment. Frankly, this should scare the daylights out of every veteran going in for any type of care at the VA.
Trust is hard won and easily lost. Right now, can any provider at the VA assure any patient that the reusable medical equipment has been properly cleaned and sterilized before being used on that patient? Since the VA-OIG report in 2009, the direct answer to this question is a resounding NO! Again, I ask only for emphasis, if a non-VA hospital, clinic, or provider’s office was caught not properly cleaning, sterilizing, and documenting medically reusable equipment, how could they remain in operation? The short answer is, they could not; unless they are an abortion clinic, but that’s and entirely different subject. The Federal Government and the lawyers would descend en masse to shut down the facility, hold the administration accountable, and demand retribution for the patients involved. Why is the VA Administration and VHA Administration, and the VAMC and VISN Administrations able to escape culpability in risking a patient’s health with dirty medical equipment?
Every single Federally elected politician should be up in arms about the double standards between VA hospitals and non-VA hospitals. If a non-VA hospital is caught with dirty medically reusable equipment, can they use the VA as an example in court as a defense? NO! Yet, here is a legal double-standard and precedence that opens the door to more questions.
Returning to the 2009 VA-OIG report, we find how the investigation was methodologically carried out. The methodology reveals just how widespread and in-depth the investigation is, and how deeply this problem is organizationally wide for the VA.
“We visited the facilities which had been the subject of considerable media attention: the Bruce W. Carter VAMC (Miami) in Miami, FL; the Tennessee Valley Healthcare System-Murfreesboro campus (Murfreesboro); and the Charlie Norwood VA Medical Center (Augusta) in Augusta, GA. We reviewed applicable regulations, policies, procedures, and guidelines. Furthermore, 26 inspectors conducted unannounced onsite visits for the total of 42 probability-based randomly selected VHA facilities to examine pertinent endoscope reprocessing documentation.
Because of the unannounced nature of the inspections and for cost-efficiency, a stratified clustering sample design was employed to maximize the number of facilities that could be inspected in a single day. Two probability-based random samples of VHA endoscope reprocessing facilities were selected from the study populations for the unannounced onsite inspection: one for colonoscope reprocessing and another for ENT endoscope reprocessing. With probability sampling, each unit in the study population has a known positive probability of selection. This property of probability sampling avoids selection bias and allows use of statistical theory to make valid inferences from the sample to the study population.”
Back in 2009, the media was very cognizant of VA issues, then the dead veteran scandal of 2012 and 2017, turned the media’s attention away from how the VA conducts business. Let me direct your attention to the final sentence of the quoted material above. As a researcher, this is a gold standard methodology statement for researching a complex organization like the VA, to pick proper probability samples, and to reduce individual inspector bias in the combined report of findings. Thus, from this quoted material we can presume both that the methods of conducting the research were sound and conclude that the egregious behavior by administrators is VA wide!
If dirty medical equipment is how the VA defines excellence in the 21st Century, America’s veterans are in trouble deep! I am now in my eleventh year of writing about the behavior of the VA and how they intentionally treat veterans. I have witnessed detestable behavior by providers as an employee, and brought this behavior to the administrator’s attention, for which I was discharged without cause! I have written about instances of negligence so terrible that there should have been a Congressional Blue-Ribbon panel assigned to demand correction and conduct and investigation, but nothing ever transpired. I have personally experienced providers so inept, their qualifications should be questioned. I have observed VA employees abuse, harass, threaten, and intentionally hinder treatment. The behavior of the VA Administration where reusable medical equipment is concerned is so far beyond the pale, words escape me to describe.
I believe in the little rocks that start landslides. I know the power of tiny snowflakes that create an avalanche. I know that if enough veterans, their families, friends, and communities rise up, the elected politicians responsible for scrutinizing the government will be forced to make veteran safety and health at the VA a priority and blessed change will finally arrive in the VA Administration and administrators. Imagine how you would feel to learn a close friend or family member caught an infectious disease during treatment at the VA. Please respond accordingly!
© 2021 M. Dave Salisbury
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