[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
CASE STUDY ON U.S. DEPARTMENT OF
VETERANS AFFAIRS QUALITY OF CARE:
W.G. (BILL) HEFNER VETERANS AFFAIRS MEDICAL
CENTER IN SALISBURY, NORTH CAROLINA
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND
INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
APRIL 19, 2007
__________
Serial No. 110-14
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio GINNY BROWN-WAITE, Florida,
TIMOTHY J. WALZ, Minnesota Ranking
CIRO D. RODRIGUEZ, Texas CLIFF STEARNS, Florida
BRIAN P. BILBRAY, California
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
April 19, 2007
Page
Case Study on U.S. Department of Veterans Affairs Quality of
Care: W.G. (Bill) Hefner Veterans Affairs Medical Center in
Salisbury, North Carolina...................................... 1
OPENING STATEMENTS
Chairman Harry E. Mitchell....................................... 1
Prepared statement of Chairman Mitchell...................... 47
Hon. Bob Filner, Chairman, Full Committee on Veterans' Affairs... 2
Hon. Ginny Brown-Waite, Ranking Republican Member................ 4
Prepared statement of Congresswoman Brown-Waite.............. 47
Hon. Timothy J. Walz............................................. 4
Hon. Brian P. Bilbray............................................ 5
Hon. Robin Hayes................................................. 6
Hon. Ciro D. Rodriguez........................................... 7
WITNESSES
U.S. Department of Veterans Affairs:
John D. Daigh, Jr., M.D., Assistant Inspector General for
Healthcare Inspections, Office of the Inspector General.... 8
Prepared statement of Dr. Daigh.......................... 48
Sidney R. Steinberg, M.D., FACS, Chief of Staff, W.G. (Bill)
Hefner Veterans Affairs Medical Center in Salisbury, North
Carolina, Veterans Health Administration................... 23
Prepared statement of Dr. Steinberg...................... 50
William F. Feeley, MSW, FACHE, Deputy Under Secretary for
Health for Operations and Management, Veterans Health
Administration............................................. 33
Prepared statement of Mr. Feeley......................... 52
MATERIAL SUBMITTED FOR THE RECORD
Letter submitted by Hon. Robin Hayes, U.S. House of
Representatives, from Daniel F. Hoffmann, Network Director,
Veterans Integrated Services Network Six, Durham, NC, Veterans
Health Administration, U.S. Department of Veterans Affairs,
dated April 18, 2007, addressed to Congressman Hayes........... 55
Post-Hearing Questions and Follow-up Letter for the Record:
Hon. Harry E. Mitchell, Chairman, and Hon. Virginia Brown-
Waite, Ranking Republican Member, Subcommittee on Oversight
and Investigations, to Hon. George J. Opfer, Inspector
General, U.S. Department of Veterans Affairs, letter dated
May 21, 2007, and responses to the questions, letter dated
June 21, 2007.............................................. 57
Hon. Harry E. Mitchell, Chairman, and Hon. Virginia Brown-
Waite, Ranking Republican Member, Subcommittee on Oversight
and Investigations, to the Hon. R. James Nicholson,
Secretary, U.S. Department of Veterans Affairs, letter
dated May 21, 2007, and their responses to the questions... 59
Followup letter, dated December 18, 2007, from John D. Daigh,
M.D., Assistant Inspector General for Healthcare
Inspections, Office of Inspector General, U.S. Department
of Veterans Affairs, to Hon. Harry E. Mitchell, Chairman,
Subcommittee on Oversight and Investigations, Committee on
Veterans' Affairs, in response to inquiry from Congressman
Timothy J. Walz during the hearing......................... 66
CASE STUDY ON U.S. DEPARTMENT OF
VETERANS AFFAIRS QUALITY OF CARE:
W.G. (BILL) HEFNER VETERANS AFFAIRS
MEDICAL CENTER IN SALISBURY,
NORTH CAROLINA
----------
THURSDAY, APRIL 19, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
[Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Filner, Space, Walz,
Rodriguez, Brown-Waite, Bilbray.
Also present: Representatives Watt, Coble, and Hayes.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. Good morning. This is an Oversight and
Investigations Subcommittee hearing for April 19, 2007. This
particular hearing will be a Case Study on the U.S. Department
of Veterans Affairs (VA) Quality of Care at the W.G. (Bill)
Hefner VA Medical Center in Salisbury, North Carolina.
I want to thank our colleagues from North Carolina for
joining us today. I know they have been very active on this
issue. I know the people of their great State appreciate their
hard work on behalf of veterans in North Carolina.
Of course, we are here today to explore the quality of care
available to our Nation's veterans. We know there have been
significant problems in the Salisbury VA Medical Center in
North Carolina and we will be using Salisbury as a case study
so we can better learn if the problems there are indicative of
quality of care throughout the VA medical system. We will
explore management accountability and leadership issues within
the VA medical system.
Today's hearing will revolve primarily around three issues.
Firstly, how does the VA ensure access to the medical system
that is timely and is delivering proper quality of care?
Second, what is the process the VA uses in determining whether
the quality of care is proper? And third, are the problems that
occurred in Salisbury indicative of a larger set of issues that
affect other VA medical facilities as well?
More than 2 years ago, in March 2005, an anonymous
allegation that improper or inadequate medical treatment led to
the death of veterans at Salisbury prompted the VA Office of
the Medical Inspector to conduct a review of medical care
delivered to both medical and surgical patients. The OMI
report, issued 3 months later, found significant problems with
the quality of care that patients were receiving in the surgery
service of the Salisbury facility. Unfortunately, we learned
that Salisbury leadership had already been notified of many of
the shortcomings in surgery service through an earlier root
cause analysis.
I know that all of us on the Subcommittee are particularly
troubled to hear about the story of a North Carolina veteran
who sought treatment at Salisbury and died. He went in for a
toenail injury. And even though doctors knew he had an enlarged
heart he was not treated. It was ignored. And the morning after
he had surgery on his toe, he died of heart failure. According
to media reports, this veteran received excessive intravenous
fluids in the O.R. and postoperative as well. The medical
officer of the day wrote orders for the patient without
examining him and the patient did not receive proper assessment
and care by the nursing staff.
More recently, we learned through the media of another
incident: a wrong site surgery at another VA medical facility
on the west coast. The list goes on and on.
We hope to hear today how the VA is working to ensure that
these types of incidents do not happen at other facilities
around the country and how the VA is working to deliver the
best quality of care throughout the system. We also hope to
hear from the VA how its leaders reacted to these problems,
worked to solve these problems, and what lessons it learned to
ensure that this never happens again.
[The prepared statement of Chairman Mitchell appears on
page 47.]
Mr. Mitchell. At this time I ask unanimous consent that Mr.
Watt, Mr. Coble, and Mr. Hayes of North Carolina, be invited to
sit at the dais for the Subcommittee hearing today. Hearing no
objections, so ordered.
Before I recognize the Ranking Republican Member for her
remarks, I would like first of all to recognize the Chairman of
the Veterans' Affairs Committee, Congressman Filner.
OPENING STATEMENT OF HON. BOB FILNER
Mr. Filner. Chairman Mitchell, thanks so much for doing
this and having this hearing. It is very important.
When we got the letter from the North Carolina
representatives, and we take requests from our colleagues very
seriously, because we know, from our own personal experience,
that we know what is going on in our own districts. I was
struck by the fact, Mr. Hayes, since you represent the three,
that your letter dated March of 2007 talked about getting a
report from June of 2005 and September of 2006 that you had not
seen before. That set off some bells right there, that reports
of what is going on in the VA hospital in your area were
unknown to you. That should not be the case. When we looked
further into the situation, we looked at the report of 2005
that outlined a lot of the problems in the hospital. Then in
2006 the Inspector General did a report basically looking at
facilities, and with no reference to the 2005 report. And then,
as you know, the VA Secretary commissioned a report of all
facilities just recently in the wake of the Walter Reed
scandal, and there did not seem to be any connection between
that report and the previous reports. So that started us
thinking, since the paper trail is so clear, that this would be
not only in and of itself an important hospital to look at, but
also serve as a window into the process when there are problems
and how we exercise accountability. And that is why we are here
today under Chairman Mitchell's leadership.
I happened to meet with the Inspector General soon after we
got your letter. And I asked him about this report and why it
did not have any reference to the earlier report. He said, ``We
did not know about it.'' I thought that was odd. But as we
looked further, these reports, which are so important, are not
public. I am not sure we will find out if they are sent to this
Committee, or whether there is just some summary, or whatever,
but this was not a public report. Without a public report,
there is no real accountability. And what we saw with these
three reports, from 2005, 2006, 2007, was that there was no
indication that any of the previous recommendations were ever
done, ever fulfilled.
Now we will talk to the folks today and they say, ``Well,
of course we did those improvements.'' But we are not sure, and
you are not sure, based on your letter, that this was done. So
you have what the Office of the Medical Inspector does in 2005,
it is not public, we do not know if the recommendations were
even carried out. We get an Inspector General report in 2006,
and we do not know if that has been carried out. And we get a
new one in 2007. There is something broken about the
accountability system and we are going to fix it with your
leadership, Mr. Chairman. And this is a good example of what we
have to deal with.
There are problems that come up. It took somebody
anonymously to mention them. I do not know why that should
occur. There were twelve deaths, I think, over a period of
time. Not everybody knew it. There was no investigation done
since somebody actually did something. I know from my hospitals
and other places I have been in the country, there is a, I will
use the word ``fear.'' There is a fear about talking about the
problems in your own hospital or in your own system. We have to
get away from that culture. If there is fear, there is no
honesty. And if there is no honesty, we cannot fix it. And if
people are scared for their jobs because they are talking about
problems with the patients they care about, there is something
wrong with the system. So we are looking forward to fixing
that, to making sure there is accountability.
One last statement, if I may. In the last 60 days, three
budget bills went through Congress. We were able to add, as a
Congress, $13.5 billion over last year to the healthcare of our
veterans in this Nation. That is about a 30 percent increase in
healthcare, bigger than any in the history of this Nation. Now
we have to make sure that those resources are spent wisely,
that they are spent for the proper care of our veterans, and
that the legislative branch of government knows what is
happening, exercises oversight, and produces excellent health
services for our veterans. I thank the Chairman.
Mr. Mitchell. Thank you. Before we get started and I ask
for opening statements, I would like to have all of the panels,
the witnesses and the aides to the panels, to please rise and I
would like to have them sworn in please. So if they would all
please rise?
[Witnesses sworn.]
Thank you. And now I would like to recognize Ms. Brown-
Waite for opening remarks.
OPENING STATEMENT OF HON. GINNY BROWN-WAITE
Ms. Brown-Waite. I thank the Chairman very much for holding
this hearing and for also yielding time.
Mr. Chairman, on March 28 through March 31, 2005, at the
request of the VA's Inspector General in September of 2004, the
Office of Medical Inspector conducted a site visit to the W.G.
(Bill) Hefner VA Medical Center in Salisbury, North Carolina,
focusing on the facility's delivery of surgical services. This
report presented some serious inadequacies of care at this
facility. On March 21, 2007, three members of the North
Carolina delegation, my colleagues the Hon. Howard Coble, the
Hon. Mel Watt, and the Hon. Robin Hayes, wrote to the Committee
expressing concern about this report. Mr. Hayes is with us
today, and I am sure the other members, as their schedules
permit, will also be with us.
You know, the members asked us to look into additional
oversight into patient safety at the VA. I am looking forward
to hearing from our witnesses today to learn how these
inadequacies have been addressed. I am particularly looking
forward to Dr. Daigh's testimony providing the results of the
Facilities 2006 OIG Combined Assessment Program (CAP) Review of
the VA Medical Center in Salisbury, North Carolina, and the
results of the OIG's inspection last week of the facility. I
also look forward to hearing from Dr. Steinberg, the current
Chief of Staff, and the former Interim Director, on how the
facility is continuing to work to address these issues. And
also, how the lessons that were learned at Salisbury can be
used to implement safer delivery of healthcare services
throughout the entire veterans system. It is my contention that
this hearing is not to single out one facility, but to take
lessons learned as a case study in patient care and the
implementation of better patient safety across the entire VA
system. I plan to continue to work with you, Mr. Chairman, to
continue this oversight of patient safety at VA facilities
throughout the Nation. Quality of care, everywhere, is my goal,
and I believe the goal of members on both sides of the aisle.
Again, I thank you Mr. Chairman. I yield back the balance of my
time.
[The prepared statement of Congresswoman Brown-Waite
appears on page 47.]
Mr. Mitchell. Thank you. At this time, I would like to ask
Congressman Walz for his opening statement.
OPENING STATEMENT OF HON. TIMOTHY J. WALZ
Mr. Walz. Well, thank you, Mr. Chairman, and thank you to
the Ranking Member for those words. I appreciate and thank all
of the witnesses who are here today. Please make no mistake
about it, the reason for this hearing, and the sole reason, is
to make sure that we are providing the best medical care
possible to our veterans. Our responsibility in this Congress
is to make sure we are doing that in the most efficient,
effective manner, and the use of taxpayer dollars is obviously
a part of that. But I think it is very critical that as we are
pointing out and trying to find areas that we can improve upon,
the reason for that is to learn from past mistakes and it is
not simply a scapegoat or trying to find reasons to point
fingers. It is trying to improve across the spectrum.
So I want to thank each of you for the work you do. I want
to thank you for being here. I want to thank you for the open,
honest dialog that we are going to get to because I think all
of us on this Committee do believe that proper oversight and
learning from past mistakes and implementing best practices is
the best possible way to get to those solutions. So this is not
a hearing to point out simply errors or simply weaknesses in
the system for the sake of pointing them out. It is here to try
and learn from this, to have you help us understand what we can
do to implement those best practices or to help you with the
resources and get the best possible care for these veterans,
and that is the sole purpose of being here.
So I want to thank you for taking time to be here with us,
and thank you for your expertise to help us understand this
better. I yield back.
Mr. Mitchell. Thank you. Mr. Bilbray?
OPENING STATEMENT OF HON. BRIAN P. BILBRAY
Mr. Bilbray. Yes, Mr. Chairman. Mr. Chairman, the full
Committee Chairman and I, have for 15, I guess almost 20 years
ago, have worked together doing oversight at different
agencies. I just ask as we go through this process, I
understand that when we are talking about people dying it is
human nature to focus on those deaths from the humanitarian
point of view. But we need to have the discipline to focus on
the systemic problems that led to those deaths, and sort of
pull back and say, ``There is a terrible tragedy here, and we
can focus on that.'' But if we focus on the deaths and not on
the process that led up to the problem, or may have led up to
that problem, then we are negating our responsibility of
oversight. And more than the problem that Chairman Filner
pointed out, about the fact of the whistle blower concept, the
employee, because we always have had that. I mean, Bob and I
know that, I do not care if it is a police officer saying a
procedure was wrong or a county hospital saying that handling
was done wrong, you will always have those in the system that
always can point out faults and problems.
What I really see of concern here is that, and I would ask
those who are testifying to address this process where we do an
assessment, a formal assessment of the operation, and that
assessment is not made available. And why is it not made
available for general review? Now, in certain situations, like
when I was working with the trauma system in San Diego County,
there was certain information we did not put out for liability
reasons, for exposure reasons. And we tried to address the
problem with the general public, because every lawyer in the
world would be showing up to sue the hospital. And you cannot
provide healthcare once the hospital has been shut down because
of litigation. But this one, I do not understand why it was not
made public. And I think Chairman Filner points out rightly
that we ought to be addressing the issue as, is there a process
here that we need to change? Even if it is a process that says,
``We are not going to make it public directly, but we may hold
it for 6 months to give the system the ability to respond to it
so that when the report comes out there are answers, there has
been time to address the concerns, whatever.''
So I would ask that we really look at the systemic problem.
It seems like a breakdown, that when you had a report that was
out there a year ahead of the other report, and no one knew
about it, what good is a report if there is not some review and
action taken on that report? And so, again, I think that is
where we can, rather than finding fault, find answers to be
able to address the item.
And I yield back, Mr. Chairman.
Mr. Mitchell. Thank you. Mr. Hayes?
OPENING STATEMENT OF HON. ROBIN HAYES
Mr. Hayes. Thank you, Mr. Chairman, and Chairman Filner.
Let me begin by thanking you, Chairman Mitchell, for making
this hearing possible, and Ranking Member Ginny Brown-Waite.
Bob Filner, we have been here for a long time. When this came
to our attention, there was absolute confidence on my part that
you and this Committee would look into this. And my point is,
for not the members and others that are here, but the larger
audience, leadership comes from all levels. But this Veterans
Committee has provided the leadership. And today I think among
other things, and Congressman Bilbray is right, we are
reinforcing from the top the attitude that first, foremost, and
always, the veteran/patient is what we are here to work on.
Again, thank to all of you for making this possible.
Quality, affordable, and accessible healthcare services to our
Nation's veterans has been a top priority for me and for you as
well. That is why I have been so concerned by recent media
reports investigating the quality of patient care some of our
veterans have received at the Salisbury Medical Center.
While there are different deficiencies ranging in various
levels of severity, I found it most troubling that a nurse
employed by Salisbury reportedly falsified care reports on
seriously ill veterans housed in private nursing homes and did
not properly monitor them. This nurse's infractions included
listing a patient in stable condition 12 days after he died.
She was also cited in the VA Office of Inspector General's
September 2006 report for not having visited some patients
under her charge for over 2 years. Yet, the unnamed nurse is
apparently still employed by the Salisbury VA. That is why I
wrote to the Veterans Integrated Services Network (VISN) 6
Director, Dan Hoffman, to express my concerns and to ask how
this could happen. There have also been allegations that more
than 12 deaths of surgical patients at the Salisbury VA had
occurred in the last 2 years which may have been prevented. I
do not think that all Department of Veterans Affairs healthcare
is bad. There is excellent care being provided. I do not think
the majority of VA healthcare employees are irresponsible or
providing inferior care. The majority of our veterans are
getting quality care from dedicated staff. The Veterans Affairs
healthcare system is one of the best in the Nation, and
continues to strive to provide better patient care. But even if
one veteran has been or is being neglected, then that is one
too many. If one employee is being negligent in their care,
then that person does not need to be a part of the VA system.
During this hearing, I look forward to hearing more about
specific incidents and the overall situation at Salisbury so
that we can take these lessons learned and apply them to VA
healthcare across the country. I am also interested in how this
relates to leadership and management within the VA, what is
being done to ensure that their best care practices are being
utilized.
Caring for our older veterans and giving them the best
access to quality healthcare is our duty as a nation. As we
continue to sustain operations in support of the Global War on
Terrorism, it is also imperative we send a strong signal to the
active duty forces that our Nation will indeed care for them
when they return home.
I appreciate each of the witnesses from the Department of
Veterans Affairs Office of the Inspector General, leaders of
the Salisbury VA Medical Center, and the Department of Veterans
Affairs Health Operations and Management for taking the time to
appear. I believe your candor and insight can and will shed
light on the issue for all of us. I look forward to continuing
to work with my colleagues on this critical issue and on behalf
of our Nation's veterans and servicemembers, again, thank you
Mr. Chairman.
Mr. Mitchell. Thank you. Congressman Rodriguez?
OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ
Mr. Rodriguez. Thank you very much, Mr. Chairman. Let me
first of all thank you for holding this hearing. My concern is
that as we look at the VA, that what happened up here and other
hospitals, that this might not be just an isolated situation,
but that it might be widespread. I look forward to hearing from
the Inspector General, and to see, if he can give us some
guidelines as we move forward regarding how we might be able to
help out.
I understand also that the VA has not received the
appropriate resources for so many years, and that they have had
to cut staff. And I do not know if that nurse had a caseload
that just was impractical to deal with, or what the situation
might be. But I do know that we are going to do our best to
begin to fund the VA appropriately with $3.6 billion additional
moneys for 2007, and the supplemental holds some additional
resources there. And we are going to work hard for 2008, to
provide that $6.6 billion. But as we do that, maybe the
Inspector General can help us out in the process to make sure
we begin to, and the VA begins to, streamline the process that
is needed in order to provide good healthcare. I know I get
criticism back home from the fact that if you look at the
private sector and what they do in certain areas, the number of
patients that they view and then the number of patients that
the VA views, it is day and night in comparison in some of
those same situations. And so, we have to make sure we hold the
system accountable, especially as we try to do the right thing.
And I concur with the fellow colleagues that have indicated
that this should be about making sure we have a system that is
held accountable for our veterans and that we have a process
there that can provide the appropriate care. And if it is not
there for them to come forward, and to feel comfortable to come
forward to tell us, ``There is no way we can deal with a
waiting list unless we are provided this, this, and that.'' We
have not had that kind of a process. And that is the process
that we need, that if they cannot handle it, for them to come
forward and tell us: ``Unless you provide this, this, or that,
we cannot do that.'' And so, I am hoping that these types of
hearings can allow us to begin to get to that level where the
administration can come forward with those requests from us,
and that we also come forward with whatever is necessary in
order to make that happen.
So Mr. Chairman, thank you very much for holding these
hearings.
Mr. Mitchell. Thank you. At this time we will proceed with
Panel One. Dr. John Daigh is the Assistant Inspector General
for Healthcare Inspections in the Office of the Inspector
General (OIG). He is accompanied by Ms. Victoria Coates, the
Director of the Atlanta Office of Healthcare Inspections, which
covers Salisbury, North Carolina, as part of its regional
mandate. Dr. Daigh, you have 5 minutes.
STATEMENT OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR
GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF THE INSPECTOR
GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY
VICTORIA H. COATES, DIRECTOR, ATLANTA OFFICE OF HEALTHCARE
INSPECTION, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT OF
VETERANS AFFAIRS
Dr. Daigh. Thank you, Mr. Chairman. I appreciate the
opportunity to testify in front of this Subcommittee today. I
prepared some written statements for the record that I hope can
be accepted into the record.
I and the members of the Office of Healthcare Inspection
take very seriously our legal challenge and mandate to ensure
the veterans receive quality healthcare. We do that through
several mechanisms, two of which I will talk about today. One
is a Combined Assessment Program (CAP) inspection, whereby my
office inspects major hospitals, there are about 158 of them,
on a 3-year cycle. So about once every 3 years we go to each
facility. We concentrate during that inspection on the
processes at the hospital that should ensure that patients
receive quality healthcare: the peer review process, the
patient notification process if there is a bad outcome, those
internal business processes that have to be successful.
A second mechanism that we use to try to ensure patients
receive quality healthcare is through our hotline. My office
publishes about 50 hotlines a year. In 2004 we were publishing
about 30 hotlines a year. The VA OIG maintains a hotline that
accepts complaints through a variety of mechanisms. If those
complaints deal with quality of healthcare issues, they are
brought to my office. And in our office we try to triage those
complaints and address the ones we think have systemic impact
or are most serious. Those that we cannot directly review
because of manpower limitations, we refer back to a level of
command at VA higher than the level of the complaint.
I would like to refer to a fiscal year 2006 summary that we
published this year of the quality management of VA as a result
of the CAP inspections. And in that publication we noted
weaknesses systemically in the peer review process; the adverse
event reporting process, which is the process whereby the
hospital would notify a patient that there had been an adverse
event; and in the utilization review process.
Let me turn specifically to the events surrounding
Salisbury. The IG received through its hotline on August 30,
2004, an anonymous complaint alleging 12 individuals had died
on the surgery service over the prior 2 years through improper
healthcare. That complaint was brought to my office, and the
next day my office accepted that complaint as one that we, the
Office of Healthcare Inspections, would review. Upon looking at
our workload and the cases that we were carrying at that time,
I determined I could not investigate this case. That is, look
at 12 deaths intensively in the timely fashion. So I,
therefore, referred this case to the Office of the Medical
Inspector (OMI), who said he did have the resources to look at
this case in a timely fashion. And so, 3 weeks after I received
the hotline, it was referred to the Medical Inspector (MI) on
September 24, 2004.
The Medical Inspector then went to Salisbury in March of
2005, and published a report in June of 2005. Between those two
timeframes the Director of Surgery for VHA visited the facility
in May. The effort that the Medical Inspector made at Salisbury
was discussed in monthly meetings that my staff has with the
Medical Inspector. The Medical Inspector's report notes that I
referred the case to them and notes that I reviewed the draft
of this report. So I was well aware, as the people in my office
were, of the issues surrounding this report. And we are aware
of all the Medical Inspectors' reports.
In June of 2006, my CAP team led by Ms. Coates, went to
Salisbury to conduct a CAP inspection. I did not make them
aware of that report. In retrospect, it would have been better
had I made them aware of that report. But in the CAP report
they noted some problems. One, the contract community nursing
home program did not have a Committee that it was supposed to
have to organize and supervise its activities. They also found
difficulties with the peer review process and the management of
internal board of investigations and Root Cause Analyses
(RCAs). They also found some deficiencies in the cleanliness of
the kitchen.
We went back in early April 2007 in preparation for this
Subcommittee's hearing to review again whether or not the
findings of OMI and the recommendations of OMI had been
implemented and whether or not the findings and recommendations
of the CAP had been implemented.
And as my time is out, I will indicate that both the OMI
findings and the defects that we found in our CAP report have
been adequately addressed currently by the facility. I thank
you for the opportunity to testify, and Ms. Coates and I would
be glad to take further questions.
[The prepared statement of Dr. Daigh appears on page 48.]
Mr. Mitchell. I have a couple questions I will start off
with. Firstly, are there any patients currently in the
community nursing homes that are on the watch list?
Ms. Coates. I would like to answer that question. There is
one nursing home that Salisbury has that is currently on the
watch list. However, the facility has increased the monitoring
and the visitation of the clinical staff to that nursing home
to our satisfaction.
Mr. Mitchell. Is your microphone on, Ms. Coates? Is your
microphone on?
Dr. Daigh. Yes, I believe it is on.
Ms. Coates. It says it is on. Is that better? Would you
like me to repeat my answer? Salisbury has one nursing home
that is on the watch list right now. That facility is being
monitored, visitation has increased, and we believe that it has
satisfactorily been addressed.
Mr. Mitchell. Thank you. I have two other questions. Why
did the OIG send the hotline to the Medical Inspector to begin
with?
Dr. Daigh. Well, sir, when we get an allegation we are
never sure what we will find in the exploration of that
allegation. So if there were 12 cases to review, that takes a
significant amount of manpower to do an in-depth review of the
care of 12 patients. And, at the time, in 2004 I had a full
plate of very significant issues I was working on. So in
discussing with the MI, the MI had staff that could look at
this in a more timely fashion than I could, so I referred this
case to the MI.
Mr. Mitchell. One last one, what are your roles and
responsibilities in overseeing the MI?
Dr. Daigh. Well, sir, in law when the MI was created, my
office was charged with overseeing the Medical Inspector's
Office and with ensuring that VA provides quality care by
looking at the mechanisms by which VA ensures that they have
quality care. From a practical point of view, the Medical
Inspector works for the Under Secretary of Health and in my
eyes is an agent of the Under Secretary of Health. I work for
the Inspector General and do not work for the Under Secretary
of Health. We cooperate in the sense that we are aware of where
each of us is working. We are aware of the significant issues
that we are each dealing with. We try very hard not to
duplicate our efforts. And I think we have been pretty
successful in recent years at working together.
For example, the MI published a report in Chicago a couple
of years ago in which there were three surgical cases of
retained instruments. That case was the basis for which my
office set out to do a national review of patient safety in the
operating room, which was published in March of this year.
Again, trying to emphasize that these same-sided surgery
mistakes should not occur, that facilities need to go through
the policies and the procedures that VA has set up to make sure
those things do not happen.
Two Under Secretaries ago, the MI came to me and indicated
that he had a report that he had written that he could not get
VHA to act on. So having that information, I then wrote a
letter and went to the Under Secretary for Health and said,
``You need to act on this report.'' It turned out that there
was then legal intervention which sort of took over in terms of
the issues of that particular case. But if the MI feels that he
is not being listened to then I am an outlet to try to make
sure that he is. And we work together cooperatively as we can
to try to ensure veterans get quality healthcare. Thank you.
Mr. Mitchell. Ms. Ginny Brown-Waite?
Ms. Brown-Waite. Thank you, Mr. Chairman, for yielding, and
thank you Dr. Daigh for being here. If there is an Inspector
General's Office, which certainly there should be in this
agency and every agency, and there also is the OMI group, how
does that overlap? How does that delay the process? Or is
having both of these groups, one of which, I believe your
office, is somewhat understaffed, is there a tug there of
territory? That is question number one. And question number two
relates to why do you think that it took an OMI investigation,
your IG CAP review, and a review over a 2-year period to
finally shake up some senior management lethargy to finally
remedy some pretty serious shortcomings? And I look forward to
having your answers.
Dr. Daigh. Yes, ma'am. With respect to the first, I believe
that my office has an independence that the OMI does not have.
I believe that the Under Secretary of Health needs an
individual or a group of individuals that can act as his agent
should an issue arise that he can send out and look at episodes
of care that might not be appropriate. The size of the group
that he has performing that task I have not made a study of and
I am unsure of how many people he needs to do that. I believe
that we have a significant workload in my office and that we
are running flat out right now.
As to the second issue, I believe that when we did the CAP
inspection in 2006, that we were content that the leadership at
that facility had in fact set course to make the changes we
thought necessary to ensure that veterans receive quality care.
We commented that there were problems with peer review and they
made those changes. We commented that there were problems with
nursing homes, and once pointed out, they made those changes.
The disappointing fact or feature is that there would be a
problem with peer review at all. They know we are coming to
look at their peer review Committee, we know they have a peer
review Committee, or should have one, they know it should meet
on a regular basis, and they know that it needs to do its work
in a timely fashion. So, yes, we wish that we did not have to
repeatedly find some of the same problems across the system.
Ms. Brown-Waite. On a scale of 1 to 10, how truly effective
to protect patients is the peer review group, in your opinion?
Dr. Daigh. I think that it is extremely important that
episodes of poor care be appropriately commented upon by
physicians' and nurses' peers to allow the administration to
decide whether or not the care provided was quality care or
not. This information is essential to allow the hospital's
leadership to decide who should have credentials and privileges
to practice in that hospital. So the peer review process is
integral to the safe functioning of a facility.
Ms. Brown-Waite. I do not think that is what I asked you.
Dr. Daigh. I am sorry.
Ms. Brown-Waite. I asked you how effective you think it
really is. Because the problem with a peer review group is,
that I have found when I chaired the Health Care Committee in
the Florida Senate, is that nobody wants to say anything
questioning another medical provider's level of expertise or
lack thereof, or even problems with substance abuse. So, you
know, peer review is something that when it works, it works
very well. But I also found that it is a great opportunity for
intimidation. For example, nurses that see something that
really say that this doctor is a danger to the patients, that
nurse frequently will lose her job and the peer review group
will then do nothing. So I think I would like you to tell me,
on a scale of one to ten, in reality, and remember you are
under oath here. How effective is the peer review in the VA?
Dr. Daigh. Well, I think I would like to parse my answer if
I could. I think that there are places where the peer review
process does not work as designed, that is by policy. It does
not meet regularly and it may not effectively get the data that
it needs to make decisions. And where it does not meet
effectively, I would agree with you entirely. There are places,
however, that do have effective peer review. And, where it does
work well, I think it does make an important contribution to
healthcare. I believe that in the VA peer review would be, on
10 being excellent, I would give it probably a 7 to 8 grade in
terms of its functioning across the system.
I will say that when we do hotline reports, and clinical
cases are addressed, we go out and seek comments from both
physicians within the VA and physicians outside the VA to help
provide the technical expertise that my office needs in certain
complex cases to determine whether the care met standard or
not. And we have had no difficulty getting quality input to our
reports to suggest that poor care was delivered in the VA. So
from a personal experience, asking for VA and non-VA
physicians, for their input, where they know the report is
going to be put on the web, as all of our reports are put on
the web, available to the country, we get very good, high-
quality input.
Ms. Brown-Waite. Thank you, Dr. Daigh. I yield back the
balance of my time.
Mr. Mitchell. Thank you. Mr. Filner?
Mr. Filner. Thank you, Mr. Chairman. Dr. Daigh, I was a
little troubled by your testimony, both in some of the things
that you said and also things you did not say, especially since
some of us asked questions that we want to know and you did not
address them in your remarks. I mean, we make these opening
statements not just to hear ourselves talk but so you know what
we are interested in.
Let me tell you a couple things. Number one, you said you
did not have the resources. I mean, your first response to the
hotline was you could not do it yourself. I doubt if that was
made known to the Congress, that you did not have sufficient
resources to do things that you should be doing. I do not think
so. Was any statement made to Congress that you would have
liked to do a report of 12 deaths, but you did not have the
resources to do it? Did anybody know about that?
Dr. Daigh. No, sir. That is an internal prioritization in
my office.
Mr. Filner. Right. But if you do not have enough resources
to do the job that you are set up to do, it is no longer
internal, Dr. Daigh.
Dr. Daigh. Yes, sir.
Mr. Filner. It is a job for some of us. Now, then you said
you took 3 weeks and you asked OMI and they got to it. You said
in March when you asked them in September, if I recall. Come
on, that is 6 months with 12 deaths. If it were my family, and
my children, or my spouse, I would be in there the next day. So
the speed of the bureaucracy worries me. That what you think is
reasonable is forever, especially to the families that are
trying to figure out what is going on here. So they did not
even get to it for 6 months. It took another, what, 3 months to
do or something like that. And then as I understand it, correct
me if I am wrong, it is not published. Your stuff is published
on the web. I do not think you made clear to the Subcommittee
that the OMI stuff is not published on the web. Is that true?
Dr. Daigh. I believe that is true, sir, but the Medical
Inspector will be here and you can ask him about that.
Mr. Filner. Come on, you are the Inspector General. You
should know this stuff. You do not know? You told me in private
that it was not public. So tell us here. I mean, come on----
Dr. Daigh. I believe their material is not public on the
web.
Mr. Filner. All right. But come on, how long have you been
in the Inspector General's Office?
Dr. Daigh. About 5 years, sir.
Mr. Filner. And you do not know whether the OHI report is
public or not? Okay, and you said you were aware of the report
but your CAP team was not. Is that not a weakness in your
system?
Dr. Daigh. That is a weakness, sir.
Mr. Filner. Okay. I mean, we need to have that, I mean, how
can the CAP team go in and report when they did not even know
what was wrong before? So OMI, did anybody do a followup of the
OMI report within a reasonable amount of time? Is there any
provision for a follow up to their report in your office or any
office?
Dr. Daigh. I would offer, sir, the example of our published
report on patient safety in the OR is----
Mr. Filner. I want to know if the 2005 report by the OMI
was ever followed up to see if the recommendations were in fact
carried out.
Dr. Daigh. Not specifically until last week, in
preparation----
Mr. Filner. For this hearing?
Dr. Daigh. Yes, sir.
Mr. Filner. Now we are 2 years later, great show. Now, you
said you thought there was an adequate response. Since nobody
actually checked down their list of recommendations, was anyone
fired for this stuff? I mean, we had a nurse who did not know
what to do. We had, I was told a doctor was sort of let go but
then rehired under a different category or a different thing.
Did anybody, was anybody held accountable for errors in terms
of being fired?
Dr. Daigh. I am not sure of the answer to that, sir. That
is a personnel issue that the facility would deal with.
Mr. Filner. You are the Inspector General. We are relying
on you for an independent analysis of this and we do not know
if it was followed up on, and we do not know if anybody was
fired. How did you follow up on your CAP report that is done
every 3 years? Is there a formal followup on that?
Dr. Daigh. Yes, sir. There is a process by which we keep
record of the recommendations that we make. We, in person,
follow up those recommendations that we think are very
significant, and those that we do not have the manpower to
follow up on we, if the plan put forward and through the
written correspondence of documents justifies to us that that
issue has been closed, then we close it.
Mr. Filner. But you do not know that that is being done in
OMI, that same process?
Dr. Daigh. I am uncertain of that.
Mr. Filner. So you follow up the CAP reports in some
organized fashion. Is there any report issued on the report?
For example, within 6 months all these things were taken care
of, or not?
Dr. Daigh. Well sir, we report to Congress all
recommendations not completed within 1 year.
Mr. Filner. Okay, my time is up. But the process bothers
me. The OMI report is not public. The OMI does not seem to have
any notion of speed. Six months later, 9 months later to do
stuff, and then we do not even know if they were carried out
because our colleagues from North Carolina write us a letter
and tell us that it does not look like they have done anything.
The system is very weak, it seems to me. And what bothers me
even more is the bureaucratic attitude on this stuff. I have
said this before in public meetings, I do not know if you were
at those meetings. We are talking about the deaths of human
beings. People ought to figure out what is going on, do it
fast, and make corrections. Here we get a bureaucratic thing
that takes forever and then by the time it is done everybody
forgot who died anyway. I do not see a passion for figuring out
what is going on. And I do not see any accountability in
personnel. There are some serious personnel problems here. It
is hard to believe that that nurse is still there. Your report
states that the nurse is still there, she was just transferred
to administrative duties. What the hell is she still doing
there? Or he, I do not know if it was a he or a she. So I think
we need a far better system with a little bit more direct
passion about carrying it out.
Mr. Mitchell. Thank you. Next, Mr. Walz?
Mr. Walz. Well, thank you Mr. Chairman and Dr. Daigh, thank
you for your time. I represent the district of southern
Minnesota that includes the Mayo Clinic, so I spend a lot of
time talking about healthcare, talking with experts, especially
on the delivery of quality care and how to improve that. And I
think as a world renowned expert as Mayo is they have some
insights on this. I am also concerned and spend a lot of time
looking at organizational design and how organizations function
or do not function, and where those gaps are. I have a couple
questions here and I do know these questions are going to be a
little bit subjective. But that is the nature of leadership, to
make subjective judgments and put them into place at times. I
know we do not always have those quantitative measures to judge
things by, but I want you to give me your best impression as
you see this.
Is it your opinion, Dr. Daigh, is the Office of Inspector
General seen as an integral part of delivering quality care? Or
is it seen as a watchdog to appease and keep at arms' length?
How do you see it, from the perspective of the VA facilities?
How would you see that? And I know it is subjective.
Dr. Daigh. I think we are an integral part of providing
quality care, and I believe that we are perceived that way. I
believe there are people that do not perceive us that way. I
mean, clearly we are here to help you. When we can write
reports that have significant impact on leaders' ability to
perform and people's jobs, people are certainly concerned when
they talk with us. But I believe that we speak the truth, we
try to lay out the issues as we see them. We have access to
senior management and we hope that people will do the right
thing in terms of making leadership decisions in VHA and that
Congress will take our information and make decisions useful to
run the organization.
Mr. Walz. Well, I can tell you from my perspective, I do
that. I do see the OIG as being an integral part of that. I
hope it is being seen that way. My concern is, and I share this
with you, and I think you are stuck in a bit of a rock and a
hard place on this one. At least in my opinion, I think many on
this panel agree, that the OIG has been an area that has been
severely under resourced in recent years. And I have deep
concern over that. And I did hear your testimony, as you said,
you have to make judgments. All of us do on the use of our
resources. You have to prioritize.
My next question to you is, do you think if you would have
had more resources, more personnel, and more ability, would
your response time and the way that you handled the situation
at Salisbury have changed? Would it have improved?
Dr. Daigh. I think it would have. I am sure that it would
have. The other ambiguity here is anonymous complaints are
sometimes difficult to ferret out what the exact facts are, and
what resources are required. So if a complainant lets us know
who they are and we can quickly assess what the risk is to
people on the ground, we respond as quickly as we can. So, yes,
with more resources, I would be able to respond more quickly
and more aggressively.
Mr. Walz. Do you feel any pressure to try and justify the
budgets that are given to you from VA management? Do you feel
the need to try and say, we have sat in this Committee and had
pointed questions from people sitting up here ask the VA that
they had the resources, and not a month ago they told us yes,
they had all they needed. Now I am hearing from you that you
think that the quality of care would have increased. I think it
is a logical conclusion to say possibly if you had more
resources we may have fewer deaths. That is a pretty important
and profound statement. My question to you is, do you feel
pressure inside the VA system to justify the budgets that are
given to you and to not come to us? To not come outside and
give us suggestions and say, ``Hey, we are overwhelmed here,
help us.''
Dr. Daigh. No, sir. In the budgeting process I put down the
proposals that I think would allow my office to deal with the
issues that should be dealt with. I put that down in terms of
manpower, usually, which is equatable into dollars, that goes
forward. I do not have any direct discussion with the decision
makers on what the VA IG appropriation is. But I feel no
pressure to do other than tell people what we need.
Mr. Walz. If you feel you are short, is there a process and
what is the process inside the VA that you can go and talk to
your superiors on where things that you think could be
increased? How does that process work? Is it an open door
policy? Is it a formal policy? Or how do you say, ``Hey, my
resources are not enough?''
Dr. Daigh. I would have to get back to you in writing, sir.
That would be handled by the management group of the IG's
office. I run the healthcare inspection group. And so the
actual formulation and requesting of a budget is done by a
different part of the IG's office.
[The information was provided in a followup letter from Dr.
Daigh, which appears on page 66.]
Mr. Walz. Do you think that might be a problem? Or are you
comfortable with it? You are the implementer. And if they are
the appropriators and there is not a lot of communication I
worry about that.
Dr. Daigh. Yes, sir. I understand what you are saying.
Mr. Walz. Okay. Thank you, Mr. Chairman.
Mr. Mitchell. Thank you. Mr. Bilbray?
Mr. Bilbray. Thank you, Mr. Chairman. Let me first clarify
that I think those of us in government cop out too often that
the answer to every problem is to throw more money at it. That
has created major problems and a break down in the credibility
of those of us in government to provide cost effective,
reasonable services. And frankly, let me just tell you
something. I am more impressed with the fact that rather than
screaming you did not have enough money and finding excuses not
to address the issue, that when you found out that this crisis,
or this review needed to be done and you basically did not have
the capability in-house, you went and looked to find somebody
to get the job done rather than screaming that you just could
not get it done.
My concern is back to the procedural issue here. Were you
aware of the 2005 report? You personally?
Dr. Daigh. Yes, sir.
Mr. Bilbray. Were the people doing their review that came
out in 2006, were they aware of the 2005 report?
Dr. Daigh. No, sir.
Mr. Bilbray. Why were they not?
Dr. Daigh. Because I did not tell them. The OMI publishes
about, five, six, seven reports a year. We have an elaborate
system so that when individuals go out on a CAP inspection they
can see all of the IG activities, that would be the auditors,
the healthcare activities, the hotlines, so that they are aware
of those issues. We did not have an adequate system to let
people know when they go out on a CAP of OMI reports. We have
subsequently placed all of the OMI reports and current drafts
on a share drive so everyone in OIG can see the OMI reports as
they conduct their business.
Mr. Bilbray. But you do not have a tickler system so that
if somebody is going into a certain facility or a certain
field, that they are automatically tickled that the fact that
there are these outstanding reports that they can use as a
base?
Dr. Daigh. Well sir, it is standard practice to query the
database for the site that you want to go to.
Mr. Bilbray. Yeah?
Dr. Daigh. Then you get a list of all the opened and closed
issues at that site. So there is a way to look at IG work. The
OMI work is listed in very simple format that is easy for one
to look at. When you know you are going to go on a project you
go look at the share drive, see the reports----
Mr. Bilbray. So the share drive, was this available for
them, the share drive?
Dr. Daigh. It was not available then. It is available now
and has been set up now.
Mr. Bilbray. Now?
Dr. Daigh. Yes, sir.
Mr. Bilbray. Okay, this is the kind of testimony that we
need.
Dr. Daigh. Yes, sir.
Mr. Bilbray. Was it oversight on your part of notifying
them, ``Hey, by the way guys, you are going in there and we
have got this report that came out and you ought to take a
review of that?''
Dr. Daigh. That is correct, sir. That is correct, it is my
oversight.
Mr. Bilbray. Okay. Now, you have now got a system that
basically if they are going in the facility, there is a tickler
to let them know that there are these outstanding reports that
are already on file?
Dr. Daigh. That is correct. There is a very simple way for
them to see what OMI's current work is and what the OIG's
current work is.
Mr. Bilbray. So you are here telling us now that you made a
mistake. The system was not working properly. But since then,
you have been able to backfill and correct the procedural
mistake that occurred in this instance?
Dr. Daigh. I am saying that I made a mistake, and that we
have corrected the problem.
Mr. Bilbray. Hang on, when you said you corrected the
problem, let us clarify. You corrected the procedural problem?
Dr. Daigh. Yes, sir.
Mr. Bilbray. Okay, go ahead.
Dr. Daigh. I am saying that I have made OMI's work
available to my staff so that we should not have the disconnect
that you are concerned with here again. That should be
corrected.
Mr. Bilbray. Because Doctor, you admit, that when anybody
goes into a facility the first thing they should be looking at
is the previous reports on that facility to have a base of
knowledge to move forward from, rather than having to reinvent
the wheel.
Dr. Daigh. I agree, both the previous and the ongoing
issues at that facility.
Mr. Bilbray. Now at this facility we have, you know, we are
talking this facility. But this is now procedure for your
entire review process? To where whatever facility they are
going into they now have the ability to automatically have a
tickler that will refer them the reports that have predated
their investigation?
Dr. Daigh. For years, my staff have had the ability to see
all of the IG reports on any site. They now have the ability,
as of very recently, the ability to see OMI's work at those
sites.
Mr. Bilbray. Thank you very much. I appreciate it.
Dr. Daigh. Yes, sir.
Mr. Bilbray. Mr. Chairman, I yield back.
Mr. Mitchell. Thank you. Mr. Rodriguez?
Mr. Rodriguez. Thank you very much Mr. Chairman, once
again. And let me thank you for taking responsibility in terms
of correcting that, and that is refreshing to hear. You
mentioned earlier that in reference to the manpower that is
needed that you submitted your budget. And I wanted to ask you
if what you requested was what you received?
Dr. Daigh. Sir, if you are talking about the actual budget
submission, I would have to refer you to the management group
at the IG's office who actually constructs the budget and moves
forward. I do not really know exactly what the documents are
that move forward with respect to the IG's budget as whole.
Mr. Rodriguez. Because you did indicate that you needed
more manpower, you needed more assistance, is that correct?
Dr. Daigh. I indicate to my boss where I think we should
allocate resources to more effectively allow me to do my job,
yes sir.
Mr. Rodriguez. And do you feel comfortable that you
received what you needed?
Dr. Daigh. I have received in the last several years an
increase in manpower of two offices, which would be 12 people,
plus 2 additional physicians since the 2004 timeframe. So I
have received additional assets. I feel people have been
generous in providing me assets. There is, however, more
significant hotlines work than I can do. I have to triage what
I do based on the demands on my staff's time.
Mr. Rodriguez. Now, based on the work that you have already
accomplished and those areas of corrective action that have
been outlined, what are some of those areas and what still
needs to occur in order for those corrective actions to take
place, if they have not taken place?
Dr. Daigh. Do you mean at Salisbury, sir?
Mr. Rodriguez. Yes, sir. On the report there was some
indication in terms of some corrective actions that were put
out there. Have those corrective actions taken place?
Dr. Daigh. It is my understanding from Ms. Coates and her
team's report to me that the CAP issues that we identified a
year or so ago, the corrective actions have been taken for
those issues. It is also my understanding that corrective
actions have been taken with respect to OMI's report on the
surgery service. So I believe that actions have been taken on
both of those reports.
Mr. Rodriguez. Okay. So then are there any recommendations
that have not been taken care of that you know of? Or that you
need to still go back and reassess?
Dr. Daigh. On our last visit we identified a couple of
issues that we have asked the facility to address. One, in
tunnels that connect buildings, there are telephones under lock
or under key. So we have asked that one consider that patients
will not have those keys, and so that needs to be addressed so
that if there is an emergency in the tunnel that can be dealt
with. Secondly, we found some sprinkler heads that were dirty
in the kitchen and needed to be fixed. And thirdly, we
identified that in the locked psychiatric ward there were
exposed pipes from the wall to the toilet, and those are also a
problem that needs to be addressed. So those three items, when
Ms. Coates' team was there last week were made known to the
facility to address, and we will follow up as we always do to
make sure that those corrections occur.
Mr. Rodriguez. Are there any other things that you feel
that you could be doing that might help improve the situation
there now?
Dr. Daigh. Well sir, I believe that the facility has made
some changes in leadership both within their surgery group and
within the senior management of the hospital. I believe we have
pointed out what recommendations we have and they have agreed
to do them. So I think they need to have a chance to address
the issues that we have just identified to you and we will
follow up on those issues.
Mr. Rodriguez. And once again, you are not aware if anybody
has lost a job as a result of what has occurred, or anything to
that nature?
Dr. Daigh. In general, sir, once we identify the issue and
the facility takes the correct action to deal with it, then I
do not follow up on whether--we occasionally do but usually do
not follow up on exactly what personnel action was taken, as
long as we are assured that some appropriate personnel action
was taken.
Mr. Rodriguez. Okay. Thank you very much. Thank you, Mr.
Chairman.
Mr. Mitchell. Thank you. Mr. Space?
Mr. Space. Thank you, Mr. Chairman. I do not really have a
question, but a request. And this is following my colleague's
question regarding personnel actions that may have been taken.
And the request I have is that you provide this Committee with
a written response concerning those personnel actions that have
been taken, or are being undertaken as we speak. And the
concern I have is that given what appears to be a callous
disregard by a collective bureaucracy for some very fundamental
points involving human life, I feel very compelled to request
that we follow through and find that these responsible parties
are not simply being shuffled from one part of that bureaucracy
to another. So I am requesting, if you would, to provide us
with a written response concerning those personnel actions that
have been taken.
Dr. Daigh. At Salisbury, I will, I would be happy to, sir.
Mr. Space. All right. Thank you.
[The information was provided in the response to Question
2, directed to Dr. Pierce, in the Questions for the Record from
the VA, which appears on page 66.]
Mr. Mitchell. Thank you. Mr. Hayes? Oh, excuse me.
Ms. Brown-Waite. Mr. Chairman?
Mr. Mitchell. Yes?
Ms. Brown-Waite. If, actually what I was going to ask was,
I was going to ask Mr. Space if he would yield some time to me
for a follow up on what he was requesting?
Mr. Space. Sure.
Ms. Brown-Waite. I appreciate the gentleman yielding. I
would also ask if you could provide this Committee with a list
of the people who were involved in this issue at the hospital
in North Carolina, and the bonuses that they received over this
period of time where obviously there was questionable quality
of care that was rendered. The hospital administrator, the
individuals who were involved, I think it would be very
revealing to also know what kind of bonuses they received while
this inferior quality of care was going on.
Dr. Daigh. Yes, ma'am.
Ms. Brown-Waite. And Mr. Chairman, if you do not object to
that addition?
Mr. Mitchell. Absolutely not, so ordered.
Ms. Brown-Waite. Well, I think that the Inspector General
certainly can provide that information also, am I correct, sir?
Dr. Daigh. Yes, ma'am, I believe we can. I will get that
for you.
Ms. Brown-Waite. Okay. Thank you very much.
[The information was provided in the response to Question
1, directed to Dr. Steinberg, in the Questions for the Record
to the VA, which appears on page 62.]
Mr. Mitchell. Thank you. Mr. Hayes?
Mr. Hayes. Thank you, Mr. Chairman. Dr. Daigh, thank you
very much for your candor. We have covered a lot of important
ground this morning but I want to focus in specifically on the
nurse issue. I have written a letter on March 15 to the VISN 6
Director and only received response yesterday, which was the
18th. And again, to go back to the issue in realizing that
there is separation between inspection, which is your purview,
and management and care, which is the purview of others. But
this person again reported a patient in stable condition 12
days after the patient had passed away. And she also, I am not
sure whether it is a she, this nurse had patients under her
charge who were not visited in over 2 years. Now, in my
response I am told, which is entirely unacceptable, that it was
decided to enter into a last chance agreement with that
employee. Again, sticking to your role as Inspector General,
does your department get into recommending whether this was an
offense that the person should have been terminated? Or is this
a question that I should ask of management coming later?
Dr. Daigh. I generally do not get into that issue. I would
ask you to ask management coming later. There are clearly cases
where significant action needs to be taken, and my office is
essentially composed of healthcare professionals. And when we
move into the issue of disciplinary action and hiring and
firing actions, we are simply not the experts on that, and do
not usually get into the legal issues involved in that.
Mr. Hayes. Well, interestingly, as time passes, and it has
been pointed out a lot of times past, then if corrective,
proper actions are not taken then you are brought back in next
year. Well, we have investigated and this person was not
terminated, so do you have an opinion based on the facts if
this individual should have been terminated? I think obviously
they should.
Ms. Coates. What we can tell you, sir, is that this
particular nurse was reassigned to another area of the
hospital, and that supervision was substantially increased. In
the contract nursing home program, the facility has assigned a
number of staff, has added a part-time nurse, and the
visitation and the monitoring of the patients in the nursing
homes really is at an acceptable level. We have confidence in
that.
Mr. Hayes. Well, again thank you. It certainly seems like
unacceptable on any level behavior. In conclusion, again, I
want to focus on the fact that dollars that are spent, and
regardless of who is in the majority here I think there is a
very high level of sensitivity to resources. But I feel
compelled to make the point that there are a limited number of
dollars. And I would say to everybody in the system, and
everybody is important. The person providing care, whether it
be the person who is in charge of the kitchen, or nursing, or
doctors, the better quality of care that is provided, that
makes it less necessary, takes less resources, for the
inspection part. So I would hope that one of the results of
this hearing is everybody will come away very clearly
understanding that quality care, taking the dollars and putting
it into care, and not further resources because they are not
needed in inspection, would be a take away that I hope results
and occurs from this meeting today.
Dr. Daigh. Yes, sir.
Mr. Hayes. I would rather have you inspecting than
answering our questions up here, but I am glad you are here and
we are going to follow it up. Thank you Mr. Chairman, I yield
back.
Mr. Mitchell. Thank you. Mr. Watt?
Mr. Watt. Thank you, Mr. Chairman, and I want to express
the appreciation of myself, Mr. Hayes, and Mr. Coble, our
colleagues from North Carolina, for the expeditious manner in
which the full Committee and this Subcommittee have followed up
on our letter and on independent information about what was
going on at the VA hospital in Salisbury, North Carolina. He,
the Inspector General, pronounces it ``Salisbury,'' but in
North Carolina we say, ``Salisbury,'' so. The hospital is in my
congressional district, but both Mr. Coble and Mr. Hayes have
had long associations with the hospital. It has been kind of in
and out of various congressional districts over time, and we
all have a strong bipartisan interest in protecting our
veterans and making sure that they get quality are. So I want
to thank you all for following up, having the hearing, and also
for allowing us to be participants in the hearing as nonmembers
of this Committee and of this Subcommittee.
Doctor, I want to zero in on the bottom of page three of
your testimony, and get pretty precise about the things that
you say there. You indicate that on August 30, 2004, the Office
of Inspector General, that is your office, received an
anonymous hotline alleging that there had been more than 12
surgical deaths in over 2 years on the surgical service at the
Salisbury VA Hospital. On September 21, 2004, and I emphasize
the next line, ``due to limited Office of Inspector General
resources, this hotline was referred to the Office of the
Medical Inspector.'' And the Office of the Medical Inspector
did the follow up. And that Office of the Medical Inspector is
not in the Inspector General's Office. Whose line of command is
it under?
Dr. Daigh. The Medical Inspector is an agent of the Under
Secretary for Health.
Mr. Watt. Okay. And is it in the VA system?
Dr. Daigh. That is correct.
Mr. Watt. So in a sense, that was kind of like having the
inside people investigate their own problems at some level. I
am not being critical of that.
Dr. Daigh. No, you are correct, sir.
Mr. Watt. And then the Office of the Medical Inspector,
according to your information, followed up and did a review in
April, in March of 2005, that was 6, 8 months after you
received the allegations. And then you got a report in April of
2005. And it issues its report of the hotline allegations and
surgical services after the Office of Inspector General's
review. I am emphasizing that again. So you reviewed that
report after they did it.
My question to you is on two fronts. And I am going to run
out of time, so you may have to give me this information. When
I walked in, you were saying that your office has sufficient
resources now. I presume that is a change since this occurred,
because your report says that you referred this to the Office
of Medical Inspector because you did not have sufficient
resources at that time. Is that a change? And the second thing
I want to find out, because we may have some obligation to the
families of those 12 people who may have died as a result of
medical misconduct, or medical negligence, is I never saw
anything in the report that suggested the outcome of the 12
allegations that were made. Did you, in fact, find that there
were any deaths that resulted as a result of inadequate medical
care? And are you able to tell us how many of those 12 deaths
that were alleged to be as a result of insufficient care, how
many of them were actually due to insufficient medical care?
Dr. Daigh. I am going to ask, sir, that you ask that
question to the Medical Inspector, who wrote the report.
Mr. Watt. I would not ask it of you except that you said
that this report was issued after the Office of Inspector
General reviewed it.
Dr. Daigh. That is correct.
Mr. Watt. So you all were involved in this after they did
the review. Did you ever see anything that really addressed the
allegations of the 12 deaths?
Dr. Daigh. Yes, sir. The patients' care that was the
subject of the report, their care was reviewed by outside
physicians who were at a local university, a well-respected
medical school. And they did a peer review of the care
provided. Some of the peer reviews came back saying that the
care provided met the standard of care. Some of them came back
saying that, ``We might have done something different.'' And
some of the peer reviews came back saying, ``We would disagree
with the care that was provided.'' The hospital then is charged
to take the information and act upon it through its privileging
and credentials committee, and through other actions that they
would take. So I am aware that the quality of care process
stepped up, looked at the problem in what I think is a
reasonable way, got outside reviews of that care. What I am
unable to tell you, sir, specifically is for each of those
cases, what the VA did in response to each of those cases. I am
satisfied that people did the kinds of things that they needed
to do to begin to properly assess this situation.
Mr. Watt. Mr. Chairman, I realize my time is out. I do
think there is a larger problem here, obviously, of what to do
going forward to improve care. But there may be some
obligations that we have to these 12 individuals, and I would
request that the Subcommittee obtain the actual reports on
those 12 individuals and see what dispositions were made of
them, if it is your pleasure to do so.
Mr. Mitchell. Yes.
Mr. Watt. I realize I am meddling in your Subcommittee's
business, but I would respectfully make that request.
Mr. Mitchell. We will do that. Thank you.
[The reports were received by the Subcommittee staff.]
Mr. Hayes. Mr. Chairman?
Mr. Mitchell. Yes?
Mr. Hayes. While we are meddling, I feel compelled to say
that, and everyone on the Subcommittee knows overlapping
hearings, but Congressman Coble is tied up in a Judiciary
Committee hearing and I assume will be here as soon as he can.
But thank you for your patience.
Mr. Watt. And I can verify that. I just came from the same
Judiciary Committee hearing. But he is the Ranking Member of
the Subcommittee that is having the hearing, so he did not have
the latitude to leave quite as quickly as I did.
Mr. Mitchell. Thank you. I appreciate you being here, and
any post-hearing questions we will get back to you, we will
have those in writing for you.
Dr. Daigh. Thank you, sir.
Mr. Mitchell. I know there are some people who have to
leave for other hearings, so thank you. I welcome Panel Two to
the witness table. Dr. Sidney Steinberg is the Chief of Staff
at the W.G. (Bill) Hefner VA Medical Center in Salisbury, North
Carolina, and has most recently been in the position to oversee
reforms at this facility. We welcome his insight and
perspectives. Dr. Steinberg is accompanied by Mr. Donald Moore,
the former Director of the Salisbury facility and current
Director of the Carl T. Hayden VA Medical Center in Phoenix,
Arizona. Mr. Eladio Cintron, the Patient Services Coordinator
of Salisbury, and Ms. Linda Shapleigh, the Patient Advocate,
are also with them. Thank you. And Dr. Steinberg, you have 5
minutes if you would like to make your statement.
STATEMENT OF SIDNEY R. STEINBERG, M.D., FACS, CHIEF OF STAFF,
W.G. (BILL) HEFNER VETERANS AFFAIRS MEDICAL CENTER IN
SALISBURY, NORTH CAROLINA, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DONALD F. MOORE,
R.PH., MBA, MEDICAL CENTER DIRECTOR, CARL T. HAYDEN VETERANS
MEDICAL CENTER, PHOENIX, ARIZONA, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS (FORMER
DIRECTOR, JUNE 2004-OCTOBER 2006, W.G. (BILL) HEFNER VETERANS
AFFAIRS MEDICAL CENTER IN SALISBURY, NORTH CAROLINA); ELADIO
CINTRON, PATIENT SERVICES COORDINATOR, W.G. (BILL) HEFNER
VETERANS AFFAIRS MEDICAL CENTER IN SALISBURY, NORTH CAROLINA;
AND LINDA SHAPLEIGH, PATIENT ADVOCATE, W.G. (BILL) HEFNER
VETERANS AFFAIRS MEDICAL CENTER IN SALISBURY, NORTH CAROLINA
Dr. Steinberg. Thank you very much, Mr. Chairman. As a
veteran and someone who served in two previous wars, it is my
pleasure to address your Committee and the members here
present. I would like to thank you for giving me this
opportunity to address your concerns regarding the quality of
healthcare provided to our veterans at the W.G. Hefner Veterans
Affairs Medical Center in Salisbury, North Carolina. The focus
of my remarks will be the improvements and expansion of
healthcare at Salisbury.
The Medical Center in Salisbury provides quality healthcare
to our veterans in our primary care clinics, including Winston-
Salem, North Carolina, and Charlotte, North Carolina, and
across many specialties of medicine and surgery with our
academic partner Wake Forest University School of Medicine. In
recent years, Salisbury has made a concerted effort to improve
the quality of our healthcare and to make access to care
readily available to our veterans. We measure our improvements
in these areas on a regular basis using a variety of measures,
both internal and external. We track disease prevention,
treatment outcomes, physician performance, educational
processes, and patient satisfaction surveys. VA is committed to
make the needs of our veterans, whatever it takes, absolutely
positive, and Salisbury is totally committed to that process.
Several years ago with the help of our VISN, the Veterans
Integrated Service Network, with their leadership and a handful
of very dedicated physicians, VA sought to make improvements in
Salisbury department by department. VA leadership brought
together the financial and manpower resources necessary to make
these changes possible. For example, the waiting list of
veterans seeking primary care appointments was a challenge and
as a result we now have in place a system where every veteran
on the wait list is seen promptly. VA was delighted to have
members of Congress join with our former Secretary and Network
Director to address the challenges that we faced in 2003 and
2004 with the addition of more than 13,000 veterans to our
primary care system.
To accommodate specialty care services in the past,
Salisbury had to rely upon a geographic partnership with the
Asheville VA Medical Center. However, the addition of such a
large number of new patients made it apparent that Salisbury
would need to develop its own specialty support system for our
veterans. To accomplish this task, VA established a new and
stronger relationship with our academic affiliate Wake Forest
University. Meeting with the dean of the medical school and the
faculty leaders paved the way for the beginning of a new
partnership to serve our patients with state of the art
healthcare in many areas of need. These efforts led to the
establishment of resident physician training programs in a
number of specialties. We now have 10 approved positions,
including ophthalmology, urology, ENT, psychiatry, medicine,
and infectious disease. The superb eye service that we provide
with multi-specialty support provided care to 27,000 patients
in ophthalmology during the last fiscal year.
VISN leadership continues to engage the Office of Academic
Affairs on the regular basis to assist Salisbury in adding more
resident positions in primary care, internal medicine, and
other specialties. This year, we have added a new affiliation.
This particular affiliation is very dear to our hearts and is
one which we warmly welcome, with Virginia Tech University in
Blacksburg, Virginia. This relationship is key to the
development of expanded primary care in the future.
The real benefit of residency training programs to our
veterans is that they bring with them the highly skilled
faculty members who are capable of providing state of the art
care to all of our veterans. The progress VA has made in
Salisbury touches every veteran and every employee of the
Medical Center. Our staff, our patients, our community leaders,
and our medical school educators, recognize the quality of
these additions. These improvements in facility staffing and
structure allowed us to provide care to more than 400,000
outpatient visits in fiscal year 2006, as well as providing
support for one of our principal components, the Veterans
Benefit Administration office in Winston-Salem.
The mental health needs of our veterans are important to
all of us and represent a program of excellence in Salisbury.
In this area of clinical expertise, we lead our VISN and have
on our staff one of the world's most prestigious investigators
in the area of traumatic brain injury. Through her efforts and
those of her principal neuroscientist, we now have a
collaboration with Massachusetts Institute of Technology,
Harvard School of Medicine, and the Department of Defense, in
providing care and evaluation for patients with traumatic brain
injury. This team also serves as a key investigative and
educational center for the Mental Illness Research, Education,
and Clinical Center know as MIRECC. And this center has the
focus of post-deployment mental health evaluations and
treatment. Together with other VA Medical Centers in VISN 6,
this program strives to advance the study, education, and
treatment of all mental health conditions resulting from war.
Mr. Mitchell. Doctor, could you please wrap it up? You are
past the 5 minutes, but more importantly we have to go take a
vote.
Dr. Steinberg. Absolutely.
Mr. Mitchell. As soon as you are through with your wrap up
right now then we are going to recess for 15 minutes while we
go vote and be back. But go ahead and finish, wrap up.
Dr. Steinberg. I will skip to just a brief statement about
the surgery programs since that has been a focus of your
interest. We faced challenges in the quality of our surgery
program in 2003. We have turned the corner and now have a much
improved program. The surgery department is totally new. It is
headed by a new Chief from Vanderbilt University, and strong
clinical staff from other major universities in the country. We
have training programs with Wake Forest in many of our
specialties, and we are very proud of the progress we have
made.
I will be happy to answer any questions you have, sir.
[The statement of Dr. Steinberg appears on page 50.]
Mr. Mitchell. Thank you very much. And as soon as we get
back from voting, after the recess we will come back and ask
the questions.
[Recess.]
The first question I have, is the Joint Commission on
Accreditation for Health Organizations (JCHO) on June 21, 2006,
the report on Salisbury said that there was no documentation to
indicate that staff was educated regarding the ability to
report concerns of patient safety and quality of care to the
Joint Commission. This includes documentation supporting facts
that no disciplinary action or retaliation will be taken toward
the individual. Can you tell me what that means?
Dr. Steinberg. Well, we do have processes in place that
address the importance of that issue. We have an online
reporting system which allows patients, family members, members
of the staff, to report incidents to the Office of Performance
and Quality which we can address. And we do have within our
organization a fairly strong peer review program, which
addresses a lot of these concerns. We had a brief interlude
when the peer review program had to be held in abeyance because
of conflicts with other governmental agencies, and that had to
do with releasing confidential information outside the
organizational structure. That has fortunately been relieved by
the Office of the Under Secretary, and we are now in synch with
a very strong and very positive peer review program that
addresses all these issues. And we do take disciplinary action
and that action is very firm.
Mr. Mitchell. Two very quick follow ups on this. The report
also states that there was an incident, and I just want to
report these incidents, where a patient was on oxygen when
admitted to a home-based program. However, there was no order
for the oxygen until September 2, when the patient was
admitted--excuse me. The order was for oxygen, until September
2 when the patient was admitted on March 5. So there was a real
gap between when they ordered the oxygen, and when they
released him with the need for oxygen. Is this problem still
going on? And how do you keep this from happening?
Dr. Steinberg. I do not know the specific answer to that
question, sir, but I will assure you that I will find the
answer to that and send it to your Committee.
Mr. Mitchell. All right, I would appreciate that. And also,
the Joint Commission Report stated that nursing staff were not
aware of the safe storage temperature ranges for the
medications administered by injection. This was their report.
Do you have any written guidelines from the pharmacy on safe
temperatures to ensure that the nurses are able to verify
medications, and that they are stable prior to administration?
Dr. Steinberg. Those are all part of the hospital policy,
and the nurses are well educated in that regard. We have had
some problems in the past with nursing leadership. Those have
been addressed, and those modifications in nursing leadership
have been taken care of.
Mr. Mitchell. Would you say all these incidents that were
part of this Joint Commission, that they brought up, you have
corrected all of these?
Dr. Steinberg. Yes, sir.
Mr. Mitchell. Is there any written verification that they
have been corrected?
Dr. Steinberg. Our Office of Quality Management addresses
all of these, and reports these questions back to the Joint
Commission on a regular basis. I have just recently made a
correspondence with the Joint Commission to address other
issues, as well. We have a website that we log onto from our
Office of Performance and Quality, the Joint Commission
website, that gives us information about our progress, what we
are doing, and how we have responded.
Mr. Mitchell. Thank you. Mr. Bilbray?
Mr. Bilbray. Yes. Doctor, you know there are references to
the construction projects and the expansion of the facilities,
and I would just like to comment, give you a chance to comment
on, frankly my perception is the problem is not your space, it
is the breakdown in the entire operational process. And how
would you reflect the issue of the construction and how that
may be part of addressing the systemic problems that we saw on
the operational?
Dr. Steinberg. We would love to have a new hospital, but I
will leave that aside. We took apart every single piece of the
hospital, building by building, and restructured it. The first
place we started was in the surgical department, where we got
the appropriate funding to build three new major operating room
suites. Those suites will open effectively on May 1 this year.
State of the art facility which will provide the support that
Wake Forest needs, and we need, for providing the technical
capabilities of the surgery department that we want to have.
The second thing we did was to take apart all of primary
care. With 60,000-plus patients in primary care, we wanted to
have a consolidated building to reduce the traveling that
veterans had to have from building to building across this 150-
acre campus. We consolidated all of primary care into one
building, so there was a single site for primary care within
the facility. And part of this is in preparation for the
opening of two other clinics, one in Hickory, North Carolina,
and one in Charlotte. But we now have a model within Salisbury
that handles all of primary care within a large building.
Mr. Bilbray. Well doctor, my point being, though, is that
as you talk about, and that is easy because there is some
vision, and there is concept of building it. You can buy the
most modern vehicle in the world with, you know, anti-roll and
all this other stuff. But if it is a reckless driver driving
the vehicle, you know, we are still going to have problems. And
I do not see where space and a lot of these capital projects
have to do with operational problems, like having a patient sit
there for over 24 hours, or 12 hours, without having
postoperative observation made by a nurse. All of these
facilities will not change that. So I think that in all
fairness, it is almost like a bait and switch I am focusing
here. It is, again, we need more money for construction, but
when we get down to the deficiencies, the deficiencies were
more internal, operational issues.
Let me just sort of, and accept that as a cheap shot if you
think it is a cheap shot. I appreciate that. But you have got
positions with vacancies now. Specifically, some of these
vacancies, how long have they been open and what are you doing
to take care of them?
Dr. Steinberg. We actually do not have very many vacancies
on the clinical side of the house. We have added probably 40 or
50 new clinical positions over the last year and a half. We
have gone to various medical schools around the country and
recruited some of the top physicians from the Mayo Clinic.
Mr. Bilbray. How about your Chief Nursing position?
Dr. Steinberg. Chief Nurse is filled. We have a wonderful
new Chief Nurse who has joined us. She was the former Chief
Nurse for the U.S. Naval Hospital in Charleston.
Mr. Bilbray. How long was that position vacant?
Dr. Steinberg. That position was vacant probably about 4 or
5 months.
Mr. Bilbray. Four or 5 months?
Dr. Steinberg. The process of bringing on a key individual
at that level is a difficult process because there are a lot of
human resource requirements in recruiting and selecting an
individual for that----
Mr. Bilbray. So you are telling this Subcommittee, under
oath, that it was 4 or 5 months. Which one was it?
Dr. Steinberg. I do not really know the exact timeline.
Mr. Bilbray. But it was not, your testimony today, doctor,
is that it was not over 5 months?
Dr. Steinberg. The position was never vacant because in the
absence of a Chief Nurse there was someone appointed
temporarily to that position until the new Chief Nurse could be
selected.
Mr. Bilbray. So are you saying to this Subcommittee, under
oath, that there was a temporary Chief Nurse for no more than 5
months.
Dr. Steinberg. I am not sure of the exact timeline of her
visits with us as an interim Chief Nurse, but Mr. Moore could
perhaps answer that.
Mr. Moore. I believe the current Nurse Executive was
removed from his position in December and the replacement was
brought in, December of 2004, and the replacement was brought
in approximately June of 2005. And as Dr. Steinberg had
mentioned, at that level recruitment is extended, takes an
extended period of time to put an appropriate search Committee
together, to interview, most of these candidates apply from
around the country so the interview process is quite lengthy.
Mr. Bilbray. So now the number kind of, that, look I was a
history major not a math major. But June tells me that it might
have been a little longer than 5 months if it was December to
June. Right? Is that fair to say?
Mr. Moore. Five to 6 months, yes sir.
Mr. Bilbray. Okay. Thank you, Mr. Chairman.
Mr. Mitchell. Over the last few years, have you had any
problems with credentialing?
Dr. Steinberg. Well, we have a very good system called
VetPro, which looks at someone's pre-appointment credentials so
that we know before someone is officially appointed whether
they meet the appropriate professional standards to be on the
staff. And this process is repeated every 2 years to be certain
that there are no gaps in the system. This includes a track
with the National Practitioner Data Bank and other issues, and
our credentialing system is very good, very capable.
Mr. Mitchell. Thank you. Mr. Watt?
Mr. Watt. Thank you, Mr. Chairman. And I thank you and Mr.
Bilbray for allowing us to be here. I want to do something that
is kind of out of the ordinary, which is somewhat spring to the
defense of Dr. Steinberg. You will note that he has been in
this position only since October of 2006. And Mr. Moore has
been in his position longer, but I will tell you from my own
personal experiences representing this area and this VA medical
facility that there was a period of time when there were major,
major problems throughout the whole campus. And at least part
of it was due to a Director of the entire operation who really
had some serious problems, management issues, over a period of
time. And it took a while to kind of work through getting him
out.
I can tell you based on the number of complaints that we
get in our office that substantial progress is being made. And
that the work that is being done by this group of managers,
while it may still leave a lot to be desired in terms of
accomplishing the overall mission, I can tell you from my own
experience that it is light-years better than the prior
management. That is not to be taken as a ringing endorsement of
everything that is going on at the VA. Obviously, there are
some problems in Salisbury. But I hope we will not cast all the
blame on this management team, because there was a management
team there before that was not as devoted to this. And I think
a lot of the problems that we are addressing today are a
function of that management team rather than this particular
one.
Having said that, Mr. Moore and Dr. Steinberg, I want to be
reassured and have the Subcommittee reassured that you all have
looked at all 12 or 13 of the points that were made in the
evaluation that was done by the OIG and the Medical Director,
and have taken specific, concrete steps to address each one of
those areas that was identified as shortcomings. Would you be
able to verify that you either have taken steps or are in the
process of taking steps? And with respect to the ones that you
are not now satisfied that you have reached a satisfactory
conclusion, would you identify those specifically either today
or in writing and tell the Committee what specific steps are
being taken in response, ongoing steps, are being taken in
response to those?
Dr. Steinberg. We have taken those steps and we are still
taking them. Our Morbidity and Mortality Review Program is as
good as any can be within the setting that we have. It is done
in concert with a very superb surgical faculty. We have taken
steps to improve peer review, including within our peer review
system the entire Medical Center peer review, not just for
physicians, but nurses, rehabilitation medicine, physical
therapists. All of the peer review programs that the hospital
identifies and looks at are all brought under one roof for
evaluations. We have taken steps to, one of, probably the most
important one, was to bring to the Medical Center a whole new
post-anesthesia care unit staff, which we did not have in 2003.
That was one of the critical shortfalls of the Medical Center.
And we now have nine fully trained and certified critical care,
or rather PACU nurses as they are called, Post Anesthesia
Recovery Nurses, who run an operation which allows us to
provide care 24/7 for the surgical patients in the hospital. We
have done all those things and we are addressing on a
continuing basis through the Office of Quality and Management
all of those issues, yes sir.
Mr. Watt. Let me ask you to be, in follow up, more specific
on the things that are still in process, not necessarily right
now because I am out of time and I know we are up against the
voting deadline. But if you could just outline, unless you have
done so in your written testimony, the specific steps that you
have taken that are still in process at a subsequent time.
Dr. Steinberg. Right. One of the specific things that is
still in process is to improve our educational program. And we
are doing that in several ways. But one of the things that we
felt was very important was to continue the ongoing educational
processes that are important for things like peer review,
morbidity and mortality review, educational processes that
physicians, nurses, and other staff members need to be certain
that they have the tools to address these issues on a regular
basis. The anonymous reporting system that we have for staff
members at the hospital that allows us to have in our hands,
anonymously, any issue that anyone wants to bring to our table
to discuss is something we welcome, and we are expanding that
program on a regular basis.
Mr. Mitchell. Thank you. Thank you. Mr. Hayes?
Mr. Hayes. Thank you, Dr. Steinberg and Mr. Moore and
others for coming today. I think fairness is important. I
appreciate Congressman Watt's comments. I, too, would like to
say that in our district office we have had a number of
compliments for exceptional care, and that is important. And we
do have an occasional complaint, and we are talking about some
very serious issues. Dr. Steinberg or Mr. Moore, should the
nurse that I referred to in my statement have been fired?
Mr. Moore. Actually, I had proposed removal of that nurse.
And we were planning to fire her. Then upon advice from
regional counsel and human resources, they recommended that we
not fire her and it was based on three issues. One, she had had
no adverse, any other adverse, actions in nearly 30 years of
service. While what she did was just terrible, it had no effect
at all on patient care. She was not the patients' caregiver in
these nursing homes. Her role was an oversight role, a vendor
oversight, to see that the vendors did under contract what they
were supposed to do. And third, regional counsel said it was
very unlikely that any outside disciplinary appeals board would
uphold the firing. That we could go through a protracted length
of time, hundreds of thousands of dollars, and wind up with her
back. So they had several recommendations which I felt were too
light for this situation. I went with the proposed removal, and
then did hold it in abeyance for 2 years.
Mr. Hayes. I appreciate the completeness and the detail of
your answer. However, the facts would ask that additional
oversight be provided here for someone to report that a patient
was stable 12 days after they had died. And again, let me stop
there and back up just a minute. We appreciate the service of
veterans hospital employees and others who are tremendous civil
servants. And there are requirements, and those employees have
rights and deserve to be protected as well. So with the
qualification, again I would like you to report back to me and
Congressman Watt and others, is to, the reluctance of the
oversight board, the problems of a termination here. I think we
should look at that a little bit more closely because number
one, you have got the 12 days after which the person had passed
away, but you have also got over 2 years where this person had
not visited. Something was wrong. This person had issues that
were keeping them from doing their job, but let us look more
deeply into that. Because the confidence of the Subcommittee,
the public, and other members of the VA, it is not as important
as the care of the patient, but it is very important going
forward that we do not have a system that allows someone whose
performance determines life or death, in some instances, of the
patient, let us investigate that further and review it more.
Dr. Steinberg. That, sir, is a very important statement.
And the CAP survey did point out another very serious flaw in
the system, which I would address with you, and that I think we
have corrected. What we found was that we were never notified
by any of the contract nursing homes when they had been placed
on a Licensed Agency Watch List. In other words, they had done
something which had raised a red flag about the care that they
provided in these contract nursing homes. We had no way of
getting that information automatically. We have had our
contracting folks change the rules now, so that as part of
their contract if they are notified by any agency that they are
placed on the Watch List that they have to report that to us
within 10 days. That is a very important change in the system,
and is a reflection, I think, of the findings from the CAP
survey.
Mr. Hayes. It is important. Thank you for pointing that
out. Mr. Cintron, or Ms. Shapleigh, do you have anything you
would like to add to that? That is what the newspaper always
does when they want to trick you into saying something. Thank
you very much. Mr. Chairman, I yield back.
Mr. Mitchell. Thank you. And I would just like to tell the
panel, any reports that were asked by either Mr. Watt or Mr.
Hayes, if you would address those to the Subcommittee, and then
we will distribute those to the members of this Subcommittee
and those who ask for it. So, please give those reports to us.
Just very quickly, a couple questions to Mr. Moore. And Mr.
Moore, it is good to see you. He took me on a tour of the Carl
T. Hayden Medical Center in Phoenix not too long ago. Just very
quickly, how are doctors and nurses screened throughout the
whole VA system to ensure that they are in compliance with the
VA medical guidelines?
Mr. Moore. Well, as Dr. Steinberg had alluded to, we have
an extensive credentialing and privileging process. And I
really can only speak to the hospitals that were under my
management, but the systems are common to all hospitals. There
is a, I would venture to say our screening and prescreening
process is far more stringent than any private sector. We have
actually had some physicians decide maybe not to come to the VA
because we went so far back in their history, getting all of
the, assuring that all of the credentials were appropriate for
them.
Mr. Mitchell. So, all their verifications with their
licenses and their practices, this is all done----
Mr. Moore. Before they walk in the door, yes sir.
Mr. Mitchell. Okay. I have one other question, Mr. Moore. I
want to depart from what we have been saying here. One question
that my constituents would like to know, are there any quality
care issues at the Carl Hayden VA Facility in Phoenix that I
should know about? Especially in light of issues that we are
addressing today. I do not want to find out that there are
problems at the Carl Hayden VA Hospital from the newspaper,
like some of the reports that we have been finding out lately.
So, are there any quality of care issues that we need to know
about at the Phoenix facility? And if there are, what are they
and what are we doing about it?
Mr. Moore. Well, I certainly hope that there are not. There
is always clinical issues that we are looking at. We look at
different rates of deaths in intensive care units and other
areas. But there is nothing that I am aware of that should be
of major concern that would put any of our veterans patients
and their care in jeopardy at the Carl T. Hayden VA Medical
Center.
Mr. Mitchell. So you do not think there is going to be
anything I am going to be reading about in the paper about the
Carl Hayden Medical Facility in terms of quality of care?
Mr. Moore. No, sir. There was an Office of the Inspector
General CAP survey at the Carl T. Hayden VA Medical Center I
believe just several weeks before I got there. And it was one
of the best CAP survey reports that I have read. So I was very
proud to be coming into a facility that achieved such a great
survey.
Mr. Mitchell. All right. I do not want to read about any
problems with that facility. Thank you. Thank you very much.
And we are going to recess this Subcommittee hearing until
after the vote, which is about 15 minutes.
Mr. Bilbray. Mr. Chairman, can I just ask quick question?
Doctor?
Dr. Steinberg. Yes, sir.
Mr. Bilbray. The sort of the last ditch tickler that there
is a major problem is usually the morbidity review. There are
no minutes of a Committee reviewing the deaths in the facility.
Did you have a review process or was there a review process?
Dr. Steinberg. We review every death at the hospital. We do
a lot of RCAs to look at these.
Mr. Bilbray. Do you do it with a review Committee?
Dr. Steinberg. We have a review Committee, we absolutely--
--
Mr. Bilbray. Is there a reason why there were no minutes to
the Committee?
Dr. Steinberg. Well, I think we have minutes.
Mr. Bilbray. Now?
Dr. Steinberg. I do not know what the history was, you
know? I was not there for that at the time, but we have good
minutes now.
Mr. Bilbray. Okay.
Dr. Steinberg. They are well recorded, and our morbidity
and mortality data ranks the VA Medical Center in Salisbury
within the top eight VAs in the country. We are below the
morbidity and mortality levels----
Mr. Bilbray. But prior to your arrival?
Dr. Steinberg. The numbers were not good. You know, part of
the reason for the issues that were brought up by that
anonymous call had to do with the fact that there were
procedures done in the operating room which belonged in an
endoscopy suite. And if you look carefully as we did at the 12
alleged deaths, many of these were in terminally ill patients
who were part of the hospice unit who had feeding tubes put in
for palliative reasons. And their deaths were anticipated
deaths, and they were not related to a surgical procedure per
se.
Mr. Bilbray. That is not what I was concerned about. Again,
I am going over the procedure. We have corrected the procedure
that, the reports I had was that they did not have a
functioning Committee reviewing these deaths, or at least we do
not have any records of them. And that, let us face it, that is
sort of the last ditch catch all, is always reviewing every
time we have a death in a facility, is to make sure that the
process that led up to that death was well within the
parameters of the facility.
Dr. Steinberg. I would not minimize the problems that were
there in years past, because they were significant. It is my
hope and prayer that we address all of them effectively as we
have in the last few years, and that we will continue to do
that. But there were mistakes made and there were serious
problems and we think they have been corrected.
Mr. Bilbray. Thank you very much, Mr. Chairman.
Mr. Mitchell. Thank you. We are going to take about a 20
minute recess. And when we come back we will see Panel Three
and will continue. This meeting is recessed.
[Recess.]
Mr. Mitchell. We will reconvene the Subcommittee on
Oversight and Investigations for the Committee on Veterans'
Affairs. And I would like to just mention that the Ranking
Member will not be here. She is tending to one of her own
bills, which is having a hearing right now. So instead I will
have the Minority Counsel follow the line of questioning that
would have occurred.
At this time we are welcoming Panel Three. Mr. William
Feeley, the Deputy Under Secretary for Health for Operations
and Management is here courtesy of the VA and I would like to
welcome his thoughts. He is accompanied by Dr. James Bagian,
the Chief Patient Safety Officer, Dr. Barbara Fleming, the
Chief Quality and Performance Officer, and Dr. John Pierce, the
Medical Inspector. Mr. Feeley, you have 5 minutes to make your
comments.
STATEMENT OF WILLIAM F. FEELEY, MSW, FACHE, DEPUTY UNDER
SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY JAMES P. BAGIAN, M.D., CHIEF PATIENT SAFETY
OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; BARBARA FLEMING, M.D., PH.D., CHIEF QUALITY
AND PERFORMANCE OFFICER, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; AND JOHN R. PIERCE, M.D.,
MEDICAL INSPECTOR, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Mr. Feeley. Good afternoon Mr. Chairman and mmbers of the
Subcommittee, and I want to thank you for the opportunity to be
here today. I want to state that Salisbury has turned a corner
and I am pleased with the positive steps they have taken to
improve the quality of care provided at the VA Medical Center
during the past 2 years. In my statement, I will focus on the
many ways VA monitors the healthcare of our veterans and
returning warriors and ensures that our VHA facilities learn
from this process.
In the late eighties, VA healthcare programs came under
intense scrutiny because of the perception that quality was not
comparable to that found in the private sector. Since that
time, VA has implemented numerous programs to ensure that
quality of healthcare provided to our veterans is world class.
The results of these efforts have brought national recognition
to VA as consistently being recognized as one of the premier
healthcare providers in the United States. VA's successes can
be attributed to the leadership and contributions made by the
offices of the talent sitting with me today, as well as the
daily efforts of the VHA workforce.
VA's performance measuring system is a key part of the
transformation of care that started in the mid-1990's. The
system has over 100 performance measurements in the areas of
access, satisfaction, cost, and quality. Data on these measures
are collected monthly and all performance is shared and
distributed in a quarterly report to the field facilities with
information broken down into aggregated totals for facilities,
network, and the VHA overall performance. Patient complaints
are assessed by a series of questions on the inpatient and
outpatient satisfaction survey asking whether each veteran has
a complaint about VA care and whether the veteran was satisfied
with the resolution of the complaint. Patient advocates in the
National VA Patient Advocacy Office monitor these results
closely to ensure that veterans' voices are being heard daily.
VA utilizes a learning system that exports and disseminates
information to all segments of the VA healthcare system so that
providers can learn how to deliver care that is not only safe,
efficient, cost effective, but clinically measurable and
evidence based. For example, the systematic ongoing assessment
and review strategy, known as SOARS, is a unique internal
initiative that was implemented within VHA in 2004. Our own
staff are trained to conduct assessments of more than 30 major
processes at facilities to identify weaknesses, best practices,
and help educate staff required for functions and activities
across the country. These are not people reviewing their own
facilities; these are people reviewing other facilities. This
innovative approach promotes a culture of continuous learning
and readiness throughout the organization.
As a public system the VA undergoes intense scrutiny from a
variety of accreditation agencies, both external and internal.
There are approximately 45 different types of reviews that can
occur at our Medical Centers during any period of time. One of
the most recognized is the Joint Commission on Accreditation
and Healthcare. All our VA facilities are accredited. Also, the
Office of the Inspector General, the Government Accounting
Office, are frequently visiting our facilities and giving us
feedback on how to improve our system. Both the JCHO and OIG
reviews give us ongoing opportunities to identify our strengths
and weaknesses.
I appreciate the opportunity to talk with you today. The
events at Salisbury have spurred us to go even farther in our
monitoring process than I have described to you. I am
instituting additional rigor with oversight in transporting our
learning throughout the system. The more rapidly we learn, the
better our patient care impacts will be. I look forward to
taking any questions that you might have, and that concludes my
statements. Thank you.
[The prepared statement of Mr. Feeley appears on page 52.]
Mr. Mitchell. Thank you, Mr. Feeley. I have a couple
questions for Dr. Pierce. I know the focus here is on
Salisbury, but we are also trying to find out if procedures and
things at Salisbury are also going on in other hospitals,
because this is a concern we all have. In the June 9, 2005,
report you stated that the culture of surgery service was not
one of quality improvement. You stated that there has been
inadequate ongoing review of the quality of care provided by
the surgery service, as their participation in performance
improvement has been lacking. Firstly, I want to know, what has
Salisbury done to rectify this? And is this problem solely one
that is at Salisbury, or is this problem found in any other VA
hospitals?
Dr. Pierce. Good afternoon, sir. I feel like Salisbury has
done a very good job to correct this. I think they have turned
this program around 180 degrees. And if they were, if I were to
grade them from when we first went I would have to give them
probably a D minus, but I would have to give them a very strong
B plus now because they have grabbed this problem by the throat
and taken care of it, I think. They have new personnel, and
they have a new commitment to quality management. They have a
new quality management nurse that is in the surgery service,
and they have grasped the requirements and they are doing a
good job with that.
We have seen some, probably not quite as broad, but some
similar issues at other facilities. For example, we went to a
place to look at their surgical program and they were doing
surgical morbidity and mortality Committee meetings but they
were not doing minutes. And so we took that information back to
the National Director of Surgery and on a systemwide conference
call he made sure all the Chiefs of Surgery understood that not
only do they have to do an M and M Committee meeting but they
have to do minutes of that Committee. And that was spread
throughout the whole system. So we do take the information we
find and try to transport it throughout the whole system.
Mr. Mitchell. I think you understand that our concern is
that while we know that you said maybe Salisbury had a D minus,
and it was very bad, and so that is why you came in. But we
want to make sure that other hospitals do not ever reach that
level. I think it is up to you to make sure that what you found
in other hospitals is transmitted. And if you had a conference
call, for example, on minutes I would hope that there are
systemwide conference calls very frequently so that what you
find in one place can be transmitted and everybody is aware of
how to correct these.
Let me ask also, Dr. Pierce, have you gone back to
Salisbury for a follow up from your initial visit in 2005?
Dr. Pierce. Yes sir, we went back last month. You know,
when we first went there, what our process is, is when we go to
a site visit and we come back and write our report, we usually
make a number of suggestions for them to change things to
improve things. And those things, when they are agreed to by
the Under Secretary for Health, the facility does an action
plan addressing each and every one of those items. And I think
the initial Salisbury report had 18 findings on it that they
had to address. The facility did an action plan, and addressed
each one of those 18 findings. We reviewed the action plan, and
then we approved the action plan. And over the course of the
next year, we tracked those items with input from the facility
to show to us that they had corrected these things.
Mr. Mitchell. And they have met them?
Dr. Pierce. There is follow up on our reports. That came up
before, that we follow those reports up and every finding that
we have, an action plan is done and we track that with the
facility, and make sure that those things are done. And then
once they are done, which sometimes it takes a year or so for
everything to be accomplished to our satisfaction, we usually
close the report.
Mr. Mitchell. Have they been closed?
Dr. Pierce. We did close the Salisbury report in August of
2006.
Mr. Mitchell. Thank you.
Dr. Pierce. And we did go back about a month ago to make
sure, just to check everything, and we felt like that they had
responded appropriately to all of the things that we had found
there. We did find that, we had asked them to make sure that
they informed the families about autopsy findings. And we asked
them to show us their autopsy reports for the last couple
years. They do not do a lot of autopsies there, and there were
seven total reports. And of those seven reports they were not
all done to our satisfaction. They need to improve that, and I
think they are aware of that. So there was only two of those
where there was documentation in the medical record that the
family had been notified. There was another documentation
elsewhere that letters had been sent to the family. There were
a couple that apparently they could not document they had
actually talked to the family about the autopsy results. So
that was one of our findings that they have not completely
responded to.
Mr. Mitchell. All right, let me ask just one quick follow
up. Every time you find a deficiency in these, I would hope
that you would pass this finding onto other medical facilities.
That you would not have to go to each facility and say, ``Oh
yeah, we just had this same problem in another State.'' That
you would make sure, that if these things were not followed in
Salisbury, for example, communicating with family members, I
assume they probably were not being followed in other hospitals
as well. I would think that every time you find a problem in
one, that you have a conference call or you have something that
says, ``Hey, we need to make sure.'' If it is done in one, I
suspect it is going to be done in another. Thank you. Mr. Wu?
Mr. Wu. Mr. Chairman, Ms. Brown-Waite, the Ranking Member
of your Subcommittee appreciates your indulgence in allowing
the Minority Counsel to pursue her line of questioning, and I
thank you again.
Mr. Feeley, we have read in your testimony about how the
VA's National Center for Patient Safety has made great strides
to have VHA understand and prevent adverse events to our
veterans patients. I would like to recognize Dr. Jim Bagian,
who is accompanying you, for all his efforts in spearheading
these preventive, lifesaving measures. I especially appreciate
his efforts in bringing the dangerous practice of incorrectly
cleaning and disinfecting a special ultrasound device used for
prostate biopsies. His discovery and immediate alert on this
potentially extremely dangerous practice prompted this
Subcommittee to bring the FDA lack of interest in issuing a
national alert to the forefront, and resulted in a national
alert warning to help protect all patients, not just veterans.
Thank you, Dr. Bagian. Would you like to talk on your role in
how we use the Patient Safety Center that you head up in
recognizing these adverse events and trends so that you can
prevent them on a systemic basis using Salisbury as a study?
Dr. Bagian. Sure. Yes, I would be glad to. Thank you. I
would like to make a few remarks to start out with. Earlier the
question was asked, I think, of Dr. Daigh, how collegial, the
word was not collegial, but the interaction between OMI, OIG,
and the VA. And I would like to say from the beginning when we
set up the Patient Safety Program with the VA one of the first
sets of meetings I had, and they were the predecessors of Dr.
Pierce and Dr. Daigh, was to talk to them because my view, and
I think the view of VHA, was that though it might not always
seem that way, we are working toward the same goal, and that is
to deliver the best quality of care and safest care we can to
our patients. And if they would know something or discover
something that we did not know, and that certainly can happen,
we want to profit by that. So that is one thing I would like to
get out front, and we continue to have, I think, a good ongoing
relationship in that regard.
We have numerous ways that we find out about things. Some
are through formal reporting systems, and we have several of
those. I would point out that we look not only at adverse
events that happen, some of which have been discussed today,
but we also look at close calls. Close calls are those events
that could have resulted in harm to the patient but did not,
either due to a good catch by somebody or sometimes just good
luck.
Mr. Wu. Well, let me interrupt you for a second here. In
your reporting system on close calls and non-attribution on
reporting near misses, using your system and the way you have
educated the system and tried to promulgate that, did any of
the events at Salisbury ever rise to your attention based upon
the system that you utilize?
Dr. Bagian. Absolutely yes. In fact, the one case that was
talked about is the index case, the surgical case that was
mentioned a little bit earlier. That case occurred, if I recall
correctly, on July 14. The RCA Panel was convened and charged
on July 14, and I believe on August 23 they had concluded the
RCA with their recommendations and action plans were filed. So
it was well within the prescribed period of time to respond and
action was already being taken. I mean, that is one for example
I know of in detail, off the top of my head.
Mr. Wu. Well, how would you follow up, once it reaches your
radar screen, and the RCA, the Root Cause Analysis is done,
that you follow up, or what is the follow up mechanism of
whether or not that facility and those findings are corrected
or remedied?
Dr. Bagian. Okay. When an RCA is submitted, well, there are
a couple of things in the flow. Firstly, when the incident is
first discovered and is SACed, that is when they prioritize it
and that is where we have a very explicit method by which we
decide does this rise to the level that requires action. In the
case of that surgical case, that met that mark. Even if it does
not, it is filed in our data collection system so we get it
right then. At that time, we will review that. If we think it
is something that has global impact based on just a few
sentences that were reported. We do not know all the things
yet, it is just that it happened. If we think this is
something, and that is what happened with the ultrasound you
talked about. Before the RCA, Root Cause Analysis, was even
completed we realized this was much bigger than that and we in
parallel did the things that you referred to.
Mr. Wu. Well, how was your system used in those issues that
rose to your attention out of Salisbury then?
Dr. Bagian. Okay. So what happens is, in this case the
Salisbury incident, that first report that there had been a
patient incident was not enough to say is this a generic
widespread thing, as the Chairman talked about a few moments
ago. It was not clear. So we waited for the results of the root
cause analysis. When the root cause analysis is finished, it is
submitted to the National Center for Patient Safety. They are
all filed with us, and they are reviewed by our analysts there.
And there are a number of criteria. But then they feed back to
the institution if there are things that appear to be lacking,
for instance specificity of causation statements or weaknesses
of corrective actions, and that is fed back in a short period
of time.
At that point, in the forms, in the system, it also sets
reminders. So, for instance, if they say----
Mr. Wu. And Dr. Bagian, I see that my time is up and I do
not want to outlive my welcome with Chairman Mitchell. And I
will pursue this on the second line of questioning. Thank you,
Chairman Mitchell.
Mr. Mitchell. Thank you. Mr. Watt?
Mr. Watt. Thank you, Mr. Chairman. And this is likely to be
my last opportunity to reinforce something I said earlier to
you and the Ranking Member of this Subcommittee and to the
Chairman and Ranking Member of the full Committee how much we
appreciate, Congressman Hayes, Congressman Coble, and myself,
the speed with which you all undertook this review and the
thoroughness and attention that you have paid to it. And also,
to thank you once again for allowing us, as nonmembers of the
Veterans Affairs' Committee, to be active participants in
today's hearing. So I know I have said that three times now, so
three times is the charm and I will try not to say it again.
Mr. Pierce, I think I want to follow up with you because
the Inspector General kind of threw a ball to you. And I want
to break this down as concretely as I can. This original
investigation was started by an anonymous phone call that
alleged that twelve veterans had died as a result of improper
medical care. And I am putting myself in the position of the
family members of those 12 people. And I would like to know,
obviously what Mr. Feeley has said, that attention has been
given to correcting the problems and that the VA Hospital at
Salisbury has a B plus report. We hope it gets up to an A at
some point going forward, and that quality medical care is
provided to all veterans going forward. But the other side of
this is that the question I raised this morning, is our
responsibility to those 12 families. An investigation was done
by your office, and an evaluation was made individually, I
assume, of those 12 cases. Is that correct?
Dr. Pierce. Sir, our office did not look at all 12 of those
cases. Those 12 cases, in fact, let me back up a little bit.
The anonymous information we had had no names of patients.
Mr. Watt. Yes.
Dr. Pierce. It mentioned one patient, the gentleman that
was the surgical index case in our report of 2005. The other,
we did not have any names for.
Mr. Watt. Well, at Salisbury VA Hospital, how many deaths
would you have on average in a 1 or 2 year period before this
anonymous tip came?
Dr. Pierce. The information that I have looked at from the
facility, their reports, including the nursing home and the
psychiatric units, they have about 50 deaths every 6 months. So
it is about 100 deaths a year.
Mr. Watt. So you would have had to go back individually and
review all 100 of those cases for the prior year?
Dr. Pierce. Well, the assumption was that these were from
the surgical service because of the way the letter was----
Mr. Watt. Okay, how many would you have in the surgical
service?
Dr. Pierce. Well, I think these 12 deaths, what they did is
they went back 2 years and it equated to about 12 deaths, and
they had all 12 deaths reviewed by their affiliate medical
school.
Mr. Watt. Now----
Dr. Pierce. We looked at those, and we looked at those
reviews that the medical school did, and thought they had done
an acceptable job in reviewing those.
Mr. Watt. Okay.
Dr. Pierce. We pulled out the case that became the index
case for us because we thought that was particularly
problematic, and went to the facility to specifically look at
that case and the care that that gentleman got.
Mr. Watt. Okay, well let us look at the other 11 cases
first. You are saying that your determination in the other 11
cases was that there was no lower than expected quality of
care?
Dr. Pierce. In those 11 cases, 5 of them were rated as they
received care that every other doctor would give.
Mr. Watt. Okay.
Dr. Pierce. Five were rated that we might have done some
things a little different, and two were rated we would have
done it differently.
Mr. Watt. Okay. Let us look at the seven, then, that we
have narrowed this down to, and what I am trying to get to is
what is our obligation then, what then happens with the
families of those seven people? There is a possibility that
less than adequate medical care has been provided to their
loved one. There is a possibility that their loved one may have
died as a result of that lower quality medical care. What is
our responsibility? What is our follow up? What do we do with a
family in that situation?
Dr. Pierce. We have a requirement if an adverse event has
occurred, whether it results in a death or not, but just an
adverse event occurs to a patient, the patient has to be told
about that. And so in these seven cases or, you know, we would
look at those cases----
Mr. Watt. Well, we know an adverse event occurred. They
died. So that was an adverse event. Who would have the
responsibility of going out and communicating with the family
of that patient and looking them in the eye? And what would you
say about the quality of care? Would you just say your loved
one died and it is unfortunate? Or how much information would
we give the family about the circumstances of that
investigation?
Dr. Pierce. I think full disclosure is what we would like
to see. That if we have done something incorrect medically, the
family should be told about that and should be offered the
opportunity to file a claim about that.
Mr. Watt. Okay. All right. I know I am out of time. I am
sorry.
Mr. Mitchell. Thank you. We can come back. Mr. Coble?
Mr. Coble. Thank you, Mr. Chairman. I want to reiterate
what Congressman Watt said. Thank you for extending the
courtesy to him, Congressman Hayes, and me for this. And I want
to thank Congressman Watt also for explaining my absence
earlier. I was tied up in a Judiciary Committee hearing and
simply could not get over here.
Congressman Watt, Congressman Hayes, and I are involved.
The facility is located in Congressman Watt's district. He and
I share the county in which it is located, and Congressman
Hayes represents the adjoining county. So that explains why we
are the triumvirate in this matter. We received responses from
our joint letter from Salisbury and it appears they are
responding favorably to criticisms that were leveled earlier. I
guess one thing that prompted a lot of attention, not only to
Salisbury but elsewhere, when the problems at Walter Reed
surfaced, I think many folks said, ``My gosh, if it is this bad
at Walter Reed, what is it like in the hinterland?'' And I
think that may have triggered a lot of the attention.
As an aside, Dr. Pierce, this has nothing to do, well, this
has something to do with Salisbury as a matter of fact. Most of
the complaints that we received down home, Mr. Chairman, in my
district, do not involve the delivery of quality healthcare.
Most of my veterans are not unhappy with that. That is not to
say we do not get complaints, we do. But for the most part, the
complaints zero in on the delay that the veterans incur before
claims are approved, as an example. And that is just for your
information. I want to throw that out.
And Mr. Chairman, let me ask you a question if I may. Does
the Committee on Veterans' Affairs plan to follow up on the
Salisbury matter?
Mr. Mitchell. Yes, Mr. Coble. In fact, in earlier panels
there were some reports that were asked for by Mr. Hayes and
Mr. Watt.
Mr. Coble. Okay.
Mr. Mitchell. And when we get those report back we will
communicate them.
Mr. Coble. And I think that is important, and that pretty
much exhausts my line of questioning because I haven't been
here earlier. And I again apologize for my delay, but thank you
for having the hearing. Thank you all for being here.
Mr. Mitchell. Thank you. Mr. Wu, do you have any followup?
Mr. Wu. After you, sir.
Mr. Mitchell. I do not have any. I am fine.
Mr. Wu. Thank you, Chairman Mitchell. Question for Mr.
Feeley. In your testimony you stated that by issuing a
multitude of important directives to improve patient safety,
``VA has acquired the ability as the largest integrated
healthcare system to affect change and impact millions of
patients.'' I think this is very important, and you can stack
those directives from the floor to the ceiling, but can you
explain how you can ensure implementation? And what is the
process to go back and check for the continuing compliance?
Mr. Feeley. I think we are really operating with a trust
and verify design. We have numerous ways that we get
information out: emails, teleconferences, directives. But we
also have a training that employees get and we have numerous
systems in place where we go out and review. And one of those
systems is the SOARS process. There are 42 different checklists
that we have got in the SOARS process, not dissimilar to the
same type of checklist that a flight crew would use before it
takes off. So you want to make sure everything is in place and
working. That goes on at a national level, it goes on at a
network level, and it also goes on at a facility level via our
quality management department and utilization review programs.
So the more rapidly we transport learning, the better we are
going to perform. But also, we are out there verifying that
actions are being taken.
Mr. Bilbray. Mr. Feeley, I have a question for you. Your
SOARS Program has been in place for how long?
Mr. Feeley. Since 2004.
Mr. Bilbray. So what happened at Salisbury that this was
not detected, then?
Mr. Feeley. SOARS visits sites on a schedule, and we I
think visit 47 sites per year. I do not know whether a SOARS
visit has occurred at Salisbury, but would like to defer to Dr.
Steinberg.
Dr. Steinberg. I am right here. We had a SOARS visit this
past year. I am not aware of a previous one.
Mr. Wu. Mr. Feeley, could we have the results of that SOARS
report for Salisbury? The other question I have, and I am
trying to make efficient time for my 5 minutes here for the
minority. Dr. Pierce, it is my understanding that you have
issued six OMI reports in the recent past. Is that not correct?
Two part question. Is a follow up to those OMI reports any more
expeditious and thorough than what has been done on the
Salisbury 2005 OMI report? And two, to the best of my
recollection as the staff director of this Subcommittee for the
minority side, we have asked for all OMI reports on a timely
basis upon release, and unless our mail system has failed us
abjectly I do not believe that we are in possession of the
majority of those OMI reports. And I know that those are, I
would not say close hold, but is there a reason why we have not
received those, this Subcommittee?
Dr. Pierce. Sir, I do not know if there is. We have
forwarded your request several times, that these reports be
sent up to you once they are approved by the Secretary.
Mr. Wu. Do you think it is the Subcommittee? Me? That we
are not receiving these?
Dr. Pierce. I will look into it, sir. I cannot answer that.
Mr. Wu. All right.
Dr. Pierce. The first part of that is, the follow up of our
reports depend upon the things that have to be done. Some of
the things that the facility has to do are relatively minor and
can be done fairly quickly. Others take longer. With this
report we had 18 things the facility needed to do and so that
took longer to accomplish.
Mr. Wu. All right. If it would not be unreasonable to
request all outstanding OMI reports for the past 2 years. If we
could have them by close of business tomorrow, if that is not
too adverse and laborious an issue. We would like to see that.
I understand that there is also an OMI report on Asheville?
Dr. Pierce. Yes, sir.
Mr. Wu. Okay. Mr. Chairman, if we could get those delivered
to us.
[The Subcommittee received the OMI reports from VA.]
I do have one other question, here. Dr. Fleming I hate to
have you come up here without being able to say anything and we
are bringing you up here. I know that you would rather not say
anything. But as the Chief of Quality and Performance, how
would you rate the 100 performance measures in the areas of
access, satisfaction, and quality at Salisbury right now?
Dr. Fleming. We checked all of our numbers. We have audited
their credentialing, we have looked at their performance from
2002 when there were really problems, we have looked at our
Joint Commission reports, we have looked at the OIG reports, we
have looked at the OMI reports. Salisbury is really a success
story. It is, in my view, a phenomenal story. They are now
ranked I believe 35 in terms of quality, access, and
satisfaction aggregate score of our facilities.
Mr. Wu. Out of the 152 facilities?
Dr. Fleming. We have enough data actually to rank I think
140 of those. So they have just done a phenomenal job. The
measures that we have looked at that they have had problems
with, they have really turned around. They have processes in
place that we actually have also replicated on a national
level. That team at that facility took their problems to heart
and really did some fixes. So I would be pleased to get care,
personally, there, and I think our veterans should feel very
comfortable at that facility at this point in time.
Mr. Wu. All right, Dr. Fleming, I know the red light is on,
Mr. Chairman, Mr. Feeley, and Dr. Pierce, how would you rate
Salisbury today? If you were the teacher, what would the report
card be? You can all three confer and come up with an average.
Mr. Feeley. I am going to stick with Dr. Pierce's rating of
B plus. Having said that, though, the goal here is to get an A,
because I think veterans deserve that and we had better be
constantly looking to improve in every one of our locations.
Dr. Fleming. And I just would like to add that they are
actually a model for the kinds of improvement and the kinds of
commitment to improvement with this team that is currently
there.
Mr. Wu. Thank you very much. One last comment I would like
to make is I am retired from the military, and I see your Chief
of Staff at Salisbury, Dr. Sid Steinberg, used to be the
Commander at the Fort Belvoir Hospital, and he had such a
reputation of being such a hard charging guy that I made every
effort that I did not have to work for him. But I am sure that
you are in good stead with him.
Dr. Steinberg. Nothing has changed.
[Laughter.]
Mr. Wu. Thank you very much, Mr. Chairman.
Mr. Mitchell. Thank you. And just add one thing to what Mr.
Coble said, I think that every Congressman and every Senator
here would say the same thing. When they get complaints, the
biggest complaint is time and waiting in line. And something
really needs to be done with that, because that is a universal
complaint that I think we all hear. Mr. Watt.
Mr. Watt. Thank you, Mr. Chairman, once again. And I will
not prolong this, but with two questions, one of which I hope
you will follow up with the Committee to provide the answers
to. A full report of whatever exists on the contacts that were
made with the families of those seven individuals that we have
narrowed this down to now, because it may have some
implication, may not, for how we deal with families and what
kind of rules of the road may be important going forward. And
second, on the one that we really zeroed in on at the end of
the day, tell us, if you can, what the remedies are in the
current legal framework that we have set up for veterans. If
somebody were in the private sector, there would be some
possibility of pursuing a cause of action for medical
negligence. What is the counterpart to that in the VA system? I
mean, what is the remedy?
Mr. Feeley. I would like to comment that Dr. Pierce
described the policy and the policy is when there is a clear
mistake we have made, we have a responsibility to sit down with
the patient. And if the patient is deceased with the family
members and explain what has happened. That is usually done by
the Quality Management Department Head and the Chief of Staff,
the Director might become involved, and at that point in time
usually some sort of investigation has occurred and findings
have occurred, and we are going to discuss with them what has
happened. We are then going to advise and give them counsel on
how to file a tort claim, which is how they seek compensation
from the Federal Government for any error that----
Mr. Watt. So it is under the Federal Tort Claims Act?
Mr. Feeley. Correct.
Mr. Watt. Okay. All right.
Mr. Feeley. And I would say to you that this is the way it
is supposed to be, and I think we have many, many people
operating that way. Healthcare providers come to work to do a
good job, but they also know the only way we are going to learn
is unfortunately from errors that we make and get better.
Mr. Watt. And when you sit down with the family, once that
is done is there a report rendered on that meeting? I mean, can
the Subcommittee expect at the end of each one of these seven
processes that there will be a report of a meeting with a
family?
Mr. Feeley. What I would indicate to you is I described the
way the process would happen in any case, across the country.
As it relates to the seven cases, I did not pick up, Mr. Watt,
what Dr. Pierce said, whether there was a negligence issue in
these cases. I may have misunderstood him.
Dr. Pierce. Well, two of the seven were level three
findings. And the other five were level two findings. And so
there may not have been any negligence, and a level two finding
is that some people might have done this differently but some
people would have done it the way you did it. And so there----
Mr. Watt. What would you say to a family under those
circumstances? I guess what I am trying to figure out is what
would be the protocol when there is even a question raised
insofar as dealing with the family member or members.
Dr. Pierce. I think that different physicians would handle
that differently. I doubt if they would have a meeting with the
Chief of Staff in a situation where the finding was that some
people would have done this the same way, and so there was no
malpractice there.
Mr. Watt. No, in those seven, as I understand it, there was
a determination that some people would have done it a different
way. The five you eliminated because some people, would all
people who reviewed it said they would have done it the same
way. The seven, that is the reason I zeroed in on the, what I
am trying to find out is what is the protocol when that
question is raised. There might be a protocol for those, and
then there might be a separate protocol for those where you
actually make a determination, ``Yes, somebody did something
wrong.'' But there should be a protocol for both and I think it
is our responsibility to the families to know what the protocol
is and if requires adjustment, have the Committee make an
evaluation of it. That is the only question I am raising. I am
not saying anybody did anything improper. I just, this is
information that is being generated retrospectively just as the
Council is trying to get information about information going
forward. So that is the request I would make.
Mr. Mitchell. Mr. Coble, anything? I think that exhausts
our questions, but I do have a concern. I know this was a case
study on Salisbury. But how many medical centers did you say we
have throughout the Nation?
Mr. Feeley. One fifty-four.
Mr. Mitchell. One fifty-four?
Mr. Feeley. Be aware, too, Mr. Chairman that we have about
850 clinics.
Mr. Mitchell. Right.
Mr. Feeley. So we take it very seriously in monitoring the
quality in those clinics as well.
Mr. Mitchell. Well, my concern is that because of the
spotlight that has been on Salisbury, things everybody has
said, even panel members here, or members of the Subcommittee,
that things have improved a great deal and are super. But my
concern is, that is because the spotlight is on here, what are
you doing with all these others? You know, I understand there
are reports out there from Asheville, Phoenix just had a report
that has not been released yet. But I am concerned, what I
would like to see is the same kind of oversight, the same type
of concern that you put on Salisbury on every one of these
medical centers. And I am not so sure that has happened. How
are we going to know that what, the findings you have made at
Salisbury are also going to be implemented and carried out in
all the other medical centers?
Mr. Feeley. There are multiple mechanisms through which
that occurs. As the SOARS process which was developed in 2004,
I have been in this position about 13 months. We have added
additional resources to that group, and we are cross working
all findings from what the SOARS group finds, and the IG finds,
and JCHO finds, or any outside review group, so we see
recurrent themes, shows us where we need to do training, we
take these issues up on national conference calls with our
quality managers and our chief medical officers at a network
level. Again, our goal is to transport that learning rapidly
across the system. I think the Committee has a legitimate
concern, that a sense of urgency exists when we do this. And
now we see Dr. Pierce going out on an issue within 24 hours.
That has happened probably four times in the last month, where
we have had a concern and we wanted to look at something. When
we go out and look, we had a wrong site surgery occur, we are
going to transport that across the system.
Mr. Mitchell. I heard you say that Salisbury is now maybe
about a 35 out of 140. I would like all those below that, the
other 100----
Dr. Fleming. Correct.
Mr. Mitchell [continuing]. To be at the same level, all
above average.
Dr. Fleming. I wanted to comment on a couple of things. I
do not think there is another medical system that measures
itself as intensively and comprehensively as this one does.
Every month facilities get reports on how they are doing that
month. Every quarter we roll that data up so that facilities
see how they are doing, their network director also sees for
the network. As a system of care, every quarter we look across
those measures and we say, ``Do we have a systems issue? Do we
have 1 facility that is really doing poorly in 1 area, or do we
have 10 facilities?'' When we do that, then there are a variety
of things that we do, including making sure that our leadership
gets that report, or picking up the telephone and calling the
Chief Medical Officer and saying, ``You know, you have got one
extra case this month we need you to review. Can you go back
and do a case review and let us know what you find?'' So there
is a tremendous amount of feedback that occurs, and a
tremendous effort to ask, ``Have we got a systems issue?'' So
hopefully we do that.
One thing I think is important to know, when the VA is
benchmarked against the private sector we do very well. For the
outpatient measures we consistently have trumped the private
sector for all of the 15 commonly measured and reported
outpatient measures. For the inpatient measures we have a
little bit more of a challenge, but we still consistently do
the same as or better than the private sector for most of the
measures that we measure. When it comes to patient satisfaction
there is only one nationally standardized survey, it is the
American Customer Satisfaction Index. And the VA consistently
does five points better than the rest of the world. Do we have
things we want to work on? Absolutely. Are we doing that?
Absolutely. But overall, I think our quality, the quality of
care that our veterans receive is excellent and there is
tremendous commitment to that. And we are working very hard
every day to make sure that that quality gets better and
better.
Mr. Mitchell. Well, I would hope that if it is, if what you
need is resources, that that request is made. And I would hope
that we have no more case studies before this Committee on
particular health centers. The last question is Mr. Wu.
Mr. Wu. Thank you, Chairman Mitchell. Mr. Hayes is asking
for his letter that was responded to him by the VISN Director,
Dan Hoffman of VISN 6 dated April 18, 2007, addressing his
concerns that were in the Charlotte Observer be entered into
the record.
Mr. Mitchell. So be it.
[The referenced letter to Congressman Hayes from VA appears
on page 55.]
If there are no other comments?
Mr. Wu. Well, just one other comment, sir. Dr. Fleming,
great benchmarks against the private sector. I think great
kudos to the VA healthcare delivery system. Is there any
possibility in talking with Mr. Feeley said about all your
cross walk and measuring performance in the SOARS report, the
IG report, the OMI reports, that you rank order these
facilities in some public forum? Is that not a good idea?
Dr. Fleming. We do rank order the facilities and we do rank
order the networks. Now at the network level there is hardly, I
mean, the networks are clustered very tightly. And the facility
ranks, there is probably maybe a 10-point difference in our
aggregate rankings. But I would also tell you that when we look
at our worst facilities, and we just actually ran these
numbers, our worst facilities based on VA standards compare to
private sector averages are still better than the private
sector averages. So----
Mr. Wu. I appreciate that. But I am talking about within,
we are concerned about veterans.
Dr. Fleming. I am sorry, I guess I missed----
Mr. Wu. Do we rank, not bench marking against private
sector, but just an internal benchmark?
Dr. Fleming. We do internal bench marking on a quarterly
basis.
Mr. Wu. And is that in a public forum? Or how is that
displayed?
Dr. Fleming. It is displayed, it is sent out to the field.
It is sent up in the VA. So everyone within the VA knows it. As
you know, there was an executive order August of 2006 that has
mandated all Federal entities will do public reporting at the
provider level.
Mr. Wu. Correct.
Dr. Fleming. So we are on a, in fact we are ahead of our
2009 timeline to do that. So our other Federal agencies will be
with us in doing that. So at that point, the veteran, or the
Medicare beneficiary, or whomever, will have access to the
provider data.
Mr. Wu. Thank you, Dr. Fleming. Dr. Bagian, Mr. Feeley, Dr.
Fleming, Dr. Pierce, I think there was a lot that was discussed
today and brought out and echoing Chairman Mitchell about we
now understand Salisbury, but how are we dealing with this on a
systemic basis? I would hope that when issues that rise to this
level, as Salisbury did indicate in 2005, that this Committee
and this Subcommittee and members that are affected in
facilities are notified on a timely basis by the VA and not by
the Charlotte Observer, the St. Pete Times, or the New York
Times. Thank you very much, Mr. Chairman.
Mr. Mitchell. Thank you. And with that, this meeting is
adjourned.
[Whereupon, at 1:32 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Harry E. Mitchell
Chairman, Subcommittee on Oversight and Investigations
This hearing will come to order.
I want to thank our colleagues from North Carolina for joining us
today. I know they have been very active on this issue, and I know the
people of their great state appreciate their hard work on behalf of
veterans in North Carolina.
Of course, we are here today to explore the quality of care
available to our Nation's veterans. We know there have been significant
problems at the Salisbury VA Medical Center in North Carolina and we'll
be using Salisbury as a case study so we can better learn if the
problems there are indicative of quality of care throughout the VA
medical system.
We will explore management accountability and leadership issues
within the VA medical system.
Today's hearing will revolve primarily around three issues:
Firstly, how does the VA ensure access to the medical system is
timely and is delivering proper quality of care?
Secondly, what is the process the VA uses in determining whether
the quality of care is proper?
And, thirdly, are the problems that occurred in Salisbury
indicative of a larger set of issues that affect other VA medical
facilities as well?
More than 2 years ago--in March 2005--an anonymous allegation that
improper or inadequate medical treatment led to the death of veterans
at Salisbury prompted the VA office of Medical Inspector to conduct a
review of care delivered to both medical and surgical patients.
The OMI report--issued 3 months later--found significant problems
with the quality of care that patients were receiving in the Surgery
Service of the Salisbury facility.
Unfortunately, we learned that Salisbury leadership had already
been notified of many of the shortcomings in Surgery Service through an
earlier Root Cause Analysis.
I know that all of us on the Subcommittee are particularly troubled
to hear about the story of a North Carolina veteran who sought
treatment at Salisbury and died. . . . He went in for a toe nail
injury, and even though doctors knew he had an enlarged heart, he
wasn't treated . . . it was ignored . . . and the morning after he had
surgery on his toe, he died from heart failure the next morning.
According to media reports, this veteran received excessive
intravenous fluids in the OR and post-operatively as well; the medical
officer of the day wrote orders for the patient without examining him;
and the patient did not receive proper assessment and care by the
nursing staff.
More recently, we also learned through the media of another
incident--a wrong site surgery at another VA medical facility on the
west coast. . . . The list goes on and on. . . .
We hope to hear today how the VA is working to ensure that these
types of incidents do not happen at other facilities around the country
and how the VA is working to deliver the best quality of care
throughout the VA system.
We also hope to hear from the VA how its leaders reacted to these
problems, worked to solve these problems, and what lessons it learned
to make sure this never happens again.
Prepared Statement of Hon. Ginny Brown-Waite
Ranking Republican Member
Thank you for yielding me time, Mr. Chairman.
Mr. Chairman, on March 28 through March 31, 2005, at the request of
the VA's IG in September 2004, the Office of the Medical Inspector
conducted a site visit to the W.G. (Bill) Hefner VA Medical Center in
Salisbury, North Carolina, focusing on the facility's delivery of
surgical services. This report presented some serious inadequacies of
care at this facility. On March 21, 2007, three members of the North
Carolina delegation, my colleagues, the Honorable Howard Coble, the
Honorable Mel Watt, and the Honorable Robin Hayes, [who are present at
this hearing,] wrote to our Committee expressing concern about this
report, requesting additional oversight into patient safety at the VA.
I am looking forward to hearing from our witnesses today to learn
how these inadequacies have been addressed. I am particularly looking
forward to Dr. Daigh's (DAY's) testimony providing the results of the
facility's 2006 OIG Combined Assessment Program (CAP) Review of the VA
Medical Center in Salisbury, North Carolina, and the results of the
OIG's inspection last week of the facility. I also look forward to
hearing from Dr. Steinberg, the current Chief of Staff and the former
Interim Director on how the facility is continuing to work to address
these issues, and how the lessons learned at Salisbury can be used to
implement safer delivery of healthcare to our veterans.
It is my contention that this hearing is not to single out one
facility, but to take lessons learned as a case study in patient care,
and implement better patient safety across the entire VA. I plan to
continue to work with you, Chairman Mitchell to continue this oversight
of Patient Safety at VA facilities across the Nation. Quality of care
everywhere is my goal.
Again, thank you Mr. Chairman, and I yield back my time.
Statement of John D. Daigh, Jr., M.D.
Assistant Inspector General for Healthcare Inspections
Office of the Inspector General, U.S. Department of Veterans Affairs
INTRODUCTION
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to testify today on patient quality of care issues at
Department of Veterans Affairs (VA) medical facilities. Today I will
present the results of the Office of Inspector General (OIG) Evaluation
of Quality Management in Veterans Health Administration Facilities
Fiscal Year 2006; the OIG Evaluation of Quality Management in Veterans
Health Administration Facilities Fiscal Year 2004 and 2005; and the OIG
Combined Assessment Program (CAP) Review of the W.G. (Bill) Hefner VA
Medical Center Salisbury, North Carolina, published on September 25,
2006. I will also present the facts surrounding the OIG hotline call
that resulted in the Office of the Medical Inspector (OMI) report of
June 9, 2005, Review of the Delivery of Surgical Services Veterans
Integrated Service Network 6 W.G. (Bill) Hefner VA Medical Center
Salisbury, N.C., and the results of our followup inspection at the
Hefner VA Medical Center (VAMC) conducted during the week of April 9-
13, 2007. I am accompanied by Ms. Victoria Coates, Director of the
Atlanta Office of Healthcare Inspections.
Since the early 1970's VA has required its healthcare facilities to
operate comprehensive quality management (QM) programs to monitor the
quality of care provided to patients and to ensure compliance with VA
directives and accreditation standards. Public Laws 99-166 and 100-322
require the VA OIG to oversee VA QM programs at every level. QM review
has been a constant focus during the OIG Combined Assessment Program
(CAP) reviews since 1999. The CAP review is an OIG initiative that
involves an inspection and publication of the inspection's findings for
approximately one-third of VA's medical centers each year.
A comprehensive VA QM program should include the following program
areas: quality management and performance improvement Committees, peer
review activities, patient safety activities (healthcare failure mode
and effects analysis, aggregated root cause analyses, and national
patient safety goals), disclosure of adverse events protocols,
utilization management programs, patient complaint management programs,
medication management programs, medical record documentation reviews,
blood and blood products usage reviews, operative and other invasive
procedures reviews, patient outcomes of resuscitation efforts reviews,
restraint and seclusion usage reviews, and staffing effectiveness
reviews.
OIG Summary Reports
The OIG published a summary of the CAP findings regarding VA
medical center QM findings for fiscal year 2006 in March of 2007 and
for fiscal years 2004 and 2005 in December of 2006. The report of FY
2006 QM findings identified three QM activities that required
systemwide improvements: peer review activities, adverse event
disclosure procedures, and utilization management programs. For FY
2006, OIG reported peer review activities were established in 46 of 47
inspected medical centers. Only 40 of 46 peer review committees
complied with Veterans Health Administration (VHA) policy to met
quarterly and only 49 percent of the Committees completed their reviews
within the required 120 days. VHA facilities have an obligation to
disclose adverse events to patients who have been harmed in the course
of their care. In FY 2006, 39 of the 47 inspected facilities documented
that patients had experienced serious adverse outcomes. Of these, 29
documented that the clinical discussions occurred with the veteran or
family member, and 22 documented that the discussion informed the
patient of the right to file tort claims or claims for increased
benefits. Utilization management is the process of evaluating and
determining the appropriateness of medical care services across the
patient healthcare continuum to ensure the proper use of resources. In
FY 2006, our review found that when resource utilization exceeded
standards, referral was not made to physician advisors 16 percent of
the time, thus bypassing appropriate review of resource utilization.
Recommendations regarding peer review, adverse event reporting, and
utilization review were made and accepted by the Acting Under Secretary
of Health.
In the OIG report on FYs 2004 and 2005, VA medical center QM
programs indicated that 2 of 93 facilities did not have comprehensive
programs in place. These programs were identified to VA in CAP reports.
Recent CAP reports indicate that one of the two facilities made
significant improvements in their QM program, while the other has been
less successful at improving the components of its QM program. There
are ongoing personnel changes at this facility and OIG will closely
monitor this facility's QM program. The FYs 2004 and 2005 QM review
made recommendations to improve the analysis of patient resuscitation
episodes, better consider the alternatives and document the use of
restraints, and adjust current directives regarding re-privileging
activities to ensure effective implementation of the continuous
professional practice evaluation process.
W.G. (Bill) Hefner Medical Center in Salisbury, North Carolina
The OIG maintains a hotline call center to permit stakeholders to
notify the OIG of problems. On August 30, 2004, OIG received an
anonymous hotline alleging that there had been more that 12 surgical
deaths in over 2 years on the surgical service at the Hefner VAMC. On
September 21, 2004, due to limited OIG resources, this hotline was
referred to the OMI. The OMI was onsite at Salisbury from March 28-31,
2005. The VHA Director of Surgery conducted a review from April 5-6,
2005. OMI issued its report of the hotline allegations and surgical
services, after an OIG review, on June 9, 2005. It contained 18
recommendations that were accepted by the Under Secretary of Health. A
regularly scheduled CAP inspection was conducted June 19-23, 2006. An
OMI followup inspection of the Hefner VAMC occurred between March 26-
27, 2007, and an OIG followup inspection occurred April 9-13, 2007.
OIG CAP Review--June 2006
During the week of June 19-23, 2006, the OIG CAP team evaluated
clinical care and patient outcomes at the Hefner VAMC. The CAP team
reported as an organizational strength, the fact that medical center
staff had significantly improved their ability to provide timely
laboratory support for the evaluation of patients who present with a
possible myocardial infarction.
The OIG CAP inspection found that the clinicians properly addressed
specific treatment issues related to diabetes that arise in the use of
atypical antipsychotic medications. The review of breast cancer
management found that clinicians at the facility met the VHA
performance measure for breast cancer screening, provided timely
surgical and oncology consultative and treatment services, promptly
informed patients of diagnoses and treatment options, and developed
coordinated interdisciplinary treatment plans. A review of the
inpatient and outpatient Survey of Healthcare Experiences of Patients
found that the Hefner VAMC measures were within acceptable ranges when
compared to national and Veterans Integrated Service Network data. The
OIG report noted the efforts taken by the VAMC leadership to respond to
this patient-derived data.
The OIG inspection team found several conditions needing
improvement in the Contract Nursing Home Program, the Quality
Management Program, and the medical center environment of care. The
Contract Nursing Home Program policy requires regular, periodic visits
to veterans in nursing homes by VA nursing staff. These did not occur
between October 2003 and June 2006 in the selected patient sample. In
addition, OIG inspectors found that 4 of the 11 contract nursing homes
were on the State nursing home ``watch list,'' meaning that they had
been found to be deficient during their last State inspection. Despite
these deficiencies, program managers continued to place veterans in
these homes without taking prudent steps to ensure veterans would
receive quality care at these homes. The medical center did not
establish the required Contract Nursing Home Oversight Committee. The
OIG inspectors made recommendations in the CAP report that were
accepted by facility managers to remedy these conditions.
OIG inspectors identified deficiencies in the medical center's QM
program in that peer reviews were not completed as required between
July 2005 and June of 2006. Further, the Peer Review Committee had not
met since November of 2005 because of actions taken by the VA's Office
of Resolution Management to review information that was protected by 38
USC 5705, Confidentiality of medical quality-assurance records. The
chief of staff acknowledged the importance of peer review activities
and reported that the peer review meetings would resume, but stated
that he would not disclose protected information to the Office of
Resolution Management. OIG did not make recommendations as the medical
center leadership indicated that the peer review process would be
resumed. A review of the Root Cause Analysis processes at this medical
center found several defects, as did a review of the Administrative
Board of Investigation process. OIG recommended and VA leadership
agreed to make the changes required to bring these programs into
compliance with appropriate policy.
A review of the facility environment of care identified several
issues that were addressed prior to the inspection team leaving the
facility. The OIG team also found that managers at the facility had not
addressed environment of care issues that were previously identified to
facility managers in 2005. Facility managers agreed with OIG
recommendations to address this issue.
OIG CAP Review--April 2007
OIG inspectors visited the Hefner VAMC between April 9-13, 2007, in
preparation for this hearing with two goals: to evaluate the surgical
service programs and processes to determine if clinical care meets with
community standards, and to determine if the facility had taken
appropriate followup actions in response to the CAP report of 2006 and
the OMI report of 2005. Our review of the facility Surgical Service
Performance Improvement Program, National Surgical Quality Improvement
Program data, morbidity and mortality minutes, surgical staffing, peer
review, and surgery infection control data combined with discussions
with hospital staff and leadership leads us to conclude that the Hefner
VAMC surgery services meet or exceed community standards. Our review of
the actions taken by the leadership of this facility in response to our
CAP recommendations permits us to conclude that these recommendations
have been appropriately addressed.
The OIG inspectors identified two new issues to facility leadership
during the April 9-13, 2007, visit. On the locked mental health unit,
there are exposed pipes that should be covered, going from the wall to
toilet fixtures. In addition, telephones in tunnels connecting
buildings on the campus were accessible by staff who had a key, but not
by patients. OIG will followup to ensure these issues are addressed.
Summary
The OIG will continue to review QM in VA medical centers as part of
the CAP process. With respect to the W.G. (Bill) Hefner Medical Center
in Salisbury, North Carolina, we believe that VA leadership has
responded appropriately to recommendations made by OMI and OIG in
reports.
Mr. Chairman, thank you again for this opportunity and I would be
pleased to answer any questions that you or other members of the
Subcommittee may have.
Statement of Sidney R. Steinberg, M.D., FACS
Chief of Staff, W.G. (Bill) Hefner Veterans Affairs Medical Center in
Salisbury, North Carolina, Veterans Health Administration
U.S. Department of Veterans Affairs
Good morning Mr. Chairman and Members of the Committee. Thank you
for giving me an opportunity to address your concerns regarding the
quality of healthcare provided to our veterans at the W.G. Hefner
Veterans Affairs Medical Center in Salisbury, North Carolina
(Salisbury). The focus of my remarks will be the improvements and
expansion of healthcare at Salisbury.
Overview
The Medical Center in Salisbury provides quality healthcare to our
veterans in our primary care clinics including Winston Salem and
Charlotte across many specialties of medicine and surgery with our
academic partner, Wake Forest University. In recent years, Salisbury
has made a concerted effort to improve the quality of our healthcare
and to make access to care readily available. We measure our
improvements in these areas on a regular basis utilizing both internal
and external tools. We track disease prevention, treatment outcomes,
physician performance, educational processes and patients' satisfaction
surveys. VA is committed to meet the needs of our veterans, whatever it
takes. At Salisbury our commitment is total.
Improvements to Patient Care
Several years ago, with the help of our Veterans Integrated Service
Network (VISN) leadership and a handful of dedicated clinicians, VA
sought to make improvements at Salisbury, department by department. VA
leadership brought together the financial and manpower resources
necessary to make these changes possible. For example, the waiting list
of veterans seeking a primary care appointment was a challenge. The
VISN came through with funding for recruitment of new employees. As a
result, every veteran on the wait list in 2003-2004 was enrolled in a
primary care clinic, examined, and received his or her initial care
needs. VA was delighted to have members of Congress join the former
Secretary and our Network Director to personally thank the dedicated
staff who gave so much of themselves to achieve that goal.
Academic Affiliate and Specialty Care Services
To accommodate Specialty Care Services in the past, Salisbury
relied upon the geographic partnership with the Asheville VA Medical
Center. However, the addition of a large number of new patients made it
apparent that Salisbury would need to develop its own specialty support
system for our veterans. To accomplish this task, VA established a new
and stronger relationship with our Academic Affiliate, Wake Forest
University School of Medicine in Winston Salem, North Carolina.
Meetings with the Dean of the Medical School and faculty leaders paved
the way for the beginning of a new partnership to serve our patients
with state of the art healthcare in many areas of need. These efforts
led to the establishment of resident physician training programs in a
number of disciplines. We now have 10 approved resident positions which
include ophthalmology, urology, otolaryngology, psychiatry, medicine,
infectious disease and dermatology. The superb eye clinic with its
multispecialty support provided care to 27,000 patient visits in fiscal
year (FY) 2006. Ten major eye operations are performed weekly by Wake
Forest faculty and resident physicians.
VISN leadership continues to engage the Office of Academic Affairs
on a regular basis to assist Salisbury in adding more resident
positions in primary care, medicine and other specialties. This year we
have added a new affiliation agreement with Virginia Tech University
and will work to incorporate their staff and residents in coming years
to expand primary care. The real benefit of the residency program to
our veterans is that they bring with them the highly skilled faculty
members who are capable of providing state of the art care to our
veterans. The progress VA has made at Salisbury touches every veteran
and employee at the Medical Center. Our staff, our patients, our
community leaders, and our medical school educators recognize the
quality of these additions. These improvements in facility staffing and
structure allowed us to see more than 400,000 out patients in FY 2006
as well as providing support for our Veterans Benefit Administration
office in Winston Salem.
Mental Health
The Mental Health needs of our veterans are important to all of us
and represent a program of excellence at Salisbury. In this area of
clinical expertise, we lead our VISN and have on our staff one of the
world's most prestigious investigators in the area of Traumatic Brain
Injury. Through her efforts and those of her principal neuroscientist,
there is collaboration with MIT, Harvard and the Department of Defense.
This team also serves as a key investigative and educational center for
the Mental Illness Research, Education, and Clinical Center (MIRECC).
This Center has a focus on post-deployment mental health. Together with
the other VA medical centers in VISN 6, this program strives to advance
the study, education, and treatment of all mental health conditions
resulting from war-time experience. This investigative center leads VHA
nationally in these efforts. Our medical center's research programs
have generated a full Association for the Accreditation of Human
Research Protection Programs accreditation through the year 2010.
Women's Health Program
Our expanded Women's Health program now serves our patients as well
as those from the Asheville and Fayetteville VA Medical Centers. The
program is headed by a Gynecologist from the University of Virginia.
The new director of our Imaging Department came to us from the M.D.
Anderson Cancer Center in Houston, with additional fellowship training
at the University of North Carolina. Her new colleagues in the
department are from Duke University and Wake Forest, respectively. The
Women's Health Program is just moving this week into newly renovated
space where additional special services are now provided. A new bone
densitometer, digital mammography and urodynamic devices are now
available. A current NRM (Non Recurring Maintenance) project is now
underway to provide more bed space for women veterans with private
rooms and private baths.
Surgery Programs
We faced challenges in the quality of our program in 2003. But we
have turned the corner and now have a much improved surgical program.
The Salisbury Surgery Department is totally new and is headed by a
chief from Vanderbilt University. A strong surgical program is
essential to our veterans' health needs and must be one of impeccable
quality. With the VISN's busiest emergency department and increasing
demands for care dictated by our 62,000 enrolled patients, our efforts
were directed to making this department a solid high quality program.
The support of our affiliate, Wake Forest University, is vital to this
effort. As additional surgical staff and residents from Wake Forest
join this effort, it will continue to gain in strength and expertise.
Our new construction project in Surgery will be completed in about 30
days and will provide the needed space and modernization required to
meet the highest standards for operating room construction. Our new
Chief is joined by a staff of surgeons from Johns Hopkins, the
University of Maryland and the University of West Virginia. Other key
members of the Surgery and Anesthesia Staff came from Emory University,
Duke University, the Cleveland Clinic, the Mayo Clinic and the
University of Michigan. We are recruiting for a new chief of Pathology,
crucial to our post mortem evaluations and tissue studies. Our Chief of
Infectious Disease and our fellowship program have brought a fresh and
important look to the evaluation, prevention and treatment of
infectious diseases at our medical center. Our large numbers of
hepatitis and HIV patients are now receiving the care they must have to
maintain their health and life.
Our approach to primary care was modified last year to provide more
adequate care to our patients with more complex diseases. At the
Salisbury VAMC we have made a concerted effort to ensure that every
patient now has been assigned to a primary care provider. Our efforts
in Primary Care were given a tremendous boost by the VISN's support of
a total renovation of all primary care clinic space to assure that each
primary physician had at least two examination rooms per physician.
This space adjustment has made it possible to meet the demands of a
higher patient volume.
Conclusion
Mr. Chairman, we acknowledge that Salisbury has faced problems with
the quality of surgical processes in the past. However, that's behind
us now, due to the hard work of the highly professional and dedicated
staff at Salisbury. We are proud of Salisbury and the patients we
serve. Through strong and meaningful leadership, our staff has turned
the focus toward a future of excellence. We will continue these efforts
in our commitment to our Nation's finest, our veterans.
Mr. Chairman, this concludes my statement. At this time I would be
pleased to answer any questions that you may have.
Statement of William F. Feeley, MSW, FACHE
Deputy Under Secretary for Health for Operations and Management
Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning, Mr. Chairman and Members of the Subcommittee. Thank
you for the opportunity to be here today to discuss the many positive
steps the Department of Veterans Affairs (VA) utilizes to monitor the
healthcare of our veterans and returning warriors. In my role as Deputy
Under Secretary for Health for Operations and Management, I am
responsible for the day to day activities at all of our facilities
across the country. I would like to focus my attention on how the
Veterans Health Administration (VHA) addresses quality improvement
activities on a systemwide basis. I am accompanied by Dr. John Pierce,
Medical Inspector, Dr. James Bagian, the Chief Patient Safety Officer,
and Dr. Barbara Fleming, Chief Quality and Performance Officer.
OVERVIEW
In the late eighties, VA healthcare programs came under a great
deal of scrutiny because of the perception that quality was not
comparable to that found in the private sector. Since that time,
numerous programs have been implemented by VA to address and ensure
that the quality of healthcare provided to our veterans is world class.
The results of these efforts and achievements have brought national
recognition to VA as consistently being recognized as one of the
premier healthcare providers within the United States. For example, on
January 20, 2006, the Washington Post published an article entitled
``VA Care is Rated Superior to That in Private Hospitals,'' and the
January/February 2005 issue of the Washington Monthly published an
articled entitled ``The Best Care Anywhere.'' And the August 27, 2006
issue of Time magazine had a feature article entitled, ``How Veterans
Hospitals Became the Best Health Care''. While VA has transformed
itself, we continue to strive to improve the quality of healthcare
provided to our Nation's veterans through shared learning, research,
and vigorous and stringent quality management and patient safety
programs.
The results of this work can be attributed to the leadership and
contributions made by the offices represented by those accompanying me
today--the Office of the Medical Inspector, the National Center for
Patient Safety, and the Office of Performance and Quality--as well as
the efforts of our VA workforce who are directly involved in patient
care.
VHA ensures the consistent quality of care that is delivered in its
Veterans Integrated Service Networks through----
Patient safety activities;
Systems that listen, teach and detect problems early;
Ongoing measurement of clinical processes;
Establishment and control of quality standards for
both clinical protocols (Peer Review, Evidence-Based
Guidelines, Utilization Management) and for the providers of
care (National Credentialing and Privileging);
Personal and anonymous patient surveys after the care
has been provided;
Oversight by external organizations such as the Joint
Commission; and
Oversight by internal organizations such as
Systematic Ongoing Assessment and Review Strategy (SOARS),
Office of Medical Inspector (OMI), Office of Inspector General
(OIG), Government Accountability Office (GAO), Veterans Service
Organizations (VSO).
PATIENT SAFETY
The VA National Center for Patient Safety (NCPS) is guided by a
mission to prevent harm to patients. The focus is to prevent
inadvertent or accidental harm that may occur as a result of incidents
such as patient falls, medication errors, malfunction or misuse of
medical devices, and hospital-acquired infections. The NCPS works with
Patient Safety Managers in all VA medical centers and Patient Safety
Officers in the network offices to facilitate the implementation of an
integrated patient safety improvement program throughout VHA. The
primary methodology used in VHA to understand and prevent adverse
events is Root Cause Analysis (RCA). The RCA teams focus on determining
what happened, why it happened, and what systems changes should be made
to prevent similar incidents from recurring. Information from RCAs is
used to inform other VAMCs of potential problems, potential solutions,
and in the development of VHA-wide policies and practices to prevent
adverse events from occurring in VHA facilities.
The NCPS also issues Patient Safety Alerts (Alerts) and Advisories
on specific issues relating to medical devices and products, and other
potential sources of harm to patients. Several Alerts have brought
problems coupled with recommended solutions to the attention of other
government agencies such as the Food and Drug Administration (FDA), and
organizations such as the Joint Commission. Topics of recent Alerts of
special interest included one that led to the withdrawal of Benzocaine
spray from our facilities due to its high potential for accidental
misuse and dangerous overdoses, and another one that described the
correct way to clean and disinfect a special ultrasound device used for
prostate biopsies. Both Alerts were of special interest to the FDA and
resulted in FDA disseminating the potential vulnerabilities brought to
light by VA to hospitals in the private sector.
Another method to improve quality and patient safety is to reduce
ineffective variation in practices. This is where VHA Directives
(Directives) are issued to address patient safety topics. Based on
information from RCAs, emerging standard practices, and other sources,
VA has developed and implemented several important Directives to
improve patient safety such as: Ensuring Correct Surgery and Invasive
Procedures; Prevention of Retained Surgical Items; Out-of-Operating
Room Airway Management; Recall of Defective Medical Devices and Medical
Products; Planning for Fire Response; Reducing the Fire Hazard of
Smoking when Oxygen Treatment is Expected; and Required Hand Hygiene
Practices (based on the CDC's Guideline on this topic). These topics
vary widely but are all related to preventing harm to patients as they
receive care at a VA facility. By issuing these Directives, VA has
acquired the ability, as the largest integrated healthcare system, to
effect change that impacts millions of patients.
PERFORMANCE MEASUREMENT
VA's performance measurement system is a key part of the
transformation of care that started in the mid-nineties. The system has
over 100 performance measures in the areas of access, satisfaction,
cost, and quality. Data on these measures are collected monthly and all
performance is shared and distributed on a quarterly basis to the field
facilities with information broken out into aggregate totals for
facilities, networks and VHA overall. The aggregated quarterly data is
also used to produce detailed annual reports shared with senior
leadership and the field.
Special reports are also produced that focus on particular measures
of concern or special populations. For example, reports have been
provided on minority health, women's health, the health of Operation
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans, and
characteristics of facilities and networks leading to high performance
with Best Practices shared across the system via video conferences
which are web-based and enhanced and national face to face meetings.
These data analyses lead directly to quality improvement efforts.
When quality concerns are identified, working task groups have been
convened to further explore these issues using collected data and
working directly with the VA facilities to find and share solutions to
the quality problems. VA consistently benchmarks its performance data,
both internally and externally. Ongoing reports are prepared that
compare VHA to other Federal and private sector healthcare
organizations.
The successful use of the performance measurement system for
driving quality is based upon widespread dissemination of information
and feedback to individuals at all levels of the healthcare system.
Also, it is important to link measures not only in performance
evaluations but also incentives in a variety of local and national
means, for example, through awards to facilities, and networks. Linkage
of measures to performance contracts result in personal accountability.
In addition, for each quarter, I conduct individual performance reviews
with each Network Director to personally review performance measure
results for their VISN and to discuss plans for improving performance
in areas that are needed. The Network Directors are held accountable
for performance improvement through performance measurements.
CREDENTIALING AND PEER REVIEW
VA also has a very sophisticated electronic credentialing program
that is used system wide. We believe that careful credentialing is a
cornerstone of assuring quality. The quality of privileging, which
defines the practice scope of a provider, is also essential to
maintaining a good clinical staff.
Peer review is another mechanism in place to assure that the
highest quality of care is delivered. Peer review is intended to
contribute to quality improvement efforts of the individual provider,
in a non-punitive way.
UTILIZATION MANAGEMENT
Utilization Management (UM) allows the VA to determine that the
right care is provided to the right patient at the right place for the
right amount of time. A national Utilization Management Committee has
put standards for UM in place, adopted nationally standardized
criteria, conducted extensive training, and is beginning the
implementation of a national data base to assure that there is
facility, national, and network learning and quality improvement around
the data collected.
Patient complaints are assessed by a series of questions on the
inpatient and outpatient surveys asking whether the veteran had a
complaint about VHA care, and whether the veteran was satisfied with
the resolution of that complaint. Patient advocates and the national
VHA Patient Advocacy Office monitor these results closely to ensure
that veterans' and their families' voices are being heard.
SYSTEMATIC ONGOING ASSESSMENT AND REVIEW STRATEGY
The VA utilizes a learning system that exports and disseminates
information to all segments of the VA healthcare system so that
providers can learn how to deliver care that is not only safe,
efficient, cost-effective, but clinically measurable and evidence-
based. For example, the Systematic Ongoing Assessment and Review
Strategy (SOARS) is an internal review initiative that was initially
implemented within the VA as an internal voluntary program that
facilities could use as a systematic method for on-going self-
improvement and to support the culture of continuous readiness. Now,
based on the success of this program, all VA facilities participate in
a SOARS site visit every 3 years. As the SOARS team members interview
staff, they frequently become aware of an excellent practice
implemented at the surveyed site that could improve patient care
quality or efficiency or reduce costs that could easily be shared with
other VA facilities. The information regarding these ``Strong
Practices'' is kept on the SOARS VA intranet Web site that is easily
accessed by all VA staff.
OFFICE OF THE MEDICAL INSPECTOR
Another internal review mechanism involves the reviews done by the
Office of the Medical Inspector who evaluates quality of care concerns
raised by veterans and other stakeholders and makes recommendations to
enhance and improve the quality of care provided by VHA. These
recommendations are directed at the facility involved in the site
visit. When common issues are identified, the recommendations may
result in a Directive or guidance to the entire VHA system.
EXTERNAL OVERSIGHT
As a public system, the VA undergoes intense scrutiny from a
variety of accreditation agencies, both internal and external
reviewers. All VA medical facilities are accredited by the Joint
Commission on Accreditation for Healthcare or organizations on a
triennial cycle.
The Office of the Inspector General (OIG) for the VA, and the
Government Accountability Office are frequent inspectors of care
provided at individual VA facilities and often address issues that cut
across specific VAMCs. For each review, VHA drafts a response and
action plan to respond to findings. We welcome the opportunity for
external regulators to help us identify areas where improvement is
needed and strives hard to make those improvements.
CONCLUSION
As a system, VA is continuously looking for opportunities to learn
and improve. The components described above provide a solid foundation
for identification of problem areas and challenges for the system of
care that can be transported to improve our entire healthcare delivery
system for individuals.
One of the advantages of being a large integrated healthcare
organization is that VHA has the ability to learn and share examples of
best practices from our clinicians and administrators across our entire
system. I personally speak with the Veterans Integrated Service Network
(VISN) Directors as well as Facility leadership on a weekly basis; best
practices are identified and shared via these teleconferences. In
addition, conference calls are held by my colleagues with patient
safety and quality management staff. There are many examples of how VA
learns from specific clinical incidents.
I appreciate the opportunity to talk with you today. The events at
Salisbury have spurred us to go even farther in our monitoring process
than I have described here. I have asked that the Network Chief Medical
Officers and Quality Managers heighten their personal ownership of
issues affecting their facilities and ensure that best practices are
shared systemwide. Mr. Chairman, this concludes my statement. At this
time I would be pleased to answer any questions that you may have.
U.S. Department of Veterans Affairs
Veterans Health Administration
Veterans Integrated Services Network Six
Durham, NC.
April 18, 2007
Hon. Robin Hayes
U.S. House of Representatives
Washington, DC 20515
Dear Congressman Hayes:
Thank you for the opportunity to respond to your letter of March
15, 2007, regarding article in The Charlotte Observer detailing the
actions of a nurse at our Salisbury VA Medical Center (VAMC) who
reportedly falsified care reports on VA patients in contract nursing
homes. You indicate that while what may have happened previously is of
concern, you are troubled by the article's assertion that the nurse is
still employed by the VA in Salisbury. You ask why, if the assertion is
correct, did VA not find this behavior grounds for dismissal?
These are appropriate questions, which relate to our oversight of
long-term care of our veterans and our personnel action procedures with
staff. I can assure you that we have taken both matters very seriously.
The VA Office of Inspector General (OIG) Review of Contract Nursing
Home Oversight at our Salisbury VA Medical Center was conducted June
19-23, 2006. The OIG report is indicative of VA's internal monitoring
to promote quality of care.
I apologize for the delay in responding to you, but a second OIG
review was just completed last week concerning the oversight of nursing
home care for our Salisbury VAMC patients. Although we do not have the
final written repot, we received an oral summary, which emphasized that
oversight is underway.
At the time of the original report, from October 2003 to June 2006,
Salisbury VA Medical Center had placed 17 veterans in 11 contract
nursing homes. We can confirm that all these veterans had been visited
at least monthly by a Salisbury VAMC Social Worker. This VA staff
member met with each veteran; spoke with clinical providers; reviewed
progress notes regarding each veteran's care; and made every reasonable
effort assure that appropriate followup treatment was being provided.
The Social Worker involved family members in the care plans for their
loved ones. Neither the veterans in these contracted nursing homes nor
the family members expressed any safety concerns or requested placement
in another facility.
Salisbury quickly assigned another nurse to resume monthly visits
to these veterans, and an Administrative Board of Investigation was
convened to analyze Salisbury VA Medical Center's oversight of veterans
placed in contracted nursing homes.
The former Salisbury VA Medical Center Director reviewed the
recommendations with the employee and that individual's
representatives. The VA Regional Counsel was consulted and it was
decided to enter into a ``last-chance'' agreement with the employee. As
a result this nurse continues to be employed at the Salisbury facility
but is no longer involved with the Contract Nursing Home Program or
with patient care. The North Carolina Board of Nursing is investigating
the individual at this time. If a bar is placed on this individual's
license, then VA will terminate this nurse's employment.
We currently have 11 veterans placed by Salisbury VAMC for long-
term care in eight contracted nursing home facilities, and the program
is working well to the benefits of these patients.
Recent media reports about this facility notwithstanding, I can
assure that our team at Salisbury is serving our veterans effectively.
With funding and other support from you and other members of Congress,
we are constructing a new 65,000 square-foot VA Outpatient Clinic in
Charlotte and another facility, of approximately 20,000 square feet, in
Hickory. These new sites of care will extend the outreach of primary
care, general mental health, eye care and other services to our
veterans in these areas. Both of these facilities will be staffed and
managed by the Salisbury VA Medical Center, along with our major clinic
in Winston-Salem.
Our Salisbury VA Medical Center and its clinics provided care to
60,000 veterans last year. It is our leading site for care of our
newest veterans returning from duty in Operations Iraqi and Enduring
Freedom, caring for 4,248 of these individuals out of approximately
16,000 served since September 11, 2001, in our Network facilities.
We want to extend a cordial invitation to you and your staff to
visit the Salisbury facility at your convenience. Please contact Dr.
Dave Raney at 919-956-5541 and he can assist you.
Please be assured that throughout our 8 VA Medical Centers and our
current 10 and soon to be 15 outpatient facilities, our mission is to
provide safe, efficient, effective, and compassionate care to the more
than 292,000 veterans we so proudly serve. I greatly appreciate your
personal support of the development of an outpatient clinic in Hamlet
and your other efforts to enhance healthcare services to our Nation's
veterans.
Sincerely,
Daniel F. Hoffmann, FACHE
Network Director, VISN 6
QUESTIONS FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
May 21, 2007
Honorable George J. Opfer
Inspector General
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Opfer:
On Thursday, April 19, 2007, the Subcommittee on Oversight and
Investigations of the House Committee on Veterans' Affairs held a
hearing using the VA Medical Center in Salisbury, North Carolina as
case study for the quality of care veterans receive across the country.
During the hearing, the Subcommittee heard testimony from Dr. John
D. Daigh, the Assistant Inspector General for Healthcare Inspections.
As a followup to that hearing, the Subcommittee is requesting that Dr.
Daigh answer the following question for the record:
1. Your site visit indicated that 4 of the 11 contract nursing
homes were on the state ``watch list'' meaning that they had
been found deficient during their last state inspection. Is it
not disturbing that Salisbury would continue to place veterans
in these homes? And furthermore, the medical center did not
establish the required Contract Nursing Home Oversight
Committee. When was this glaring deficiency finally remedied?
Would you not characterize this situation as less than
proactive and a symptom of senior management malaise?
2. How and when did you realize that your budget and staffing
would not allow you to address these investigations?
We request you provide responses to the Subcommittee no later than
close of business, Friday, June 8, 2007.
If you have any questions concerning these questions, please
contact Subcommittee on Oversight and Investigations Acting Staff
Director, Dion S. Trahan, Esq., at (202) 225-3569 or the Subcommittee
Republican Staff Director, Arthur Wu, at (202) 225-3527.
Sincerely,
HARRY E. MITCHELL
Chairman
VIRGINIA BROWN-WAITE
Ranking Republican Member
__________
U.S. Department of Veterans Affairs
Office of Inspector General
Washington, DC
June 21, 2007
Hon. Harry Mitchell Chairman
Hon. Ginny Brown-Waite
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman and Congresswoman Brown-Waite:
Enclosed are responses to followup questions from the April 19,
2007, hearing before the Subcommittee that were included in a letter
from you and the Ranking Republican Member. A similar letter is being
sent to the Ranking Republican Member of the Subcommittee.
Thank you for your interest in the Department of Veterans Affairs.
Sincerely,
George J. Opfer
Inspector General
Enclosure
__________
Questions from Hon. Harry E. Mitchell, Chairman and
Hon. Ginny Brown-Waite, Ranking Republican Member
Subcommittee on Oversight and Investigations, to
Mr. Opfer, Inspector General, U.S. Department of Veterans Affairs
Question: Your site visit indicated that 4 of 11 contract nursing
homes were on the state ``watch list'' meaning that they had been found
deficient during their last state inspection. Is it not disturbing that
Salisbury would continue to place veterans in these homes? And
furthermore, the medical center did not establish the required Contract
Nursing Home Oversight Committee. When was this glaring deficiency
finally remedied? Would you not characterize this situation as less
than proactive and a symptom of senior management malaise?
Answer: A nursing home may be placed on a state watch list for a
variety of reasons ranging from not meeting safe food preparation and
storage standards to inadequate care practices. Inclusion of a nursing
home on a state watch list is not by itself disqualifying for placement
of veterans. However, OIG expects that in these circumstances medical
center staff review and consider watch list data to ensure that the
nursing home is appropriate for the veteran's clinical condition. A
patient's family should also be provided the opportunity to participate
in the selection of a nursing home and be made aware of watch list and
other data regarding the nursing home's performance. As reported in the
results of our 2006 CAP review, we found that veterans were placed in
four substandard nursing facilities that were on the state watch list
without proper oversight by medical center staff. We recommended that
medical center staff increase monitoring of substandard nursing
facilities where veterans remain under contract care. A Contract
Nursing Home Oversight Committee was established just prior to our site
visit in June 2006. The lack of a VHA contract nursing home oversight
Committee is not acceptable and is not consistent with VHA policy.
Question: How and when did you realize that your budget and
staffing would not allow you to address these investigations?
Answer: Due to resource limitations, OIG has historically lacked
the capacity to meet all demands for review of complaints about VA
services and programs. OIG has adopted a system of triaging incoming
work to determine which cases require independent OIG review based on
the seriousness and urgency of the complaint and current workload
priorities. A substantial number of cases are referred to other VA
elements for fact-finding and review. In these cases, the responsible
VA office reports their findings back to us for final review before a
case is closed.
The OIG Hotline received allegations from an anonymous complainant
that 12 patient deaths occurred on the surgical service of the W.G.
(Bill) Hefner Medical Center in Salisbury, North Carolina, on August
30, 2007. The next day, the case was referred to and accepted by the
OIG Office of Healthcare Inspections (OHI) based on the serious nature
of the allegations. OHI staff began development of an inspection plan,
staff requirements, and project schedule. During this early planning
phase, however, it became apparent that the scope and significance of
the project demanded more immediate attention then OHI originally
anticipated. After careful assessment of OHI's workload and priorities,
OHI contacted the Office of the Medical Inspector (OMI), and both
offices agreed that OMI was better positioned from a resource
perspective to conduct and complete the review. Shortly thereafter, on
September 21, 2007, the OIG made a written referral to OMI to conduct
the review and to report back its findings. Consistent with OIG policy,
we reviewed the OMI report prior to its issuance. Given current
resource levels and workload, OIG will continue to triage incoming work
and make referrals to OMI and other VA elements when appropriate.
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
May 21, 2007
Honorable R. James Nicholson
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Nicholson:
On Thursday, April 19, 2007, the Subcommittee on Oversight and
Investigations of the House Committee on Veterans' Affairs held a
hearing using the VA Medical Center in Salisbury, North Carolina as
case study for the quality of care veterans receive across the country.
During the hearing, the Subcommittee heard testimony from Mr.
William F. Feeley, the Deputy Under Secretary for Health for Operations
and Management; Dr. Sidney Steinberg, the Chief of Staff at the
Salisbury VAMC; Mr. Donald Moore, the former Director of the Salisbury
VAMC and current Director of the VAMC in Phoenix, Arizona; and various
other officials from the VA and the Salisbury facility. As a followup
to that hearing, the Subcommittee is requesting that the following
questions be answered for the record:
Questions for Mr. Feeley:
1. What was the Peer Review process at Salisbury VAMC, and how
has it changed to ensure better patient care and reduce the
incidents of surgical and post surgical deaths? Please be
specific in your response.
2. How frequently does the OMI investigate and provide
oversight to a VAMC such as Salisbury when allegations are made
about inadequacies of care?
3. What changes have been made to the culture of care
providers, such as surgeons, nursing staff, attending
physicians, and anesthesiologists at Salisbury VAMC to provide
better quality of care? Has VHA taken lessons learned at
Salisbury and implemented directives to the rest of VHA to
provide better care throughout the VA?
4. Is it your opinion that the problems outlined during the
March 2005 investigation by the OMI have been resolved, and if
so, what changes occurred to implement the changes necessary to
resolve these issues?
5. Please provide the results of the last SOURCE visit to
Salisbury.
6. Please provide SES Bonus information for staff at the
Salisbury VAMC and VISN 6 during the time period in question.
Questions for Dr. Steinberg:
1. According to your testimony, the Salisbury Surgery
Department has made improvements since the March 2005 OMI
report, Congress received in June of 2005. Most of these
improvements deal with new construction projects. How have
surgical facilities expanded, and how do you anticipate further
improvements in care stemming from these expansions?
2. When do you anticipate filling the Chief of Pathology
position? How long has this position been empty? What criteria
are you using to evaluate candidates for this position?
3. How long had the Chief nursing position been empty prior to
the OMI report, and after the issuance of the OMI report?
4. It should be noted that the Women's Health Program is
moving into a newly renovated space in order to provide
additional services specific to the medical needs of women. How
many female veterans do you anticipate being able to serve in
this new space? When will this facility be fully staffed?
5. What future plans for construction do you anticipate for
the future at Salisbury in order to continue to meet the needs
of the veteran community in western North Carolina?
6. What specific actions have been taken to hold personnel
found at fault in the deaths of the twelve patients which
initiated the original OMI investigation accountable?
Questions for Mr. Moore:
1. Now that you are in a position of greater responsibility
and bigger staff, how do you insure all egregious IG and OMI
findings of 22 inadequate actions in identifying and
implementing specific corrective actions do not reoccur under
your leadership in Phoenix?
2. Did you receive any performance bonuses during your tenure
at Salisbury?
Questions for Dr. Pierce:
1. What were the steps taken to follow up on personnel
reviews, oversight, and holding individuals accountable at the
Salisbury VAMC? How did your office ensure all recommendations
were being complied with? Please be specific in your response.
2. Please provide written documentation of all actions taken
against personnel in Salisbury, North Carolina following the
misconduct/malpractice instances of the seven deaths?
We request you provide responses to the Subcommittee no later than
close of business, Friday, June 8, 2007.
If you have any questions concerning these questions, please
contact Subcommittee on Oversight and Investigations Acting Staff
Director, Dion S. Trahan, Esq., at (202) 225-3569 or the Subcommittee
Republican Staff Director, Arthur Wu, at (202) 225-3527.
Sincerely,
HARRY E. MITCHELL
Chairman
VIRGINIA BROWN-WAITE
Ranking Republican Member
__________
Questions from Hon. Harry E. Mitchell, Chairman, and
Hon. Ginny Brown-Waite, Ranking Republican Member
Subcommittee on Oversight and Investigations to
Hon. R. James Nicholson, Secretary
U.S. Department of Veterans Affairs
Case Study on the Department of Veterans Affairs (VA) Quality of
Care: W.G. Hefner VA Medical Center in Salisbury, North Carolina
Questions for Mr. Feeley:
Question 1: What was the Peer Review process at Salisbury VAMC, and
how has it changed to ensure better patient care and reduce the
incidents of surgical and post surgical deaths? Please be specific in
your response.
Response: The peer review process at the Salisbury VA Medical
Center (VAMC) included critical reviews of episodes of care performed
by a peer or by a group of peers.
Inspectors from the Office of the Inspector General (OIG)
identified deficiencies in the Salisbury VAMC's quality management
program during a June 2006 combined assessment program (CAP) survey.
They found that peer reviews were not completed as required between
July 2005 and June 2006. They also found that the peer review Committee
(PRC) had not met since November 2005.
The local peer review process was stopped in response to VA Office
of Resolution Management's request to review information protected by
38 USC 5705, Confidentialityof Medical Quality-Assurance Records.
When informed that the confidentiality of documents regarding peer
reviews would be compromised, the physicians refused to further
participate in what is understood to be a confidential process.
During the OIG CAP survey, the chief of staff acknowledged the
importance of peer review activities and reported that the peer review
meetings would resume, but stated that he would not disclose protected
information to the Office of Resolution Management. The OIG did not
make recommendations as the medical center leadership indicated that
the peer review process would be resumed. The peer review process was
resumed immediately.
Question 2: How frequently does the OMI investigate and provide
oversight to a VAMC such as Salisbury when allegations are made about
inadequacies of care?
Response: The Office of the Medical Inspector (OMI) investigates
all allegations made about inadequate quality of care provided to
veterans brought to their attention--The OMI monitors, along with the
Deputy Under Secretary Health for Operations and Management, the VA
medical center's action plan, developed as a result of the OMl's
recommendations.
Question 3: What changes have been made to the culture of care
providers, such as surgeons, nursing staff, attending physicians, and
anesthesiologists at Salisbury VAMC to provide better quality of care?
Has VHA taken lessons learned at Salisbury and implemented directives
to the rest of VHA to provide better care throughout the VA?
Response: A total change in surgical, anesthesia and nursing
leadership was effected. Dr. Charles Graham was appointed as chief of
surgery with concurrence of Dr. Ralph DePalma, national director of
surgery. With his guidance, new policies and procedures were
implemented directed at improving and maintaining the highest quality
of surgical care. A new chief of anesthesia was appointed, Dr. Robert
Slok, from Ohio University with an assistant chief, Dr. John Murphy
from Duke University. Ms. Judith Pennington, RN, was selected as the
new chief operating room nurse from a major medical center in Denver,
Colorado.
With this leadership team in place, all aspects of surgical care
are being addressed, including fundamental education of staff, addition
of critical support staff and establishment of key management tools to
assure highest quality and adherence to all performance measures. Input
from existing staff was readily sought and team building was begun in a
new and dynamic fashion.
Everyone involved in surgical care was brought to the table to
learn, address and execute a comprehensive plan for ``their'' surgical
program. The result has been a dramatic improvement in all aspects of
surgical care, surpassing all national quality standards for morbidity
and mortality.
The Veterans Health Administration (VHA) has published several
handbooks and directives regarding provision of quality, safe patient
care. In addition, a weekly national conference call is held which
includes the presentation of lessons learned and best practices in the
delivery of patient care. In January 2007, the VA national surgical
quality improvement program (NSQIP) sent out a newsletter to the field
that provided information, data and updates on the program.
Question 4: Is it your opinion that the problems outlined during
the March 2005 investigation by the OMI have been resolved, and if so,
what changes occurred to implement the changes necessary to resolve
these issues?
Response: Yes. To begin the process of correcting problems
identified by the OMI, removal of some staff was required. The existing
chief of surgery was removed and his surgical privileges terminated.
The physician in charge of the medical management issues was terminated
and no longer practices medicine. The anesthesia chief was terminated.
Conferences and training programs are now in place to assure
adequate continuing education for all staff. Preoperative and
postoperative care issues are continually reviewed to assure quality of
care at every step, A new medical center director and the chief of
staff provide day to day oversight. All issues reported in the OMI
report have been addressed and resolved.
Question 5: Please provide the results of the last SOURCE visit to
Salisbury.
Response: A system wide ongoing assessment and review strategy
(SOARS) site visit was conducted at the Salisbury VA medical center
(VAMC) December 6-9, 2005. Written reports were not required during
this period, a verbal out-briefing of findings and recommendations were
provided to facility leadership and staff at the conclusion of the
visit. The visit found many areas of compliance with standards, and
others that appeared to be improving. Areas identified as needing
attention and improvement included:
Medication and controlled substance management. Comprised
of several issues around medication storage.
Information security. Specifically related to ensuring
that access to computer systems are terminated immediately when
employees, volunteers, and contractors leave VA service.
Patient transportation. Ensuring that all drivers meet
standards for training, physical screening, and license checks.
General safety concerns related to fire extinguishers and
exit doors.
Process improvements needed to enhance medical care cost
recovery insurance identification and billing.
The discrepancies identified during the SOARS site visit have been
addressed.
Questions for Dr. Steinberg:
Question 1: Please provide SES Bonus information for staff at the
Salisbury VAMC and VISN 6 during the time period in question.
Response: The following individual received bonuses at that time:
Timothy May--Director Salisbury VAMC
2000--no VISN records of any awards or bonuses
2001--no VISN records of any awards or bonuses
2002--no VISN records of any awards or bonuses
2003--no VISN bonuses--retired
Stephen Lemons--Director Salisbury VAMC--11/1/03-6/12/04
2003--$20,000
Donald Moore--Director Salisbury VAMC--6/13/2004-11/11/2006
2004--0
2005--$12,000
2006--$9,000
James L. Robinson III Associate Director, Salisbury VAMC
August 4, 2004--$1,000
August 8, 2004--$2,000
September 15, 2004--$3,000
April 22, 2005--$5,000
November 15, 2005--$5,000
November 14, 2006--$4,000
January 18, 2007--$5,000
Sidney R. Steinberg Chief of Staff, Salisbury VAMC
September 15, 2004 $5,000
April 22, 2005--$5,000
April 22, 2005--$2,500
November 15, 2005--$5,000
January 24, 2007--$5,000
Mark Shelhorse, MD Chief Medical Officer--VISN 6
2001--$6000
2002--$15,000
2003--$15,000
2004--$24,500
2005--$25,000
2006--$19,000
Daniel F. Hoffmann Network Director--VISN 6
2000--$15,000
2001--$12,000
2002--$26,000
2003--$26,000
2004--$29,120
2005--$20,000
2006--$24,000
Question 2: According to your testimony, the Salisbury Surgery
Department has made improvements since the March 2005 OMI report,
Congress received in June of 2005. Most of these improvements deal with
new construction projects. How have surgical facilities expanded, and
how do you anticipate further improvements in care stemming from these
expansions.
Response: In mid-2003, a vigorous recruiting effort was begun to
attract the highest quality professional staff to the VAMC at
Salisbury. Efforts were also initiated to build an academic
relationship with Wake Forest University School of Medicine to gain
their support in improving the professional staff at Salisbury and to
develop the framework for establishing training programs for resident
education in a variety of medical and surgical specialties. Contingent
on developing a strong and effective surgical program was the need to
improve surgical nursing capabilities, anesthesia support, an
appropriate post anesthesia care unit (PACU) and improving both the
equipment available and the physical plant.
Project requests were submitted to address the physical plant needs
through a nonrecurring maintenance proposal. The physical plant
improvements included the construction of a completely new surgical
suite with adequate space and proper air flow to improve the safety and
efficiency of surgical care. Better air flow reduces the risk of
airborne infection and cross contamination. The larger space allows for
introduction of modern endoscopic equipment important for safer
inpatient and ambulatory surgical interventions with reduced operative
morbidity and mortality. This construction replaced an out-dated
operating room and air handling system essential to improve quality of
care. The addition of both space and staff for the PACU assures maximum
post anesthesia safety for patients. The first part of this project
will be completed in the summer of 2007. A second proposal to complete
the physical plant modifications has been submitted. The completed
projects will allow for the addition of important specialties and
better support from our academic affiliate with the addition of vital
resident training programs and faculty.
Nursing support was completely retooled. A new and very experienced
operating room supervisor, Judith Pennington, RN, was recruited from
Denver and is the nurse in charge of surgical operations. She has
selected a superb staff of qualified and experienced surgical nurses in
a variety of discipline specialties to support the surgical programs. A
PACU staff was recruited and is now in place.
Key surgical staff members were recruited. Dr. Charles Graham,
Vanderbilt University trained, was selected as the new chief of
surgery. Dr. David Crist, Johns Hopkins trained, was selected to head
the section of gastrointestinal surgery. Dr. Valerie Moore was
recruited from the University of Maryland to provide expertise in
breast surgery and laparoscopic surgery. Dr. Anthony Burke from West
Virginia University joined the staff with expertise in colon and rectal
surgery. The women's surgical unit was expanded to provide expert
gynecological surgery with the addition of Dr. Helen Malone from the
University of Virginia.
Key anesthesia staff were recruited and added to the staff. Drs
Block, Murphy and Breton, all highly qualified anesthesiologists have
added great expertise in anesthesia and pain management at the medical
center.
Expanded training programs in ophthalmology, and otolaryngology
were established with Wake Forest University with both resident and
faculty support from the University. A new program in urologic surgery
supported by Wake Forest is set to begin the summer of 2007. A new
chief of urology has been selected, Dr. Hector Henry, an adjunct
clinical Professor from Duke University.
All quality measures including morbidity and mortality data exceed
national standards. Effective monitoring is in place to ensure
continued high quality performance and excellent patient care outcomes.
Additional residency program commitments from Wake Forest and the
Office of Academic Affairs are being sought to further the professional
expertise at Salisbury.
Additional support in other related disciplines has been added.
These include critical care specialists, infectious disease
specialists, and others.
Question 3: When do you anticipate filling the Chief of Pathology
position? How long has this position been empty? What criteria are you
using to evaluate candidates for this position?
Response: The position is posted and a team of highly regarded
pathologists has been appointed to serve on the selection Committee.
Several excellent candidates have been identified and a selection is
anticipated by September 2007. The current pathologist will remain in
place until a new chief is selected and has had adequate time to be
oriented to the department.
Question 4: How long had the Chief nursing position been empty
prior to the OMI report, and after the issuance of the OM I report?
Response: The chief nurse on staff during the OMI site visit was
removed on December 30, 2004. A new executive nurse was selected and
joined the staff on June 10, 2005.
Question 5: It should be noted that the Women's Health Program is
moving into a newly renovated space in order to provide additional
services specific to the medical needs of women. How many female
veterans do you anticipate being able to serve in this new space? When
will this facility be fully staffed?
Response: The new women's health clinic space was completed in May
2007 and is now occupied. A complete staff is in place and includes a
gynecologist, physician assistant, two nurses, a clinic clerk, an
administrative officer and a dedicated primary care physician. Plans to
add an additional staff gynecologist are in place and recruitment will
be completed in the fall of 2007. The new space will allow for
important additions to the women's health program, Primary care
physicians will be added to the clinic in order to provide
comprehensive care to our female patients. This is particularly
important for those women with a history of military sexual trauma.
Additionally, for completeness in our comprehensive approach to women's
health, the new space will include a new digital mammography unit for
prompt breast cancer screening for all patients.
Capacity will be doubled, thus allowing the center to increase the
number of female veterans seen and referred for complex gynecologic
issues from Fayetteville and Asheville VAMCs along with the anticipated
surge from Charlotte's new facility scheduled to open in early 2008.
Currently the number of women veterans represents nearly 3000 veterans.
With expansion into Charlotte and Hickory, numbers should exceed 5000
by the end of 2008.
Question 6: What future plans for construction do you anticipate
for the future at Salisbury in order to continue to meet the needs of
the veteran community in western North Carolina?
Response: Two minor projects have been funded and are currently
under design for construction in 2008 and 2009. These projects will add
9,000 square feet to the existing medical surgical building and will
provide space for radiology, pharmacy, dental service, a post
anesthesia care unit (PACU) and special clinic space for urology and
oncology.
There is a renovation project currently underway to add additional
patient rooms with private baths to accommodate the needs of female
patients and an expanded medicine service. A new eight bed intensive
care unit is included in the project. Additional renovations are
planned for the surgical care unit. A major project has been submitted
to add additional needed space for specialty clinics and
rehabilitation. This project is essential to meet the demand for
additional services at Salisbury and is particularly important with the
future addition of major clinics in our service area at Charlotte and
Hickory. Major renovations have also been completed in mental health
and existing primary care units.
Question 7: What specific actions have been taken to hold personnel
found at fault in the deaths of the 12 patients which initiated the
original OMI investigation accountable?
Response: There were three specific actions taken that affected
hospital personnel.
The chief of surgery was removed from his position. His
surgical privileges were withdrawn permanently. After consultation with
VA authorities, he was allowed to remain on the staff in a non-surgical
capacity with the provision that he obtain additional training and meet
the requirements for and obtain re-certification in his specialty. He
will, however, not be allowed to operate independently again.
The second index case was a non-surgical case and
involved poor care on the part of an internal medicine physician. He
was removed from the staff, his license to practice medicine in North
Carolina was terminated and he moved from the State. To our knowledge
he no longer practices medicine in any venue.
The nursing issue that led to the failure to notify the
appropriate on call physician in the index surgical case resulted in
changing nursing leadership at the medical center and on the care unit
involved.
The allegation of 12 suspicious deaths was not substantiated by the
OMl or the national surgical director. After a review of all deaths at
the medical center for a period of 1 year, there were two index cases,
where death was related to substandard care. One surgical index case as
noted, and one medical index, as noted. The personnel actions taken
were related to those cases.
Questions for Mr. Moore:
Question 1: Now that you are in a position of greater
responsibility and bigger staff, how do you insure all egregious IG and
OMI findings of 22 inadequate actions in identifying and implementing
specific corrective actions do not reoccur under your leadership in
Phoenix?
Response: The Carl T. Hayden VAMC has multiple systems/structures
in place to anticipate or prevent adverse events. These include the
following:
Chief of Staff Oversight--The chief of staff provides
oversight of clinical programs, is involved in medical staff activities
and leaders are held accountable for performance.
Performance Improvement Program--The program has active
participants from both clinical and administrative staff. There is an
executive performance improvement council which meets monthly to review
performance and other key indicators in the medical center.
Peer Review Committee--The Committee meets quarterly and
provides oversight for the peer review program. The peer review program
meets standards required by VHA Directive 2004-054, Peer Review for
Quality Management and is chaired by the chief of staff.
Risk Management Program--The program includes
anticipation of risk, staff education and prevention of adverse events.
It also includes disclosure of adverse events to patients and review of
100 percent of patient deaths and adverse events.
Surgical Risk Assessment Program--This facility
participates in the national surgical quality improvement program
(NSQIP). Surgical cases are reviewed and compared with all VA
facilities nationally for mortality and morbidity. Outliers are
immediately identified and actions taken to address any concerns.
Patient Safety Program--This active program promotes a
strong safety culture. Both clinical and administrative staff are
involved with ongoing patient safety activities.
Infection Control Program--The comprehensive infection
control program focuses on prevention and monitoring of infections. The
infection control committee works with providers offering feedback to
clinicians about infection and related issues in the medical center.
Infection control also serves as liaison with local and State health
departments for reporting and followup activities related to infections
that are public health concerns.
Medical Staff Monitoring & Active Medical Staff
Committees--The external peer review program (EPRP) is in place. There
are several active medical staff Committees which monitor and improve
patient care. These include the invasive procedures Committee,
transfusion Committee, pharmacy and therapeutics Committee, medical
records Committee.
Review by External Agencies--We are reviewed by Joint
Commission and had successful surveys. The next survey is expected
during 2008.
Review by Internal VA Agencies--We are reviewed by the
Office of the Inspector General, Office of Research, etc. Our most
recent OIG/ CAP review was completed in November 2006 and was
successful resulting in only one recommendation.
Credentialing and Privileging--This program provides
oversight for a credentialing and privileging system of medical staff.
VetPro (VHA's electronic system) used for credentialing all providers,
assures appropriate documentation, credentialing, privilege delineation
and service review and adheres to VA's regulations.
Question 2: Did you receive any performance bonuses during your
tenure at Salisbury?
Response: Yes. $12,000 in 2005, $9,000 in 2006
Questions for Dr. Pierce:
Question 1: What were the steps taken to follow up on personnel
reviews, oversight, and holding individuals accountable at the
Salisbury VAMC? How did your office ensure all recommendations were
being complied with? Please be specific in your response.
Response: Personnel issues are outside the purview of the OMI;
however, as part of the closure of the case resulting in the report,
Review of the Delivery of Surgical Services, Salisbury VAMC, of June 9,
2005, we noted that the following actions were taken by the VHA
leadership ``the physician involved in the surgical case has had his
privileges removed and the physician in the medical case resigned after
having a summary suspension of his privileges'' as part of the medical
center's fulfillment of its corrective action plan.
Medical centers are routinely required to submit a corrective
action plan responding to all OMI recommendations within 2 weeks of
their receiving the final report approved by the Under Secretary for
Health. The OMI makes a judgment to accept the corrective action plan
based on the medical center's timely, positive, and enthusiastic
response; whether the proposed actions will suitably address the
recommendations; and after reviewing evidence of proposed corrections.
Some actions, e.g., clear VAMC policy on a particular issue, may be
judged complete on the documentation; other actions, e.g., suitable
nursing coverage, may require more intense follow up, such as
conference calls and additional documentation. In some cases, the OMI
conducts follow up site visits to be certain the corrective actions are
all in place and effective.
In this case, the corrective action plan was accepted by the OMI,
monitored, and the investigation closed when the intent of the
recommendations were met. However, due to publicity surrounding this
report and Congressional interest, the OMI conducted a follow up visit
March 26-27, 2007 to assure all parties that the recommended corrective
actions had been completed.
Question 2: Please provide written documentation of all actions
taken against personnel in Salisbury, North Carolina following the
misconduct/malpractice instances of the seven deaths.
Response: Personnel issues are outside the purview of the OMI. With
regard to the seven deaths, these cases were reviewed under VHA's peer
review program which is governed by title 38 United States Code 5705
Confidentiality of Medical Quality Assurance Records and found to be
Level two on a scale of one to three. This means, ``Most experienced,
competent practitioners might have managed the case differently in one
or more aspects.'' However, this difference in practice does not equate
to misconduct/malpractice.
U.S. Department of Veterans Affairs
Office of Inspector General
Washington, DC.
December 18, 2007
Hon. Harry E. Mitchell
Chairman, Subcommittee on
Oversight and Investigations
Committee on Veterans Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
During the Subcommittee hearing on April 19, 2007, on Case Study on
U.S. Department of Veterans Affairs (VA) Quality of Care: W.G. (Bill)
Hefner Veterans Affairs Medical Center in Salisbury, North Carolina,
Congressman Walz inquired about the process for requesting additional
resources within the Office of Inspector General (OIG). We indicated
that we would provide additional information for the record.
The OIG is an independent entity within the VA and has a separate
line item in the VA appropriations bill. During the year, the funds
available to the OIG are limited to this specific budget authority. The
VA may not reprogram funds to augment the OIG's funding nor can VA take
funding away from the OIG. The only way to ensure the OIG has
sufficient resources to meet its mandated oversight responsibilities is
though the annual internal VA budget formulation process and subsequent
congressional appropriation actions.
Thank you for your interest in the Department of Veterans Affairs.
Sincerely,
John D. Daigh, Jr., M.D.
Assistant Inspector General for Healthcare Inspections