Systemic Problems at the Department of Veterans Affairs under the Microscope


images_08 Several decades of systemic failures at Department of Veterans Affairs Medical Centers once again took center stage in Congress as the media (CNN) exposed several VAMCs in the Southeast that placed Veterans in several states at risk. This is a follow up on VT General Manager John Allen’s posting on VA Addresses Failures of Contaminated Equipment Use

John mentioned in his report that the concerns of the Chairman of the Subcommittee on Oversight and Investigations, House Veterans Affairs Committee shared by a Congressman from Florida focused on issues of responsibility, accountability, and credibility of the VA systems. Most significantly they focused on the systemic problems infecting the Department of Veterans Affairs.

John left us with a link to the proceeding that includes a webcam of what Congressional reps asked and the panel composed mostly of VA senior managers and medical personnel had to say. I received a phone call from a former VA employee who attended this meeting as a public observer. The feedback I got was that professional medical personnel tend to blame the systemic problems on mismanagement of administrative personnel at higher levels within VA upper and middle management. In sum, finger pointing. This inspired me to do another multi-part expose on what really transpired at this hearing and others in the future in laymen’s terms that any one like me with a high school GED can understand and relate to.

 Veterans and military families under pressure, stress, and distrust of the Department of Veterans Affairs are not going to make or take the time to look up or read Congressional testimony unless it is spoon fed to them. We just don’t have the time or motivation.

 I kick off the first part with opening statements made by the Chairman and Representative from Florida and by stating that the systemic problems running rampant in the VA practically makes the optimism of politicians and others who do not use the VA unrealistic. As you shall see first the members of Congress beat up on the VA representatives as well they should then end it with expectations that a slap on the wrist will change anything.

Ladies and Gentlemen, members of Congress, I’m among those here to tell you that nothing is going to change systemic problems that have existed for decades until VA upper and middle management regardless if medical or administrative personnel are disciplined for such failures to follow the VA’s own directives and policies. The employees, especially the upper and middle managers who supposedly set an example for the rank and file should be held to the same standards of responsibility and accountability as if they worked in the Pentagon or served in the Armed Forces where over delegating authority, responsibility, and accountability will get senior managers, military officers, and NCOs not promoted at best or fired at worse.

Robert L. Hanafin
Major, U.S. Air Force-Retired
Editorial Board of Directors
VT News Network

Last Tuesday, June 16, the House Committee on Veterans’ Affairs, Subcommittee on Oversight and Investigations held a hearing in response to media attention and public outcry about ,Endoscopy Procedures at the U.S. Department of Veterans Affairs: What Happened, What Has Changed? I believe by what has changed if anything really means what corrective actions the VA plans on making or promises to make in order to correct their image and regain the confidence of Veterans across the nation who will be very reluctant to get an endoscopy screening at any VAMC due to the risks involved. In laymen’s terms nothing has changed until VA upper and middle management’s forced to follow their own directives. Congressional representative setting nothing but expectations from the Department of Veterans Affairs have the authority, but lack the determination necessary to back up or enforce what they expect from VA.

As VA panel members, and every panel member was an apologists for the VA systemic problems not an impartial observer or two or three Veterans Advocates. These panel members represent the Department of Veterans Affairs not the Department of Veterans Advocacy. Without a disciplinary stick or punishment for incompetence, Congress forfeits this to medical malpractice and VA Claims attorneys that will result in the VA budget being far more than it ever has to be, and more money going toward legal litigation than treating America’s Veterans.

In his opening statement, Arizona Democrat Congressman Harry E. Mitchell, Chairman, Subcommittee on Oversight and Investigations noted just how systemic the problems of the DVA have been for decades, "We have been here before, and time and again, we have seen the VA violate the trust of those who have bravely served this country. The endoscopy issues in Murfreesboro, Augusta, and Miami are yet another reason for veterans to lose confidence in a system they rely on for the care we owe them."

Congressman Mitchell expressed his outrage that any of our nation’s [Veterans] was potentially infected or that they even have to worry about that possibility. He noted that since Congress has been made aware of the improper reprocessing, incorrect usage, and substandard cleaning of endoscopic equipment – at Murfreesboro, Tennessee; Augusta, Georgia; and Miami, Florida -approximately 53 veterans, and maybe more, were potentially exposed to HIV and Hepatitis.

Ironically, I was at a medical appointment at Wright-Patterson AFB when the news hit the airwaves about this scandalous disgrace as CNN flashed enlargements of VAMCs involved and stressed that this involved not one VAMC or even two VAMC but six and lord only knows the VA Medical facilities the VA Inspector General did not have time or resources to investigate.

Most infuriating for Congressman Mitchell and should be of special concern to any and all Veterans who use the VA system or someday may have not alternatives, the irony that these veterans were undergoing routine medical evaluations to keep them safe and to prevent illness, but ultimately, they may be in more danger now than before the procedure.

Congressman Mitchell challenged the VA apologist testimony he knew was coming by saying that there is no question that shoddy standards systemic across the VA – put veterans at risk and dealt a blow to their trust in the VA. He stressed that "whether or not any veterans contracted illnesses from these procedures, it is outrageous that they even have to worry about that possibility."

He exposed that between December 2008 and January 2009 all VA Medical Centers were required to review their processes to ensure that they are in compliance with the endoscopy device manufacturer’s instructions in response to these shocking wrongdoings Congressman Mitchell further emphasized that this latest of a long going trend of VA managers and so-called professionals not following guidelines establish by their own federal bureaucracy serves as yet another example of why standardization of VA medical procedures is needed.

After these very strong expressions of outrage, Congressman Mitchell roared in like a lion and out like a lamb by saying to VA panel members that he expected that the VA could report today that all VA Medical Centers are now in compliance. What we have here fellow Vets and Military Family members are setting unrealistic expectations when there is no means of enforcement or punishment if expectations are not met.

His expressions of outrage would have been more influential if Congressman Mitchell had told the panel of VA defenders that if expectations are not met, the Congressional Committee would recommend to the Secretary of DVA the removal of managers and professionals within the VA who failed to comply with Congressional expectations.

My fellow Veterans and Military Families we are way past time (decades behind) in politicians setting unrealistic expectations that have no back bone to enforcement of those expectations outside VA excuses and false promises. Congressman Mitchell also said that he was eager to hear what the VA has done to ensure that proper policies and training are in place so that mistakes like these will not happen again. He then expressed yet another expectation to learn what will be done to care for those who may have been exposed to HIV or Hepatitis. And I want to know how they are going to regain the trust of the veterans they serve.

What Congressman Mitchell failed to mention or comment on was just how many medical malpractice suits were going to be filed against the DVA. Any Congressional Rep sitting on the House or Senate Veterans Affairs committee must get serious about tax payer funding that is diverted from patient (veteran) care to the VA hiring defense lawyers to fend off malpractice lawsuits. Not to mention the increasing number of attorneys who will be getting involved in the VA Claim appeal process. For the VA to fend off legal litigation regardless from where the allegations come from is going to cost tax payer dollars that need to be budgeted for.

In closing, he recognized the VA’s cooperation, but noted that despite this cooperation and enhanced transparency with the Obama administration, Congress must provide persistent oversight to identify problems, motivate improvement, and help the VA to provide the safe, timely, and thorough care veterans deserve. Here is where Congressman Mitchell despite his expressed outrage parts ways with most of America’s Veterans and Military Families, when members of Congress limit themselves to assisting VA upper and middle management in doing their jobs of placing America’s Veterans above cost savings or internal strife within the VA system that further aggravates the systemic problems folks assistance to the VA is far from short of what is needed. Congress must start to provide no shit oversight with bite.

In would have been appropriate on C-Span, webcam, media release of whatever for both Congressman Mitchell and Stearns to say with conviction Congress will provide persistent oversight to identify problems, motivate improvement, and demand that the VA provide the safe, timely, and thorough care veterans deserve. Better yet, they need to include that when VA panels come before Congress to apologize for or defend the VA, they need to be prepared to face disciplinary action from the DAV Secretary should Congressional expectations and demands not be met.

In his opening statements, Florida Republican Congressman Cliff Stearns noted he was alarmed to learn that VA medical facilities have not been complying with [their own] multiple directives to ensure the endoscopic equipment they use is properly reprocessed and sterilized, and that as a result, many of our veterans have been put at serious risk." He noted that America’s Veterans come to the VA expecting some of the best care in the country, and this is what they get.

Congressman Stearns further expressed his concern that VA failures to follow their own directives and manuals leaves thousands of Veterans asking questions that he and other Congressional Reps responsible and accountable for VA oversight must answer. He expressed the hope and expectation that these hearings lead to frank and honest discussion about what happened and what the VA is going to do to ensure this never happens again.

You see my fellow Veterans and Military Families, regardless of partisan ideology, Congressman Stearns suffers from the same handicap that Democrat Congressman Mitchell does in sum where has he been for decades of this VA management trend? How many inside VA whistleblowers have contacted their Congressional representatives about shabby treatment of Veterans within the VA system, how many have been retaliated against? We at VT would like to hear from you. Not about what the VA did to you that’s a given, but about how what they retaliated against you may have prevented the systemic problems all along, how had this sort of retaliation hurt America’s Veterans?

Congressman Stearns said that placing our Veterans at risk to be inadvertently exposed to blood borne pathogens such as Hepatitis and HIV via improper use of endoscopy equipment is completely unacceptable. The numbers reported from the medical centers at fault in Miami, Augusta, and Murfreesboro is truly disturbing: over 10,000 patients have been put at risk at these 3 facilities with 53 reported cases thus far. Thirteen veterans have been diagnosed with Hepatitis B, 34 with Hepatitis C, and six with HIV. And while we will never really know if these veterans contracted these diseases because of the improper use of the equipment and lack of proper sterilization, or if these diseases were present in the body prior to the procedures, it is pertinent that the VA provide comprehensive care for all of these patients regardless of the source of the infection.

Red Flag: thus far both Congressman Mitchell and Stearns are either trying to sell Veterans a bill of goods or they have bought into VA excuses and smoke screens to avoid accountability. Note that both promote "we will never really know if these veterans contracted these diseases because of the improper use of the equipment and lack of proper sterilization, or if these diseases were present in the body prior to the procedures," my fellow Veterans that is frankly the position the VA and Congress is going to take when the individual or class action law suits start pouring in from every Veteran getting diagnosed with Hepatitis and HIV "after" being subjected to a dirty endoscope and related equipment. This lame claim to pre-existing condition is bullshit.

Frankly, most people I know would rather pay to get an endoscopy now rather than risk their lives at any VAMC, and there’s but one way round this pre-existing condition shield the VA is throwing up (pun intended) and evidently members of Congress on the Veterans Affairs Committee are buying, and that is if said Veterans has never been diagnosed with HIV or Hepatitis prior to getting an endoscopy or whatever, the blame can only lie in but one direction the incompetent VAMCs involved.

Congressman Stearns says, [members of Congress] must put [themselves] in the shoes of these veterans and imagine what it would be like to have received a letter from the VA notifying you that you could have been inadvertently exposed to diseases such as Hepatitis and HIV while undergoing a procedure that is designed to ensure you are healthy. No veteran should ever have to receive such a letter, and no veteran should ever have to worry about the quality of care they receive at a VA medical facility.

Readers just imagine how many members of Congress it would take in our shoes to get seriously action and accountability against those responsible. Unless I missed something from the transcripts and such not one member of Congress called for accountability or disciplining of those VA employees involved.

Congressman Stearns admits that "there is [clearly] a systemic problem at the VA, or we wouldn’t be here today. The VA needs standardized reprocessing procedures for all of its medical centers and these procedures should not be open to the interpretation of the medical staff. Additionally, the management and communication at all VA medical centers needs to be improved.

Amen to that Congressman, however standards, manuals and directives have always existed at the VA, nothing is more standardized than a federal government regulation bar none. However, if VA management and professional medical staff ignore or don’t know how to read their own regulations having all the standardization providing the Pentagon, Army or Marine Corps as a model would not change the outcome.

We here at Veteran Today have evidence from reliable sources that these trends have been going on for decades, and members of Congress both on and off the Veterans Affairs Committees have been warned by former VA employees who everybody blew off a disgruntled VA employees. We want to hear from you, connect you with each other, compare notes, expose the apathy of Congress, and march on Congress with a united front of former disgruntled VA employees, so we can put this myth back in fantasy land where it belongs.

You see that too is a trend. Whistle blowers from inside the VA system on the norm have reported systemic problems, mismanagement, failure to take responsibility and accountability for years to Congress from an isolated position that makes it easy for both the VA and Congress to paint you with the stereotype "disgruntled employee." Constructive criticism, if you ladies and gentlemen contacted each other, circled the wagons, and gave testimony before Congress that jives with each other; it will be hard but not impossible for Congress to ignore you. Contact VT so that we can get you connected, compare notes, and UNITED WE STAND.

Congressman Stearns also shares Congressman Mitchells bipartisan delusion that they expect (not demand but expect) to leave this meeting (until the next one and the one after that, etc) feeling confident in the VA’s plan to ensure all of its medical centers are complying with proper procedures from here on out and the VA as a whole fosters a culture that encourages honesty and an environment that ensures the safety of our veterans.

You mean to tell us at VT that when Congressman Steve Buyer of Indiana was Chair of the House Veterans Affairs Committee, and Congressman Filner after him that no one knew that the VA fostered a culture that encouraged dishonesty and an environment that ensures our veterans are harmed. Listen carefully to what Congressman Stearns is admitting to – IGNORANCE of the law is no excuse if any member of Congress was driving drunk.

As noted previously, we here at VT have it from reliable sources from within the VA, and I quote from one confidential source that the arrogance is that in the VA the cronies at the top can do anything to employees, patients, veterans in general, and get away with it. No one is responsible at the top. Just cut costs. Deny claims, close their eyes and hope not too much of their bonus money is wasted on legal claims, EEO claims, and assorted attorney’s fee and court costs. (Here he is referring to bonus monetary awards federal employees get periodically for cost cutting and performance) Likewise, they can kill and maim patients, assault them in research protocols, and also get away with it. They even have the VFW in their hands. There is no end to the depth of fraud, waste, abuse and civil service bonuses for cutting costs on the backs of America’s Veterans. The level of physical, mental, and emotional violence on VA campuses is terrifying, and this medical professional was not talking only about the patients.

In closing for now, I project there will be a significant increase in legal litigation against the VA from serious malpractice issues to routine VA Claim and Appeals process, especially since the Congress changed the law making it affordable to Veterans to hire a lawyer, and Veterans groups are in the process of recruiting pro-bono volunteers to handle Vets cases on a needs basis.

This VA insider notes that a few years ago the VACO pot of gold that paid for malpractice and other legal and corruption allegations was emptied. Now every VA medical facility had to pay for their own legal expenses for bad decisions and errors VA managers and professionals make. This of course leads to even more emphasis on an arrogant attitude of cutting costs at American Veterans expense. This is an area Congress needs to be paying closer attention to regulation of the VA, and holding VA manager at the top accountable and punishable for either documented proof of employee retaliation or a track record reflecting cost savings a priority over patient care.

What America’s Veteran now have is a trend where Congressional Representative who cannot relate to us periodically will focus on corruption or mistreatment of Veterans issue until the media fervor moves on, then it’s back to arrogance and business as usual for both these VA panel members and Congress. Don’t take my word for it, check it out yourself. How many Veterans does your Senator or House representative have on staff as he/she seriously honors Veterans with Vet preference in hiring, and this is where you will find the key to why Congressional reps pretend concern than move on to other distractions. Several may have a few Vets on staff in the DC beltway, but mark my words they have precious few at their local offices back home.

Why should they have Vets on staffs that know the VA system, because politicians THINK that they can turn to the Old Guard VSOs for such unbiased expertise that has no conflict of interest given their plaque and logo hangs in most every VA Hospital? Example: when several fledgling non-traditional Veterans advocacy groups focused attention on the shame that was Walter Reed how many traditional VSO gave lip service but in reality circled the wagons to defend military medical mismanagement and systemic problems? That was a military hospital inundated with political motivations from all sides. We can only imagine who fast the Old Guard VSOs will circle their wagons to defend, protect, and apologize for the systemic problems at the VA instead of telling some VA whistle blower that the Director of this VAMC or that VAMC is a golfing buddy and our VSOs best friend.

We at VT feel strongly that it is way past time for members of Congress charged with oversight of the Department of Veterans Affairs to stop stacking the deck with panels full of VA apologists be they from within the VA or one of the VSOs who proudly display their logos in the same hospitals where Veterans are subject to HIV and Hepatitis. The fairest thing to do is recruit and invite not one disgruntled former VA employee, but a half to a dozen who can prove no doubt they’ve been retaliated against from exposing mismanagement, corruption, and unsafe conditions by termination under trumped up charges.

Robert L. Hanafin
Major, U.S. Air Force-Retired
Editorial Board of Directors
VT News Network


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Readers are more than welcome to use the articles I've posted on Veterans Today, I've had to take a break from VT as Veterans Issues and Peace Activism Editor and staff writer due to personal medical reasons in our military family that take away too much time needed to properly express future stories or respond to readers in a timely manner. My association with VT since its founding in 2004 has been a very rewarding experience for me. Retired from both the Air Force and Civil Service. Went in the regular Army at 17 during Vietnam (1968), stayed in the Army Reserve to complete my eight year commitment in 1976. Served in Air Defense Artillery, and a Mechanized Infantry Division (4MID) at Fort Carson, Co. Used the GI Bill to go to college, worked full time at the VA, and non-scholarship Air Force 2-Year ROTC program for prior service military. Commissioned in the Air Force in 1977. Served as a Military Intelligence Officer from 1977 to 1994. Upon retirement I entered retail drugstore management training with Safeway Drugs Stores in California. Retail Sales Management was not my cup of tea, so I applied my former U.S. Civil Service status with the VA to get my foot in the door at the Justice Department, and later Department of the Navy retiring with disability from the Civil Service in 2000. I've been with Veterans Today since the site originated. I'm now on the Editorial Board. I was also on the Editorial Board of Our Troops News Ladder another progressive leaning Veterans and Military Family news clearing house. I remain married for over 45 years. I am both a Vietnam Era and Gulf War Veteran. I served on Okinawa and Fort Carson, Colorado during Vietnam and in the Office of the Air Force Inspector General at Norton AFB, CA during Desert Storm. I retired from the Air Force in 1994 having worked on the Air Staff and Defense Intelligence Agency at the Pentagon.