Mismanagement at VAMCs needs to be addressed by Congress not the VA


1239219792large_120Mismanagement at VAMCs needs to be addressed by Congress not the VA

This is part two in a several part expose of Congressional hearings on mismanagement of the Department of Veterans Affairs (DVA). The initial post can be found HERE.

The title of this second part means that given the long history of mismanagement of the Department of Veterans Affairs that goes back to the Vietnam War, we know the VA is never going to clean up its own act or house regardless who is Secretary. Congress needs to do a better job of VA oversight to include reminding the VA Secretary that he has the authority to terminate anyone he so desire and it he doesn’t Congress will grant him the authority.

While Congress is taking a much closer look at the VA system on a national scale, for we believe that what’s coming out of the southeast is most likely a VA mismanagement problem nationwide. The VA needs to get a handle on exactly how much is being diverted from patient care and improvements to fend off legal litigation, and it doesn’t take a Supreme Court Justice to figure out the law suits are going to come pouring in from all over the country.


According to the statement made by Dr. John D. Daigh Jr., M.D., CPA, the
Assistant Inspector General for Healthcare Inspections, Office of Inspector General
U.S. Department of Veterans Affairs, the endoscopy errors by the VA that placed Veterans at risk of viral infections was the result of improper endoscopy procedures performed at several VA medical centers (VAMC). The hard questions the Senate and House Veterans Affairs Committees need to be asking instead of having or making unrealistic "expectations" are just how wide spread is this scandal?

The VA Secretary, the Chairmen and Ranking Members of Congressional VA oversight committees, and other Members of Congress tasked the VA Office of Inspector General (OIG) review VA’s procedures at those facilities as well as nationwide. Ok, fine reports are coming into Congress (and better yet the media) focusing on the southeast. What about the rest of the nation when are reports going to be coming in from the other Veterans Integrated Service Networks?

The VA OIG report, Healthcare Inspection, Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities, was published the day Dr. Daigh Jr. gave testimony.

The doctor noted previous testimony he had given before the same House Veterans Affairs subcommittee yet he still believes the VA provides high quality health care to veterans; [Say What?] however; he was concerned that controls are not in place to ensure the delivery of a uniform, high quality medical benefit. Question is what did this VA OIG representative of the really mean by controls, and how can he still believe the VA provides high quality care if he’s been called on the Congressional carpet before?

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

theinsigniaoftheveteransad260420081016134_120 According to the VA Office of Inspector General, VA medical facilities did not comply with multiple directives to ensure endoscopes are properly reprocessed. [To readers out there with a high school GED like me, "reprocessing" in terms that even a Congressional Rep can understand means CLEANING dirty medical equipment, so why don’t VA panel reps just say that? Major Hanafin]

Unannounced OIG inspections on May 13 and 14, 2009, found that medical facilities do not have endoscope Standard Operating Procedures (SOPs) available 22 percent of the time, have not documented proper training of VA staff 50 percent of the time, and do not comply with SOPs magnitudeofd_400and proper training of VA staff on how to clean dirty endoscopes 57 percent of the time. [I’d hate like hell to be the VA attorney[s] who have to defend my agency from the onslaught of law suits coming our way. Major Hanafin]

Dr. John D. Daigh Jr noted that the impact of improper high level disinfection of reusable endoscopes places veterans at risk of image2_400infection from viruses including Hepatitis B, Hepatitis C, and human immunodeficiency virus (HIV). Medical research has shown Hepatitis B and Hepatitis C infections have been transmitted through endoscopes. There has not been a documented case of HIV transmission with colonoscopes.

As a result of the improper cleaning of colonoscopes by VA employees, 10,716 veterans were notified by the Miami, Florida, VAMC [3,260 veterans], Augusta, Georgia VAMC [1,069 Veterans], and va_04Murfreesboro, Tennessee, VAMC, having the laregest number of Vets exposed [6,387 veterans] and at risk of HIV and Hepatitis viral infections due to improper cleaning of dirty ear, nose, and throat (ENT) endoscopes

There had been multiple notifications to VA medical centers that cleaning of dirty endoscopes required close attention to detail and compliance with the manufacturers’ recommendations for high level disinfection. The responsibility for reprocessing endoscopes is described in VA Handbook, "Supply, Processing, and Distribution (SPD) Operational Requirements."

On February 10, 2003, based on problems identified at non-VA facilities, the Olympus Corporation issued a safety alert. On February 13, 2004, the National Center for Patient Safety (NCPS) issued another alert related to "an incorrect connector being used to link cleaning solution to endoscopes during [cleaning]."

Based on a January 2006 incident involving the cleaning of dirty prostate biopsy devices, the Veterans Health Administration (VHA) conducted a national review in September 2006 to assess compliance with cleaning standards. All VHA facilities conducted self-assessments [there’s the problem right there. Major Hanafin] and the aggregated results were published in 2007. Facilities were directed to create local policies based on manufacturers’ instructions, including requirements for demonstration of VA employee competence in performing cleaning.

On December 22, 2008, in response to incidents at the Murfreesboro VAMC, the National Center for Patient Safety (NCPS) issued a Patient Safety Alert regarding the incorrect tube/valve combination and the frequency of cleaning auxiliary water system accessories. The alert emphasized the importance of following manufacturers’ instructions, and required VA facilities to have SOPs available to all personnel who clean endoscopes and accessories and that staff be evaluated for cleaning competence. Facilities were directed to certify compliance with these action steps by January 7, 2009. Sixteen facilities reported that they were not in compliance with the manufacturers’ instructions for cleaning endoscopes. [Question remains exactly how many VAMCs nation-wide were not in compliance and failed to report period? Are we to assume that the remaining VAMCs were in compliance, I don’t think so! Major Hanafin]

The results of the unannounced inspections by the VA OIG led to the conclusion that serious management issues [mismanagement] need to be addressed by VA with respect to the mismanagement of industrial processes such as the cleaning of endoscopes. The OIG report recommends that VA:

  • Ensure compliance with relevant directives regarding endoscope reprocessing.
  • Explore possibilities for improving the reliability of endoscope reprocessing with VA and non-VA experts.
  • Review the VHA organizational structure and make the necessary changes to implement quality controls and ensure compliance with directives.

Clinical Risk Assessment Advisory Board (CRAAB)

VHA Directive 2008-002, Disclosure of Adverse Events to Patients (January 18, 2008), provides guidance for disclosure of adverse events related to clinical care to patients or to their personal representatives. Adverse events are defined as "untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided within the jurisdiction of a medical center, outpatient clinic, or other VHA facility."

VHA Directive 2008-002 describes three adverse event scenarios and their corresponding notification processes:

  • Clinical Disclosure of Adverse Events. pertains to disclosure of an adverse event to a single patient at the local level. Generally, such events are of a relatively minor nature.
  • Institutional Disclosure of Adverse Events. focuses on "cases resulting in serious injury or death, or those involving reasonably expected serious injury, or potential legal liability."
  • Large Scale Disclosure of Adverse Events. "involving a large number of patients, even if at a single facility." Often the issues will be clear and the VA will proceed according to the facts and available medical science. However, if the issues are unclear, the VA can request that the VA convene the VA, an ad hoc consultative board.

Key issues that the CRAAB is expected to address include the number of veterans exposed or potentially exposed; the probability that the adverse event will cause harm; the nature, magnitude, and duration of the potential harm; and the availability of treatment to prevent or ameliorate harm. [How many readers can spell ‘double talk?’ Major Hanafin]

VHA Directive 2008-002 recognizes that although it is difficult to weigh all benefits and harms, situations prompting a decision whether to conduct large scale disclosure of adverse events likely involve the following considerations. [Likely involve, doesn’t the doctor know? Major Hanafin]

  • Are there medical, social, psychological, or economic benefits or burdens to the veterans, resulting from the disclosure itself?
  • What is the burden of disclosure to the institution, focusing principally on the institution’s capacity to provide health care to other veterans?
  • What is the potential harm to the institution of both disclosure and non-disclosure in the level of trust that veterans and Congress would have in VHA?

CONCLUSION: The OIG’s review of these issues concluded that effective mechanisms for providing guidance to VHA leadership on disclosure of adverse events to veterans are in place, however, the results of our unannounced VA OIG inspections found serious mismanagement issues that need to be addressed by the VA with respect to the simple management of industrial processes such as cleaning endoscopes.

Posted by: 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.