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VA Report Paints Grim Picture of Widespread Systematic Failings

“It's impossible to solve problems by whitewashing them or denying they exist. This is a lesson VA should have already learned."

by
Bill Straub

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June 27, 2014 - 4:36 pm
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WASHINGTON – The official responsible for assuring that ex-service members received high quality medical care from the Department of Veterans Affairs regularly downplayed the agency’s shortcomings in treatment, according to a new report, indicating that care under the system is worse than previously reported.

In an official letter to President Obama, Special Counsel Carolyn Lerner asserted that the department’s medical inspector ignored legitimate information provided by whistleblowers who raised questions about the low-quality treatment being provided within the system.

For instance, according to Lerner, one veteran housed in a VA psychiatric unit in Brockton, Mass., didn’t receive his first comprehensive evaluation until eight years after the beginning of his residency. A VA pulmonologist at a VA facility in Montgomery, Ala., cited old test results, rather than more recent ones, in more than 1,200 patient files. Lerner said the likely result was “inaccurate patient health information being recorded.”

In each instance, according to the report, the medical inspector was made aware of the problem but failed to adequately respond, often characterizing the result as “harmless error,” maintaining the problems carried no effect on the patient care being provided. Regarding the Brockton case, the inspector said the office concluded the veterans’ care “could have been better, but OMI doesn’t feel that their patients’ rights were violated.”

The result of such indifference, Lerner said, has prevented the VA from acknowledging the severity of “systematic problems” within the Department of Veterans Affairs and “taking the necessary steps to provide quality care” to former service members.

Sloane Gibson, the acting secretary of the Department of Veterans Affairs, acknowledged the report’s findings, saying he was “deeply disappointed not only in the substantiation of allegations raised by whistleblowers but also in the failures within VA to take whistleblower complaints seriously.”

“I reminded all 341,000 of our employees that we must protect whistleblowers and create workplace environments that enable full participation of employees,” Gibson said. “As I told our workforce, intimidation or retaliation – not just against whistleblowers, but against any employee who raises a hand to identify a problem, make a suggestion, or report what may be a violation in law, policy, or our core values – is absolutely unacceptable. I will not tolerate it in our organization.”

Reacting to the Lerner report, Rep. Jeff Miller (R-Fla.), chairman of the House Veterans Affairs Committee, said the deaths of dozens of veterans across the country have been linked to delays in VA care and other severe department healthcare problems.

“But in the fantasy land inhabited by VA’s Office of the Medical Inspector, serious patient safety issues apparently have no impact on patient safety,” Miller said. “It’s impossible to solve problems by whitewashing them or denying they exist. This is a lesson VA should have already learned as part of its delays in care crisis, but President Obama needs to help reiterate it to each and every VA employee to ensure the department’s focus is on pinpointing and solving problems, rather than downplaying them.”

The medical inspectors’ office, Miller said, “owes it to America’s veterans and American taxpayers to provide an immediate and thorough explanation as to why it keeps reaching the same implausible conclusions in one report after another.”

Rep. Mike Michaud (D-Maine), the panel’s ranking member, said he was “angered” by the Lerner revelations.

“Unfortunately, it’s becoming increasingly clear that this is not a problem that we can blame on outdated software or a bulky, multi-layered leadership infrastructure – but also a cultural problem within the VA,” Michaud said. “We must get to a place where the VA is driven by ensuring it delivers high-quality, timely care to every single veteran, rather than be driven by things like shallow metrics.”

The Office of Special Counsel is an independent federal agency that is now reviewing a reported 50 pending complaints from whistleblowers within the VA who reported what they consider harm to patient safety or health. Lerner’s office is further looking into about 60 cases involving VA workers who maintain they faced reprisals for raising issues about patient care.

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All Comments   (11)
All Comments   (11)
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I blame the VA management for not running an effective organization. It was simply to easy to fudge numbers and collect bonuses.
21 weeks ago
21 weeks ago Link To Comment
The VA budget has expanded, but at a slower rate than the increased influx of injured veterans. There were also expansions in coverage that increased the load. There are systemic problems and the performance evaluation needs a broad and deep overhaul, but don't lose sight of the fact that demand for VA services is rising faster than VA budgets. Both problems need addressing and I wish I could be confident that the politicians would work together to fix them rather than digging in and posturing.
21 weeks ago
21 weeks ago Link To Comment
Has anyone ever calculated the cost of just giving veterans a voucher for private sector health insurance or putting them on Medicare. Why on earth are we not focusing on the government's absolute ineptitude at running any kind of a business or providing any complex service, Hell, just their provider payment operations in Medicare result in $50 Billion per year in waste and fraud.

They can assign every single tax dollar to the VA and they will still screw everything up. Like all government employees, VA workers are expensive, get lavish pensions and benefits for life, can't be fired, are not held to any kind of productivity standards and have captive customers whose satisfaction matters not to them. It is never going to work.
21 weeks ago
21 weeks ago Link To Comment
Government workers are slightly more expensive than the private sector at the bottom and much less than the private sector at the top. Public sector employees top out less than 300K. That is middle management money in a large corporation. I'm willing to bet that you have no evidence that there is more waste fraud and abuse in the public sector than in the private sector for public works or in general. You take it as a given, as though it has been conclusively proven, without the conclusive proof.
21 weeks ago
21 weeks ago Link To Comment
A Government Accountability Office report, a watchdog website created by an executive order from President Barack Obama, and an article from the U.S. Administration on Aging give fraud rates that range from 7.9 percent to 8.5 percent for the largest Medicare program, and up to 11 percent for a smaller program, Medicare Advantage. Medicare mandatory spending for 2013 was $550 billion.

The world wide credit card fraud rate in the private sector is .04%

As for waste and inefficiency, that is harder to pin down but if you want to believe that workers managed by political appointees and protected by powerful unions (who essentially elect their bosses) are as efficient as the private sector, then go ahead. But it is your myopia that will drive us to a much lower standard of living as government gobbles up more and more from the private sector - from which you currently benefit tremendously whether you like to acknowledge it or not.
21 weeks ago
21 weeks ago Link To Comment
Just fabulous! The Socialist Bernie Sanders is going to "pass legislation" - yeah, that'll help. What a bunch of crap.
21 weeks ago
21 weeks ago Link To Comment
NOW with Obamacare...we can ALL look forward to this level of "care"!!
21 weeks ago
21 weeks ago Link To Comment
Lets not forget that the VA received large increases in its budget between Bush 2 and O 1 and 2; the question is, where was the money spent? Was all of it spent on manager bonuses??
I can state that the VA facility in White River Junction, VT seems to be the best of the lot, especially their Mental Health services.
21 weeks ago
21 weeks ago Link To Comment
A very big problem with the VA and many other government agencies is that they have gone big for "pay-for-performance" (PFP) management systems. In PFA, employees get significant pay enhancements (bonuses) for meeting agreed-upon performance measures. In theory, this solves the problem of civil service employees getting the same pay (based on grade level and time of service) whether they are top performers or slackers.

The problem with PFP is that it is easy to game by setting goals that appear wonderful on paper but are slam-dunks to meet. If you add in the ability to manipulate or even falsify performance measurements, and lack of management oversight to make sure that the right things are being measured and those are measured honestly, you have a recipe for managing an organization right into the ground. The VA seems to have succeeded at this failure mode exceedingly well.

This rot is present in almost all our government bureaucracies. VA is just the current poster-child.
21 weeks ago
21 weeks ago Link To Comment
DaveK OR, I have a friend who worked at the V.A. Region VII General Office for many years & the reports of patient abuse at the hospital got so bad, she couldn't stand it, so she transferred to the USDA & retired from there. She also REFUSED to let her Dad (a WWII Vet, who's still with us) go to the V.A. Hospital & insisted he keep his medical insurance & go to a "normal hospital".
21 weeks ago
21 weeks ago Link To Comment
Of course this is terrible, but don't be too quick to blame the V.A. alone; as usual, in true Congressional "oversight" tradition, the Senate and House Veterans Affairs Committee members are the guilty ones here for being so lax in not arranging this new appropriation years ago when the influx of Veterans from Afghanistan and Iraq in need of V.A. facilities should've been anticipated by the V.A, then telegraphed to both Veterans Committees and all the while under the continuous "oversight" of these committee members. All working together.

Shame on these Veterans Affairs Committee Members for not being on top of this from the very start of our military interventions. Now of course it's way too late, so much suffering could've been avoided, but better late than never.
21 weeks ago
21 weeks ago Link To Comment
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