VA Report Paints Grim Picture of Widespread Systematic Failings

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.