Located up the road from the U.S. Capitol, the Washington VA Medical Center should be an exemplar of veterans’ health care.
The Department of Veterans Affairs hospital certainly is an example, but not one to be followed. It has been hit again with sharp criticism from the agency’s Office of Inspector General regarding health services.
One image illustrating its poor state is the facility’s current 1-Star rating, downgraded in June. That’s as low as it can go. It fell from its 2-Star rating (out of five possible stars) in 2017. To put that in context, 1-Star facilities are in the bottom 10 percent of VA medical centers.
It’s enough for District Del. Eleanor Holmes Norton (D) to declare, “I’m fed up.” She plans to call for congressional hearings into a facility that has been dogged by difficulties for years.
The most recent inspector general’s report, dated last month, outlines a series of problems, including:
• Frequent turnover among facility executives. This contributed to the “the lack of evidence of ongoing, coordinated efforts to improve identified deficiencies, employee relations and patient care.”
• “Deficiency in staff education.”
• “1,550 inches of patient reports dating back to 2014.” They “had not been scanned into the electronic health records,” so patient information was not available to health-care providers. Stacking the records would reach the height of a 12-story building.
• “Deficiencies in infection prevention, environmental cleanliness, sterile supplies, medical equipment safety and mental health seclusion room safety.”
A November 2015 review found that patients needing home health care based out of the District’s VA facility waited more than a year. In April 2017, after a Rapid Response Team was deployed to assess complaints, the inspector general took the unusual step of issuing an interim report describing “a number of serious and troubling deficiencies at the Medical Center that place patients at unnecessary risk.” In March 2018, another report found that “dysfunctions identified at the Medical Center were prevalent and deeply intertwined” and that there was “a culture of complacency.”
The District’s facility, the inspector general added in March, “has for many years suffered a series of systemic and programmatic failures that made it challenging for healthcare providers to consistently deliver timely and quality patient care. These breakdowns also heightened the potential for fraud, waste, and abuse of government resources.”
There are many ugly tales behind each bullet point of the current review. “The OIG identified a serious and widespread lack of cleanliness and maintenance throughout the patient care areas,” the report said, including “dirty, stained, or damaged floor tiles and dirty, stained, or damaged walls; dirty, dusty, and/or rusty ventilation grills; and stained, dusty, cracked, and/or broken ceiling tiles. Six patient care areas had damaged furniture and light fixtures, three patient care areas had privacy curtains needing repair or replacement, and three patient care areas had dusty fire sprinkler heads.”
Washington Medical Center Director Michael S. Heimall, who has been in the post since October, said in an email that the hospital “is under new leadership and on a new path, and we look forward to working with Veterans, community stakeholders and local and national VA leaders in order to complete all of the IG’s recommendations.”
In an email, Randy Reese, Washington executive director of the Disabled American Veterans (DAV), praised top executives of the department and the medical center, while at the same time criticizing VA leadership.
The report “placed a much needed spotlight on the complacent DC VA Medical Center,” said Reese, who gets care there. “The findings were absolutely unacceptable to the more than 1-million-member DAV, who are heavy users of the VA Healthcare System. The OIG Report pointed out that this had been primarily a failure of leadership.”
Reese added that the report, which was based on an unannounced week-long site visit in May, “found some significant improvements, though there is still a long path forward to rebuild the confidence of the staff and trust of their veteran patients.”
Another veterans service organization executive, who spoke on the condition of anonymity so he could speak candidly, said the hospital should be a paragon, “a place to take foreign heads of state to see . . . instead it is one of the worst in the system.”
VA officials might not agree with that characterization, but they do say the medical center is improving.
During the past nine months the medical center “revised its care processes for the prevention of central line associated blood stream infections, ventilator associated pneumonias, and catheter associated urinary tract infections,” a department statement said. “This included education of staff on the new processes and weekly monitoring for compliance. This resulted in significant reductions in hospital acquired infections (only two in the last six months).”
The 1,550 inches of patient reports “have been triaged by registered nurses to ensure required follow up care as needed,” the VA statement added. “Currently there are 905 inches of documents left to be scanned, 800 inches of which consist of redundant information, such as discharge instructions. Although these documents have no impact on patient care, we are actively evaluating contract options to expedite the scanning.”
The District’s VA Medical Center needs many expedited improvements. VA officials have developed plans addressing 18 recommendations in the last inspector general’s report.
But that might not be enough, in Norton’s view.
This facility, she said, “needs to check itself in a hospital somewhere, because it’s got a chronic problem.”