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Watchdog report: Failed VA leadership put patients at risk
By HOPE YEN, Associated Press
WASHINGTON (AP) — “Failed leader- ship” at the Department of Veterans A airs during the Obama years put patients at a major hospital at risk, an internal probe nds — another blow to Secretary David Shulkin, who served at the VA then and is ghting to keep his job.
e 150-page report released Wednes- day by the VA internal watchdog o ers new details to its preliminary nding last April of patient safety issues at the Wash- ington, D.C., medical center.
Shulkin acknowledged to reporters that the problems were “systemic,” but said he was not aware of the issues at the Washing- ton hospital. He pledged wide-scale change across the VA.
Painting a grim picture of communi- cations breakdowns, chaos and spending waste at the government’s second largest department, the report found that at least three VA program o ces directly under Shulkin’s watch knew of “serious, persistent de ciencies” when he was VA undersec- retary of health from 2015 to 2016. But it stopped short of saying whether he was told about them.
Shulkin, who was elevated to VA secre- tary last year by President Donald Trump, told government investigators that he did “not recall” ever being noti ed of prob- lems.
Among the changes he promised — unannounced audits of its more than 1,700 medical facilities from health experts in the private sector, immediate hiring to ll vacancies at local hospitals and plans in the coming months to streamline bureau- cracy and improve communication.
Shulkin pointed speci cally to VA med- ical centers in the New England, Arizona and Washington D.C. regions that needed improvements to address patient safety. “Not to act when you identify systemic failures I think would be negligent,” he said.
Shulkin has been struggling to keep a grip on his job since a blistering report by the inspector general last month conclud-
ed that he had violated ethics rules by improperly accepting Wimbledon tennis tickets and that his then chief of sta had doctored emails to justify his wife traveling to Europe with him at taxpayer expense.
He also faces a rebellion among some VA sta and has issued a sharp warning to them: Get back in line or get out. “I sus- pect that people are right now making de- cisions on whether they want to be a part of this team or not,” he said last month.
e latest IG investigation found poor accounting procedures leading to tax- payer waste, citing at least $92 million
in overpriced medical supplies, along
with a threat of data breaches as reams of patients’ sensitive health information sat in 1,300 unsecured boxes.
No patient died as a result of the patient safety issues at the Washington facility dating back to at least 2013, which resulted in costly hospitalizations, “prolonged or unnecessary anesthesia” while medical sta scrambled to nd needed equipment at the last minute, as well as delays and cancellations of medical procedures. e report also noted improvements made at the Washington facility since the IG’s rst report in April, when Shulkin replaced
the medical center’s director and pledged broader improvements.
Still, VA inspector general Michael Missal cautioned of potential problems without stronger oversight across the VA network of more than 1,700 facilities.
“Failed leadership at multiple levels within VA put patients and assets at the DC VA Medical Center at unnecessary
risk and resulted in a breakdown of core services,” Missal said. “It created a climate of complacency ... at there was no nd- ing of patient harm was largely due to the e orts of many dedicated health care pro- viders that overcame service de ciencies to ensure patients received needed care.”
In the report, Shulkin responded that
he had expected issues involving patient harm or operational de ciencies to be raised through the “usual” communication process, originating from the local level and regional o ce to VA headquarters
in Washington — and that it apparently didn’t happen.
While the IG did not make speci c con- clusions on whether Shulkin actually was warned by direct subordinates, it broadly faulted an “unwillingness or inability of leaders to take responsibility for the e ec- tiveness of their programs and operations,” and cited a “sense of futility” at multiple levels in bringing about improvements.
“It was di cult to pinpoint precisely how the conditions described in this report could have persisted at the medical center for so many years,” Missal wrote.
“Senior leaders at all levels had a respon- sibility to ensure that patients were not placed at risk,” he said.
Shulkin has maintained White House support despite the travel controversy.
He has acknowledged some mistakes in the handling of the trip and said he relied too much on the judgment of his sta to ensure full compliance with travel poli- cies. He has since said he reimbursed the $4,000 plane ticket for his wife. His chief of sta , Vivieca Wright Simpson, has le the agency.
Several major veterans organizations are standing behind him as the best guardian of the VA amid a planned overhaul of the Veterans Choice program, a Trump cam- paign priority aimed at expanding private care outside the VA system.
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Follow Hope Yen on Twitter at https:// twitter.com/hopeyen1
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