Special Counsel Faults VA’s Reports on Quality of Patient Care

Vindicating the claims of veterans medical center whistleblowers, the Office of Special Counsel on Monday reported to the White House and Congress that the Veterans Affairs Department “often admits to serious deficiencies in patient care, while implausibly denying any impact on veterans’ health.”

The letter from Special Counsel Carolyn Lerner reflects a review of complaints about quality from VA facilities nationwide. Acting Veterans Affairs Secretary Sloan Gibson immediately expressed his disappointment with the department and ordered a 14-day review of its Office of the Medical Inspector.

“The VA, and particularly the VA’s Office of the Medical Inspector, has consistently used a ‘harmless error’ defense, where the department acknowledges problems but claims patient care is unaffected,” Lerner said. “This approach hides the severity of systemic and long-standing problems. OSC raised similar concerns previously, and today’s letter is OSC’s most thorough accounting.”

Ten cases are detailed in Lerner’s letter, their nature ranging from nurse practitioners illegally prescribing narcotics, to chronic understaffing in primary care units, to the use of “ghost clinics” at which veterans were scheduled for appointments with no provider assigned.

In one case, the medical investigator’s office looking at a VA facility in Fort Collins, Colo., said it could not find “a danger to public health and safety,” though its investigators confirmed that nearly 3,000 veterans there were unable to reschedule canceled appointments, including veterans whose “routine primary care needs were not addressed,” the special counsel found.

At a VA medical facility in Montgomery, Ala., a pulmonologist copied prior provider notes in more than 1,200 patient records, “likely resulting in inaccurate health information being recorded,” the counsel reported.

Gibson’s statement in response said he was disappointed both in the medical failures and the failure to take whistleblowers seriously. “At VA, we depend on the service of VA employees and leaders who place the interests of veterans above and beyond self-interest, and who live by VA’s core values of integrity, commitment, advocacy, respect, and excellence,” he said. Gibson reiterated his June 13 statement reminding the 341,000-strong VA workforce that “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.”

The 14-day review, Gibson added, will look at process, structure, resources, and how recommendations are tracked, as well as how personnel actions are implemented. As recommended by Lerner, he is also appointing a single high-level official to “assess the conclusions and the proposed corrective actions in OSC reports.”

Rep. Jeff Miller, R-Fla., chairman of the House Veterans' Affairs Committee, said, "In reality, the deaths of dozens of veterans across the country have been linked to delays in VA care and other severe department health care 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. 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,” Miller said, “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. In the meantime, OMI 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."

The special counsel, meanwhile, is working on more than 50 pending disclosure cases alleging threats to patient health or safety at the VA; 29 of which have been referred to VA for investigation. About 60 cases involving retaliation against whistleblowers are also being reviewed.