'Culture of Complacency:' Investigators Fault VA Leadership for Medical Facility's 'Systemic' Failures

Widespread, systemic failures at a Veterans Affairs Department medical facility in Washington, D.C., persisted for years, according to a scathing new watchdog report, despite managers throughout the agency knowing about the problems.

VA leaders at multiple levels failed to address a series of issues that put veterans’ health at risk since 2013, the inspector general said, creating a “culture of complacency” that allowed well-known issues to fester. The full, 144-page report was released Wednesday after the IG put out rare interim findings in April just three weeks after launching its investigation into the Washington facility, which led to the immediate demotion and eventual firing of its medical director Brian Hawkins.  

“Despite the many warnings and ongoing indicators of serious problems, leaders failed to engage in meaningful interventions or effective remediation,” the IG said in its final report. The auditors added that in interviews, various VA officials “abrogated individual responsibility and deflected blame to others.”

The report comes at a precarious time for VA Secretary David Shulkin, who served as undersecretary of health and head of the Veterans Health Administration during some of the years in question. Shulkin has faced significant criticism for another recent IG report that found he improperly charged the government for his wife’s travel and accepted gifts while on an official visit in Europe last year. Shulkin was only briefly cited in the new report, telling investigators he did not recall any senior leaders bringing issues related to supplies and equipment at the medical facility to his attention.

“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,” Michael Missal, the VA’s IG, said in a statement.

On Tuesday, asked about the previous IG report faulting Shulkin’s travel practices, White House Press Secretary Sarah Sanders said Shulkin “has done a great job.” She added the IG’s investigation “continues to be under review” by the White House.  

VA identified more than 300 “patient safety events” that involved problems with supplies, instruments or equipment from Jan. 1, 2014, through Sept. 6, 2016. The facility did not maintain an accurate inventory, resulting in staff not knowing which items were available or where to find them. Sterile equipment processing had severe flaws, including broken instruments reaching clinical areas and a lack of quality assurance. The IG questioned “unsecured access to and mismanagement of” more than 500,000 items in an off-site warehouse and $92 million in purchase card charges made without proper controls.

The IG found examples of facility staff running out of oxygen tubes, alcohol pads, vascular patches and other critical supplies while patients awaited care that required them. The investigators found no evidence any of this led to patient deaths, but the facility put patients at risk by delaying or canceling scheduled procedures. Some patients faced unnecessary anesthesia or hospitalization as a result of the lack of instruments and supplies. The efforts of “committed health care professionals” who worked around challenges by borrowing supplies and conducting their own inventories helped prevent further negative outcomes, the IG said.

The regional directorate in charge of the facility, known as the Veterans Integrated Service Network, received at least seven written letters detailing deficiencies, which went unaddressed. VISN and headquarters leadership were aware of the problems and did not take “adequate corrective action,” the IG said.  

Shulkin addressed the report at the Washington facility on Wednesday, saying he has already taken important steps to right the ship. He noted the new leadership team, vacancies that had been filled, eliminating the backlog of prosthetics consults lasting longer than 30 days and contracting a new $9 million facility for the Sterile Processing Service.

“We appreciate the work of the OIG,” Shulkin said. “Their report is a critical step in improving the overall performance of this facility. Further, it is especially valuable as VA strives to markedly improve the care we provide to our veterans and as we move forward in restoring veterans’ confidence in the medical care they receive.”

He added that the findings were “unacceptable,” of great concern to leadership and emblematic of more widespread problems throughout the department.

Rep. Phil Roe, R-Tenn., chairman of the House Veterans' Affairs Committee, said veterans deserve "the very best care and treatment" and the Washington facility "failed them." He expressed confidence in Shulkin, however, saying he was grateful to the secretary for "being proactive in addressing the problems at the D.C. facility and across the department." 

The IG made clear VA still has a long way to go fix the issues at the medical facility.

“Since the issuance of the OIG interim report, the medical center has made progress in reducing the number of open and pending prosthetic consults, updating standard operating procedures and competencies in sterile processing of instruments, and the overall cleanliness of storage areas, among other improvements,” the auditors said. “However, the magnitude, breadth, and longevity of the problems likely means it will take some time to fully correct the conditions that exist at the medical center.”

The IG made 40 recommendations, all of which were accepted by VA management. It specifically tasked various levels of VHA management, including the undersecretary for health, with ensuring proper oversight and clear lines of communications when problems arise. The auditors said the suggestions would “serve as a roadmap” for VA medical facilities around the country.