A highly critical report of the U.S. Department of Veterans Affairs (VA) that highlighted poor leadership, excessive waste, the misplacement of medical supplies and endangering patients at its Washington, D.C., hospital has led to senior leadership changes at more than 20 hospitals throughout the country.
The fallout from the report released in early March by Inspector General Michael Missal led VA Secretary David Shulkin to admit that “many of these issues are unacceptable” and it was time for the VA “to do business differently.”
Changes at facilities throughout country
Shulkin then announced the VA’s latest leadership changes at large hospitals and clinics in the Washington metro-area, New England, Phoenix and California. Previously in the last year, he appointed 24 new facility directors in states that included Maryland and Virginia.
The Washington Medical Center was the focus of Missal’s report and year-long review. The center’s hospital and three clinics care for 93,000 veterans including members of the U.S. Congress. Although no patient died, Missal cited a “failed leadership” that oversaw a “climate of complacency” that risked the lives of VA patients.
Report findings highly critical
The findings were alarming, and included:
- Because some surgical instruments were unavailable, patients spent lengthy and unnecessary times under anesthesia.
- When the hospital’s supply of bloodlines for dialysis patients ran out, the staff was forced to borrow supplies from a nearby private hospital. Separately, supply runs to other hospitals sometimes took place during surgeries.
- The government spent excessively on supplies. For example, it rented three hospital beds for $875,000. The beds would have cost $21,000 to purchase.
- More than 1,000 boxes of documents – including patient files with confidential information – were stored in unsecured areas such as a dumpster and off-site warehouse.
Last year, Shulkin removed the hospital’s previous director and the hospital has seen some improvements. Still, Shulkin promised an “entire new leadership” at the Washington hospital, and admitted that the issues reported there are likely similar to what’s happening at other VA facilities throughout the U.S.