Just months ago, another scandal was uncovered at yet another VA Hospital. Did you hear about it? Probably not. Scandal and the Veteran’s Administration have become so closely linked, so synonymous, that we have come to expect it.
The latest scandal is particularly embarrassing in that it occurred at the Department of Veterans Affairs Medical Center in Washington, D.C., not more than minutes from the White House. The inspector general’s office (IG) issued a rare preliminary report before the full investigation was completed. Why? Because the conditions and controls were so substandard, they felt the patients and the public needed to be warned. Another Scandal at Another VA Hospital.
One problem after another
In addition to vital equipment and supplies that are in short supply (in fact, the VA was forced to “go begging” at a private hospital for kidney dialysis equipment!), they found that of 25 so-called sterile storage areas that 18 were dirty.
Though the problems were given short-term fixes, the conclusion was that they were, “potentially insufficient to guarantee the implementation of an effective inventory management system and address the other issues identified.”
The inventory system is in such poor shape that they expect problems to continue. After the preliminary investigation the VA medical center director was relieved from his position and placed on administrative duty. To my way of thinking, it does little good to identify and point fingers at any one administrator in particular.
In an official statement issued by VA Secretary David Shulkin’s office on the state of the facility that treats more than 98,000 veterans:
“The department considers this an urgent patient-safety issue. VA is conducting a swift and comprehensive review into these findings. VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law.”
Origins of the complaint
How did this scandal on the horrible inventory and cleanliness issues at the Washington, D.C. VA facility get exposed? It was a whistle-blower, an anonymous complaint. However, it should not have come as a complete surprise. In the past three years alone, there were reputedly 194 reports of insufficient equipment to perform procedures such as fractures and biopsies. There were also cases of expired equipment and in addition, the VA is not certain if equipment was properly sterilized.
The question that does begging is why are inventory problems so rampant and why are the most basic of controls such as the sterilization of equipment and cleanliness in such poor shape?
It is a given that the VA has had long-term, well ingrained problems. From administration to administration, director to director, the problems continue to persist. Is it a lack of funds? A lack of oversight? Insufficient staff to meet the needs of the patient load?
The new director of the VA, David Shulkin, says he would welcome outside oversight, and perhaps that is a great first step, but it also speaks to creating more of layered bureaucracy and more channels of conflicting communication.
I believe that much of the VA’s problems come down to ethics, and an ethical set of failures from the top down. There is a lack of communication, coordination and good choices at the higher levels. The interactions between patients and providers are surprisingly good given all of the stresses. It is the lack of ethical policy making that needs to be addressed. Virtually every conceivable type of fix has been envisioned at the VA, but very little has been done in the way of ongoing ethical training.
Choices and consequences
The VA is a massive operation within the massive government bureaucracy. Perhaps those at the highest levels fail to understand that every policy that is made, the choice to make that policy will have a consequence down the line in an ethical sense. A couple of years ago, when “hidden waiting lists” were created at a VA hospital in Arizona, the choice to make those lists was not so much bureaucratic as unethical. Patients died as a result of those choices. In this recent case in Washington, D.C., a lack of proper supplies, inadequate inventory monitoring and poor sanitation were also choices that have resulted in consequences.
No one, especially me, is minimizing the enormous challenges faced by the VA. However, I believe the bureaucracy of serving our veterans has lost sight of the fact that its sometimes-unethical choices directly impact the health of those it is charged to treat. What harm would there be in ethical training seminars for those in positions of authority at the VA? I cannot see a downside. Another Scandal at Another VA Hospital.
-YOUR COMMENTS ARE WELCOME!
