Durbin, Burris, Costello, Shimkus: VA Management Must Be Held Accountable for Failures at Marion Facility
Illinois members call for meeting with VA Secretary to discuss change needed in order to return quality of care aat Marion to highest standards
[WASHINGTON, D.C.] – Calling the recent findings of a Department of Veterans Affairs (VA) Office of the Inspector General (OIG) “appalling” and “inexcusable”, U.S. Senators Dick Durbin (D-IL) and Roland Burris (D-IL) and Congressmen Jerry Costello (D-IL) and John Shimkus (R-IL) today pledged to hold the VA accountable for the failure of leadership at the VA Medical Center in Marion, Illinois to meet VA patient safety and quality care guidelines.
In a sharply worded letter, the Illinois members called for a meeting with Secretary of the VA, Eric Shinseki, as soon as possible to discuss the unacceptable standards and treatment of veterans at the Marion facility noting: “It is clear that those in the direct line of command at Marion have violated the public’s trust and should be relieved of their duties until serious questions over management can be answered.”
“It is inexcusable that after more than two years of adjustments and reviews, Marion VA is still failing our veterans in quality of care,” said Durbin. “This cannot and must not continue. We have asked for a full accounting and are calling on Secretary Shinseki to make immediate changes at the facility. We have also asked the Secretary to provide us with the VA’s plan for restoring the quality of veterans care at Marion.”
“As a member of the Committee on Veteran Affairs, I am deeply disturbed and troubled by this report,” said Burris. “As we continue to fight for better health care for all Americans, it seems our own veterans' needs continue to go unmet. This direct dereliction of duty endangers the health and lives of those who bravely served our nation and needs immediate remedy.”
“This report from the VA Inspector General is shocking and must be addressed immediately,” said Costello. “It is absolutely unacceptable that many of the quality management issues we learned about over two years ago have not been addressed. Particularly troubling to me is the fact that the VISN does not appear to be aware of what is going on at the facility. We need to know what the VA is going to do to solve these problems and restore the confidence of our veterans – it is not enough to simply say the VISN Director needs to ensure compliance, as this hasn’t worked to this point. This situation needs to have the full attention of VA leadership - that is why we are asking for a response directly from Secretary Shinseki – and additional senior staff changes at Marion must occur. Obviously, this must be the top priority of the new facility director.”
“My office has continued to look into complaints from patients and employees who have been unhappy with the lack of progress at Marion,” said Shimkus. “Unfortunately, this report only reinforces what we have been hearing. As the Congressional delegation has stated since this controversy began, we will not rest until our veterans are getting the care they deserve at Marion.”
The OIG reviewed the period between October 2007 and August 2009 under the Combined Assessment Program, which includes recurring evaluations of health care facilities focusing on patient care and quality management. Many quality management failures that were found during previous reviews were identified in this most recent review including lack of sufficient oversight and fragmented and inconsistent reporting structure, inadequate peer review, failure to meet mortality screening requirements, and failure to integrate the patient safety program into all areas of the medical center. Additionally, the OIG identified new problems in records review, patient data analysis, staff life support certifications, compliance with environmental standards, and medication management.
In some cases, the IG found that medical personnel at the Marion facility performed procedures for which they did not have proper privileges and safety guidelines involving patient health were routinely ignored.
Following the release of today’s report, the VA announced that the current Director of Marion VA Medical Center is to be replaced by Mr. James Roseborough, former Director of the regional Veterans Integrated Service Network (VISN) 12, and that a new quality management team at Marion will be lead by Dr. Luke Stapleton, Chief Medical Officer for VISN 7.
Poor leadership and communication led to serious problems at the Marion VA Medical Center in 2007, including surgical malfeasance associated with the deaths of nine veterans. The VA reassigned five individuals, including the Marion facility’s director, chief of staff, and chief of surgery, to non-clinical areas after concerns about the quality of patient care at the facility arose. Various reviewers from the Veterans Health Administration, Office of Health Inspection, and Office of Inspector General, have identified concerns with quality management and deficiencies in medical center leadership. Many of these reviews have focused on oversight of quality management processes and, compliance with policies designed to ensure patient safety.
[Text of letter below]
November 2, 2009
The Honorable Eric K. Shinseki
Secretary of Veterans Affairs
Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420
Dear Secretary Shinseki:
We write with great concern regarding the Combined Assessment Program Review of the Marion Veterans Affairs Medical Center (Marion VAMC), Marion, Illinois, released today by the Department of Veterans Affairs Office of Inspector General.
The Inspector General’s report indicates that patient safety and quality care management at the Marion VAMC once again has fallen short of VA standards and guidelines. Simply put, we find this situation appalling.
We would like to meet with you as soon as possible to discuss how to dramatically change course and return the quality of care at Marion to the highest standards. In the meantime, it is clear that those in the direct line of command in VISN 15 and at the Marion facility have again violated the public’s trust and should be relieved of their duties until serious questions over management can be answered.
It is our understanding that you have taken some initial steps to replace Marion VAMC leadership. However, since the problems at Marion have continued through multiple Department reviews and endured previous personnel changes, we believe you must take more comprehensive and immediate action to ensure the quality of care for veterans and their families.
Problems in the quality of care at Marion VAMC date to at least 2006. Since that time, the Veterans Health Administration, Office of Health Inspection, and Office of Inspector General have all identified concerns with patient safety, quality of care and deficiencies in medical center leadership. We have been told time and again that various elements of the VA were closely monitoring the situation and that appropriate steps were being taken to rectify the problems. And yet, nearly three years later, this IG report has uncovered serious problems that raise alarm bells.
In this most recent review, the Office of the Inspector General (OIG) reported many quality management failures that were found during previous reviews. These include lack of sufficient oversight and fragmented and inconsistent reporting structure, inadequate peer review, failure to meet mortality screening requirements, and failure to integrate the patient safety program into all areas of the medical center. In addition, the OIG identified new problems in records review, patient data analysis, and identification of staff needing to maintain life support certifications.
We have been deeply concerned about the quality of care at Marion since news of problems first surfaced and the deaths of nine veterans were attributed to surgical malfeasance two years ago. We have visited the facility, as have our staffs, over the past two years. We also periodically questioned Marion and VA’s Washington office personnel regarding the status of the surgery program and quality management processes at the facility. We are deeply disappointed that yet another report identifies entrenched and serious problems at Marion VAMC. This level of care is unacceptable; the problems must be rectified and they must be rectified now.
Because we know that you are deeply concerned about the safety of veterans entrusted to your care, you must be as outraged as we are about this latest report. We need to hear the VA's plans to ensure that veterans treated at Marion VAMC are safe and receiving the highest quality of care. They deserve nothing less.
We look forward to working with you to address the serious issues at Marion VAMC.
Sincerely,