Critical Deficiencies at the Washington DC VA Medical Center

VETERANS HEALTH ADMINISTRATION Critical Deficiencies at the Washington DC VA Medical Center REPORT #17-02644-130 MARCH 7, 2018 OIG MISSION To serve veterans and the public by conducting effective oversight of the programs and operations of the Department of Veterans Affairs (VA) through independent audits, inspections, and investigations. In addition to general privacy laws that govern release of medical information, disclosure of certain veteran health or other private information may be prohibited by various federal statutes including, but not limited to, 38 U.S.C. §§ 5701, 5705, and 7332, absent an exemption or other specified circumstances. As mandated by law, the OIG adheres to privacy and confidentiality laws and regulations protecting veteran health or other private information in this report. Report suspected wrongdoing in VA programs and operations to the VA OIG Hotline: www.va.gov/oig/hotline 1-800-488-8244 ` Critical Deficiencies at the Washington DC VA Medical Center Executive Summary In March 2017, in response to a confidential complaint, the Department of Veterans Affairs (VA) Office of Inspector General (OIG) deployed a Rapid Response Team to conduct an inspection of the Washington DC VA Medical Center (Medical Center). The OIG took the unusual step of issuing an Interim Report three weeks later that described serious conditions that put both patients and federal government assets at risk.1 The April 2017 Interim Report identified a number of significant deficiencies at the Medical Center, including the lack of accurate supply and equipment inventories that made it difficult to ensure patient needs were met, generally dirty conditions in clean/sterile storerooms,2 and millions of dollars in unaccounted for supplies and equipment. The inspection continued and this final report details the overall findings and related recommendations. In summary, the OIG found that the Medical Center has for many years suffered a series of systemic and programmatic failures that made it challenging for healthcare providers to consistently deliver timely and quality patient care. These breakdowns also heightened the potential for fraud, waste, and abuse of government resources. Hospitals by their very nature carry an intrinsic risk to patients as personnel contend with unpredictable situations, infection control, large numbers of vulnerable individuals with significant care needs, and changing demands on a daily basis. Given these challenges, it is critically important for hospitals to have effective core services that promote quality patient care and safety. Moreover, strong management and fiscal controls must be in place for appropriate stewardship of taxpayer-funded resources. The OIG found widespread and formidable inadequacies in many essential functions at the Medical Center that contributed to the deficiencies described in this report, including • The inability to consistently provide supplies, equipment, and instruments to patient care areas when needed; • Ineffective sterile processing contributing to delays or postponements of procedures due to unavailable usable instruments; 1 VA OIG, Interim Summary Report: Healthcare Inspection—Patient Safety Concerns at the Washington DC VA Medical Center, Washington, DC, Report No.17-02644-202, April 12, 2017. 2 VHA Directive 1761, Supply Chain Inventory Management, 2016, p. 3, uses the term “clean/sterile storeroom” to mean a primary or secondary inventory point location where clinical items are stored to protect them from accidental contamination. VHA Directive 1116 (2), Sterile Processing Services, 2016, p. 4, uses the term Sterile Storage Area to mean an area designed to store clean/sterile supplies or instruments and to protect them from contamination. Within the context of this report, the OIG uses the term clean/sterile storerooms to describe primary and secondary storage areas containing medical supplies, instruments, or equipment that are sterile or otherwise clean and ready for use on patients. Critical Deficiencies at the Washington DC VA Medical Center • The lack of consistently clean storage areas for medical supplies and equipment; • The failure to accurately and consistently track and trend patient safety events; • Excessive vacancies in leadership positions and other pervasive staffing issues across multiple departments, including Logistics, Prosthetics, Sterile Processing, and Environmental Management Services; • More than 10,000 open and pending prosthetic and sensory aid consults as of March 31, 2017, causing some patients to wait months for needed items; • Financial and inventory systems producing inadequate data, lacking effective internal controls, and yielding no assurances that funds were appropriately expended; • Approximately $92 million in supplies and equipment being charged to purchase cards over a two-year period without proper controls to ensure the purchases were necessary and cost-effective; • Underutilization of the prime vendor contract that was designed to purchase supplies at more favorable prices; • More than 500,000 noninventoried items maintained in an inadequately secured warehouse; and • Patient protected health information (PHI) and personally identifiable information (PII) stored in unsecured areas. Despite these significant issues, the OIG did not find evidence of patient deaths or other adverse clinical outcomes resulting from these deficiencies. This was due in large part to the efforts of a number of committed healthcare professionals who worked around these challenges and improvised as necessary to provide veterans with the best possible services under the circumstances. For example, in a number of situations, doctors and other health professionals borrowed supplies from a nearby hospital, conducted their own inventories, and took other steps in efforts to provide patients with quality and timely care. However, these stopgap measures are not accordant with an effectively managed healthcare facility. Moreover, patients were put at risk, such as when the lack of supplies or instruments caused surgical procedures to be canceled or delayed. The dysfunctions identified at the Medical Center were prevalent and deeply intertwined. They could not be attributed to any single individual, but rather were the result of inadequate actions and accountability across many services and positions. The OIG encountered a culture of complacency among VA and Veterans Health Administration (VHA) leaders at multiple levels who failed to address previously identified serious issues with a sense of urgency or purpose. In interviews, leaders frequently abrogated individual responsibility and deflected blame to others. VA OIG 17-02644-130 | Page ii | March 7, 2018 Executive Summary Since 2013, there were reports and documentation of many of these problems that leaders at the Medical Center and its oversight entities, including the Veterans Integrated Service Network (VISN) 5 and the VHA, failed to adequately address (see Appendix B, Relevant Reports). Despite the many warnings and ongoing indicators of serious problems, leaders failed to engage in meaningful interventions or effective remediation. This report is organized into the following four broad areas: 1. Risk of Harm: Whether patients were placed at risk for experiencing adverse clinical outcomes because of the Medical Center’s inability to ensure that supplies and instruments reached clinical areas when and where they were needed.3 2. Service Deficiencies Affecting Patient Care: Whether deficiencies in the Medical Center’s services that manage inventory, prepare medical instruments for use, procure prosthetic devices, and hire qualified personnel affected healthcare providers’ ability to provide quality and timely services. 3. Lack of Controls Over Assets: Whether Medical Center practices put medical equipment and other assets of the federal government at risk for fraud, waste, and abuse. 4. Failures in Leadership: Whether leaders at the Medical Center, VISN 5, and Veterans Health Administration Central Office (VHACO) effectively addressed Medical Center problems and unsafe conditions. A summary of key findings within each of these four areas follows: 1. Risk of Harm Although the OIG did not identify patients who suffered death or other adverse clinical outcomes as a result of the identified problems, veterans were put at risk because important supplies and instruments were not consistently available in patient care areas. The OIG identified cases in which 3 Within the context of this report, the OIG considered an adverse clinical outcome to be death, a change in diagnosis, a change in the course of treatment, or a significant change in the patient’s level of care. The OIG recognizes that in addition to the potential for adverse clinical outcomes, avoidable delays and cancellations associated with the deficiencies discussed in this report may impact the convenience and quality of care received by veterans, some of whom travel long distances to seek care from a VA hospital. The OIG was unable to quantify the frustration, confusion, or disturbances in a veteran’s activities of daily living that may have resulted from these deficiencies and focused its evaluation of patient harm in terms of adverse clinical outcomes. VA OIG 17-02644-130 | Page iii | March 7, 2018 Critical Deficiencies at the Washington DC VA Medical Center • Needless hospitalizations (with attendant risks) occurred when patients’ procedures were canceled following their admission, sometimes for overnight stays, because items could

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