Veterans Affairs practices face more criticism

WASHINGTON — The Department of Veterans Affairs has played down instances of poor medical care by describing them as a “harmless error,” even in the face of its own employees’ concerns, according to a federal watchdog agency.


WASHINGTON — The Department of Veterans Affairs has played down instances of poor medical care by describing them as a “harmless error,” even in the face of its own employees’ concerns, according to a federal watchdog agency.

In a letter to President Barack Obama and Congress on Monday, the Office of Special Counsel substantiated a long list of problems at VA medical centers, from high levels of Legionella bacteria at a clinic in Grand Junction, Colo., to a psychiatric patient who waited eight years for his first evaluation after being admitted to a VA mental-health facility in Brockton, Mass.

The OSC, which investigates whistleblower complaints and protects federal employees from retaliation, is reviewing more than 50 complaints from VA workers who alleged that inappropriate practices harmed patient safety or health. The watchdog agency said it has referred 29 of those cases to VA for further investigation.

In its letter, it detailed 10 cases nationwide in which VA and its Office of the Medical Inspector acknowledged treatment issues but refused to acknowledge their impact on veterans.

“These cases are part of a troubling pattern of deficient patient care at VA facilities nationwide, and the continued resistance by the VA, and [Office of the Medical Inspector] in most cases, to recognize and address the impact on the health and safety of veterans,” U.S. Special Counsel Carolyn Lerner wrote.

Lerner said the harmless-error defense has “prevented the VA from acknowledging the severity of systemic problems and from taking the necessary steps to provide quality care to veterans.” She added that “veterans’ health and safety has been unnecessarily put at risk” because of the issue.

Monday’s letter follows recent revelations about widespread falsification of scheduling records to hide treatment delays at VA medical centers across the country.

The OSC substantiated claims of related scheduling schemes at VA clinics in Jackson, Miss., and Fort Collins, Colo. The watchdog said it is examining reports that VA removed two Fort Collins schedulers from their positions for refusing to “zero out” wait times to cover up delays.

The OSC announced earlier this month that it is investigating allegations of VA retaliation against 37 agency whistleblowers, including some who tried to report actions related to the scheduling scandal.

Much of Monday’s letter focused on the Jackson hospital, where the agency substantiated claims of improper credentialing, unlawful narcotic prescriptions, non-compliant pharmacy equipment used for chemotherapy drugs and unsterile medical devices, among other issues.

“Despite confirming the problems in each of these (and other) patient-care areas, the VA refused to acknowledge any impact on the health and safety of veterans seeking care,” Lerner said, adding that the approach represents a “serious disservice to the veterans who received inadequate patient care.”

Lerner recommend that VA designate a high-level official to assess the watchdog agency’s conclusions, consider corrective and disciplinary actions and determine whether the substantiated claims indicate systemic problems.

Acting VA secretary Sloan Gibson, who took over as head of the agency after Eric Shinseki resigned last month, said he accepts the OSC recommendations and directed a comprehensive review of the Office of the Medical Inspector’s operations to be completed in two weeks.

“I am deeply disappointed not only in the substantiation of allegations raised by whistleblowers, but also in the failures within VA to take whistleblower complaints seriously,” Gibson said in a statement.

The secretary added that he reminded all VA employees that retaliation and intimidation of workers who expose problems is “absolutely unacceptable.”

House Veterans’ Affairs Committee Chairman Jeff Miller, R-Fla., said that VA has inhabited a “fantasy land” with its stance toward patient-care concerns.

“It’s impossible to solve problems by whitewashing them or denying they exist,” Miller said in a statement. “This is a lesson the VA should have already learned as part of its delays-in-care crisis, but President Obama needs to help reiterate it to each and every VA employee to ensure the department’s focus is on pinpointing and solving problems, rather than downplaying them.”

Senate Veterans’ Affairs Committee Chairman Bernie Sanders, I-Vt., said in a statement Monday that “legitimate concerns must not be covered up or papered over by administrators” at VA. He noted that lawmakers are set to begin finalizing legislation to address some of VA’s recent problems on Tuesday.

“A conference committee will meet tomorrow to try to iron out differences on legislation passed by the Senate and the House that I hope will significantly improve the quality and timeliness of care,” Sanders said.


The Senate this month approved a Sanders-sponsored bill that would allow VA to address treatment delays by contracting more with private medical centers and shifting $500 million from its budget toward hiring medical staff. The measure would also give the VA secretary greater power to fire or demote senior executives for poor performance.

The House has passed stand-alone bills that would have similar effects, but the conference committee must come up with final legislation that combines the proposals and works out their differences.