About 10 veterans were apparently killed by unnecessary insulin shots at a Department of Veterans Affairs hospital in West Virginia, with two of the deaths now labeled homicide. At least a dozen veterans died in Arkansas, allegedly because a VA pathologist botched their diagnoses.
These recent high-profile cases have drawn new attention to concerns the Government Accountability Office and the VA Office of the Inspector General have raised within the last two years about how the VA hires its doctors.
"It would be easy to dismiss any one of these cases as just an isolated incident or just one bad apple," said Rep. Chris Pappas, D-New Hampshire, the chairman of the Veterans' Affairs subcommittee on Oversight and Investigations, at an Oct. 16 hearing on the subject. "Collectively, these cases speak to wider problems with the VA's ability to identify clinicians who are negligent, abusive or committing criminal acts or to prevent them from practicing."
He added, "We need to see that the VA is as outraged as we are."
GAO staff investigating VA physician hires earlier this year found Veterans Health Administration staff overlooked disqualifying information, such as a revoked or surrendered license, when hiring doctors.
The inspector general has found similar issues, including one case in which the VA hired an eye surgeon, even though he was not board certified in ophthalmology and had not completed a U.S. residency program in his field. It further found the surgeon took one to two hours to complete cataract surgeries when the industry standard is 26 minutes, increasing the risk of complications for his patients.
Both investigative bodies concluded the VA's hiring issues arise from poor oversight and training of the credentialing staff on VA hiring policies.
"If VA medical centers fail to properly review and address concerns that have been raised about a provider," GAO staff said in this year's report, "veterans may be exposed to unsafe care and potential harm."
Meanwhile, an OIG staffer said at last week's hearing that he was not sure whether providers and staff were not speaking up or instead leadership had ignored their concerns.
"To kind of sum up," said ranking committee member Rep. Jack Bergman, R-Michigan, who had chaired the subcommittee on the subject two years ago, "the observation is no clear chain of command, no structural review process and no requirement for direct observation."
Pappas pointed out the decentralized nature of VHA hospitals as another factor.
Dr. Steven Lieberman, Veterans Health Administration acting principal deputy under secretary for health, said the VA strives for the best care and holds those who don't adhere to the department's standard of care accountable.
"I am sorry for any pain that any veteran or their families have experienced as a result of our employees acting inappropriately," Lieberman testified last week. "When something goes wrong, we learn from those experiences."
But he added VA staff have not found a "common thread between the recent incidents," saying it was "a small number of people who acted inappropriately."
"Some recent events are deeply disturbing," Lieberman said. "It is extremely troubling that the actions of a few flawed staff might overshadow the great work of the nearly 348,000 employees who provide quality care every day to veterans and their families."
Dr. Gerard Cox, VHA deputy under secretary for health for organizational excellence, said the department will probably have new policies to address the GAO and inspector general's concerns completed by next summer.
"An organization's policies and procedures alone do not make for success," Bergman said. "It is the leadership of these organizations that established the culture, empowers individuals to think and act autonomously, and drives the organization toward a more improved version of itself."
-- Dorothy Mills-Gregg can be reached at Dorothy.Mills-Gregg@Monster.com.