Last summer, a veteran in Las Vegas died by suicide two hours after he was discharged from a Department of Veterans Affairs inpatient mental health facility, despite having told a family member while he was hospitalized that maybe he "should just die."
An investigation found that the facility failed to address the patient's complaints and didn't flag him as high risk.
Furthermore, the facility didn't fully examine the circumstances that led to the death and never listed it as a "sentinel event" -- in effect, hiding the death from scrutiny up the leadership chain, according to the VA's Office of Inspector General.
In the past five years, the Veterans Health Administration has grappled with several high-profile patient safety issues, including the murder of seven veterans at a Clarksburg, West Virginia, VA hospital; an alcoholic pathologist who went unchallenged on his job, resulting in 3,000 diagnostic errors; and a VA gynecologist who made graphic and lewd comments to patients while conducting pelvic examinations.
While these cases center on errors or malfeasance by individuals, they demonstrate a systemic failure of leadership and indicate a need to accelerate the VA's efforts to overhaul its health care culture, according to the top watchdogs for the VA and the federal government.
Dr. Julie Kroviak, deputy assistant inspector general for health care inspections in the VA's Office of the Inspector General, told members of the House Veterans Affairs Subcommittee on Health on Wednesday that while the department has undertaken initiatives to improve its reliability, the effort is still in its infancy and mistakes continue.
"OIG oversight work has shown that these missed opportunities were nearly always due in large part to the actions and, even more often, inactions, of leaders," Kroviak said. "Changes to [Veterans Health Affairs'] patient safety approaches are necessary and overdue, but impossible without the dedication of strong leaders who recognize that a cultural transformation is required to support meaningful and sustainable change."
Sharon Silas, director of the health care team at the Government Accountability Office, noted that VA health care, which has been on the GAO's "high-risk list" since 2015 -- a designation that means the department requires transformation or is vulnerable to waste, fraud, abuse or mismanagement -- has failed on several accounts to improve its standing.
Silas noted that the VA lacks the capacity, including personnel and resources, to effectively institute changes to reduce risk to patients; has not developed a comprehensive plan to improve performance; and has failed to demonstrate progress.
She added that the VA also lacks leadership commitment across the board -- a lapse most notable in its failure to name a permanent head of the Veterans Health Administration, a position that has not had a Senate-confirmed leader for nearly five years.
"The number and repetition of recommendations we have made to address deficiencies in oversight and accountability are symptomatic of deeper issues underlying these efforts to oversee [VA's] delivery at health care," Silas said.
VA officials noted that the department has undertaken steps to improve the entire health system.
They say the department has introduced and will expand its "high reliability" patient training initiative to improve treatment and care. It has reorganized the Veterans Health Administration's headquarters to better support medical centers. And it has revised its action plan to address shortcomings identified by the GAO this year.
"In our ongoing efforts to identify which processes work and which do not, VA continues to examine how our [medical centers] are designed and functioning and how processes can be configured to function in a manner that ensures the highest-quality and safest care possible," said Renee Oshinski, assistant health under secretary for operations.
Lawmakers expressed skepticism over the VA officials' pledges that a culture change is underway.
Subcommittee Chairwoman Rep. Julia Brownley, D-Calif., began the hearing noting that the Veterans Health Administration "needed to change."
"The tone of the testimony seems to be one of defensiveness, not an organization that has taken a hard look at itself and embraced the kind of humility and individual accountability it is seeking from its frontline employees," Brownley said.
"The testimony is quite frankly damning," said Michigan Rep. Jack Bergman, the top Republican on the subcommittee. "I have said before that many of VA's problems are the result of lapses of leadership. This is as true today as it ever was."
Subcommittee members urged VA Secretary Denis McDonough to fix what Kroviak called a "broken culture" at the VA and promised additional oversight in the coming months on patient safety and the under secretary search.
VA officials pledged that the work is underway.
"One bad outcome is too many," Oshinskii said.
-- Patricia Kime can be reached at Patricia.Kime@Monster.com. Follow her on Twitter @patriciakime.