Culture Shift Needed to Combat Patient Safety Failures at VA, Watchdog Says

VA Inspector General Michael J. Missal addresses the House Veterans Affairs Committee.
Veterans Affairs Inspector General Michael J. Missal addresses the House Veterans Affairs Committee's hearing on the Department of Veterans Affairs community care program, on Capitol Hill in Washington, Tuesday, March 7, 2017. (Cliff Owen/AP Photo)

The murder of seven veterans at a West Virginia Department of Veterans Affairs hospital and thousands of missed diagnoses by a pathologist who was drunk on the job at a Fayetteville, Arkansas, facility are signs that the Veterans Health Administration, or VHA, has significant leadership and cultural problems, according to the VA's top watchdog.

VA Inspector General Michael Missal said Wednesday that such egregious events should not be treated as "one-offs" but should be used as painful lessons to transform the culture at the department's medical centers, with many working well but others staffed by employees who are "complacent and disengaged."

"Incidents in Fayetteville, Arkansas, and Clarksburg, West Virginia, serve as devastating examples of the most catastrophic consequences of disengaged leadership and the dangerous culture that is fostered when leaders are not attentive to and invested in their staff and the veterans they serve," Missal told members of the Senate Veterans Affairs Committee during a hearing on patient safety Wednesday.

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Reta Mays pleaded guilty in 2020 to murdering seven veteran patients at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia, injecting them with deadly doses of insulin between 2017 and 2018.

A subsequent investigation found that staff did not vet Mays before hiring her, which would have revealed previous marks on her employment history, and they failed to follow procedures for securing pharmaceuticals or notice that doses of insulin were missing. They also failed to conduct investigations following the series of unexpected deaths in patients who all had unusually high blood sugar levels.

In Fayetteville, two patients died and more than 3,000 discrepancies resulted from pathology interpretations by Dr. Robert Morris Levy, who worked at the VA from 2005 to 2018, a period during which he was suspected of being impaired at work.

A VA Office of Inspector General investigation said a conviction of drunk driving before he was hired should have triggered close supervision during his employment probation period, but he received very little oversight. Leadership also failed to manage Levy, despite concerns from subordinates, and placed him in a position of authority.

"The events leading to these failings are often nuanced and multifactorial. However, common contributing factors the OIG has identified are poor, inconsistent, or ineffective leadership that cultivate a complacent and disengaged medical facility culture in which the VHA goal of 'zero patient harm' is improbable, if not impossible," Missal said.

During the hearing, West Virginia Sen. Joe Manchin called out VA leaders for a lack of accountability and noted that he didn't learn much about the investigation until Missal briefed him.

"Individuals in places of leadership were able simply to resign with benefits, like retirement benefits. ... How do the people stay in the system? How are they able to stay until retirement?" the Democrat said.

Missal called for a top-down overhaul of hospital culture from "the highest levels” of leadership at the Veterans Health Administration.

"VHA staff have repeatedly overcome extraordinary obstacles to meet the complex needs of veterans," Missal said. "The OIG continues to emphasize the need for a cultural transformation within VHA, guided by accountable and attentive leaders that prioritize the safety of each veteran they encounter."

The Veterans Health Administration has not had a permanent undersecretary in five years, since Dr. David Shulkin was promoted to VA secretary in 2017.

During his confirmation hearing on April 27, the nominee for the position, Dr. Shereef Elnahal, pledged to invest in the VHA leadership and staff, as he has in his current job heading University Hospital in Newark, New Jersey.

"In addition to leading the hospital through the pandemic before I arrived, the hospital was under the oversight of a state monitor for failures in care quality, patient safety, financial performance, and poor community trust. Together with my workforce, I turned that hospital around by investing in a culture of respect and accountability," Elnahal said.

During the Wednesday hearing on patient safety, Dr. Gregg Meyer, a professor of medicine at Massachusetts General Hospital and Harvard Medical School, warned Congress not to extrapolate the issues seen at the Fayetteville and Clarksburg VA hospitals across the system, adding that numerous studies show that, by many measures, patient outcomes at the VA are better than in civilian health care.

"The American public should be both reassured yet unsatisfied with the quality of care provided to its veterans," Meyer said. "Reassured that the care provided by the VA's direct care system is comparable to and oftentimes better than that available in civilian facilities ... yet unsatisfied that we can do better by veterans by continuing to improve care, learning from failures and ensuring that they have high-quality care regardless of where they access the system."

-- Patricia Kime can be reached at Follow her on Twitter @patriciakime

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