A stinging internal investigation finds “failed leadership at multiple levels” at the Veterans Administration during the Obama administration that put patients at a major hospital at risk.
The 150-page report by the VA internal watchdog offers new details to its preliminary finding last April of patient safety issues at the Washington, D.C., medical center.
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Painting a grim picture of communications breakdowns, chaos and spending waste at the government’s second largest department, the report found that at least three VA program offices under former President Barack Obama’s watch knew of “serious, persistent deficiencies” when he was VA undersecretary of health from 2015 to 2016, but stopped short of saying whether he was told about them.
David Shulkin, who was elevated to VA secretary last year after working for Obama for many years, told government investigators that he did “not recall” ever being notified of problems.
Shulkin has been struggling to keep a grip on his job since a blistering report by the inspector general last month concluded that he had violated ethics rules by improperly accepting Wimbledon tennis tickets and that his then chief of staff had doctored emails to justify his wife traveling to Europe with him at taxpayer expense.
He also faces a rebellion among some VA staff and has issued a sharp warning to them: Get back in line or get out. “I suspect that people are right now making decisions on whether they want to be a part of this team or not,” he said last month.
The latest IG investigation found poor accounting procedures leading to taxpayer waste under Obama, citing at least $92 million in overpriced medical supplies, along with a threat of data breaches as reams of patients’ sensitive health information sat in 1,300 unsecured boxes.
No patients died as a direct result of the patient safety issues at the Washington facility dating back to at least 2013, which resulted in costly hospitalizations, “prolonged or unnecessary anesthesia” while medical staff scrambled to find needed equipment at the last minute, as well as delays and cancellations of medical procedures.
The report also noted improvements made at the Washington facility since the IG’s first report in April, when President Donald Trump took over. Still, VA inspector general Michael Missal cautioned of potential problems without stronger oversight across the VA network of more than 1,700 facilities.
“Failed leadership at multiple levels within VA put patients and assets at the DC VA Medical Center at unnecessary risk and resulted in a breakdown of core services,” Missal said. “It created a climate of complacency … That there was no finding of patient harm was largely due to the efforts of many dedicated health care providers that overcame service deficiencies to ensure patients received needed care.”
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These men and women that fight for our country deserve the most professional health care. Instead, under the Obama administration they were put at risk of death. They did not fight for our country to come home and have their lives put at risk again.
In the report, Shulkin responded that he had expected issues involving patient harm or operational deficiencies to be raised through the “usual” communication process, originating from the local level and regional office to VA headquarters in Washington — and that it apparently didn’t happen.
While the IG did not make specific conclusions on whether Shulkin actually was warned by direct subordinates, it broadly faulted an “unwillingness or inability of leaders to take responsibility for the effectiveness of their programs and operations,” and cited a “sense of futility” at multiple levels in bringing about improvements.
In its written response to Wednesday’s report, the department generally agreed to implement recommendations for improved health procedures at the Washington facility and pledged a “reliable pathway” for local VA and regional officials to report high-priority concerns to senior leadership at VA headquarters.
“It was difficult to pinpoint precisely how the conditions described in this report could have persisted at the medical center for so many years,” Missal wrote.
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“Senior leaders at all levels had a responsibility to ensure that patients were not placed at risk,” he said.
Under Obama, this problem should have been identified properly years ago.
Just another mess left for Trump to clean up.
The Associated Press contributed to this article.