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Even more systematic failures at VA Dept, new Inspector General reports say
WASHINGTON, DC - FEBRUARY 15: Veterans Affairs Secretary David Shulkin testifies before the House Veterans' Affairs Committee on Capitol Hill on February 15, 2018 in Washington, DC. Failures at the Department of Veterans Affairs were the subject of the latest report by the Office of Inspector General. (Photo by Aaron P. Bernstein/Getty Images)

Even more systematic failures at VA Dept, new Inspector General reports say

The ongoing VA scandal just got worse.

A scathing report from the Inspector General’s office revealed “critical deficiencies” at the Washington D.C. Veterans Affairs Medical Center. The 144-page report details rampant problems including lack of supplies, “chronic staffing shortages,” “excessive vacancies in leadership positions,” and a “lack of consistently clean storage areas for medical supplies and equipment.”

The report described the “dysfunctions” at the Medical Center as being “prevalent and deeply intertwined.” While the report did not find any deaths that were caused by the problems at the D.C. medical center, it did find evidence of “delays or postponements of procedures due to unavailable usable instruments.” In some cases, patients were forced to “wait months for needed items.”

This report came a day after a 22-page report from the Inspector General revealed that VA’s Network Contracting Office awarded a $3.3 million dollar contract for interior design services and floor renovations “without adequate competition.”

As an example of the widespread problems, the latest report stated that out of 25 purportedly clean/sterile storerooms, 18 were dirty, and seventeen “lacked a method to monitor pressure, temperature, and humidity.”

In one incident that the report found from 2016, a patient was undergoing surgery to remove skin cancer when the surgeon discovered that a handle to a device needed in the surgery was missing. The surgeon had to improvise and perform that portion of the surgery manually instead of with the device, which she described as “not state of the art for this procedure.”

The report blamed the entire leadership of the VA for the problems it found at the Medical Center. The Office of Inspector General (OIG) reported that it “encountered a culture of complacency among VA and Veterans Health Administration (VHA) leaders at multiple levels who failed to address previously identified serious issues with a sense of urgency or purpose.” As a further evidence of the bad leadership at the department, the report added that “in interviews, leaders frequently abrogated individual responsibility and deflected blame to others.”

While the OIG did not call out Veterans Affairs Secretary David Shulkin specifically, it did state that at least three of the program offices, the Office of Network Support, the National Program Office for Sterile Processing, and the Veterans Health Administration Procurement and Logistics Office, all had “information sufficient to inform the Under Secretary for Health (USH) that serious, persistent deficiencies existed within the Medical Center that could potentially impact patient care.” Before becoming VA secretary, Shulkin was USH from March 2015 to February 2017. while these issues were occurring.

Shulkin also is personally under fire after an IG report from last month found that he misled ethics officials about using taxpayer money to pay for his wife’s $4,000 trip to Europe, and accepting tickets to a Wimbledon match.

Despite its condemnation of the VA leadership, the report gave high praise to the medical staff working at the Medical Center. The Office of Inspector General credited the determination of these healthcare professionals for why it “did not find evidence of patient deaths or other adverse clinical outcomes resulting from these deficiencies.”

According to the report: “[I]n a number of situations, doctors and other health professionals borrowed supplies from a nearby hospital, conducted their own inventories, and took other steps in efforts to provide patients with quality and timely care. However, these stopgap measures are not accordant with an effectively managed healthcare facility. Moreover, patients were put at risk, such as when the lack of supplies or instruments caused surgical procedures to be canceled or delayed.”

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