October 18, 2007
The Honorable Gordon Mansfield
Acting Secretary of Veterans Affairs
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420
Dear Secretary Mansfield:
Thank you for your response to our offices dated October 12, 2007. While we appreciate the timeliness of your reply, the letter raised more questions than it answered. We are therefore writing to request additional answers and clarifications to your responses to our original letters and to ask that you respond to new information that has come to light regarding health care quality and patient safety at the Marion VA Medical Center (VAMC).
We respectfully request answers to the following questions:
1) How many fatal and non-fatal patient safety events have occurred at the Marion VAMC since the beginning of 2006? Specifically, for all surgeries conducted at the Marion VAMC since the beginning of calendar year 2006 through September 2007, please provide figures broken out by quarter and attending physician on the following:
a. Actual and expected rates of post-operative infection and other surgical complications, and death;
b. Actual and expected average lengths of hospitalization;
c. Actual and expected rates of hospital readmission within 30 days;
d. Citations from JCAHO and other accreditation and licensing entities; and
e. Other relevant indicators of surgical care quality.
2) You reported that over the period between April 1 and September 1, 2007, there were 36 hospital deaths at the Marion VAMC. To the extent allowable under HIPAA, please elaborate on the reasons for hospitalization, causes of death and how many of these deaths were unexpected? How many of these deaths involved Dr. Veizaga-Mendez?
3) You provided comparative data that implied that the frequency of deaths between April 1 and September 1, 2007, was within normal bounds for the VA. Yet you have previously described there being a "spike" in deaths during this time period. What data or evidence led you to believe there was a spike?
4) You reported that, at the time of Dr. Veizaga-Mendez' original appointment, VA "made a query of the National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank (NPDB-HIPDB)." Please provide documentation of your query and the information obtained as a result of that query. Was any information returned that would give the VA a reasonable cause for concern in allowing Dr. Veizaga-Mendez to care for veterans?
5) Please provide any material regarding Dr. Veizaga-Mendez you received from the Massachusetts Medical Board during the time he was under consideration for employment at the Marion VAMC as well as any materials or notifications received from the Massachusetts Medical Board while he was employed at the Marion VAMC. Specifically, did the information provided by the Massachusetts Medical Board describe two malpractice payments (one each in 2004 and 2005) made by Dr. Veizaga-Mendez and a record of the hospital disciplinary action taken against Dr. Veizaga-Mendez in 2004? If not, why was that material not made available to the VA since those actions were already final when Marion VAMC allegedly requested information from the Massachusetts Medical Board?
6) As part of their credentialing processes, many hospitals require doctors to answer written questions regarding past charges or claims filed. Did the VA pose such questions to Dr. Veizaga-Mendez as part of his VA application, and if so:
a. What were the specific questions VA asked of Dr. Veizaga-Mendez?
b. What were Dr. Veizaga-Mendez' answers to these questions?
c. Does any of the information he provided conflict with known information about charges or claims related to his practice in Massachusetts?
In addition, did the VA contact Dr. Veizaga-Mendez's former employers and former hospitals at which he held clinical privileges in Massachusetts? And if so, did any of the information obtained in those instances provide cause for concern regarding Dr. Veizaga-Mendez? Please provide copies of the five written letters of reference that you obtained.
7) In describing the VA's general approach to conducting background checks on medical hires, you reported that the VA Health Administration "also checks the names of all applicants against a Federal list of individuals who have been excluded from participation in any Federal health care programs." Did the VA perform such a check on Dr. Veizaga-Mendez and what were the results? What procedures does the VA have in place to ensure that all VA facilities perform such checks when hiring new health care professionals?
Our offices have received at least one new complaint involving a veteran who may have sustained a life-altering injury in a VA facility as a direct result of a preventable medical error. Our offices are working closely with the family to ensure this individual gets the help and benefits he deserves.
This new case, which we are sharing with the Office of the Inspector General, is all the more troubling because it involved a second physician, and not Dr. Veizaga-Mendez. This case - and we are concerned there may be others like it - suggests that the problem with health care quality, particularly patient safety, may be more widespread than previously believed.
Underscoring this concern is the account from the veteran's mother that one health professional at the Marion VAMC went so far as to warn her to take her son elsewhere for care, suggesting that concerns over the quality of health care were well known among at least some of the hospital's staff. This raises the question as to whether this concern was known by the VA's leadership. Obviously this case must be reviewed and verified, but we expect that you would agree that, given the situation, this case raises serious concerns that must be addressed.
8) Does the VA believe that the problems with patient safety and patient care extend beyond the problems associated with Dr. Veizaga-Mendez and the other three Marion staff that have been reassigned? Was the leadership of the VA aware of other allegations of poor patient care and lax patient safety? And what steps has the VA taken to ensure that health care quality and patient safety are at the highest levels at all VA facilities nationwide?
We want to underscore our belief that the majority of VA health staff perform their jobs with exceptional competence and compassion on a daily basis. They deserve our praise for their dedication and patriotism, and we know that Marion is proud that its VA facility serves veterans across the region. At the same time, Marion residents share our view that any concerns over health care quality at this VA facility must be immediately addressed.
We know that you are committed to investigating and remedying quality and patient safety issues, and to preventing similar occurrences at Marion and other VA health facilities around the country.
Thank you for responding to our request by October 26, 2007.
United States Senator
United States Senator