U.S. Senators Dick Durbin (D-IL) and Barack Obama (D-IL) and Congressmen Jerry Costello (D-IL) and John Shimkus (R-IL) today issued the following statement after reviewing a report issued by the Veterans Affairs Administrative Investigation Board (AIB) which makes employment recommendations concerning former leadership at the VA Medical Center in Marion, Illinois. This is the first part of a three part report.
"Every report from the VA seems to confirm our worst suspicions about the leadership at the Marion VA Medical Center," said Durbin. "The report shows that the management team at Marion failed to act when questions were raised about the credentialing of Dr. Veizaga-Mendez, and they failed again when they ignored desperate pleas for additional staff needed to provide adequate care. The VA needs to implement the recommendations in this report, but that is not enough. It is past time that a new leadership team is in place in Marion and the VA must act swiftly to make that happen."
"Veterans in Illinois and throughout the country should expect nothing less than the best health care and treatment at our nation's veterans' facilities," said Senator Obama. "This report confirms that a failure in leadership and a breakdown of safeguards allowed these tragedies to occur at the Marion VA. It appears the VA has taken action to relieve several individuals of their responsibilities since this investigation was conducted. As we wait for the next reports to be published, I will continue working with Senator Durbin and Congressman Costello to ensure that the VA makes leadership changes, adds the necessary safeguards and thoroughly reviews its standards at the Marion VA and other facilities throughout the country."
"It is truly staggering that the behavior documented here, and the effect that it was having on patient care and morale, could occur for years without anyone at the regional level demanding changes," said Costello. "Perhaps most troubling is the fact that patient health was secondary to the financial health of the facility. We owe it to our veterans to put their needs first, and we owe it to the staff that labored in very difficult conditions to respond to their concerns and create an environment that is conducive to caring for patients. We will continue to work with the VA to make sure this happens."
"As I have noted before, there should be nothing other than the care of the veterans as the priority at the Marion VA Medical Center," Shimkus said. "Clearly, that was not the case under the previous leadership. My colleagues and I will continue to work to see that appropriate changes are carried out, and carried out quickly."
The AIB report confirms numerous problems that existed at the Marion VA Medical Center. The Veterans Health Care Quality Improvement Act (S. 2377), introduced by Durbin and Obama in the Senate and Costello and Shimkus in the House, contains a number of provisions that would help prevent such problems in the future.
Ensuring Proper Credentialing of Physicians
- The report confirms that Marion management knew that doctors at the Medical Center, including Dr. Jose Veizaga-Mendez, were not properly credentialed. However, according to the report, such warnings were dismissed as administrative difficulties. The Veterans Health Care Quality Improvement Act would strengthen the credentialing process by requiring the director of the regional network to personally approve the appointment of any new physician in the network, helping to ensure that bad doctors can't slip through the VA credentialing process. The director would be required to certify in writing that a thorough investigation of the new physician had been completed.
Quality Assurance Officer at Every VA Medical Center Facility
- According to the report, the former Medical Center director failed to properly focus on the quality of care at the Marion VA Medical Center by ignoring troubling patient incident reports, failing to establish a follow-up process for patient deaths, and allowing financial considerations to predominate over quality of care issues. The Veterans Health Care Quality Improvement Act requires a dedicated quality assurance officer at each VA medical facility. That officer would have the primary responsibility for designing and implementing quality assurance programs and activities for the facility and reporting to the director of the facility and also to the quality assurance officer in the regional office.
Quality Assurance Officer at the Network Level
- The AIB report determined that the former Nurse Executive had a duty to report the poor relationship between the Director and the Chief of Staff, but did not because she was afraid of retribution. The Veterans Health Care Quality Improvement Act would require a quality assurance officer in the regional network office, who would have been responsible for ensuring that the Nurse Executive's concerns were resolved in a confidential way. This officer would also receive confidential reports from the quality assurance officers at the medical centers in the network.