U.S. Senators Dick Durbin (D-IL) and Barack Obama (D-IL) and Congressmen Jerry Costello (D-IL) and John Shimkus (R-IL) today released the final two parts of a report issued by the Veterans Affairs Administrative Investigation Board (AIB) regarding the former leadership of the VA Medical Center in Marion, IL. The first part of the three part report was released on August 14 and dealt with problems in leadership at the veterans hospital; today's report makes employment recommendations concerning the former leadership of the facility. Additionally, the four lawmakers confirmed that the Secretary of Veterans Affairs (VA), James Peake, will visit the Marion VA Medical Center on Saturday, September 13.
"While part one of the Administrative Investigation Board's report shined a bright light on the dysfunctional former management at the Marion VA, parts two and three highlight the consequences of this broken leadership," said Durbin. "It is inexcusable that the VA's regional network was unaware of Marion's widespread management problems, but that appears to be the case. The Marion VAMC needs qualified, long-term leadership to move on from the tragedies of last year. I look forward to discussing this with Secretary Peake on Saturday."
"The AIB report confirms that a failure in leadership, a lack of coordination among medical personnel, and a breakdown of safeguards allowed these tragedies to occur at the Marion VA," said Obama. "The VA must now make critical leadership changes, add the necessary safeguards and thoroughly examine its standards at Marion, which I expect Secretary Peake to review during his visit this weekend. I will continue working with my colleagues to ensure our nation's veterans receive care that is worthy of their sacrifices."
"Now that the full AIB report is completed, we must continue to move aggressively to make sure that such mismanagement never happens again," said Costello. "This Saturday's visit by Secretary Peake is a chance for the VA to fully inform the public about these findings and hear directly from local residents regarding their ongoing concerns. We will continue to work to ensure that patient care is the top priority of facility officials."
"I look forward to discussing solutions to the problems uncovered by the Administrative Investigation Board with Secretary Peake," said Shimkus. "I believe this weekend's visit by the secretary can mark a turning point for the Marion VA Medical Center. We must make sure the care of our veterans is again the priority at Marion."
Parts 2 and 3 of the AIB report further confirm the existence of numerous problems 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.
Problems with the Quality of Care - First, the report finds that patient mortality levels increased significantly as early as April 2007, but the medical center failed to take sufficient action to find out why. Second, basic support services were not in place to handle the expansion of the scope and complexity of surgeries and there was no appropriate review process to monitor surgical outcomes. Finally, the quality manager did not have enough control over the quality assurance process.
The Veterans Health Care Quality Improvement Act would create a National Quality Assurance Officer in the VA, who would be responsible for developing a confidential system for quality assurance reports, mechanisms for peer review, and mechanisms to hold a VA facility's director and chief medical officer responsible for the medical actions in the facility.
The bill would also ensure that the quality assurance officers at a VA medical facility would not have other duties that could prevent them from effectively doing their jobs, ensuring that they will have effective control over the quality assurance process. With such systems and officials in place, some of the problems identified above could have been caught before they led to the deaths of veterans at the medical facility in 2007.
Network Level Management - The report determined that network management officials including Dr. Peter Almenoff were not aware of the poor relationship among Marion management; did not receive the facility's surgery data on a regular basis from the facility; were not aware of external reviews of the facility; and were not aware of Marion's surgery program expansion. Dr. Almenoff has since been moved from Director of the regional network to a position where his supervisory duties will be reduced considerably.
The Veterans Health Care Quality Improvement Act would create a quality assurance officer for each regional network, and would require each facility quality assurance officer to report to that officer. Doing so would create another independent path for information to travel from a VA medical facility to VISN management.