Filthy supply closets for sterile materials. Shortage of equipment and surgical items that alarmed medical staff. No accounting for $150 million worth of supplies. A staff roster so full of holes it looked like Swiss cheese.

The Veterans Affairs Department needs another scandal like a surgeon needs a rusty knife. But thanks to an inside whistleblower, and a rapid-response team investigation by the VA inspector general, we know about conditions the IG says threaten patients at a VA flagship — the Washington D.C. medical center.

How a 21st-century hospital of that size and import can lack a basic system for monitoring and controlling medical gear is hard to fathom. I asked IG Michael Missal if this is the case at any other — or maybe all — VA medical centers. He said that’s something he intends to have his office look into. Something called the Generic Inventory Package — the software authorized by VA for medical centers to use for managing supplies — was supposed to be tested at D.C. nearly two years ago. Maybe it was, but staff told the IG investigators no one relied on it and a contract with a vendor was not renewed.

It looks like management was asleep where this basic responsibility was concerned. The 10-page IG report states VA was shuffling people around as of mid-March, upon orders from the deputy undersecretary for health for operations and management. But the damage was done. The IG received reports of shortages of basic supplies needed for testing dangerous equipment like endoscopes and of supplies needed during surgeries. In one case a nurse had to scramble to find a doodad to supply oxygen to a patient during an “acute episode.” In another case, medical staff had to borrow bone cement from a vendor to finish two knee replacements.

In other cases, vendors pulled important equipment out of the hospital for lack of payment.

In still others, surgeries were canceled altogether for lack of supplies.

Missal says he found the results of the investigation disturbing. He’s low-key. In my opinion, they’re hair-raising. Don’t even ask about storage areas that were supposed to be clean but were dirty or had sterile and used items all mixed together.

The whole place sounds like a Civil War battlefield medical tent, not a carefully-run facility in the middle of the nation’s capital.

Perhaps most disturbing is that there’s no quick fix. Hiring the missing people, installing a usable inventory system, and redoing procedures for greater patient safety — those don’t happen with the snap of a finger. Missal says he’s been told the medical center director has been replaced. That might be a good start, but the center will need a comprehensive approach to fix these problems. A rogue or incompetent doctor is relatively easy to get rid of and replace. Longstanding systemic management and technology challenges take long-term effort.

Recall nearly a year ago when the D.C. Metro rail system went essentially into code-red because of the threat of fires, caused principally by old and worn jumper cables. Hundreds of them needed close-up inspection and maybe replacement. It’s still working out its safety problems from long-term neglect.

The D.C. Medical Center is VA’s jumper cable.

Copyright © 2024 Federal News Network. All rights reserved. This website is not intended for users located within the European Economic Area.