VA promises rapid solutions to problems exposed by ‘extremely disturbing’ IG report

Veterans Affairs Secretary David Shulkin promised rapid resolution to problems afflicting the Washington, D.C. VA medical center outlined in a new inspector general report.

“I do believe we have the ability to fix these issues,” he said. “We will have an electronic inventory system in place here in Washington like we have at most of our other medical centers by Monday, and we have a full time team right now working to make sure that happens.”

The IG identified serious issues with the medical center’s inventory management system — or lack thereof.

“It was extremely disturbing to us, what we found,” VA IG Michael Missal told the Federal Drive with Tom Temin.


The IG found there has been no inventory management system at the Washington, D.C. VA medical center since the failure to implement a new experimental system in May 2015. Because of this, the center didn’t know what supplies it had or needed. There was also no way to track which equipment and supplies were subject to safety recalls, or to keep them from being used on patients.

The report also motivated the department to walk back an internal promotion in favor of an official from outside the facility.

“After further consideration, it was determined that naming an acting director from outside the facility would allow leadership to concentrate on addressing the many challenges identified in the OIG report, without compromising the ongoing internal review,” the department said in an April 12 news release.

Originally, VA announced the promotion of Dr. Charles Faselis to the director position, following the standard line of succession. But after the OIG issued the report, the agency instead decided on Col. Lawrence Connell, currently the senior adviser on policy matters focusing on development, adoption and implementation of department-wide programs and strategic issues.

In an April 13 press conference, VA Secretary David Shulkin said he chose Connell because he wanted someone from his personal staff in charge of putting the situation in order.

“Patient safety is paramount, and we took these actions with this in mind,” Shulkin said.

The OIG report in question stemmed from a confidential tip that the medical center had serious problems.

The OIG rapid response team found that the medical center had previously run out of dialysis bloodlines, oxygen nasal tubing, cement used for bone replacements, certain needles, surgical devices and vascular patches, forcing staff to borrow from other nearby medical facilities or delay procedures.

OIG staff also found a storeroom that was missing alcohol pads, slipper socks, denture cups and certain wound dressings. Several hours later, only the alcohol pads had been restocked.

They also found reports of instances where expired surgical equipment had been used in operations, and expired testing equipment used to determine the sterility of instruments due to the lack of an inventory system.

“Certainly, patients were put at unnecessary risk,” Missal said. “We know procedures were either postponed or cancelled. Our continuing work is going to include looking very closely to see if there was any patient harm.”

In addition, the OIG found 18 out of 25 sterile storage areas were dirty, some mixing clean equipment and supplies with dirty. Some also lacked environmental controls, security or measures to reduce cross-contamination.

Despite regulations saying that certain property needed to be inventoried yearly, the OIG found that more than $150 million of equipment and supplies had not been inventoried in the past year.

Finally, the IG found that a number of senior positions that shouldn’t be impacted by the hiring freeze because they were patient-facing and thus exempted, were left empty, depriving the center of leadership that could have made a difference in rectifying these issues. These positions include the associate VA medical center director, the nurse executive, the chief of logistics, assistant chief of logistics and supply technicians.

And what leadership did exist may have been looking the other way.

“We understand that a number of senior officials at VA were aware of at least some of these issues for some time,” Missal said. “Again, that’s what we’re going to be looking at more closely in our continuing work there.”

While VA had sent in temporary staff to help solve these problems, including a logistics chief, technicians and Veterans Integrated Network Staff, the OIG said it would take a much larger, more coordinated effort to fix the situation.

Missal said that these inventory systems and procedures should be standardized across the Veterans Health Administration. While he said he hasn’t heard of anything like these conditions outside of the Washington D.C. center, the OIG would be taking a look at medical centers in other regions to ensure these problems aren’t systemic.

Sens. Ben Cardin (D-Md.) and Chris Van Hollen (D-Md.) weighed in with a joint press release.

“The idea that these unsatisfactory conditions even existed at the Washington, DC VA Medical Center — much less that they were allowed to continue for so long — is unacceptable. The VA’s swift action to remove and replace the director is a commendable first step, but the underlying problems must be addressed immediately and protections put in to place so this never happens again  — here or at any other VA center,” the statement said.