WASHINGTON, D.C. - Responding to a report issued today by the Department of Veterans Affairs Inspector General blaming the deaths of three patients at an Illinois VA Medical Center on substandard medical care and a systemic failure of management and oversight, U.S. Senator Daniel K. Akaka (D-HI) called the findings "appalling" and said: "It is simply unacceptable that veterans could survive the battlefield only to die prematurely due to shoddy medical care."
Akaka, Chairman of the Senate Veterans' Affairs Committee, continued: "I am appalled by the Inspector General's findings, which indicate that substandard care led to the deaths of a number of patients at the Marion VA hospital. While this investigation was specific to the Marion, Illinois facility, the findings have ramifications for veterans nationwide and all Americans who trust that veterans' hospitals will care for our nation's heroes."
In November, Chairman Akaka held a hearing on hiring practices and quality control in VA medical facilities, prompted by a sharp spike in deaths at the Marion, Illinois VAMC as found by VA's internal tracking. The VA Office of Inspector General conducted their investigation at the request of Congress.
Akaka noted: "The investigation revealed a critical shortcoming: there is no national directive defining how facilities set up their quality management program. In the case of Marion, the surgeons in question were responsible for reviewing one another's work. The lack of a national directive or any required external oversight is deeply problematic and is simply unacceptable.
"The investigation also exposed great deficiencies in how VA monitors the credentialing of physicians. An aggressive response is needed to address the credentialing of physicians, especially when multiple licenses are held. VA must increase the scrutiny upon physicians with lapsed or expired licenses. These licenses are more likely to bear information of past disciplinary proceedings or malpractice claims that are otherwise not readily identified.
"I am also concerned about the process of privileging physicians to conduct new diagnostic and therapeutic procedures. VA must do a much better job documenting the professional competency and performance record of physicians before allowing them to conduct complex procedures. Moreover, at a management level there needs to be a more thorough review of which facilities have the resources and equipment to safely perform certain procedures.
"The Committee on Veterans' Affairs will continue to follow this matter closely," Chairman Akaka said.
The Medical Inspector's report is available at: http://www.va.gov/oig/54/reports/VAOIG-07-03386-65.pdf
January 29, 2008