"Shocking" and "inadequate" were words used to describe the report on the investigation into the higher-than-normal death rate at the Marion Veterans Administration Medical Center. The report by the Department of Veterans' Affairs Office of Inspector General and VA's Medical Inspector was released Monday and showed that there were clearly problems at the facility.
"Shocking" and "inadequate" were words used to describe the report on the investigation into the higher-than-normal death rate at the Marion Veterans Administration Medical Center. The report by the Department of Veterans' Affairs Office of Inspector General and VA's Medical Inspector was released Monday and showed that there were clearly problems at the facility. The OIG report reviewed 29 deaths that occurred during fiscal year 2007. Of those, three cases did not meet the standard of care. The medical inspector's report examined cases over a two-year period and determined that nine deaths resulted from sub-standard care, and that an additional 10 cases were still under review. Both reports pointed to problems in four major areas: quality management; credentialing; privileging and leadership. According to the report, some reviews of the quality of care at the MVAMC were improperly done, and cases culled for peer review among physicians were not always adequately evaluated. During the credentialing process, the Marion VA at times failed to document its consideration of such important credentialing information as malpractice claims. Documentation related to the verification of licensure, registration and certification requirements was not always timely. The inspector general found instances in which surgeons performed procedures they were not authorized to perform, and the site also failed to adequately consider past performance and outcomes in deciding whether to renew surgeons' permission to continue doing certain procedures. The IG also believed there were warnings for many of the problems, meaning the hospital's former administrators should have taken action before others discovered the issues. According to the report, Marion's leadership should have acted upon problems before outside sources discovered the problem. Information was not given to other entities such as the VA headquarters in Washington, D.C. "The results of these investigations are shocking and point to gross mismanagement at Marion and the need for much better standardized procedures in the VA system to make sure that such a situation cannot occur again," Illinois Congressman Jerry Costello D-12th District said. "Our veterans deserve to know that the medical professionals that are taking care of them have been thoroughly checked out and are qualified. Oversight of each VA facility is critical, and we will be working to fully inform the public about the findings of these investigations and implement much needed changes." Last September, VA removed Marion's hospital director, chief of staff, chief of surgery and an anestesiologist from their position and placed them in other administrative positions or on administrative leave. The anestesiologist resigned and the director and chief of staff will not be returned to work at the facility, even if they should be exonerated upon further investigation. It was also reported that a surgeon who had not previously disclosed information related to his license to practice medicine had been fired. "This report is very critical of the way healthcare was delivered at the Marion VA Medical Center," said Congressman John Shimkus. "While many patients received quality care, others did not. There were many people, doctors and staff, who failed in their duties, who failed the veterans in their care. The former administrative staff at Marion also withheld information from the public and legislators. Something like this must not be allowed to ever happen again. Those responsible will now face administrative action." While the report did not name a specific doctor, Dr. Michael Kussman, U.S. veterans affairs undersecretary for health, acknowledged that much of the criticism has focused on Dr. Jose Veizaga-Mendez. Viezaga-Mendez resigned from the hospital on Aug. 13, three days after a patient from Kentucky bled to death after gallbladder surgery. Sen. Dick Durbin has said Veizaga-Mendez has been linked to 10 patients' deaths at the Marion site. Kussman would not comment further on this issue, saying he didn't want to influence additional internal investigations of six of the site's surgeons he said had at least one episode of substandard care. "There was gross mismanagement here," Durbin said. "Decisions were made to undertake surgical procedures beyond the competence of the doctors involved and beyond the competence of the institution. That is absolutely unacceptable." Durbin went on to say that he did not want "any veteran or their family subjected to someone when there's a question of competency." Kussman, in pledging reforms, said the VA had launched an administrative investigatory board to review care issues and matters raised by employee groups. The VA will begin immediately to contact those veterans and families of veterans who are believed to have been harmed by surgical care at the facility within the past two years to review their care with them, and known instances of substandard care will be disclosed. The Department of Veterans Affairs will also assist patients and families in their efforts to receive compensation if they believe they have been harmed. The department has set up a toll-free phone number for patients and families who are concerned about the care received at the Marion VA. The number is 800-983-0932. "I am angered about the issues at Marion that are identified in these reports," Kussman said. "We sincerely apologize to those who have received poor care, to their loved ones, to the Marion community, and to all veterans and their families. We are determined to correct the problems we have uncovered and return Marion to a level of health care our veterans deserve." The Medical Inspector's report is available at http://www.va.gov/health/docs/2007-D-1356Marion. Contact Diane Wilkins at firstname.lastname@example.org or 618-993-2626 Ext. 106.