WASHINGTON - The Department of Veterans Affairs (VA) today affirmed its determination to quickly address problems at its Marion, Illinois hospital. The VA today released the results of two investigations into concerns involving patient care at the Marion facility.
VA’s Inspector General was contacted by Dr. Michael J. Kussman, VA’s Under Secretary for Health on September 10, 2007, and also subsequently by Congress, to perform a comprehensive review of surgical services at the facility after VA’s National Surgical Quality Improvement Program (NSQIP) found there was a higher death rate than expected during the period from October 1, 2006 through March 31, 2007. Representatives of the NSQIP program visited Marion from August 29-30, 2007. Their follow-up report led to the immediate suspension by Veterans Health Administration (VHA) leadership of all major surgeries at the hospital, which have not been resumed.
“We found the problems ourselves; we took immediate action to keep patients from being harmed as soon as we knew what was going on; we’re extremely sorry for what happened; and we’ll hold those who created the problems accountable,” said Dr. Michael J. Kussman, VA’s Under Secretary for Health. “We’re determined to do what’s right for our veterans and their families, not only at Marion, but everywhere in VA’s medical system.”
The Inspector General’s report, augmented by a separate internal review by VA’s Medical Inspector begun on September 4, 2007, identified four areas in which Marion employees failed to comply with Federal and local regulations and VA directives and procedures. They include:
Quality management: Some reviews of the quality of care at the facility were improperly done; cases selected for review by physicians’ peers (a required practice in health care settings called “peer reviews”) were not always properly evaluated; and patient deaths were inadequately and insufficiently evaluated to be able to address issues in a timely manner.
Credentialing: Credentialing is the process by which health care organizations screen and evaluate medical providers in terms of licensure, education, training, experience, competence and health status. The facility, at times, failed to document its consideration of important credentialing information such as malpractice claims; and documentation related to the verification of licensure, registration and certification requirements was not always done in a timely manner.
Privileging: Privileging is the process by which physicians are granted permissions to practice and to perform various diagnostic and therapeutic procedures. The Inspector General found instances in which surgeons performed procedures they were not authorized to perform. The MedicalCenter also failed to adequately consider past performance and outcomes in decisions whether to renew surgeons’ permission to continue to perform certain procedures. In addition, both the Inspector General and the Medical Inspector’s reports criticize the facility for allowing surgeries to be performed that were more complex than the facility could handle based on its staff and capabilities. Concerns include the fact the MedicalCenter did not have 24-hour coverage in respiratory therapy, pharmacy, and radiology.
Facility Leadership: The Inspector General believed there were warnings on many of the problems identified in NSQIP’s site visit, including NSQIP’s own data, Marion’s leadership should have acted upon before others discovered the problem. According to the IG, though, most of this information was “not disseminated to other VHA managerial entities such as VISN 15 (the facility’s parent network) or VA headquarters in Washington, DC.”
VA is examining each of these areas, not only at Marion but throughout the Department’s health care system, to ensure these types of issues are not present at other facilities, and to enhance regulations to prevent these problems from occurring in the future. A VHA work group has been convened to develop new requirements for peer reviews, augmenting peer reviews conducted at smaller facilities by requiring external reviews and establishing improved parameters for future peer reviews of all types. These additional directives will be enacted within the month.
Both the Inspector General and the Medical Inspector’s reports agreed there had been numerous instances of poor medical care at the facility. The Inspector General’s report states the care of three patients who died following surgical procedures during Fiscal Year 2007 had “significant problems.” The Medical Inspector’s report, which reviewed Fiscal Years 2006 and 2007, and therefore substantially more cases, identifies a total of nine deaths directly attributable to substandard care. There were 34 cases in which care complicated patients’ health, including 10 others who died. In these cases, the Medical Inspector could not determine if the care they received caused their deaths.
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 will also assist patients and families who believe they have been harmed in their efforts to receive compensation. The Department has set up a toll-free phone number for patients and their families who are concerned about the care they received at the Marion VA hospital to call to receive additional information. The number is 1-800-983-0932.
“I am angered about the issues at Marion that are identified in these reports. 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,” said Dr. Kussman. “We are determined to correct the problems we have uncovered and return Marion to a level of health care our veterans deserve.”
Last September, VA removed Marion’s hospital director, chief of staff, chief of surgery and an anesthesiologist from their positions and placed them in other administrative positions or on administrative leave. (The anesthesiologist has since resigned.) Today, the Department also announced it has initiated an Administrative Board of Investigation to review quality of care issues and issues raised by employee groups, and neither the previous director nor the chief of staff will be returned to work at the facility, even if they are exonerated. In addition, a surgeon who had not previously disclosed information related to his license to practice medicine has been fired.