VA has a ‘broken culture’ regarding patient safety, watchdog warns

A federal watchdog on Wednesday blasted the “broken culture” at the Veterans Health Administration in regards to patient safety and said major reforms are needed to protect the lives of vulnerable individuals who rely on the medical system.

“Despite employing hundreds of thousands of qualified and dedicated clinical and support staff, some leaders across various levels of VHA do not consistently ensure the safety of the veterans they serve,” said Dr. Julie Kroviak, Deputy Assistant Inspector General for Healthcare Inspections at the Veterans Affairs Inspector General’s office, said during testimony before the House Veterans’ Affairs Committee.

“Changes to VHA patient safety are necessary and overdue. But they are impossible without the dedication of strong leaders who recognize that a cultural transformation is required to support meaningful and sustainable change.”

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Veterans Affairs officials said that work is underway, to include the expansion of “high reliability” patient safety training to all department medical centers in coming months.

“Our VHA governance board begins each day of our meeting with a safety review from the field,” said Renee Oshinski, assistant health under secretary for operations at VHA.

“Sometimes there are individual errors. Sometimes there are system problems. But they are all issues that we see, fix and share across the system, so that we avoid these errors in the future.”

The scathing report from the inspector general’s office comes after a series of high-profile tragedies related to poor patient care practices at VA medical centers, including the conviction last spring of a former nursing assistant at a department hospital in West Virginia for the murder of at least seven patients.

Following that incident, the inspector general’s office found “serious pervasive and deep-rooted clinical and administrative deficiencies” at the Louis A. Johnson Veterans Affairs Medical Center in Clarksburg, West Virginia.

Kroviak said her office has seen similar but less dramatic issues throughout the medical system. Her office found at least 21 incidents over the last two years where officials promised prompt reviews of adverse patient health events but instead failed to formally assess what went wrong.

She pointed to insufficient transparency of problems as a key issue in implementing reforms, and insufficient accountability by senior leaders who fail to make changes.

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VA officials insisted that they are working to improve the system, but lawmakers were skeptical of their response.

“The tone of the testimony this morning seems to be one of defensiveness, not an organization that has taken a hard look at itself and embraced the kind of humility and individual accountability it is seeking from its frontline employees,” said Rep. Julia Bownley, D-Calif., chair of the committee’s panel on health issues. “That needs to change.”

Several panel members expressed concern that the department has not had a Senate-confirmed VHA leader since January 2017, which may be leading to the lack of focus on safety issues. VA leaders earlier this month launched a new commission to review candidates for the post.

Browley promised more investigation into the issues in coming months to ensure that patient safety issues are being prioritized, with or without that position being filled.