The veteran’s hospital in Washington, D.C., is so poorly managed that it’s endangering military service members and wasting millions of taxpayer dollars, government inspectors determined in an investigation released Wednesday.
The findings of the 158-page report show a hospital plagued with inefficiency and details numerous examples of poor procedures that could easily have been deadly.
“Failed leadership at multiple levels within VA put patients and assets at the DC VA Medical Center at unnecessary risk and resulted in a breakdown of core services,” Michael J. Missal, inspector general for the Department of Veterans Affairs, said in a statement. “It created a climate of complacency that allowed these conditions to exist for years.”
The report didn’t find that any veterans had been directly harmed as a result of the mismanagement, but stated that patients could have been hurt if it weren’t for dedicated doctors and nurses. “That there was no finding of patient harm was largely due to the efforts of many dedicated healthcare providers that overcame service deficiencies to ensure patients received needed care,” Missal said.
The hospital had poor sterile processing procedures, leading to delays in surgeries and risk of infection, the report said. The lack a solid inventory system led to supply shortages and delays that could have been disastrous. For example, the hospital “ran out of disposable surgical staplers needed to close surgical incisions” on Sept. 15, 2017, the report said. The operating room staff “borrowed staplers from a nearby private hospital to get through the weekend,” and got a new shipment of the staplers Sept. 18.
In another example, the hospital had to re-order “tissue expanders” needed for breast implants three times because each time the equipment was checked in at the loading dock, it got lost. The hospital finally ordered the needed equipment with overnight delivery, and it arrived just in time for a scheduled surgery, the report noted.
More than 10,000 patients at the hospital were waiting for prosthetic requests to be filled at one point in 2017, with at least one person waiting more than a year to receive his or her prosthetic limb. Since the investigation began, the hospital has been able to clear the backlog of patients waiting for prosthetics for more than 30 days.
When equipment did arrive, it was often lost or stored improperly. One $350,000 batch of endoscope for the ear, nose and throat clinic delivered in 2015 was stored in various ways, some tucked into a closet covered by an unsterile blanket, because the department didn’t have skilled staff to process the equipment for use.
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An interim report by inspectors in March 2017 found that of 25 sterile storerooms reviewed, 18 were dirty, five mixed clean and dirty equipment, and several were cluttered. Emergency room staff said the rooms “were dirty was because the Medical Center did not have the staff to clean them.”
The administrative issues were greater, including financial mismanagement like overuse of government-issued credit cards, designed for small purchases, to buy equipment on a regular basis. The hospital’s logistics center was not quick enough to identify inventory purchases, so department heads would routinely use the purchase cards to replace equipment, often at higher prices. The medical staff told investigators in July that “they did not trust Logistics Service to order necessary medical supplies in a timely and accurate manner.”
Hospital staff reported that the delays and inefficiencies certainly affected patient care. Some patients had to stay under anesthesia longer or had surgeries canceled because practitioners couldn’t locate the appropriate equipment.
In one case, a patient was placed under anesthesia before surgeons discovered that the Henley retractor, used in vascular surgeries, wasn’t in the operating room. It had not been on the list of necessary equipment, the report notes. The surgeon canceled the surgery, and found that the Henley retractor in the hospital “had not been sterilized in the week since its last use.” The patient had the surgery a few days later, and recovered fine, the report said.
The Department of Veterans Affairs noted that since inspectors began the investigation in early 2017, the hospital had taken steps to improve its operations, including constructing a new sterile processing center. In a written response to the report, the undersecretary for health at the VA thanked staff who “demonstrated strength, creativity and commitment” to providing care to veterans, and initiated a response team to ensure no patients had been harmed by the poor conditions.
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