VA: 19 deaths in Ill. traced to care

[David]

AP


ST. LOUIS - Substandard care at a southern Illinois Veterans Affairs hospital may have contributed to 19 deaths over the past two years, a VA official said Monday as he apologized to affected families and pledged reform.

The hospital in Marion, Ill., initially drew scrutiny over deaths connected to a single surgeon, but two federal reports found fault with five other doctors.

The hospital undertook many surgeries that its staffing or lack of proper surgical expertise made it ill-equipped to handle, and hospital administrators were too slow to respond once problems surfaced, said Dr. Michael Kussman, U.S. veterans affairs undersecretary for health.

"I can't tell you how angry we all are and how frustrated we all are. Nothing angers me more than when we don't do the right thing," Kussman told reporters during a conference call after releasing findings of the VA's investigation and summarizing a separate inspector general's probe.

Still, Kussman insisted, "what happened in Marion is an exception to what otherwise is a truly quality health-care system" across the VA.

The VA will help affected families file administrative claims under the VA's disability compensation program, he said. Families also could sue.

The VA investigation found that at least nine deaths between October 2006 and March last year were "directly attributable" to substandard care at the Marion hospital, which serves veterans from southern Illinois, southwestern Indiana and western Kentucky.

Kussman declined to identify those cases by patient or doctor, though Rep. Jerry Costello, an Illinois Democrat, said those nine deaths were linked to two surgeons he did not name.

Of an additional 34 cases the VA investigated, 10 patients who died received questionable care that complicated their health, Kussman said. Investigators could not determine whether the care actually caused the deaths.

Inpatient surgeries have not been performed at the facility since problems first became public last August. They will remain suspended indefinitely, Kussman said.

In pledging reforms, Kussman said the VA has launched an administrative investigatory board to review care problems and matters raised by employee groups.

The VA last September also installed interim administrators to replace the Marion VA's director, chief of staff, chief of surgery and an anesthesiologist, moving them to other positions or placing them on leave, Kussman said. The anesthesiologist has since quit, Kussman said.

"The previous leadership will not return" to their former jobs, he said.

The VA's investigation cited by Kussman covered a two-year span, the VA said.

The inspector general's office blamed three deaths on substandard care at the Marion site, but that review covered only the past fiscal year, which ended in October, the VA said. That report was not immediately available Monday.

Telephone calls on Monday seeking comment from the Marion VA were directed to spokespeople with the agency's Washington headquarters.

Neither Kussman nor the VA investigation's 41 pages of findings named surgeons involved in the deaths, though Kussman acknowledged that much of the criticism has focused on Dr. Jose Veizaga-Mendez.

Veizaga-Mendez — identified in Monday's report as "Surgeon A" — resigned from the hospital Aug. 13, three days after a patient from Kentucky bled to death after gallbladder surgery. All inpatient surgeries stopped a short time later.

Sen. Dick Durbin, an Illinois Democrat, has said Veizaga-Mendez is linked to 10 patients' deaths at the Marion facility, about 120 miles southeast of St. Louis. Kussman declined to discuss that claim Monday, 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."

Veizaga-Mendez and another surgeon no longer practice at the Marion VA. The remaining four surgeons remain on staff but are "only doing minor cases at this time," Kussman said.

"We don't think the physicians killed the patients," he said. "We think the physicians were trying to care for the patients and did so in an inadequate way."

Costello and fellow Rep. John Shimkus, a Republican from Collinsville, Ill., called Monday's findings "shocking." Durbin said the reports "confirm what many of us in Illinois feared" — that the Marion VA's medical care was substandard and that protocol for protecting patients was ignored.

"As the inspectors who reviewed the Marion hospital put it, the quality of care at Marion was 'horrible,'" Durbin said.

Veizaga-Mendez's whereabouts are unclear. He has no listed telephone number and has been unreachable for comment.

The Marion VA hired Veizaga-Mendez in January 2006 after he practiced in Massachusetts, where he was under investigation for substandard care in 2004 and 2005. The claims include allegations that he botched seven cases, two ending in deaths.

Veizaga-Mendez was permanently barred from practicing medicine in Massachusetts last November — a disciplinary move that also requires him to resign other state medical licenses he may hold and withdraw pending license applications. He has also made payouts in two Massachusetts malpractice lawsuits.

[Boats]

Chicago radio station this morning was talking about how they shut down all surgury's at this facility as the doctor's there weren't qualified to preform the ones they were doing. That's great.

[SuperScout]

Originally, I had posted this under antoher thread. Here's a quote that is indicative of what I see as wrong/bad/incompetent about the VA:

Veizaga-Mendez's whereabouts are unclear. He has no listed telephone number and has been unreachable for comment.

The Marion VA hired Veizaga-Mendez in January 2006 after he practiced in Massachusetts, where he was under investigation for substandard care in 2004 and 2005. The claims include allegations that he botched seven cases, two ending in deaths.

Veizaga-Mendez was permanently barred from practicing medicine in Massachusetts last November — a disciplinary move that also requires him to resign other state medical licenses he may hold and withdraw pending license applications. He has also made payouts in two Massachusetts malpractice lawsuits.

So this butcher wasn't good enough to proactice his trade in the Peoples' Republic of Massachusetts, but manages to find his way into the VA hospital system. Anybody else see a problem with that?

[Gimpy]

Originally Posted by SuperScout

Originally, I had posted this under antoher thread.

So this butcher wasn't good enough to proactice his trade in the Peoples' Republic of Massachusetts, but manages to find his way into the VA hospital system. Anybody else see a problem with that?

Yeah, I got got a problem with that. If we'd had BETTER leadership at the VA these past 7 years (remember Jim Nicholson??? Another "Bush Crony" who knew abso-phuckin-lutely NOTHING about VA health care) maybe these "hiring procedures" would've been FIXED by now!

But, regardless........this IS a tragedy---but NOT the 'common-place' scenario at the overall majority of VA health care facilities.

Until the early 1990s, care at VA hospitals was so substandard that Congress considered shutting down the entire system and giving ex-G.I.s vouchers for treatment at private facilities. That all changed in the mid-1990's when Bill Clinton appointed Dr K. Kiser to head a transformation of the VA health care system. Today it's a very different story. The VA runs the largest integrated health-care system in the country... And by a number of measures, this government-managed health-care program ... is beating the marketplace.

For the sixth year in a row, VA hospitals scored higher than private facilities on the University of Michigan's American Customer Satisfaction Index... Males 65 years and older receiving VA care had about a 40% lower risk of death than those enrolled in Medicare Advantage, whose care is provided through private health plans or HMOs...

And, Harvard University just gave the VA its Innovations in American Government Award for the agency's work in computerizing patient records.

In addition, overall findings from a recent private study show that in-hospital mortality rates were similar between VA and the private sector (5.0% vs. 5.6%, respectively). After adjusting for severity of illness, in-hospital mortality was again similar in VA patients compared to private sector patients.

However, there were some significantly different mortality rates in regard to individual diagnoses. For example, the mortality rate for stroke was 9.2% in the private sector vs. 6.5% in the VA, and for acute myocardial infarction the mortality rate was10.1% for private sector vs. 1.1% for VA.* ( Rosenthal GE, Sarrazin MV, Harper DL, Fuehrer SM. Mortality and length of stay in a Veterans Affairs Hospital and private sector hospitals serving a common market. Journal of General Internal Medicine 2003;18:601-608.)

Pretty damn good results when compared to private institutions, huh?

And all that was achieved at a relatively low cost. In the past 10 years, the number of veterans receiving treatment from the VA has more than doubled, from 2.5 million to 5.7 million, but the agency has cared for them with 10,000 fewer employees. The VA's cost per patient has remained fairly steady during the past 10 years. The cost of private care has jumped about 40% in that same period.

Vets still gripe about wading through red tape for treatment. Many have been waiting 90 days or more for their first appointment. The Iraq and Afghanistan wars have stressed the system ...And the system has been consistently UNDERFUNDED by the Bush administration these past seven years. But, the FACTS remain uncontested....patients receive substantially better care at VA hospitals than they do at private hospitals!

So let's make SURE the F-A-C-T-S are presented truthfully...and ACCURATELY before folks start attempting to undermine and discredit a health care system like the VA's based on unproven and obviously biased 'personal opinion' without any professional references and/or substantial, documented evidence to support their claims.


Gimp

[SuperScout]

It shouldn't require the director of the VA to 'vet' every doctor that is hired by the VA system. The local chief of surgery should have simply reviewed the findings on the butcher that was eventually hired, and reams of negative material was there for the asking. I don't care if this butchery is common place, or if this is a related incident; the mere fact that it happened, and sadly happened in a VA hospital, is tragedy enough.

You get your panties in a wad so easily. I wasn't impugning the VA system, but simply stating FACTS - way too many deaths in a medical facility, staffed by what appears to be incompetent people, who were hired with too lame professional standards. In summary, if the butcher couldn't ply his sorry trade in M'Chusetts, why was he good enough to be hired by the VA? Probably because he couldn't get a job anywhere else.

[Gimpy]

Sadly, I must say I cannot disagree with you in this particular case.

I just hope and pray they can get the problems at this VA hospital straightened out and all guilty parties subjected to the full measure of the justice system.

Heads need to roll and some folks need to go to federal prison over this situation.


Gimp

[Packo]

At one time, until the nationwide nursing/doctor crunch, the VA was the most prestigious place for nurses to work. It also payed the best. A VA nurse had to be top notch or she was not hired or fired soon after employment. All this began to change in the 60's / 70's as we returned from Vietnam. By the 70's the nursing crunch was so bad that private hospitals began paying more than the VA, substantially more, and nurses were bailing out of the failing system for private/community hospitals. I even went to 1 year of a 2 year RN program hoping to nail a job in the private sector. Hospitals in Florida, not the only place, were offering pay for a 40 hour week if you would just work a 12 on Saturday and a 12 on Sunday. (Booger's wife did this.) I figured that I could hang at the beach Mon-Fri. Not a bad life. My hip stopped my chances in my second year. Doctors also began bailing for private sector and private practice. The VA began cutting back on medicines and would use old outdated ones, which they still do, because they wouldn't spend the money on new ones, frustrating good doctors who wanted to practice good medicine. While in Med school, my buddy, who did Pighumpers surgery, said that when they went to VA hospitals to train, they were basically told that they would be working with drunks, drug addicts, and other indigents, because any veteran with insurance wouldn't set foot in a VA facility. When I was in the VAMC, Washington, DC, he visited me every day from George Washington University Hospital because, and I quote, "I NEVER EXPECTED YOU TO GET OUT OF THERE ALIVE".

The ONLY way the VA is ever going to get back to where it was during and right after WWII is to make it a place that EXCELLENT MEDICAL PROFESSIONALS line up to work there due to pay and working conditions. It really is as simple as that. I know mistakes are made everywhere, but unless it's some killer nurse, you will never see these problems at places like John's Hopkins, George Washington University Hospital, Mayo Clinics, Mt. Siani, etc. It's simple folks....you get what you pay for.

Pack

[SuperScout]

Roger your last! In addition to the pay differential, there has to be better screening in the employment or pre-employment process. I still find it totally unacceptable that some chief of surgery didn't properly 'vet' the butcher from M'Chusetts. From the "care" I have received from the VA hospitals in either Temple, Texas, or San Antonio, Texas, I seriously questioned the medical competence of either "physician." Thankfully, what they did to me was neither life-threatening or invasive.

And I do not why is is so sad to agree with me, Gimpy. I'm really not the ogre you envision.

[Packo]

that explains that at Martinsburg VAMC the head of Internal Medicine was not board certified in IM and the Chief of Staff, who would approve this stuff, hiring etc, had been sued clean out of private practice. As long as these people can make much better money and have better working conditions, the monster will perpetuate itself. I've got so many stories from my experiences, personally, and my work for all those years with the VA....I otta write a book.

Pack

[SuperScout]

Pack,
Go ahead and write that book. I'll be it will be a best seller, especially among vets who have had to deal with the system. In the meantime, here are some recommendations for improvements:
1. Hire a real IG for the VA, not a careerist, but an outsider, who has policie investigative experience. Once he finds an unqualified doctor, he fires him, and then goes to find who hired him, who is next fired.

2. Offer vets a choice of either VA care, or a Master Card, which will provide them with a doctor of their choice + meds. Similar to a means of improving the educational process, give the end-user a choice.