This month the Atlanta VA underwent a mass leadership exodus as directed by their oversight body, Veterans Integrated Service Network (VISN) 7. The chief of staff was offered a different location and instead decided to retire, while the deputy chief of staff, and the chiefs of primary care, emergency, and clinical access services were all moved to new positions. Oddly, the initial memo and spokesperson assured the media that the Director would stay, yet as the Atlanta Journal Constitution reported, orders were crafted that very same day replacing the Director.
The ostensible reason was that the Atlanta VA had been abruptly demoted from a three star facility to a one-star facility, suffered lapses in their mammogram program, and were found to have a ton — literally, one ton or two thousand pounds — of hazardous waste in a portable building. But the ratings took priority. These are updated annually for VAs nationwide and reflect access to care, customer service, patient deaths, and hospital-based infections. Like hotels, a five-star rating is considered exceptional while a one-star rating is the lowest possible score and only given to a few VAs. For a while, these ratings were kept secret until reporters at USA Today revealed them to the public; now they are freely reported.
Healthcare moves very slowly, especially for improvements. Some have likened it to ‘turning around a battleship,’ in that a core of leadership, foresight, and initiative is required to effect any change. And similarly, once these systems are in place, declines also occur slowly.
But how do we predict when a hospital is about to go bad? Were there any clues that hinted at the Atlanta VAs precipitous decline? And if so, could leadership have taken action to change course?
We know from a recent study that having a Joint Commission (JC) seal of approval on a hospital doesn’t mean much in terms of quality. Healthcare CEOs spend tens of thousands of dollars on this largely bureaucratic process — boxes have to be so many inches below the ceiling, the area under a sink should be spotless, there should be a written protocol in case you spill a bottle of peroxide, etc. — yet patient deaths are the same in accredited and non-accredited hospitals. And there is nothing special about JC accreditation versus other independent accrediting companies.
Let’s look at the VA oversight, which in addition to Joint Commission, includes the Office of the Inspector General (OIG). Every VA must participate in a full assessment by the OIG that occurs at least once every three years. The OIG generally looks at the same things as JC does such as leadership, quality, and patient safety, but is less likely to be fooled by a disingenuous VA leadership. It’s worth noting that former Secretary of Veterans Affairs, Eric Shinseki, admitted he had been ‘too trusting’ and had difficulty explaining the ‘lack of integrity among some of the leaders of the [VA] healthcare facilities.’
About a year and a half before the mass leadership purge occurred, the OIG performed an assessment of the Atlanta VA. The executive summary is revealing that the OIG ‘could not gain reasonable assurance,’ on seven things most people take for granted about a healthcare system.
First, there was concern that clinical managers weren’t monitoring the professional competency of providers. This means no one was overseeing staff to make sure they were safely treating veterans. Now in most instances, doctors and nurses are caring, competent individuals called to a higher level of duty, but this isn’t always a given.
Second, the OIG couldn’t guarantee that facility leaders maintained a clean and safe patient care environment. A specific example was given about keeping glucometers clean. A glucometer is a handheld device that checks the blood sugar of a diabetic patient by pricking their finger and putting a drop of blood on a test-strip for analyzing. Yet the hospital staff was unable to keep these clean by simply using latex gloves and wiping the device with a cotton swab moistened in rubbing alcohol!
The list of deficiencies continues — dirty ice machines in kitchen areas, not having a plan or checking on patients taking blood thinners, not properly transferring patients out of the institution — and by the end of the report, the OIG formally makes a whopping twenty-one recommendations to improve care and patient safety. As a comparison, an OIG comprehensive inspection at the Durham VA, affiliated with Duke University, resulted in two formal recommendations.
What was disturbing is that the Director and Chief of Staff didn’t give serious thought to these recommendations. And while the Quality Management department may have responded to the OIG with the appropriate follow-up paperwork, a wholesale change in culture was needed. Unfortunately, it took another investigation a year and a half later to make this a priority.