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Submission For The Record of Congressman Brian Higgins (NY-26)

Chairman Miller, Ranking Member Michaud—

I want to thank you for holding this very important hearing, and I commend the committee's commitment to making the health and safety for our veterans a top priority.

The Veterans Health Administration is America’s largest integrated health care system with over 1,700 sites of care, serving 8.3 million Veterans each year. Given the recent revelations of deaths and infection disease outbreaks, it is incumbent on this committee and the Congress en masse, to ensure that the VA has proper management and accountability structures in place to stop the emerging pattern of preventable patient-safety issues at VA medical centers across the country.

As the committee is aware, at the VA facilities serving my community – the VA Western New York Healthcare System – a series of health safety issues have compounded to form a troubling pattern incompetence and preventable bureaucratic inefficiency. From issues surrounding the improper use of insulin pens, to the mismanagement of Medical Records, to the improper staffing of the emergency department, our veterans have been let down and their safety compromised. I encourage the committee to continue to look into these events to ensure they are never repeated.

Insulin Pen Misuse

On November 1, 2012 staff at WNYHCS discovered that insulin pens intended for individual patient use were being incorrectly used for multiple patients.  In January 2013, the VA disclosed that between October 19, 2010 and November 1, 2012, 716 patients at the Buffalo VA Medical Center may have been exposed to HIV, hepatitis B or hepatitis C because nurses and medical personnel improperly reused insulin pens on multiple patients.

The insulin pen issue was investigated by the VISN 2 Network Office, WHYHCS, and VA’s Office of Inspector General. They found multiple factors leading to the misuse of the pens including: lack of stable nursing leadership during the time of implementation, lack of training and education, length of time between training and actual implementation, and absence of a warning placed on the insulin pens themselves.

The VA Office of Inspector General Report (OIG) issued in May 2013 disclosed that twenty veterans treated at the Buffalo VA tested positive for hepatitis, fourteen of which tested positive for hepatitis B and six for hepatitis C.

 

Mismanagement of Records

Earlier this year, the Office of Special Counsel (OSC) investigated whistleblower information about poor record keeping and serious mishandling of medical records at both the Buffalo and Batavia VA sites. In May 2013, the OSC issued a report finding that for at least eight years, 20,000 to 30,000 medical files were randomly thrown in boxes and not maintained in accordance with requirements for records management, Social Security numbers were sometimes not properly attributed to the correct veteran name or mislabeled entirely, mold infested files were not handled properly to prevent further contamination and to ensure their restoration, and on several instances when veteran records were requested, rather than searching for information, staff deemed the documents to be “unavailable.”

 Timeline:

 

January 17, 2012

The employees initially report to the Director of VA Health Care Upstate New York that During a record retirement project they found five boxes contaminated with mold and were ordered the workers to put the moldy files in new boxes and ship them to a storage facility in Missouri – a violation of agency rules.

January 27, 2012

The Director instructed the facility’s Associate Medical Director to review the claims and he reports back that his review “did not substantiate any of the concerns”

February 8, 2012

The employees turned whistleblowers met with the Associate Medical Director to reiterate their complaint about the records at Batavia

May 1, 2012

the whistleblowers file a complaint with the Office of Special Counsel and they notify Secretary Shinseki

September 6, 2012

The VA releases the findings from their investigation confirming the majority of the employees’ concerns

February 4, 2013

the VA asserts that corrective actions related to the recommendations were completed

 

Investigation:

The internal VA investigation unveiled systemic problems with record-keeping in Buffalo and Batavia that would have affected not only the records of hospital patients, but also veterans who visited VA facilities for outpatient services. The VA’s response showcased a complete lack of accountability. The OSC contacted the VA to determine whether any disciplinary action was taken as result of the investigation and the VA General Counsel responded that individuals received “written counseling” to ensure they understood the severity of the findings of the report, and were provided a point of contact for future guidance. The Associate Medical Director who did the initial check after the whistleblowers complained to him and concluded in his review that it “did not substantiate any of their concerns” was not disciplined but credited for his role with responding quickly, providing appropriate oversight and fully cooperating.

 

Improper Staffing in Emergency Department

On April 26, 2011, the OIG’s Hotline Division received an anonymous complaint regarding quality of care and physician staffing in the Emergency Department (ED). Specifically, a complainant alleged that the facility appointed an ED physician who was considered “unsafe,” and, following the physician’s first ED shift, three patients treated by this physician required return visits to the ED. Further, the number of physicians has been insufficient to staff the ED since November 2010, resulting in “long shifts” and impacting patient care.

A Feb 2012 VA OIG report found that the Emergency Department at the Buffalo VA has been understaffed since at least November 2010, resulting in questionable appointment decisions by facility managers, as well as quality of care concerns.  The OIG also found that facility managers had previously identified quality of care concerns with the physician, yet they had not taken appropriate corrective actions in response to these concerns, as required by VHA policy.

VA Responses

In response to the respective issues the Department of Veterans Affairs initiated reviews of the practices at the Buffalo VA Medical Center. These reviews and subsequent reports revealed several layers of systemic inefficiencies and proposed numerous recommendations to address them. The VA concurred with the recommendations and committed to conduct further reviews of policies and procedures to ensure inappropriate actions are prevented in the future.  With the insulin pen issue the VA responded that all recommendations by OIG have been complied with as of May 31, 2013. With the medical records the VA responded that as of February 4, 2013 all required actions for WNYHCS Buffalo have been completed and additional records management training for all file room and medical center leadership have been completed.  With regard to the understaffing of the emergency division, The VISN and Interim Facility Directors concurred with the findings and recommendations and provided an acceptable action plan.

In dealing with these issues I have had several discussions with the leadership at the Department of Veterans Affairs, and recently Undersecretary for Health Robert A. Petzel, walked me through the reforms implemented at the VA Western New York Health System in response to these incidents. Though most of these reforms have been implemented or are being implemented, one of Congress’ most important roles is to conduct oversight. It behooves us to aggressively conduct this role to ensure that reforms are implemented on time and system wide, assuring the public that these incidents will never occur again.

I want to thank the committee again for holding this important hearing and I appreciate the opportunity to testify on this important issue.