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Hon. Harry E. Mitchell, Chairman, Subcommittee on Oversight and Investigations

This hearing will come to order.

We are here today to address the fallout from events at the Marion Illinois VA Medical Center. I was troubled to find out about a pattern of deaths at this VA Hospital that went unaddressed… and further concerned that the system in place to catch this substandard care has no rapid response measures.

According to the VA’s Office of Medical Inspector, from the beginning of 2006 through August of 2007, nine patients at Marion died as a result of substandard care. Another 34 had post-operative complications resulting from substandard care.

The Marion, Illinois VA Medical Center serves veterans in southern Illinois, southwestern Indiana, and northwestern Kentucky. In August of 2007, the Veterans’ Health Administration noticed a disturbing pattern—patient deaths following surgery were more than four times the average. 

VHA sent an inspection team. They suspended all surgeries at the hospital and placed the leadership of the hospital – including the chief of surgery – on administrative leave.

The VHA responded quickly when the data became available, but that data was more than six months old.

The data came from the National Surgical Quality Improvement Program, known as NSQIP. This program collects information from several hundred thousand surgeries performed at V-H-A facilities every year. Unfortunately, NSQIP reports only become informative an average of five months after an incident… due to a lag in gathering and inputting the data. 

When VHA responded in August 2007 to the pattern of excessive deaths at Marion, they were using data that covered October 2006 to March 2007.

This is unacceptable. The VHA cannot respond to problems in its hospitals if it does know what they are.

There must be controls to ensure that doctors and other health care providers have the required credentials and are fully qualified to perform the specific medical procedures they undertake. Events at the VA Hospital in Marion, Illinois tragically show what happens when these essential controls break down.

The Inspector General and Office of the Medical Inspector found that there is a serious hole in the system. The VA does not have a way to identify all jurisdictions where a physician has been – or is – licensed. This is because some states do not have an electronic registry or are not willing to share records.

The VHA requires that surgeons must receive a clinical privilege to perform specific procedures at the hospital, the IG and OMI discovered that this process had been abused at Marion. In fact, privileges were granted at Marion regardless of experience or training.

Even more disturbing is that privileges were granted at Marion for procedures that the hospital didn’t even have the facilities to accommodate, such as radiology access 24 hours a day.

The events at the Marion hospital demonstrate a failure in the VA system to quickly bring important information forward so that the VHA can respond with appropriate action. This is a real problem.

Our first witness today, Ms. Katrina Shank, drove her husband, Bob Shank, to Marion for a routine surgery. Bob passed away within 24 hours of the procedure due to the substandard care at the hospital. I believe that if the safe guards had been in place and administrators had been properly notified of past incidents, Bob’s death could have been prevented. 

I want to know why no one outside of Marion was aware of the problems until August 2007 and what VHA is doing to make sure that this failure of information flow never happens again.

Additionally, what is VHA going to do to fix the serious quality management issues, credentialing and privileging that have been disclosed by this tragedy?

I am afraid that once we start looking at this issue deeper, we may find that what happened at the Marion hospital isn’t an isolated incident.

Our veterans served honorably to protect our nation. We have a responsibility to take care of them when they come back home.