Report: VA officials ignored issues
Thursday, August 14, 2008
Printable FormatThe Southern By JOHN D. HOMAN
MARION - The most recent investigation into the VA Medical Center in Marion reveals hospital managers knew some doctors there were not properly credentialed, including Dr. Jose Veizaga-Mendez, a surgeon suspected of being at least partly responsible for nine confirmed patient deaths last year.
The first of a three-part report filed by the Veterans Affairs Administrative Investigation Board (AIB) charges that numerous problems existed at the VA Medical Center in Marion.
The AIB will make employment recommendations concerning the former leadership at Marion.
In its report, the AIB notes that management at Marion dismissed warnings about Veizaga-Mendez's credentials as "administrative difficulties."
The report says the former medical center director failed to properly focus on the quality of care by ignoring troubling patient incident reports; failed to establish a follow-up process for patient deaths; and allowed financial considerations to predominate over quality-of-care issues.
The investigative report also contends the former nurse executive had a duty to report the poor relationship between the director and the chief of staff, but did not because she was afraid of retribution.
The Southern Illinoisan's attempts to reach Veizaga-Mendez for comment were not successful.
"The first part of the report by the Department of Veterans Affairs' Administrative Board of Investigation demonstrates VA's continued determination to fix the underlying causes of the quality of care problems which existed at the Marion VA Medical Center during parts of 2006 and 2007," said Alison Aikele, press secretary for the U.S. Department of Veterans Affairs.
"It is a major step in our efforts to hold those who allowed those problems to happen accountable. VA remains saddened by what has happened to some of our patients at Marion and is determined to do what's right for our patients and their families," Aikele said. "We are determined not only to correct the problems we ourselves uncovered, but to make Marion and all VA facilities models for excellence in health care throughout the nation."
U.S. Sen. Dick Durbin, D-Springfield, said every report from the VA seems to confirm his worst suspicions about the former leadership at the Marion VA Medical Center.
"The report shows that the management team at Marion failed to act when questions were raised about the credentialing of Dr. Veizaga-Mendez and failed again when they ignored desperate pleas for additional staff needed to provide adequate care," he said.
"The VA needs to implement the recommendations in this report, but that is not enough. It is past time that a new (permanent) leadership team is in place in Marion and the VA must act swiftly to make that happen."
U.S. Sen. Barack Obama, D-Chicago, said veterans in Illinois and throughout the country should expect nothing less than the best health care and treatment from the nation's veterans' facilities.
"This report confirms that a failure in leadership and a breakdown of safeguards allowed these tragedies to occur at the Marion VA," Obama said. "It appears the VA has taken action to relieve several individuals of their responsibilities since this investigation was conducted."
Congressman Jerry Costello, D-Belleville, said it's truly staggering that the behavior documented and the effect that it was having on patient care and morale could occur for years without anyone at the regional level demanding changes.
"Perhaps most troubling is the fact that patient health was secondary to the financial health of the facility," he said.
Congressman John Shimkus, R-Collinsville, said Marion's priority should be caring for the veterans.
"Clearly, that was not the case under the previous leadership," he said. "My colleagues and I will continue to work to see that appropriate changes are carried out, and carried out quickly."