Second Report Shows Marion VA's Blindness to the Depth of Problems
Wednesday, September 10, 2008
Printable FormatThe Southern By JOHN HOMAN
MARION -- The final two parts of Veterans Affairs review of the VA Medical Center in Marion have been released, further revealing the depths of the problems that plagued the hospital.
First, the report finds that patient mortality levels increased significantly as early as April 2007, but the medical center failed to take sufficient action to find out why.
Second, basic support services were not in place to handle the expansion of the scope and complexity of surgeries, and there was no appropriate review process to monitor surgical outcomes.
Finally, the quality manager did not have enough control over the quality assurance process.
The first part of the three-part report by the Administrative Investigative Board was released on Aug. 14 and dealt with problems in leadership at the Marion hospital.
The second and third parts of the report released Tuesday make employment recommendations concerning the former leadership of the facility.
The report, although heavily redacted in some parts, also determined that network management officials, including Dr. Peter Almenoff:
-Were not aware of the poor relationship among Marion management;
-Did not receive the facility's surgery data on a regular basis from the facility;
-Were not aware of external reviews of the facility;
-Were not aware of Marion's surgery program expansion.
Almenoff has since been moved from director of the regional network to a position in Washington where his supervisory duties will be reduced considerably.
"While part one of the AIB report shined a bright light on the dysfunctional former management at the Marion VA, parts two and three highlight the consequences of this broken leadership," said U.S. Sen. Dick Durbin, D-Springfield.
"It is inexcusable that the VA's regional network was unaware of Marion's widespread management problems, but that appears to be the case," Durbin said. "The Marion VAMC needs qualified, long-term leadership to move on from the tragedies of last year. I look forward to discussing this with Secretary (Dr. James) Peake on Saturday (in his visit to Marion)."
U.S. Sen. Barack Obama, D-Chicago, said the report confirms that a failure in leadership, a lack of coordination among medical personnel, and a breakdown of safeguards allowed tragedies to occur at Marion.
"The VA must now make critical leadership changes, add the necessary safeguards and thoroughly examine its standards at Marion, which I expect Secretary Peake to review during his visit this weekend."
U.S. Rep. Jerry Costello, D-Belleville, said now that the full AIB report is completed, legislators must continue to move aggressively to make sure that such mismanagement never happens again.
"This Saturday's visit by Secretary Peake is a chance for the VA to fully inform the public about these findings and hear directly from local residents regarding their ongoing concerns. We will continue to work to ensure that patient care is the top priority of facility officials."
U.S. Rep. John Shimkus, R-Collinsville, said he is looking forward to discussing solutions to the problems uncovered with Peake.
"I believe this weekend's visit by the secretary can mark a turning point for the Marion VA Medical Center," he said. "We must make sure the care of our veterans is again the priority at Marion."
The investigating team was convened to complete a thorough review of conduct and performance issues related to personnel linked to questionable quality of care, sexual harassment and promoting a hostile work environment in Marion.
Efforts to reach Matt Smith, Veterans Affairs spokesman in Washington, were unsuccessful Tuesday.