By Patrick Yoest, CQ Staff

The chairman of the Senate Veterans Affairs Committee said Monday he was "appalled" by a new government report that cited an Illinois veterans' hospital for inadequate care during an unusual spike in patient deaths from late 2006 to early 2007.

Sen. Daniel K. Akaka, D-Hawaii, called for a new national directive to define how veterans' hospitals manage care. Akaka noted that the report, released Monday by the Veterans Affairs Department, cited instances in which surgeons with questionable pasts were being allowed to work at the facility in Marion, Ill.

"The lack of a national directive or any required external oversight is deeply problematic and is simply unacceptable," Akaka said.

The new report came after reports last year of shoddy conditions at Walter Reed Army Medical Center in Washington - managed by the Defense Department, not Veterans Affairs - prompted President Bush to order a comprehensive review of the nation's military and veterans' hospitals and to promise the nation's war wounded would receive only the best quality care.

A House Veterans' Affairs Oversight and Investigations Subcommittee was scheduled to hold a hearing Wednesday, when the department was expected to come under harsh scrutiny for the high mortality rate at the Marion medical center.

According to the report, during the first half of fiscal year 2007, the department's Office of the Medical Inspector observed a mortality ratio nearly five times as high as that in fiscal year 2006. The medical inspector's report blamed poor leadership and management, as well as a deficient process for vetting medical personnel.

The medical inspector's office reported that outside experts found "a general fear of retaliation that discouraged the staff from expressing the seriousness of the problems" to hospital managers.

"We found the problems ourselves; we took immediate action to keep patients from being harmed as soon as we knew what was going on; we're extremely sorry for what happened; and we'll hold those who created the problems accountable," said Dr. Michael J. Kussman, the head of the Veterans Health Administration.

Sen. Richard M. Burr, the ranking Republican on the Veterans' Affairs panel, said in a statement that "the VA should conduct a thorough review to ensure this is an isolated incident."

The vetting and credentialing of surgeons emerged as a major problem at the Marion hospital. The report found that "across the board, surgeons were allowed to work without any assessment of their performance. In one case, a surgeon was retained even after the Marion facility was informed that he had entered into an agreement not to practice medicine in the state of Massachusetts.

"We have exceptional caregivers across the VA health care system," said House Veterans Affairs Oversight and Investigations Subcommittee Chairman Harry Mitchell, D-Ariz. "But limited resources at the VA are forcing us to hire physicians with questionable pasts."

Source: CQ Today Online News
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