Department of Veterans Affairs Secretary David Shulkin announced plans Wednesday to replace senior leadership at hospitals across the country after an investigation exposed severe instances of mismanagement at the VA's flagship medical center.
Shulkin will replace the leaders of 20 medical centers across the country after an outside consultant found low-performance hospitals in Maryland, Virginia, California, Arizona, and parts of New England, the Washington Post reported.
During a press conference announcing the changes, Shulkin said that dismissals resulted from the recognition that the situation had become "unacceptable."
"It is time for this organization to do business differently," Shulkin said. "These are urgent issues, and many of these issues are unacceptable."
The VA department, the second largest federal agency in the federal government, provides health care and other services to millions of former military service members across the country.
Wednesday’s report stemmed from a year-long review that was initiated after an initial, confidential complaint was filed in 2017. The review, in addition to another conducted by Inspector General Michael J. Missal last summer, found that gross inadequacies existed in the VA hospital system. It especially found problems in the hospital and three clinics making up the Washington Medical Center.
The center is the VA hospital system's flagship facility, serving approximately 100,000 military veterans in the Washington, D.C. area. Missal's report found that there existed a nonfunctioning system of inventory control, which resulted in medical equipment and instruments being misplaced or not re-ordered. This flaw, the report stated, put patients "at risk because important supplies and instruments were not consistently available in patient care areas."
The failure to adequately control inventory resulted in over $92 million being spent on supplies and equipment at the center without properly ensuring cost-effectiveness.
The report also found that patients were hospitalized needlessly, especially in cases where procedures had to be delayed or canceled post-admission because medical equipment could not be accessed for pre-scheduled surgeries. Furthermore, investigators found the hospital's process for sterilizing surgical instruments did not meet requirements.
Apart from medical and inventory deficiencies, the hospital was also found to be storing thousands of documents containing sensitive personal information in unsecured areas.
Hospital administrators told investigators that since many of the uncovered problems had not resulted in patient deaths or injuries, there was no rush to rectify the situation. Investigators and Shulkin disagreed.
The shakeup also follows a critical eye falling on the VA health system in recent years for its structural and fiscal inadequacies.
In May of 2017, the Veterans Affairs Office of the Inspector General found that over 100 veterans died while awaiting care at a Los Angeles VA hospital. In December, the Washington Free Beacon reported that a Marine Corps veteran was denied care at a VA hospital in Florida after waiting over a year for treatment.