Auditor that Accredited VA Hospitals Where Patients Died to Review Same Hospitals

Veterans want independent authority to investigate

Phoenix VA Health Care Center / AP
August 29, 2014

The same independent auditor who accredited Veterans Affairs hospitals where multiple patients died from delays in care—and in some cases named them as "top performers"—has been chosen by the VA to complete a new review of those same hospitals.

Earlier this month, new VA Secretary Robert McDonald announced that the Joint Commission, a hospital accreditor, would review scheduling practices across the VA system.

"VA is committed to instilling integrity into our scheduling practices to deliver the timely care that veterans deserve," McDonald said in a statement. "It is important that our scheduling practices be reviewed by a respected, independent source to help restore trust in our system, and I’m grateful to the Joint Commission for taking on this critical task."

Since VA Secretary Eric Shinseki resigned in the wake of the national VA scandal, the VA has taken steps to repair its image and address the serious, sometimes deadly, lapses in accountability across the VA system.

However, the Joint Commission is the same auditor that accredited VA hospitals before the national scandal broke, and while hospitals were using secret waiting lists.

After allegations of gross malpractice first surfaced earlier this year, an internal VA survey in July found 110 VA medical centers used secret wait lists to hide the long delays faced by veterans.

In September 2013, The VA Inspector General found mismanagement at the William Jennings Bryan Dorn Medical Center in Columbia, South Carolina, contributed to a nearly 4,000 gastro intestinal appointment delays, leading to 19 serious injuries and six deaths.

Two months after the inspector general’s report, the VA sent out a press release citing the Columbia VA medical center as one of the VA health care system’s "Top Performers."

A February report by the VA Inspector General found the Dorn hospital faced staffing and equipment shortages that led to delays. The report also noted that Dorn ranked 127th out of 128 VA facilities in health care-associated infections during 2013.

In response, the Dorn VA hospital said it was immediately taking steps to fix the problems.

The fixes came too late for 44-year-old Army veteran Barry Coates, who was diagnosed with advanced colorectal cancer after more than a year of waiting for a colonoscopy.

"It is likely too late for me," the 44-year-old Army veteran testified before a congressional committee earlier this year. "The gross negligence of my ongoing problems and crippling backlog epidemic of the VA medical system has not only handed me a death sentence, but ruined the quality of life I have for the meantime."

In a speech Tuesday at the 96th annual American Legion conference, McDonald continued to cite the Dorn Center’s "top performer" award.

It’s clear that somewhere along the line, some people’s behavior was at odds with VA’s mission and core values," McDonald said. "The result was seen in the stark difference between receiving care at, say, one of our highest performing locations, like the medical center not far from here in Columbia, S.C.—and until recently, at Phoenix."

"I just mentioned Columbia a moment ago," McDonald continued. "I think it’s important to note that last year, The Joint Commission—which accredits and certifies health care organizations—named the William Jennings Bryan Dorn Medical Center there … and 31 other VA hospitals … as ‘Top Performers’ in its annual review of patient care."

The Joint Commission did not respond to a request for comment. However, in a statement to the Daily Caller, a spokeswoman for The Joint Commission said the award does not indicate the level of service individual patients will receive.

"The Top Performer on Key Quality Measures program is designed to inspire better performance on accountability measures, it is not a reflection of the overall care at an organization," a commission spokeswoman said.

The VA Inspector General issued a final report this week on misconduct at the Phoenix VA hospital, where the most serious allegations of misconduct and whistleblower retaliation were reported.  The report found more than two dozen instances of clinically significant delays in care, but was unable to conclusively prove many of the allegations.

However, many whistleblowers and advocacy groups criticized the report’s findings. The American Legion called for an independent investigation in a statement.

"VA’s internal investigation of patient deaths in Phoenix may not have proven conclusively those deaths occurred through negligence, but VA needs to do more than investigate itself on this matter," the American Legion said. "The American Legion wants a non-VA authority to determine whether negligence was involved in the deaths of those veterans. In fact, we want an independent authority to investigate all the VA facilities where patients died while waiting for medical care.

The VA did not respond to a request for comment by press time.

Published under: Veterans Affairs