VA has a “broken culture” regarding patient safety: surveillance

A federal watchdog on Wednesday slammed the “broken culture” in Veterans Health Administration Regarding patient safety, he said, major reforms were needed to protect the lives of vulnerable individuals who depend on the medical system.

Dr. Julie Kruviak, Deputy Assistant Inspector General for Health Care Examinations at Office of the Inspector General for Veterans Affairs, he said while testifying before the House Veterans Affairs Committee.

“Changes in VHA are both necessary and overdue. But they are impossible without the dedication of strong leaders who understand that a cultural shift is required to support meaningful and sustainable change.”

Veterans Affairs officials said work is in progress, to include expanding “high reliability” patient safety training to all departmental medical centers in the coming months.

“Our VHA board begins each day of our meeting with a safety review from the field,” said Renee Oshinsky, assistant undersecretary of health for operations at VHA.

Rita Mays, a Virginia nursing assistant, was convicted last spring of murdering at least seven patients.

“Sometimes there are individual bugs. Sometimes there are system problems. But they are all problems that we see, fix, and share across the system, so that we avoid these bugs in the future.”

The scathing report from the inspector general’s office follows a series of high-profile tragedies related to poor patient care practices at Virginia medical centers, including last spring’s conviction of a former nursing assistant at a West Virginia hospital for murder in. At least seven patients.

In the aftermath of that incident, the SIGIR found “widespread and deeply rooted clinical and management deficiencies” at the Louis A. Veterans Affairs Medical Center. Johnson in Clarksburg, West Virginia.

Kruviak said her office has seen similar but less dramatic problems throughout the medical system. Her office has found at least 21 incidents in the past two years where officials promised immediate reviews of patients’ adverse health events, but instead failed to formally assess what went wrong.

AP

She cited insufficient transparency of problems as a major issue in implementing reforms, and insufficient accountability by senior leaders who fail to make changes.

VA officials insisted they were working to improve the system, but lawmakers were skeptical about their reaction.

“The tone of testimony this morning appears to be one of defensiveness, not of an organization that has taken a hard look at itself and embraced the kind of individual humility and accountability it seeks from its frontline staff,” Representative Julia Bownley said. D-California, Chairman of the Committee’s Health Affairs Committee. “This needs to change.”

Several committee members expressed concern that the department had not had a Senate-certified VHA leader since January 2017, which could lead to a lack of focus on safety issues. VA leaders earlier this month launched a new committee to review candidates for the position.

Broley promised further investigations into the problems in the coming months to ensure patient safety issues are prioritized, with or without the position.

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