More Patient Care Problems Cited at VA

A new report found numerous problems with patient care at a VA facility. Here is a summary and solutions suggested to improve caring for veterans in the VA.

The Department of Veterans Affairs (VA) has been unable to escape a consistent barrage of bad publicity over failures of the agency as it tries to take care of the nation’s veterans.

In the latest known problem, the VA’s Office of Inspector General (OIG) has identified a number of serious issues at a VA facility, the Washington, DC, VA Medical Center (VAMC).

Fallout of the Report and A Summary of What Was Discovered at the VAMC

The Office of Inspector General has issued an Interim Summary Report on inventory management practices and staffing deficiencies that place patients at the facility. As a result of the findings in this report, the VA relieved the facility’s director, Brian Hawkins, of his duties. According to the data from, Hawkins’ latest reported salary was $179,099 and he is in the ES pay system. Hawkins, who began his career with the Department of Veterans Affairs as a Clerk/Typist, was appointed to the job at the VAMC on September 25, 2011.

The VA’s acting undersecretary for health, Poonam Alaigh, also told the Associated Press that she is going to be conducting a broader review of the VA health system for similar patient safety issues at other medical centers.

OIG deployed its Rapid Response Team to the VAMC on March 29, 2017 to investigate. A number of serious deficiencies were identified at the VAMC that places patients at unnecessary risk. The issues that have been identified by the Inspector General include:

  • There was no effective inventory system for managing the availability of medical equipment and supplies used for patient care;
  • There was not an effective system to ensure that supplies and equipment that were subject to patient safety recalls were not used on patients;
  • 18 of the 25 sterile satellite storage areas for supplies were dirty;
  • Over $150 million of equipment or supplies had not been inventoried in the past year and therefore had not be accounted for;
  • A large warehouse stocked full of non-inventoried equipment, materials and supplies has a lease expiring on April 30, 2017, with no effective plan to move the contents of the warehouse by that date; and
  • There are numerous and critical open senior staff positions that make it difficulty to correcting these problems.

OIG notified the VA of its initial findings on March 30, 2017. The agency took several immediate actions to address the issues. It established an incident command center, temporarily assigned an additional logistics chief, technicians, and Veterans Integrated Service Network staff to the facility.

It is the opinion of the OIG that these actions are only short-term solutions. Shortages of medical equipment and supplies continued to occur while the OIG team was at the facility. This confirmed to the investigators that correcting these problems is going to require a coordinated long term effort by the agency.

The Inspector General’s review of these issues is continuing.  A comprehensive report will be completed at a later time.

OIG’s Rapid Response Team is a new initiative. It provides a team that can be quickly deployed to address high-risk/high priority cases, events, or system failures in VA facilities or programs such as the situations that have been identified at the VA Medical Center in Washington, DC.

Response by VA Union

The American Federation of Government Employees (AFGE) issued a statement shortly after the interim report was issued. The press release quoted AFGE National President David Cox who expressed the concern that the continuing problems at the VA will be used to provide more work to private companies instead of relying primarily on the Veterans Administration:

Some politicians and outside groups will inevitably try to exploit this situation to justify their privatization agenda. Others will use it to further their interest in politicizing the VA by installing political cronies rather than competent managers to fix the problems that have been identified. Neither privatization, nor putting political hacks in charge of hospitals is the answer to the crises the IG has identified. Either of these responses will only worsen the situation at the VA.

If there were too few staff, or inadequate funding for the volume of work at the hospital, it is up to the leaders at the Veterans Health Administration to fix these problems immediately.

The union’s response to the latest issue in the VA may be primarily addressing previous conclusions of the Committee on Care. Those conclusions could have an impact far beyond one VA facility. The Committee was established by Congress to examine veterans’ access to Department of Veterans Affairs health care and to examine how best to more effectively organize the Veterans Health Administration, locate health resources, and deliver health care to veterans. The Commission concluded:

Under the Commission’s proposal, VA would continue as the exclusive veterans’ provider of such distinct services as specialized behavioral health care, spinal cord injury care, prosthetics, and rehabilitative services. To assure veterans receive better access to care, the Commission proposes VA establish high-performing, integrated health networks that include both VA and community-based providers who meet stringent VA credentialing requirements.

The union disagreed with the conclusion that using more private sector services was a good approach. (See Union Challenges Recent Recommendations on Care for Veterans)

The union concluded:

The Final Report (of the Commission on Care) anticipates that 60 percent of eligible care will shift from VHA facilities to outside networks (p.31). The net result will reduce, not expand, Veterans’ choices, since to pay for this shift, a VHA Care System will incrementally downsize the number of VHA providers and programs. The VHA system would be weakened.

Ironically, the union itself has been cited as part of the problem with veterans receiving better care at the VA. At a recent hearing on the amount of “official time” used by union representatives at the VA, a representative fr0m the Competitive Enterprise Institute made this observation:

Hundreds of federal employees spend 100 percent of their time performing union activity instead of any public service. It is impossible for a federal employee who never conducts any public service to promote the public interest, contribute to effective performance of public services, or achieve efficient government operations. Activity performed on official time benefits only labor unions and their members, not the public.

That contention was disputed at the hearing by AFGE’s National President who contended that a GAO report found union representatives improved decision making and helped to resolve problems within the VA and therefore helped in improving care for veterans.

House Passes Bill to Provide VA Secretary With More Authority

On a related note, the House of Representatives has passed a bill (H.R. 1259) which would institute reform at the Department of Veterans Affairs (VA) by providing the Secretary with the authority to expeditiously remove, demote, or suspend any VA employee, including Senior Executive Service (SES) employees, for performance or misconduct.

H.R. 1259 would also:

  • Provide improved protections for whistleblowers;
  • Allow the Secretary to reduce an employee’s federal pension if he or she is convicted of a felony that influenced his or her job at VA;
  • Recoup a bonus provided to an employee who engaged in misconduct or poor performance prior to receiving the bonus; and allow the Secretary to recoup any relocation expenses that were authorized for a VA employee only through the employee’s ill-gotten means, such as fraud waste, or malfeasance.

While the bill passed in the House, it has not been considered by the full Senate. It is given a 19% chance of passage according to PredictGov.


A variety of patient care problems continue to crop up at the Department of Veterans Affairs in its various divisions. Part of the answer often provided by the agency and the union is that more money and a larger number of employees are required to correct the problems. Whether Congress will pass other possible solutions to try and resolve the problems at the agency remains to be seen.

In this instance, a more complete report is expected from the OIG regarding the VAMC in Washington, DC which obviously is the latest example of serious, on-going problems with patient care at some locations in the VA.

Washington D.C. VA Medical Center OIG Report – April 12, 2017

About the Author

Ralph Smith has several decades of experience working with federal human resources issues. He has written extensively on a full range of human resources topics in books and newsletters and is a co-founder of two companies and several newsletters on federal human resources. Follow Ralph on Twitter: @RalphSmith47