USA Today reported on Wednesday that officials at the Department of Veterans Affairs knew for YEARS about the poor conditions at the DC VA Medical Center and did nothing. The horrific conditions left patients at risk and wasted our tax money.

Officials Knew

An inspector general investigation discovered officials within the department “were either unwilling or unable to fix the problems.” Since 2013, people told those in charge at the local, regional, and national level all about the issues, “but investigators concluded ‘a culture of complacency and a sense of futility pervaded offices at multiple levels.” USA Today continued:

“In interviews, leaders frequently abrogated individual responsibility and deflected blame to others,” the investigation report says. “Despite the many warnings and ongoing indicators of serious problems, leaders failed to engage in meaningful interventions of effective remediation.”

However, the investigation did not discover any evidence that showed anyone informed VA Secretary David Shulkin or his top deputies of these problems.

Last April, I blogged about how the IG at the VA found that veterans at the VA Medical Center faced “imminent danger” due to the horrific conditions. USA Today reported:

The VA inspector general found that in recent weeks the operating room at the hospital ran out of vascular patches to seal blood vessels and ultrasound probes used to map blood flow.

The facility had to borrow bone material for knee replacement surgeries. And at one point, the hospital ran out of tubes needed for kidney dialysis, so staff had to go to a private-sector hospital and ask for some.

The hospital, which serves more than 98,000 veterans in the nation’s capital, lacks an effective inventory system, the inspector general determined, and senior VA leaders have known about the problem for months and haven’t fixed it. Investigators also inspected 25 sterile storage areas and found 18 were dirty.


• In February 2016, a tray used in repairing jaw fractures was removed from the hospital because of an outstanding invoice to a vendor.

• In April 2016, four prostate biopsies had to be canceled because there were no tools to extract the tissue sample.

• In June 2016, the hospital found one of its surgeons had used expired equipment during a procedure

• In March 2017, the facility found chemical strips used to verify equipment sterilization had expired a month earlier, so tests performed on nearly 400 items were not reliable

Shulkin Response

Shulkin fired the hospital’s medical center director after the IG published the April 2017 report and “also dispatched teams of specialists from headquarters to inventory and ensure adequate supplies were available to treat patients.”

On Wednesday, USA Today noted that Shulkin has taken action by announcing “sweeping plans” to reorganize the agency from top to bottom:

Three regional directors who oversaw 23 hospitals serving nearly 3 million veterans are out, and their offices now will report directly to a new executive in Washington.

Two of the directors opted to retire — Michael Mayo-Smith, who oversaw VA medical centers in New England, and Marie Wheldon, director of VA hospitals in Arizona, New Mexico and Southern California. The third, Joseph Williams, was reassigned. He had supervised VA facilities in West Virginia, Maryland and Washington.

Shulkin told USA Today that he recognizes “this as a failure issue, and this isn’t just about fixing the specific problems that the report mentions.” He views this an “opportunity to address similar issues around the country.”

Bryan Gamble, who works at the Orlando VA Medical Center, will have the responsibility to overlook “three regions and to lead an effort to draft a plan to reorganize VA regional governance as a whole by July 1.”

In the 1990s, the government split the agency hospitals into regions with their own directors who then report to national headquarters. But as USA Today points out, “the extra layers of bureaucracy have grown, defusing accountability and at times throwing up barriers to improvement of front-line health care provided to veterans.”

Shulkin wants to reorganize the VA national headquarters to make sure these situations do not fall through the cracks and the right people receive the information:

Shulkin ordered staff to come up with a plan to reorganize VA headquarters offices as well to better serve veterans. He expects that plan by May 1.

“We are looking to make sure that the central office has greater accountability, that it is streamlined and that it is de-layered and that we can return resources from administrative functions back out to the field where they more directly impact veterans,” he said.

If Shulkin succeeds in implementing his goals in full, it would mark the biggest transformation of the VA in more than 20 years. Many such plans have been considered in recent years, and some have been implemented.


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