Watchdogs condemn ‘patient safety breakdowns’ at VA

Stars & Stripes


WASHINGTON – Government watchdogs criticized the Department of Veterans Affairs on Wednesday for a “broken culture” that has allowed breakdowns in patient safety and led to tragic deaths at facilities across the country.

Leaders within the Veterans Health Administration “do not consistently ensure the safety of the veterans they serve,” said Julie Kroviak, who is with the VA’s Office of Inspector General. She and other watchdogs urged the VA to create an environment in which employees can speak up about safety issues and where staff will be held accountable.

“A clear, underlying theme appears to be a broken culture that results from actions, and more often inactions, by leaders at these locations,” Kroviak said. “Only when a culture is laser-focused on patient safety, makes an effort to report concerns, reacts to concerns with urgency, and when leaders hold themselves and their staff accountable, can [the VA] truly earn the trust of veterans.”

Members from the inspector general’s office, as well as the Government Accountability Office, testified Wednesday at a subcommittee hearing of the House Committee on Veterans’ Affairs. The subcommittee met to discuss recent, tragic events at VA facilities and to see how the agency has responded.

A former nursing assistant at the VA hospital in Clarksburg, W.Va., was sentenced in May to serve seven consecutive life sentences after she was convicted in the murders of seven patients. Reta Mays confessed to using insulin to kill elderly veterans in 2017 and 2018.

Earlier this year, a former pathologist at the VA hospital in Fayetteville, Ark., was sentenced to 20 years in prison after pleading guilty to involuntary manslaughter in the death of a patient who he misdiagnosed. Investigators discovered Robert Morris Levy routinely drank on the job and made thousands of errors and misdiagnoses from 2005 until he was fired in 2018.

Kroviak on Wednesday also mentioned an inspector general’s report from February that detailed instances of a VA gynecologist in Biloxi, Miss., who made graphic and lewd comments to patients. The doctor was kept on staff for years, despite complaints to administrators.

“In each of these examples, the outcome could’ve been minimized if patient safety was prioritized,” she said.

The Government Accountability Office first added the VA health care system to its list of “high risk” areas of government in 2015, and it remains on the list. Part of the problem is oversight and accountability, said Sharon Silas, a director at the GAO.

The VA has resolved some of the GAO’s concerns. However, the agency still needs to address root causes, such as a fragmented process for oversight and accountability, Silas said.

Lack of leadership also poses a problem, she said. As of now, the VA is without an undersecretary for health – the position charged with leading the Veterans Health Administration.

A candidate for the job must be appointed officially by the president, meaning the person must be approved for the position by the Senate. The VA has been without a Senate-confirmed leader in the role for more than four years.

Dr. Richard Stone served as the acting undersecretary for nearly three years and led the department’s response to the coronavirus pandemic. Stone resigned in June, once it was clear that the commission charged with finding an undersecretary did not select him to stay in the role on a permanent basis.

“Fully addressing oversight and accountability concerns requires sustained leadership attention as well as leadership stability,” Silas said.

Rep. Jack Bergman, R-Mich., the ranking Republican on the subcommittee, said it was unacceptable that the job was still unfilled.

“The VA is facing a leadership vacuum following the departure of Dr. Stone this past summer,” Bergman said. “That is unacceptable given the life-or-death consequences of the continued absence of leadership at the top of the largest health care system in our country.”

VA officials testified Wednesday that they’re finding ways to reconfigure their processes to ensure the “safest care possible for veterans.” Rep. Julia Brownley, D-Calif., the chairwoman of the subcommittee, criticized the agency for being defensive in their testimony. Brownley and Kroviak suggested the agency change its tone.

“The responsiveness and tone of VA leaders will echo across the system,” Kroviak said. “Sentiments describing patient-safety failures as one-offs and the use of defensive language will undermine initiatives aimed at accountability, and opportunities to learn and improve will be lost.”