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Chief of Staff Dorn VA Medical Center Jan 2012 – Do Not “…send out anymore non-VA care GI requests for endoscopy until further notice.”

According to VA IG Report No. 12-04631-313 “Healthcare Inspection: Gastroenterology Consult Delays William Jennings Bryan Dorn VA Medical Center Columbia, South Carolina”, Former Chief of Staff Barbara Temeck, M.D, sent an email to the Business Office “not to “…send out anymore non-VA care GI requests for endoscopy until further notice.”” According to the IG Report the email stated ““…attempting to internalize as many of these 700 cases as possible.”. During January 1–March 29, 2012 only 100 Veterans were seen outside the VA for Colonoscopies while the In-house Colonoscopies declined during the same time period.

VA DORN No Fee BAsed care

Why the Chief of Staff made this decision is unclear.  The IG Report report substantiated claims of a lack of priority by HR and Nursing Admin to staff open positions in the GI Clinic.

We substantiated that GI staffing was not optimal and that critical nursing positions went unfilled for months. It was difficult to determine specifically when some critical positions were vacant, primarily because interviewees recalled dates and events differently or documentation was sparse. However, most GI managers and clinicians we interviewed relayed similar accounts of staffing deficiencies, positions not being backfilled, and difficulty getting approval for new hires. During the AIB, the former CoS testified that the GI Service lacked nurses and clerks, and that the problem was “fairly long standing.”

The Chief of Medicine requested funds in 2011 from VISN 7 to address the growing backlog in the GI CLinic. The Request was approved and the facility received $1.02M but only appropriated  $275,000 for Non-VA Care Colonoscopies.

We substantiated that VISN 7 gave the facility $1.02M in early September 2011 to use to address the GI backlog but that only approximately $275,000 was actually used for this purpose through August 2012. The Business Office was not aware that the additional monies were “earmarked” to address the GI backlog and obligated the funds as usual. The VISN 7 CFO told us that although the facility was given $1.02M expressly to address the GI backlog, they did not have to report back to the VISN on how the funds were used. The CFO reported that facilities may use their discretion to determine how to best meet the needs of their patients; however, fee care was specifically identified as a mechanism to reduce the backlog.

Clearly the funds were available to refer Veterans to Non-VA Facilities but the CoS chose not to. Why would the CoS make this decision when clearly the Facility did not have the capacity due to staffing issues. Veterans DIED. People need to be held accountable.

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#VASCANDAL White House Office of Management and Budget KNEW of Veteran Deaths in South Carolina

The following report is the most horrendous and damning VA Inspector General Report I have found.

VA 2012 Patient Death GI

Report No. 12-04631-313
Healthcare Inspection
Gastroenterology Consult Delays
William Jennings Bryan Dorn
VA Medical Center
Columbia, South Carolina
September 6, 2013

Executive Summary

The VA Office of Inspector General Office of Healthcare Inspections conducted a review to evaluate policies and practices related to gastroenterology (GI) consult and resource management at the William Jennings Bryan (WJB) Dorn VA Medical Center (the facility) in Columbia, SC. The purpose of the review was to determine whether deficient practices contributed to or caused delays in care, and whether facility leaders appropriately addressed clinical managers’ concerns.

We substantiated the allegations and found additional factors that contributed to the events. Veterans Integrated Service Network (VISN) and facility leaders became aware of the GI consult backlog in July 2011 involving 2,500 delayed consults, 700 of them “critical.” A funding request was made at that time and the VISN awarded the facility $1.02M for fee colonoscopies in September 2011. However, facility leaders did not assure that a structure for tracking and accountability was in place and by December, the backlog stood at 3,800 delayed GI consults. The facility developed an action plan in January 2012 but had difficulty making progress in reducing the backlog. An adverse event in May 2012 prompted facility leaders to re-evaluate the GI situation, and facility, VISN, and Veterans Health Administration leaders aggressively pursued elimination of the backlog. This was essentially accomplished by late October 2012. However, during the review “look-back” period, 280 patients were diagnosed with GI malignancies, 52 of which had been associated with a delay in diagnosis and treatment. The facility completed 19 institutional disclosures and 3 second-level reviews are still pending. As of May 2013, nine patients and/or their families had filed lawsuits.

A confluence of factors contributed to the GI delays and hampered efforts to improve the condition. Specifically, the facility’s Planning Council did not have a supportive structure; Nursing Service did not hire GI nurses timely; the availability of Fee Basis care had been reduced; low-risk patients were being referred for screening colonoscopies, thus increasing demand; staff members did not consistently and correctly use the consult management reporting and tracking systems; critical VISN and facility leadership positions were filled by a series of managers who often had collateral duties and differing priorities; and Quality Management was not included in discussions about the GI backlogs.

The GI consult backlog has been the subject of multiple reviews and recommendations, and overall, the conditions have improved and the GI backlog has resolved. However, continued vigilance is needed to ensure that the conditions do not recur. We recommended that the VISN, in accordance with the Administrative Investigative Board conclusions and recommendations, take appropriate action in relationship to facility leadership deficits contributing to the GI consult backlog.

The VISN Director concurred with our recommendation and provided an acceptable action plan. (See Appendixes A, pages 15–17 for the Director’s comments.) We will follow up on the planned actions until they are completed.

JOHN D. DAIGH, JR., M.D.
Assistant Inspector General for Healthcare Inspections

 

Read Entire Report Here

 

When the VA Office of the Inspector General – OIG conducts this type of Inspection, the Final Report is then distributed.  At the end of the Report is the Distribution List.

This Report was Distributed to the Following:

Appendix D
Report Distribution

VA Distribution

Office of the Secretary
Veterans Health Administration
Assistant Secretaries
General Counsel
Director, VA Southeast Health Care Network (10N7)
Director, WJB Dorn VA Medical Center, Columbia, SC (544/00)

Non-VA Distribution

House Committee on Veterans’ Affairs
House Appropriations Subcommittee on Military Construction, Veterans Affairs, and
Related Agencies
House Committee on Oversight and Government Reform
Senate Committee on Veterans’ Affairs
Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and
Related Agencies
Senate Committee on Homeland Security and Governmental Affairs
National Veterans Service Organizations
Government Accountability Office
Office of Management and Budget
U.S. Senate: Lindsey Graham, Tim Scott
U.S. House of Representatives: James E. Clyburn, Joe Wilson

VA SC CARE DELAY Distro List

 

As you can see from the Distribution List not only was the Report sent to the OMB Office at the White House it was sent to every Congressional Committee having Jurisdiction and Oversight of the VA.  If anyone on the Distribution list claims to have not known about the Situation at Dorn VA Medical Center, WHY NOT?

None of the Leadership of Dorn VAMC was disciplined appropriately. Only the Center Director and Chief of Staff were replaced, but not Terminated.

  • Rebecca Wiley, Former Medical Director of Dorn VA Medical Center, has since Retired
  • Barbara Temeck, M.D., Former Chief of Staff of Dorn VA Medical Center, Currently Practicing Medicine St. Louis VA Medical Center
  • Ruth Mustard, RN, Current Director for Patient Care/Nursing Services of Dorn VA Medical Center,
  • David L. Omura, Current Associate Director of Dorn VA Medical Center
  • Jon Zivony, Current Assistant Director of Dorn VA Medical Center,

The VA suffers from systemic problems which have been identified many times over the decades. Very rarely is anyone held accountable or does anyone take responsibility as can be seen by the situation at Dorn VAMC.

VETERANS DIED.

As a 21+ year Veteran of the US Army and Army National Guard, I am just too angry to detail everything. But I will say I am tired of the “well we fixed it” attitude of the VA while no one is held accountable.  The VA is NEVER “fixed”.

 

The REAL #VAScandal: Failure To Refer Veterans to NON-VA Facility For Care

 The VA is allowed by law to authorize Non-VA Facility Care.

Title 38 of the United States Code (USC) §1703 establishes clinical access
criteria and individual eligibility criteria for non-emergency fee care. VHA
must ensure that both criteria are met before authorizing inpatient care.

http://www.law.cornell.edu/uscode/text/38/1703

Clinical Access Criteria—The statute authorizes the use of fee care only if
VHA: (1) does not have the clinical capability, (2) does not have capacity, or
(3) facilities are geographically inaccessible for the veteran.

The VA even has a Website about Non-VA Care

http://www.nonvacare.va.gov/

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