Report cites problems at veterans hospital

By Dennis Conrad

WASHINGTON – A Veterans Affairs medical center in southern Illinois has a long list of problems that require the removal of its “senior leaders,” according to an agency report that looked into complaints of sexual harassment, forced retirements of elderly staff and the hiring of poor physicians.

The report, ordered last year after a spike in patient deaths led to a suspension of surgeries at the Marion facility, found its management has been “dysfunctional and inefficient” and many of its operations and employees are in need of greater oversight or further investigation.

“It is evident that the work environment requires changes to improve morale and create an environment of care for our employees and the veterans they serve,” said the report, obtained Wednesday by The Associated Press.

“There is no indication that the behavior is reversible in the near or long-term,” the report adds.

Gordon Mansfield, the then-acting VA secretary, assigned investigators to the case last fall at the urging of Illinois lawmakers, including Sen. Dick Durbin, the Senate’s second-highest ranking Democrat, and Sen. Barack Obama, the Democratic presidential candidate.

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At that point, the VA had already suspended the facility’s director, Robert Morrell, and chief of staff, Dr. Joe Herman.

Physicians with “well known poor reputations were recruited aggressively for the medical staff,” the report said.

Many of the dozens of pages in the report are heavily redacted so virtually no names and very few job titles are even mentioned, except for Morrell.

Besides the facility’s leadership, the VA’s 22-member assessment team focused on everything from hiring practices, merit staffing, equal employment opportunity issues to labor relations, credentialing privileges for physicians and the custodial care of the facility.

“The team’s overall assessment of the organizational climate at the Marion (facility) is characterized as hostile and an environment where management has used reprisal, retaliation and constructive discharge to manage the work force,” the report said.

Durbin, along with some other lawmakers, was scheduled to meet with VA Secretary James Peake in his Capitol office on Thursday to discuss the findings.

Durbin and Obama issued a joint statement after reviewing the report issued by the VA’s Office of Resolution Management, saying that it confirmed their suspicions about problems at Marion.

“The report paints a disturbing picture …,” the senators said. “The environment described in this report was ripe for the tragedy which occurred at the Marion VAMC last year.”

The widows of Robert Shank III and James Marshall have filed lawsuits against the federal government, which runs the Veterans Affairs system, and seek a combined $22 million in damages. Shank, 50, bled to death following gallbladder surgery at the hospital. Marshall, 61, died of a blood infection, six days after a lymph node biopsy there.

Obama and Durbin said legislation they introduced last year – the Veterans Health Care Quality Improvement Act – would strengthen hiring practices and improve quality control measures at all VA medical facilities.

Comment on the report from VA headquarters was limited Wednesday to a brief statement issued by Matt Smith, deputy assistant secretary for public affairs.

“The VA assessment team’s report was one step in a process dealing with several sensitive personnel and work place issues,” he said. “VA continues to ensure the assessment recommendations are fully implemented and the Marion VA can move forward in providing quality health care to our nation’s veterans.”

Marion VA spokeswoman Deborah Walker had no comment.

The VA assessment teams met with employees as well as senior and midlevel managers. They held two town meetings, with at least 140 employees attending one.

Also, at the request of employees at the Evansville, Ind., Community Based Outpatient Clinic, they also held a four-hour town hall meeting there and interviewed 14 employees one-on-one.

Investigators found “compelling evidence of significant operating room quality, manpower and competence issues,” adding that “similar issues most likely exist in cardiac cauterization, endoscopy, and other procedural areas.”

The report cited a need to restructure the quality management and patient safety programs – something described as “ineffective.”

The VA also needs to look into possible ethics and criminal violations, including the use of property for personal reasons. Exact violations were redacted.