March 13, 2018

After Alarming Report About Patient Death At Buffalo VA And Systemic Failures By Facility Leadership, Gillibrand Urges Immediate Changes To Protect Western NY Veterans

Gillibrand: Providing the Highest Standard of Care for Our Veterans is a Solemn Promise That Should Never be Broken

Washington, DC – U.S. Senator Kirsten Gillibrand today called on Michael Swartz, Interim Healthcare Systems Director of the VA Western New York Healthcare System, to implement immediate changes to the Buffalo VA after the release of the Veterans Affairs Office of the Inspector General report that highlights major systemic problems including mismanagement of a resuscitation and other concerns affecting the care and treatment of patients.

“Providing the highest standard of care for our veterans is a solemn promise that should never be broken,” said Senator Kirsten Gillibrand. “This report has confirmed my fears of a pattern of subpar treatment of veterans in Western New York at the Buffalo VA. These veterans risked their lives for our country, and they should be guaranteed the best care and the best treatment, period. We owe that to them, and there is no excuse otherwise. Incidents like this should never happen, and we need to take steps to provide oversight and accountability to ensure this never happens again.”

In August 2017, Senator Gillibrand wrote to the Secretary of Veterans Affairs to call for an independent investigation after reports surfaced that 526 patients of the Buffalo VAMC may have been put at risk of infection due to improperly cleaned medical scopes. Yesterday’s Inspector General report outlines a separate series of shortcomings, but underscores a continued trend of mismanagement that is hurting patients and their families in Western New York.

The full text of the Senator’s letter is available here and below:

March 13, 2018

Mr. Michael J. Swartz

Interim Healthcare System Director

VA Western New York Healthcare System

3495 Bailey Avenue

Buffalo, NY 14215

Dear Interim Director Swartz,

I am writing to express my alarm in receiving yesterday’s report by the Veterans Affairs Office of Inspector General (OIG) outlining mismanagement of resuscitation and other concerns at the VA Medical Center in Buffalo, New York.  The report details the tragic death of a VA patient as the result of a mismanaged resuscitation and the troubling series of actions taken by facility personnel in the aftermath of the incident. 

This is not the first troubling revelation regarding the Buffalo Veterans Affairs Medical Center in recent years.  In August of 2017, I wrote the Secretary of Veterans Affairs to express my deep concern in learning that 526 patients of the Buffalo VAMC may have been put at risk of infection due to improperly cleaned medical scopes.  Yesterday’s Inspector General report outlines a separate series of shortcomings, but underscores a continued trend of mismanagement negatively affecting patients and their families in Western New York. 

I believe you must take immediate action on the recommendations outlined by the Inspector General’s report.  Nine of the ten recommendations call for direct action by the Facility Director.  Some of these items seem painfully basic in the proper administration of a medical facility, but can make the difference between life and death for patients.  No veteran should have to wonder whether his or her local VA facility is properly training its staff in the management of life or death emergency scenarios when a patient’s health suddenly escalates.  Further, the Facility Director and staff should handle serious incidents with professionalism and transparency—not attempts to obfuscate the truth or withhold information from patients or their families. 

I firmly believe our men and women in uniform—past, present, and future—deserve a Department of Veterans Affairs worthy of their sacrifices.  I plan to stay directly involved with you and your staff to ensure the well-being of our patients and the implementation of the Inspector General’s recommendations.  I respectfully request your acknowledgement of this letter and plan for implementation of the Inspector General’s recommendations no later than Friday, March 23, 2018. 

Sincerely,

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Below are the ten recommendations from the VA Inspector General’s Investigation:

  1. We recommended that the VA Office of the General Counsel, pursuant to VA Directive 6311, work in conjunction with the Office of Information Technology, Veterans Health Administration offices, and other interested offices to advise the Under Secretary for Health regarding the refinement (or development) of policies reasonably designed to ensure the preservation of electronically stored information when legally necessary (or desirable for purposes of quality improvement), including, but not limited to electronically stored information that is subject to auto-deletion, such as telemetry data.
  2. We recommended that the Veterans Integrated Service Network Director conduct an evaluation of the Facility’s quality management practices (including but not limited to Root Cause Analyses, Issue Briefs, Administrative Investigation Boards, and Institutional Disclosures) to ensure that they align with Veterans Health Administration policies and also address the following specific deficiencies in this case: (a) the failure to conduct a Root Cause Analysis, (b) the failure to conduct a timely Administrative Investigation Board, (c) the failure to provide an Issue Brief, (d) the failure of the Administrative Investigation Board to consider all available evidence, and (e) the failure to make an Institutional Disclosure consistent with Veterans Health Administration Policy.
  3. We recommended that the Facility Director review the care of the patient who is the subject of this report and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
  4. We recommended that the Facility Director ensure that staff conduct interprofessional mock code training throughout the Facility with debriefing and monitor outcomes.
  5. We recommended that the Facility Director conduct an evaluation inclusive of, but not limited to, unit 9B and the Respiratory Department to determine if there are issues undermining teamwork at the work place, take action to address those issues, and monitor compliance.
  6. We recommended that the Facility Director ensure that staff adhere to the Facility’s telemetry policy including, but not limited to, saving rhythm strips when a patient has a change in his/her baseline or a significant arrhythmia, that a competent staff member is always at the telemetry station, and that facility managers monitor compliance.
  7. We recommended that the Facility Director ensure that the Facility’s Education Department staff review the adequacy of its annual telemetry monitoring re-certification process including, but not limited to, evaluating whether to institute additional requirements for staff who rarely have practical experience in telemetry monitoring and establishing procedures to ensure that re-tests are conducted and tracked appropriately and monitor compliance.
  8. We recommended that the Facility Director evaluate the Respiratory Department handoff communications process including the timing of patients’ treatments and code status and modify as appropriate.
  9. We recommended that the Facility Director ensure staff assess patients before and after breathing treatments, document the patient’s response in the electronic health record, and monitor compliance.
  10. We recommended that the Facility Director review the content of Facility staff’s communication to the patient’s family and take corrective action if it is determined that the communication was insufficient to convey that the Facility was disclosing potentially inadequate care.