By Donovan Slack and Todd Spangler

USA TODAY and Detroit Free Press

WASHINGTON – An undersecretary for the Department of Veterans Affairs says that the John D. Dingell VA Medical Center in Detroit is the only one among the system’s hospitals given a low, one-star rating out of a possible five stars earlier this year that has seen overall quality deteriorate instead of improve.

VA Undersecretary for Health David Shulkin told USA TODAY recently that all of the other hospitals that received one-star ratings this year had improved with the exception of Detroit, though he didn’t elaborate. He cautioned against using the internal star ratings — based on dozens of factors — as a way to compare hospitals.

“It is essentially a system within VA to see who’s improving, who’s getting worse, so we can identify both,” Shulkin said of the usually secret star ratings, which USA TODAY obtained for certain one-star and five-star facilities for both the final three months of 2015 and the quarter ending June 30 of this year.

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Detroit had been a two-star facility in 2015, but by June had fallen to one star, a quality-of-care rating that administrators in Detroit acknowledged was due in part to “performance deteriorations” in a wide set of health care measures that includes hypertension and diabetes control, as well as areas like wait times for specialty care appointments, and some heart disease and medical readmission rates.

Dr. Pamela Reeves, medical center director for the Dingell VA Center, also told the Free Press that while Detroit’s rating steadily improved from 2010 through 2014, changes since then in the data used to gauge patient experience and quality of care have in some cases “given no weight” to measures “where Detroit traditionally did well,” such as wait times for primary and mental health care, leading to the fall.

“Our leadership team is working closely with our performance improvement teams in the development and oversight of action plans to address the opportunities identified by the … data,” said Reeves. “The staff will continuously work to improve the care and services we provide to our veterans.”

For years, the VA has secretly assigned star ratings for each of its medical centers based on measures of their quality of care, but it has refused to release the ratings, saying they are not meant for public consumption. Star ratings obtained by USA TODAY found 10 one-star centers out of a total of 146 at the end of June, with several clustered in Texas and Tennessee. Detroit’s was the only one in Michigan.

The internal ratings are based on dozens of factors, including death and infection rates, instances of avoidable complications and wait times, much of which comes out of the VA’s Strategic Analytics for Improvement and Learning, or SAIL, database. The precise formula for setting star ratings is unknown.

For Detroit’s VA center, SAIL data for the most recent three-month period publicly available — the quarter ending March 30 of this year — shows a mixed bag: In some areas, such as projected deaths from heart attacks and infections from certain intravenous bloodstream catheters, the center lagged other VA hospitals with rates in the highest 10% nationally.

But in other measures — including primary and mental health care appointments completed within a month of the patient’s preferred date, and the center’s speed in responding to phone calls and its call center hang-up rate — the Dingell center outperformed many other centers.

Reeves said the rate of projected deaths from heart attacks was based on old data and has since been improved largely through “proper hospice placement” for patients facing end-of-life care. She also said so-called central line associated bloodstream infections cited in the SAIL reports are generally low in VA hospitals and that Detroit, with better oversight, has had only two this year and none since July.

While Detroit was mentioned by Shulkin as a center that still needs improvement, some other low-ranking centers have remained poor performers despite high-profile crises and years of attention and resources from Washington.

For instance, the Phoenix VA was a one-star medical center in 2014 when news broke that veterans had died awaiting care there while schedulers kept secret wait lists masking how long veterans were waiting for appointments.

The revelations triggered a national scandal, hearings on Capitol Hill and the replacement of the VA secretary. Detroit’s VA center has faced no such questions about whether veterans may have died waiting for care.

Phoenix remained a one-star facility in the most recent ratings.

Shulkin said he was apprehensive about any ratings becoming public.

“My concern is that veterans are going to see that their hospital is a one-star in our system, assume that’s bad quality and veterans that need care are not going to get care,” he said. “And they’re going to stay away from hospitals and that’s going to hurt people.”

But without the star ratings, members of the public — including patients, members of Congress and others outside the agency who could hold it accountable — have no way of knowing whether VA medical centers are improving or declining, except to plow through a dizzying array of hundreds of spreadsheets on the agency’s website.

Shulkin said 120 of the 146 medical centers that the VA rates on the star scale have shown improvement since he began overseeing the Veterans Health Administration in July 2015. For those where quality has declined, Shulkin said they get extra scrutiny and help from national VA officials — and could see hospital management replaced if they don’t show sufficient progress.

U.S. Rep. Jeff Miller, R-Fla., chairman of the House VA committee, said the VA should release all the ratings and quality data and do so on a continuing basis, arguing that “VA officials often attempt to downplay and sometimes mislead the public about serious problems until it's too late.”

"The secrecy with which VA treats these quality ratings is alarming,” Miller said. “Veterans seeking care at VA hospitals deserve to know exactly what they are walking into. Additionally, Congress, taxpayers and other stakeholders need to have a quick and efficient means of comparing the performance of various VA medical centers in order to identify facilities in need of improvement.”

Internal documents released to USA TODAY by the VA showing average quality-of-care measurements at medical centers nationwide indicated that veterans are dying at lower rates and contracting fewer staph and urinary tract infections from catheters in VA medical centers since 2014. They also showed veterans are not staying as long in VA hospitals and they are being readmitted within 30 days at lower rates.

At the same time, veterans are experiencing higher rates of preventable complications during hospital stays. Those on ventilators suffered more problems, such as catching pneumonia, and the rate of turnover for nurses has increased. The VA has also seen increases in the percentage of veterans who have to wait longer than 30 days for appointments when they are new patients.

As of Nov. 15, more than 500,000 veterans were still waiting longer than 30 days to be seen — though Shulkin said half of that total were for more minor needs such as dental, hearing, vision and diet consultations.

“I can sleep at night,” he said. “The ones I worry about are the ones who can’t wait or shouldn’t be waiting, so that’s where our entire focus of our system is right now. I don’t care about you waiting for eyeglasses, I mean that’s poor customer service, I understand, but I do care if you have a lung nodule.”

Shulkin said the number of veterans waiting longer than a month for urgent care has decreased from 57,000 to 600 since he took over last year.

Contact Todd Spangler: 703-854-8947 or at tspangler@freepress.com. Follow him on Twitter at @tsspangler.