VA internal investigations minimized safety issues at Chicagoland hospital, federal official says

The Department of Veterans Affairs inadequately addressed patient safety issues raised by a whistle-blower at a Chicago-area facility six years ago, according to a letter from the U.S. Office of Special Counsel dated March 9 and addressed to the White House.

In 2011, Lisa Nee, MD, a cardiologist at Edward Hines Jr. VA Hospital in Hines, Ill., raised concerns regarding patient safety. Dr. Nee said patients were undergoing unnecessary coronary artery bypass surgeries, the hospital's echocardiogram laboratory was working with a one-year backlog and that patients died and experienced health complications while waiting for their echocardiograms to be reviewed. Dr. Nee left her post at the VA in 2013 after her concerns went ignored, according to CNN.

"I have absolutely no doubt patients died as a result of the care they did not get at the VA Hines facility," Dr. Nee told CNN.

A VA inspector general report released in February found more than 1,200 cardiology tests were delayed in 2014 at the Hines hospital — some wait times were as long as 120 days. While this backlog caused at least one delayed diagnosis in a patient who needed surgery, the investigation yielded no evidence of direct patient harm.

Another inspector general report from 2014 identified nine patients who may have had "inappropriate" heart procedures and other quality issues at the hospital. However, like the previous report, the 2014 VA report identified no evidence suggesting actual patient harm.

In her March letter to President Donald Trump, Carolyn Lerner, head of the OSC, took issue with the VA's internal findings.

"I do not find reasonable the VA's conclusion that none of the findings constitutes a substantial and specific danger to public health or safety," wrote Ms. Lerner. "The reports confirm deficiencies in cardiovascular care at Hines, where, in many cases, the cardiac procedures performed on patients were not indicated and the standard of care was not met."

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While Ms. Lerner acknowledged in her letter that the VA has taken some actions to correct issues identified in the internal investigation, she argued many of the safety issues Dr. Nee raised continue to go unresolved. Among the unresolved issues cited by the OSC is the continued poor quality of echocardiogram imaging conducted by staff.

"Providing a safe environment and quality care for our veterans is the top priority at the Hines VA Hospital," the hospital said in a statement provided to CNN. "All cardiology peripheral vascular procedures in 2016 were completed without adverse complications and with good outcomes. Hines VAH has implemented an ongoing cardiology quality improvement plan that includes validation of the accuracy of the interpretation and technical quality of echocardiography studies, and ensures that all echocardiography technicians have the opportunity for continuing education and training."

In the letter, Ms. Lerner called for further review into the VA's improvement efforts to ensure the safety issues have been adequately addressed.

"It's only because of Dr. Nee's persistence that these troubling practices came to light. It's time for the VA to fix them," said Ms. Lerner.

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