6 big things the new Veterans Affairs chief will have to address

Show Caption Hide Caption David Shulkin out as Veterans Affairs Secretary President Donald Trump announced he will replace his Veterans Affairs Secretary David Shulkin with Ronny Jackson, who currently is the president's physician

On the front lines at the Department of Veterans Affairs — in the agency’s 1,240 hospitals and clinics — it doesn’t much matter these days who holds the secretary’s job in Washington.

David Shulkin, who was fired Wednesday, was the third VA secretary in four years. If President Trump’s nominee to lead the agency, physician and Navy Rear Adm. Ronny Jackson, is confirmed, he will be the fourth.

Each has sought to fix the department, laying out visions and priorities — Shulkin’s top priority was “access,” making sure veterans get appointments when they need them. His predecessor, former Procter and Gamble CEO Bob McDonald, focused on staffing, training and veteran-centered customer service.

But year after year, critical deficiencies remain and veterans are bearing the brunt of the failures. Here are some key, seemingly intractable shortfalls that continue to plague the system — and that Jackson will face if confirmed.

Veterans are still waiting

The furor over VA health care exploded in 2014 when whistle-blowers in Arizona divulged that thousands of patients were backlogged at the Phoenix veterans hospital, and some of them had died awaiting care. VA investigators soon determined that medical center administrators knew about the crisis, yet put out fraudulent wait-time data to collect bonus pay.

The problems weren’t just in Phoenix. A USA TODAY investigation in 2016 found supervisors instructed employees to falsify patient wait times at VA medical facilities in at least seven states. And employees at 40 VA medical facilities in 19 states and Puerto Rico regularly “zeroed out” veteran wait times.

A few weeks after Shulkin was sworn in last year, the VA inspector general released a report finding widespread inaccuracies in scheduling records at a dozen hospitals in North Carolina and Virginia. The records vastly understated how long veterans were waiting for appointments and prevented as many as 13,000 from getting VA-funded care in the private sector — an option they were entitled to if they waited longer than 30 days. At the time, Shulkin said the findings were based on outdated rules and that he had instituted new regulations to prevent such problems in the future.

But just two weeks ago, another inspector general investigation found the problems continued.

Looking at 64 VA hospitals and clinics in a swath of states from Kentucky to Illinois, investigators found scheduling staff entered the wrong dates in the system in more than 5,000 cases. That masked how long veterans were actually waiting for specialty care and mental health appointments.

They estimated 2,500 of those waited longer than a month, but the scheduling system falsely showed only 1,300 waited that long. Even in the cases accurately reflected in the system, they concluded, most weren’t offered the chance to get care in the private sector.

“VA data continues to be a high-risk area,” wrote Larry Reinkemeyer, VA assistant inspector general for audits and evaluations.

Quality of care

The VA’s lowest performing hospitals remained at the bottom of the pack on the agency’s own internal quality measures for two years in a row.

The VA regularly scores its medical centers based on dozens of quality factors, including death and infection rates, instances of avoidable complications and wait times. The agency uses a five-star scale with one being the worst and five being the best.

The rankings compare VA hospitals against each other but the number of one-star hospitals is not constant. Medical centers in that bracket can be elevated to two stars based on quality-of-care factors.

Among the facilities who received only one star in both 2015 and 2016 were the VA hospital in Phoenix and another in Memphis, Tenn. One Memphis employee dubbed the facility a “house of horrors” when USA TODAY obtained internal documents revealing reported threats to patient safety soared in recent years from 700 to more than 1,000.

One veteran had to have his leg amputated after a VA provider there left a piece of plastic tubing in a critical blood vessel during a procedure.

On a number of patient safety factors, the VA overall on average scores better than the private sector on many key patient-safety measures, including instances of avoidable death, respiratory failure, and infection. But there are vast disparities among VA hospitals, according to VA data collected from October 2015 to March 2017.

The death rate for surgical patients with treatable complications ranged from zero at the VA hospital in Sacramento, Calif., to more than 20% in Miami; Columbia, Mo.; and Washington, D.C. In Long Beach. Calif, it was 29%. That’s more than double the private sector average of 14%, according to Medicare data.

Bureaucratic breakdowns

In Washington, the VA inspector general issued a rare emergency report last year saying that patients were in imminent danger at the hospital. The facility had dirty sterile storage areas and was regularly running out of critical supplies needed for surgeries and other procedures, including patches to seal blood vessels and tubes for kidney dialysis.

Shulkin quickly removed the hospital director there and sent teams from headquarters to try to fix the problems. But an inspector general report released this month found that VA officials at every level — local, regional and national — knew about the problems for years but didn't fix them.

Investigators found “a culture of complacency and a sense of futility pervaded offices at multiple levels.”

“In interviews, leaders frequently abrogated individual responsibility and deflected blame to others,” the investigation report says. “Despite the many warnings and ongoing indicators of serious problems, leaders failed to engage in meaningful interventions of effective remediation.”

Morale at the agency has taken a beating amid the constant drumbeat of crises. Employees ranked it as the second to worst agency to work for among large departments last year. The only department scoring lower was Homeland Security.

The inspector general singled out frontline workers at the Washington hospital, saying they went to great lengths to make do and they may be the only reason no patients were actually harmed.

“The OIG did not find evidence of adverse clinical outcomes, a condition that is largely attributable to front-line care providers who were committed to providing the best possible care by borrowing supplies, improvising, or personally ensuring patients received what they needed,” the investigation report said.

Vetting failures

The VA has had persistent difficulties recruiting and keeping enough medical care providers to meet veterans needs.

In 2015, one in six critical VA jobs — intake workers, doctors, nurses and assistants — were unfilled, a USA TODAY investigation found. Though the agency has made headway, there are still shortfalls.

In some cases, that has created an incentive to hire medical care providers with problem records that may have prevented them from getting jobs in the private sector.

A VA hospital in Oklahoma knowingly hired a psychiatrist sanctioned for sexual misconduct who went on to sleep with a VA patient, according to internal documents obtained by USA TODAY. A Louisiana VA clinic hired a psychologist with felony convictions. The VA ended up firing him after they determined he was a “direct threat to others” and the VA’s mission.

The Iowa City VA hospital knowingly hired John Henry Schneider last year, a neurosurgeon who had racked up more than a dozen malpractice claims in two states and had his license revoked in one.

After USA TODAY revealed the case in December, the VA forced him out and discovered that conflicting VA policies allowed its hospitals to illegally hire doctors with revoked licenses for 15 years. Shulkin ordered the policies rewritten but with the current process, that could take up to two years.

In a report released Monday, the inspector general found vetting failures go beyond medical providers. Investigators determined that the VA did not conduct required background checks on more than 6,000 employees and managers failed to properly document and oversee background checks.

“As a result, VA cannot reliably attest to the suitability of its largest workforce, exposing veterans and employees to individuals who have not been properly vetted,” the report said. “Unless internal controls and data are improved, VA and the public lack assurance that VHA has a workforce suitable for serving our nation’s veterans.”

Hiding shoddy care

The agency has failed for years to ensure medical care providers found to have provided poor care are reported to state licensing boards or to a national database created to prevent them from crossing state lines and endangering other patients.

In one case in Maine revealed in a USA TODAY investigation, the VA found a podiatrist had harmed 88 patients but didn’t report him to the national database and took years to report him to state boards. By the time the VA told his patients, one of them, U.S. Army veteran April Wood, had decided to have her leg amputated after two failed surgeries by the podiatrist.

The investigation found VA hospitals also signed secret settlement deals with dozens of doctors, nurses and health care workers in recent years that included promises to conceal serious mistakes — from inappropriate relationships and breakdowns in supervision to dangerous medical errors — even after forcing them out of the VA.

In response to the story last fall, Shulkin required increasing vetting of future such deals and he ordered policies on reporting to state boards and the national database rewritten. Again, five months later, the new policies still are not in place and could take months or years more.

Politics

Jackson, Trump's pick to be the new secretary, has no experience running a huge government agency, and dealing with veterans’ health care challenges will require deft politics and bureaucratic acumen.

His predecessor, Shulkin, was ousted despite being well regarded in Congress and assured of job security by Trump.

Now, a White House physician and former Navy admiral faces not just a plethora of VA maladies, but partisan politics and special interests that bitterly disagree on the cures.

The most perilous and important controversy involves decisions on privatizing veterans’ healthcare.

Powerful unions and veteran service organizations, such as the American Legion, oppose a radical change, and they are supported by most Democrats on Capitol Hill. But Republicans and key advocacy groups, such as Concerned Veterans for America, are demanding a system that would let veterans decide whether they go to the VA for care, or get private treatment subsidized by the government.

On Thursday, Trump suggested that Shulkin was dismissed because he was not aggressive enough in promoting the private-care option.

The existing Choice Program, which ate up billions of dollars and had to be re-funded, promises to be even more expensive if expanded. And those costs already have included tens of millions of dollars in improper payments to contractors.

Veteran enrollment for healthcare has skyrocketed, and Congress continues to expand benefits for those already in the system, with care for Agent Orange victims and high-cost medications for hepatitis patients. Bringing in enough funding to meet that demand also requires political aplomb.

Opinion: Can Trump's doctor cure what ails VA?

Opposing view: Expand private health care options for veterans