Phoenix VA inspection reveals issues with care, safety, public trust

Dennis Wagner | The Republic | azcentral.com

Department of Veterans Affairs inspectors uncovered multiple issues in a new review of the Phoenix VA hospital that was ground zero for a national crisis in veterans health care four years ago.

The Office of Inspector General report comes a day before President Donald Trump is scheduled to sign reform legislation in a White House ceremony, with Phoenix VA Health Care System Director Rima Nelson in attendance.

The wide-ranging review of the Phoenix VA, based on an unannounced visit by inspectors in February, found flaws in five of eight areas scrutinized, including deficient safety processes, inspections, geriatric medical evaluations and mental health diagnostics.

The report says the Office of Inspector General "is concerned with the number of potential in-hospital complications and adverse events following surgeries." It also notes inspectors found dirty floors, food without expiration dates and other problems.

The Phoenix VA Healthcare System encompasses the main hospital and related clinics serving more than 92,000 veterans.

In 2014, whistleblowers and The Arizona Republic reported that patients were dying while awaiting care amid an atmosphere of mismanagement and falsified appointment data. Those issues turned out to be widespread in the Department of Veterans Affairs. Congressional hearings, inspector general investigations and media reports triggered public outrage leading to the replacement of the VA secretary and extensive reforms.

On Wednesday, Trump is expected to sign legislation that some deem the biggest overhaul of VA operations in history, with several Arizona veterans at his side.

The inspector general's report notes that the Phoenix VA Healthcare System has been through a management upheaval, including seven directors in four years. It concludes the administration has been stable since April 2017, and leaders are committed to "turn things around."

However, the report says, in evaluations by veterans the Phoenix hospital scored lower than VA averages, and the medical center "continues to struggle to gain patients’ and public trust, as evidenced by low patient satisfaction survey results."

A VA tool used to measure clinical risk and patient satisfaction still gives the Carl T. Hayden VA Medical Center just one star, the lowest rating in a five-star system. And inspectors warned of "procedures that may contribute to lapses in patient safety unless corrective actions are implemented and continuously monitored."

The Office of Inspector General issued 13 recommendations, which Phoenix VA supervisors are expected to act on.

The report includes an addendum showing Nelson concurred with all recommendations.

Phoenix VA spokeswoman Cindy Dorfner said action plans have been developed to address those issues, and two have been resolved already.

"We welcome the opportunities that come with inspections, surveys and reviews of our hospital since they show us areas where we need to continue to improve the healthcare delivery for our veterans," Dorfner added via email.

"We’re dedicated to improving the patient experience so that veterans want to choose VA."

Top to bottom: Cleaning an operating room at the Phoenix VA Hospital After a rash of surgery-related infections hit Carl T. Hayden VA Medical Center, a flurry of new protocols were enacted. Watch as cleaners sterilize a surgical room from top to bottom. Michael Chow/azcentral.com

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