VA Identified Problems in Marion, Illinois

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VA Leadership Vows to Fix Problems Identified
At Marion VA Medical Center
WASHINGTON (January 28, 2008) - The Department of Veterans Affairs (VA)
today affirmed its determination to quickly address problems at its
Marion, Ill., hospital. The VA today released the results of two
investigations into concerns involving patient care at the Marion
facility.

VA's Inspector General was contacted by Dr. Michael J. Kussman, VA's
Under Secretary for Health, on September 10, 2007 and also subsequently
by Congress, to perform a comprehensive review of surgical services at
the facility after VA's National Surgical Quality Improvement Program
(NSQIP) found there was a higher death rate than expected during the
period from October 1, 2006 through March 31, 2007. Representatives of
the NSQIP program visited Marion from August 29-30, 2007. Their
follow-up report led to the immediate suspension by Veterans Health
Administration (VHA) leadership of all major surgeries at the hospital,
which have not been resumed.

"We found the problems ourselves; we took immediate action to keep
patients from being harmed as soon as we knew what was going on; we're
extremely sorry for what happened; and we'll hold those who created the
problems accountable," said Dr. Michael J. Kussman, VA's Under Secretary
for Health. "We're determined to do what's right for our veterans and
their families, not only at Marion, but everywhere in VA's medical
system."

The Inspector General's report, augmented by a separate internal review
by VA's Medical Inspector begun on September 4, 2007, identified four
areas in which Marion employees failed to comply with Federal and local
regulations and VA directives and procedures. They include:

* Quality management: Some reviews of the quality of care at the
facility were improperly done; cases selected for review by physicians'
peers (a required practice in health care settings called "peer
reviews") were not always properly evaluated; and patient deaths were
inadequately and insufficiently evaluated to be able to address issues
in a timely manner.

* Credentialing: Credentialing is the process by which health care
organizations screen and evaluate medical providers in terms of
licensure, education, training, experience, competence and health
status. The facility, at times, failed to document its consideration of
important credentialing information such as malpractice claims; and
documentation related to the verification of licensure, registration and
certification requirements was not always done in a timely manner.

* Privileging: Privileging is the process by which physicians are
granted permissions to practice and to perform various diagnostic and
therapeutic procedures. The Inspector General found instances in which
surgeons performed procedures they were not authorized to perform. The
medical center also failed to adequately consider past performance and
outcomes in decisions whether to renew surgeons' permission to continue
to perform certain procedures. In addition, both the Inspector General
and the Medical Inspector's reports criticize the facility for allowing
surgeries to be performed that were more complex than the facility could
handle based on its staff and capabilities. Concerns include the fact
the medical center did not have 24-hour coverage in respiratory therapy,
pharmacy and radiology.

* Facility Leadership: The Inspector General believed there were
warnings on many of the problems identified in NSQIP's site visit,
including NSQIP's own data, Marion's leadership should have acted upon
before others discovered the problem. According to the IG, though, most
of this information was "not disseminated to other VHA managerial
entities such as VISN 15 (the facility's parent network) or VA
headquarters in Washington, DC."

VA is examining each of these areas, not only at Marion but throughout
the Department's health care system, to ensure these types of issues are
not present at other facilities and to enhance regulations to prevent
these problems from occurring in the future. A VHA work group has been
convened to develop new requirements for peer reviews, augmenting peer
reviews conducted at smaller facilities by requiring external reviews
and establishing improved parameters for future peer reviews of all
types. These additional directives will be enacted within the month.

Both the Inspector General and the Medical Inspector's reports agreed
there had been numerous instances of poor medical care at the facility.
The Inspector General's report states the care of three patients who
died following surgical procedures during Fiscal Year 2007 had
"significant problems." The Medical Inspector's report, which reviewed
Fiscal Years 2006 and 2007, and therefore substantially more cases,
identifies a total of nine deaths directly attributable to substandard
care. There were 34 cases in which care complicated patients' health,
including 10 others who died. In these cases, the Medical Inspector
could not determine if the care they received caused their deaths.

VA will begin immediately to contact those veterans and families of
veterans who are believed to have been harmed by surgical care at the
facility within the past two years to review their care with them, and
known instances of substandard care will be disclosed. The Department
will also assist patients and families who believe they have been harmed
in their efforts to receive compensation. The Department has set up a
toll-free phone number for patients and their families who are concerned
about the care they received at the Marion VA hospital to call to
receive additional information. The number is 1-800-983-0932.

"I am angered about the issues at Marion that are identified in these
reports. We sincerely apologize to those who have received poor care,
to their loved ones, to the Marion community, and to all veterans and
their families," said Dr. Kussman. "We are determined to correct the
problems we have uncovered and return Marion to a level of health care
our veterans deserve."

Last September, VA removed Marion's hospital director, chief of staff,
chief of surgery and an anesthesiologist from their positions and placed
them in other administrative positions or on administrative leave. (The
anesthesiologist has since resigned.) Today, the Department also
announced it has initiated an Administrative Board of Investigation to
review quality of care issues and issues raised by employee groups, and
neither the previous director nor the chief of staff will be returned to
work at the facility, even if they are exonerated. In addition, a
surgeon who had not previously disclosed information related to his
license to practice medicine has been fired.

The Medical Inspector's report is available, in redacted form to comply
with privacy laws, at
http://www.va.gov/health/docs/2007-D-1356Marion.pdf.