As a long-standing recipient of quality care from Veterans Affairs and the executive director of a nonprofit organization committed to serving veterans and their families, I am moved to call for fairness regarding Gov. Rick Scott’s call for the Florida Agency for Health Care Administration to inspect Department of Veterans Affairs hospitals after reports of five deaths at VA facilities in VISN 8, which includes Florida, Puerto Rico and part of Georgia. Months ago, VA identified an issue with consult delays in the diagnosis and treatment of veterans with cancer that needed to be corrected. This issue was not discovered by media or state inspectors; it was disclosed by VA.
Although no health-care system is perfect, VA is more transparent than private health-care systems. Private hospitals don’t do disclosures, but they do spend millions on advertising the care they provide. I am proud to receive care from a health-care system that holds itself to higher standards, but when that system is threatened by political games at the expense of my fellow veterans, I am concerned that unfair negative publicity may unfortunately discourage veterans from seeking care they have earned and deserve.
The consult delay issue was initially discovered at two medical centers outside Florida. Once these were discovered, the Veterans Health Administration conducted a national review of consults across the VA system. It was determined there were about 301,000 consults for gastroenterology (GI) and GI endoscopy for fiscal years 2010 and 2011 in VISN 8. In 2012, VISN 8 received a list of patients with new GI malignancies identified during fiscal years 2010 and 2011 from the cancer registry for review for evidence of harm related to wait time delays or delay in diagnosis. This review resulted in the need for 14 patients to receive institutional disclosures. Of these 14 patients, five had died. Of these five, two deaths were determined, by a review, to not be related to the delays. Of the remaining three patients who died of their malignancy, two were from North Florida South Georgia VA Health System (based in Gainesville), and one was from West Palm Beach.
VA has a well-established record that when an incident like this occurs, they aggressively identify, correct and work to prevent additional risks. VA has conducted a thorough review to understand what happened, prevent similar incidents in the future and will publicly share lessons learned.
In VISN 8, they have taken a number of steps to greater strengthen the consult process and prevent a similar delay at any of its hospitals. They continue to diligently monitor and track the consult management process (which includes not only GI consults, but all consults) through various mechanisms to avoid delays or potential adverse events. VISN and local consult management teams have been established in their facilities with subject matter experts, including information technology, medical administration and clinical representatives, to monitor and track processes for consults, implement revised business rules for immediate and future care and to validate data. Processes have been strengthened to track high-risk consults, and VISN 8 is piloting a clinical tool for health-care providers, as an additional resource, to validate abnormal test results to ensure timely follow-up care.
Although I believe VA should be held to higher standards of transparency and care delivered to the men and women who have worn our nation’s uniform, it seems that a similar incident at any private health-care system would not garner the political or media attention given to VA. Because VA does not — and cannot — go on the offensive to describe its efforts to identify and correct adverse incidents, I am writing to request evenhandedness in your coverage of this issue.
John E. Pickens is executive director of VeteransPlus & The Yellow Ribbon Registry Network.