PITTSBURGH – The upstate head of the Veterans Health Administration received nearly $26,000 in bonuses at the same time as employees at the Buffalo VA Medical Center were improperly reusing insulin pens and mishandling patient records – part of a pattern at VA facilities where executives were rewarded despite medical errors made under their watch.
Those were among House members’ conclusions Monday as they grilled the head of the Veterans Health Administration at a hearing on the VA’s medical problems, held here to focus on a Legionnaires’ disease outbreak at the Pittsburgh veterans hospital that claimed at least five lives.
Hearing gut-wrenching testimony from relatives who lost loved ones due to the VA medical errors as well as outraged employees – including a VA police officer from Buffalo – members of Congress vowed to force the sprawling hospital system to change its ways.
Above all, they were outraged that VA leaders got bonuses despite problems at the facilities they oversaw.
David J. West, the VA’s upstate New York network director, got nearly $26,000 in bonuses in 2010 and 2011, while the insulin pen and medical records problems were occurring.
And Michael E. Moreland, the VA’s regional medical director in Pittsburgh, received a performance award from President Obama and $62,895 bonus despite the Legionnaires’ disease outbreak – and despite a criminal investigation into whether hospital officials tried to cover it up.
“Just put yourselves in the shoes of the family members here today who lost loved ones,” Rep. Jeff Miller, R-Fla., chairman of the House Veterans Affairs Committee, told a panel of VA officials, including Brian G. Stiller, director of the Buffalo VA Medical Center. “How would you feel if one of your loved ones died and the person overseeing the facility received an award or a bonus?”
Enduring three hours of such comments, Dr. Robert A. Petzel, undersecretary for health at the Veterans Health Administration, defended the bonuses and awards as routine, and insisted that the problems at the five VA facilities discussed at the hearing were anomalies.
“The problems being discussed here are serious, but they are not systemic,” Petzel said. “The VA has a long-established record of providing safe health care.”
In Buffalo, though, the VA’s recent record includes at least 20 exposures to hepatitis that stemmed from the improper reuse of insulin pens on diabetic patients, as well as the misfiling or damage of thousands of patient records.
And while those problems have not appeared to lead to a loss of life, the snafus in Buffalo nevertheless received plenty of attention at the hearing, with Miller bringing up the hepatitis cases and the bonuses given to West.
Petzel praised Stiller’s response to the problem, noting that the Buffalo VA’s employees discovered the insulin pen problem and conducted an investigation.
“These findings triggered a national change in how our system manages the use of insulin pens, ultimately positively impacting care in over 1,800 sites,” Petzel said.
Petzel did not directly address the bonuses West received in 2010 and 2011, but he said VA executive awards are based on an employee’s overall leadership impact, not the “adverse events” that every VA leader will encounter.
Others testified, though, that the bonuses are symbolic of a VA culture that seems to reward the wrong things.
Gerald J. Rakiecki, a VA police officer at the Buffalo hospital, testified that Jason C. Petti, associate medical center director for the local VA facilities, conducted a review that found no major problems with the medical records in Buffalo. Yet when higher-ups found out that there were indeed problems, they exonerated Petti and said he provided appropriate oversight.
In light of that, “I do not trust the VA system,” said Rakiecki, a union leader who represents the whistle-blowers who brought the records problem to light. “It is a system in which managers commit wrongdoing, cover it up and get rewarded for doing so.”
Rakiecki also alleged that the VA has done nothing to correct the records problem, which surfaced when the Office of Special Counsel – which presses federal agencies to address problems brought forth by whistle-blowers – validated the allegations that local employees had made regarding the mishandled patient files.
In response, Evangeline E. Conley, a Buffalo VA spokeswoman, said: “New concerns were brought forth regarding record management in the last two weeks, and a team was immediately put in place to look into the items. This review is currently ongoing.”
While Petzel repeatedly stressed that the VA’s problems were isolated and rare, witnesses from across the country told their harrowing stories.
The daughter of a veteran being treated at the Dallas VA hospital told how his surgeons accidentally cut off the blood flow to his brain, inducing a stroke that eventually ended his life.
The sister of another veteran discussed how her psychologically troubled brother was prescribed 20 drugs by VA physicians in Atlanta – and how they did nothing to prevent his suicide at the hospital there.
And a VA doctor from Jackson, Miss., told of mismanagement there that left the VA facility grievously short of doctors and relying on nurse practitioners to get by.
Hearing all those stories, Petzel offered condolences to the families of those who lost loved ones, saying, “I’m very saddened by the stories of loss.”
What’s more, he said the VA is responding to all the problems that have surfaced. For example, the VA has new leadership teams in place in Atlanta and Jackson, and is continuing to investigate what happened in Dallas.
The outbreak of Legionnaires’ disease in Pittsburgh drew the bulk of the attention at the hearing, though, as two witnesses described watching their fathers die from a disease they got from the hospital’s water system.
“I was outraged” to hear that Moreland, the hospital chief, had won the Presidential Distinguished Rank Award, said Bob Nicklas, whose father, William Nicklas, died of Legionnaires’ disease at the hospital last November. “It was a huge slap in the face.”
Lawmakers were equally outraged.
“What we’re hearing today breaks our heart and makes our blood boil,” said Rep. Michael F. Doyle, D-Pa. “We will get to the bottom of this.”
Lawmakers vowed to force improvements to the VA medical system and to consider redrawing the VA’s bonus system.
In the meantime, Rakiecki, the Buffalo VA police officer who testified at the hearing, told lawmakers that even though he’s a veteran, he will not seek treatment at the local veterans hospital.
“Veterans,” he said, “should not have to put their lives on the line twice for their country.”