WASHINGTON — As a top Veterans Administration official in the Obama administration, current Secretary David Shulkin took no action to fix longstanding problems of dirty syringes and equipment shortages that put patients at risk at a major veterans hospital, according to an investigation released Wednesday that finds "failed leadership" and a "climate of complacency" at the agency.
The 150-page report by the VA internal watchdog offers new details to its preliminary finding last April of patient safety issues at the Washington, D.C., medical center. Painting a grim picture of communications breakdowns, chaos and spending waste at the government's second largest department, the report found that at least three VA program offices directly under Shulkin's watch knew of "serious, persistent deficiencies" when he was VA undersecretary of health under former President Barack Obama from 2015 to 2016.
Shulkin, who was elevated to VA secretary last year by President Donald Trump, told government investigators that he did "not recall" ever being notified of problems.
He also faces a rebellion among some VA staff and has issued a sharp warning to them: Get back in line or get out.
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"I suspect that people are right now making decisions on whether they want to be a part of this team or not," he said last month.
The latest IG investigation found poor accounting procedures leading to taxpayer waste, citing at least $92 million in overpriced medical supplies, along with a threat of data breaches as reams of patients' sensitive health information sat in 1,300 unsecured boxes.
No patient died as a result of the patient safety issues at the Washington facility dating back to at least 2013, which resulted in costly hospitalizations, "prolonged or unnecessary anesthesia" while medical staff scrambled to find needed equipment at the last minute as well as delays and cancellations of medical procedures. The report also noted improvements made at the Washington facility since the IG's first report in April, when Shulkin replaced the medical center's director and pledged broader improvements.
Still, VA inspector general Michael Missal cautioned of potential problems without stronger oversight across the VA network of more than 1,700 facilities.
"Failed leadership at multiple levels within VA put patients and assets at the DC VA Medical Center at unnecessary risk and resulted in a breakdown of core services," Missal said. "It created a climate of complacency ... That there was no finding of patient harm was largely due to the efforts of many dedicated health care providers that overcame service deficiencies to ensure patients received needed care."
In the report, Shulkin responded that he had expected issues involving patient harm or operational deficiencies to be raised through the "usual" communication process, originating from the local level and regional office to VA headquarters in Washington — and that it apparently didn't happen.
While the IG did not make specific conclusions on whether Shulkin actually was warned by direct subordinates, it broadly faulted an "unwillingness or inability of leaders to take responsibility for the effectiveness of their programs and operations," and cited a "sense of futility" at multiple levels in bringing about improvements. In its written response to Wednesday's report, the department generally agreed to implement recommendations for improved health procedures at the Washington facility and pledged a "reliable pathway" for local VA and regional officials to report high-priority concerns to senior leadership at VA headquarters.
"It was difficult to pinpoint precisely how the conditions described in this report could have persisted at the medical center for so many years," Missal wrote.
"Senior leaders at all levels had a responsibility to ensure that patients were not placed at risk," he said.
Shulkin has maintained White House support despite the travel controversy. He has acknowledged some mistakes in the handling of the trip and said he relied too much on the judgment of his staff to ensure full compliance with travel policies. He has since said he reimbursed the $4,000 plane ticket for his wife. His chief of staff, Vivieca Wright Simpson, has left the agency.
Several major veterans organizations are standing behind him as the best guardian of the VA amid a planned overhaul of the Veterans Choice program, a Trump campaign priority aimed at expanding private care outside the VA system.
Major veterans groups are wary of an aggressive Choice expansion as a potential threat to the viability of VA medical centers, which it sees as best-suited to treat battlefield injury such as post-traumatic stress disorder.