The management of the Dorn VA Medical Center did a lousy job of keeping its operating rooms staffed and reacting to infection problems, according to a report from the Department of Veterans Affairs Office of Inspector General.
The report, issued Thursday, comes less than a year after an even more scathing report on backlogs in the gastroenterology program at Dorn that led to several cancer-related deaths. The latest report doesn’t link problems to any deaths, but it does note that Dorn ranked 127th out of 128 VA hospital facilities in the country in health care-associated infections at one point in 2013.
Regional VA officials and current leaders at Dorn responded to the 19-page report with a 10-page list of steps that had been taken to reduce the problems. The Dorn response agrees that the problems once existed but contends they have been solved or are on the way to being solved.
U.S. Rep. Joe Wilson said he is confident Dorn is headed in the right direction with the name of new chief of staff Dr. Bernard DeKoning this week, but he hates that the quality of hospital management and care reached such depths in 2012 and 2013.
“It makes you angry,” Wilson said. “This is supposed to be world-class service for people who make it possible for us to enjoy our freedom.”
The report confirmed what many hospital patients and employees had told Wilson in recent years. The congressman said he remains especially concerned about the staffing shortages among surgeons and nurses. “It’s going to take extraordinary focus” to complete a transformation of the Dorn facility, Wilson said.
The most important step could be hiring a new director for the facility. Dorn has had five directors, three associate directors and eight chiefs of medicine in the past three years, many of them on temporary assignment. The Southeast office of VA hospitals said it has identified a top candidate for the Dorn director’s job and is awaiting approval for the hiring.
The VA started looking into the facility after a detailed, confidential complaint filed by an employee. But when the Inspector General’s office contacted the employee whose name was on the complaint, the individual denied submitting the complaint. The employee surmised a former coworker initiated the complaint under the employee’s name. The report notes that it was difficult to investigate some of the complaints without more details from the informant.
Based on visits to Dorn in the first half of 2013, the Inspector General’s report substantiated several of the original complaints:
General and vascular surgery chief residents kept hard-copy logbooks that included protected patient information. Dorn has since stopped that violation of security procedures, according to the report.
• Surgery clinics were understaffed, forcing physicians to monitor and record vital signs and clean rooms between patients. Also, the two full-time nurse anesthetists, one full-time anesthesiologist and one part-time anesthesiologist positions were vacant in early 2013.
Operating room scheduling practices were rife with “communication deficits and dysfunctional surgical processes that contributed to surgical case delays.” Some patients weren’t properly informed when they were put on or taken off surgical calendars, and surgeries scheduled for late in the day were postponed at the last minute to prevent staff working overtime.
• Infection control efforts were “fragmented and inconsistent, surveillance activities were superficial, and corrective actions were rarely discussed, implemented or completed.” Despite having one of the worst records on infection in the country, Dorn leaders often responded to committee reports on the problem by writing: “continue to monitor.”
• Some surgical equipment used multiple times wasn’t pre-cleaned after use. The pre-cleaning is just one step in the process, but not performing that step makes each of the remaining steps less effective at preventing infection, according to the report.
• Surgeries often were delayed due to a lack of back-up surgical instruments, and surgical mesh devices weren’t in stock. Those problems were related to purchase problems that have been remedied, according to the report.
• Dorn has had trouble providing the proper oversight for the surgical residency affiliation it has with the University of South Carolina School of Medicine and Palmetto Health. Of the three staff general surgeons who were supposed to monitor the residents, one was on extended sick leave, one retired and one resigned early in 2013. The residents temporarily were reassigned to Palmetto Health until new general surgeons were hired. Also, during one visit, the Inspector General called the listed on-call surgeon for the emergency department, who said he was unaware he was on-call that night.
• Dorn didn’t always provide peer-review reports on deaths in the facility that met criteria for such reviews. “Therefore, we may never know the harm caused by the deficiencies the inspector general identified,” said Rep. Jeff Miller, R-Fla., chairman of the House Veterans’ Affairs committee. “This isn’t a money problem. It’s management problem, and this report should serve as a wake-up call to VA leaders at all levels to do whatever it takes to assemble a competent and stable team” at Dorn.