IG Report Points to Lack of Responsiveness by Iowa City VAMC Management

By Sandra Basu

WASHINGTON — While medical care has not been compromised in the Iowa City VA Healthcare System, a “pervasive lack of support for staff problem-solving” could threaten patient safety, a recent investigation concluded.

The findings were part of a VA Inspector General’s report examining allegations about quality of care in the Iowa City VA Healthcare System and whether the concerns of employees there had been “largely ignored” by the leadership.

The report came in response to a request for an investigation by Sen. Chuck Grassley (R-IA). In a letter to the VA IG in March, he wrote that his office had received reports of a variety of serious allegations at the Iowa City facility. Many of the allegations, Grassley said, came from individuals “who are concerned about the direction of the facility and its impact on patient care” but felt their concerns had been ignored by the leadership of the VA facility.

These whistleblowers, he said, “fear retaliation” and describe the work environment as “vindictive.”

“Morale has been described as ‘terrible,’ causing many employees to consider looking elsewhere for employment,” he wrote. “Furthermore, it is alleged that those who keep their mouths shut about problems are rewarded with promotions, while more qualified individuals are passed over for not going along with the ‘status quo.’ Also, according to these individuals, there have been many complaints from patients and families regarding the quality of care and, while these complaints are reported, the problems reoccur.”

VA Investigation

For the investigation, OIG invited employees of the Iowa City VA Healthcare System to respond to an anonymous survey about working conditions and patient care. In addition, OIG made two site visits to the parent facility and two community-based outpatient clinics, also conducting interviews with about 125 individuals.

While the investigation found that high-quality medical care had been maintained, the review revealed “a highly competent professional staff frustrated by the persistent ineffectiveness of senior leadership.”

“During a prolonged period when key leadership positions were held by individuals on a temporary basis, decisions were delayed or never made, and a highly competent professional staff was frustrated by the persistent ineffectiveness of senior leadership,” the report stated.

Examples of problems identified in the report included frontline staff and managers reporting that the process for hiring new staff to fill vacancies was inadequate, with positions remaining unfilled for prolonged periods of time. Investigators also learned that individuals who were serving in “acting” positions did not always have the authority they needed to make decisions.

“Individuals temporarily leaving a leadership role have not relinquished their authority to the individual assuming the ‘acting’ position,” the report stated. “Consequently, the acting member is unable to fully function within the responsibilities of the temporarily assigned position. It is unclear to middle managers to whom they should report in order to effect change and conduct daily business.”

The investigators also gave specific examples of the lack of responsiveness by leadership in addressing concerns reported to them, such as addressing an increase in patients admitted to non-VA hospitals because of unavailability of beds.

“The primary reason for the increase was a new restriction on the number of inpatients for which resident physicians are allowed to have ongoing responsibility,” the report stated. “The change was implemented one year ago, and the number of diversions was noted to rise soon thereafter. In anticipation of the change, staff developed plans to limit its impact on patient care. At least one intervention was made, but no solution was achieved. Although several approaches were proposed, none was implemented. The consequences of patient diversion are substantial. Patients are subjected to the risks associated with discontinuous care, including limited communication among providers and incomplete transmission of treatment records.”

The investigators recommended that the VISN director “ensure that system leaders take appropriate action in response to identified problems and communicate action plans to staff.”

“We also recommended that system leaders clarify organizational lines of authority and responsibility and improve components of Environment of Care and Pharmacy management,” the report stated.

In response to the recommendations made by the IG, VA said it concurred and would take action.

For his part, Grassley said he appreciated the whistleblowers’ willingness to come forward and alert him to these problems.

“The key for the management is to immediately take steps to address the problems laid out by the Inspector General before patient care is impacted,” he wrote.

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