Tag Archives: Veterans Affairs

VA makes little headway in fight to shorten waits for care

VA makes little headway in fight to shorten waits for care

Veterans turn back on Obama
Veterans turn back on Obama

FAYETTEVILLE, N.C. (AP) — A year after Americans recoiled at new revelations that sick veterans were getting sicker while languishing on waiting lists — and months after the Department of Veterans Affairs instituted major reforms costing billions of dollars — government data shows that the number of patients facing long waits at VA facilities has not dropped at all.

No one expected that the VA mess could be fixed overnight. But The Associated Press has found that since the summer, the number of vets waiting more than 30 or 60 days for non-emergency care has largely stayed flat. The number of medical appointments that take longer than 90 days to complete has nearly doubled.

Nearly 894,000 appointments completed at VA medical facilities from Aug. 1 to Feb. 28 failed to meet the health system’s timeliness goal, which calls for patients to be seen within 30 days.

That means roughly one in 36 patient visits to a caregiver involved a delay of at least a month. Nearly 232,000 of those appointments involved a delay of longer than 60 days — a figure that doesn’t include cancellations, patient no-shows, or instances where veterans gave up and sought care elsewhere.

A closer look reveals deep geographic disparities.

Many delay-prone facilities are clustered within a few hours’ drive of each other in a handful of Southern states, often in areas with a strong military presence, a partly rural population and patient growth that has outpaced the VA’s sluggish planning process.

Of the 75 clinics and hospitals with the highest percentage of patients waiting more than 30 days for care, 12 are in Tennessee or Kentucky, 11 are in eastern North Carolina and the Hampton Roads area of Virginia, 11 more are in Georgia and southern Alabama, and six are in north Florida.

Seven more were clustered in the region between Albuquerque, New Mexico, and Colorado Springs, Colorado.

Those 47 clinics and hospitals represent just a fraction of the more than 1,000 VA facilities nationwide, but they were responsible for more than one in five of the appointments that took longer than 60 days to complete, even though they accounted for less than 6 percent of patient visits.

That has meant big headaches for veterans like Rosie Noel, a retired Marine gunnery sergeant who was awarded the Purple Heart in Iraq after rocket shrapnel slashed open her cheek and broke her jaw.

Noel, 47, said it took 10 months for the VA to successfully schedule her for a follow-up exam and biopsy after an abnormal cervical cancer screening test in June 2013.

First, she said, her physician failed to mention she needed the exam at all. Then, her first scheduled appointment in February 2014 was postponed due to another medical provider’s “family emergency.” She said her make up appointment at the VA hospital in Fayetteville, one of the most backed-up facilities in the country, was abruptly canceled when she was nearly two hours into the drive from her home in Sneads Ferry on the coast.

Noel said she was so enraged, she warned the caller that she had post-traumatic stress disorder, she wasn’t going to turn around — and they better have security meet her in the lobby.

“I served my country. I’m combat wounded. And to be treated like I’m nothing is unconscionable,” she said.

The AP examined wait times at 940 individual VA facilities from Sept. 1 through Feb 28 to gauge any changes since a scandal over delays and attempts to cover them up led to the resignation of VA Secretary Eric Shinseki in May and prompted lawmakers to pass the Veterans Access, Choice and Accountability Act in August. The analysis included all VA hospitals and outpatient clinics for which consistent wait time data was available. It excluded residential treatment centers, homeless dormitories and disability evaluation centers. Data for individual facilities were not available for August.

It is difficult to quantify exactly how things have changed because the VA introduced a new method for measuring wait times at the end of the summer. VA officials say the new methodology is more accurate, but its adoption also meant that about half of all patient appointments previously considered delayed are now being classified as meeting VA timeliness standards. That means published wait times now can’t be directly compared with data the VA released last spring.

The trend, however, is clear: Under the VA’s old method for calculating delays, the percentage of appointments that took longer than 30 days to complete had been steadily ticking up, from 4.2 percent in May to nearly 5 percent in September. Under the new method — the one that counts half as many appointments as delayed — the percentage went from 2.4 percent in August to 2.9 percent in February.

The number of appointments delayed by more than 90 days abruptly jumped to nearly 13,000 in January and more than 10,000 in February, compared to an average of around 5,900 the previous five months. That’s not a change that can simply be blamed on bad winter weather; many of the places reporting the largest gains are warm year-round.

VA officials say they are aware of the trouble spots in the system. They cite numerous efforts to ramp up capacity by building new health centers and hiring more staff; between April and December, the system added a net 8,000 employees, including 800 physicians and nearly 2,000 nurses.

And they say that in at least one statistical category, the VA has improved: The number of appointments handled by VA facilities between May and February was up about 4.5 percent compared to the same period a year earlier.

But they also readily acknowledge that in some parts of the country, the VA is perpetually a step behind rising demand.

“I think what we are seeing is that as we improve access, more veterans are coming,” Deputy Secretary of Veterans Affairs Sloan Gibson told the AP.

He also acknowledged that the VA has historically been “not very adroit as a bureaucracy” in responding to those changes. It takes too long to plan and build new clinics when they are needed, he said, and the VA isn’t flexible in its ability to reallocate resources to places that need them most.

“We are doing a whole series of things — the right things, I believe — to deal with the immediate issue,” Gibson said. “But we need an intermediate term plan that moves us ahead a quantum leap, so that we don’t continue over the next three or four years just trying to stay up. We’ve got to get ahead of demand.”

He also asked for patience. President Barack Obama signed legislation in August giving the VA an additional $16.3 billion to hire doctors, open more clinics and build the new Choice program that allows vets facing long delays or long drives to get care from a private-sector doctor.

It will take time to get some of those initiatives expanded to the point where they “move the needle,” Gibson said.

Between Nov. 5 and March 17, according to VA officials, only about 46,000 patients had made appointments for private-sector care through Choice — a drop in the bucket for a system that averages about 4.7 million appointments per month.



In many parts of the country, the VA can boast of being able to deliver care that is just as fast, or even faster, than patients would get in the private sector. Relatively few VA facilities in the Northeast, Midwest and Pacific Coast states reported having significant numbers of patients waiting extended periods for care.

Of the 940 hospitals and outpatient centers included in the AP analysis, 376 met the VA’s timeliness standard better than 99 percent of the time. A little less than half of all VA hospitals and clinics reported averaging fewer than two appointments per month that involved a wait of more than 60 days.

The difference between the haves and have-nots can be stark.

The Minneapolis VA, one of the system’s busiest medical centers, completed 276,094 medical appointments between Sept. 1 and Feb. 28. Only 424 of them involved a wait of more than 60 days.

At the VA’s outpatient clinic in Jacksonville, Florida, a facility handling a third of the volume, 7,117 appointments involved a wait of more than 60 days.

That means there were more vets experiencing extended delays at that one clinic than in the entire states of New York, New Jersey and Connecticut combined.

Equally surprising: The Jacksonville clinic is practically brand new. It opened in 2013 with the express intent of improving access to care in a fast-growing city with a lot of military retirees and a close relationship with three U.S. Navy bases: Naval Air Station Jacksonville, Naval Station Mayport and the Kings Bay Naval Base.

But like other VA facilities built recently in spots now struggling with long waits, the clinic took so long to plan and build — 12 years — that it was too small the day it opened, despite late design changes that added significantly more space.

“Even our best demographic models didn’t anticipate the rate at which the growth would occur,” said Nick Ross, the assistant director for outpatient clinics at the VA’s North Florida/South Georgia Veterans Health System.

In recent months, the clinic has been enrolling another 25 new patients per day — a growth rate that would require the VA to hire another doctor, nurse and medical support assistant every 10 weeks to keep up with demand, said Thomas Wisnieski, the health system’s director.

Officials are hoping to lease 20,000 square feet of additional clinic space while they begin the planning process for yet another new building.

Clinic construction is also underway in an attempt to ease chronic delays in care on the Florida panhandle. A new outpatient VA clinic is scheduled to open in Tallahassee in 2016, and a groundbreaking ceremony was held in August for a new clinic in Panama City.



The Fayetteville VA hopes to celebrate its 75th anniversary this fall with the opening of a huge new outpatient health care center that could ease the types of chronic delays that caused Rosie Noel so much anxiety. (After her canceled exam, the VA paid for Noel to get care at a private-sector clinic; she doesn’t have cervical cancer.)

With 250,000 square feet of usable space, the center will be almost as large as the main hospital building itself. The new campus will have 1,800 parking spots, a women’s clinic and scores of new treatment rooms. It is sorely needed for a region that is home to two of America’s largest military bases, the Army’s Fort Bragg and the Marines’ Camp Lejeune, and one of the highest concentrations of vets in the country. In two core counties, one in five adults is a veteran.

Yet the new building is also emblematic of the slow pace of change at the VA.

Planning for the facility began in 2008, and Congress approved funding the next year. Construction hadn’t even begun when the first target completion date came and went in June 2012. The VA’s Office of Inspector General said in a 2013 report that the VA’s management of the “timeliness and costs” of seven planned health care centers, including the one in Fayetteville, had “not been effective.”

The hospital’s director since 2010, Elizabeth Goolsby, cited the VA’s failure to expand quickly as a primary reason for why eastern North Carolina now has some of the longest waits for care in the country.

“The contracting and building time in the Department of Veterans Affairs is a lengthy process,” she said.

During her tenure in Fayetteville, Goolsby has opened new outpatient clinics in Wilmington, Goldsboro, Pembroke and Hamlet. All now rank among the VA locations with the highest percentage of appointments that fail to meet timeliness standards.

At the VA’s clinic in Jacksonville— a small medical office built in a shopping plaza near Camp Lejeune’s main gate in 2008 — nearly one in nine appointments completed between Sept. 1 and Feb. 28 involved a wait of longer than 60 days.

“It’s not big enough to accommodate the number of veterans we are seeing or the number of providers we need,” Goolsby acknowledged.

One solution, she said, has been to keep building.

A new 15,000-square-foot clinic is under construction to serve the area around Camp Lejeune. The VA also is trying to develop a clinic in Sanford, north of Fort Bragg. And there have been stopgap measures, like the construction of modular buildings at the Fayetteville hospital this winter to host mental health clinics, and an emergency lease for a temporary medical office that allowed it to bolster staff in Jacksonville.

Some vets whose doctors were moved over to the new Jacksonville space said things improved immediately, even if that has not yet been reflected in the statistics.

“It used to take me six months to a year to get a doctor’s appointment,” Jim Davis, a retired Marine who fought in the first Gulf War and now has Lou Gehrig’s Disease. Since he transferred to the temporary clinic, he said, “I’ve called, and within three or four days I can get in to see the doctor.”

He called the change a relief, because he preferred to stay within the VA system for care if he could.

“There’s not a pharmacist at Wal-Mart calling me at home and asking me if the latest change in medicine made me feel sick. But that is happening in the VA,” Davis said. “They are so much more respectful, because they know you served.”



After years of planning, a large, new outpatient center also is scheduled to open this fall to expand care offered at the VA medical center in Montgomery, Alabama.

That expansion also is long overdue. Among the VA’s full-service medical centers, the Montgomery VA had the highest percentage of appointments that took longer than 30 days to complete. More than one in 11 appointments completed between September and February failed to meet timeliness standards. A sister hospital, a short drive to the east in Tuskegee, was No. 2.

There’s no guarantee, though, that a new building will help the Central Alabama Veterans Health Care System solve one of its other longstanding problems — a difficulty recruiting enough doctors and specialists needed to handle demand.

Both hospitals are surrounded by largely poor, rural counties designated by the government as having severe physician shortages.

“They are on the frontier of some of the most medically underserved areas of the country,” said Dr. William Curry, associate dean for primary care and rural health at University of Alabama School of Medicine.

That could mean that veterans who might otherwise get care in the private sector are more reliant on the VA. It also has historically meant big challenges recruiting physicians, who can make more money in metropolitan areas.

“Not a lot of medical students want to go work for the VA in a rural community medical clinic,” said Dr. Kevin Dellsperger, chief medical officer at the Georgia Regents Medical Center and former chief of staff at the VA medical center in Iowa City, Iowa.

Dr. Srinivas Ginjupalli, acting chief of staff for the Central Alabama Veterans Health Care System, confirmed that recruiting is a challenge, but he said the VA has been boosting salaries since the summer in an attempt to be more competitive in attracting staff.

Goolsby cited similar rural recruiting problems in her enterprise, which serves a sprawling region of hog farms and tobacco fields. Other VA officials said difficulty attracting health care providers to remote or poor parts of the country was an issue throughout the system.



A few places struggling the most with long waits did report improvements.

At the VA in Montgomery, Alabama, the percentage of appointments that take longer than 30 days to complete has fallen from 12.6 percent in September to 6.4 percent in February. That’s still a bad number compared to other VA hospitals but, looking at performance only in February, it would be enough improvement to take the hospital from worst to third in terms of the percentage of delays.

The VA’s most chronically delayed outpatient clinic throughout the summer and fall, located in Virginia Beach, Virginia, reported improvement, too. In September, 24 percent of its patient visits were delayed by at least 30 days. By February, that had fallen to 11 percent — still terrible, but much better.

The VA site that had the most trouble meeting the VA’s timeliness standard during the whole six-month period reviewed by the AP was a small clinic near Fort Campbell in Hopkinsville, Kentucky. One in five appointments took longer than 30 days to complete, and the rate has gotten steadily worse over time.

The centerpiece of the legislation signed over the summer was a plan to expand the number of veterans who are approved to get care outside of VA facilities. Yet the Choice program has barely gotten off the ground.

ID cards for the program were mailed starting in November, but many vets still don’t understand how it works. It theoretically is open to patients who can’t been seen within 30 days, or who have to drive longer distances for care, but enrollees still have to get VA approval to see a private-sector doctor and only some physicians participate in the payment system.

“It’s not working the way it needs to work,” said Gibson, the deputy VA secretary, though he added that he was enthusiastic about its potential. He said some consultants advising the VA said it might take 18 months to build the program.

In a meeting with congressional aides and state veterans service officials in March, Goolsby gave some figures to illustrate how the program was working in southeastern North Carolina: Of the 640 patients offered an opportunity for outside care through mid-March, only four were ultimately seen a private-sector doctor.

“We’re finding that a lot don’t want an outside appointment,” she said.

Reasons vary, she said, but one factor is that switching to a new doctor can be disruptive for someone with an ongoing medical issue.

In March, officials loosened the eligibility rules for the program slightly so it would cover more vets who have to drive longer distances for care.

The VA also has been trying to tackle long wait times in other ways.

The Central Alabama Veterans Health Care System, Ginjupalli said, has been promoting the use of “telehealth” systems that allow patients in rural or backed-up areas to see doctors elsewhere via video conferencing.

It also has reached an agreement with the Defense Department to help reduce long delays for care at its clinic in Columbus, Georgia, by moving some staff to a 19,000-square-foot building at the military’s medical center at Fort Benning.

Dr. Daniel Dahl, psychiatrist and associate chief of staff for mental health at the Central Alabama VA, said the new space will triple the VA’s capacity for mental health care in the area. In February, the average delay for a mental health appointment at the Columbus clinic was 25 days — seven times the national average.

Obama’s secretary of Veterans Affairs, Robert McDonald, has cautioned that it will take time for reforms to make a difference.

He also warned in recent testimony to Congress that the system may still be decades away from seeing peak usage by the generation of servicemen and servicewomen who fought in Iraq and Afghanistan.

Total enrollees in the VA system have ballooned from 6.8 million in 2002 to 8.9 million in 2013. During that same period, outpatient visits have soared from 46.5 million to 86.4 million annually; patient spending has grown from $19.9 billion to $44.8 billion; the number of patients served annually has grown from 4.5 million to 6 million.

McDonald told Congress the number of mental health outpatient visits alone is up 72 percent from 2005.

“Today, we serve a population that is older, with more chronic conditions, and less able to afford private sector care,” McDonald said.

That could mean that without further change, waits will only grow.


The AP National Investigative Team can be reached at investigate@ap.org

VA secretary apologizes for special forces claim

VA secretary apologizes for special forces claim

David Jackson, USA TODAY

Veterans Affairs Secretary Robert McDonald is apologizing for falsely claiming that he once served in the military’s special forces.

“That was inaccurate and I apologize to anyone that was offended by my misstatement,” McDonald said in a statement.

The Huffington Post, which broke the story, reported that McDonald made the claim while touring a Los Angeles neighborhood with a CBS camera crew for a story on homeless veterans. One homeless man told McDonald he had served in special forces, prompting the response from the secretary.

Reports The Huffington Post:

“‘Special forces? What years? I was in special forces!’ McDonald told the homeless man. That exchange was broadcast in a Jan. 30 CBS News story about the VA’s efforts to find and house homeless veterans.

“In fact, McDonald never served in special forces. He graduated from the U.S. Military Academy at West Point in 1975, completed Army Ranger training and took courses in jungle, arctic and desert warfare. He qualified as a senior parachutist and airborne jumpmaster, and was assigned to the 82nd Airborne Division until he retired from military service in 1980. While he earned a Ranger tab designating him as a graduate of Ranger School, he never served in a Ranger battalion or any other special operations unit.

“‘I have no excuse,’ McDonald told The Huffington Post, when contacted to explain his claim. ‘I was not in special forces.'”

More Than 500 Vets Died at VA Hospitals Due to Mistakes Since 2010

More Than 500 Vets Died at VA Hospitals Due to Mistakes Since 2010

Records show fatal delays in cancer treatment, response to suicidal gestures

James Alderson - deceased Veterans Affairs VA died
James Alderson – deceased. Died in 2014 under Veterans Affairs care.

More than 500 military veterans died because of serious mistakes at Veterans Affairs hospitals across the country between 2010 and 2014, VA records show.

There were a total of 1,452 “institutional disclosures of adverse events” between fiscal years 2010 and 2014, 526 of which resulted in patient deaths, according to VA data obtained by the Washington Free Beacon through a Freedom of Information Act request.

According to the Veterans Health Administration, such disclosures are required when “an adverse event has occurred during the patient’s care that resulted in or is reasonably expected to result in death or serious injury.”

Specifically, adverse events are defined by the department as “untoward incidents, diagnostic or therapeutic misadventures, iatrogenic injuries, or other occurrences of harm or potential harm directly associated with care or services provided” by the VA.

See the documents here: Institutional Disclosure Data Summary; Institutional Disclosures in FY2011; Institutional Disclosures in FY2012; and Institutional Disclosures in FY2013.

The 1,452 disclosures represent a miniscule portion of the hundreds of thousands of patients who are treated annually at VA hospitals, but they reveal for the first time a fuller picture of errors and lapses in medical coverage that affect veterans across the country.

The disclosures include feeding tubes being placed in patients’ lungs, patients being sent home with undiagnosed rib and shoulder fractures, and in one case extracting the wrong tooth from a patient.

But buried among the more common mistakes that occur in even the best hospitals—incorrect dosages, surgical equipment accidentally left in patients’ bodies—are reports of the fatal delays in cancer diagnoses and follow-up treatments that would later lead to a national scandal and the resignation of the VA Secretary.

“Chest X-Ray for [patient] showed an ill-defined one centimeter nodule overlying the left anterior fourth rib,” a 2011 entry from a San Diego VA hospital reads. “Radiology recommended a CT scan of the chest for a more complete evaluation of possible left midlung nodule. Patient was not informed about abnormal imaging and no follow-up was arranged. Patient was seen in the ER six months later. Patient diagnosed with Stage IV small cell lung cancer and passed away two months later.”

“[Patient] had chest X-ray in 2010; no follow-up until patient presented for ER visit in 2010,” another entry from Erie, Pennsylvania reads. “Patient ultimately found to have lung cancer. He expired in 2011. A delay in work-up of approximately 6 months occurred.”

“Follow-up CT scan ordered at CBOC to be completed at parent facility. Order faxed to unmanned printer and it did not get scheduled. Delay of diagnosis of lung cancer of approximately 9 months.”

Scores of similar entries are scattered through the quarterly reports from every corner of the United States, from Puerto Rico to Fargo to Los Angeles.

In fiscal year 2012 alone, 74 patients with some form of cancer saw delays in their treatment or the initial findings were overlooked. Twelve of those veterans ultimately died from their illness.

Less frequent but equally troublesome are reports of VA staff not properly screening patients at risk for suicide.

“Missed Opportunities prior to Suicide Completion” is the entirety of one entry from 2011.

Medical privacy laws strictly bar from disclosure the names of patients and other details, making it difficult to document individual cases, but the data does show general trends. Reports of patient deaths and injuries rose steadily from 2010 to 2013, peaking with 126 reported deaths.

As U.S. troop drawdowns in Iraq and Afghanistan accelerated over those years, VA hospitals struggled to handle the surge in patients and simultaneous shortage of doctors and staff. Some did the best they could under the circumstances, but other hospitals turned to dishonest means to hide the scope of the problem from VA headquarters in Washington.

VA Whistleblowers first began coming forward in late 2013 with allegations that schedulers at the Phoenix VA hospital used secret paper waiting lists to hide the long wait times faced by patients. Whistleblowers alleged that up to 40 veterans died while their requested appointments languished on unofficial paper lists.

The VA disclosed in April that, since 1999, 76 patients nationwide were seriously injured because of delayed gastro-intestinal cancer screenings, and 23 died.

A May audit of the Phoenix hospital found 1,700 patients were put on unofficial wait lists and subjected to treatment delays of up to 115 days.

VA Secretary Eric Shinseki resigned as a result of the scandal, and the department ordered a nationwide audit of its consulting practices.

That audit released in June, found that 57,436 newly enrolled veterans face a minimum 90-day wait for medical care, while 63,869 veterans who enrolled over the past decade requested an appointment that never happened.

According to the audit, 8 percent of scheduling staff nationwide used something other than the official electronic wait lists, and 13 percent of staff had been instructed by a supervisor to enter a date other than the veteran’s requested appointment into the “desired date” field, fudging the actual wait times.

Since then, the new VA Secretary has fired five senior administrators at problematic VA facilities, including the director of the Phoenix VA hospital.

The number of patient deaths due to errors dropped to 107 in fiscal year 2014, according to VA records.

However, the widespread use of secret waiting lists means that there are potentially many more cases of patients who died because of long-delayed appointments than appear in the reports that were filed to VA headquarters. For example, the Phoenix VA hospital appears relatively few times in the reports, and no significant delays were reported there in 2013.

Columbia, South Carolina

The Williams Jennings Bryan Dorn Veterans Medical Center in Columbia, South Carolina reported the highest number of delays in cancer care, of any facility, in 2012.

The cancer care of at least eight veterans was delayed significantly enough that officials said it may have impacted the rate of survival and the ability to later provide sufficient treatment.

Four disclosures note that a “delay in diagnosing impacted [the veteran’s] cancer staging and survival rate.” Four others use similar language, explaining that delays “in diagnosis impacted… cancer staging and treatment” of the patients.

The Dorn facility first came under scrutiny for delays in cancer care, specifically gastrointestinal (GI) care, following a CNN report in November of 2013.

The facilities’ own disclosures show that delays in gastrointestinal care have plagued the facility for a number of years.

In 2013, nine patients experienced delays between their initial consultation and necessary diagnostic procedures, such as endoscopies and colonoscopies.

The delays in GI care for two veterans, in 2012, meant they were required to undergo surgery to remove a mass in their colon, which “might have been removed endoscopically” instead of surgically if the procedure was completed earlier.

There have been six total deaths since 1999 due to delayed cancer screenings, according to the VA report.

A February report by the VA Inspector General found the Dorn hospital faced staffing and equipment shortages that led to delays. The report also noted that Dorn ranked 127th out of 128 VA facilities in health care-associated infections during 2013.

In response to the report, the Dorn VA hospital said it was immediately taking steps to fix the problems.

The Dorn VA hospital did not immediately return requests for comment.

Gainesville, Florida

The Malcom Randall VA Medical Center in Gainesville, Fla., reported 31 “adverse events” during fiscal year 2013, the most of any VA facility. Three of those incidents were delays in cancer diagnosis and treatment.

The VA also confirmed earlier this year that two patients died at North Florida/South Georgia system, where the Gainesville hospital is located, due to delayed cancer screenings.

Additionally, the hospital conducted an “incorrect autopsy,” according to a 2013 disclosure.

The system is the busiest in the country, serving roughly 125,000 VA patients per year. However, numerous congressional investigations and internal audits by the VA also describe a corrosive work environment, where leadership encouraged staff to cook the books to meet performance standards and where whistleblowers were harshly punished.

Three VA officials in Gainesville were placed on leave this year after an audit by the VA Inspector General found the hospital was using a secret paper list to keep track of appointments.

There were also allegations that surgeons were not allowed to perform certain operating room procedures to avoid increased mortality rates, and that patients with a high mortality risk were sent to a local hospital. However, the VA Inspector General said in a report it could not substantiate those claims.

Augusta, Georgia

The Charlie Norwood VA Medical Center in Augusta, Ga., reported 14 “adverse events” during fiscal year 2013, and three cancer patients died as a result of delayed screenings over the past two years.

In 2013 alone, there were ten reports of delayed colonoscopies, two of which resulted in patient deaths.

According to a 2012 report from the VA Inspector General’s Office, five patients died or sustained serious injury as a result of mismanagement between 2007 and 2010, and more than 4,500 gastrointestinal endoscopy consults went unresolved.

A VA audit this year reported that 26 new patients in Augusta had to wait at least 90 days for an appointment. Additionally, 133 veterans were not scheduled for an appointment despite requesting one in the past 10 years.

Since then, Augusta officials say they have reduced the number of veterans waiting at least 90 days for an appointment from 26 patients to two.

There were four open federal investigations into whistleblower retaliation at the hospital as of July.

‘Missed opportunities prior to suicide completion’

Twenty-two veterans are said to commit suicide each day, and decreasing that number has become a key mission of the VA. However, some disclosures raise questions about the steps being taken inside the department’s facilities to ensure veterans receive appropriate attention for mental health issues.

“[Registered nurse] documented patient had frequent thoughts of suicide,” one 2011 entry reads. “RN did not perform a suicide risk assessment with the patient and the patient attempted suicide by overdose.”

“Providers did not listen to patient complaints that psychiatric meds not working,” a 2012 report from a Salt Lake VA hospital said. “Patient overdosed on acetaminophen.”

In one case, the family of a veteran reached out to staff at the facility in Albuquerque, New Mexico after they became concerned with the patient’s depressive behavior, but staffers failed to follow up on those concerns.

“Patient attempted suicide by stabbing with a knife to his neck requiring emergency surgical repair,” the report notes. “Family had contacted facility with concern of patient depression behavior on [redacted]; lack of appropriate follow-up and medication regime.”

In Saginaw, Michigan a veteran “on a day-pass from an inpatient PTSD treatment facility” died after ingesting medications prescribed by his primary care doctor without a “face to face assessment.”

He was found dead in a motel room, two days after receiving the prescription, from “an accidental or intentional overdose of medications.”

How common are deaths due to medical error in hospitals?

There are several caveats to the VA data. In many cases, the “adverse events” occurred from one to several years prior to the year they were reported. Many patients were also injured in falls or other accidents that were not strictly the result of staff error.

In other cases, the VA was scrupulous in reporting events that could not be conclusively connected to the death of a patient, some of whom had other severe medical problems.

Sometimes the mistakes did not even result in an injury. For example, in fiscal year 2013, 67 patients suffered no injury despite an error requiring a disclosure. Even in cases where the VA reported a mistake, some patients were still grateful for the care they received, according to the reports.

Although it is difficult to make a direct comparison without more detailed information, VA hospitals are not alone in committing serious, sometimes fatal mistakes.

According to a 2010 Department of Health and Human Services Office of Inspector General report, “an estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.”

In a groundbreaking 1999 study, the Institute of Medicine estimated that medical errors killed between 44,000 and 98,000 patients at hospitals nationwide every year. However the Journal of Patient Safety said in a report released last year that the numbers may be as high as between 210,000 and 440,000 patients each year.

Every year, an estimated 4,000 cases of “retained surgical items— in other words, things accidently left inside patients’ bodies—reported in the United States.

The Department of Veterans Affairs did not immediately respond to a request for comment for this article.

Robert McDonald: Cleaning up the VA

Robert McDonald: Cleaning up the VA

The Secretary of Veterans Affairs tells Scott Pelley about his personal mission to reorganize the troubled agency for his fellow vets

VA Robert McDonald

The following is a script of “Cleaning up the VA” which aired on Nov. 9, 2014. Scott Pelley is the correspondent. Guy Campanile, producer.

Tomorrow, the day before Veterans Day, the new head of Veterans Affairs will announce the biggest reorganization in the history of the VA, which comes after the agency’s biggest fiasco.

It was last spring that we learned that tens of thousands of vets were waiting months for medical care while managers cooked the books to hide the delays. The former secretary was forced out. Tonight we have the first interview with the new man in charge. Sixty-one-year-old Robert McDonald has no government or medical experience but he does know management.

He was chief executive officer of Procter & Gamble, the largest consumer products company in the world. And we wanted to know how a soap salesman will go about cleaning up the VA.

Scott Pelley: How many employees do you think should be fired based on what you know?

Secretary McDonald: The report we’ve passed up to the Senate Committee and House Committee, has about 35 names on it. I’ve got another report that has over 1,000.

Scott Pelley: If 1,000 people need to go, give me a sense of what are some of the things that they did?

Secretary McDonald: We’re simplistically talking about people who violated our values.

Scott Pelley: And those values are what?

Secretary McDonald: It’s integrity, it’s advocacy, it’s respect, it’s excellence. These are the things that we try to do for our veterans.

But Bob McDonald can’t punish or fire a thousand people right now. He’s discovering how different the Capitol is from capitalism. To fire a government manager he has to put together a case and prove it to an administrative judge.

“I could not guarantee their safety in the middle of metropolitan Phoenix in my ER because we didn’t have adequate staffing or training.”

Secretary McDonald: Scott, the reason this is, reason this is okay in some respects is that…

Scott Pelley: A lot of people think it’s not okay…

Secretary McDonald: Well…

Scott Pelley: …that if people lied and put veterans second…

Secretary McDonald: That’s different.

Scott Pelley: …and their self first, they should be cleared out.

Secretary McDonald: Absolutely. Absolutely. But we’ve got to make it stick.

Scott Pelley: How do you mean?

Secretary McDonald: So we propose the action, the judge rules and the individual has a time to appeal that’s why we have a lot of people on administrative leave. We’ve moved them out because we don’t want any harm to our veterans.

[Volunteer: Bob I’d like you to meet my district commander.]

He’s been on the job four months and in that time he’s been getting an education. McDonald has inspected 41 VA facilities. We caught up with him in Boston, where we discovered that he refuses to be called “Mr. Secretary.”

[Woman: It’s so good to meet you Mr. Secretary.]

[Secretary McDonald: I’m Bob. Please call me “Bob.”]

His Washington staff can’t get their heads around calling the boss by his first name so they’ve taken to calling him “Secretary Bob.”

[Secretary McDonald: So you were with Patton in North Africa?]

[Volunteer: No, he was with me.]


He’ll need that sense of humor because McDonald is battling a behemoth cobbled together over decades. The VA is the second largest agency in the entire federal government behind only the department of defense.

Secretary McDonald: We have no hope of taking care of veterans if we don’t take care of each other.

She Engineered the VA Scandal – Now She’s Being Paid to Get Away With It

She Engineered the VA Scandal – Now She’s Being Paid to Get Away With It

Sharon HelmanSharon Helman is the former director of the notorious VA hospital in Phoenix, Arizona.

Under her watch, data was manipulated, wait times were expanded, and the average number of veterans being treated was greatly reduced.

According to the Concerned Veterans for America, Helman is “the poster girl for VA accountability.”

And that’s why it’s so shocking that ever since she was placed on administrative leave by the Obama administration,she continues to get paid.

You read that correctly.

Helman has been placed on a paid administrative leave — which is the equivalent of a long paid vacation.

Bear in mind that her actions while at the helm of the Phoenix VA are believed to be responsible for somewhere in the neighborhood of 40 preventable deaths.

As Concerned Veterans for America said:

It’s maddening, but true. Despite the fact that an Inspector General report and the VA’s own internal audit demonstrated that she pressured employees to falsify wait time data and punished Phoenix VA whistleblowers on numerous occasions, Sharon Helman is STILL on the VA’s payroll — on PAID ‘administrative leave.’

Even worse, the VA has been less than transparent about when — or even if — she will be disciplined at all. Sadly, the same is true for several other VA administrators that have been found to have engaged in misconduct.

This is how the Obama administration holds their employees responsible.

By rewarding them with lavish, taxpayer-funded vacations… rather than holding them responsible for their misdeeds.

There is no system of accountability.

There is no method to the madness.

It’s been well over three months since the scandal broke and taxpayers are still footing the bill.

This is why these upcoming elections are so incredibly important.

America needs strong, principled conservatives in office who will viciously root out corruption.

They need lawmakers who will stamp out mismanaged spending, so that taxes can be lowered and America can return back to its original ideology of self-determination and individual freedoms.

We can’t have bloated bureaucratic offices calling the shots any longer.

It’s time for real independence, real freedom.

And no one believes that more than those of us here at Tea Party Update.

Records show Obama met just once with Shinseki during VA scandal

Records show Obama met just once with Shinseki during VA scandal

President Obama touted the newly passed Veterans Affairs reform bill Thursday as he signed the measure into law and lamented the scandal that triggered it.

But a review of records by Fox News shows the president – despite the urgency he placed publicly on the crisis – only met one-on-one with then-VA Secretary Eric Shinseki once during the scandal.

The records, provided through a Freedom of Information Act request, showed they met on May 30, the day Shinseki resigned.

VA records show Shinseki also attended Cabinet meetings on Jan. 14 and Jan. 22.

The revelation comes as lawmakers, on the heels of passing the bill that Obama signed Thursday, press the president to commit his administration to fixing the department.

“I am pleased President Obama has finally recognized what we have been telling administration officials for years: that VA’s widespread and systemic lack of accountability is jeopardizing the health of veterans and contributing to all of the department’s most pressing problems,” Rep. Jeff Miller, R-Fla., chairman of the House Veterans Affairs Committee, said in a statement. “But I sincerely hope the president views this event as more than just a photo-op or speaking engagement.

“Instead, it should serve as a wakeup call. … In order to prevent history from repeating itself, President Obama must become personally involved in solving VA’s many problems.”

Over 40 veterans died on secret death listThe VA has confirmed that at least 35 veterans died while awaiting appointments at VA facilities in the Phoenix area, while 24 died at other locations blamed on delays in care.
Now that Shinseki is gone, there is pressure on new VA Secretary Robert McDonald to fix the systemic problems there.

To help, the president signed the $17 billion bipartisan compromise legislation designed to address some of the issues revealed during the scandal.

James Alderson - deceased Veterans Affairs VA died
James Alderson – deceased veteran who was on hidden list

Obama, during the signing ceremony, noted in addition to hiring new doctors and nurses, and allowing some veterans the ability to see private doctors, it will allow McDonald to fire incompetent senior executives.

“If you engage in an unethical practice, if you cover-up a serious problem, you should be fired period. It shouldn’t be that difficult,” the president said at the bill signing.  “And, if you blow the whistle on an unethical practice or bring a problem to the attention of higher ups, you should be thanked.”

Some veterans groups are emphasizing this is an important first step, but more work needs to be done.

“We are expecting [McDonald] to hold his senior leaders accountable. And in turn, that will roll down hill and his senior leaders will then hold mid-level managers accountable who will then hold employees accountable,” Louis Celli, legislative director at the American Legion, told Fox News in an interview.

And Pete Hegseth, with Concerned Veterans for America, expressed the concern that Washington will be eager to turn the page.

“Congress will be tempted to wipe their hands of this, go to the Election Day and say ‘we’ve done our part’ and that’s where groups like ours, Concerned Veterans for America, veterans across the country have to keep the heat on them to say this is just the start. VA is not fixed,” Hegseth said.

VA ‘Death List’: For whistleblowers, a bold move can be followed by trip to basement

VA ‘Death List’: For whistleblowers, a bold move can be followed by trip to basement

A VA worker in Phoenix experiences an old federal tradition

by Washington Post

VA Veterans Affair Death List Whistleblower
Paula Pedene, a former chief spokeswoman for the Phoenix Veterans Affairs hospital, works in the basement of the hospital, where her desk was relocated amid a misconduct investigation after she blew the whistle on the hospital’s director. (SAMANTHA SAIS)

On her 71st workday in the basement, Paula Pedene had something fun to look forward to. She had an errand to run, up on the first floor.

“Today, I get to go get the papers. Exciting!” she said. “I get to go upstairs and, you know, see people.”

The task itself was no thrill: Retrieve the morning’s newspapers and bring them back to the library of the Phoenix Veterans Affairs hospital. The pleasure was in the journey. Down a long, sunlit hallway. Back again, seeing friends in the bustle of the hospital’s main floor.

Then, Pedene got back in the elevator and hit “B.” The day’s big excitement was over. It was 7:40 a.m.

“I will not be able to do this forever,” Pedene said later that day.

Related: Veterans Turn Their Backs to Obama’s Motorcade

Pedene, 56, is the former chief spokeswoman for this VA hospital. Now, she is living in a bureaucrat’s urban legend. After complaining to higher-ups about mismanagement at this hospital, she has been reassigned — indefinitely — to a desk in the basement.

In the Phoenix case, investigators are still trying to determine whether Pedene was punished because of her earlier complaints. If she is, that would make her part of a long, ugly tradition in the federal bureaucracy — workers sent to a cubicle in exile.

In the past, whistleblowers have had their desks moved to break rooms, broom closets and basements. It’s a clever punishment, good-government activists say, that exploits a gray area in the law.

The whole thing can look minor on paper. They moved your office. So what? But the change is designed to afflict the striving soul of a federal worker, with a mix of isolation, idle time and lost prestige.

“I was down there in that office for 16 months. Nothing. They gave me no meaningful work,” said Walter Tamosaitis, a former contract worker at an Energy Department installation in Washington state.

Four years ago, he raised concerns about the processing of radioactive waste. Then he was transferred to a windowless room in the building’s basement.

“It was so lonely,” he said. One day, there was a big snowstorm outside. In the basement, the phone rang. It was his wife, who’d seen a TV report that his workplace had been shut down. He went upstairs: lights out. Doors locked. Nobody told him.

“I thought the Rapture had occurred,” Tamosaitis said. “And I said, ‘Well, [expletive]. I’m the good guy, it can’t be the Rapture. I should be gone, and they should be here.’ ”

A four-year punishment

In Phoenix, Pedene believes she is stuck in the basement now because of something she did four years ago.

At the time, she was a 20-year employee at the hospital who oversaw everything from news releases to the hospital newsletter to the annualVeterans Day parade. In 2010, Pedene joined a group that complained to VA’s upper management about the Phoenix hospital’s director. They alleged that the director had allowed budget shortfalls and berated subordinates.

And it seemed to work. VA’s inspector general investigated and found an $11 million shortfall in the hospital’s budget. The director retired voluntarily. “I felt we had actually done the right thing,” Pedene said.

But that turned out to be the beginning of her troubles, not the end.

Pedene said the hospital’s new leaders were still suspicious of her, since she’d made trouble for the old leader. In December 2012, she said, those new bosses accused Pedene of violating VA rules.

The chief accusation was that Pedene had let her husband upload photos of a VA-sponsored Veterans Day parade onto her work computer. He was helping her finish a PowerPoint presentation she was working on. He was a non-VA employee, working on a VA computer.

Pedene and her allies admit that this happened. (She was also accused of excessive spending, which she denies.) But they say her punishment has been far greater than the offense.

“They took her out from there like she’d sold nuclear secrets to the Iranians,” said Sam Foote, a former doctor at the Phoenix VA hospital, who had been an ally of Pedene.

While the allegation was being investigated, Pedene lost her BlackBerry, her e-mail address, her office and her position as spokeswoman. She was shifted, instead, to the hospital’s library.

Back then, the library was on the third floor. The library had windows. But not for long.

“They knew that it was moving to the basement,” Pedene said. In April, it did.

Today, the library is one room stuffed with bookshelves and computers. Pedene is a kind of backup receptionist there, sitting in the second desk that visitors get to.

“I used to be the first reception person,” she said. “Now I’m the second reception person. So my days are even more boring.”

That’s because the library’s visitors don’t really need that much help. Many of them are here to do personal business on the free computers and phone.

On one recent morning, for instance, a man at one computer was loudly doing a telephone interview. (“Occasionally, I’ll have a beer. But that’s it,” the man said. “No addiction. No felony.”) Another visitor said his truck had been stolen.

He wanted to borrow the library’s phone.

“If it’s not back today — in the yard and parked — those boys will be looking for you,” he said in one phone call. He seemed to be leaving a message to the actual truck thief, threatening to call the police.

Pedene’s role in all this is to log visitors onto the computers, help them make copies, and occasionally lend a stapler or a pencil. In her idle time, the wheels still spin. One day last month, she was constantly thinking about how she would be handling the hospital’s P.R. — if that were still her job.

The Facebook postings have been pretty poor lately, she said one day last month. And they’ve done nothing with the health observation calendar! Nobody has a clue that this is World Hepatitis Day, or Cord Blood Awareness Month.

“I don’t feel like I’m using the full potential that God has given me,” Pedene said. She is staying on in the basement because she thinks someday, the VA will let her out. “My goal is to be an awesome PR person for VA again,” she says.

A non-answer from the VA

So how does VA explain what has happened to Pedene?

Here, things turn slightly nightmarish. At the Phoenix hospital, a spokeswoman said she couldn’t answer the question.

“Why she was moved to the library was Ms. Helman’s decision,” said spokeswoman Jean Schaefer. She meant Sharon Helman, the hospital’s director from 2012 until this year.

Could Helman explain it, then?

The spokeswoman said no to that, too.

The reason was that this spring, Sam Foote — the doctor who was Pedene’s old ally — revealed an enormous scandal that occurred on Helman’s watch. Phoenix VA staffers were using bogus wait lists to hide the fact that patients were waiting too long for care.

Helman was put on leave, Schaefer said. She couldn’t be reached (Helman didn’t respond to an e-mail from The Washington Post).

So the person who forced Pedene out of her office has been forced out ofher office. Has anybody checked to see whether Pedene should get out of the basement now?

Schaefer said she couldn’t answer the question.

“Since these are personnel actions, we are unable to provide any comment,” she said in an e-mail.

A spokesman for the House Veterans’ Affairs Committee said the committee is looking into Pedene’s case — and so is the Office of Special Counsel, which is in charge of protecting federal whistleblowers. The Office of Special Counsel declined to comment, citing privacy rules.

Across the country, there are no reliable statistics about how often federal employees and contractors are sent into this kind of internal exile. In a 2010 survey, 13.7 percent of federal workers said they had personally been punished by their bosses, by being moved to a different “geographical location.” But the question was too broad. Its wording could include a relocation to the basement, or to North Dakota.

‘A long, rich tradition’

But activists who help whistleblowers say they’ve seen it happen again and again.

“There’s a long, rich tradition of exiling whistleblowers to dusty, dark closets, or hallways, or public spaces,” said Tom Devine, of the watchdog group Government Accountability Project.

He said that, in many cases, the new, bad office is close enough to the old, good office that the person’s colleagues see what’s become of them. “The bureaucratic equivalent of putting a whistleblower in the stocks,” Devine said.

In the 1980s, for instance, Air Force chemist Joseph Whitson testified in a military court about mismanagement in his office. When he got back to work, he was given a new job in a basement: dusting file cabinets and sweeping the floor.

More recently, Sen. Charles E. Grassley (R-Iowa) has drawn attention to the case of Robert Kobus, an FBI employee who complained that agents were entering false information into the FBI’s time-and-attendance system. Grassley said that in 2005, Kobus was moved to a cubicle on an otherwise vacant floor of an FBI building in New York. Kobus’s own attorney declined comment on the case.

In theory, it is illegal to make the basement into a bureaucratic purgatory. In 1994, for instance, Congress prohibited agencies from making significant changes in a whistleblower’s “working conditions” as punishment for speaking out.

But in practice, the situation is murkier. Some courts have said moving an employee to a basement or closet usually amounts to punishment. But others have said this is a decision that should be made case by case. How nice is the basement office? How big is the closet?

“To get a lawyer to take your case, you need to have damages. And the damages for that kind of claim, standing alone — it just wouldn’t be a great case to bring in court,” said Sandra Sperino, a University of Cincinnati law professor who has studied this kind of scenario.

“If you’re fired, you might be able to get damages for your lost income. There may be some damages for getting moved to the basement or a dingy closet, but they’re minimal.” She said a lawyer’s best bet would be to seek punitive damages, or compensation for emotional distress.

Back in the basement of the Phoenix hospital, Pedene’s day unspooled slowly. Somebody asked her how to repair his home printer. Someone needed help printing a résumé. Somebody needed her to look up Home Depot in the phone book.

“What can you do?” a woman in a doctor’s coat asked Pedene, inquiring quietly about her situation.

“Nothing,” Pedene told her. “Just hope it gets better.”

This was a rare good moment: a friend who’d ventured downstairs into the hospital basement. But eventually, the friend revealed why she was there.

“But anyway,” she said, “I’m looking for a copy machine.”

Lawmakers Reach Deal on VA Reform

Lawmakers Reach Deal on VA Reform

by Bryant Jordan, military.com

VA Healthcare

Key House and Senate lawmakers have reached a deal that promises to end the partisan battle that late last week threatened to derail plans to get a Department of Veterans Affairs reform bill passed before Congress adjourns for the summer.

Sen. Bernie Sanders, I-Vermont, and Rep. Jeff Miller, R-Florida, who co-chair a legislation conference committee, will announce Monday “that an agreement has been reached to deal with both the short-term and long-term needs of the VA,” Sanders spokesman Michael Briggs said.

Sanders serves as chairman of the Senate Veterans Affairs Committee and Miller chairs the House Committee on Veterans Affairs.

Offices for both lawmakers released announcements on Sunday saying the two had worked through the weekend and made “significant progress” on legislation intended to hold the VA more accountable and recruit more doctors, nurses and other healthcare professionals.

The two sides have agreed to add $15 billion in emergency mandatory spending to the legislation, according to CQ Roll Call, which got hold of a summary of the agreement. The amount includes $10 billion to enable vets to get care from private providers and $5 billion to hire medical staff and upgrade facilities.

On Friday, Miller proposed $10 billion in emergency funding. Sanders had wanted $17.6 billion, a figure requested by Acting VA Secretary Sloan Gibson earlier this month.

In recent months, VA investigations prompted by whistleblower complaints have confirmed that the department has for years fallen far short of providing timely access to care for thousands of veterans. The investigation also confirmed systemic manipulation of patient data and secret appointment wait lists intended to conceal the scope of the problem.

Lawmakers have threatened to pursue criminal charges against VA officials after investigations found dozens of veterans have died while waiting for care.

The Senate and House in June passed bills intended to hold officials accountable, to include making it easier to fire problem executives and improve access to care by enabling more veterans to go outside the VA.

Lawmakers from the House and Senate veterans’ committees began conferring to come up with a single bill that could pass, but the work stalled, in particular over the $17.6 billion that Gibson said was needed to resolve the access problem.

Miller and other GOP lawmakers, as well as some veterans groups, said the VA offered no substantive documentation to back up the $17.6 billion figure.

Late last week, both Sanders and Miller released separate proposals for final legislation — Miller during a hastily called conference committee meeting that only Republicans attended and Sanders during a press conference attended by Democrats.

As the talks fumbled into bickering, there was concern that no deal would be reached before Congress goes on summer break.

VA: Sorry about retaliation against whistleblowers

VA: Sorry about retaliation against whistleblowers

James Tuchschmidt, a top official of the Veterans Health Administration, the VA's health care arm, during opening statement while testifying before a House Veterans' Affairs
James Tuchschmidt, a top official of the Veterans Health Administration, the VA’s health care arm, during opening statement while testifying before a House Veterans’ Affairs Committee hearing on Capitol Hill in Washington, Tuesday, July 8, 2014  AP

WASHINGTON — A top official at the Veterans Affairs Department says he is sorry that VA employees have suffered retaliation after making complaints about poor patient care, long wait times and other problems.

James Tuchschmidt, the No. 2 official at the Veterans Health Administration, the VA’s health care arm, apologized on behalf of the department at a congressional hearing Tuesday night.

“I apologize to everyone whose voice has been stifled,” Tuchschmidt said after listening to four VA employees testify for nearly three hours about VA actions to limit criticism and strike back against whistleblowers. “That’s not what I stand for. I’m very disillusioned and sickened by all of this.”

A federal investigative agency said Tuesday it was examining 67 claims of retaliation by VA supervisors against employees who filed whistleblower complaints — including 25 complaints filed since June 1 — after a growing health care scandal involving long patient waits and falsified records at VA hospitals and clinics became public.

The independent Office of Special Counsel said 30 of the complaints about retaliation have passed the initial review stage and were being investigated further for corrective action and possible discipline against VA supervisors and other executives. The complaints were filed in 28 states at 45 separate facilities, Special Counsel Carolyn Lerner said.

Instead of using information provided by whistleblowers as an early warning system, the VA often “has ignored or attempted to minimize problems, allowing serious issues to fester and grow,” Lerner told the House Veterans’ Affairs Committee hearing. Worse, officials have retaliated against whistleblowers instead of investigating their complaints, she said.

Lerner said her office has been able to block disciplinary actions against several VA employees who reported wrongdoing, including one who reported a possible crime at a VA facility in New York.

The counsel’s office also reversed a suspension for a VA employee in Hawaii who reported seeing an elderly patient being improperly restrained in a wheelchair. The whistleblower was granted full back pay and an unspecified monetary award, and the official who retaliated against the worker was suspended, Lerner said.

The VA said earlier Tuesday it was restructuring its Office of Medical Inspector following a scathing report by Lerner’s agency last monthscathing report by Lerner’s agency last month.

Acting VA Secretary Sloan Gibson said the department would appoint an interim director of the medical inspector’s office from outside the current office and was suspending the office’s hotline immediately. All complaints would be referred to the VA’s Office of Inspector General.

The head of the medical inspector’s office retired June 30 following a report by the Office of Special Counsel saying that his office played down whistleblower complaints pointing to “a troubling pattern of deficient patient care” at VA facilities.

“Intimidation or retaliation – not just against whistleblowers, but against any employee who raises a hand to identify a problem, make a suggestion or report what may be a violation in law, policy or our core values – is absolutely unacceptable,” Gibson said in a statement. “I will not tolerate it in our organization.”

A doctor at the Phoenix veterans hospital, where dozens of veterans died while on waiting lists for appointments, said she was harassed and humiliated after complaining about problems at the hospital.

Dr. Katherine Mitchell said the hospital’s emergency room was severely understaffed and could not keep up with “the dangerous flood of patients” there. Mitchell, a former co-director of the Phoenix VA hospital’s ER, told the House committee that strokes, heart attacks, internal head bleeding and other serious medical problems were missed by staffers “overwhelmed by the glut of patients.”

Her complaints about staffing problems were ignored, Mitchell said, and she was transferred, suspended and reprimanded.

Mitchell, a 16-year veteran at the Phoenix VA, now directs a program for Iraq and Afghanistan veterans at the hospital. She said problems she pointed out to supervisors put patients’ lives at risk.

“It is a bitter irony that our VA cannot guarantee high-quality health care in the middle of cosmopolitan Phoenix” to veterans who survived wars in Iraq, Afghanistan, Vietnam and Korea, she said.

Scott Davis, a program specialist at the VA’s Health Eligibility Center in Atlanta, said he was placed on involuntary leave after reporting that officials were “wasting millions of dollars” on a direct mail marketing campaign to promote the health care overhaul signed by President Obama. Davis also reported the possible purging and deletion of at least 10,000 veterans’ health records at the Atlanta center. More records and documents could be deleted or manipulated to mask a major backlog and mismanagement, Davis said. Those records would be hard to identify because of computer-system integrity issues, he said.

Rep. Jeff Miller, R-Fla., chairman of the House veterans panel, praised Mitchell and other whistleblowers for coming forward, despite threats of retaliation that included involuntary transfers and suspensions.

“Unlike their supervisors, these whistleblowers have put the interests of veterans before their own,” Miller said. “They understand that metrics and measurements mean nothing without personal responsibility.”

Rather than push whistleblowers out, “it is time that VA embraces their integrity and recommits itself to accomplishing the promise of providing high-quality health care to veterans,” Miller said.