VA Secretary to Delegation: Correcting Marion VA Failures is a Department Priority

High-level Quality Management team will assess need for further action, report back to Delegation in December

[WASHINGTON, D.C.] – The Secretary of the Department of Veterans Affairs (VA), General Eric Shinseki, today assured members of the Illinois Congressional Delegation that correcting the failures at the VA Medical Center in Marion, Illinois identified in a report by the Office of the Inspector General (OIG) is a priority for the VA and a high level Quality Management team will be sent to the facility to assess the need for further action. Shinseki vowed to report back to the Illinois Delegation with the team’s findings in about six weeks.


On Monday, U.S. Senators Dick Durbin (D-IL) and Roland Burris (D-IL) and Congressmen Jerry Costello (D-IL) and John Shimkus (R-IL) called for a meeting with Shinseki after reviewing the OIG’s report by calling the failure of leadership at the Marion facility to meet VA patient safety and quality care guidelines both “appalling” and “inexcusable”. Congresswoman Debbie Halvorson (D-IL) and Illinois Governor Pat Quinn also attended today’s meeting.


“After two years and nine deaths due to substandard care, the same problems at the Marion VA still exist,” said Durbin. “To deal with this, General Shinseki has made a change in leadership at Marion and called in a Quality Management team to immediately assess the medical center from top to bottom. He assured us that this is a priority. When we promise our veterans we will stand behind them when they come home, we must stand behind them with the very best medical care. We owe it to veterans and their families in Marion to correct the problems at the VA Medical Center as quickly as possible.”


“After an informative and productive meeting this morning, I have confidence that Secretary Shinseki shares our deep concerns over this matter, and is committed to taking immediate steps to restore the high level of quality care that our veterans deserve,” said Burris. “I will continue to closely and personally monitor the progress of improvements in Marion, and to work with Secretary Shinseki, fellow members, and my colleagues on the Senate Committee on Veteran’s Affairs to make sure that the needs of Illinois’s veterans are met.”


“I feel confident that Secretary Shinseki has a plan to address the issues that still exist at the Marion VAMC,” said Costello. “It is clear that the processes in place to ensure quality care need revision and greater attention. We will continue to push the VA to make sure that our veterans are getting the finest quality care.”


“We had a very good meeting with the secretary,” said Shimkus. “I have known him since I was his student at West Point, and I trust him. I believe he will do whatever is needed to rectify the problems at Marion.”


“Our veterans have sacrificed so much for us, we owe it to them to provide them the best care possible,” said Halvorson. “As the lone representative from Illinois on the House Veterans Affairs Committee, I will continue to fight for our veterans through my work in the committee and working with my fellow delegation members.”


In its report issued on Monday, the OIG reviewed the period between October 2007 and August 2009 under the Combined Assessment Program, which includes recurring evaluations of health care facilities focusing on patient care and quality management. Many quality management failures that were found during previous reviews were identified in this most recent review including lack of sufficient oversight fragmented and inconsistent reporting structure, inadequate peer review, failure to meet mortality screening requirements, and failure to integrate the patient safety program into all areas of the medical center. Additionally, the OIG identified new problems in records review, patient data analysis, staff life support certifications, compliance with environmental standards, and medication management.


In some cases, the IG found that medical personnel at the Marion facility performed procedures for which they did not have proper privileges and safety guidelines involving patient health were routinely ignored.


Following the release of the report, the VA announced that the current Director of Marion VA Medical Center has been replaced by Mr. James Roseborough, former Director of the regional Veterans Integrated Service Network (VISN) 12, and that a new quality management team at Marion will be led by Dr. Luke Stapleton, Chief Medical Officer for VISN 7.


Poor leadership and communication led to serious problems at the Marion VA Medical Center in 2007, including surgical malfeasance associated with the deaths of nine veterans. The VA reassigned five individuals, including the Marion facility’s director, chief of staff, and chief of surgery, to non-clinical areas after concerns about the quality of patient care at the facility arose. Various reviewers from the Veterans Health Administration, Office of Health Inspection, and Office of Inspector General, have identified concerns with quality management and deficiencies in medical center leadership. Many of these reviews have focused on oversight of quality management processes and, compliance with policies designed to ensure patient safety.