The VA is linking 19 deaths in the past two years to poor health care at the veterans' hospital in Marion, Illinois. (See http://www.usatoday.com/news/nation/2008-01-28-illinois-hospitaldeaths_N.htm for details.) According to USA Today, "The hospital undertook many surgeries that its staffing or lack of proper surgical expertise made it ill-equipped to handle, and hospital administrators were too slow to respond once problems surfaced," according to Dr. Kussman (emphasis added).
It's a little late, but the VA investigated thoroughly and here are some appropriate actions and statements that make the agency worthy of compliment:
- I love Dr. Kussman's quote. "I can't tell you how angry we all are and how frustrated we all are. Nothing angers me more than when we don't do the right thing." He accepts responsibility for overlooking a serious problem and expresses agency and personal outrage. He added another good point later when emphasizing that what happened in Marion isn't at all typical of other VA hospitals.
- The VA will help victims' families file claims under the VA's disability compensation program. The agency isn't sitting back. It's helping alleviate the burden on these families. For a 180-degree-different approach, see the Sierra Pre-Filled thread elsewhere in this blog.
- The hospital suspended inpatient surgeries in August when problems first came to light, and Dr. Kussman said they'll remain suspended indefinitely. Good for you! Make sure the problem is fixed and you can credibly assure patients that what happened before can't happen again. If you work at a production facility, don't be in a hurry to come back on line after a crisis shuts you down. Take a small financial hit now instead of a potentially large hit later. Get it right.
- The VA started an administrative investigatory board to review care at the hospital and follow up on issues and concerns raised by employees. That's a great move! If the hospital had heeded the employees' caution flags, which almost always are waved before a problem goes crashing into the rail, it might have averted the crisis and, more important, saved some lives. Listen to employees. Take their concerns seriously. No one knows your organization's weak spots better than the employees working in the pit.
- Last September, the VA responded quickly to the crisis by replacing the Marion VA's director, chief of staff, chief of surgery and an anesthesiologist. Kussman assured, "The previous leadership will not return (to their former jobs)." In addition, hospital officials apparently didn't bother checking the references of one of the key surgeons whose skills are suspect. According to USA Today, "The Marion VA hired (the surgeon) in January 2006 after he practiced in Massachusetts, where he was under investigation for substandard care in 2004 and 2005. The claims include allegations that he botched seven cases, two ending in deaths." That's information that shouldn't have been too hard for HR to uncover.
- Spokespersons with the Marion VA referred reporters' calls to the agency's headquarters in Washington. That means the VA was still answering the phone in Marion instead of hiding. And it means the national VA is controlling the flow of official information to ensure a single consistent response to reporters.
If you want a good example of how not to deal with a smoldering crisis, may the item posted below be a reminder to you.