November 6, 2007 – Today, U.S. Senator Barack Obama (D-IL) submitted the following statement for the Senate Veterans’ Affairs Committee hearing on “Hiring Practices and Quality Control in VA Medical Facilities.” He specifically addressed the issue at the Marion, Illinois VA Medical Center, which saw an increased number of patient deaths over the last months and was found to have employed a surgeon who had been barred from practicing in another state.
Obama, along with Senator Dick Durbin, has repeatedly pressed the VA for information on the situation in Marion. The senators sent a letter to Acting Secretary of Veterans Affairs Gordon Mansfield asking additional questions that were raised by the VA’s response, in regard to the unexpected deaths, other patient safety events and the credentialing process for VA doctors. Previously, the senators wrote outgoing Secretary of Veterans Affairs Jim Nicholson asking specific questions about the VA’s response to the increase in deaths at the center.
They also asked why Dr. Jose Veizaga-Mendez, who had been barred from practicing in another state, continued to practice at the Marion VA Center until August, and asked about the background check performed before he was hired. This followed a previous letter to Secretary Nicholson, sent by Durbin and Obama, asking for more information on the ongoing investigation.
Obama has also joined Durbin in calling on the U.S. Attorney’s office to investigate allegations of criminal wrongdoing at the Marion VA.
Below is Senator Obama’s statement to the Committee, which is submitted for the hearing record:
“Senator Durbin and I have worked to get to the bottom of what went wrong at the Marion facility – and many questions still remain. We will keep fighting for answers, not only for our veterans and those families who have lost a loved one, but for all who have been affected by this loss. That is part of keeping our sacred trust to these true American heroes.
“While some may argue that the problems at Marion were isolated, I have serious concerns that medical errors, including fatal errors, may have occurred because of more systemic failings in the VA’s quality safeguards. GAO testimony about weak internal controls over privileging and physicians practicing with expired privileges in at least one VA facility strongly suggest that this problem may be more widespread. We have asked important questions about the VA’s medical credentialing and privileging process, and I hope that Dr. Cross, the Principal Deputy Under Secretary for Health, can provide evidence today as to whether the VA views its current process as adequate. If not, he owes us answers about what he is doing today to improve the process.
“We also need to address the VA’s quality measurement tracking system. The data analysis that flagged the spike in unexpected deaths at the Marion facility – which was part of the National Surgical Quality Improvement Program (NSQIP) – triggered action almost six months after the period in which that death rate was observed. When we are talking about the quality of care and safety of our veterans, we cannot wait six months to be alerted to and start investigating a tragedy like this one. We must have safeguards that would flag any problems much more quickly and accurately.
“Furthermore, we still have not yet been able to confirm how many of the deaths from April – September 2007 were unexpected at the Marion VA, and I urge Dr. Cross to provide that answer today. This is an important question because doctors who have since been dismissed were still authorized to operate during this time period.
“Last week, allegations of serious misconduct and possible criminal wrongdoing were presented to my office by a group of current and former VA employees. These allegations must be thoroughly investigated, not only by the Office of the Inspector General, but by the U.S. Attorney’s Office. If true, they reinforce the failure in oversight from the VA Health Administration of facilities across the country. When VA employees seek to report a medical error or a problem with the management, they must have protected avenues to do so.
“The majority of VA health staff perform their jobs with exceptional competence and compassion on a daily basis. They do not have an easy job. And they are the first to agree that our veterans deserve world-class medical care. So today, the VA must show us how they will put air-tight quality controls in place to anticipate and catch problems before they turn into tragedies.”