Clipping 4, 1985 Problems with Quality Assurance Program and Infection Control

#NewSameProblem

Microsoft Office Clip Art

Another clipping from - the VA Office of the Inspector General report, 1985, is the earliest internal documentation I found on the escalating cyclical threat of horrible outcomes at some facilities.  The cycle shows that policies were in place to guide processes that help radiate consistently good outcomes throughout all facilities.  Here is an excerpt mentioning one of those policies.

     “Infection control review determines the trend and extent of hospital-related infections, proposes corrective actions, when appropriate, and should ensure that exposure to such infection is minimized.” Chapter 2 page 6

Yet, the inspectors noted that no data, trends, or standards were developed in some facilities.  This included monitoring problems with surgeries.  A chart on the 24^th page (pdf) of the Inspector General Report shows that 8 of the 13 hospitals inspected complied with the infection control QA program. 

There are plenty of direct statements by inspectors that show different interpretations and complete misinterpretations of policy by VA Medical Center Directors.   Weaknesses in consistent oversight exacerbated the problem.  In the case of infection control programs, one can see how different interpretations developed.  It is downright hard to see how the policy could have been misinterpreted as not requiring any activity whatsoever. 

The implications of having no program are:

- Even if an infection occurred in the patient, it may have gone unreported.

- The process was meant to drive down infection rates but in some cases there was no process in place to determine the actual infection rate.  If infection rates are neither monitored nor driven down, they probably rise. 

- Leap forward to 2010.  This gives a quick look at how horrible this situation may have been in 1985.  In 2010, the VA announced that it may have infected over a thousand patients with infectious diseases.  As awful as it was, the VA centered on the causes, tracked the cases, and responded.  The 1985 report certainly points to the possibility of even more dangerous incidents may have occurred.  And it could have happened without even so much as the ability to become aware of it.    

Back to the report:

    Infection control review determines the trend and extent of hospital-related infections proposes corrective actions when appropriate – This was not tracked. There was no corrective action because no need could be identified.

    And should ensure that exposure to such infection is minimized.  - No clue of the infection rate exited.  There was no adherence to the policy or process.  Nothing was minimized.  The infection rates probably rose.

The repetitiveness of this blog post is purposeful.  Then so is the entire matter… repetitive… new leader, same problems.  Final words for this blog post, in 2 questions.

-  What would you do if you had been treated at a hospital that had no clue of whether it infected customers and were not doing anything to find out?

-  What kind of culture has to develop to perpetuate this type of failure?