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?    

How to Buy a Vision Pt. 2

In part 1, I wrote of President Barack Obama’s appointment of General Eric Shinseki as Secretary of Veterans Affairs in 2009.  General Shinseki’s vision allowed the current RTLS initiative to come to the forefront.  

I indicated that federal regulations could hinder the VHA’s approach.  Specifically, I stated that guidance may be taken as mandates to ensure that the solicitation is written in accordance with the law. 

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Before I re-familiarized myself with acquisition law, I examined documents as far back as the mid-80s. The reports reflected investigative findings from Quality Programs and Supply Distribution and Processing inspections by the General Accounting Office and the Veterans Inspector General’s Office. 

For example on June 27, 1985, the General Accounting Office published GAO/HRD 85-57,  VA Has Not Fully Implemented Its Health Care Quality Assurance Systems.  Senators Frank Murkowski, Alan Cranston, and Alan Simpson set the investigations into motion.  These 3 Senators were mentioned by name or signed the letters requesting the investigations.   The mission was quite clear.  Senator Simpson wrote December 21, 1983:

    I am writing as Chairman of the Senate Committee on Veterans' Affairs to request that the General Accounting Office review the Office of Medical Inspector and Evaluation which was established July 30, 1981, by the Administrator of Veterans' Affairs to monitor and report on the quality of care within the Department of Medicine and Surgery - Appendix I

The GAO’s mission was further described as to determine if facilities had implemented quality programs that included five mandated quality assurance functions.  The GAO team visited 13 facilities that represented a “cross-section” of the VA Medical Facilities. - Page i

The inspectors from the GAO wrote of very methodical approaches in all instances.  The inspectors went as far as looking into budgets, those who had external oversight of the quality programs, explanations of how the program should work and who had organizational responsibility.  The findings were clear and often very detailed.  

There were not many outright recommendations in this reports.  The inspectors’ comments are woven into each chapter.
  
One thing I find particularly interesting, the detail of the 2nd request coming from the Senate Committee.  The 1st request, December 21, 1983, shows a very general request.  The 2nd request, September 6, 1984, contained very detailed areas in which the GAO was requested to review - 22 bullets, some with multiple questions.  Either the Senators understood or a staffer understood what should have been happening.  It was probably both.  More can be found in The Veterans Administration RTLS, Recommendations for Success 

It's Official! VA118A-12-RP-0118, IBM Bid Protest Sustained

IBM-U S Federal
Solicitation Number: VA118A-12-RP-0118
Agency: Department of Veterans Affairs
File Number: B-406934.3  Outcome: Sustained  Date Decided: Oct 3, 2012

IBM-U S Federal
Solicitation Number: VA118A-12-RP-0118
Agency: Department of Veterans Affairs
File Number: B-406934.2  Outcome: Sustained  Date Decided: Oct 3, 2012

IBM-U S Federal
Solicitation Number: VA118A-12-RP-0118
Agency: Department of Veterans Affairs
File Number: B-406934.1  Outcome: Sustained  Date Decided: Oct 3, 2012

I found articles listing the GAO's (General Accounting Office) recommendations for courses of action but I haven't seen any documentation directly from the VA. 

Update 20 Sep 21012, VA RTLS - Protest of Solicitation# VA118A-12-RP-0118

Here is a portion of the statement I received from the Vetaran's administration.  "FOIA Exemption 5, [5 U.S.C. § 552 (b)(5)], which protects from disclosure all inter-agency or intraagency memorandums or letters which would not be available by law to a party other than an agency in litigation with the agency."

Basically, they are saying I can't have the information.  The letter goes on to say that it is not within the function of the Veterans' Office of the Freedom of Information Act to provide other than copied documents and I can't have that either. 

I was referred to the General Counsel's office.  My rebuttal was pretty simple.  What is asserted as not in compliance with the regulations?

Even in matters of national security or Security and Exchange Commission violations, we can know the charges.  Not that anyone broke the law.  If the protest claims that some function within the regulation was not followed, we should be able to obtain that right?

I am putting together the information that the General Counsel requires. What do you think? For a bid protest, should the public have access to the information about specific regulations a plaintiff says the government did not follow?