MARION, IL - VA officials paint a picture of improvement, while a report from the Inspector General finds several problems that need immediate attention.  The report released Monday finds inconsistencies with reporting deaths and problems with patient safety, including surgeons performing two procedures they were not authorized to perform.

Hospital officials say they just hired Acting Chief of Staff Dr. Alan Cohen start Sunday.  James Roseborough is the new Interim Marion VAMC Director, following Warren Hill's departure 18 months after arriving at the Marion facility.

VA leaders say hospital staff and patients are much more pleased with the care they receive now versus surveys taken in 2007 and 2008.  Nine patient deaths were directly linked to substandard care between October 2006 and March 2007; substandard care was a contributing factor in the deaths of another ten patients during the same period.  Then, the Chief of Staff, VA Director and Chief of Surgery were removed from the facility.

According to the Inspector General's report, problems at the facility were wide-ranging.  For example, three sets of documents showed three different death totals for April 2009.  The report also reveals outdated staff training and patient data analysis.

"It is inexcusable that after more than two years of adjustments and reviews, Marion VA is still failing our veterans in quality of care," Sen. Dick Durbin, D-Illinois, says.

VISN 15 Network Director James Floyd says the Marion VAMC has already corrected eight of the ten issues the report uncovered.  He says the remaining two are expected to be corrected within the next two weeks.

"Particularly troubling to me is the fact that VISN does not appear to be aware of what is going on at the facility," Rep. Jerry Costello, D-Illinois, says.  "we need to know what the VA is going to do to solve these problems and restore the confidence of our veterans--it is not enough to simply say the VISN Director needs to ensure compliance, as this hasn't worked to this point."

Marion VAMC leadership maintain they are on their way to restoring inpatient surgeries.  The problem now is getting the surgeons and support staff they need in a timely manner.

"It does take some time, but we feel that time is well worth it that we spend on the front end to make sure we have qualified people come into our facilities," VISN 15 Network Director James Floyd says.

The Department of Veterans Affairs adopted new hiring practices after they found a surgeon at the Marion VA Medical Center had his license pulled in another state, and whose negligence contributed to the death of several patients.

To read the entire Inspector General's Report for yourself, click here.

Letter from Illinois lawmakers to Veterans Health Administration:

November 2, 2009

The Honorable Eric K. Shinseki

Secretary of Veterans Affairs

Department of Veterans Affairs

810 Vermont Ave., NW

Washington, DC 20420

Dear Secretary Shinseki:

We write with great concern regarding the Combined Assessment Program Review of the Marion Veterans Affairs Medical Center (Marion VAMC), Marion, Illinois, released today by the Department of Veterans Affairs Office of Inspector General. 

The Inspector General’s report indicates that patient safety and quality care management at the Marion VAMC once again has fallen short of VA standards and guidelines. Simply put, we find this situation appalling.

We would like to meet with you as soon as possible to discuss how to dramatically change course and return the quality of care at Marion to the highest standards.  In the meantime, it is clear that those in the direct line of command in VISN 12 and at the Marion facility have again violated the public’s trust and should be relieved of their duties until serious questions over management can be answered.

It is our understanding that you have taken some initial steps to replace Marion VAMC leadership.  However, since the problems at Marion have continued through multiple Department reviews and endured previous personnel changes, we believe you must take more comprehensive and immediate action to ensure the quality of care for veterans and their families.

Problems in the quality of care at Marion VAMC date to at least 2006.  Since that time, the Veterans Health Administration, Office of Health Inspection, and Office of Inspector General have all identified concerns with patient safety, quality of care and deficiencies in medical center leadership.  We have been told time and again that various elements of the VA were closely monitoring the situation and that appropriate steps were being taken to rectify the problems. And yet, nearly three years later, this IG report has uncovered serious problems that raise alarm bells.

In this most recent review, the Office of the Inspector General (OIG) reported many quality management failures that were found during previous reviews.  These include lack of sufficient oversight and 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.  In addition, the OIG identified new problems in records review, patient data analysis, and identification of staff needing to maintain life support certifications.

We have been deeply concerned about the quality of care at Marion since news of problems first surfaced and the deaths of nine veterans were attributed to surgical malfeasance two years ago.  We have visited the facility, as have our staffs, over the past two years.  We also periodically questioned Marion and VA’s Washington office personnel regarding the status of the surgery program and quality management processes at the facility.  We are deeply disappointed that yet another report identifies entrenched and serious problems at Marion VAMC.  This level of care is unacceptable; the problems must be rectified and they must be rectified now.

Because we know that you are deeply concerned about the safety of veterans entrusted to your care, you must be as outraged as we are about this latest report.  We need to hear the VA's plans to ensure that veterans treated at Marion VAMC are safe and receiving the highest quality of care. They deserve nothing less.

We look forward to working with you to address the serious issues at Marion VAMC.

                                                                        Sincerely,