"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," U.S. Sens. Dick Durbin and Roland Burris and U.S. Reps. John Shimkus and Jerry Costello said in a letter to the Secretary of Veterans Affairs.
"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 (Veterans Integrated Service Network) 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."
The Inspector General's review covered five operational activities at the medical center, making compliance recommendations in four of those areas including quality management, physician credentialing and privileging, environment of care and medication management.
The center complied with selected standards in the fifth activity, which was coordination of care.
According to the report, the center had continued problems with mortality assessment, a patient safety program, outdated staff training, patient data analysis and peer review.
For example, three sets of documents showed three different death totals for April 2009.
Some of the findings are repeated from previous evaluations, although VA officials said steps have already been taken or are under way to make improvements at the hospital.
James Floyd, VA regional network director, spoke at a news conference in Marion shortly before the report was released to the public.
He said of the report's 10 findings, eight were already remedied, while the other two would be within the next two weeks.
He also announced the imminent departure of Marion director Warren Hill, who has taken a position in Wisconsin.
Hill has overseen operations at the Marion facility for the past 18 months and did "a terrific job here," Floyd said.
Retired VA employee James Roseborough will act as director for a period of one year, Floyd said, while a search for a long-term director is conducted.
Changes at the facility can't come fast enough for the lawmakers, who said care of the nation's veterans is a health care priority.
"This report from the VA Inspector General is shocking and must be addressed immediately," Costello said. "It is absolutely unacceptable that many of the quality management issues we learned about over two years ago have not been addressed. Particularly troubling to me is the fact that the VISN does not appear to be aware of what is going on at the facility. 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. This situation needs to have the full attention of VA leadership - that is why we are asking for a response directly from Secretary Shinseki - and additional senior staff changes at Marion must occur. Obviously, this must be the top priority of the new facility director."