Legion focuses attention on VHA patient safety

Following a series of scandals in the Veterans Health Administration (VHA) involving patient safety, the House Committee on Veterans’ Affairs (HVAC) conducted a hearing Sept. 9 in Pittsburgh where an outbreak of the Legionella bacterium claimed the lives of at least five patients in the VHA medical system in the past year.

Chairman Jeff Miller of Florida opened by stating that he was not in Pittsburgh "for a witch hunt" but nevertheless relentlessly hammered VHA officials for a lack of accountability over a series of patient safety incidents at facilities across the country that have resulted in multiple patient deaths, injuries and misdiagnoses.

At issue were the substantial bonuses paid to VHA executives, including a $63,000 bonus for the director of the Pittsburgh Veterans Integrated Service Network during the time when at least five veterans died from Legionella infection and at least 16 others became seriously ill. In addition to Pittsburgh, the hearing addressed problems in the Atlanta region where veteran suicide was near epidemic proportions amid questions about how mental health was being dealt with; problems in Buffalo, N.Y., where whistleblowers decried a "total disregard for veterans’ health;" and Jackson, Miss., where a pattern emerged of misdiagnoses, improper blood transfusions and a lack of sterilization of medical instruments.

Dr. Robert Petzel, VA’s undersecretary for health, offered "sincere apologies" yet cited ongoing investigations for the apparent lack of public discipline for any senior officials in responsible positions in the health care system. Petzel insisted VA was following the guidance of the Office of the Inspector General in its handling of the situations.

The American Legion was the only veterans’ service organization to provide testimony for the hearing, in written form as the witness list was deliberately limited by the committee to government officials and victims of the tragedies. The Legion testimony reflected a belief these incidents were not yet systemic within the VHA system, which System Worth Saving visits still find to be overall excellent care for veterans, but that without disciplinary action for responsible individuals, these isolated incidents could grow into more serious problems. At the root of the situation, the testimony noted, "It has been 338 days for the veterans of Pittsburgh and two things are certain: five veterans are still dead, and the public has not seen any consequences for the leadership failures that led to those deaths."

The American Legion testimony further noted that all regions where problems had been identified had been targeted for future System Worth Saving visits in the coming year to determine whether patient safety errors had been satisfactorily rectified in the aftermath of the revelations.

In other news:

Congressional testimony: National Commander Dan Dellinger testified before a joint hearing of the House and Senate Veterans’ Affairs committees on Sept. 10 in the Dirksen Senate Office Building. The Legion’s written testimony can be downloaded.

VA’s FDC program investigated: The Disability and Memorial Affairs subcommittee of the House Committee on Veterans’ Affairs conducted a hearing Sept. 11, to examine the Department of Veterans Affairs implementation of the Fully Developed Claims (FDC) program. The FDC program allows veterans, who provide all of the necessary information to decide a claim up front, a reduced decision wait time by cutting out long periods where VA employees "develop" the necessary information needed to decide the claim. Whereas the typical wait time for a decision under VA’s regular system can be 400 days or more, the decision times in the FDC program average just over 100 days, and could be low as 90, 60, or in rare cases, just over 30 days to complete a claim.

Verna Jones, The American Legion’s director of Veterans Affairs and Rehabilitation Division (VA&R), testified before the committee regarding what the Legion has found after nearly a year of intensive study of the program. For the past year, our organization has worked in partnership with the White House and Joining Forces to promote and better understand the FDC program. During that time, VA&R staff conducted week long, intensive site visits to eight VA Regional Offices (VAROs) to evaluate how the program was working in the field, as VA Central Office (VACO) conception from Washington, D.C., can often differ from actual implementation in the field.

Jones noted, "I’m excited about FDC because this program can be a great example of what happens when all the stakeholders – the veterans, VSOs, VA and Congress – all get together on the same page and work to put the veteran first." The director further noted the importance of "buy-in" citing to success in VAROs such as Indianapolis where everyone bought in to the program and turned out extremely positive results, even at high volume, contrasted with a VARO like Baltimore, where employees actively worked to exclude claims from FDC, and still languish with poor results. Simply put, the program works when everyone involved works together to make it work.

There are still areas for improvement. The American Legion recommended expanding eligibility to include National Guard and Reserve claims, so the large component of Guard and Reservists who served over the past decade in the Global War on Terror would not be left by the wayside. A Disabled American Veterans employee from the Chicago VARO noted he had seen strong cooperation from that office in terms of working with VSOs to make reasonable exceptions to make sure claims weren’t unreasonably kicked out of the program, and recommended those reasonable accommodations be made into national policy. One such example was if evidence was later submitted that could help clarify the extent of an injury, but did not require further development, there was no reason to kick out that veteran’s claim simply because new evidence had been introduced.

PTSD report: The American Legion released a report on Sept. 11 that is the culmination of a study the wartime veterans organization did on current treatments and best practices for traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). The report, entitled "The War Within," includes findings and recommendations based on comprehensive research, conducted from January 2011 to February 2013, by an American Legion ad hoc committee chaired by Past National Commander William Detweiler. "The War Within" report is being distributed to the White House, Members of Congress, VA officials and the American Legion’s membership. The report can also be downloaded here.

Assisting County VSOs: The Economic and VA&R divisions participated in the Department of Minnesota’s County Veterans Service Officer’s (CVSO) Conference in Nisswa. The conference was attended by CVSOs from all across the state, where training in claims and benefits took place. Legion staff members made presentations regarding education, credentialing, upcoming legislation and claims development to the CVSOs.

Post 9/11 GI Bill: The Economic Division met on Sept. 11 with Amanda Meredith, minor general counsel, Senate Veterans’ Affairs Committee, to discuss adding wording to the Post-9/11 GI Bill that would allow on-line certification programs that are currently approved under current law the opportunity to be approved by State Approving Agencies. The change will provide additional opportunities to student-veterans and necessary flexibility within their Post-9/11 GI Bill benefits. Further conversation with the committee will take place to ensure if such a change would occur, it will be beneficial to the student-veteran, and not harmful to their educational goals.

Job fairs: The Department of New Jersey completed its 12th Hiring Our Heroes Job Fair on Sept. 11 in Lawrenceville at the Department of Military and Veterans Affairs (DMAVA) headquarters, and at the 50th Brigade Armory. The event was successful because of the strategic partnership which included the U.S. Chamber of Commerce, DMAVA and the Department of New Jersey. Eighty employers and support organizations attended the job fair as exhibitors and the armory was packed with veteran jobseekers and spouses for the duration. A special thanks goes to Bob Looby, Economic and Employment Chairman for New Jersey, who coordinated and managed the job fair.

Letters of support: The American Legion recently sent out two letters of support:

  • On Sept. 6, a letter of support was sent to Rep. Julia Brownley of California for H.R. 2485, the Helping Homeless Veterans Act of 2013. This measure would amend title 38, United States Code, to extend programs assisting homeless veterans and other veterans with special needs. Our organization requested this legislation be authorized for a period of five years. [Resolution 306-2012]
  • On Sept. 13, a letter of support was sent to Rep. Jim McGovern of Massachusettes for H.R. 2847, the Wounded Warrior Service Dog Act of 2013. This legislation will direct the Departments of Veterans Affairs and Defense to jointly establish a program for the awarding of competitive grants to non-profit organizations that address physical and mental health needs of service members with assistance from service dogs. [Resolution 127-2012]

Claims: During the week ending Sept. 6, 2013, the Board of Veterans’ Appeals reached dispositions on 118 American Legion represented appeals. Of those dispositions, 70.3 percent of the denials were overturned with outcomes favorable to the veteran. In 32 cases, the board granted benefits outright after considering The American Legion’s arguments. In 51 cases, The American Legion was able to point out errors in the development of the veteran’s claims which mandated corrective action under the law. Of the total number of dispositions, 30 (25.4 percent) were outright denials.

POW/MIA Update

• 2nd Lt. Vernal J. Bird, U.S. Army Air Force, 5th Air Force, 3rd Bombardment Group, 13thBombardment Squadron was lost in March 1944 when his A-20G Havoc bomber crashed in Papua New Guinea. He was accounted for Aug. 28, 2013. He will be buried with full military honors Sept. 28, 2013, in Springville, Utah.

• Sgt. Melvin E. Wolfe, U.S. Army, K Company, 31st Regimental Combat Team, was lost Dec. 12, 1950, during the battle of the Chosin Reservoir. He was accounted for Aug. 26, 2013. He will be buried with full military honors Sept. 23, 2013, in Boulder City, Nev.

• Pfc. Ronald C. Huffman, U.S. Army, K Company, 3rd Battalion, 38th Infantry Regiment, 2nd Infantry Division, was lost on Feb. 12, 1951, during a battle near Saemal, South Korea. He was accounted for on Aug. 8, 2013. He will be buried with full military honors in Princeton, W.Va.

A complete listing of recently account-for servicemembers can be found on the Recently Accounted-For page.