July 13, 2010


JULY 13, 2010

Mr. Chairman and Members of the Subcommittee: Thank you for this opportunity to submit The American Legion's views on this pressing issue brought to light by recent developments at the John Cochran VA Medical Center (VAMC).The American Legion from its inception has been both a strong advocate for veterans and a proponent for an effective federal entity whose mission is to care for those veterans. In fact, it was following a recommendation from The American Legion's 1920 National Convention that the Dawes Committee with The American Legion representation, advocated for and was instrumental in the development of the predecessor of today's Department of Veterans' Affairs. Throughout this long history with The Department of Veterans' Affairs The American Legion has worked hard to develop a relationship of trust and mutual respect. Central to The American Legion's efforts is a program called "A System Worth Saving." This Task Force, first established in 2003, annually conducts site visits at VA Medical Centers nationwide to assess the quality and timeliness of VA healthcare. In preparing for these visits, The American Legion team researches General Accountability Office (GAO) reports, VA's Office of Inspector General (VAOIG) reports, and news articles relating to potential breakdowns in a system that we consider, "The Best Care Anywhere." This task force, we believe, has identified some issues contributing to the issue at hand. In March of this year, during a routine inspection of the John Cochran VAMC by VA's Infectious Disease Program Office, it was determined that dental instruments were not being cleaned in accordance with specifications of the manufacturers, or in accordance with VA's own procedures for proper sanitations and sterilization. These instruments were being cleaned without proper detergent, potentially putting veterans at risk for blood borne illnesses such as HIV and Hepatitis. VA Central Office (VACO) convened a special committee to determine an appropriate response. The committee could not determine that the risk to the approximately 1,800 patients treated during this period could be assessed as an absolute zero chance of infection; therefore the decision was made to notify all affected veterans. These 1,812 veterans, notified through certified mail, will be provided with free testing for HIV and the B and C strains of Hepatitis, and they will be provided with whatever follow up care is deemed necessary. As of this time, no veteran is known to have contracted any of these diseases through this exposure.

The American Legion feels that VA showed great responsibility and demonstrated an act of good faith to bring this issue to the attention of the veterans and the public. Placing patient safety before "good publicity," deserves to be acknowledged.

Nevertheless, The American Legion National Commander Clarence Hill recently stated, "This is an extremely serious problem that has happened before and will happen again unless VA ensures strict adherence to proper sanitation and sterilization protocols." To expose trusting veterans to blood borne illness through routine medical treatment because of avoidable errors in sanitization of medical equipment is inexcusable.

The medical protocols to prevent such occurrences were already in place; however a lack of compliance with those protocols has led to a situation where veterans' confidence in their health care system is being eroded. Simply put, a veteran should never have to fight misgivings about seeking health care from what is overall an excellent system for the delivery of their earned health care benefits. The problem exists not in the business process structure of the system, as the existing protocols were designed to prevent such exposures, but rather in the failure of those operating the system to execute those protocols. This can only be overcome by diligent and attentive management and training. This event is not the only reported occurrence of failure to follow procedures within the VHA system. A Department of Veterans Affairs Office of Inspector General (VAOIG) report from 21, April 2010, concerning suspected issues in the Supply, Processing, and Distribution (SPD) department relating to endoscope reprocessing and communications at the St. Louis facility, substantiated alleged cleaning issues of equipment. In its findings the VAOIG identified turnover in several key staff positions. The American Legion believes that turnover and shortages in staffing are contributing factors in these serious events.During the 2010 "System Worth Saving" Task Force visits to 32 VA Medical Centers across the country, a commonly repeated theme was the shortage of personnel, especially nurses and personnel with specialty training. It is the opinion of the American Legion that turnover of personnel and the shortage of personnel at most facilities require renewed emphasis on standardized procedures, quality review and individual training, as well as documentation of that training. If an emphasis on training is subverted to day to day operations, dedicated people will make mistakes. Further, The American Legion believes that VACO must maintain proper oversight of medical care, utilization of facilities and resources in order to ensure veterans receive the highest quality of care.


In a May 2010, VAOIG report concerning the review of Brachytherapy Treatment of Prostate Cancer at Philadelphia, PA and other VA Medical Centers, a recommendation was made for VHA to "standardize to a practical extent, the privileging, delivery of care, and quality controls for the procedures required to provide treatment." As technologies continue to change and treatments and procedures continue to develop, it is critical that VA staff delivering care be properly trained and held accountable. The American Legion supports training and the accountability highlighted and also the standardization of all patient care delivered across the VHA system.

In an April 28, 2010, PITTSBURGH TRIBUNE-REVIEW article, after a reported incident at the Pittsburg VAMC in 2007, it was noted that the Food and Drug Administration had cited the VA facility for not doing a routine blood type confirmation test, a violation of standard procedure. This resulted "in the patient receiving 6 units of the wrong blood before he died." It was reported that, "VA officials told the FDA the error stemmed from "a heavier than usual workload in the blood bank."We believe, and it has been supported by our visits, that the VA Health care system does in fact have SOP's and procedures in place. However, The American Legion understands that policies developed at VA Central Office, with the best of intentions, are for the most part executed at the discretion of the Veterans Integrated Service Network (VISN) Director or even Facility Director level and therefore, vary in local implementation. As was testified by The American Legion during a 1 July subcommittee hearing, we believe there is a breakdown in the lack of follow-up and accountability by Central Office to insure procedures are being followed. This autonomy of the facility directors is a function of the over decentralization of the VA structure. It is in no means unique to VHA. It is, we believe, systemic to VA's mode of operation. For example, in VBA we have seen and, in fact, been told by VA personnel themselves that, "When you see one Regional Office, you have seen One Regional Office." The implication is that there is no standardization in VA.It appears that only when a significant issue is identified such as this unfortunate breakdown in what appears to be cleaning procedure training is action taken on the part of VACO to rectify the lack of follow-up. Again, one of the rising concerns of The American Legion, as stated in testimony over the last few months, has been that VA needs to do a better job in training its people more effectively and making sure they understand and follow the correct protocols that have already been established. There is also a need to enforce central oversight of the regional Veterans Integrated Service Networks (VISNs) thereby insuring consistency and accountability nationwide. It is not enough to simply move people to different facilities doing the same job. Unfortunately, at times accountability means negative impact on the individual who is responsible. VA has undoubtedly turned their attention to addressing this matter, and is treating it with the seriousness it deserves. With the correct and effective accountability, there is hope for continued faith in the veterans' health care system. However, we must always be mindful of the fact that this has happened before, and unfortunately, it has happened again.

The American Legion is committed to working with the Secretary to ensure that this situation is successfully resolved and that incidents such as this do not become an ongoing issue with the otherwise excellent VA Health Care System.

Mr. Chairman and Members of the Committee that concludes my testimony.