Testifying before a congressional committee in St. Louis on serious violations of cleaning procedures at the city’s John Cochran VA Medical Center, American Legion expert panelist Barry Searle said, “To expose trusting veterans to blood-borne illness through routine medical treatment – because of avoidable errors in sanitization of medical equipment – is inexcusable.”
Searle, director of the Legion's Veterans Affairs & Rehabilitation Division, was one of several experts called to testify before the House Veterans’ Affairs Committee, holding a field hearing on “Veterans at Risk: The Consequences of VA Medical Center Non-Compliance.” The committee’s chair, Rep. Bob Filner, D-Calif., called Tuesday’s hearing in response to the recent failure of the St. Louis VA facility to clean its dental equipment properly. As a result, more than 1,800 veterans were exposed to the risk of infection with HIV and hepatitis viruses. According to St. Louis television station KMOV, blood tests have confirmed that some veterans who received dental care at the Cochran are infected with HIV, Hepatitis B and Hepatitis C.
While The American Legion commended VA for showing “great responsibility” in bringing the violation of cleaning protocol to public attention, Searle reminded the committee that, “a lack of compliance with those protocols had 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. With the correct and effective accountability, there is hope for continued faith in the veterans health-care system,” Searle said. “However, we must always be mindful of the fact that this has happened before and, unfortunately, it has happened again.”
For some time, The American Legion has been alerting Congress that high turnover and shortages in VA staffing are contributing factors in events such as the one in St. Louis – proper cleaning protocols were already in place, yet the staff failed to follow them.
During its 2010 “System Worth Saving” Task Force visits to 32 VA medical centers nationwide, The American Legion heard a common theme repeated in staff interviews: a shortage of personnel, especially nurses and other staff with specialty training. That kind of problem, Searle told the commitee, requires greater emphasis on standardized procedures, quality review and individual training.
If an emphasis on training is neglected, “dedicated people will make mistakes. 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,” Searle said.
At a July 1 House subcommittee hearing, The American Legion noted a lack of oversight by VA’s central office to ensure that proper procedures were being followed by directors at its medical centers and regional offices, who operate with substantial autonomy.
“This autonomy of the facility directors is a function of the over-decentralization of the VA structure,” Searle said. “We have 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.”
In closing, Searle told the subcommittee that The American Legion is strongly committed to working with VA Secretary Eric Shinseki, “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.”