Mat-Su VA clinic report reveals need for reform

WASILLA — The Mat-Su veterans' clinic, under investigation for the past year due to an alleged lack of adherence to clinical guidelines, is finally moving toward reform.

But not before its flaws have been presented to the general public.

The federal Department of Veterans Affairs Office of Inspector General released a health care inspection report Tuesday regarding scheduling, staffing and quality of care concerns within the Alaska VA health care system. U.S. Senator Lisa Murkowski, who requested the inspection and report, called the results “devastating and disappointing.”

The Office concluded that, “provider workload and staffing negatively impacted access to care” at the Mat-Su clinic, and, “patient care was compromised by a lack of communication, care coordination, and follow-up, in addition to outright delays in the provision of care,” among other things.

“We found organizational structure and processes lacking, particularly in areas under the domain of clinical leadership,” the report reads. “Insufficient processes in peer review, provider evaluation, and committee activity and reporting, as well as issues of culture and employee morale, have the potential to compromise patient safety.”

In short, “the VA allowed veterans with serious health conditions to fall through the cracks, causing them to be denied potentially life-saving care,” Murkowski said.

To illustrate that point, the report described challenges faced by nine patients seeking care at the Mat-Su Veterans Administration Community Based Outpatient Clinic during 2013 and 2014 — some of whom perished.

Patient No. 2, a man in his 70s “with multiple serious medical conditions,” for example, was seen in the winter of 2013 at the clinic and had lab studies done in early 2014. The studies showed his conditions were stable and “near treatment goals.”

The doctor requested he follow up that summer. But the appointment was never scheduled, and the doctor left the clinic shortly after their last meeting. Before that summer arrived, the patient went to a non-VA emergency facility with severe back pain, and left with a diagnosis of shingles.

Five days later, the condition worsened, and a nurse at the Mat-Su VA clinic told him to go to an emergency department or urgent care clinic. He was admitted to a non-VA hospital, treated for urosepsis — a urinary tract infection that has entered the bloodstream — and discharged with an antibiotic three days later.

A test done to determine the type of bacteria causing the patient’s infection and type of antibiotics that would best treat the condition were sent to a VA health care provider in Anchorage. There it was discovered that the bacteria were not sensitive to the antibiotic prescribed. The patient was called and told to pick up a new antibiotic at the VA clinic in Anchorage, but to continue taking the first antibiotic until he could get to the clinic.

The doctor who called did not offer the patient a follow-up appointment in Anchorage or with an interim provider at the Mat-Su clinic. The patient did not pick up the new antibiotic.

Four days after discharge from the non-VA hospital, the patient’s condition had worsened. He was readmitted to an outside hospital and found to have worsening kidney disease, an infection in the bloodstream, and enterovesicular fistula (abnormal communication between bladder and bowel). The patient died at the outside facility, following a surgical procedure to repair the fistula.

The Office of Inspector General concluded in the report that this patient received poor access to care, as neither he nor his family members were advised “that the patient could receive primary care or urgent care at the Anchorage facility, or another VA facility, or that an urgent appointment would be arranged with a community provider. Even in the absence of acute medical issues, this patient was due for a primary care appointment in summer 2014.”

But it appears no follow-up appointment with a VA or non-VA clinic in the Valley or Anchorage was scheduled.

Because the scope of the review was limited to the quality of care provided at the Mat-Su clinic, and no Mat-Su VA provider saw the patient following his last regularly scheduled appointment — November 2013 — the inspector general did not make a conclusion on quality of care in this case.

Murkowski, however, made the facts known.

“We know there is a lack of follow-through in providing care and medical attention. We know the Wasilla (clinic) needs to be fully staffed. We know the Alaska VA system is facing an overload of cases, a lack of scheduling organization and has systemic, long-term shortcomings in providing care,” she said. “But we must also come to know — through actions and positive reform — that the Alaska VA will reaffirm its commitment to the men and women who served this nation.”

Recommendations

To address these issues, the Office of Inspector General made nine recommendations to the Veterans Integrated Service Network director and system director:

1. Implement an action plan that includes recruitment and retention of physicians to provide better access to care, and ensure continued provision of primary care by a permanent provider at the Mat-Su VA Community Based Outpatient Clinic.

2. Implement contingency plans for ensuring patients receive continuity of and access to appropriate primary care during periods of inadequate resources.

3. Implement the requirements of Veterans Health Administration Handbook 1101.10, Patient-Aligned Care Teams (PACT), regarding care coordination.

4. Provide access to care at the Mat-Su VA Community Based Outpatient Clinic in accordance with Veterans Health Administration policy and provider recommendations for follow-up.

5. Implement a peer review process consistent with VHA policy.

6. Perform peer review and consult regional counsel as appropriate for the cases identified in the report.

7. Implement a provider evaluation process consistent with VHA policy.

8. Strengthen processes for committee reporting to align with VHA directive 1026, “Enterprise Framework for Quality, Safety, and Value.”

9. Assess the culture, morale, and leadership issues identified in the report, and take appropriate action as necessary.

Alaska VA Healthcare System Director Susan Yeager concurred with all recommendations. In an April letter to the director of the Northwest Health Network, Yeager affirmed that changes have been made or are in the process of being made, to be complete by Aug. 31 (recommendations 1, 2, 4, 5, 6) or Dec. 31 (3, 7, 8, 9).

Contact Caitlin Skvorc at 352-2266 or caitlin.skvorc@frontiersman.com.