[Senate Hearing 112-23]
[From the U.S. Government Publishing Office]
S. Hrg. 112-23
FIELD HEARING ON IMPROVING PATIENT SAFETY AND QUALITY CARE AT THE
DAYTON VA MEDICAL CENTER
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TWELFTH CONGRESS
FIRST SESSION
__________
APRIL 26, 2011
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
Patty Murray, Washington, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Daniel K. Akaka, Hawaii Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont Roger F. Wicker, Mississippi
Sherrod Brown, Ohio Mike Johanns, Nebraska
Jim Webb, Virginia Scott P. Brown, Massachusetts
Jon Tester, Montana Jerry Moran, Kansas
Mark Begich, Alaska John Boozman, Arkansas
Kim Lipsky, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
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April 26, 2011
SENATORS
Page
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 1
WITNESSES
Turner, Hon. Michael, U.S. Representative from Ohio.............. 4
Daigh, John D., Jr., M.D., Assistant Inspector General for Health
Care Inspections, Office of Inspector General, U.S. Department
of Veterans Affairs; accompanied by George Wesley, M.D.,
Director, Medical Consultation and Review Division, Office of
Health Care Inspections; and Kathleen Shimoda, Health Care
Inspector, Office of Health Care Inspections................... 7
Prepared statement........................................... 9
Hetrick, Jack G., Network Director, Veterans Integrated Service
Network 10, Veterans Health Administration, U.S. Department of
Veterans Affairs; accompanied by William D. Montague, Acting
Director, Dayton VA Medical Center; and Lisa Durham, Chief,
Quality Management, Dayton VA Medical Center................... 23
Prepared statement........................................... 24
FIELD HEARING ON IMPROVING PATIENT SAFETY AND QUALITY CARE AT THE
DAYTON VA MEDICAL CENTER
----------
TUESDAY, APRIL 26, 2011
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2 p.m., at the
Dayton VA Medical Center, Dayton, OH, Hon. Sherrod Brown of
Ohio, presiding.
Present: Senator Brown of Ohio, presiding.
OPENING STATEMENT OF HON. SHERROD BROWN, ACTING CHAIRMAN, U.S.
SENATOR FROM OHIO
Senator Brown of Ohio. Thank you for joining us. I am
Senator Sherrod Brown. This is an official hearing of the U.S.
Senate Veterans' Affairs Committee, an official hearing even
though it is not in Washington. Senator Patty Murray, who is a
Democrat from the State of Washington, has empowered me as a
Member of the Veterans' Affairs Committee to hold this hearing
in Dayton at the VA Medical Center.
I thank you all for joining us. I thank Senator Murray,
Ryan Pettit of her staff, and the Veterans' Affairs Committee
staff. Also, John McDonald, to my right behind me, is with the
Minority Staff of the Committee's Ranking Member, Senator Burr,
a Republican from North Carolina. Also behind me is Doug
Babcock of my office staff who advises us on veterans issues.
The investigation of the VA Dental Clinic has affected so
many local veterans and their families that it makes sense to
hold the hearing here. I will recognize Congressman Turner in a
moment, who has been very, very involved in this. They will
hold a hearing about Dayton and St. Louis in Washington with
the Veterans' Committee there soon.
As I said, Chairman Murray and Secretary Shinseki and I
have had many discussions about what happened, as has
Congressman Turner with the Secretary. This hearing is a result
of this work. It will operate with the same authority of any
other hearing in the U.S. Senate that is held in Washington,
DC.
We will be hearing from the Office of the Inspector General
of VA and members of the VA leadership on what happened at the
Dayton VA Dental Clinic. We need to know how we got here. We
need to know how we move forward.
To any audience members who would like to submit testimony
for the official record, please contact Mr. Babcock from my
office and Rachel, if she would put her hand up, Rachel Miller
of my staff in our Cincinnati office.
Before we start, I would like to ask anyone who is a
veteran to please stand or put your hand up. Thank you.
[Applause.]
All of us thank you, and I think I can speak for the Senate
here, thank you for your service and we commit to doing better
with this Vet Center, as the VA does in a great majority of
places around the country.
A special thank you to the leaders of Ohio's Veterans
Service Organizations. Tom Burke of the Buckeye State Council,
President for Vietnam Veterans--is Tom here? If Tom would put
his hand up. He was going to join us. Dave Kenyon, who is a
State Service Officer for the AMVETS, thank you for joining us.
And Susan Getz, who is National Vice Chair of the Women
Veterans of America--where is she? Thank you for joining us,
too.
For 150 years, Ohio has been a leader in providing
veterans' services. Ohio founded one of the Nation's first
chapters of the Veterans of Foreign Wars. Ohio has the Nation's
best county Veterans Service Officers and Organization. The
Dayton VA Medical Center was one of the Nation's first VA
hospitals, providing continuous care and service to veterans
for some 14 decades, 140 years.
As a Member of the Senate Veterans Committee, it is not
only an honor for me to serve our Nation's veterans, it is a
sacred responsibility that we all take when we take our oaths
of office. We should not have to be here. This hearing should
not have to take place. I would much rather have a hearing on
the future of the VA in Dayton, how we can help the community
leverage Federal resources to ensure that the hospital and the
campus meet the needs of our veterans. I would rather be
talking about our strong bid for the VA Archives, a distinction
clearly earned by Ohio veterans and deserved by Ohio veterans.
One of the most important duties of representing Ohio's
veterans on this Committee is to provide oversight of the
Veterans Administration. That means undertaking what works at
VA, this Vet Center, and other centers around the country. It
also means making it better when it does not, finding out what
is not working, and fixing it. In the process, it means
recognizing that serving our veterans is a nonpartisan
responsibility of our government. Our veterans deserve nothing
less. That is why we are here today.
Most of us are aware of the inexcusable facts and
unconscionable consequences behind what happened at the Dayton
VA Dental Clinic. Over the course of 18 years, the clinic
failed in its duty, in far too many cases, to serve our
veterans. A dentist disregarded basic sterilization practices.
Nurses and assistants were ignored when they reported
substandard care. We heard reports of employees punished for
reporting unsafe practices. Petty, mean-spirited interpersonal
dysfunction led to physical and verbal confrontations. Dental
students allegedly provided care beyond that for which they
were qualified based on VA standards and regulations.
Management at the dental clinic and medical center studiously
ignored problem after problem after problem, a symptom of
general management chaos. These are the irrefutable,
inexcusable facts.
More than 500 patients, as we know too well, at the Dayton
VA Dental Clinic have been told that they have to be tested for
bloodborne pathogens as a result of the care they received at
this facility. Some experts are saying that thousands should be
tested. As many as nine patients have tested positive for
hepatitis; perhaps there are more. Veterans received life-
threatening bloodborne pathogens instead of high-quality health
care.
The patients at the clinic are our Nation's veterans and
their families. They served our Nation when called upon. High-
quality health care is a benefit they have earned, they
deserved, and we have pledged to them, and in most cases, that
is what the VA system does--ensure a high standard of care to
veterans who have earned it. I often tell people that nowhere
in the world will you find better care than when you step into
a VA facility. During the debate on health insurance reform,
the VA health system was an example to emulate.
So this hearing is not a trial. It is not a witch hunt on
the entire VA medical system. Far from it. We want to restore
the public's confidence in the system. We want to ensure
accountability for those responsible for these horrific wrongs.
We want to instill transparency as we move forward to ensure no
veteran is ever treated with such blatant disregard. We want
transparency. We want accountability. We want to hear about the
clinic's mistakes and learn from the clinic's mistakes so those
mistakes are not repeated. This hearing is grounded in those
goals.
We will explore specific questions about what happened over
the last 18 years. Why was the clinic allowed to operate in
this fashion for more than a decade? Why did it take so long to
close the clinic? Has every person exposed to contagions from
unsafe medical practices been notified and treated and tested?
What is being done to hold those accountable, including those
who knew and sat idly by and those who should have known?
We will explore where we are today. Is the Dayton Dental
Clinic now safe for patients who rightfully expect the world-
class care that VA rightfully, most of the time, prides itself
on? Are systems in place for this to never happen again? What
is VA doing to make those exposed whole? What is VA doing to
reassure every veteran that VA care is, in fact, the best care
anywhere? We will explore how to restore the public's
confidence in this hospital.
I have heard from hundreds of veterans about the Dayton VA.
Most are angry. Many are just disappointed. I want to share two
of them. One veteran from just north of here, from Huber
Heights, told me, ``I desperately need dental care, but not at
the expense of my health.'' A veteran in Minster in Auglaize
County wrote, ``I am one of the veterans who was potentially
exposed by the dentist in question. I have been tested. Now I
have to wait in limbo, being treated as if I am positive until
said test results come back. No offense, Senator, but the
testing is being done by the same agency that ignored the
problem for 18 years. It put me in jeopardy to begin with. Am I
to trust that the VA this time will get it right?''
I am not happy with the pace of the administrative process
regarding the disciplining of those involved. I understand
there are legal and procedural hurdles, and for that matter,
criminal processes that need to be followed. But people must be
held accountable. Transparency, accountability, making sure
this crisis in care and confidence must never, ever happen
again, that is what this hearing is about today.
That is why I have asked Congressman Turner to offer his
testimony. Congressman Turner and I have worked together to
push for answers and accountability. While we represent two
different parties in two different chambers, we represent the
same Ohio veterans. He represents Ohio's Third Congressional
District, and home to his district is home to this VA medical
center. I have asked him to make a brief statement before we
hear testimony. Congressman Turner, thank you for joining us.
STATEMENT OF HON. MICHAEL TURNER,
U.S. REPRESENTATIVE FROM OHIO
Mr. Turner. Thank you, Senator Brown. I want to thank you
for holding this important hearing.
The importance of what you are doing here today is that you
are not just sitting here as the Senator from Ohio, concerned
about these veterans and this issue that is occurring in your
State. I understand that this is a hearing that is occurring
under the auspices of the Senate Veterans' Affairs Committee. A
transcript is being taken, and I know this becomes a part of
the official record of the work of the Senate in evaluating the
VA, both this instance and nationally, so I appreciate that
this is a special visit as we look to investigate this issue
and broaden the scope, really, of what needs to be reviewed
here at this site.
I appreciate your statement on what occurred here. This is
abhorrent, that any patient who would enter the VA would be
placed at risk. The fact that these practices were ongoing and
none of us knew, you acknowledged, is equally abhorrent, and I
think that is part of what brings everyone here with such
anger.
We know that the dentist in question violated standards for
practice for at least 18 years. The support staff was aware of
the infractions, but apparently their reports were not followed
through or they did not report it, because when he was found
reported, the leadership, I believe, moved forward trying to
cover up what had happened here and continues to not be
forthcoming about the actions that had occurred here.
I believe that the VA is acting more as an obstacle than
they are of help to resolve this, and I think this hearing that
you have brought forth, Senator Brown, will help us in trying
to dislodge some of the information that has occurred, and I
would like to highlight some of that difficulty.
First, the VA notified my office that they wished to meet
with our staff to provide what they called an update concerning
the dental clinic at the Dayton VA Medical Center. The notice
was provided at 9:30 p.m. the night before the briefing, which
was scheduled at 10 a.m. the next morning. At this briefing,
the VA informed us that standards of practice concerning
infection control had been violated, and that 535 veterans in
the Dayton community were going to be notified that they should
come in and be tested for bloodborne pathogens, including HIV,
along with hepatitis A, B, and C.
Following that notification, Senator Brown, yourself,
Senator Portman, and I requested copies of the report and that
they be provided to the Greater Dayton Area Hospital
Association for their review and determination as to how the
community should proceed. Instead of embracing this
relationship and working together to solve an obvious problem,
the VA has very lethargically and reluctantly responded to our
request. I will give you a few examples, which I know you are
aware.
First, my office requested a copy of the investigative
report on February 17. Following that request, we were informed
that the VA would have to redact information in the report and
that would cause some delay. We were told that patient
information was going to be protected. The documents really
contained no patient information, but as you are aware, Senator
Brown, the report that was released had many redactions of
information which were important for us to be able to review as
a community to determine what happened here and how we need to
proceed.
Despite numerous requests, we did not receive the reports
until 9:30 p.m. Friday, March 11, 2 days before Chairman Miller
of the House Veterans' Affairs Committee and I were scheduled
to meet with the leadership in Dayton. The delay inhibited our
ability to both inform the Greater Dayton Area Hospital
Association and the community. We later learned that the
regional facility had released the report to the Dayton Daily
News on February 9, a full month before they released it as a
result of Congressional request.
Second, Chairman Miller and I visited the hospital to speak
with the leadership to learn about what had happened. However,
just prior to our visit, we learned that the VA had removed the
director, Guy Richardson, from his position and moved him into
a higher-level supervisory role. We were unable to meet with
Mr. Richardson and still have been unable to meet with him to
date.
Finally, during our visit, I raised concerns about the
redactions made in the report. When I later met with the VA
FOIA (Freedom of Information Advisory Council) office in April,
they informed me that it took their office only 4 hours to
redact the report, and it still took a month for the report to
be released, for us to be able to provide it to the Greater
Dayton Area Hospital Association.
Senator, as you are aware, the Greater Dayton Area Hospital
Association has reviewed the information to date that has been
released by Veterans Affairs, and the Dayton VA Task Force has
released this report which they say concludes that additional
veterans need to be tested and additional veterans need to be
provided care. They believe that the practices that occurred
here exposed many more veterans than VA is currently
acknowledging were at risk. We are calling on Secretary
Shinseki to provide testing and notice to those additional
patients so that they can be properly cared for and VA can
properly acknowledge the risk that these veterans were placed
in.
With regard to the Office of Inspector General
investigation that is the subject of discussion today, I would
like to thank that panel for investigating this issue, but I
would be remiss if I did not point out that the scope of the
OIG investigation was limited by internal constraints. As the
report itself states, the OIG investigative body was unable to
interview several key witnesses simply due to their retirement.
These witnesses include the original source complainants, a
fellow dentist, and the facility's chief of staff. Their
absence raises serious concern over the comprehensive scope of
the investigation and brings their conclusions into question.
What the investigation does do, however, is highlight a
systematic flaw that allowed employees to evade the
investigative process by retiring. This escape-hatch option
neither serves our Nation's veterans nor the taxpayer and
merits further investigation. After all, our country has
thousands of young men and women that are making a great
sacrifice, just as the generations before them. We need to make
sure that they have the peace of mind to know that if they need
help, there will be a fully functioning and competent VA here
to give them that help when they need it, just as was promised.
Senator, thank you for reviewing this matter. Thank you for
bringing this hearing. I believe that the VA has additional
information that they need to provide to this community for us
to be able to evaluate what happened here and what actions need
to be taken to address the concerns of the veterans who
received care, and for us to be able to have confidence that
the other types of care beyond dental that are provided at this
facility meet the highest standards for our veterans. Thank
you, Senator.
Senator Brown of Ohio. Thank you, Congressman Turner. Thank
you for being here. We will address, I hope, all of those
concerns that you brought up today. Thank you very much, and
thanks for your work on this since the story broke. You got so
involved. Thank you. Thanks very much, Congressman Turner.
The first panel will consist of Dr. John Daigh, Assistant
Inspector General for Health Care Inspections, Office of
Inspector General. Dr. Daigh joined the VA as Associate
Director of Medical Consultation in the Office of the Inspector
General in January 2002 and was appointed as the Assistant
Inspector General for Health Care Inspections in January 2004.
He is responsible for the Office of Inspector General
initiatives that review the quality of health care provided to
veterans in Veterans Affairs hospitals, clinics, in nursing
homes, in addition to the care provided to veterans through
various health care contracts. Prior to joining the Office of
Inspector General, he was active duty with the U.S. Army for 27
years, retiring as a Colonel 10 years ago.
Dr. Daigh is joined by Dr. George Wesley, Director of
Medical Consultation and Review Division, Office of Health Care
Inspections; and Kathleen Shimoda, Health Care Inspector,
Office of Health Care Inspections, and you are a registered
nurse, I believe?
Ms. Shimoda. Yes.
Senator Brown of Ohio. Yes. Dr. Daigh, please begin with
your testimony. I may end up asking questions of the other two
with you, and they can certainly consult with you on the
answers. So proceed, Dr. Daigh.
STATEMENT OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR
GENERAL FOR HEALTH CARE INSPECTIONS, OFFICE OF INSPECTOR
GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY
GEORGE WESLEY, M.D., DIRECTOR, MEDICAL CONSULTATIONS AND REVIEW
DIVISION, OFFICE OF HEALTH CARE INSPECTIONS; AND KATHLEEN
SHIMODA, HEALTH CARE INSPECTOR, OFFICE OF HEALTH CARE
INSPECTIONS
Dr. Daigh. Yes, sir. Senator Brown, it is a pleasure to be
here in Dayton, a community that is recognized worldwide for
its innovation, hard work, and success. It is especially a
privilege to be here at a hospital that has been one of the
oldest in the VA. As you identified, Dr. Wesley and Kathleen
Shimoda are here with me. These are the two individuals that
led the team that resulted in the report that was published
Wednesday, or yesterday, on our Web site, of which you speak.
We were both horrified and surprised when we were asked by
the Senate and House Veterans' Affairs Committee to come to the
Dayton Dental Clinic and review the allegations that infection
control practices were not being adequately followed. As a
result of those efforts, we published the report that I
mentioned.
I believe that at the current time that these breaks in
infection control policy that we saw in the dental clinic are
not typical of what is seen in this hospital at all, nor do I
believe that the issues that we discovered and have reported on
in our report are typical of VA as a whole. I believe that this
is an outlier from how VA normally operates.
I have a couple of suggestions that I think should be
considered moving forward that I hope will prevent these issues
from occurring again.
One, I think that there are a group of individuals in the
hospital whose input may not be--and I do not speak
specifically about this hospital but VA hospitals in general--
whose input may not flow unfiltered to the leadership, and I
would speak of the group of individuals who I would call
hospital technicians. They would be the individuals who run the
ultrasound machines, who are cath lab techs, who work in the
ophthalmology clinic, and who would be the technicians in the
dental clinic. I think that the physicians and providers, in
fact, have a direct line of communication to the hospital
leadership through the standard chain of command. I think that
the nurses and the nursing staff have a direct line of
communication to hospital leadership through the head nurse. I
think this other group of people might, if talked to on a
regular basis, might, in fact, allow some of these issues to
come to light sooner and be dealt with more quickly.
The second recommendation that I would have would be that
among the senior leadership group in the hospitals, that VA
consider rotating or having terms of office for those leaders,
that they ought to plan to move from hospital to hospital or
that their positions be changed up on some program basis. There
is a cost to that, and I am not sure, we have not studied it as
to whether that should be done in all cases. But I think it
provides for a relook at the relationships that exist in a
hospital. It requires leaders at lower levels to prove to their
new boss that, in fact, the standards that they have in place
and the criteria that they are managing their organization by
are effective.
The third recommendation I would make is that the VA uses a
policy which I think is quite excellent which deals with
adverse event disclosure. That policy was written in 2008, and
it essentially is the playbook that is used to try to determine
who should be notified when more than one individual needs to
be notified as a result of an outbreak or the risk of an
outbreak. There have been many more notifications around this
issue and reusable medical equipment than I think anyone
expected.
I would refer you all to the New England Journal editorial
of September 2, 2010, which discusses the notification issue
broadly in the United States and which lays out 30 or 40
notifications countrywide. VA has a few of those on the list,
but there are many other institutions that have covered that
problem. I think that it is reasonable to consider empaneling
someone like the Institute of Medicine or some other group to
sit down and think about the risk that--the risk issues, where
the limit of science comes up with policy in terms of whom and
how we should notify individuals.
I think that the basic scientific fact that HIV has never
been transmitted, that is found in published literature,
through saliva from one patient to the next, I think is
understood. The risk of whether hepatitis B could be
transferred from one patient to another has limits in what
people know and understand and what people think good
government or good policy ought to be. So I think that there is
a wider expanse with these issues beyond VA, and I think a
discussion would be of some value.
I also think that included in that discussion at the
Federal level is the relationship between the administration
and the legislature. I think that the policy currently lays out
that the administration, the Principal Deputy Under Secretary
for Health, the PDUSH, will advise the Under Secretary for
Health on an action to take. These actions involve many
individuals at great expense, and I think that one should
consider how, in fact, those discussions occur.
The last piece of advice or issue that I think should be
considered is one that is difficult to articulate exactly
except to say that it is not uncommon in medical institutions
for physicians who are prominent in their society at that
hospital, who have worked there for decades or many years, have
established a wonderful working relationship in that hospital,
to over time decide that their capabilities are less. What they
typically then do is request a set of privileges in the
hospital. It is not the full set of privileges that they might
have had 10 years ago.
So an example might be a surgeon who fully engaged in the
operating room and in clinic might at some point in time
request privileges not to operate but simply to work in the
clinic for a variety of reasons. Maybe their hand was injured.
Maybe there is some other issue. But I think it is incumbent
upon the leadership of the VA to take careful thought and look
and be especially careful in the granting of privileges when
there is a change over time. One wants to limit the privileges
of a practitioner based on data. Certainly, one does not want
to have to have adverse events occur or patients be harmed
before a credentialing and privileging committee makes the
decision to limit the privileges of an individual or deny
privileges to an individual.
I talked about this issue with the leadership of VHA. I
think it is one that, through discussion and consideration,
that credentialing and privileging committees can focus on and
do a better job at that issue. I know that my office will
assign more time to looking at that issue as we look at the
performance of credentialing and privileging committees
throughout VHA. I think that is the fourth suggestion I would
have, is to have--these issues might, in fact, be improved and
be made less likely to occur in the future.
My staff will be privileged to take questions from you as
you see fit. Thank you, sir.
[The prepared statement of Dr. Daigh follows:]
Prepared Statement of John D. Daigh, Jr., M.D., Assistant Inspector
General for Healthcare Inspections, Office of Inspector General, U.S.
Department of Veterans Affairs
Senator Brown and other Members of the Committee, thank you for the
opportunity to testify on the results of our review involving the
Dental Clinic at the VA Medical Center (VAMC), in Dayton, Ohio. At the
request of the Chairmen and Ranking Members of the Senate Committee on
Veterans' Affairs and the House Committee on Veterans' Affairs, the
Office of Inspector General (OIG) reviewed infection control issues at
the Dental Clinic at the Dayton VAMC and on April 25, 2011, we issued
our report, Healthcare Inspection--Oversight Review of Dental Clinic
Issues, Dayton VA Medical Center, Dayton, Ohio. We concluded that the
subject dentist did not adhere to established infection control
guidelines and policies, and multiple dental clinic staff had direct
knowledge of these repeated infractions. These violations of infection
control policies placed patients at risk of acquiring infections
including those that are bloodborne.
background
Dental Clinic--The Dayton Dental Clinic performs a full spectrum of
dental and oral surgical procedures. The dental specialties recognized
by the American Dental Association (ADA) practiced at the medical
center include general dentistry, oral and maxillofacial surgery, oral
and maxillofacial radiology, periodontics, and prosthodontics. In
July 2010, the dental clinic had seven dentists and an oral surgeon,
two dental hygienists, seven dental assistants (two expanded function,
five non-expanded function), and three dental laboratory technicians.
In fiscal year (FY) 2009, the dental clinic treated 3,164 unique
patients, and in FY 2010 the clinic treated 3,005 unique patients.
The dentists, oral surgeon, administrative officer, expanded
function dental assistants, registered dental hygienists, and dental
laboratory technicians report to the service chief, while the non-
expanded function dental assistants and administrative program staff
report to the Dental Service's administrative officer. The Chief of
Dental Service reports to the VAMC Chief of Staff. The dental clinic
has a General Practice Residency, which is an independent medical
center residency (as opposed to being the recipient of university
residents rotating through the dental clinic). At the time of the
review, there were three residents, although it is authorized four. The
last accreditation review occurred in September 2006, and the
Commission on Dental Accreditation adopted a resolution to grant the
program the accreditation status of ``approval without reporting
requirements'' at its January 25, 2007 meeting. The next scheduled
accreditation site inspection is scheduled for September 2013.
VA Oversight--The Veterans Health Administration (VHA) operates a
program of proactive inspections through its System-Wide Ongoing
Assessment and Review Strategy (SOARS) program. Its mission is ``to
provide assessment and educational consultation to volunteer facilities
using a systematic method for on-going self-improvement.'' SOARS
inspection teams are composed of program staff and field (Veterans
Integrated Service Network (VISN) and medical center level) health care
experts.
During the week of July 20-23, 2010, a SOARS team inspected the
Dayton VAMC. On the morning of July 21, 2010, during the course of this
inspection, two dental clinic employees approached a team member. The
employees articulated allegations about aspects of a staff dentist's
practice that pertained to this dentist's handling of dental burs and
noncompliance with dental infection control guidelines. These
improprieties allegedly were ongoing.
The allegations, if true, would have represented significant
breaches of both medical center and VHA national standards regarding
the handling of reusable medical equipment (RME), adherence to
standards of infection control, and professional comportment expected
of VHA dentists. At that time, it was also alleged that these concerns
had been previously brought to Dental Service management's attention.
From August 19, 2010, through September 9, 2010, the dental clinic
temporarily suspended operations. The VISN and medical center
supervised an extensive re-organization of the dental clinic. This
included employee training, employee counseling, environment of care
improvements, and updates in operating procedures. Dayton's Quality
Manager notified The Joint Commission (the JC) and the Commission on
Accreditation of Rehabilitation Facilities that as of August 19, 2010,
as a precautionary measure in order to evaluate infection control
practices, dental services at the Dayton VAMC were temporarily
suspended.
The allegations set in motion no less than five VHA investigations
culminating in the notification, on February 8, 2011, to 535 patients
of the medical center, that infection control practices in the Dayton
Dental Clinic were not always followed.
oig review
As a result of the requests from Congress, the OIG began a review
of infection control issues at the Dayton Dental Clinic. Our review
encompassed a review of VHA actions in response to the allegations as
well as an evaluation of selected aspects of the daily functioning of
the dental clinic and its management oversight.
Dental infection control practices are governed by a multitude of
regulations, standards, and recommendations related to the appropriate
use of personal protective equipment (PPE), hand hygiene, reprocessing
of RME, and other measures to safeguard the health of patients and
staff. VHA, Centers for Disease Control and Prevention (CDC), The JC,
and the Occupational Safety and Health Administration (OSHA) have
published documents to facilitate compliance with recommendations and
requirements. The medical center has also developed local policies
related to hand hygiene, RME, bloodborne pathogens, and disinfectants.
The medical center requires its employees to comply with these
established infection control policies.
We visited the VAMC from December 14-16, 2010. We interviewed
relevant clinical and administrative staff at all levels of VHA,
extending to the Under Secretary for Health, as well as medical
consultants from the Prevention and Response Branch of the CDC, VA's
Office of Public Health and Environmental Hazards (OPHEH), and
attorneys from VA's Office of General Counsel.
We reviewed already completed VHA investigations as well as Issue
Briefs; VHA Clinical Review Board (CRB) charters, memoranda, and
reports; relevant medical and dental literature; facility-level
Standard Operating Procedures (SOPs) and policies; relevant committee
minutes; credentialing and privileging documents; dental clinic
infection control training records; and e-mail communications. We also
reviewed VHA directives, CDC guidelines, OSHA's Bloodborne Pathogens
Rule, and ADA guidelines.
vha responses to the dental service allegations
Immediately after the allegations concerning the Dental Service
were made to the SOARS team, VHA launched a series of reviews and
investigations at the local VAMC, VISN, and VA Central Office (VACO)
levels. Additionally, VHA convened an Administrative Investigative
Board (AIB) and Clinical Review Board (CRB).
Administrative Investigative Board
On July 29, 2010, the VISN 10 Director charged the medical center
to convene an AIB. The AIB was composed of five members: the Chair (an
Associate Chief of Staff/Podiatrist), a dentist; an infection control
nurse; a Supply, Processing and Distribution technical advisor; and a
human resources/labor relations technical advisor (regional counsel).
The AIB's expressed purpose was to investigate the facts and
circumstances regarding allegations outlined in the July 2010, SOARS
Report of Contact (ROC) documents received by the VISN 10 Director from
the VAMC Director. Initially, the AIB was tasked to determine:
Whether there was a deviation in any dental standard of
practice and/or improper handling, cleaning and/or disinfection of
dental burs during fitting procedures by the dentist as alleged in the
ROC and occurring in the dental clinic and/or dental laboratory at the
medical center.
Whether there was evidence to support that the dental
technicians referenced in the ROC (or others) communicated their
concerns to their supervisor or other management official(s) as
indicated/implied in the ROC. If so, identify who knew what, and when,
or if action was taken.
The AIB concluded its testimony on September 14, 2010, and its
findings and conclusions were accepted by the VISN 10 Network Director
on October 5. During the course of the AIB, a total of 31 witnesses
were interviewed. They offered testimony sworn under oath and in the
presence of a court reporter. Select witnesses were called back two or
even three times in an effort to allow AIB members to ask follow-up or
additional questions and to provide an opportunity to obtain fully
comprehensive testimony. All witnesses were afforded the option of
having personal counsel accompany them to their depositions.
After considering the totality of the record and the depositions,
the AIB concluded that the subject dentist did, in fact, repeatedly
violate infection control standards over a multiyear period. The AIB
also concluded that testimony supported the subject dentist's
violations as beginning in 1992, and without curtailment of this
dentist's privileges by knowing superiors, there was potential exposure
of patients to bloodborne pathogens.
Clinical Review Board
VHA Directive 2008-002, Disclosure of Adverse Events to Patients
(January 18, 2008), provides guidance for disclosure of adverse events
related to clinical care to patients or to their personal
representatives. This directive recognizes that although it is
difficult to weigh all benefits and harms, situations prompting a
decision whether to conduct large-scale disclosure of adverse events
likely involve the following considerations:
Are there medical, social, psychological, or economic
benefits or burdens to the veterans resulting from the disclosure
itself?
What is the burden of disclosure to the institution,
focusing principally on the institution's capacity to provide health
care to other veterans?
What is the potential harm to the institution of both
disclosure and non-disclosure in the level of trust that veterans and
Congress would have in VHA?
The CRB may choose to recommend notification if ``one patient or
more in 10,000 patients subject to the event or exposure is expected to
have a short-term or long-term health effect that would require
treatment or cause serious illness if untreated.''
We found that the need to convene a CRB was anticipated early on
during VHA's initial investigations into the allegations. On August 30,
2010, VACO senior leadership held a meeting with subject-matter experts
in which the decision was made to convene the full CRB. The initial
scope of the CRB as outlined in the charge letter was to:
Conduct a clinical risk assessment.
Identify the types of dental procedures at risk for
disease transmission.
Make a recommendation as to whether a large-scale
disclosure was indicated. If the CRB recommended a large-scale
disclosure, it was to identify which patients should be notified,
determine whether the disclosure should include deceased veterans' next
of kin, and define the look back timeframe. The CRB was also tasked to
provide justification for its recommendations.
The CRB met on September 2, 2010, and issued its first report to
the Principal Deputy Under Secretary for Health (PDUSH) on September 3,
2010. It conducted its review with VAMC members, the VISN 10 leadership
team, members of the site visit team, the VHA dental program office,
and the VHA National Director for Infectious Diseases. Multiple
documents for fact finding included the charge letter, the issue brief
and update, AIB testimony of one dental clinic staff member, the AIB
summary, a VACO August fact finding team report, a dental office review
by the Office of Dentistry Consultant for Infection Control, OPHEH
reviews, VACO's summary of the site visit to the medical center, a
timeline of events, and a universal precautions history and synopsis.
The CRB report identified three practices by the subject dentist
that posed a potential risk for infection transmission. First, the
subject dentist did not properly disinfect dentures when taking them to
and from the dental laboratory. This practice breach potentially
contaminated laboratory equipment and surfaces. Second, the subject
dentist wore soiled gloves and gowns outside the dental operatory and
the dental clinic and did not change gloves between patients,
potentially contaminating common use areas. Third, the subject dentist
used the same dental equipment on patients without cleaning or
sterilizing the equipment between patients.
In forming its recommendations, the CRB considered only the risk of
transmission of bloodborne viral infections (HIV, hepatitis B, and
hepatitis C). To assess the risk to patients posed by these practices,
the CRB also considered reviews of the medical and dental literature on
the transmission of bloodborne viral infections in dental clinics. It
was able to risk stratify the patients based on the invasiveness of the
procedure a patient received in the clinic, including removable and
fixed prosthodontics (crowns and bridges), restorative fillings, and
invasive procedures such as extractions and periodontal scaling.
Initial CRB Recommendations
The initial September 3, 2010, CRB report recommended disclosure to
all patients who had received invasive dental procedures and
restorative care from the subject dentist since 1975. It recommended
that testing for the bloodborne pathogens (HIV, hepatitis B, and
hepatitis C) should be offered to these patients. The CRB also
recommended that the AIB obtain further testimony from the dental staff
to determine whether the subject dentist was reusing needles and/or
drug vials and to clarify the subject dentist's infection control
practices prior to 1990. The CRB advised that, with evidence that the
subject dentist did not reuse needles or vials and practiced with a
dental assistant who monitored the dentist's infection control
practices prior to 1990, it could narrow its disclosure recommendations
to include fewer patients and shorten the look back timeframe.
Second CRB Review
After multiple senior level discussions, the CRB was re-convened to
further clarify risk assessment and disclosure issues. The CRB was to
review additional AIB testimony indicating that the subject dentist did
not reuse needles or vials and that he/she had a dental assistant prior
to 1992. The CRB was also directed to review the AIB's supplemental
testimony and reports. Using this additional information, it was to
again outline a recommendation on disclosure, identify the specific
patient population and dental procedures, and define the look back
timeframe.
The CRB met again on November 23, 2010, and December 2, 2010, to
consider the new information provided by the subsequent AIB testimony,
the analysis of the testimony by the Office of General Counsel, and
additional VACO and VISN 10 summary reports and findings. The meetings
were conducted with members of the VISN 10 leadership team, members of
the site visit team, the VHA dental program office, the AIB Chair, the
VHA National Director for Infectious Diseases, the Director of Public
Health Surveillance and Research, and the Senior Medical Advisor of
OPHEH.
A key factor in determining the CRB's final recommendations was its
conclusions regarding the extent and duration of the subject dentist's
infection control infractions. In its review of the testimony, the CRB
felt there was sufficient evidence to support a conclusion that major
infection control breaches did not likely occur prior to 1992, when the
subject dentist was practicing with a dental assistant. It was also
able to limit the size of the patient population placed at risk to
those undergoing only more invasive procedures that might provide a
portal of entry into the bloodstream. Such exposure could thus result
in disease transmission from one patient to another.
The CRB submitted its revised set of recommendations to the PDUSH
on December 3, 2010. By a six to one vote, it recommended that the
original disclosure recommendations be narrowed to include only more
invasive dental procedures and that the look back be limited to
patients treated from January 1, 1992, onward. It identified specific
invasive dental procedures to include: extractions and periodontal
scaling, some restorative fillings, and fixed prosthodontics (crowns
and bridges). The dissenting voter felt there was insufficient clinical
or scientific proof that hepatitis C or HIV has been transmitted in
dental settings. The dissenter also noted that ``the risk of patient-
to-patient transmission of bloodborne pathogens from occult blood in
saliva cannot be determined and is biologically plausible.''
The CRB further recommended that the disclosure ``should emphasize
that the risk of a bloodborne infection to patients is low.'' It also
recommended that each patient be offered serologic testing for
hepatitis B, hepatitis C, and HIV. This testing would be part of an
investigation for the purpose of identifying whether exposure in a
dental clinic is associated with transmission of bloodborne pathogens,
as there is little scientific evidence of known transmission. OPHEH
would conduct the investigation in collaboration with the VAMC.
CRB Recommendations and Final CRB Review
On reviewing the final CRB recommendations, VACO senior leadership
required further clarification regarding the specifics of its
decisionmaking process and justification of its conclusions. In a
letter dated December 14, 2010, the PDUSH requested that the CRB
address issues including the following:
How it chose the 1992 date, whether other dates were
considered, and whether it considered the availability of electronic
versus paper records?
What was its estimate of risk to patients and was it
quantified?
What information should be disclosed and to provide
evidence supporting disclosed information?
Did it consider input from the OGC's evaluation of the
credibility of the witness' testimony?
Did it consider the testimony of the dental residents?
Why did it defer the issue of employee risk assessment and
disclosure to the local medical center and local public health
officials rather than VISN leadership and OPHEH?
The CRB met for a fourth and final time on December 17, 2010, to
address the PDUSH's questions regarding its decisionmaking process and
risk assessments. It submitted a written response to the PDUSH on
December 17, 2010. The Chair of the CRB then met with senior VACO staff
to review and discuss its written response.
On January 4, 2011, VACO senior management made the decision to
proceed with a disclosure as recommended by the CRB's final report. The
patient selection for notification was based on those patients who
received invasive procedures performed by the subject dentist from
January 1, 1992, to July 28, 2010. An algorithm and process were
developed that identified 535 patients who met the CRB criteria for
disclosure.
OIG Conclusions
We concluded that the subject dentist did not adhere to established
infection control guidelines and policies, and multiple dental clinic
staff had direct knowledge of these repeated infractions. These
violations of infection control policies placed patients at risk of
acquiring infections including those that are bloodborne.
This was based on many facts including:
A June 29, 2010, e-mail, from a clinic dentist to the
Chief of Dental Services reporting violations of basic infection
control protocols by one specific dentist.
An August 16, 2010, memorandum for the record in which the
Dental Service Chief indicated that he witnessed violations of basic
infection control protocols by the same dentist on several occasions.
Multiple dental clinic employees telling us they had
personally observed various infection control policy violations by the
same dentist. Violations included failure to disinfect, or incorrectly
disinfect, denture prostheses prior to transferring them to the dental
laboratory and wearing gloves outside the operatory. They told us that
the subject dentist went directly from one patient to another without
changing exam gloves and did not properly clean and disinfect the
operatory. Individuals told us that unsterilized instruments were
reused on more than one patient.
We concluded that the AIB was thorough in its fact finding process.
It deposed 31 witnesses, some witnesses were called back for a second
and even third appearance before the AIB. Witnesses included current
and former leadership in the Dental Service as well as current and
former staff, support staff, and trainees. Testimony was gathered by
various methods including such instruments as written affidavits,
verbatim transcripts, or recordings of live testimony. Conducting the
AIB was a time-consuming assignment and was carried out seriously and
conscientiously by the AIB.
We also concluded that the CRB acted in good faith to address the
potential risks to VA patients. The CRB incorporated an extensive
amount of data from which to base its decisions. All recommendations
were carefully considered, with input from a solid counsel of national
subject area experts. Its recommendations appropriately followed VHA's
notification for disclosure policy.
With regards to staffing and workplace environment issues, we found
that the staffing levels at the dental clinic were persistently below
their organizational approved FTE levels and the level recommended by
VHA for optimal performance. Optimal staffing may have decreased the
likelihood that deviations from approved infection control practices
would occur. Senior leadership and committees at the VAMC did not fully
support efforts to staff the dental clinic at these optimal ratios.
During our dental clinic staff interviews, employees discussed
concerns as to work climate and morale. We heard multiple concerns
regarding ongoing staff shortages, favoritism, and demeaning comments
to staff, and we were told of staff altercations that resulted in
formal police investigations. We found indications that interpersonal
staff relations were strained, which negatively impacted the dental
clinic.
OIG Recommendations
The OIG made two recommendations:
The VISN Director review the findings related to the
Dayton Dental Clinic, to include staffing issues, and take whatever
action deemed appropriate.
The VISN Director ensure that the Dayton VAMC Director
requires the Dental Service to comply with the relevant infection
control policies.
The VISN Director and Medical Center Director agreed with the
findings and recommendations and provided acceptable action plans. We
will follow up on the planned actions until they are completed.
conclusion
Established infection control practices and policies were not
properly or consistently adhered to at the Dayton VAMC Dental Clinic.
There was evidence that staff assigned to the Dental Clinic observed
these poor infection control practices over an extended time period.
While Dental Clinic management was notified of these unacceptable
practices, it was not until a VACO review body was at the Dayton VAMC
conducting a routine inspection that definitive actions began. These
practices constitute unacceptable breaches of patient safety
precautions and a violation of the OSHA Bloodborne Pathogens Standard--
standards that veterans have a right to expect are followed with care
and diligence.
Senator Brown and other Members, this concludes our statement and
we would happy to answer any questions that you may.
Senator Brown of Ohio. Thank you, Dr. Daigh.
I will start with you. I have some general questions and
some very specific questions. I want to talk first about a
couple of your recommendations. You said at the outset, the
number 1 recommendation, the inputs of individuals do not flow
to leadership--some individuals do not flow to leadership. How
do you encourage structurally the VA, not just in Dayton but in
Chillicothe and everywhere, so that the lab techs and the rad
techs and others can feel that they will not be punished as
whistleblowers or simply that they can share information up the
chain, that they have confidence and patients can have
confidence that that information is heard? They know things
that no doctor and nurse perhaps know, as the doctors and
nurses know things they do not know. How do we build that
structure so they can do that, let us just say in Dayton for
now?
Dr. Daigh. I would say that I think that there are many
different leadership styles, and I think individuals have
different ways of being effective. But one way would be to have
a regular meeting between the director or the chief of staff,
to sit down and talk to the health techs or the senior techs in
each of the different areas of the hospital, either as a group
or individually in some, and in a group forum on a regular
basis, where real issues are discussed, where real issues that
are important to the hospital are discussed, and through the
administration then or the leadership responding back with
sound data and change, how things can be built and the flow of
information that is helpful to preventing these sorts of
things, I think, would occur. So it is a communication problem
and that level of communication, I think, needs to be set up,
that is separate from being filtered through the chief of the
dental clinic or the chief of whatever service you are talking
about.
Senator Brown of Ohio. How do you then--understanding that
can be the structure with the right kind of administration--how
do you protect that worker who wants to talk about a medical
person not changing her gloves, not doing the right kinds of
sterilization procedures? How do you protect that x-ray
technician or that--maybe they saw something on the elevator or
whatever. How do you protect them from any repercussions from
management for that sort of whistleblower action that way?
Dr. Daigh. I think that you have to first trust that the
leadership of the hospital will do the right thing and not take
repercussions. If the leadership does take action which is
viewed as negative toward the person who made the allegation,
then they can certainly--a variety of offices--the Office of
the Inspector General will certainly point them in the right
direction of where they can get help. I think that we----
Senator Brown of Ohio. If I can interrupt----
Dr. Daigh. Yes.
Senator Brown of Ohio. Would every employee of this
hospital right now at this center know that if they came
directly, no matter how low paid or whatever their position
here, no matter how newly hired, that they could go directly to
the VA Inspector General anonymously and protect themselves
from any repercussions from management?
[Murmuring from audience.]
Dr. Daigh. So the crowd says no, but I will say that we do
have--hopefully that our telephone number is in each of these
facilities. In every report we write, we put out our
identifying and contact information. We get over 30,000
allegations a year that come into our hotline, which we sit
down and look at. We work very hard to protect the identify of
those sources that choose to remain confidential. One of the
issues is that people who complain to us often, or complain to
whoever, so it is not sometimes probable that the name of the
person who made the allegation could be discerned. But we do
everything we can to protect the name of the person who made
that allegation. So we work very hard not to have adverse
events occur to someone who makes an allegation. We work very
hard to ferret out what the truth of the allegation is.
Senator Brown of Ohio. I would assure--and while this is a
hearing, I will for a moment speak to the audience--I would
assure anyone in this center or any other, whether it is an
employee or a family of a veteran or a patient, that is in
touch with my office, with Doug Babcock or Rachel Miller, the
two people I mentioned earlier, that their names will be
confidential and protected. I mean, I will assure anybody that
makes complaints to us.
Let me go in a different direction for a moment. Well, let
me take your second recommendation, that terms rotate--that top
management rotate between and among hospitals. Give me a
suggestion there specifically. How much of top management? How
long are they at a hospital? Where would they--would it matter,
geographic or size of hospital movement in moving them around?
Give me thoughts on that, if you would, more specifically.
Dr. Daigh. I would say that between the director, the chief
of staff, and probably the head nurse, depending on what the
organization of the hospital is, that--and again, there are a
variety of scenarios that one could put forth that would be
least disruptive to all concerned and yet would achieve the
goal of changing the leadership structure and causing them to
re-equilibrate and to, in fact, rejustify that what they are
doing is the right thing. So I would think on a period of, I do
not know, 3 or 4 years, that you would rotate in some pattern
at least one of the members of that group. I do not have the
study to back that up. I do not have data to cost account this
out for you, but it seems to me that that would be a very
reasonable thing to do.
Senator Brown of Ohio. OK. Every VA hospital must pass
inspection by two organizations, the Joint Commission on
Accreditation of Health Care Organizations, as you know, and
the VA Systemwide Ongoing Assessment Review Strategy. How could
what happened in Dayton over the last 18 years not have been
ferreted out? How could it have slipped past both of these
review panels?
Dr. Daigh. Well, I cannot speak for JCAHCO, but I can speak
for--we do a--every 3 years we go to VA hospitals and do what
is called a CAP inspection, and that CAP inspection is an
inspection where we come in and we look at the systems within
the hospital, like the quality assurance committees and how
they function, the peer review process, and other committees
that are set up to try to ensure that when bad things happen in
the hospital, that the hospital takes that data seriously, that
it reacts to that data seriously, and that change is made. So
whether it is an internal review group from VA or the group
that I operate that goes through this hospital and has been
here three times in the last 10 or 12 years, that we missed it
is really dreadful. I am horrified that we missed that.
We look at the hospital at committees that look across all
the organizational elements of the hospital. We typically do
not look from leadership down to the dental clinic, or from
surgery down to the plastic surgery clinic, or from medicine
down to cardiology. We try to look at those committees that
look across all elements of the organization and we did not
find that.
It also means that nobody came up and talked to us and
said, we are here when the visit is announced, when I have five
or six people in the hospital going through the books and
records. Nobody came up and said, we have a problem in the
dental clinic. Nobody called us.
So I do not have a good explanation for how this remained
encapsulated for so long other than poor leadership, at least
at the level of the head of the dental clinic, who did not over
several leaders of the clinic enforce the standards of
infection control that everyone knows should be enforced, both
for the protection of the providers and, more importantly, or
equally importantly, for the protection of the veterans. So I
have no----
Senator Brown of Ohio. Dr. Daigh, if you are not sure how
this happened as you came in from this direction in your
analysis or as the Systemwide Ongoing Assessment Review
Strategy came in, the VA, or JCAHCO, and I understand you
cannot speak for them, what assures us that this will not
happen other places, again in Dayton or in Chillicothe or in
Omaha? How do we know this, that these panels, these review
panels will not see something this serious?
Dr. Daigh. Well, I----
Senator Brown of Ohio. A better question: What have we
learned? What does this--sorry to interrupt you. What does this
review panel--what do these review panels, what did they learn
from not being able--from the failure to find this, ferret this
out on more than one occasion over 18 years? It was not just
one time that JCAHCO came or one time that SOARS came in,
correct?
Dr. Daigh. That is correct. The SOARS is an internal VA
group, but I understand your point. The group I have is a CAP,
which is a different--but point well taken.
I think that I have seen this actually twice, and what I
have seen is a provider who is well-supported and respected in
the community who, over time, the procedures are stepped down,
if you will, and might go from being a full-speed dentist to
someone who just does dentures. They might go from a practicing
surgeon who spends time in the operating room to a surgeon who
just sees patients outside the operating room. The community
supports that individual; they like that individual. And that
individual, over time, might, in fact, deviate in some way from
the standard of care, and somehow people call it an
eccentricity or they call it something else. There is
agitation, then, when younger people come into that clinic and
say, no, the standard of care is being broken. In this case, it
is infection-control policies.
Finally, when you look at it, everyone goes, oh, my gosh,
what has happened here really is a catastrophe, and what were
seemed to be minor deviations from the standard of care or
eccentricities really were quite major breaks. The leadership
who knows they should have enforced the rule, but they are
friends who worked with that individual for a long time and did
not enforce the rule are then wholly embarrassed at this
outcome. That is the best explanation I can give you for how
something like this could occur over a period of time.
Senator Brown of Ohio. Let me ask you this, or suggest
this. You came up with four or five, depending on how you
divided them, very specific points about what you suggest we do
differently, ``we'' meaning the Dayton VA. Can you come up with
similar specific prescriptive recommendations on what SOARS
should do differently, learning from their failures at the
Dayton VA and apparently in St. Louis? Can you, as Inspector
General, give them--is that in your power, and would you do
that for them so they do not make these mistakes elsewhere or
ever again here?
Dr. Daigh. I certainly can. We would--so the answer is yes.
I must say that when I do an inspection proactively and I do
not know anything is wrong. We look hard, but I simply cannot
guarantee that I will uncover all problems every time I do an
inspection. So I do the best I can. We lay out what we think
are the most critical things to look at. If we find a problem,
we write the pattern down. We bring it to the leadership's
direction and ask them to fix it. When I say that a hospital
has passed the CAP inspection or has identified defects, you
know, I simply cannot uncover every rock.
With respect to the issues here, we will work hard to make
sure that this does not occur again.
Senator Brown of Ohio. Thank you. Walk me through the
timeline regarding when the VA knew there was a problem and
when patients were contacted. If I have this right, the VA
closed the clinic in August 2010. They did not contact patients
for testing until February 2011. That is September, October,
November, December, January--6 months, more or less. Is that
standard practice? Should patients have been notified? Are you
agreeing with the process VA followed in determining who and
when to notify all possible exposures? I mean, I assume that
the 535 number is far, far, far fewer than the number of
patients that said dentist had over the last 18 years. Why 535?
Why 6 months? What did the VA not do that they should have? Run
through those answers for us.
Dr. Daigh. I am going to ask Dr. Wesley.
Dr. Wesley. Sure. Yes, sir. I would like to speak to that a
bit. I do agree with what I think you are implying, is that
notification process and the Clinical Review Board process was
protracted. The CRB, or the Clinical Review Board, which deals
with large-scale notifications, first reported up the line to
the Principal Deputy Under Secretary on September 3, and again,
as you note, the notification letters did not go out until
February 8. I think part of that----
Senator Brown of Ohio. Put the microphone a little closer
to you, please.
Dr. Wesley. Oh, I am sorry. So the first recommendation of
the notification went out September 3, but letters did not go
out until February 8. Part of that was----
Senator Brown of Ohio. Was September 3 the first
notification----
Dr. Wesley. No. The Advisory Board that dealt with the
issue of who, if anyone, we should notify, in essence, reports
or makes a recommendation to the Principal Deputy Under
Secretary of the VA for Health. They convened very early in
September, I believe it was September 2 of 2010----
Senator Brown of Ohio. After the clinic had been closed,
knowing there was a problem----
Dr. Wesley. Correct. Correct. I think the clinic closed for
about 3 weeks between August and reopened about that time. So
they convened about September 2, reported on September 3 up
their chain, if you will, basically to the Principal Deputy
Under Secretary, and, in fact, in their report recommended a
fairly large-scale notification, in fact, actually more than
500 patients. They actually recommended notifying virtually
everyone going back to 1975, when the dentist in question was
first employed.
Senator Brown of Ohio. A lot longer than the 18 years
that----
Dr. Wesley. Correct. Even longer than the 18 years. It was
not--it should be appreciated that it was not a simple issue,
though, because we have talked to CDC about this, and it is
easy when you have harm, it is easy to notify when there is
harm. But here, there was theoretical harm. It was possible
harm. So, in essence, over the ensuing 3 months they kept
revisiting the issue and attempting to figure out from the
universe of patients who should be notified. Quite frankly,
again, that was about a 3-month process. It was not until
December that they came up with more definitive
recommendations.
Senator Brown of Ohio. Tell me who ``they'' is.
Dr. Wesley. Oh, I am sorry. I apologize. When you live
this, it----
Senator Brown of Ohio. OK----
Dr. Wesley. It is the so-called Clinical Review Board. It
is an ad hoc advisory board which recommends to the Principal
Deputy Under Secretary if and how there should be large-scale
notification of adverse events in a VA facility.
Senator Brown of Ohio. These were all VA employees in
Washington?
Dr. Wesley. They were VA employees, although they--experts
throughout the system--did consult with external bodies, most
specifically the CDC.
Senator Brown of Ohio. So none of these were Dayton----
Dr. Wesley. Dayton management certainly had input.
Certainly at the VISN level, Dayton was involved. The Chairman
of the AIB was involved. VA's National Infection Control
Director was involved. It was a very--again, it was a very
excruciating, carefully thought-out process as to who to--as to
what universe of people to notify. Again, I think the core
issue is it was theoretical harm and, in a way, theoretical
exposure rather than known exposure.
Senator Brown of Ohio. It was theoretical because--was
there no real sense of urgency among this board?
Understanding----
Dr. Wesley. Right.
Senator Brown of Ohio. I do not want to belittle your
comments about how complicated it is, that there were thousands
of patients and you do not want to scare everybody and you do
not want to test everybody.
Dr. Wesley. Right.
Senator Brown of Ohio. I understand that. But if they
settle on the number 535 and it takes them 6 months to do it
and the word begins to leak out that there is a problem and
nobody really quite knows what is next, the affected
population, most of whom were not damaged--I understand that--
but was there not some sense of urgency by the VA around the
country or in Washington to move on this a little quicker to
reassure these potentially thousands of families?
Dr. Wesley. I think that point is well taken. I think they
worked very hard over 2 or 3 months, but I think by the time
they decided in late December, and I distinctly remember
meeting with the Under Secretary for Health on January 4, and
by that time, a decision had been made to notify at 535, and
again, why it takes another month, I do not know.
Senator Brown of Ohio. Well, how about as you were
analyzing this, and again, I do not belittle at all or dispute
the complexity of it, but as you are looking at this, I would
assume almost immediately, you knew that Patient X, Y, and Z,
with names attached, some number of them were at risk, and if
that is the case, why would you not notify them in October
instead of waiting until you could decide on some macro system
of doing this?
Dr. Wesley. Right. Again, I think the point is well taken.
Actually, when I looked at the witness list, I regretted that
the chairman of the CRB was not here. I think that is the best
person to answer about, you know, the time course. An equally
complex question is, again, what number. Do you notify, again,
basically, the patients that had invasive procedures going back
to 1992 or do you notify every patient that this dentist saw
going back to 1992, which is what the Greater Dayton Hospital
Association says? So not simple at all.
Senator Brown of Ohio. Do you in your mind now, or did any
of the three of you settle on a number, what the number should
have been? Should it be much higher than 535? Is 535 about the
right number?
Dr. Daigh. Let me comment. I actually think there are--I
guess what I was speaking to when I said there was a limit to
our science and then after that you had to apply policy or what
you thought were good ethics. Science would say that people who
did not have invasive procedures or had procedures in which
there was little chance that there was significant contact with
saliva would be unlikely to get any of these bloodborne
pathogens. So there is no clear answer. I think that what the
VA authored is one of many reasonable possibilities, and I
think that the Dayton--that the local view that much wider
testing should occur is also a reasonable possibility.
But I will say, if you go to the Ohio State Health site and
you plot the incidence of acute hepatitis by county, by year,
and you look at that, it is not clear to me that there has been
an epidemic of acute hepatitis here. So I think there are data
sets out there that one could look at, veterans versus, you
know, compared to the excellent work done by the Ohio medical
group collecting the incidences of these infectious diseases,
to see if, in fact, there has been an outbreak of hepatitis in
this community that could be traced back to this event.
Senator Brown of Ohio. I appreciate that answer. I still am
not clear. Should I walk out of here today, when I meet with a
VFW group or a Legion group or a Vietnam Veterans group and
they ask me, is 535 the right number? Should I be tested?
Should my friends at this post be tested? I went to that doctor
and had some minor surgery in 2007 or 2001 or whatever. What do
I tell them?
Dr. Daigh. I think that the decision to test those
individuals who had procedures by the dentist in question which
were invasive and more likely to cause blood from the mouth to
be mixed with sputum is a very reasonable set of people to
test. I do not----
Senator Brown of Ohio. That number is significantly greater
than 535.
Dr. Daigh. No, that would be the 535 number.
Senator Brown of Ohio. That is the 535.
Dr. Daigh. If you only talk about people who had a denture
pulled out, adjusted, put back in, no blood transfer, then the
risk would be much less. The problem, sir, is that if you took
a denture out of a person's mouth and you did not properly
sterilize it, you bring it to the lab where the dentures are
worked on and you worked on that denture not being sterilized,
you have contaminated the burrs in the lab. So if the next
person has their dentures----
Senator Brown of Ohio. I have read in these reports the
word ``burr.'' What is that referring to?
Dr. Daigh. It would be a device that spins rapidly that
cuts a tooth, drills a hole in----
Senator Brown of Ohio. I really hate when I go----
Dr. Daigh. Yes. So I think there are some just absolutely
practical limits from science, and I think it is a difficult
answer. I think VA authored a reasonable solution. We knew with
the hearing in St. Louis recently, and a similar problem
occurred, and I had a staff member sit in the audience and
listen to that hearing. She sat next to a lady who had gotten a
letter saying that her husband might be at risk of HIV and she
was mortified. As I sit there and think about the letter that
said, you might be at risk of HIV for, again, a removable--for
a piece of dental equipment that was not properly sterilized. I
mean, I personally think the risk that they had HIV is remote,
maybe even close to zero with no reportable cases of
transmission through saliva of HIV. I sit there and want to
make sure that we are not creating harm when we send these
letters that scare people absolutely to death.
So it is a very difficult question in terms of how to
decide and our science here. So I think there are several
reasonable solutions to it.
Senator Brown of Ohio. Would you personally go to the
dental clinic here right now?
Dr. Daigh. Yes.
Senator Brown of Ohio. OK. Ms. Shimoda?
Ms. Shimoda. Yes, I would.
Senator Brown of Ohio. Dr. Wesley?
Dr. Wesley. Yes.
Senator Brown of Ohio. My last request is to walk me
through the allegations that whistleblowers have been punished.
Can you tell me what has happened to people that have tried to
speak up, because we know of reports that people, in fact, saw
some less than proper practices in the dental clinic. What
happened to them? What were their lives--tell me what happened.
Dr. Daigh. I do not have information on that.
Dr. Wesley. Yes. I----
Dr. Daigh. I would have to have--well, I would not address
that issue.
Senator Brown of Ohio. Should you not?
Dr. Daigh. If I have to have an answer, I have to have the
name of an individual who makes a complaint to me that that
happened to them, and if they would like us to look at that or
if you would like us to look at that, we would be more than
happy to take a look at that. But whistleblower issues are
generally reviewed not so much by our office but by the Office
of Special Counsel. So if they would apply through the Office
of Special Counsel, they are the office that looks at
whistleblower retaliation issues. It has been the case where we
have done work, but they would provide it through the Office of
Special Counsel, who makes determinations on whistleblower
actions.
Senator Brown of Ohio. It seems to me from your--one more
second, Dr. Wesley--it seems to me that from the inputs of
individuals who do not flow--that the information does not flow
to leadership. It seems to me that we need to know more. If you
are making that recommendation, I appreciate that you did and I
think the employees of the VA medical center in Dayton
appreciate it. But we have to know more about what happened to
whistleblowers here and what could happen and we need to
establish protections.
I will call on you after the hearing, OK, sir?
We need this throughout the VA to be something that
whistleblowers feel some confidence in doing. I know it is an
age-old problem in government, an age-old problem in government
management, but we need to do that.
Dr. Wesley, you wanted to say something?
Dr. Wesley. All I was going to say, briefly, to expand on
your question and Dr. Daigh's reply, was in this particular
review, and we probably interviewed about 40 people and
virtually everyone that was currently employed in the dental
clinic, it was not so much whistleblower fear that came up. It
was more of a sense of general frustration that if you
articulated your concerns, nothing was done about them. So this
was more frustration, I would have to say, than fear.
Dr. Daigh. The other issue, sir, is not everyone will talk
with us. If they are an employee, we can sit down and have a
conversation. But if they have retired, then we cannot have a
conversation, so----
Senator Brown of Ohio. Could you address that? I said it
was the last question before, but I was looking at my notes
from Congressman Turner's statement, his testimony, and that
was a major concern of his. People who have retired can avoid
any kinds of accountability or any kinds of reprimand or any
kinds of punishment, apparently, unless it is criminal,
correct? So what do we do about that?
Dr. Daigh. Sir, I am not a lawyer, so I am going to talk
about what I believe the answer is. If a crime has been
committed or alleged to be committed, then our Investigations
Unit, which is separate from our Office of Health Care
Inspections, I believe, does have the authority to go look at
that and bring it to the AUSA as a potential crime, retired or
not. But if a crime has not been alleged, or there is no crime
that has been alleged, then our ability--my office's ability to
compel the discussion ends if they are not a VA employee.
Senator Brown of Ohio. So sloppy or worse safety practices,
procedures, surely are not a criminal offense, I would not
think. I assume they are not.
Dr. Daigh. I am not a lawyer and I would assume they are
not, too, sir.
Senator Brown of Ohio. So retirement basically protects
that employee from--shields that employee from being
accountable.
Dr. Daigh. There is not a clawback provision.
Senator Brown of Ohio. Thank you for your testimony. Thank
you all. Thank you for being here.
I would like to call up the second and concluding panel.
Jack Hetrick is Network Director for the Veterans Integrated
Service Network. Mr. Hetrick was appointed as a Network
Director of VA Health Care System of Ohio, known as VISN 10, in
November 2006. VISN 10 is comprised of four fully functional
medical centers that, I guess, is Cleveland, Columbus,
Chillicothe--or Cleveland, Chillicothe, Dayton, and Cincinnati,
and one independent outpatient clinic and a network of 30
Community-Based Outpatient Clinics, including the Dayton
Veterans Area Medical Center. Dayton is the satellite and four
CBOCs around you, correct?
Mr. Hetrick is joined by Lisa Durham, who is the Chief of
Quality Management at the Dayton VA Medical Center. Ms. Durham,
thank you for joining us and for your public service. Bill
Montague, who I have known for years, is the Acting Director of
the Dayton VA Medical Center. I thank Bill for coming out of
retirement. I have worked with Bill in the VA, his work with
the VA in the Cleveland Stokes VAMC, the former Director. I am
pleased Secretary Shinseki convinced him to return to service,
help restore a culture of care here. Next month, the Stokes
VAMC is going to have the grand opening of a new state-of-the-
art domiciliary, is that right?
Mr. Montague. It is the domiciliary, the bed tower, and it
is big, and thank you for your help.
Senator Brown of Ohio. It is certainly large. Thank you for
your work in that new facility.
Mr. Hetrick, if you would proceed, and perhaps Mr. Montague
or Ms. Durham can answer questions, too.
STATEMENT OF JACK G. HETRICK, NETWORK DIRECTOR, VETERANS
INTEGRATED SERVICE NETWORK 10, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WILLIAM D.
MONTAGUE, ACTING DIRECTOR, DAYTON VA MEDICAL CENTER; AND LISA
DURHAM, CHIEF, QUALITY MANAGEMENT, DAYTON VA MEDICAL CENTER
Mr. Hetrick. First of all, thank you, Senator Brown, for
the opportunity to discuss the way forward for the veterans in
the Dayton VA Medical Center. I am accompanied today by Mr.
William D. Montague, as you introduced, Acting Director of
Dayton, and Lisa Durham, Chief of the Quality Management at
Dayton. I would like to request for my written statement to be
submitted for the record.
We are here today to discuss the lapse in proper infection
control practices of one dentist at the Dayton Dental Clinic.
More importantly, we are here to inform everyone about what we
have done and will continue to do to ensure that care veterans
receive meets the highest standards of quality and safety. We
appreciate the OIG's support in reviewing our program and
developing recommendations, as well as our participation in
today's hearing.
My written statement provides an overview of how we
discovered the lapse in infection control. In the time I have
now, I will discuss the efforts currently underway as well as
those that will soon be implemented in response to this
incident.
Our quality management enhancement efforts have taken many
forms. First, we provided additional education and training and
updated standard operating procedures in the dental clinic. We
have evaluated dental equipment and instruments, making changes
where indicated, and repaired the physical infrastructure in
the dental clinic. Monitoring and compliance are two critical
aspects of our quality and safety programs. I directed that
there be unannounced inspections of all network dental services
to ensure proper dental policies and procedures are in place
and that instruments are properly maintained. We have made
several changes to infection control procedures, and through
regular and even daily assessments we are documenting our
compliance with standard practices.
Turning to personnel matters, I convened an Administrative
Investigation Board to determine if there was any deviation in
dental standards of practice or improper handling, cleaning, or
disinfection of dental equipment. I directed facility
leadership and network staff to identify any possible trends
based on available records.
Looking ahead, our immediate focus is on implementing the
recommendations our colleagues at the OIG have offered. The OIG
made two specific recommendations, to review the findings
related to the dental clinic, including staffing issues, to
take appropriate action, and to ensure the Dayton Director
requires the dental service to comply with infection control
policies. I concur with their recommendations.
By the end of June, we will be in full compliance with the
first recommendation. We are taking administrative actions
against the parties responsible for allowing this lapse to
occur and we are modifying the organization of the dental
service for better oversight. By the end of May, we will have
systems in place to track dental service mandatory infection
control training and will be randomly auditing compliance
through documentation and observations to ensure quality care.
VA's central office has convened a Management Program
Review Team to assess the Dayton VAMC to identify factors that
may have allowed this particular practice to continue
undetected or unreported. The team will ensure that we have
implemented systems to properly identify and effectively
address issues that require immediate response. Information
from this review will help VA look at systemwide opportunities
for management improvement.
In closing, I would like to emphasize that this is
unacceptable that the situation went on so long. We have taken
administrative actions to ensure those responsible for this
serious error are held accountable. In the days and weeks
ahead, we will be working closely with our colleagues at the
OIG as we continue to enhance the care we provide. I have
discussed the lessons we have learned here at Dayton with other
VA leaders so they can benefit from our experience.
For those veterans who were affected by this incident,
there is a dedicated hotline, and I will read the number, 1-
877-424-8214, that is available 24 hours a day, 7 days a week.
If veterans or family members have questions about the Dayton
Dental Clinic, we strongly encourage them to call. We are
asking veterans that want to be tested to report to the primary
care clinic for an appointment. Veterans may walk in during
clinic hours or call the hotline number for an appointment.
Thank you for inviting me here to testify to discuss these
plans and to listen to your recommendations. My colleagues and
I are prepared to answer your questions.
[The prepared statement of Mr. Hetrick follows:]
Prepared Statement of Jack G. Hetrick, FACHE, Network Director,
Veterans Integrated Service Network (VISN) 10, Veterans Health
Administration, U.S. Department of Veterans Affairs
Senator Brown, Thank you for the opportunity to discuss the way
forward for Veterans and the Department of Veterans Affairs Medical
Center (VAMC) in Dayton, Ohio. I am accompanied today by Mr. William D.
Montague, Acting Director, Dayton VAMC; and Lisa Durham, Chief, Quality
Management at the Dayton VAMC. We are here today to address the lapse
in proper infection control practices of one dentist at the Dayton
VAMC's Dental Clinic. More importantly, we are here to inform our
stakeholders, including our Veterans, their families, the public and
Congress, what we have done and will continue to do to ensure that the
care Veterans receive meets the highest standards of quality and
safety. We also want to reassure stakeholders that we are taking action
to ensure that an event like this does not occur again. Part of the
process of restoring confidence requires an honest and transparent
account of what occurred. My testimony will begin with an overview of
how we discovered the improper practices of the single dentist. From
there, I will discuss the actions VA has already taken in response to
this incident. I will conclude by describing our future plans.
infection control deficiency at the dayton vamc dental clinic
During a scheduled internal review process by one of VA's System-
wide Ongoing Assessment and Review Strategy (SOARS) teams in July 2010,
concerns were raised about adherence to infection control procedures in
the Dayton VAMC Dental Clinic. The leadership of the facility, in
consultation with me, immediately initiated a fact finding review to
assess the concerns. Once the concerns were confirmed, I immediately
expanded the investigation. Rapid response teams from VA Central Office
helped us analyze the problem and determine corrective actions, and we
decided to suspend dental services. The dental service closed for
approximately three weeks beginning August 19, 2010, while all
employees in the clinic received extensive refresher training and
competency certification on proper infection control techniques.
Investigation and outside review confirmed that a single dentist
was not following proper infection control practices. VA initiated a
Clinical Review Board (CRB) process to determine the level of risk to
Veterans receiving care from this provider. This included an intensive
review of our records dating back to January 1992. Though the risk for
infection was considered very low, the CRB recommended VA notify
Veterans who received specific procedures involving invasive dental
treatment performed by this dentist.
When the extensive review of records was completed and validated,
it was determined that 535 Veterans should be notified about the
possible exposure. The Dayton VAMC provided Veterans information
regarding their potential exposure, and extended an opportunity for
testing. As of April 15, 2011, all 535 Veterans have been contacted.
506 have been tested. Two new cases of hepatitis B have been
identified. While it is impossible at this time to determine if the
source of the infection arose from the dentist's failure to comply with
infection control practices, the investigation through VA's Office of
Public Health is continuing, and these patients are being actively
evaluated and followed.
There have been no new cases of HIV identified, and only one
patient has tested positive for hepatitis C. This patient does not
exhibit evidence of illness and, again, we cannot determine the source
of infection at this time. Testing to confirm hepatitis C, and research
to determine a possible relationship to the dental clinic, is ongoing.
If additional cases are confirmed, and even if we cannot determine if
the source of the infection arose from treatment in the dental clinic,
VA will offer treatment to any newly diagnosed Veteran.
actions taken to ensure high quality care at the dayton vamc dental
clinic
VA has taken a series of actions to assure high quality care is
provided and maintained in the dental clinic at the Dayton VAMC. We
have provided additional education and training for dental staff and
completed a review of staff competencies related to the education and
training they received. During the dental clinic closure, we updated
and standardized operating procedures in the dental clinic. We also
evaluated dental equipment and instruments and made changes where
indicated. In addition, we completed repairs to improve the physical
environment of the dental clinic. These measures are in addition to
those taken to improve conditions for employees, which we expect will
improve morale and performance. Improvements to increase communication
among all dental employees, including leadership, have been
implemented. Regular meetings and morning huddles provide the
opportunity for increased communication and openness. The Acting Chief
of the Dental Service held regular conference calls with other Dental
Chiefs within the VISN to make certain they benefited from the lessons
learned at Dayton. This information was also shared nationally among
dental professionals.
Beginning last July, a number of initiatives were instituted at the
Network level. I convened an Administrative Investigation Board (AIB)
to determine if there was a deviation in any dental standards of
practice or improper handling, cleaning, or disinfection of dental
equipment. This Board was composed of experienced external clinical
members and an internal infection control professional. I directed the
Dayton VAMC leadership and VISN 10 staff to review results of previous
investigations, workplace evaluations, performance improvement plans,
credentialing and privileging, VISN Readiness Reviews, and environment
of care rounds. Patient safety and risk management reports were
carefully reviewed to determine if there were any trends. Based upon
the events at Dayton, I directed VISN professional staff members to
conduct unannounced inspections of all VISN 10 dental services to
ensure all expected dental policies and procedures were in place, all
dental equipment and instruments were properly maintained, and all
practices were in compliance with standards. I required VISN 10
facility directors to visit and conduct similar reviews of their
internal dental operations. I received the final AIB report in October
and accepted the findings and conclusions. After reviewing the AIB
report, Dayton VAMC Leadership proposed administrative actions. The
dentist in question chose to retire before that process was complete.
In December, I attended a meeting in Washington, DC, to discuss the
lessons we learned at Dayton with other Network Directors from across
the country. VISN 10 staff has continued to conduct follow-up,
unannounced, inspections of the Dayton Dental Service and other areas
of the facility related to infection control.
In the area of infection control, the Dayton VAMC now includes a
dentist as the Dental Representative on the Infection Control
Committee. A dashboard was developed to summarize infection control
practices and compliance. The Dayton VAMC infection control staff
conducts quarterly observations of dental staff proficiency. Infection
Control Practitioners maintain a daily log of their activities to
document compliance with standard practices. Dayton developed a
checklist for conducting clinical inspections and chart reviews to meet
the requirements of focused and ongoing peer review programs. New
standard operating procedures were implemented prior to the reopening
of the clinic in September.
VA's National Center for Organizational Development staff visited
Dayton and offered a number of recommendations that have subsequently
been enacted. In the area of leadership, the Dayton dental
organizational chart was revised to ensure oversight and sufficient
staffing support. Position descriptions have been reviewed and revised.
Dayton has updated performance appraisal plans to emphasize
accountability for safe and quality care, and these updates have been
communicated and issued to employees. Efforts are underway throughout
the Dayton VAMC to improve communication by offering additional
opportunities for providing information to leadership through regular
meetings, committee assignments, and participation in the relationship-
based care initiative.
We are evaluating staffing levels in the Dental Clinic. A new
position of Assistant Chief for Dental Service was established.
Recruitment has been completed for a new Lead Dental Assistant and
Dental Lab Technician. Recruitment is being finalized for a general
dentist and administrative support staff. Dental hygienists have been
relocated into larger space to accommodate clinical need, and
administrative support was added to improve customer service and
scheduling. The Dayton VAMC set up a dedicated Dental Communication
Center Hotline (1-877-424-8214) that is available 7 days a week, 24
hours a day. If Veterans or family members have any questions about the
care provided at the Dayton VAMC Dental Clinic, we strongly encourage
them to call. A special clinic was established for Veterans to come in
for testing. Since we have been successful in contacting all of the
Veterans, in the identified cohort, we are asking remaining Veterans
that are interested in being tested to report to Primary Care, Monday
through Friday from 8:00 a.m. to 4:30 p.m. and follow-up with their
Primary Care provider. Veterans may walk-in during clinic hours or call
the hotline number for an appointment.
Since we began this series of improvements last summer, the Dayton
VAMC has been inspected multiple times by various VA teams and the
Office of the Inspector General (OIG). We appreciate the OIG's
independence and counsel and have collaborated with them to ensure they
have access to any information they need. In November, The Joint
Commission conducted an unannounced review of the Dayton VAMC, with an
additional surveyor focused specifically on the Dental Clinic. There
were no dental service infection control issues identified.. The
hospital has received full 3-year accreditation.
the way ahead: continuing to deliver high quality care at dayton
We have made significant progress and major changes to ensure that
health care is delivered timely, safely and appropriately at the Dayton
VAMC. While these accomplishments are notable, we still have more to
do. We will continually strive to be the Veteran-centered, results-
oriented and forward-looking organization the Secretary has called us
to be, and that our Veterans deserve. Our immediate focus is on
implementing the recommendations our colleagues at the OIG offered
following their review of infection control practices at the Dayton
VAMC in December 2010. The OIG issued a draft report to the VISN in
March. We provided our comments on this report back to them in early
April.
The OIG made two specific recommendations: first, I am to review
the findings related to the Dayton VAMC Dental Clinic, including
staffing issues, and take appropriate action; and second, I am to
ensure the Dayton VAMC Director requires the Dental Service to comply
with relevant infection control policies. I concurred with their
recommendations. By the end of June, we will be in full compliance with
the first recommendation as all necessary actions will have been taken.
Administrative actions have been initiated against the parties
responsible for allowing these lapses of infection control practices
and inadequate oversight to occur. We will be finished modifying our
Dental Service organizational structure consistent with findings in the
OIG report. Regarding the second recommendation, by the end of May,
systems will be in place to track all Dental Service mandatory
infection control training. We will institute periodic random audits of
infection control training compliance and observations, and will
document staff knowledge of the infection control on the checklist in
the Dental Dashboard. We will continue to work closely with infection
control experts available in VA's system to ensure infection control
practices are current with health care standards and expectations.
We are also taking other actions to improve the care we deliver
beyond the OIG's recommendations. First and of greatest importance, we
will continue to reach out to Veterans who had contact with this
dentist to provide them whatever support they may need. VA Central
Office has convened a Management Program Review Team to conduct an
organizational assessment of the Dayton VAMC. The primary purpose of
this assessment is to identify any organizational or leadership factors
that may have allowed this particular practice to continue undetected
or unreported. The Team's report will be used to evaluate operations
and to assess whether similar conditions may be potentially present in
other parts of the Dayton facility and potentially at other VA
facilities. The Team will ensure that current key leaders have
implemented systems to properly identify and effectively address
clinical or administrative issues that require immediate response. The
Team is being asked to do a retrospective review of the organizational
and management structure and governance, operational dynamics and
culture, key reporting structures, leadership, attitudinal factors, and
other pertinent areas. Information gathered from this review will help
VA look at system-wide opportunities for management improvement. The
Team consists of experts with years of experience across the VA system,
and will also include a representative from the National Center for
Organizational Development, who will serve as a consultant and advisor.
A member of my staff will accompany and support the team as needed.
conclusion
Our primary mission is to serve the Nation's Veterans. We sincerely
apologize to the Veterans who received notices regarding infection
risks related to dental procedures while under our care. We also
apologize to the public, whose trust may have been questioned. It is
unacceptable that this situation went on for so long. The Dayton VAMC
leadership took action when employees raised concerns in an internal
review process, and the facility has been inspected multiple times by
VA and non-VA experts. We have taken administrative actions to ensure
that those responsible for this serious error are held accountable. In
the days and weeks ahead, we will be working closely with our
colleagues at the OIG to ensure we have addressed the concerns
identified and to institute changes in the organizational and
management structure and governance, operational dynamics and culture,
and the overall environment of care. We will work closely with national
VA program offices to make certain our practices and policies are
current and responsive to changes in health care standards.
Thank you for inviting me here to testify today to discuss these
plans and to listen to your recommendations. My colleagues and I are
prepared to answer your questions.
Senator Brown of Ohio. Thank you, Mr. Hetrick.
You heard the Inspector General, Dr. Daigh's,
recommendations. Give me general thoughts on implementing his
ideas.
Mr. Hetrick. Well, I think, first of all, the
recommendation about making sure that the management team,
regardless of where the hospital is located at, listening to
employees within the various levels of their organization is
clearly a sound recommendation. I would not argue with that. I
think that, as our testimony goes on, Mr. Montague will show
you some of the things that he has already done to try to make
that happen here at Dayton by getting the message out to
employees in the hospital and making sure they understand that
they have the option to talk or to write anonymously, as the
case may be, with their name, whatever way they want to do it.
We certainly will listen.
I have the advantage in my office, which is located, as you
know, in Cincinnati, but we receive messages, letters, e-mails
from a variety of employees from around the network with
concerns. I have said publicly when I visit a hospital, have a
town hall meeting, or whatever forum that I am asked to speak
in that we will address every issue that comes to our
attention, whether we know who it was that brought that issue
to our attention, even--I cannot obviously respond to somebody
who sent me something anonymously, but we will document it for
our records in the case we hear about it again or see something
that happens similar in the future that we looked into it. If
an employee has an issue and they bring it to my attention
personally or through some other of the many message chains we
have available to us, we will get back to them and give them an
explanation of what happened.
We, just as in this case, when the situation was uncovered
in the dental clinic, one of the first things we did was inform
the employees who were working there they had two options. They
could let the Joint Commission, as Dr. Daigh referenced in his
testimony, they can call them and they would, in turn, come and
perhaps do an on-site review of that issue. They would notify
us of that complaint and we could look into it and get back to
them, or they could call the OIG hotline number, which was
provided to the employees at the time the incident was
uncovered.
We certainly work very closely--Dr. Daigh mentioned, I
think, 30,000 complaints his office gets. I am pleased to
report we do not get that many in Ohio, but we do get referrals
from the OIG hotline, and we provide a very comprehensive
review and response back to them. So I am all for that. I think
we will do everything within our power to make certain that we
try to expand those levels of communication so we get to as
many people as possible within the organization.
I am not sure--I only heard Dr. Daigh's recommendation
about management movements in a period of time. I really have
no comment on that at this point. I would need some time to
think about that. But I am really rather focused on how we can
continue to make things better with the people we have to work
with.
Senator Brown of Ohio. Mr. Montague, tell us, if you would,
from listening to Dr. Daigh's recommendations and thinking
about what you have implemented since you have been here, give
me the two or three most important things, most important
changes you have recommended based on, or not based on, the IG
report.
Mr. Montague. Well, I think the most important change we
made is we made the lines of communication and the lines of
authority and responsibility the same. Authority and
responsibility are now at the same level, and there is no
ambiguity as to whose task or whose responsibility something
is, and they have the necessary authority to implement it. That
helps with communications. It helps with figuring out what goes
on.
For example, I think--well, number 2 would be patient
satisfaction. We have truly emphasized patient satisfaction
when we made a distinct change. In the past, the complaint
department, namely the patient representatives, who are
excellent, were given the responsibility for patient
satisfaction. That is too late in the game. We made a formal
move to give nursing responsibility for patient satisfaction,
obviously in collaboration with the physicians and the support
staff. But the nurses now own the wards. They know they own the
wards. They have a number of relationship-based care
initiatives which should cement better relationships between an
individual patient and the staff.
Then, finally, on the cultural affairs question that you
have been asking, we are sending cards to everyone that say, do
not be afraid. We have to know. It is part of our quality
management program.
Senator Brown of Ohio. Do you know, Mr. Hetrick, the total
number of patients seen by the dentist in question?
Mr. Hetrick. I do not, sir, have the exact number at my
disposal. The numbers range, because of the long period of time
and the reliance on paper records versus computerized records,
so we are more certain about the time period about the--when
records are electronic versus the----
Senator Brown of Ohio. What year was that?
Mr. Hetrick. I believe that goes back for dental in the
early 2000s, if my memory serves me correct.
Senator Brown of Ohio. Can you give me a rough estimate,
within a few hundred, of how many he saw over 18 years?
Mr. Hetrick. Over 18 years? I do not know. I would have
to--I was not totally involved in that. Let me----
Mr. Montague. Twenty-three hundred.
Mr. Hetrick. Twenty-three hundred, OK.
Senator Brown of Ohio. Twenty-three hundred? OK.
Mr. Hetrick. Yes. Thank you.
Senator Brown of Ohio. If someone wants to be tested and
was not in, what do you call it----
Mr. Hetrick. The cohort.
Senator Brown of Ohio [continuing]. The cohort----
Mr. Hetrick. Yes.
Senator Brown of Ohio [continuing]. The identified cohort,
what do they do?
Mr. Hetrick. I would point out that the defined cohort of
535 number, we have tested close to 100 the last time I checked
outside of the cohort because they showed up and wanted to be
tested.
Senator Brown of Ohio. So some were of the difference
between 2,300 and 500, 100 of those 1,800, roughly.
Mr. Hetrick. Mm-hmm.
Senator Brown of Ohio. When they are tested, they get--if
they are tested positively, they, I assume, get total VA
benefits and compensation and care?
Mr. Hetrick. All patients that have--a special clinic was
set up for the testing and counseling and explanation of what
the next steps would be, should there be a positive finding. So
the answer would be yes. That will be part of what will play
out.
Senator Brown of Ohio. You have been in this position since
November 2006, in the position of being the head, if you will,
of these four medical centers, a very responsible position. How
do you think this could have happened in one of your four
medical centers without your knowing it?
Mr. Hetrick. Well, I have asked myself that question a
number of times----
Senator Brown of Ohio. I am sure you have.
Mr. Hetrick. It is very troubling. I do not want to be
using the same words as others, but I cannot find any other
word to fully describe----
Senator Brown of Ohio. Is there some culture----
Mr. Hetrick [continuing]. How troubled----
Senator Brown of Ohio. Our office--we have been working
with this--I have only been in office since the same time you
took office, around 2006, 2007, and we had been working to try
to improve--there were significant management problems here. We
knew that. We did not know anything about the dental issue.
Maybe not a culture of recklessness, but morale was an issue.
There were all kinds of patients--I mean, all kinds of
employee-employer/management-labor issues going on. Did that
not alert somebody like you, or else somebody else, to a
carelessness, a recklessness, or a dysfunction that should have
meant a deeper look at what was happening here?
Mr. Hetrick. Yes. If I remember correctly, I think this
goes back to about April 2007, and you and some folks from here
and myself had a conversation on the telephone about the issues
you just raised. I think we had a very strong response to that
at the time.
Addressing patient satisfaction was an issue with me across
the network, not just here in Dayton. Despite the fact we have
very good numbers with many performance measures and many with
access numbers among the best anywhere in the VA system, we
still had ongoing issues with our patient satisfaction results,
primarily inpatient. So that was clearly something that I was
very concerned about, and it resonated with me that you brought
it up, and I certainly appreciated your support at the time,
because I think that helped us to move into a number of new
territories. Although it has not been as fast as I would like,
we continuously see improvement in those numbers.
Now, with regards to the culture of the facility and the
management, that part of your question, we worked very closely
with the National Center for Organizational Development,
affectionately known in our group as NCOD, which is sort of
bipartisan in a way. They come in and do organizational
assessments. They help figure out what is going on, what works
right and what does not work right and how we can set a course
to try to make improvements.
We took all of that--that followed your initial call with
us and they came in, and they did a very top all the way down
assessment and met with hundreds of employees, did all kinds of
individual assessments, and really put together a good plan.
Mr. Richardson at the time brought somebody in from their
organization to be onsite to help carry that out. While Dayton
was not the leader in moving up in employee satisfaction or
results, they had made steady improvements in that area and
were actually above the VA average, as I recall, the last time
on the all employee satisfaction.
So when looking at those kinds of things, I saw things
moving in the right direction. Was it perfect? No. We always
have a lot of work to do. But I was satisfied that we were
moving--that still does not answer the 18-year gap. I think
that what I am trying to do now is to make sure that that never
happens again and pooling all the resources I have available to
me to figure out the way that we can possibly change that, that
no one ever thinks it is OK to observe something that is wrong
and not report it. So that is what I am trying to focus on now,
because I just realize I am not going to be able to explain to
you 18 years.
I sat down after this incident came to my attention. We
went through every record that we had in our office and every
review, every organization, and it has been the OIG, it has
been SOARS, it has been you name it, they have been here. We
looked to see, did we miss a trend? Did we miss something that
should have alerted us? And, quite frankly, there were no--we
did not have any record of patient complaints that came to us,
any letters from an individual saying they had a concern about
the dental practices. If any of those things had been there and
I had missed that, I would be the first person to acknowledge
that. But I did not see that, and so what I am trying to do now
is just do the best we can to make sure we never have that
situation happen again.
Senator Brown of Ohio. Was there an issue with--did you, or
have you heard from others within the Dayton Medical Center
that there was perhaps a problem with staffing shortages, that
there was too much work being done by too few people here?
Mr. Hetrick. Well, staffing is always an interesting
subject to take up. I would say most departments, if we went
around and asked, might say they did not have enough staff. I
think that the board, during their investigation, addressed
that in terms of staffing--particularly in relationship to the
residency program that they were operating--and I believe, and
have discussed this with Mr. Montague, that he feels that the
recommendations that they made in terms of what should have
been in place, we do not disagree with.
Whether or not there are--I think that over the years, and
again, this covers a long period of time and what rationale
related to what decisions at that point in time is hard to
speculate on, but I do think that as practice patterns change
over time and more dentists now have assistants in use, I think
we need to move along with that. I think they were partway
there and not the entire way there. We have since done a top-
down review. We are making, of course, changes once again to
make sure that that staffing mix is right for the amount of
work they have to do.
Senator Brown of Ohio. Does the VA put more emphasis on not
rocking the boat than it does on patient care?
Mr. Hetrick. Well, that is a tough question. Not in my
network. I personally do not think that we emphasize that in
the field level. I really feel that since Secretary Shinseki
has been in place--this is not about him, of course, but he has
been very engaged in talking with leadership at the VISN level.
As a matter of fact, tomorrow morning, I have a briefing with
him on another subject. This is unprecedented in my time in the
VA.
So I think that we are moving beyond rocking the boat. No
one in the chain of command above me has attempted to make
light of this or to slow things down. I think that folks were
appalled at all levels and tried very hard to work their way
through. You know, rocking the boat is something, I think, all
of us should do all the time whenever patient care is involved.
Senator Brown of Ohio. Does the VA owe veterans in the
Miami Valley an apology?
Mr. Hetrick. Well, I think we have done that. I know I
personally wish I could meet every single one of them and
apologize for what happened over the course of these years
without--I mean, the only reason why we exist is to take care
of veterans, so there is no question whatsoever about our
mission, and what we should be doing. I believe that if anyone
has been shaken in our confidence, we have a big job ahead of
us to try to gain that confidence back, and I think that that
has been the focus, once we got past the issues involving
investigation and all the things that come with that. Now the
work here at this hospital under the leadership of Mr. Montague
and his staff is to try to restore that confidence, and
whatever I can do as a Network Director, we will be certainly
participating in.
Senator Brown of Ohio. Thank you for that. What kind of
notification or outreach are you doing to those people outside
the identified cohort of 535 patients?
Mr. Hetrick. There has been no direct communication via
calls or letters to those outside the cohort.
Senator Brown of Ohio. Should there be?
Mr. Hetrick. Well, that is a policy question that I believe
that many very highly qualified experts looked at, and I go
back to Dr. Daigh's statement about notifying someone about
something that is a very, very low risk can sometimes cause
more harm than what it solves.
If the decision is made to do that, we would certainly do
everything in our power to get to those folks and bring them
back. But again, I think the focus is on doing sort of
grassroots efforts now, that Mr. Montague and his staff are
meeting with various groups, service organizations, and others
to try to restore the confidence. Again, if someone wants to be
tested, they are welcome to come forward.
Senator Brown of Ohio. For my last question, Mr. Montague,
tell us what you are doing to restore trust to a public that
includes veterans and non-veterans alike in the Miami Valley
and the area beyond the Miami Valley that this clinic serves,
that this hospital serves, what specifically are you doing to
give people more trust and more faith and more certainty that
this is not going to happen again here?
Mr. Montague. Well, our goal, day one, when Congressman
Turner had the last presentation, we brought the media into the
dental clinic, and we would invite anybody else to come into
the dental clinic and actually see it. We will go to any
organization that invites us, any service organization, any
community, town, whatever, explain what happened, why. We stand
ready to test anybody that wishes to be tested, and if the CRB
changes its guidelines, we stand ready, willing, and able to
test whomever it is clinically determined is appropriate.
Senator Brown of Ohio. How many Veterans Service
Organizations and others have you gone out to speak to so far,
roughly?
Mr. Montague. Thus far, I have visited the Chief Service
Officer of each of the six major service organizations. I have
not been to a post or an American Legion hall yet, but I did
offer the invitation to the leadership. I am involved in the
Memorial Day parade, and I am sure--you know how many times I
came to Lorain.
Senator Brown of Ohio. I do know that. [Pause.]
Thank you for your testimony and for your service.
I will adjourn the Committee meeting in a moment. For
people who want to talk to me specifically, I will stay around
for 30-40 minutes or so. My staff will stay around a little
longer than that, I assume. I will stay around pretty much as
long as I need to and people can individually bring up things
to me. Understand, be assured that anyone that wants to speak
to me or to my staff or to the Inspector General or to the VA,
I will protect their confidentiality. That is a commitment from
me to any of you or to your family members or to your
coworkers.
The Committee will prepare a print of this hearing. The
Committee staff and I may have other questions of the
witnesses, which we will submit in writing to them, which they
will, I would assume, answer promptly and that will be in the
Committee print, also.
I thank the six witnesses. I thank you for your service. I
thank particularly the people that work here and the patients
who have served here. The apology from the VA was, I think,
heartfelt, but the actions were not excusable and we need to
assure people and we need to make sure that this does not
happen again at this fine institution or any other, the Vet
Centers, and the Community-Based Outpatient Clinics that serves
veterans in this State. Your service is too important to
deserve anything less. I thank you for your service.
The Senate Committee on Veterans' Affairs is adjourned.
[Whereupon, at 3:20 p.m., the Committee was adjourned.]