[Congressional Record Volume 155, Number 8 (Wednesday, January 14, 2009)]
[Senate]
[Page S394]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DURBIN:
  S. 246. A bill to amend title 38, United States Code, to improve the 
quality of care provided to veterans in Department of Veterans Affairs 
medical facilities, to encourage highly qualified doctors to serve in 
hard-to-fill positions in such medical facilities, and for other 
purposes; to the Committee on Veterans' Affairs.
  Mr. DURBIN. Mr. President, in the fall of 2007, at least nine 
veterans died at the Marion VA Medical Center as a result of the poor 
medical care they received. We immediately learned that a VA surgeon, 
who had operated on some of these veterans, was not qualified to work 
at the VA but slipped through the hiring process. Later, VA 
investigations revealed much larger problems in the management of the 
facility--problems that employees kept secret out of fear for losing 
their jobs. Today, I am reintroducing legislation to help ensure that 
incidents like these never take place again at Marion or another VA 
medical center.
  I asked the VA to investigate the circumstances surrounding these 
unfortunate deaths as soon as they came to light. The VA investigation 
revealed that Marion hospital management knew that doctors, including 
the surgeon at issue, were not properly credentialed but failed to act. 
The surgeon remained employed at the Marion hospital and practiced 
there for more than a year. Had he not been hired to work at Marion, 
many of his patients may have survived their surgeries.
  The VA investigation revealed additional quality of care issues at 
the Marion hospital. Management disregarded VA quality care directives 
in the face of serious patient incident reports and surgical data 
collected to ensure quality of care. They ignored or failed to 
recognize warning signs that there were problems in the surgical 
program.
  The investigation also showed many Marion Medical Center employees 
feared reporting quality of care issues. They worried that quality of 
care might be suffering at the facility but hesitated to report those 
concerns for fear of losing their jobs. A primary reason is that such 
reports were funneled through management at the facility, rather than 
being handled by an independent and confidential outlet focused solely 
on quality of care.
  The legislation I am introducing would improve quality of care across 
the VA medical care system.
  First, it would improve the process of vetting doctors who apply to 
or work for the VA and restore accountability to physician hiring and 
retention practices.
  Second, the legislation would expand the quality control programs in 
the VA health care system. The bill creates new quality assurance 
officer positions, gives VA employees new forums to raise concerns 
about the quality of care at a VA facility, without fear of 
retribution, and establishes strong peer review mechanisms for 
physicians.
  Third, the legislation would create incentives to encourage high-
quality doctors to practice at VA hospitals. In return for agreeing to 
practice in hard-to-serve areas, doctors and medical students could 
participate in student loan forgiveness and tuition reimbursement 
programs. Doctors would also be eligible to participate in the federal 
employee health insurance program.
  Fourth, where practical, VA medical facilities would be required to 
establish affiliations with nearby medical schools. These partnerships 
would expose medical students to careers with the VA. In return, the VA 
would benefit from the energy and innovative ideas brought by students 
working in their facilities. In addition, VA hospitals would benefit 
from access to experienced medical school faculty members.
  Finally, the bill would encourage the VA to increase its recruitment 
of experienced doctors who are willing to practice for our veterans. 
The VA must hire and retain only highly qualified doctors as it takes 
on these tremendous responsibilities.
  Every one of the tragic deaths at the Marion VA hospital violated the 
obligation our Nation owes to its veterans. Each of their lives can 
never be replaced. The Veterans Health Care Quality Improvement Act is 
a strong step toward avoiding such tragedies in the future and 
reestablishing trust in the veterans health care system.
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