HOUSE COMMITTEE ON VETERANS’ AFFAIRS
JULY 13, 2010
STATEMENT OF THE HONORABLE ROBERT A. PETZEL, M.D.
UNDER SECRETARY FOR HEALTH,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
July 13, 2010
Chairman Filner, and distinguished members of the Committee: thank you for the opportunity to discuss our finding that there was a failure to clean dental handpieces according to manufacturer instructions and VA standard operating procedures at the St. Louis Department of Veterans Affairs (VA) Medical Center. We understand our Veterans, the public, and Congress are deeply concerned about this revelation, and we appreciate the opportunity to address this issue in detail and on the record. Simply put, what happened at St. Louis was unacceptable.
It is the first responsibility of every government agency to be open and honest with the public and its clients—in our case, the brave men and women who wore the uniform and promised to defend this Nation. We at VA have the great privilege and solemn responsibility to provide health care and benefits to this population. We strive every day to improve the quality of health care for our Veterans. We constantly monitor and inspect more than 1,000 VA clinical sites performing millions of procedures each year. We are dedicated to taking immediate steps to set things right whenever we discover problems.
We understand that honesty and good intentions are not enough; public confidence in government is equally important in delivering quality health care to our Veterans. Every employee of the Department of Veterans Affairs understands that incidents like what happened in St. Louis can lead Veterans and their families to question the care we provide, delay needed health care or seek it from another source. We deeply regret the emotional and psychological burden that we have placed on our Veteran patients and their loved ones. Even though the risk of infection to our Veteran patients is in this instance statistically low, the psychological consequence of the error is a high price to pay for those men and women who have already paid so much on behalf of this nation.
VA is grateful for the sustained confidence in our ability to provide world class care demonstrated by our Veterans, their family members and the Veteran Service Organizations. We believe we have a system of quality assurance and safety that is second to none. This belief is buttressed by the findings of a range of independent investigations that have reported health outcomes are better for Veterans seen in VA facilities than those seen in other settings. We know that public confidence is a resource not to be esteemed lightly or taken for granted. Following setbacks in the quality of care we delivered in several of our endoscopy programs, and now this issue in St. Louis, we have to demonstrate with actions and not words that we continue the care and safety of our Veterans as a priority. When our care does not meet the high standards we have set, we notify our Veterans and arrange the necessary care to alleviate their concerns and restore their confidence. But we also must hold our people accountable. I have always believed that accountability is a two-way street: leaders must provide clear expectations and the resources necessary to meet them, and employees must use those resources carefully to achieve our objectives. Accountability can take many forms. In some cases, errors are made because of a lack of training or information, and in these cases, it is our duty to provide our front line staff with what they need. In other cases, disciplinary action is warranted. We have convened an Administrative Investigation Board to review the issues we identified in St. Louis to determine what further action we need to take as an organization to ensure the protection of our Veterans, and we will keep Congress informed as this Board makes its recommendations. In the rest of my testimony, I will outline the chronology of events at St. Louis and our response to this incident, and provide information that every potentially affected Veteran needs to know.
In March 2010, the National Infectious Diseases Program Office (IDPO) conducted an announced site visit of the St. Louis VA Medical Center. During this inspection several issues concerning the proper processing of dental instruments were identified, including a failure to clean dental handpieces according to manufacturer instructions and VA standard operating procedures. VA procedures call for the instrument to be cleaned with a detergent before it is sterilized, and the facility was not doing this. It is important to note these instruments received additional cleaning prior to use, but VA cannot establish conclusively their sterility because of the pre-cleaning deficiency. Upon learning of these findings the Acting Medical Center Director immediately suspended Dental Services until the identified issues could be fully addressed and resolved.
Coinciding with the IDPO inspection findings, VA officials immediately initiated and completed an in-depth review of the program, including staff training and direct observation, ultimately resulting in a redesign of dental equipment cleaning processes. On March 18, 2010, the Oral Surgery and Dental Hygienist Clinics reopened with corrected procedures in place, and on March 26, 2010, the General Dentistry Clinic was reopened.
On May 6, 2010, VA convened a Clinical Risk Assessment Advisory Board (Board) at VA Central Office. This Board’s membership is comprised of many VA national program leaders representing both clinical and non-clinical expertise. The Board thoroughly reviewed the findings related to the dental issues. While the Clinical Risk Assessment Advisory Board identified the risk of infection to be extremely low, in keeping with VA’s commitment to informing Veterans about issues related to their care, the Board recommended notification of 1,812 St. Louis patients receiving dental care between February 1, 2009 and March 10, 2010 of the possible risk through disclosure information letters and that serology testing for hepatitis B, hepatitis C and HIV be offered. Between May 10 and 12, 2010, the National Director of Medicine and the Acting Executive Manager of the Supply, Processing and Distribution Program with a team from VA Central Office conducted a new site visit of St. Louis and found that all issues at the dental clinic had been resolved. VA sent disclosure letters to 1,812 affected Veterans, offering testing for hepatitis B, hepatitis C and HIV on Monday, June 28, 2010.
Upon learning of the identified issues, the Acting Medical Center Director took immediate action to temporarily suspend St. Louis Dental Services until the issues identified could be fully assessed and resolved. All Veterans with appointments were given the option to reschedule at the St. Louis dental clinic, or to receive care in the community at VA expense during the suspension.
St. Louis VAMC is contacting all potentially affected Veterans through certified mail. Additionally, VA staff members are working with local Congressional offices and Veteran Service Organizations to ensure Veterans know of this issue and receive the care they have earned. We appreciate the opportunity to participate in a forum like this where Veterans can see our commitment to their care and can hear directly from us what we are doing to address this issue. More importantly, this forum offers us an opportunity to hear from our Veterans, to address their concerns directly and to answer their questions honestly.
We recognize there were missed opportunities to uncover this issue sooner. We have implemented safeguards system-wide to prevent a similar situation from happening again. We are reviewing our experience at St. Louis and our response to it to identify lessons learned, and I can promise you that our policies for identifying these issues early and notifying our Veterans and stakeholders promptly will change to create a faster response system. We hear too often that VA is too big a ship to respond quickly, but I will not accept this as an excuse. I will submit a letter describing the improvements and our standards for ensuring compliance by our facilities to the Committees on Veterans’ Affairs by August 15, 2010.
One of the safeguards we have already identified involved elevating the Supply, Processing and Distribution program to the level of a stand-alone national program. This alignment will allow for improved oversight of the program and specific dedication of additional resources. Supply, Processing and Distribution Boards are being created at all 21 VA Networks to review local facilities and their compliance with VA policies and procedures.
VA also is in the process of standardizing the operating procedures for the cleaning of all reusable medical equipment to reduce variation and errors. VA has committed to implementing industry principles (in the form of International Organization of Standardization, or ISO 9001 standards) system-wide, in its ongoing efforts to reduce variation. No other health care system in the country has adopted the industrial practices that ISO requires, and VA will lead the way in this area as we have in so many others before. Moreover, VA has arranged for the International Association of Healthcare Central Service Material Management, a nationally recognized organization promoting excellence in the sterile processing of reusable medical equipment, to intensively train all VA Chiefs of Sterile Processing and Distribution in state-of-the-art techniques for sterile processing.
VA has set up a St. Louis Dental Review Call Center that is being operated 7 days a week, 24 hours a day. Veterans and family members with questions or concerns can call 1-888-374-3046 to speak to our health care staff who will be available to answer any questions and to assist with scheduling an appointment and obtaining the necessary blood tests. A Dental Review walk-in clinic opened on June 29, 2010 at the John Cochran Division at the St. Louis VA Medical Center (hours of operation Monday through Friday 8:00 am to 6:00 pm and Saturdays 8:00 am to 4:00 pm). Blood tests can be obtained at the Jefferson Barracks Division, St. Louis Community-Based Outpatient Clinic (CBOC), Belleville CBOC or St. Charles CBOC (a full list of addresses and contact information is available at the end of this statement). For Veterans and family members located outside the St Louis area, the St. Louis VA Medical Center will arrange for them to receive service at the most conveniently located VA facility. Wherever Veterans receive services related to this issue, there will be no co-payments associated with the necessary appointment or testing. Through July 7, 2010, 778 Veterans had accepted testing, and 615 have scheduled appointments in the St. Louis Dental Review Clinic.
Finally, we are strengthening our system of accountability for compliance with national directives. These directives are developed and promulgated after careful review by clinicians with years of experience, and it is essential that they be followed. We have a rigorous system of monitoring in place to determine if these directives are being implemented, and employee performance is assessed based upon success in attaining the standards we set. We will reinforce the importance of these principles so that new policies and procedures are adhered to when they are issued.
What Veterans Need to Know
It is important for our Veterans and their families to know that VA has attempted to contact every Veteran seen and possibly exposed to a blood-borne disease between February 1, 2009 and March 10, 2010. If you are a Veteran and you were seen in the St. Louis VA Medical Center Dental Clinic during this time and you have not received a letter from the Department, or if you know a Veteran who was seen during this time who has not received a letter, please call 1-888-374-3046 to notify us so we can arrange testing and monitoring.
It is also important to know that while the risk of exposure is extremely low, it does exist. It is imperative that our Veterans be tested, both for their health and for the health of their loved ones. For Veterans who are worried about being seen in a VA facility, we will arrange for these tests to be done by another party at no cost to the Veteran.
VA has long had staff members known as patient advocates who are available in each of our major medical facilities who can help Veterans with whatever concerns they have. If Veterans need counseling or advice or have any concerns with the quality of care or the nature of our response, VA strongly encourages them to please contact the patient advocate at the facility and discuss these issues with that person.
In the past 18 months, VA has implemented more stringent oversight of the existing safety guidelines for reprocessing of reusable medical equipment in all of its medical facilities. It is this more rigorous standard that directly led VA to identify and address problems at the St. Louis VA Medical Center. The St. Louis VA Medical Center provides quality health care services to more than 50,000 Veterans a year, and employs more than 2,600 individuals from the community. The Veterans potentially affected are their neighbors and friends.
VA, from the Secretary to the staff at the St. Louis VA Medical Center and in every VA facility, has expressed a deep commitment to preventing this, or any similar situation, from happening again, and has taken steps to accomplish that goal.
We deeply regret that this situation occurred and VA is taking all the necessary steps to make certain that testing is offered quickly and that results are communicated in a timely manner. We understand the responsibility and trust Veterans place in us and we want Veterans and our stakeholders to know that the staff at the St. Louis VA Medical Center is doing everything possible to address this situation and prevent it from occurring again.
Thank you again for the opportunity to appear before you today. My colleagues and I are prepared to answer any questions you may have.
List of Facilities in the St. Louis Area
VA Medical Centers
John Cochran Division
915 North Grand Blvd.
St. Louis, MO 63106
Phone: 314-652-4100 or 1-800-228-5459
Jefferson Barracks Division
1 Jefferson Barracks Dr.
St. Louis, MO 63125
Phone: 314-652-4100 or 1-800-228-5459
6500 W Main St
Belleville, IL 62223
Phone: 618-398-2100 or 800-228-5459 ext. 56988
Hwy 72 North
Salem, MO 65560
Phone: 573-729-6626 or 1-888-557-8262
St. Charles Clinic
7 Jason Ct.
St. Charles, MO 63304
Phone: 636-498-1113 or 1-800-228-5459 ext. 56988
St. Louis Clinic
Missouri Veterans Home - VA Clinic
10600 Lewis and Clark Blvd.
St. Louis, MO 63136
Phone: 314-286-6988 or 1-800-228-5459 ext. 56988
U.S. Department of Veterans Affairs - 810 Vermont Avenue, NW - Washington, DC 20420
Reviewed/Updated Date: August 17, 2010