VA Testimony of Smith Jenkins before Congress on March 22, 2004

United States Department of Veterans Affairs

STATEMENT OF
SMITH JENKINS, JR.
DIRECTOR, VA MEDICAL CENTER, BAY PINES, FLORIDA
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
HEARING ON THE STATE OF HEALTH CARE AT
THE BAY PINES VA MEDICAL CENTER AND SURROUNDING FACILITIES
U.S. SENATE VETERANS AFFAIRS COMMITTEE

March 22, 2004

Mr. Chairman and members of the Committee, it is my pleasure to appear before you today to address the state of health care at the Bay Pines facility. Although I reported for duty at Bay Pines on June 23, 2003, I did not assume my duties as Director on a full-time basis until August 11, 2003, because of my assignment and commitment to the CARES Project in VA Central Office.

Quality Management

The Bay Pines VA Medical Center has a systematic method for reviewing the quality of care provided at our medical center and clinics. Each department has a performance improvement plan and reports results quarterly through our governance structure. These plans include national Veterans Health Administration (VHA) performance measures and monitors, Joint Commission on the Accreditation of Healthcare Organization (JCAHO) indicators, and other specific indicators as appropriate.

VHA currently measures the quality of care in six areas of disease management and preventive health that are prevalent in veteran patients. These areas include cardiovascular care, diabetic care, cancer screening, infectious disease, mental health and tobacco cessation. Each of these six areas consists of multiple measures that are aggregated into a composite performance score. Over the past several years, Bay Pines has consistently met or exceeded national performance targets in all of these composite areas. This level of performance has continued into the first quarter of 2004.

Patient satisfaction with care and services is monitored through VA’s quarterly Survey of Veterans Healthcare Experiences (SHEP) process. The most recent results from the second quarter of fiscal year 2003 indicate that Bay Pines performs significantly better than the national average in overall quality, based on inpatients surveyed. Bay Pines is significantly better than the national average in the categories of physical comfort and preferences. Bay Pines performed better than the national average in coordination of care and courtesy. Results from outpatients surveyed during the same time period indicate that Bay Pines performed significantly better than the national average in overall quality, provider wait times (how long it takes to see a provider when the patient has an appointment), and courtesy of staff.

In summary, our systematic review of quality, national performance measure results, and internal reviews indicates that the quality of care provided at the Bay Pines VAMC exceeds national targets and is comparable or better than that within the community.

Access to Care

As Dr. Headley mentioned in his testimony, the Bay Pines VA Medical Center has and continues to experience significant growth in the number of veterans provided healthcare. As a result, we are striving to meet the workload demands placed on our system. In mid 2003, our waiting list for primary and specialty care exceeded 15,000 patients. Through the hard work of dedicated staff and with additional resources provided by the VISN, we have reduced that number to a level where few patients must wait more than 120 days to have their first primary care appointment. All veterans with priority status are seen within 30 days.

Our efforts to get all new veteran enrollees seen by a primary care provider in a timely manner have resulted in increased demand for specialty care. This has increased our waiting times in high volume areas such as optometry and audiology. To reduce these waiting times, we have developed contracts with community providers for eye exams, eyeglasses and hearing aid exams. With the 2004 budget passed by Congress, we anticipate elimination of all waiting lists in primary and specialty care by the end of this summer.

Patient Safety Initiatives

Patient safety has always been a high priority at the Bay Pines VA Medical Center. As workload has increased, we have continued to place great emphasis on patient safety as evidenced by our active patient safety program that is well documented and communicated throughout the organization. We have created and support a “no-blame” environment that encourages reporting of patient safety or quality issues. All medical center staff are responsible for reporting any and all events that have, or have the potential to have, an adverse effect on patients. Reported issues are investigated and prioritized to determine the need for focused review, root cause analysis or further actions such as peer review. Physicians, nurses and other clinicians serve on root cause analysis teams, performance improvement teams, and the Patient Safety Committee.

Temporary Cancellation of Surgery

On Friday, February 13, 2004, I was presented with information from the Associate Director for Patient and Nursing Services and from the Quality Systems Coordinator that necessitated I make one of the most sensitive and critical decisions of my forty-year career with the Department of Veterans Affairs – to temporarily suspend surgery at this facility for the sake of patient safety. Difficulties in implementing the CoreFLS System and personnel issues within our own Supply, Processing and Distribution (SPD) Section raised significant concern that the integrity of carts supplying necessary surgical supplies to the Operating Rooms was in jeopardy. This decision was made with the concurrence of the Chief of Staff, the Associate Director for Patient and Nursing Services, the Acting Chief of Surgery Service and the Chief of Acquisition and Materiel Management Service.

Non-emergent patient surgeries were rescheduled, and those patients who could not wait for surgery were sent to other VA facilities or to community hospitals at our expense. The patients were given the choice in this regard. Emergency surgeries, however, were very carefully monitored and were successfully performed during this same weekend. On February 20, 2004, we resumed surgery with a restricted schedule. Four cases were scheduled and two emergency surgeries were performed with no problems encountered. I made the decision at that time to limit the surgical cases to ten per day until I, the Chief of Staff, the Associate Director for Patient and Nursing Services, the Acting Chief of Surgery, the Operating Room (OR) Nurse Supervisor and the Quality Systems Coordinator were confident that it was safe to resume the normal surgical schedule. Since we have resumed our surgical schedule, we have completed two-thirds of the originally delayed cases with the last case scheduled for completion on April 9.

Our SPD operation, which is responsible for providing medical, surgical and sterile supplies, is functioning at a very high level now, and will contribute to our success in achieving a full surgical schedule. While CoreFLS played a significant role in our decision to cancel surgeries due to the lack of surgical supplies being ordered and received in a timely manner, our staff also contributed to these difficulties. Three key leadership positions in SPD become vacant over the past three months, along with several tech positions. Our sister hospitals in VISN 8 came to our aid by sending tech staff, along with staff in leadership positions to assist SPD. With this help, the recruitment actions we have taken to fill positions, and the reorganization of the SPD operation, our ability to provide supplies, including surgical case carts, has increased to our targeted level. Much work, and the efforts of numerous Bay Pines staff have transformed our SPD section into a more dependable and efficient support operation.

CoreFLS

Our ability to get our SPD operation running efficiently depends on our ability to have supplies on hand. Over two years ago, Bay Pines was selected as the operational test site of VA’s new financial and logistical system, CoreFLS. CoreFLS is a set of commercial software programs that consist of three separate products, Oracle, Dynamed and Maximo, operating in a web-based environment. It replaces VA developed programs that have been in place for approximately 15 years. Although a wide range of organizations including health care facilities in the private and public sector have used these three software packages, this is the first time we are aware of that all three have been used in conjunction with one another.

Over the past two years, Bay Pines has participated in a series of staged tests of the software, along with VA CoreFLS staff and the contractor, Bearing Point. On October 1, 2003, the Bay Pines VAMC moved into the next phase of testing, and fully converted to CoreFLS for operational use. As the first medical center pilot site, we knew there would be significant challenges; however, when conversion took place, the number and complexity of these challenges were significantly greater than expected. Immediate issues that surfaced include insufficient staff training, staff not having the right access to perform their jobs, and interface problems between the three software packages. These issues led to:

Delayed vendor payments, and subsequently, increased interest payments;
Uncertain account balances; and
Supply shortages.

CoreFLS and Bay Pines staff have and continue to work diligently to resolve these issues. While issues are resolved often on a daily or weekly basis, other issues continue to be identified as we test the software.

Our staff, in concert with VA CoreFLS staff and the contractor, are fully committed to providing a thorough test of the system and assisting in the resolution of these issues prior to deployment to other sites within VHA.

Radiology Workload

I was made aware of a large number of unread radiology exams several weeks ago. Upon receipt of this information, I immediately began developing improvement strategies. Through the great efforts of many clinical and administrative staff, particularly in our Radiology Service, contracts were developed, additional fee basis and locum tenens physicians were hired, and remote readings at other VA medical centers were initiated. As of this date, the backlog has been eliminated and all routine exams are read within 24 to 48 hours. Stat and urgent exams, as always, are being read the same day. With the services and process changes we have initiated, we fully expect to continue operating at a very high level of efficiency and patient satisfaction.

Medical Staff Issues

Almost immediately upon my arrival in August, it was apparent from meetings I had with members of the physician staff, that there were significant issues concerning morale and leadership within Medicine Service. After researching the situation and the allegations made, I found it necessary to reassign the Chief of Medicine to a staff physician position in the Cardiology Section on September 1, 2003, pending further investigation. The investigation resulted in this individual resigning from his position when his term appointment expired on January 12, 2004. Immediately, acting Co-Service Chiefs of Medicine were assigned, and a Search Committee was assembled. The Search Committee is working to identify a highly qualified, viable candidate to insure the Medicine Service is the professional service that our veterans deserve -- continuing its tradition of providing excellent patient care. I continue to meet and work with additional members of the physician staff to identify other areas of concern and correct them. It is vitally important that we have a climate of mutual respect between our physician staff and management to provide the highest quality of care to our Nation’s veterans.

On November 13, 2003, I met with a group of approximately 20 physicians from various clinical services to listen to their many concerns, including their allegations of a hostile work environment fostered by the aforementioned Chief of Medicine Service, lack of support by the current Associate Director and Chief of Staff, and their concern whether I would or would not address their issues. I assured this group that I would look into their claims and decided it would be best for all concerned to have a third party group of administrators and clinicians from outside this facility investigate their concerns and allegations. Based on this review, it was my intention to focus on specific areas of concern with an in-depth analysis to develop corrective action if found necessary.

On December 8, 2003, a reporter from the St. Petersburg Times called requesting my reaction to an anonymous, unsigned letter written by the medical staff. I informed the reporter that I had never received a letter and requested that he fax me a copy. After receiving it, I notified Elwood J. Headley, M.D., Director, VISN 8, that I felt, as I had before, that an outside group should do a review so that we at Bay Pines could focus on identifying issues and solving problems brought to bear by this selective group of physicians. It was decided that John Vara, M.D., Chief of Staff, VAMC Miami, would lead this group, and three or four additional members would be appointed. Due to the holidays and scheduling conflicts, the review, initially scheduled for January 5, 2004, was rescheduled to January 26, 2004. The site team conducted an independent review at Bay Pines January 26-28, 2004. The overall purpose of the review was to assess the quality of health care, evaluate the utilization of health care resources, and recommend improvement actions where needed. The team was asked to:

Review the process for cardiac catherization and interventions;
Review the systematic process used to ensure timely neurosurgical care for patients;
Review functioning of radiology services to include leadership and completion of studies;
Assess the backlog of films requiring reading;
Review the process used to ensure timely filling of clinical leadership vacancies and other personnel actions;
Review medical staff allegations regarding a pattern of harassment and/or a hostile work environment; and,
Assess actions taken by leadership to address theses allegations.

As a result of that review, we are currently taking the following actions as recommended by the review team.

Implement strategies to successfully eliminate backlogs in radiology;
Improve informed consent process for cardiac catheterizations;
Establish more detailed contracts for surgical back-up and emergency transportation to community hospitals;
Establish interdisciplinary team for reviewing and improving the process for neurosurgical referrals, monitoring, timeliness and communication regarding care provided;
Aggressively fill leadership positions in laboratory, radiology, medicine and surgery; and
Implement a comprehensive plan to openly communicate with staff and dispel rumors;

Staff Morale and Communication

Bay Pines staff has consistently expressed high levels of employee satisfaction, compared with other facilities in VISN 8 and throughout the VA system. However, the past several months have been particularly challenging for staff as a result of the barrage of media attention, increased workload and testing of CoreFLS. Despite these and other obstacles, Bay Pines staff have remained focused on our primary mission of providing quality, accessible healthcare to our Nation’s veterans. I have kept staff informed of the issues we are facing and the progress we are making to improve service to veterans. In communicating information about upcoming reviews or investigations, I have also instructed all employees to be open and honest with the reviewers. We continue to emphasize that above all else, we are here to serve those who have served.

The majority of staff has and continues to express their strong support and commitment to the Bay Pines VA Medical Center and our mission of caring for veterans. As much of the recent media activities and investigations may have had an adverse effect on employee morale, I am reviewing options for organizational development to help us begin the healing process. It’s important to have a specific course of action to re-establish a sense of cohesion through mutual trust and respect. I am confident that my staff will rebound with a renewed sense of purpose and well-being as we work together to provide the best care possible to the veterans we serve.

Thank you, Mr. Chairman. That concludes my formal comments. I would be glad to take any questions at this time.