Health care administrators at the Charlie Norwood Veterans Affairs Medical Center said Thursday that the hospital botched its gastrointestinal program so badly that it had to re-engineer its floor plan and bring in extra personnel and equipment to handle a consultation caseload that topped 5,100 unresolved diagnostic screenings last year.
The large-scale effort, which was launched in August 2012 and completed three months later, helped the facility determine appropriate treatment plans for 4,560 patients and reduce its backlog to 540 unresolved consults, Director Bob Hamilton said.
However, he said Thursday that more than 50 veterans continue to wait for an appointment and that three cancer patients, who were not seen in time by the overworked gastrointestinal program, died between 2011 and November 2012 while in the course of receiving medical care.
Citing patient confidentiality laws, Hamilton declined to release the victims’ names. He said he believes backlog problems were focused on the program and that his administration will continue to conduct patient mortality reviews to ensure the standard of care has been met.
“All of us at the Charlie Norwood VA Medical Center are deeply saddened by the loss of any veteran at our facility,” said Hamilton, a 30-year Air Force health care administrator who took over the hospital in July 2012. “We offer our sincerest condolences to veterans affected by delays in GI care and families who have lost a loved one.”
Hamilton, the former leader of the Wilford Hall Medical Center in Texas, said he first realized the center had significant delays in gastrointestinal consults a month after he arrived in Augusta.
At the height of the problem, Hamilton estimated the gastrointestinal program had 5,100 unresolved consults.
“Patients were in the system, but there was very little activity associated with getting them an appropriate treatment plan,” Hamilton said.
He attributed some of the problem to the Department of Veterans Affairs shifting its policies in 2011 to offer more screening colonoscopies. As a result, Charlie Norwood was soon flooded with colonoscopy requests and did not have the resources or procedures in place to handle the caseload.
In order to reduce the surge in consults, Hamilton said Charlie Norwood brought in extra personnel for two to three months; leased and purchased additional scopes; and even re-engineered the hospital to increase space and create a more optimal patient flow.
Administrators also began distributing a blood test for patients to submit stool samples themselves.
“Part of the issue was really getting to the bottom of identifying who needed the test and how we could get them in for a consult in a timely manner,” said Dr. Michael Spencer, the chief of staff at the medical center.
Spencer said the center typically averages about 20 colonoscopies per day. At the height of the gastrointestinal backlog, the hospital was doing more than 70 per day.
“Our tracking mechanisms were nothing like what we have established in the meantime, and as we went through those consults, there were some patients that had already received a colonoscopy at another site,” he said.
While the delay in care has largely been tied to former Director Rebecca Wiley, who was leader of the facility when the problem escalated, Spencer said it was not all her fault.
“There were many people involved and opportunities to correct,” he said. “Just like it takes a team to deliver the best medical care possible, there were many touches of these individuals, and to attribute it to one entity I think would be an error.”
Wiley’s tenure in Augusta lasted from February 2007 to December 2010. She was named director of the Williams Jennings Bryan Dorn Veterans Medical Center in Columbia in November 2011, almost a year after she left Augusta and the city’s VA center lost full accreditation.
According to a 2012 report from the VA Inspector General’s Office, Wiley is connected to five care-related injuries or deaths at Charlie Norwood and nearly 90 percent of its unresolved consults. Additionally, the inspector general found that mismanagement during some of Wiley’s tenure in Columbia contributed to a backlog of nearly 4,000 gastrointestinal appointment delays, which in turn led to 19 instances of serious injury and six patient deaths.
In light of the allegations, the House Committee on Veterans Affairs in late September requested copies of all current accounts of appointment backlogs and patient injuries. It also asked for any records reflecting performance reviews, pay bonuses and disciplinary actions issued since 2002 to those who oversee patient safety in Augusta.
Hamilton said his staff fulfilled all records requests to corporate and regional offices three weeks ago. Curt Cashour, the committee’s communications director, said Thursday that the “VA has not responded to the committee’s attached information requests.”
Spencer said Thursday that the medical center has built a system to track the timelines of colonoscopy delivery and that any patient suspected to have cancer either through weight loss or positive stool sample are scheduled for a screening within 30 days. He said depending on medical history, patients can be seen the same day or by the end of the week.
“We are very attentive to tracking incidents, not just those related to GI (gastrointestinal), but every incident throughout our facility, and we definitely know that there have not been any similar cases since we wrapped up our cleanup efforts in early November of last year,” Spencer said.
Hamilton said the experience has forced the VA as a whole to look more broadly at all consults and to make improvements in all specialties.
“We are a much better organization today than we were a year ago,” he said. “Our access, our consult management and our quality indicators have all improved significantly. There is no comparison of where we are today to where we were a year ago when this particular issue became known to us.”