From January 2011 to November 2012, at least 21 patients at the VA Pittsburgh Healthcare System contracted Legionnaires’ disease. Five died.
At the Atlanta VA Medical Center, three mental health patients died in 2011 and 2012, including a former Army paratrooper who killed himself in a hospital bathroom — the result of a system that did not “adequately oversee or monitor contracted patient care services,” according to the Veterans Affairs Department inspector general.
The Buffalo, N.Y., VA Medical Center in January revealed that more than 700 patients were exposed to infectious diseases when attendants reused insulin cartridges designed for single use. At least 18 veterans contracted hepatitis as a result.
And the list continues: chronic understaffing at the G.V. Sonny Montgomery VA Medical Center, Jackson, Miss., and VA Medical Center Dallas; surgeons performing procedures without clinical privileges at the Bill Hefner VA Medical Center, Salisbury, N.C.; a veteran committing “suicide by cop” a day after being improperly discharged from the Miami VA Healthcare System.
Yet according to the Pittsburgh Post-Gazette, Atlanta Journal-Constitution and CBS-11 News Dallas, VA medical leaders at facilities in those cities garnered more than $150,000 in performance bonuses during the past four years — while patients were dying from preventable illnesses.
In Pittsburgh, where five veterans died after contracting Legionnaires’ disease, Terry Gerigk Wolf, Pittsburgh Medical Center director, received the highest ratings possible on her performance evaluation in September 2012 and earned a bonus of $12,924 in 2011.
“Mrs. Wolf has both embodied and advanced VA’s ICARE initiatives,” wrote Michael Moreland, Gerigk Wolf’s supervisor and regional director of the Pittsburgh-area VA medical facilities, in a document obtained by Military Times.
The VA maintains it runs a “good system ... the finest medical system in the country,” said Dr. Robert Petzel, the department’s undersecretary for health.
But Congress has started questioning whether problems at individual facilities signal systemic leadership problems across the Veterans Health Administration.
House Veterans’ Affairs Committee Chairman Rep. Jeff Miller, R-Fla., wrote President Obama in May asking him to address the “management, oversight and leadership failures that are pervasive throughout the department.”
Rep. Mike Doyle, D-Pa., has called for accountability after the VA inspector general found leadership failed to protect veterans from deadly Legionella bacteria.
At a joint meeting of the House Veterans’ Affairs and Armed Services committees, Rep. Hank Johnson, D-Ga., questioned the propriety of awarding performance bonuses to directors when patients die as a result of mistakes or negligence.
And during a media interview July 18, Rep. David Scott, D-Ga., called for VA Secretary Eric Shinseki’s resignation.
“After many months there hasn’t been a strong response at VA to show they are serious about cleaning house. The congressman is frustrated,” Press Secretary Michael Andel said.
Miller said he doesn’t understand why VA halted performance bonus awards for veterans benefits administrators in response to continued problems with the department’s disability claims backlog but has barely touched awards to managers whose medical centers place patients at risk.
“Department officials seem more intent on issuing bureaucratic slaps on the wrist,” Miller said.
The legislative pressure does not appear to be fazing VA officials. Under questioning from Johnson, Petzel said he was not aware of specific payouts to Atlanta directors.
He did add that bonuses at VHA have been “dramatically reduced.”
Miller expressed disappointment in the lack of response he has received from the White House or VA executives. Congressional sources say his committee likely will hold an oversight hearing to address what the chairman considers “pervasive patient safety concerns.”
“VA owes us all — especially the families of those who died — an explanation as to why the department awarded these bonuses and how they plan to eliminate similar payments in the future,” Miller said.
A White House official said the administration reviews all letters it receives and will “respond as appropriate” to Miller’s call for action.
A VA spokeswoman said July 21 that some fiscal 2012 performance awards for senior executives, including some in the VHA, have been deferred “pending further review.”
But the official also noted that VA must attract and retain quality executives, and that includes being able to offer them incentive pay packages.
“Performance awards take into account both individual and overall organizational performance goals. ... To continue to serve our nation’s veterans, VA must continue to attract and retain the best and brightest leaders,” she said.
According to VA, the department’s performance award total decreased by one third from 2009 to 2012, dropping from $3.3 million to $2.3 million.
The highest bonus awarded in 2009 was 17.5 percent of salary; in fiscal 2012, it was 9 percent of salary.
Patients, meanwhile, remain divided on the quality of care they receive. Speaking at Jackson, Miss., meeting on April 3, Dr. Gregg Parker, a retired naval officer who serves as the chief medical officer for VA’s regional office that oversees the Jackson facility, was diagnosed with bladder cancer last year.
“I receive all my care at the Jackson VA Medical Center. I chose that care because I am very knowledgeable of the commitment to quality, safety and how the care is done,” Parker said.
“I guess if I had a ‘D’ and an ‘R’ in front of my name, I’d get good care too,” shouted a patient who had complained of receiving inadequate treatment.