Veterans are facing a deadly new threat that is coming not from faraway battlefields, but from stateside hospital rooms, according to the results of a Government Accountability Office investigation released Wednesday.
In a hearing before the House Veterans’ Affairs Committee, representatives from the GAO and American Legion detailed problems with the Veterans Affairs Department and its Veterans Health Administration, citing critical flaws in the purchasing and tracking of surgical implants such as skin and bone grafts, cardiac pacemakers and artificial joints.
They also criticized procedural flaws that permit surgical implant vendors to be present in operating rooms — and, in some cases, operate on patients, against industry practices.
“Without proper caution, allowing a representative to participate in direct patient care can compromise veterans’ safety,” said Randall Williamson, a director in GAO’s health care team.
Though VA procedures state vendors are to provide only “technical assistance and advice,” the vendors’ role is established through a waiver signed by the patient, leaving no consistent policy across hospitals, Williamson said.
The GAO investigation found that those patient waivers were not always obtained, or were incomplete.
“It’s just a contract between the patient and vendor,” said Roscoe Butler, American Legion assistant health care director. “We want the VA to establish a national policy, then use the consent form as an agreement between the vendor and the patient.”
Williamson said national VA policies “do not adequately define how much vendors can be involved in patient care,” and proposed an additional provision clarifying how to deal with vendors should they break policy.
Philip Matkovsky, an assistant deputy in the Veterans Health Administration, insisted that he had never witnessed vendors engaging in direct patient care, and that the presence of representatives in operating rooms was standard practice.
The GAO report also noted structural problems with tracking which veterans are receiving which implants, “putting some veterans at risk” in case of an emergency or product recall. An audit two years ago by the VA Inspector General identified expired surgical products on VA shelves.
“The grave concern to the American Legion is that, in addition to having expired products on the shelves, veterans potentially could be walking around today with expired surgical implants,” Butler said.
Improper system management also was linked to a failure on the part of VA to seek the most market competitive prices for implants. Matkovsky defended the spending as part of a transition begun in fiscal 2012 to guarantee proper procurement of surgical implants and prosthetics.
The solution, as Rep. Phil Roe, R-Tenn., sees it, is simple. “I don’t believe we have a problem here that can’t be easily solved with the systems that we already have,” he said. “This should be data-driven, and not just cost-driven.”
That solution could be as basic as a barcode system, the GAO and American Legion said.
As committee member Rep. Mike Coffman, R-Colo., argued, proper management of implant records remains an issue that “has been unresolved for far too long.”
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