Warning: These measures may cause dizziness
If you’re confused by the VA’s quality ranking system, there’s good reason.
On one hand, the system, called SAIL (Strategic Analytics for Improvement and Learning) divides hospitals into five equal groups, called quintiles, on a host of specific performance measures. Each quintile includes one-fifth, or 20 percent, of all facilities.
The first quintile is the best and the fifth quintile is the worst. On the aggregate measure simply called “quality” the Atlanta VA is in the fourth quintile, placing it in the bottom 40 percent.
SAIL also rates hospitals on a star system. But in this case, one is bad and five is good. To complicate matters even further, some of the five groups include more hospitals than others:
- 5-star hospitals are the top 10 percent;
- 4-star hospitals are the next 20 percent;
- 3-star hospitals are the middle 40 percent;
- 2-star hospitals are the next 20 percent;
- 1-star hospitals are the worst 10 percent.
The Atlanta VA is a 2-star hospital, placing it in the bottom 30 percent.
QUALITY OF CARE
The Department of Veterans Affairs ranked its Atlanta facility with just two out of five stars in terms of quality, meaning it falls into the bottom 30 percent among the VA’s 128 acute care and surgery facilities. The Atlanta hospital scores poorly in 12 out of 21 categories reviewed in the data.
Top 20 percent
- Readmission rate for heart attack
Bottom 20 percent
- Call responsiveness
- Mortality rate for pneumonia
- Best place to work
Source: Strategic Analytics for Improvement and Learning, Department of Veterans Affairs
Veterans who wait weeks or months for appointments at Atlanta’s VA Medical Center can expect care that, in many ways, falls far short of standards set by the Department of Veterans Affairs itself.
The Decatur hospital gets two stars out of a possible five on the VA’s rating system for quality, putting it in the bottom third of the agency’s 128 acute care and surgery facilities.
Veterans and their families interviewed by The Atlanta Journal-Constitution tell what those numbers mean in their lives: deaths caused by mistakes, botched surgeries, needless suffering and nerve-wracking delays in life-saving care.
“They messed me up. I’ll never let the VA cut me open (again) as long as I live,” said Vietnam veteran Mike J. Maloof Jr. He said he’s still recovering from a four-year cascade of complications that began when the Atlanta VA damaged a prosthesis during surgery.
According to VA data, the hospital’s record of mediocrity stretches back for years. That’s a marker of failed management and leadership, according to some people who keep a watch on the agency’s performance.
“When you look up and down the chain there’s been a lack of responsiveness,” said Rep. David Scott, D-Atlanta. “There’s been a culture of people there serving their own interests and not the veterans’.”
The hospital was engulfed in scandal last year when investigators linked mismanagement in the mental health wing to a string of veteran suicides. One veteran was found dead in a locked hospital bathroom with a trash bag tied around his head.
Director Leslie Wiggins was hired in May 2013 to clean up the mess. But Atlanta’s problems transcend any one issue, such as shortages of resources or medical professionals, said Dr. Ashish Jha, a professor of health policy at Harvard University’s School of Public Health.
“This is not about nurses and doctors. It’s about organizational leadership,” said Jha, who also works in the VA hospital in Boston. “There are longstanding issues not being addressed.”
Thomas Grace, associate director of the Atlanta VA, defended the hospital’s performance last week in an interview with the AJC.
“In general, I would say the quality of care here is very good,” Grace said. “Do we have opportunities that we are looking for continuous improvement? Yes. But there are a lot of things here that this medical center does very well.”
Wiggins, in an email Friday to the AJC, said that there may be little difference in the quality of care between a two-star hospital and one with the highest rating of five stars. A two-star ranking does not necessarily indicate a poor quality of health care, she said.
“There will always be someone at the bottom (of the rankings) even if it is not even a clinically relevant difference,” Wiggins said.
The Atlanta VA hospital stacks up better against other metro Atlanta hospitals than it does against its peers in the VA system. It scores above or near the average for local hospitals on four of six quality measures tracked by the federal Centers for Medicare & Medicaid Services. The measures cover mortality and hospital readmission rates for heart attacks, congestive heart failure and pneumonia.
The VA’s performance management system, which goes by the acronym SAIL, uses those numbers and many more. Its performance targets are ambitious. To earn five stars, a facility must be in the top 10 percent, and every hospital is charged with striving to equal that top-tier performance.
Far from it, the Atlanta hospital scores poorly on 12 of 21 measures reflected in latest figures, which cover the first quarter of fiscal year 2014 (on the calendar, the last three months of 2013).
On the plus side, the percentage of patients who die within 30 days of being admitted for care has improved significantly since 2011. So too, has the facility’s success in preventing hospital-borne infections.
But the overall quality ranking hasn’t budged in the past three years, and the hospital remains lodged near the bottom rung of VA hospitals.
Specifically, the Atlanta VA has struggled to lower the rate of patients who die of common conditions such as pneumonia and congestive heart failure, according to the SAIL data. That has been the case at least since 2011, with only modest improvement.
Atlanta VA officials say these rates can be altered by a small number of deaths.
The hospital also has a poor record of preventing medical complications, medical errors and other “adverse events” that threaten patient safety. The rate of complications has grown worse since 2011.
Death by inattention
For Rick Alfaro, a mistake at the Atlanta VA became the first in a chain that would cost him his life, said his widow, Sharon Alfaro. In January, she settled a lawsuit with the government over his death.
Alfaro, an ex-Marine and Vietnam vet, had multiple sclerosis, which had damaged his kidneys. The dye put in his body during an MRI ordered by an Atlanta VA doctor nearly shut down his kidneys.
To correct the mistake, doctors ordered dialysis and sent Alfaro to the VA hospital in Augusta, to its spinal cord injury unit. (The Augusta VA ranks even lower on SAIL than Atlanta’s.)
Alfaro’s treatment plan said a staff member should always be present when he ate, because the MS made it difficult for him to swallow. But the Augusta staff didn’t follow the plan. Left alone during dinner on the evening of July 20, 2009, Alfaro choked to death on a cherry tomato. He was 56.
“My husband died a horrific death,” Sharon Alfaro said. “I want to see improvements. I want everything they did wrong to be out there and cleaned up. It would be the best way to honor my husband.”
In recent months, the nation’s VA system of hospitals has been reeling from problems with access to care, an issue largely separate from quality. The agency’s director, Gen. Eric Shinseki lost his job as a result. Last week the Senate confirmed his replacement: Robert McDonald, a West Point graduate who went on to lead Procter & Gamble.
McDonald takes over an agency described in a recent White House report as having a “corrosive” management culture unable to effectively manage or communicate.
Last week Congress also reached a compromise on $17 billion in emergency funds. The bill, which will enable the agency to hire more doctors and nurses, also makes it easier to fire top VA executives if they fail to perform.
Atlanta VA officials point to steps they’ve already taken to improve care in areas red-flagged by SAIL. For example, they said, they’ve acquired devices to remotely monitor patients with congestive heart failure. The devices transmit data on the patient’s condition back to workers at the hospital, allowing them to respond quickly when trouble arises, officials said.
In addition, recent SAIL reports show improvements in the care of congestive heart failure, pneumonia and medical complications.
But Wiggins, who is now more than a year into her tenure as director, has declined several requests for interviews with the AJC.
Grace defended his boss to the AJC. “You have to realize she is effectively the CEO of one of the largest VA health systems in the country,” he said.
“From a leadership standpoint, we’re certainly not taking a complacent approach,” Grace said. “We are actually looking to engage with the challenges in this organization.”
Maloof, for one, isn’t willing to give the VA another chance. He said he still suffers from a botched hernia surgery at the Atlanta hospital in 2010.
Fresh from graduating Grady High School, Maloof enlisted in the Marines in 1967. While on patrol in a Vietnam rice paddy the next year, he stepped on an explosive device. Shrapnel from the explosion injured his leg, buttocks, back, arms, wrist, stomach and head. He underwent multiple surgeries at military hospitals over the next year.
“I’ve still got shrapnel in the middle of my brain to this day,” Maloof said. “They said if I lived it would be a miracle.”
After he was discharged, he started receiving care from the VA. A hernia surgery in the 1970s helped repair one of the shrapnel holes in his midsection. Four years ago, he needed surgery to repair another one. During that operation at the Atlanta VA, the doctor sliced a prosthesis, a mistake that went undetected for several months, he said.
Maloof said it took him more than a year to get the VA to agree to replace the prosthesis. He was sent to the Augusta VA for that procedure, which wasn’t fully successful. In 2013 a private doctor discovered a massive infection that had been festering for a year.
“I’m still dealing with it after four years,” Maloof said. “I’ll sell everything I own to pay for something before I’ll let the VA do a surgery on me again.”
VA officials would not comment on Maloof or other patients, citing privacy law.
Marine veteran Richard Thiede has amyotrophic lateral sclerosis, often called Lou Gehrig’s disease. ALS is a devastating malady that attacks the central nervous system.
Thiede said that when he ran out of pain pills and visited the Atlanta VA emergency room last December, a worker there refused to provide the meds, insisting that those with Lou Gehrig’s disease don’t require them. (According to the ALS Association, some patients do experience significant pain as a result of the immobility caused by the disease.)
Thiede’s wife got so upset in the emergency room that security had to escort her out of the building.
“It is absolutely shameful,” he said.
Fighting for care
Harold Cheek’s family said they had to resort to a letter-writing campaign to senators, congress members, cancer advocates, local hospitals and the VA’s Facebook page to get his cancer treated.
After Cheek’s chronic back pain worsened in January, the Army vet’s primary care doctor at a VA clinic in Lawrenceville tried to schedule an appointment at the VA hospital near Decatur. But she couldn’t get him an appointment, and instead he received a voucher for private care.
An MRI ordered by a private doctor in May showed that Cheek had spots of cancer in several organs, including his lungs, liver and one kidney. It took nearly another month to see an oncologist at the VA hospital. At a followup appointment in July, Cheek’s oncologist didn’t show.
Cheek’s son, Shane, started his letter campaign on July 18. It finally got attention at the VA. The Auburn vet started cancer medication last week. His doctor has told Cheek he may only have six months to live if the treatment doesn’t work. If it takes hold, he could live another two to three years or more.
Cheek and his family worry that the months lost to inaction could spell the difference.
“I really think they are pretty slack to be honest with you,” said the veteran, who volunteered during the Vietnam era. “I think it could have been caught quicker.”
Scott, the Atlanta congressman, credits Wiggins with making progress since taking the helm at the hospital last year, but he said those responsible for poor care should pay the price.
“It’s going to take punishing people that violate our veterans,” Scott said. “We are going to have to hold them accountable. We’re going to have to set some examples.”