Chairman Bost, Rep. Kiggans Launch into Hampton VA Medical Center Following Reports of Patient Safety Concerns

Chairman Bost, Rep. Kiggans Launch into Hampton VA Medical Center Following Reports of Patient Safety Concerns

WASHINGTON, DC - Today, House Committee on Veterans' Affairs Chairman Mike Bost (R-Ill.), and Subcommittee on Oversight & Investigations Chairwoman Rep. Jen Kiggans (R-Va.), released the following letter they sent to Department of Veterans Affairs (VA) Secretary Denis McDonough regarding credible allegations of employee retaliation, patient safety concerns, and medical incompetence at the Hampton VA Medical Center, located in southeast Virginia.

In March, Chairman Bost's oversight team traveled to Hampton, Virginia to meet with medical professionals and whistleblowers who work at the medical center to discuss the scope of issues that have allegedly crippled the delivery of care, including lifesaving surgery, to veterans and the expansive military community in the Hampton Roads area. In 2022 and 2023, the VA Office of the Inspector General (OIG) released two reports on delays in diagnosis and treatment, and overall failures with the level of service at the Hampton VAMC and made recommendations for improvements. The Committee is investigating whether medical center leadership are working to fix the many alleged issues at the facility, including those identified by the reports, or covering up issues by retaliating against medical professionals who raise concerns.

"Patient safety should be VA's highest priority. To hear allegations that substandard care may be present at the Hampton VAMC, and that when it is flagged by medical professionals who have a responsibility and oath to their patients later leads to retaliation is incredibly concerning," the Members wrote in their letter. "I trust you would agree that this is unacceptable. We hope to work with you to ensure that the Hampton VAMC is a facility where all veterans in Hampton Roads can proudly and safely seek their healthcare."

Full text of the letter the Members sent can be found here and below:

Dear Secretary McDonough:

We have received disturbing information from credible sources regarding the Hampton Veterans Affairs Medical Center (Hampton VAMC) and its Surgical Services department. Allegedly, the [REDACTED] has created a dangerous environment where retaliation against VA employees who report patient safety concerns is commonplace, and gross medical incompetence is prevalent and goes unaddressed. Most troubling, however, is that allegedly when these serious issues are flagged to Hampton VAMC leadership, including the [REDACTED] and [REDACTED], issues are swept under the rug and their root causes continue to go unaddressed.

As you know, patient safety should be VA's highest priority. To hear allegations that substandard care may be present at the Hampton VAMC, and that when it is flagged by medical professionals who have a responsibility and oath to their patients later leads to retaliation is incredibly concerning. I trust you would agree that this is unacceptable. We hope to work with you to ensure that the Hampton VAMC is a facility where all veterans in Hampton Roads can proudly and safely seek their healthcare.

Given the extreme nature of these allegations involving a direct risk to veterans' lives, we ask you expedite this request. Please provide on a rolling basis, but no later than Friday, April 26, 2024, responses to the following questions, including copies of all responsive documents.

1. Please provide copies of all memoranda and final documents related to the decision to detail [REDACTED] out of [REDACTED] position from February 2023 to August 2023.
2. Please provide copies of all documentation, including investigation transcripts and all written communications produced since January 1, 2023, related to any Administrative Investigations Board (AIB), fact finding, and any other administrative investigations of [REDACTED].
3. Please provide copies of all memoranda and final documents related to proposed or actual disciplinary actions, against the following Hampton VAMC employees: [REDACTED].
4. Please provide copies of all Ongoing Professional Practice Evaluations ("OPPE") and Focused Professional Practice Evaluations ("FPPE") of [REDACTED] and [REDACTED] between January 2022 and present.
5. Please provide copies of all Joint Patient Safety Reports (JPSRs) related to Hampton VAMC's surgical services department between January 2023 and present.
6. Please confirm whether there has been any proposed or final administrative action taken against [REDACTED] following their return to the [REDACTED] position in August 2023. If no proposed or final action was taken, please explain the reasoning behind this inaction.
7. Please provide copies of all Veteran Integrated Service Network 6 ("VISN 6") reports, on Hampton VAMC, including its Surgical Services Department, drafted between January 2022 and present.
8. Please confirm who directed [REDACTED] to access [REDACTED] personal employee medical chart on September 19, 2023, and [REDACTED] to access [REDACTED] personal employee medical chart on October 7, 2022.
   1. Please provide copies of any related written communication to or from [REDACTED] and [REDACTED] on, or about, the date of the employee medical chart access.
9. Please provide copies of all Hampton VAMC specific bylaws including all versions, effective between January 2022 and present.
10. Please provide a copy of any recording and transcript of the Hampton VAMC meeting held September 6, 2023, 3:30PM-4:15PM, titled Mandatory Surgery Service and Associated Services All Hands Meeting.
11. Please provide any VA/VHA policies governing the cleaning of exam and procedure rooms where surgical services/procedures are conducted.
    1. Are doctors responsible for cleaning exam and procedure rooms? If not, who is responsible for their cleaning?
    2. How often are the Hampton VAMC exam and procedure rooms cleaned? What does the cleaning involve? Who performs the cleaning?
       1. Please provide any documentation showing the cleaning schedule of the Hampton VAMC Med Subspeciality clinic from January 2023 to present.
12. Please provide copies of all complaints, and any related investigations, regarding the cleanliness of Hampton VAMC.
13. Please explain how Hampton VAMC is planning to address its anesthesiologist shortage?
    1. Are Certified Registered Nurse Anesthetists being considered as an option to supplement the lone permanent available anesthesiologist at Hampton VAMC?
    2. What is Hampton VAMC's procedure for treating veterans, including conducting emergency surgery, when an anesthesiologist is unavailable? Please provide any written documentation which includes Hampton VAMC's plans to ensure patient safety risks caused my anesthesiologist shortages are minimized.
14. Please provide copies of all documents produced by "The Joint Commission," and its affiliates, regarding Hampton VAMC. Please include all Joint Commission reports, including corrective action plans and survey reports, and any other associated supporting documents.

When producing documents, please do not alter them in any way, including but not limited to application of redactions or a watermark. Additionally, digital copies should be provided in a format that enables their printing and copying by the House Committee on Veterans' Affairs. Thank you for your attention to this important issue. Please do not hesitate to have your staff contact our staff with any questions.

Sincerely,

MIKE BOST

Chairman

JEN KIGGANS

Chairwoman

Subcommittee on Oversight & Investigations