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Investigative report: Senior VA leadership created environment of intimidation; radiology, cardiology, psychiatric issues identified

March 2, 2018

The federal Office of the Medical Inspector has called on the Roseburg Veterans Affairs Medical Center to make some changes, including removing some managers, a summary report reveals.

The report follows an investigation into alleged whistle-blower retaliation and clinical concerns at the Roseburg VA. The investigation was requested by U.S. Rep. Peter DeFazio, D-Springfield, who said he had been contacted by hundreds of current and former employees alleging problems with VA management.

A brief, two-page summary of the Blue Cover Report, dated Wednesday, and received by the News-Review Thursday, said investigators looked into seven allegations and substantiated six of them.

Investigators visited the Roseburg VA, and the Eugene VA clinic, which it runs, in October, November and December. They interviewed 131 present and former employees, according to the report summary. The report said investigators found Roseburg VA senior leadership had created an environment of intimidation, an apparent confirmation of multiple anecdotal reports of bullying and whistle-blower retaliation. Chief of Surgery Dinesh Ranjan, who had been the focus of some allegations of bullying and retaliation, stepped down about a month ago, followed shortly afterward by Director Doug Paxton.

Other substantiated allegations listed in the report involved radiology practices that impacted timely and accurate results; inadequate supplies and resources identified by nursing staff; mismanaged cardiology consultations; “suboptimal utilization” of Eugene operating rooms; and clinical and leadership concerns in the acute psychiatric unit. The items are presented in list form, without details.

A complaint about access to primary care was said to be partially substantiated, while a claim that a surgeon had been improperly terminated was not substantiated. The surgeon was not named.

The OMI made 22 recommendations for changes at the Roseburg VA, and said the facility leadership must develop action plans to meet those recommendations. The OMI will monitor the VA until all the action items are completed, the report said. It also issued recommendations to the regional network that oversees Roseburg.

DeFazio issued a written statement Thursday afternoon, in which he said the OMI recommendations will lead to significant improvements, not only at the Roseburg VA, but at VA hospitals around the country.

“I’m pleased to see that the VA has substantiated the numerous claims employees, patients and former staff have raised with my office,” DeFazio said. “The recommendations laid out in the summary are only the beginning, though—I will continue to work with stakeholders on the local, regional and national levels to ensure these recommendations are implemented and Oregon’s veterans and veterans nationwide get the care they deserve.”

DeFazio said the VA has “suffered from years of mismanagement,” and it’s “long past due that the VA implements lasting, meaningful change.”

VA spokesman Shanon Goodwin said the VA appreciates the OMI’s review.

“While OMI found a number of opportunities for improvement, we welcome the scrutiny and consider this an opportunity to redouble our efforts to serve Veterans,” he said in a written statement. “The Roseburg VA Health Care System is under new leadership and on a new path, and we look forward to working with Veterans, community stakeholders and local and national VA leaders in order to complete all of OMI’s recommendations.”

Among the OMI’s recommendations is that three associate chiefs of staff be removed from supervisory responsibilities, and that the nurse manager of mental health be removed from supervisory duties. The report also calls on the regional network, VISN 20, to “investigate the Chief of Staff concerning actions related to the hostile work environment,” and to “provide immediate support for the replacement of three Associate Chiefs of Staff.”

It calls for the Roseburg VA to perform a root cause analysis study into the death of a veteran who was diagnosed with frostbite. Another root cause analysis is called for on a case identified only as having been “described in the Report.”

A number of recommendations involve radiology. Some of those include refining standard operating procedures, standardizing methods to communicate clinically significant findings, and following national practice standards.

It also calls for assigning an experienced clinician to oversee the psychiatric unit and for evaluating after-hours coverage by a telepsychiatrist.

A full report from the OMI is expected in the near future. The VA Office of Accountability and Whistleblower Protection also sent investigators to the Roseburg VA, and is expected to produce a separate report.