After a year-and-a-half wait, The News-Review has received a copy of a report by federal investigators looking into concerns about the Roseburg Veterans Affairs Medical Center’s former emergency department operations.
The report received last week wasn’t the one the newspaper expected to get when it filed a May 2018 Freedom of Information Act request, but the report did answer some questions raised at the time.
The newspaper sought a copy of an Office of Medical Inspector’s report based on investigations that office made of the Roseburg VA in late 2017. The OMI had released a two-page summary of its report in early 2018, but never made the full report public.
The end came with more of a whimper than a bang.
What the newspaper received instead was a report to the U.S. Department of Veterans Affairs Office of the Special Counsel. This report, dated Jan. 7, 2019, contained information gathered through 2017 and 2018 federal investigations of the Roseburg VA.
Most of the report details the Office of Special Counsel’s reasons for rejecting an anonymous whistleblower’s claim that a policy change was harming VA patients with advanced or terminal illnesses.
However, the report also confirms newspaper reporting from early 2018 suggesting previous administrators had been turning away high-risk patients from the emergency department to manipulate statistics used to determine the hospital’s star ranking — reporting that the Roseburg VA’s then-director Douglas Paxton called “absolutely false” and “fake news.”
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Both the emergency department and the star ranking system have since been scrapped. Roseburg VA spokesman Tim Parish noted the report found no patients had been harmed, and that it focused on events that occurred when the facility was under previous leadership.
“Since then, the Roseburg VA Health Care System has made many improvements, including the addition of urgent care services, which average 32 patient visits each day, compared to 31 ER visits each day before August 2019. Additionally, 98% of claims submitted for ER visits through our Office of Community care are being covered,” Parish said in an email.
The report does, however, offer a window into concerns about patient safety that pitted medical professionals against management when Paxton was director.
The Office of Special Counsel report said in 2017 “bed control teams” routinely decided whether patients should be admitted to the emergency department and had the power to overrule emergency doctors’ determinations about whether admission was in the patients’ best interest.
The bed control teams included nurses and administrators who did not have the credentials necessary to practice inpatient medical care. Investigators determined the bed control teams’ purpose was to make admissions decisions that would improve the metrics used in determining the facility’s star ranking. At the time, the Roseburg VA was rated a one-star hospital, the lowest possible ranking.
As The News-Review reported in 2018, investigators also found that the leadership created a toxic environment in which staff members felt too intimidated to report concerns about practices impacting patient safety. Based on investigators’ recommendations, several top officials were removed from supervisory positions. According to the report the newspaper received last week, the bed control teams were also eliminated based on investigators’ concerns. Paxton left the directorship in February 2018.
The national Department of Veterans Affairs has dropped its star ranking system under which …
Dave Whitmer was brought in as an interim director following Paxton’s departure and raised the rating to two stars. The federal VA system abandoned the star ranking program in 2019. Current Roseburg VA Director Keith Allen closed the emergency department and replaced it with a 12-hour-a-day Urgent Care center in August 2019.
The other issue addressed in the Office of Special Counsel report involved a 2018 decision to rescind policies around the treatment of patients with advanced or terminal diseases. An anonymous whistle-blower alleged the change compromised patient care and contributed to an increase in unexpected deaths, measured by the VA’s Standardized Mortality Ratio. The ratio measures the number of deaths that actually occur within 30 days of admission to the VA hospital compared to the number of predicted deaths.
The report said VA investigators visited Roseburg in October 2018 and reviewed 12 cases provided by the whistle-blower in which patients had died. The deaths had occurred over a three-month period in 2018 and were double the death rate of the previous six months.
The investigators found no evidence of substandard care, and the report said the ratio statistic was skewed by two factors — increased admissions after the bed control teams were discontinued and the timing of consultations with patients about end of life care.