Maintain That Quality of Care Varies Markedly Among the Networks
WASHINGTON, DC — The Veterans Integrated Service Networks (VISNs), which group VA’s facilities into 18 interconnected regions, has been a key part of the department’s structure since they were created in the late 1990s. Now, following a series of key oversight failures at VA facilities and years of watchdog agencies reporting frustrating inconsistencies from VISN to VISN, legislators are wondering if this structure is really the best way to oversee VA’s 172 hospitals nationwide.
“Over the years, VISNS have evolved significantly, sometimes leading to inconsistent administrative practices across the networks. [This has] resulted in variable treatments, differences in care quality, and access to care issues nationwide,” declared Rep. Mariannette Miller-Meeks (R-IA) at a recent House VA Health Oversight hearing. “These administrative variabilities have often caused veterans to receive different treatment based on their location rather than their healthcare needs.”
Officials from the VA Office of the Inspector General (OIG) testified how their investigations have shown time and again that incidents at VA facilities that endangered patients could be blamed in part on those variabilities at the VISN level and inconsistencies in how VISN leaders define their oversight role.
At the Tuscaloosa, AL, VAMC, investigators found that a patient safety manager had not performed essential functions for close to a year, and neither facility leaders or the VISN Patient Safety Office were aware.
At the Montana VAMC, confusion between the medical center director and the VISN chief medical officer’s responsibilities delayed reporting of the facility chief or staff’s substandard practice of obstetrics and gynecology to the state licensing board. Because of the delay, after resigning from the VA that provider was able to practice privately in California.
Then, there is the recent report of extensive leadership failures at the Rocky Mountain VAMC in Aurora, CO. Investigators found that a toxic work environment resulted in a mass departure of top-level staff and in a year-long shut-down of the hospital’s cardiac surgery program. VISN officials said they were only peripherally aware of the issues.
“OIG has repeatedly discovered inconsistent practices and inefficiencies that run counter to VA’s initiative to transform into a high reliability organization,” explained Julie Kroviak, MD, principal deputy assistant inspector general for Healthcare Inspections. “When roles and responsibilities and not defined and standardized across the highest levels of leaders, ensuring that accountability is challenging. Confusion over VISN authority undermine the essential function of medical facilities and highlight a VISN structure that is ineffective in delivering safe care to patients.”
The lack of defined roles and responsibilities also cuts the other way, making it difficult for qualified and experienced leaders to “take ownership and exercise authority over performance improvement initiatives,” Kroviak added.
The need for VA to firmly define what those VISN roles are has only increased with the implementation of major initiatives like community care and the PACT Act.
“[Strong nationwide oversight] is needed to provide accountability for the efficient and effective [administration] not only these high cost and necessary efforts but also for safe and consistent practice of day-to-day patient activities,” Kroviak told legislators.
Ken Kizer, MD, MPH, who served as VA’s undersecretary for Health from 1994 to 1999, was one of the architects of the VISN system. Testifying before the committee, he defended the structure in principle, but noted that it has yet to become the tool for nationwide standardization and efficiency that it was meant to be.
“[The VISNS] were an element in a radical reengineering of the VA healthcare system,” he said. “I think the rationale and conceptual underpinnings of [the VISN structure] is sound. The fact that so much of American healthcare is pursuing integrated delivery network structures should provide the community with some reassurance that it’s a sound structure.”
“I do think that much has happened over the last 25 years,” he added. “VA does face many challenges today that it did not necessarily face then. I don’t think that VA has done enough to develop and nurture and grow the necessary leadership and management skills needed to address the system’s many challenges.”
Kizer did suggest that VA examine whether the current number and distribution of VISNS is still appropriate for the department’s needs.
“I think it’s worth considering whether the present number and configuration of VISNs is optimal,” he said. “Especially with regard to those networks that have experienced marked increases in enrolled veterans, they serve.”
