...
VA hospital whistleblowers still have unresolved
questions; hear from them on podcast

'Reveal' is available on the Stitcher app
Ellen Weiss
Sep 17, 2016

Questions about the quality of care and problems at Veterans Affairs
hospitals around the country will be the focus of this week’s "Reveal," a
national investigative public radio program produced by the Center for
Investigative Reporting.

LISTEN: Reveal podcast by the Center for Investigative Reporting

For almost a year, a team of reporters from WCPO and the Scripps
Washington bureau have been speaking to more than three dozen
whistleblowers, made up of former and current staff at the Cincinnati VA.

The group, including doctors and heads of departments, allege a pattern
of cost-cutting that forced out experienced surgeons, reduced access to
care and put patients in harm's way. Many believe the hospital forced
veterans out of the hospital and into a program called Choice,
intentionally reducing services to make the hospital’s budget look better;
they also described problems with sterilization inside the operating room.

Scott Landrum worked as a surgical technician at the hospital and was in
charge of making sure all the instruments were ready and clean before
the procedures began.

Read the WCPO/Scripps Washington investigation here

“Well, over the past couple years there have just been some serious
problems with sterile processing,” Landrum said. One of those problems,
he said, was water left on the bottom of instrument trays.

“Water is your enemy when it comes to sterilization," Landrum said.
"Water harbors bacteria.”

According to internal hospital records obtained by Scripps and WCPO
these kinds of “quality events” or “non-conforming products” occurred in
one in every six surgeries in fiscal year 2015.

The one-hour radio program includes an interview with a whistleblower
from the Phoenix VA hospital who exposed a wait-time scandal where
veterans died while on waiting lists to see doctors. The Choice program
was born out of the problems in Phoenix and Congress established a 10
billion dollar fund to pay for care outside the VA.

The VA has yet to release a final report on an inquiry into problems
inside the Cincinnati hospital, but in a preliminary report the VA said it
“could not substantiate any allegation involving quality of care for
veterans.”

That led to a dramatic moment in the radio documentary at a Veteran’s
town hall meeting presented by Scripps and WCPO in April.

“I just now understand that the investigations show there was no bone
and nothing was wrong with the instruments,” Landrum said, addressing
acting VA regional director Robert McDivitt. “I'm the person who found
the instruments and what was wrong with them. How in the world can they
say that? I'm the person who filled out the report. Where did those
reports go?”

That and many other questions the whistleblowers have raised remain
unresolved.

Two days after that exchange, Landrum said he was summoned to the
front office of the local VA and told he would be fired. He hired an
attorney to challenge his firing, but in early June Landrum resigned and
took a new job outside the VA.
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Medical whistle-blowers
Exclusive: Whistleblowers cite disorder at VA hospital
Special investigation: Dereliction of Duty

Mark Greenblatt, Dan Monk, Aaron Kessler
WCPO Cincinatti
Feb 16, 2016

Nearly three dozen whistleblowers have come forward saying the VA Medical
Center in Cincinnati is in a state of disorder. They say veterans are not getting the
care they need in the backyard of Secretary of Veterans Affairs Bob McDonald,
the former chief executive of Cincinnati-based Procter & Gamble Co.

Since October, a team of Scripps reporters has been talking to a group of 34
current and former medical center staff members. The group, including 18 doctors
from several departments, sent an unsigned letter to McDonald in September
describing "urgent concerns about quality of care" at the facility, which serves
more than 40,000 area veterans. They allege a pattern of cost cutting that forced
out experienced surgeons, reduced access to care and put patients in harm's way.

At the center of the controversy are Dr. Barbara Temeck, acting chief of staff for
the Cincinnati VA Medical Center, and Jack Hetrick, the Department of Veterans
Affairs' regional director.  
Whistleblowers describe poor care at the VA hospital in Cincinnati, OH

The VA has launched one investigation and requested the Office of Inspector
General open an additional independent investigation. The VA also temporarily
removed oversight authority of the Cincinnati hospital from Hetrick, the highest-
ranking VA official in Ohio, Michigan and Indiana. The agency did this "to ensure
no conflict of interest." The Cincinnati VA is reporting to a Pittsburgh-based
regional director while the investigations proceed.

The findings of a joint investigation by the Scripps News Washington Bureau and
WCPO triggered the federal probes.

[READ MORE: 'Dereliction of Duty' exclusive investigation]

Several local veterans described long delays and substandard care during Dr.
Temeck's tenure. Ted Dickey, a 72-year-old Vietnam veteran, had depended on
the Cincinnati VA for care for some 30 years. When the VA told Dickey he needed
a hip replacement last May, instead of treating him, they gave him a referral and
showed him the door. He was told there were no longer hip surgeons on staff.
Dr.  Barbara K. Temeck assumed the role of acting chief of staff at the Cincinnati
VA Medical Center in July 2013. (Scripps Photo by Matt Anzur)

"They don't know how to run a hospital," Dickey said. "Their way of running a
hospital is not doing surgery and farming it out."

Dr. Temeck declined to comment for this story. Mr. Hetrick walked out of an
interview after praising the Cincinnati hospital for overcoming "resource
challenges" and improving quality.

"I've worked very closely with them to make sure we get them back on track," he
said. "I wanted to make sure that this organization was set solid for the future. I
think we're there." The hospital has consistently received four or five stars, which
are the highest ratings by the VA.

Here  are some of the Scripps-WCPO findings, all based on interviews and
documents:

   Services to veterans have been reduced, including spine and orthopedic
surgeries, along with customized prosthetic services for artificial limbs.
   Dr. Temeck prescribed controlled substances, including hydrocodone and a
generic form of Valium, to Mrs. Hetrick, the wife of her regional boss, Jack Hetrick.
State and federal authorities confirm Dr. Temeck does not have a valid controlled
substances license that would allow her to write prescriptions privately for Mrs.
Hetrick.
   Dr. Temeck cut around-the-clock staffing by emergency airway specialists to
save money, resulting in at least one close call involving a patient who could not
breathe.
   Dr. Temeck told operating-room staff they were being "too picky" when they
reported surgical instruments delivered to operating rooms with blood and bone
chips from previous surgeries.
   Dr. Temeck is paid separately as a VA administrator and cardiothoracic
surgeon. But whistleblowers say she has never served as the operating surgeon
since coming to Cincinnati.

The nearly three dozen whistleblowers have been voicing their concerns for the
better part of a year, including meeting in person with regional director Hetrick and
reaching out to members of Congress and Secretary McDonald. They say little has
been done to remedy the problems.

The chairman of the House Committee on Veterans Affairs, Florida Republican Jeff
Miller, said his staff has been talking to Cincinnati whistleblowers, but he wanted to
give McDonald some time to address the issues they raised. "If in fact this is true, I
would hope the secretary will take it seriously because if he doesn't, we'll examine
it from the committee standpoint," Miller said.
Local VA 'just not up to standard'

Three longtime employees of the Cincinnati VA agreed to go public with their
concerns because they believe hospital leaders are no longer acting in the best
interest of veterans.

Their public comments reflect the private concerns of dozens of doctors and
nurses who also agreed to be interviewed and provided documents but asked not
to be named for fear of retaliation.

"This was a model hospital," said Dr. Richard Freiberg, former chief of orthopedics
for the Cincinnati VA.  
'We were serving veterans with almost every imaginable problem and doing state-
of-the-art care. Now, we're unable to care for almost all of them'

"We were serving veterans with almost every imaginable problem and doing state-
of-the-art care. Now, we're unable to care for almost all of them." He recounted
that shortly after Dr. Temeck came to Cincinnati, she called a sudden meeting of
the hospital's full-time total joint surgeons: "We were told that we were going to be
reduced to one full time between the three of us."

Dr. Freiberg ended his VA employment in October, frustrated by cuts that
rendered the hospital unable to do complex joint replacements for hips, knees and
shoulders.

He continues to volunteer for the facility.

"Things I've observed at the Cincinnati VA are just not up to standard," said Mike
Brooks, a certified registered nurse anesthetist who joined the VA after a 24-year
Navy career that began when he was 17.  Brooks is a shop steward for the
national nurses union and began working in Cincinnati in 2008. "It bothers me
because I know the veterans who deserve the best care we can give them are
being put at risk."

Susan Ware is a nurse practitioner who decided to speak publicly because of the
dismantling of a neurosurgery practice that treated 686 patients in 2013 and now
refers all brain and nervous-system procedures elsewhere. Ware worked in
neurosurgery for 16 years.

"What's happening at the Cincinnati VA is sad," she said. "There is a reason why
the VA exists and there's a reason veterans want to come to the VA. And it's being
ignored."

Ware said she and other employees started complaining about Dr. Temeck's
management decisions more than a year ago, but the regional director Jack
Hetrick took no action.

"It seems that Mr. Hetrick supports her," Ware said, "despite the knowledge that he
has about how unhappy the staff is."
The boss' wife

Mr. Hetrick and Dr. Temeck have a work relationship that dates back to at least
2002. He was the director of the Edward Hines Jr. VA near Chicago and Dr.
Temeck was the hospital's chief of staff, records show. Both moved on to jobs
outside of Illinois, but stayed with the VA.
Jack G. Hetrick is Network Director of the VA's regional office that oversees
hospitals in Ohio, Indiana and Michigan. (U.S. Air Force photo by Wesley
Farnsworth/Released)

According to documents obtained by Scripps, on Dec. 26, 2012, more than two
years after Dr. Temeck left her position in Illinois, she prescribed pain medication
for Mr. Hetrick's wife — 50 pills of a generic form of Valium. On May 17, 2013, Dr.
Temeck prescribed 100 pills of hydrocodone.  This was eight weeks before Dr.
Temeck was named Cincinnati's acting chief of staff. Both drugs are labeled
controlled substances by the U.S. Drug Enforcement Administration.

During an interview, Mr. Hetrick walked out of the room when asked about the
prescriptions.

"You're not going to engage me," he said.

At the time of publication, Mrs. Hetrick's attorney had not responded to requests
for comment.

These prescriptions raise several issues:

   Dr. Temeck was working at a VA hospital in South Carolina when the 2013
prescription was written, but she used an Illinois address tied to the VA hospital
she had left in 2010 to issue the prescription.
   Dr. Temeck's Illinois license does not allow her to write prescriptions for
controlled substances outside the VA.
   Dr. Temeck's authority to prescribe controlled substances in Illinois expired in
2011.
   State and federal officials told Scripps that Dr. Temeck did not have in 2011,
nor does she have now, a valid controlled substance license that would allow her
to write prescriptions privately for Mrs. Hetrick.
   According to medical ethics experts interviewed by Scripps, it poses a conflict of
interest for a doctor to provide treatment, particularly controlled substances, for
his or her work superior, or their family members.

Click to view the interactive timeline in a new window.

According to a statement from Derek Atkinson, spokesperson for the VA regional
network headed by Mr. Hetrick, Dr. Temeck has "an active state medical license in
Virginia that includes prescribing controlled substances." An official with the
Virginia Department of Health Professions, which regulates the state's doctors and
pharmacists, told Scripps that Virginia medical licenses do not include the ability to
write prescriptions for controlled substances.

"To write controlled substances, the physician must hold a DEA registration,"
department spokeswoman Diane Powers said. Dr. Temeck has not held a Drug
Enforcement Administration controlled substances registration outside the VA
system for nearly two decades, the DEA told Scripps. Instead, in recent years
she's held what's known as a "limited registration," which allows her to write
prescriptions only within VA facilities she's working in.

When asked about the prescription matter, Rep. Miller said rules appear to have
been broken. "Was the person allowed to receive the prescription? From what I
can gather they were not." He added, "I believe that it needs to be fully
investigated."
The boss' pay

As acting chief of staff, Dr. Temeck earns $137,191.  According to the VA, Temeck
earns an additional $194,343 for her role as a cardiothoracic surgeon, for a total
of $331,534.

Multiple sources, including those who have been inside the operating room with
Dr. Temeck, say she only serves as an assistant and has never worked as the
operating surgeon since arriving in Cincinnati.  "It's certainly common knowledge in
the hospital that she's gaming the system," Dr. Freiberg said.

Brooks said it's an "open secret" in the hospital that Dr. Temeck earns the
additional salary as a cardiothoracic surgeon for work he has never seen her
perform.

VA rules allow physicians to receive a "market pay augmentation" in specialties
where it's competing with private-sector hospitals for labor talent. The VA
handbook says the amount of market pay depends on several factors, including
the doctor's level of experience, credentials and accomplishments along with
analysis of the local health care labor market.
Mike Brooks, a certified registered nurse anesthetist, began working at the
Cincinnati VA in 2008. (Scripps News photo by Matt Anzur)

"It's certainly not right by the taxpayer," said Brooks, a certified nurse anesthetist
who participated in several surgeries in which he says Dr. Temeck scrubbed in,
then assisted in surgery.

Sometimes, she holds a retractor, Brooks said, but she never took the lead. A
retractor is a medical instrument used for drawing back the edges of an incision.

"She's in the room when surgeries happen," he added, "but I can't say I've ever
seen her pick up a scalpel and do a surgery."

The Cincinnati VA declined to say how many times Dr. Temeck has led a thoracic
surgery since joining the hospital staff, but stated her "workload is consistent with
other provider(s) in Cincinnati and other facilities of similar complexities."

The VA also said Dr. Temeck is "privileged and in good standing" at the Cincinnati
VA "and works within the scope of privileges."

Bryan Snyder, a supervisory human resources specialist at the hospital, made the
case for awarding the permanent chief of staff job to Dr. Temeck, along with a
substantial pay raise. According to an internal memo, Snyder sought an exception
to let Dr. Temeck exceed the federal salary cap of $385,000 for her role as a
cardiothoracic surgeon if she gets the permanent job.

"Dr. Temeck has already proved invaluable in the short time she has been
detailed to this facility," Snyder wrote. "Her input and assistance have assisted with
decision-making and planning and facilitated a 'fresh eyes' approach to the clinical
operations of the facility that is transforming several patient services and
processes."
Cost-cutting close call

When Dr. Temeck arrived in 2013, the hospital was paying overtime to nurse
anesthetists so they would be available 24 hours a day, seven days a week to
handle emergency breathing problems. As a cost-cutting measure, sources say
Dr. Temeck replaced that system with a requirement that on-call surgeons perform
intubation during off hours. Intubation is the insertion of a plastic tube into a
patient's windpipe to assist in breathing.

On May 9, 2014, Dr. Temeck was the on-call surgeon when a patient stopped
breathing.  "She had trouble," said Brooks, referring to Dr. Temeck. "She had to
call for backup." Others who were involved in the incident confirmed his account.

Sources told us the VA's Office of Medical Inspector recently interviewed
employees about the incident.

Days after the incident, sources say Dr. Temeck reversed the policy. The
Cincinnati VA says it now provides "Certified Registered Nurse Anesthetists
coverage 24/7."
Bones on blades

Brooks and other operating-room staff said one of the most disturbing problems
involved contaminated surgical instruments. "I've seen surgical instruments that
once we open the sterile pack, they will have pieces of debris, possibly bone or
other debris from previous surgeries still on the instrumentation," Brooks said.

Instead of committing to better training or spending to hire more certified
technicians, Brooks said Dr. Temeck told operating-room staff to stop complaining.

She also required them to notify her when they spotted problems so she could
inspect the tools before they could be replaced with clean ones. Brooks said
surgeries were halted, sometimes with patients cut open, waiting for Dr. Temeck to
arrive for an inspection.

"She felt that these were all fabrications, that we were making up stories about the
instruments not being clean, so she wanted to see for herself," he said. "If she was
in another meeting, it could be 20 minutes, half an hour, with the patient under
anesthesia."
CLICK TO ENLARGE - Source: U.S. Department of Veterans Affairs

Under Dr. Temeck's tenure at the Cincinnati VA the rate of MRSA infections has
increased substantially.  The highly contagious, drug-resistant infection is
commonly associated with surgeries. According to the most recent publicly
available data, Cincinnati now has one of the highest rates of MRSA infections for
VA hospitals nationally.

Brooks said he and many of the other whistleblowers filed complaints with the U.S.
Office of Special Counsel, a federal agency that reviews whistleblower complaints,
but does not have independent investigative authority. The agency notified him in
May that no action would be taken. Brooks shared the written response he
received.

"You were unable to provide our office with detailed information regarding the
gravity and frequency of the problem," said Olare Nelson, an attorney in the OSC's
disclosure unit.

Brooks is undeterred.

"I'm ringing the bell," he said. "I'm letting people know there's an issue here. They
continue to say that everything's fine, but we know on the inside that we have an
institutional culture that is not promoting safe patient care."

Scripps News Washington Bureau and WCPO will continue to report on conditions
and factors in the Cincinnati VA and nationwide in the coming days and weeks. If
you have a tip for us to investigate or if you're a veteran who wants to share your
experience seeking care at any VA hospital in the nation, drop us a line.

Mark.Greenblatt@Scripps.com

Daniel.Monk@WCPO.com

Aaron.Kessler@scripps.com

(SiuTan Wong contributed to this report)
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