A 26-page federal report says officials at the VA hospital knew of the dangers to patients.
By PAUL DE LA GARZA
Published March 20, 2004
ST. PETERSBURG - Officials at the troubled Bay Pines VA Medical Center have known for years that a lack of surgical equipment and lax procedures put patients at risk, according to a preliminary federal investigation.
The investigation also shows that Veterans Affairs officials failed to properly document the way they awarded a contract for a $472-million pilot computer system that has caused numerous problems at the hospital since its installation last October.
"I think that this is far more serious than we even expected that it would be," House Appropriations Chairman C.W. Bill Young, R-Largo, said of the 26-page report.
"I think also that when we're finished with all of these investigations, we're going to find that it goes beyond Bay Pines, that it comes all the way up to the Central Office" in Washington, he said.
The investigation by the Veterans Affairs inspector general found that:
- Hospital officials have known since January 2001 about problems in equipping surgeons with proper surgical tools.
- Patients have been endangered by inefficiency and error within the supply and distribution system for surgical equipment.
- Nurses in the operating room "identified foreign matter that appeared to be dried blood on instruments that were presented for use."
- Investigators documented missing files governing the contract of the pilot computer program, known as the Core Financial and Logistics System, or CoreFLS.
- Four days before the pilot was launched Oct. 6, CoreFLS project managers ignored warnings by the VA inspector general that "several risks had not been mitigated."
- VA project managers of CoreFLS and contractor BearingPoint "still have significant work" before it operates properly. There are no assurances that CoreFLS, which was scheduled to be rolled out nationally within two years, will meet the needs of the VA.
"VA management needs to aggressively oversee and act on this initiative because they are paying over $4-million to BearingPoint per month to bring CoreFLS operational, and as implementation and testing at other VA locations is delayed, costs will significantly increase."
The IG investigation was ordered by VA Secretary Anthony J. Principi. Sen. Bob Graham and Sen. Bill Nelson, both Florida Democrats, also requested the IG probe.
In a statement Friday, the VA said Principi was reviewing the IG report.
"If any issue identified in the interim report can be resolved now without having to wait for additional information, then the secretary is committed to resolving it," the statement said.
CoreFLS was developed to track and control finances, vendor payouts and supply inventories within the VA. But Bay Pines officials, including the VA regional chief, Dr. Elwood Headley, have said the computer system doesn't work.
Headley says the three software programs that make up CoreFLS do not communicate with one another. As a result, the hospital faces a backlog of hundreds of surgeries.
Hospital staff complain that they cannot keep track of expenditures, and vendors say they're not getting paid.
In one instance, according to the report by the IG, a vendor sent the medical center a final notice that it was disconnecting water and sewer service for failure to pay a $160 bill.
"The bill was paid prior to the discontinuation of service," the report said, "but this example illustrates the uncertainty of payments for many services, many of which are required to be paid timely in accordance with the Prompt Payment Act."
The VA had planned to roll out CoreFLS nationally within two years. That plan is being revised because of the problems at Bay Pines.
Software is not the only problem affecting the implementation of CoreFLS at Bay Pines.
The report said that some employees have not been properly trained, and some have not bothered to take the training offered over the Internet.
The chief of the surgical supply division did not take the training before Bay Pines switched over to the new computer system.
"The confluence of CoreFLS implementation, (supply and distribution) staff performance and training deficiencies, and lack of effective leadership has resulted in an organizational culture where clinical staff works around the system to ensure patient needs are met," the report said.
The report also raised questions about the way BearingPoint was awarded the CoreFLS contract.
"From our review of the contract files, we could not locate the original (request for proposal), nor could we determine on what basis VA made the award to BearingPoint over the other offerors," said the report, which credited the St. Petersburg Times for helping to launch its investigation.
Young, who has a special investigative team reviewing CoreFLS and allegations of mismanagement at Bay Pines, said he would be reviewing the CoreFLS contract.
"Actually, it opens up a lot more questions," Young said. "It's questionable how the contract was awarded, and it's questionable as to whether or not the contract was carried out."
Among other things, Young pointed to the lack of training of hospital staff who use CoreFLS. As chairman of the House Appropriations Committee, and as a Largo resident, Young said he had a two-pronged responsibility.
He wants to make sure that veterans get quality care and that the government spends its money wisely. Young offered some thoughts on the way BearingPoint has executed the contract at Bay Pines.
"I have a suspicion that ... there's been no strong push to train the people at Bay Pines to use the system, because until they're up and running with it themselves, we're paying $4-million a month to the contractor to run it."
"I think we have a lot more to do, and I tell you my investigative team they're pretty much amazed what they're finding there relative to this CoreFLS situation."