This is really horrifying Theo.
They basically allowed 22 deaths to occur and how many Vets were ill that survived the illness?
When I was a nurse manager in acute care hospitals, we constantly were improving our infection control processes. I know that you also worked in acute care.
It made me wonder if the VA actually has Joint Commission surveys or from Department of Health Services inspections in each state.
The most recent survey from Joint Commission I could find online was published in 2016. Infection control was one of the areas surveyed and that required improvement.
It made no mention, that I could find, of legionella in the water systems at the facility in the CNN investigation and I don't know if it was even one of the 139 reviewed:
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The Joint Commission Releases Results of VA Health Care Surveys to VA
August 4, 2016, 04:05:00 PM
The Joint Commission Releases Results of VA Health Care Surveys to VA
Surveys Note Challenges and Improvements
Note: This release was updated on August 5 and now contains a link to the report.
WASHINGTON - The Joint Commission today provided the results of its Special Focused Surveys of the Department of Veterans Affairs (VA) healthcare facilities to VA leadership. The special focused surveys, prompted by reported allegations of scheduling improprieties, delays in patient care and other quality-of-care concerns, were conducted October 2014 to September 2015 and focused on measuring the progress VA has made to improve access to care and barriers that might stand in the way of providing timely care to Veterans.
“One of my top five priorities is to seek best practices in research, education, and management. We invited The Joint Commission in to conduct these unannounced focused surveys at 139 medical facilities and 47 community based outpatient clinics (CBOC) across the country, to give a better understanding of areas for improvement and areas where the processes are worth replicating,” said VA Under Secretary for Health Dr. David Shulkin.
The Joint Commission assessed the following:
>>Processes related to timely access to care;
>>Processes that may potentially indicate delays in care and diagnosis;
>>Processes related to patient flow and coordination of care;
>>Infection prevention and control
>>The environment of care; and
>>Organizational leadership and culture.
VA provided The Joint Commission with organization-specific data addressing performance in the key areas targeted for review. This data allowed surveyors to focus on areas of greatest risk for each organization and to validate whether the VA-provided data reflected observed practice. The Focused Survey project provided an opportunity to see patterns across the organization, to make an assessment about the system in general and most importantly, to identify solutions to system-wide issues that are best addressed through internal processes.
“We commend VA for being proactive by requesting The Joint Commission to conduct unannounced site visits at all their medical centers to review and evaluate their efforts to improve access and quality of care. VA was the first system ever to request an assessment with an important focus on access so that deficiencies could be identified and rapidly addressed,” said Mark Chassin, MD, FACP, MPP, MPH, president and CEO of The Joint Commission. Chassin also noted, “The Joint Commission will track and report on the extent to which improvements occurred, when the same facilities undergo their triennial accreditation surveys.
To date, results from 57 hospitals that have undergone full accreditation are promising. We are pleased with VA’s ongoing commitment to quality improvement and patient safety.”
The full report, with findings and recommendations can be found at:
http://www.va.gov/opa/docs/Joint-Com...n-May-2016.pdf
https://www.va.gov/opa/pressrel/pres...se.cfm?id=2808