Wnited States Senate WASHINGTON, DC 20810 March 14, 2018 ‘The Honorable David Shulkin Secretary of Veterans Affairs 810 Vermont Avenue, NW Washington, DC 20240 Dear Secretary Shulkin, We write to you to express our concer regarding the recent Department of Veterans Affairs (VA) Office of Inspector General (OIG) report that outlines critical deficiencies at the Washington D.C. VA Medical Center (DCVAMC). While we are disturbed by the numerous breakdowns in essential functions at the DCVAMC that are documented by the OIG, we are particularly troubled by the massive leadership failures at multiple levels of the VA despite consistent warnings. In April 2017, we asked you to take immediate action to improve management at the DCVAMC_ following the release of the OIG Interim Status Report that first brought to light many of these serious problems. The final report expands upon the OIG’ initial findings and details significant inadequacies in executing basic hospital functions, including an inability to maintain an appropriate inventory of medical supplies and sanitary storage facilities, which resulted in an inereased risk of harm to veterans at the facility. Thankfully, the OIG found that the efforts of DCVAMC health care professionals prevented patients from suffering adverse medical outcomes as.a result of the identified deficiencies. We applaud those health care professionals for their herculean efforts in the face of such adversity, but their outstanding dedication to veterans should not minimize the egregious management problems at the DCVAMG, including historically high vacancy rates in logistics and sterile processing positions dating back to 2014. We found the most troubling aspect of the OIG’s Report to be the massive failures in leadership that occurred throughout multiple levels of the VA. Veterans Integrated Service Network (VISN) 5, and Veterans Health Administration Central Office (VHACO) staff all filed and received reports from 2013 to 2017 that outlined many of the supply, equipment, and inventory issues that ‘were later outlined in the final OIG Report. However, despite repeated recommendations for action, these DCVAMC leaders failed to take appropriate steps to address these issues. This, failure in leadership endangered the health and safety of veterans at the facility. The lack of leadership identified by the OIG highlights the need for more stringent oversight measures that would prevent these breakdowns from occurring at other VAMCs. We are pleased that you already addressed some of the failings of the DCVAMC documented in the April 2017 OIG interim Status Report, including personnel changes and the implementation of new supply and cleanliness processes. In addition, we applaud your initiative to implement measures that would help prevent similar failures in leadership at VAMCs across the nation, such as increasing accountability at the VA Central Office.While progress has been made since the release of last year’s report, fundamental problems still exist al the Medical Center. We request that you provide a comprehensive update on the progress made in implementing corrective actions at the DCVAMC and a full description of the VA-wide measures you are planning to enact that would increase accountability throughout the organization. Finally, we ask that you identify any legislative action that is required to carry out remedial measures. ‘The Washington D.C. VA Medical Center serves thousands of Virginians each year. Failure to execuite basic hospital functions at the VA’s flagship medical facility erodes the trust our veterans have in the VA. We can and must do more to guarantee the health and safety of our veterans in your care. We look forward to working with you to correct the persistent problems at the DCVAMC and prevent similar deficiencies from occurring elsewhere within the VA. Thank you for your attention to this important matter. We look forward to your prompt response. Sincerely, Moh. © Wevez Mark R. Warner United States Senator United States Senator