Senate Hearing Examines Mismanagement and Unhygienic Practices at Dayton VA Medical Center

Members of the House Veterans Affairs Committee heard testimony this week regarding lapses in leadership and unhygienic practices at the Dayton VA Medical Centers dental clinic, where a dentist did not sterilize surgical instruments nor change gloves between patients and thus potentially exposing 535 patients to bloodborne pathogens.

Robert Petzel, the under secretary for health at the VA in Washington, D.C. placed the blame on dental clinic administration and leadership for not providing adequate oversight of this dentist who has since retired from practice.

In late April, the Department of Veterans Affairs' inspector general released a report, "Healthcare Inspection: Oversight Review of Dental Clinic Issues, Dayton VA Medical Center," that asserted that the dentist "did not comply with infection control and related procedures" and that there was evidence that dental service management was aware of these infractions prior to a VA System-Wide Ongoing Assessment and Review Strategy (SOARS) team visit. The report adds, "Additionally, we confirmed that staffing levels in the dental clinic were suboptimal, and this may have increased the likelihood that deviations from approved infection control practices would occur. We also found that interpersonal relations among dental clinic staff were, at times, strained and negatively impacted the dental clinic."

The report made two recommendations: that the Veterans Integrated Service Network (VISN) director review the findings related to the Dayton Dental Clinic, to include staffing issues, and take whatever action deemed appropriate; and that the VISN director ensure that the Dayton Medical Center Director requires the dental service to comply with the relevant infection control policies.

In a statement, U.S. Sen. Sherrod Brown (D-OH) said, "Ohios veterans have earned and deserve the highest quality care. Its inexcusable that some patients at the Dayton VA Dental Clinic were not served to that standard. We must restore the publics confidence in the system and we must ensure accountability for those responsible for horrific wrongs. I will work to create transparency moving forward to ensure no veteran is ever treated with such blatant disregard and to learn from the clinics mistakes so that those mistakes are never repeated."

At an April 26 hearing, "Improving Patient Safety and Quality Care at the Dayton VA Medical Center," Brown received testimony from the Office of the VA Inspector General and employees of the Dayton VA Medical Center. The committee explored the history and specifics of mismanagement and neglectful practices which led to the exposure of bloodborne pathogens to patients of the VA Medical Center Dental Clinic.

Witnesses include John D. Daigh, Jr., MD, assistant inspector general for healthcare inspections at the Office of Inspector General, and Jack Hetrick, network director of the Veterans Integrated Service Network 10. Also attending the hearing were George Wesley, MD, director of the Medical Consultation and Review Division in the Office of Healthcare Inspections; Kathleen Shimoda, healthcare inspector in the Office of Healthcare Inspection; William D. Montague, acting director of the Dayton VA Medical Center; and Lisa Durham, chief of quality management at the Dayton VA Medical Center.

Brown, a member of the Senate Committee on Veterans Affairs, wrote to Sen. Patty Murray (D-WA), chair of the Senate Committee on Veterans Affairs, to request a hearing to investigate this situation and identify preventive actions that would ensure that a situation like this never arises again. Last year, Brown sent a letter to U.S. Department of Veterans Affairs Sec. Eric Shinseki urging the VA to investigate the complaints at the VAMC. Brown has spoken with Shinseki and VAMC officials repeatedly urging them to correct any issues and install effective leadership. In February, the Administrative Investigation Board issued a report on the Dayton VAMC indicating that several employees may have known for years that a practitioner was using unhygienic practices for 18 years exposing veterans to blood-borne pathogens because dental equipment was not sterilized. In response, Brown joined U.S. Sen. Rob Portman (R-OH), and Turner in writing to Shinseki to request increased oversight and a more expansive investigation.

Source: Compiled from news reports, press releases and VA-sourced materials