Poor care went undetected at a suburban Chicago veterans hospital because "review systems failed us," Veterans Affairs Secretary Edward Derwinski said Tuesday.
After linking eight deaths at the North Chicago hospital to a variety of errors, Derwinski said his department is drafting a checklist that will be used to measure the quality of care at all VA medical centers."We're emphasizing the simplicity aspect - yes, no, quickly identified indicators," Derwinski said in testimony prepared for a congressional hearing. "In an imperfect world we only have imperfect systems, but we're striving to come as close to perfection as we can."
A House Veterans Affairs subcommittee summoned Derwinski and others to testify, a month after the VA's inspector general issued a damning report on the 1,004-bed North Chicago hospital.
The report includes details on 15 deaths, including eight that the VA has labeled "therapeutic misadventures." The agency is negotiating compensation with families of the eight victims.
Vascular and orthopedic surgeries have been discontinued at North Chicago. The chief of staff has been demoted, and the hospital's former director, now at VA headquarters here, has been reassigned.
"The larger implications of the North Chicago situation have not been lost on the department," Derwinski said. "We are facing up to the fact that existing review systems failed us in this instance."
The VA's former deputy chief medical officer, D. Earl Brown Jr., told the subcommittee that veterans hospitals across the country do not deserve a black eye because of the North Chicago scandal.
"If there are so many checks on the VA system, why are they not able to avoid such problems as precipitated this hearing?" Brown said.