Watchdog report critical of St. Cloud VA was quietly shelved

Prominent Minnesota lawmakers are demanding to know why a 2013 investigation that found serious problems with the work environment at the St. Cloud Veterans Affairs hospital was quietly shelved.

The investigation validated complaints of a hostile work environment created by senior managers and problems with canceled appointments for patients because of insufficient staffing. But congressional committees responsible for monitoring the VA were never informed that it existed and the report was never made ­publicly available.

Rep. Tim Walz, D-Minn., who sits on the House Veterans Affairs Committee, said he's disturbed that the VA inspector general, supposedly the independent watchdog of an agency under increasing criticism, may be keeping important information from finding the light of day.

GOP Rep. Tom Emmer, whose district includes the St. Cloud VA, said he is considering drafting legislation that would require the VA to release all similar inspector general (IG) reports to the public in the future.

"The thing I find absolutely unacceptable is when we have completed IG reports they basically enter into a black hole," Walz said. "Its just ­maddening to me that it feels like I am on some super sleuth mission to go find these things."

The VA Inspector General's Office is responsible for investigating allegations of wrongdoing at the VA, the country's second largest federal agency. But, as was the case in the St. Cloud investigation, the inspector general routinely farms out inquiries to local and regional VA officials and closes the case if it believes the problems have been addressed.

Walz said many of the report's findings warranted further review from outside the VA. He's asked the Inspector General's office why the report was not made public and whether there appears to be a pattern of whistleblower suppression and retaliation within the agency.

A spokeswoman for the VA inspector general said the office was still formulating a response to Walz's questions and would not comment until it was completed.

But in an initial letter to Walz's office in August, the deputy inspector general said the investigation was not performed or prepared by her office. Because the inspector general receives more complaints than it has the resources to investigate, the office often refers allegations back to the VA for an internal review. This investigation was conducted by officials from within the same five-state service network as the St. Cloud VA and signed off by an official from the Minneapolis VA.

A spokesman for the St. Cloud VA said the hospital has since addressed the issues by hiring more staff and reducing patient loads. It has also conducted more town hall meetings and forums between employees and managers.

It began with complaints to the inspector general's telephone hot line after five providers resigned in a little over a month's time in 2013. In addition, 26 primary care doctors resigned between 2011 and 2013. The complaints said the resignations caused skyrocketing patient loads and resulted in numerous canceled appointments. The complaints also painted a picture of a hospital where managers were so abusive that workers were afraid to complain for fear of reprisal.

The subsequent investigation by a team from the regional VA concluded that overall veteran care was not compromised. But it did substantiate significant allegations, including evidence of a "pervasive" fear of reprisal among primary care employees and a disrespectful manner by senior management, who had dismissed the ­allegations as coming from a small group of disgruntled employees. It also substantiated that a large number of appointments had been canceled because of insufficient staffing.

There was even a revelation that a provider at a community clinic was under "active surveillance" because of higher than normal death rates.

The report makes a passing reference to death rates "within normal variance in all but two providers," located at separate Community Based Outpatient Clinics. The report said one provider was to be evaluated by a manager and the other "is under active surveillance." But it says nothing further.

The local investigators point out that "aggressive recruitment" has taken place and efforts at retaining existing staff were being pursued. It also said the facility's director had pledged to meet regularly with primary care providers to increase visibility and improve communication.

A spokesman for the St. Cloud VA said the allegations attempted to paint a picture of poor care as a result of overworked physicians, but the review found that St. Cloud VA took additional measures to ensure patient safety.

"We have taken the review findings seriously — including those allegations which were substantiated and those which were not — and incorporated them into our ongoing, continuous efforts to improve our organization and the care provided to veterans," said St. Cloud VA spokesman Barry Venable in a statement.

Concerns about the lack of transparency with the VA inspector general are not new. Earlier this year, USA Today reported the office had declined to release the findings of 140 health care investigations across the country since 2006. After the investigations were released, the newspaper reported that they showed what it called a litany of instances of dysfunction or maltreatment of veterans. In many of the cases, the newspaper said, the inspector general relied on the VA to correct problems on its own rather than make the findings public.

The St. Cloud investigation became public only after testimony from a whistleblower during a U.S. Senate hearing in July, even though it was conducted in 2013 and completed early in 2014. The witness, a doctor at a troubled Phoenix VA hospital, said she had obtained the St. Cloud report from a source as an example of the materials that continued to be suppressed.

Despite the attention it has received, the report still is not easily available. Walz's office received a redacted copy after asking for it. The Star Tribune filed a Freedom of Information Act request for the report in early August and received a copy of it on Wednesday, the day the Inspector General's Office was told of the newspaper's plans to publish a story. A spokeswoman for the VA inspector general said the timing was just a coincidence.

A spokeswoman for Emmer said he and his staff have met with staff and management at the St. Cloud VA and will continue to monitor the situation. She said Emmer voted for the VA Accountability Act, which expands whistleblower protections, because of concerns that VA staff might be afraid to come forward.

Walz said the St. Cloud case is further evidence that the VA has trouble policing itself and is an example of why he has proposed legislation to require the VA to undergo a biannual, independent audit by a nongovernmental entity.

"I'm the VA's staunchest supporter and their harshest critic," Walz said. "I'm certainly leaning now in their 'harshest critic' phase."

Mark Brunswick • 612-673-4434