VA Administrators Breathe a Sigh of Relief

On May 30, Eric Shinseki, the Secretary for Veterans Affairs (VA), resigned under pressure amidst a growing scandal regarding falsification of patient wait times at nearly 40 VA medical centers. Before leaving office Shinseki fired Sharon Helman, the former hospital director at the Phoenix VA, where the story first broke, along with her deputy and another unnamed administrator. In addition, Susan Bowers, director of VA Veterans Integrated Service Network (VISN) 18 and Helman’s boss, resigned. Robert Petzel, undersecretary for the Veterans Health Administration (VHA, head of the VA hospitals and clinics), had resigned earlier. You could hear the sigh of relief from the VA administrators.

With their bosses resigning left and right, the VA leadership in shambles and the reputation of the VA  soiled for many years to come, why are the VA administrators relieved? The simple answer is that nothing has really changed. There for a moment it looked like real reform might happen. Even President Obama in announcing Shinseki's resignation said the "There is a need for a change in culture..." (1). Shinseki’s resignation would indicate that any action to change the culture is unlikely. Sure a few administrators, like Helman, will lose their jobs, perhaps a few patients will get outsourced to private practioners, but nothing is being done or proposed to change the VA culture. A new interim VA secretary was named and his tenure is likely to be lengthy since no confirmation appears to go unchallenged in the US Congress, and who would want the job?

I was at the VA, when then undersecretary for VHA, Kenneth Kizer, made the fundamental change that resulted in the present mess. Kizer had come to the VA with a program he called the “prescription for change” (2). Indeed, Kizer made several changes but the one that really counted was that the chiefs of staff, doctors who ran the medical services in VA hospitals, were replaced by the head of the Medical Administration Service, usually a business person. This made the VA director the monarch over their own little kingdom, and we all know “it’s good to be the king”. Furthermore, we all know that power corrupts and now with absolute power, the VA director was absolutely corrupted. The hospital directors eliminated any sources of potential opposition. Physicians who did not “play ball” could suddenly find themselves as a target of an investigation (3). After being found guilty by a kangaroo court, their names would be turned over to the National Practioner Databank as bad doctors making it difficult to find a job outside the VA. Those cooperative physicians were rewarded, often for limiting the care of patients. In other words, putting the VA administrators’ interests before the patients’ (4). Lastly, the long-standing relationship with the Nation’s medical schools was destroyed (remember VA dean’s hospitals?). It was argued that the medical schools used the VA to serve their needs. Although this had some truth, it is part of the two-way street that makes cooperation possible. No VA administrator wanted a bunch of doctors and academics telling them what to do.

After eliminating any possible oversight from the physicians or the medical schools, an insulating administrative layer had to be placed between the hospitals and VA central office. Therefore, the Veterans Integrated Service Networks or VISNs, were created. Although ostensibly to improve oversight and efficiency (2), only in Washington would they believe that another layer of bureaucracy would do either. As more and more patients were packed into the system, the numbers of physicians and nurses decreased (5). Not surprisingly, wait times became longer and there was no alternative but to hide the truth. The administrators, the VISNs and VA Central office were all complicit in these lies. Their bonuses depended on it and even when it was discovered by the VA Office of Inspector General (VAOIG) nothing was done.

Congress, who supposedly also provides oversight, was swift to propose action that does not change the VA culture and accomplish little. In this election year Congressional cries to throw those VA bums out have been consistent and loud. However, plenty of clues were available to know that the wait time data was false. First, the concept that you can cut the numbers of physicians and nurses and improve wait times defies common sense. Second, the VAOIG had repeatedly reported that wait times were being falsified. Helman had already been accused of this when she was the director at the Spokane VA (6). This week the Senate passed a bill allowing veterans to see private doctors outside the VA system if they experience long wait times or live more than 40 miles from a VA facility; make it easier to fire VA officials; construct 26 new VA medical facilities and use $500 million in unobligated VA funds to hire additional VA doctors and nurses (7). The VA already is able to do the first two, and as the present crisis illustrates, funds can be diverted away from healthcare. It seems likely this is exactly what will happen unless additional oversight is provided.

Kizer and Ashish Jha authored an editorial on this crisis in the New England Journal of Medicine this week (8). They made three recommendations:

1. The VA should refocus on fewer measures that directly address what is most important to veteran patients and clinicians-especially outcome measures.
2. Some of the resources supporting the central and network office bureaucracies could be redirected to bolster the number of caregivers.
3. The VA needs to engage more with health care organizations and the general public.

All these recommendations are reasonable. Outcome measures, not process of care, should be measured (9). Paying bonuses to administrators for clinicians completing these process of care measures should stop. Many of these measures serve mostly to increase administrative bonuses and not improve patient care. By giving administrators supervisory authority over physicians, healthcare providers were forced to complete a seemingly endless checklists rather than serve the patients' interests.

Bureaucracies should be reduced. VA's central-office staff has grown from about 800 in the late 1990s to nearly 11,000 in 2012 (8). VISN offices have reflected this growth with over 4500 employees in 2012 (10). This diversion of funds away from healthcare is the source of the present problem.

The VA needs to re-engage with the medical schools and with its patients. Reestablishment of the Dean's Committee or other similar system that provides oversight of the VA hospital directors and administrators may be one method of achieving this oversight. The association of the medical schools with the VA served the VA well from the Second World War until the 1990s (11).

Poor pay and micromanagement of physicians to perform meaningless metrics makes primary care onerous. Appropriating funds might improve the salary discrepancy between the VA and the private sector but will not fix the micromanagement problem. The VA may find it difficult to recruit the needed physicians and nurses unless a more friendly work environment is created. How do we know that any appropriated money will be spent on healthcare providers and infrastructure unless additional oversight is put in place? Without oversight the VA positions will become VA vacancies and the VA hospitals will become administrative palaces. Local oversight by VA physicians, nurses and patients is one method of ensuring that appropriated monies are actually spent on healthcare.

VA health care is at a crossroads. New leadership can help the VA succeed but only if the administrative structure is fixed changing the VA culture. Until this occurs the same administrative monarchs will continue to rule their realms and nothing will really change.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Cohen T, Griffin D, Bronstein S, Black N. Shinseki resigns, but will that improve things at VA hospitals? CNN. May 31, 2014. Available at: http://www.cnn.com/2014/05/30/politics/va-hospitals-shinseki/ (accessed 6/7/14).
2. Kizer KW. Prescription for change. March 1996. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf (accessed 6/7/14). 
3. Wagner D. The doctor who launched the VA scandal. Arizona Republic. May 31, 2014. Available at: http://www.azcentral.com/longform/news/arizona/investigations/2014/05/31/va-scandal-whistleblower-sam-foote/9830057/ (accessed 6/7/14).
4. Hsieh P. Three factors that corrupted VA health care and threaten the rest of American medicine. Forbes. May 30, 2014. Available at: http://www.forbes.com/sites/paulhsieh/2014/05/30/three-factors-that-corrupted-va-health-care/ (accessed 6/7/14).
5. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54. Available at: http://www.swjpcc.com/editorial/2012/5/5/va-administrators-gaming-the-system.html (accessed 6/7/14).
6. Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9. Available at: http://www.swjpcc.com/editorial/2014/5/26/va-scandal-widens.html (accessed 6/7/14). 
7. O'Keefe E. Senators reach bipartisan deal on bill to fix VA. Washington Post. June 5, 2014. Available at: http://www.washingtonpost.com/blogs/post-politics/wp/2014/06/05/senators-reach-bipartisan-deal-on-bill-to-fix-va/ (accessed 6/7/14).
8. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014 Jun 4. [Epub ahead of print]. Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1406852 (accessed 6/7/14). [CrossRef]
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353(17):1860-1. [CrossRef]
10. VA Office of Inspector General. Audit of management control structures for veterans integrated service network offices. March 27, 2012. Available at: http://www.va.gov/oig/pubs/VAOIG-10-02888-129.pdf (accessed 6/7/14).
11. VA policy memorandum no. 2: policy in association of veterans' hospitals with medical schools. January 30, 1946. Available at: http://www.va.gov/oaa/Archive/PolicyMemo2.pdf (accessed 6/7/14).

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado, or California Thoracic Societies or the Mayo Clinic.

Refence as: Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. doi: http://dx.doi.org/10.13175/swjpcc077-14 PDF

VA Scandal Widens

On Memorial Day, which honors those who died in service to the country, the Department of Veterans Affairs (VA) Office of Inspector General (OIG) is investigating medical facilities in at least 26 cities (1). The scandal started in Phoenix where Sam Foote, a retired VA physician, alleged that up to 40 patients in Arizona died awaiting care in a network where some veterans could not get appointments for more than a year. Foote claimed that Phoenix VA officials were misrepresenting wait times to collect bonus checks while maintaining "secret lists" of patients. These accusations resulted in the suspension of Sharon Helman, the Phoenix VA hospital director, along with her associate director and another unnamed senior administrator. Dennis Wagner in an article in the Arizona Republic listed many of the accusations made against various VA hospitals outside of Phoenix (1). These include:

• Chicago: Germaine Clarno, president of a federal employee union, said secret lists and falsified wait times had been an "everyday practice" at the Hines VA Hospital, and complaints of data fraud were ignored. Hellman was previously at the Hines VA director prior to coming to Phoenix. Clarno also said the inspector general conducted an inquiry, but targeted tangential issues. "The problem is the government covers up for the government — the OIG is a bed partner of VA administration." The OIG had investigated the Phoenix VA in late 2013 but Robert Petzel, then undersecretary for Veterans Healthcare Administration, said the OIG found no evidence to support Foote's claims (2). Petzel later resigned and the White House has nominated Jeffrey Murawsky who previously served as director of VA Veterans Integrated Service Network (VISN) 12 which oversees the Hines VA and who directly supervised Helman (3).
• Walla Walla, WA: VA auditors who visited the Walla Walls VA, where Helman previously served as director prior to coming to Hines VA, identified improper and inconsistent patient-scheduling practices, according to the Walla Walla Union-Bulletin. A psychiatric nurse, who won a whistle-blower settlement after being terminated, told NBC News that intimidation and retaliation were commonplace at the medical center.
• San Antonio, Texas: Dr. Joseph Spann, who retired in January after 17 years with the VA, told federal investigators that physicians were regularly asked to alter the "request date" for medical procedures to hide backlogs for tests. Spann attributed the practice to pressure to meet performance measures that reward administrators bonuses. When told local VA officials had conducted a review and denied the allegation, Spann said, "Central Texas (VA) investigating itself is just worthless." Raymond Chung who was the previous Chief of Staff at the Phoenix VA came to Phoenix from San Antonio.
• Cheyenne, WY: Congressional investigators uncovered an e-mail written by a nurse to other VA employees describing techniques for "gaming the system" by falsifying appointment records to meet goals set by bosses. The nurse was suspended after the e-mail was made public. The director of the Cheyenne VA is Cynthia McCormack who previously was chief of nursing at the Phoenix VA.
• Fort Collins, CO: OIG investigators in December found that medical clinic staffers were trained to make it appear veterans were getting appointments within 14 days, per department guidelines, even though waits were longer. McCormack supervises the Fort Collins clinic.
• Albuquerque: U.S. Sen. Tom Udall, D-N.M., called for an investigation after allegations that  wait-time records were falsified Phoenix. Phoenix and Albuquerque are both supervised by Susan Bowers, the VISN 18 director.

As the above illustrates, the connections between these administrators is striking. Beginning several years ago, according to internal VA records, VA central office in Washington realized medical centers around the country were finding ways to manipulate the numbers. The VA had for several years been the subject of congressional inquiry and criticism not just due to long waits for care, but because of mismanagement but no action was taken.

Although Congress, VA central office in Washington and the local VISNs are all charged with overseeing the VA hospitals, the task of supervising this large, complex bureaucracy is daunting and appears to have been inadequate. A system needs to be put in place where healthcare providers who care for veterans and veteran patients who use the facility have a role in the oversight of their local VA hospital.  Creation of a hospital board of directors consisting predominately of healthcare providers from the facility and veterans might be able to provide the supervision that this ever widening scandal suggests is needed.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. Delayed care, fraud point to ailing VA health system. The Arizona Republic. May 25, 2014. Available at: http://www.azcentral.com/story/news/politics/investigations/2014/05/25/va-medical-care-woes/9564605/ (accessed 5/26/14).
2. Wagner D. VA: We found no evidence to support allegations in Phoenix. The Arizona Republic. April 30,2014. Available at: http://www.azcentral.com/story/news/politics/2014/04/30/phoenix-veteran-hospital-deaths-investigation/8518721/ (accessed 5/26/14).
3. O'Dell R, Nowicki D, The Arizona Republic. May 16, 2014. Available at: http://www.usatoday.com/story/news/nation/2014/05/16/top-va-health-official-resigns-under-fire/9182311/ (accessed 5/26/14).

*The opinions expressed are those of the author and do not necessarily represent those of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9. doi: http://dx.doi.org/10.13175/swjpcc070-14 PDF

Don’t Fire Sharon Helman-At Least Not Yet

Several developments have occurred over the past few days regarding prolonged wait times and secret lists at the Phoenix VA and its embattled director, Sharon Helman. President Obama has asked for an investigation and several Arizona Senators and Representatives have called for investigations and/or asked for the resignation of Helman and her administrative team (1,2). On 4/30/14, Dr. Robert Petzel, VA undersecretary for health, testified that an administrative team visited Phoenix soon after the controversy erupted and found “no evidence of a secret list… [or] patients who have died because they [were] on a wait list." (3). On 5/1/14 CNN posted an interview with Sharon Helman and her Chief of Staff, Dr. Darren Deering, who denied the allegations. Dr. Sam Foote, who made the original allegations, accused Helman and Deering of lying (4). CNN apparently confirmed Foote’s story with several sources inside the VA including a second physician, Dr. Katherine Mitchell (5). Later the same day, Eric Shinseki, Secretary of Veterans Affairs, suspended Helman and two others (5).

This all sounded very familiar (6). In 2012 the VA Office of Inspector General (OIG) issued a report on the accuracy of the Veterans Healthcare Administration (VHA) wait times for mental health services (7). The report found that “VHA does not have a reliable and accurate method of determining whether they are providing patients timely access to mental health care services. VHA did not provide first-time patients with timely mental health evaluations and existing patients often waited more than 14 days past their desired date of care for their treatment appointment. As a result, performance measures used to report patient’s access to mental health care do not depict the true picture of a patient’s waiting time to see a mental health provider.”

After the 2012 OIG report came the inevitable Congressional hearing (8). Although misrepresenting actual wait times has been known for many years, there has been inadequate action to correct the practice according to the VA OIG. Sen. Patty Murray, then chair of the Senate Committee on Veterans' Affairs, said the findings showed a "rampant gaming of the system." (8). A review of the OIG’s website revealed multiple instances of similar findings dating back to at least 2002 (6). In each instance, unreliable data regarding wait times was cited and no or inadequate action was taken.

The providers at the VA should not necessarily view this as not good news. The VA has usually sought to refocus blame away from the administrators to “lazy” or “poor” doctors. My guess is that we will soon see a number of accusations about Drs. Foote and Mitchell in an effort to administratively circle the wagons. VA administrators usually seize on such opportunities to control physicians. Remember the computer fiasco from several years back when an information technology administrator lost a computer with confidential patient information (9)? This not only resulted in information technology being placed in charge of the electronic healthcare record but a number of restrictions were placed on physician use of data. Furthermore, administrators can now not only regulate a physician’s salary but “black ball” physicians by false accusations through sources such as the National Practioner Data Bank (NPDB). Not surprisingly, physicians are reluctant to speak out when their livelihood can be threatened.

Clearly, the present system is not working. Firing Sharon Helman will solve nothing at the present other than giving some politicians the opportunity to congratulate themselves on weeding out a bad apple in this election year. Furthermore, firing Helman could be an attempt to hide a systemic problem by offering Helman as the “fall guy”. So instead of redoing the OIG investigations and the Congressional hearings which have accomplished nothing in the past, how about doing something else? Here are a few suggestions:

1. Have Helman investigated by an independent source, not the OIG. Examine other VAs for similarly misrepresenting patient wait times. Over thirty years at the VA taught me that if wait times are being "gamed" by one VA, the times are also likely being "gamed" by others.
2. Create a National Healthcare Administrator Data Bank similar to the NPDB with all the same safeguards and checks and balances available to physicians. Helman apparently had a history of misrepresenting data (10). It seems unlikely that she would have been hired if this was publically known.
3. Provide adequate oversight. The local Veterans Integrated Service Network (VISN), VA Central Office in Washington, and Congress is not providing the oversight needed. Create a hospital board of directors consisting predominately of a majority of healthcare providers from the facility and Veterans (not to be appointed by the director) to provide oversight.
4. Quit hiring more administrators while reducing the number of doctors. Inadequate numbers of providers is the root cause of prolonged wait times and has been present for a number of years (6). The numbers of administrators, nurses and doctors should be transparent and publically available.
5. Quit paying administrators bonuses for work done by doctors. This only encourages cheating on reports (6,7). If administrators need a bonus, reward them for achievements in administrative efficiency or similar administrative goals. Both the criteria for and the amount of the bonus should be transparent and publically available.
6. Scrap the VISN system. These local collections of administrators are another source of waste and appear to add no real oversight or patient benefit.

The optimist in me hopes the situation at the Phoenix VA and possibly other VAs is thoroughly investigated. If Helman is the “bad apple” many would like to portray-then fire her. If her actions are more a result of a systemic problem-then fix the problem.  However, the cynic in me fears that Helman will be sacrificed without a thorough investigation and no change will occur.  In that case I will again be writing about an investigation of VA administrators "gaming the system", probably in 2016.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. McCain, Flake call for Senate probe of Phoenix VA. The Arizona Republic. April 23, 2014. Available at: http://www.azcentral.com/story/news/arizona/politics/2014/04/23/mccain-flake-call-senate-probe-phoenix-va/8061141/ (accessed 5/1/14).
2. Harris C, Wagner D. Phoenix VA officials deny there's a secret wait list; doctor says they're lying. The Arizona Republic. April 29, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/04/29/phoenix-va-director-congressman-call-for-removal/8447131/ (accessed 5/1/14).
3. Wagner D. VA: We found no evidence to support allegations in Phoenix. The Arizona Republic. April 30, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/04/30/phoenix-veteran-hospital-deaths-investigation/8518721/ (accessed 5/1/14).
4. Bronstein S, Griffin D, Black N. Phoenix VA officials deny there's a secret wait list; doctor says they're lying. CNN. May 1, 2014. Available at: http://www.cnn.com/2014/04/30/health/veterans-dying-health-care-delays/ (accessed 5/1/14).
5. Wagner D. Second VA doctor blows whistle on patient-care failures. The Arizona Republic. May 1, 2014. Available at: http://www.azcentral.com/story/news/investigations/2014/05/02/second-va-doctor-blows-whistle-patient-care-failures/8595863/ (accessed 5/1/14).
6. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54.
7. VA Office of Inspector General. Review of Veterans’ Access to Mental Health Care. 1.http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf  (accessed 5-1-14).
8. Vogel S. VA mental health system sharply denounced at hearing. Washington Post. April 25, 2012. Available at: http://www.washingtonpost.com/politics/va-mental-health-system-sharply-denounced-at-hearing/2012/04/25/gIQAXG3mhT_story.html (accessed 5/1/14).
9. Lee C, Goldfarb ZA. Stolen VA laptop and hard drive recovered. Washington Post. June 30, 2006. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2006/06/29/AR2006062900352.html (accessed 5/1/14).
10. Corbin C. Arizona VA boss accused of covering up veterans' deaths linked to previous scandal. Foxnews.com. April 24, 2014. Available at: http://www.foxnews.com/politics/2014/04/24/arizona-va-boss-accused-covering-up-veterans-deaths-linked-to-previous-scandal/ (accessed 5/1/14).

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado, or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. Don't fire Sharon Helman-at least not yet. Southwest J Pulm Crit Care. 2014;8(5):275-7. doi: http://dx.doi.org/10.13175/swjpcc060-14 PDF

Questioning the Inspectors

In the early twentieth century hospitals were unregulated and care was arbitrary, nonscientific and often poor. The Flexner report of 1910 and the establishment of hospital standards by the American College of Surgeons in 1918 began the process of hospital inspection and improvement (1). The later program eventually evolved into what we know today as the Joint Commission. Veterans Administration (VA) hospitals have been inspected and accredited by the Joint Commission since the Reagan administration.

The VA hospitals often share reports regarding recent Joint Commission inspections and disseminate the reports as a "briefing". One of these briefings from a recent  Amarillo VA inspection was widely distributed as an email attachment and forwarded to me (for a copy of the briefing click here). There were several items in the briefing that are noteworthy. One was on the first page (highlighted in the attachment) where the briefing stated, "Surveyor recommended teaching people how to smoke with oxygen, not just discuss smoking cessation". However, patients requiring oxygen should not smoke with oxygen flowing (2,3).  It is not that oxygen is explosive but a patient lighting a cigarette in a high oxygen environment can ignite their oxygen tubing resulting in a facial burn (2,3). A very rare but more serious situation can occur when a home fire results from ignition of clothing, bedding, etc. (3).

A quick Google search revealed no data for any program teaching patients to smoke on oxygen. It is possible that the author of the "briefing" misunderstood the Joint Commission surveyor. However, the lack of physician, nurse and respiratory therapist autonomy makes it easy to envision administrative demands for a program to "teach people how to smoke on oxygen" wasting clinician and technician time to do something that is potentially harmful.

Although this is an extreme and absurd example of healthcare directed by bureaucrats, review of the remainder of the "briefing" is only slightly less disappointing. Most of the Joint Commission's recommendations for Amarillo would not be expected to improve healthcare and even fewer have an evidence basis. The Joint Commission focus should be on those standards demonstrated to improve patient outcomes rather than a series of arbitrary meaningless metrics. For example, a Joint Commission inspection should include an assessment of the adequacy of nurse staffing, are the major medical specialties and subspecialties readily accessible, is sufficient equipment and space provided to care for the patients, etc. (4-5).  By ignoring the important and focusing on the insignificant, the Joint Commission is pushing hospitals towards arbitrary and nonscientific care reminiscent of the last century. These poor hospital inspections will undoubtedly eventually lead to poorer patient outcomes.

Richard A. Robbins, MD*

Editor

References

1. Borus ME, Buntz CG, Tash WR. Evaluating the Impact of Health Programs: A Primer. 1982. Cambridge, MA: MIT Press.
2. Robb BW, Hungness ES, Hershko DD, Warden GD, Kagan RJ. Home oxygen therapy: adjunct or risk factor? J Burn Care Rehabil. 2003;24(6):403-6. [CrossRef] [PubMed]
3. Ahrens M. Fires And Burns Involving Home Medical Oxygen. National Fire Protection. Association. Available at: http://www.nfpa.org/safety-information/for-consumers/causes/medical-oxygen (accessed 3/12/14).
4. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002 Oct 23-30;288(16):1987-93. [CrossRef] [PubMed]
5. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14(8):499-511. [CrossRef] [PubMed]

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. Questioning the inspectors. Southwest J Pulm Crit Care. 2014;8(3):188-9. doi: http://dx.doi.org/10.13175/swjpcc032-14 PDF

Qualitygate: The Quality Movement's First Scandal

Charles R. Denham is probably not a name familiar to most of our readers. Denham's name popped into the news when the Justice Department alleged that CareFusion, then a division of Cardinal Healthcare, paid Denham $11.6 million to influence the Safe Practices Committee at the National Quality Forum (NQF).

Dr. Charles R. Denham

Even though Denham may not be well known, readers might recognize the names of some of the organizations and individuals with whom Denham worked (2,3). Besides the NQF, these include the Institute of Medicine, Leapfrog Group, Centers for Disease Control and Prevention, Clinton Global Health Initiative, Discovery Channel, General Electric, Cleveland Clinic, Vanderbilt University Medical Center, Catholic Healthcare Partners, and Seton Medical Center. Prominent individuals associated with Denham include actor Dennis Quaid (whose newborn twins were nearly killed by a medication mistake) and Capt. Chesley "Sully" Sullenberger, famous for safely landing a crippled jetliner in the Hudson River. Lesser known, but prominent in the patient safety movement, are Dr. Kenneth Kizer (former Under Secretary for Health in the U.S. Department of Veterans Affairs and founding president and former CEO of the NQF) and Dr. Donald Berwick (founder and former President of the Institute of Healthcare Improvement and former Administrator of the Centers for Medicare and Medicaid Services).

Denham is a member of the President's Circle of the National Academies of Science of the Institute of Medicine, the National Academy of Sciences and the National Academy of Engineering. He has been a Senior Fellow in the Advanced Leadership Initiative at Harvard University and instructor at the Harvard School of Public Health. He teaches leadership and innovation on the faculty of Harvard Medical School and was an adjunct Professor at the Mayo Clinic College of Medicine. He played a leadership role in the development of a computerized prescriber order entry (CPOE) simulator that measures performance improvement of hospital medication management systems, driving patient safety through healthcare information technologies. He founded CareMoms, CareKids, and CareUniversity, which are programs that are focused on helping families survive healthcare harm and waste. He was until very recently the editor of the Journal of Patient Safety (4).

Many groups have benefitted by recommending best practices, but an endorsement by the NQF can mean riches for companies and individuals (4). Created in 1999 at the behest of a Presidential commission, the Washington, D.C.-based nonprofit takes private donations and collects fees from members, including consumer groups, health plans and medical providers. Five years ago, Health and Human Services hired the NQF to endorse measures to show whether health care spending is achieving value for patients and taxpayers. The contract has since grown substantially and by 2012 made up nearly three-fourths of the organization’s $26 million in revenue. The NQF’s standards are widely adopted. The report produced by the committee Denham co-chaired included recommendations for best practices in 34 areas of care.

The quality movement is distancing itself from Denham and denying any knowledge of Denham's conflicts of interest or alleged kickbacks (5). However, there were multiple clues. Although Denham was trained as a radiation oncologist, he was not a practicing physician (6). Known as an entrepreneur, Denham had formed and folded numerous for-profit and non-profit companies. Those listed by the Texas Secretary of State’s office include the Texas Institute of Medical Technology; Health Care Concepts; TD Enterprises Management; Spectrum Holdings International (also known as Austin Liberty, Inc.); Tetelestai, Inc. (Greek for “It is finished,” a New Testament reference); Aircare International, Inc. (Denham at one time worked in the aviation industry); CRD Health Ventures, Inc.; and Assisted Better Living Everywhere, Inc. Denham and his family live in a palatial waterfront home in Laguna Beach, California, whose value Zillow estimates at $10.5 million (6). The speaker’s bureau lists Denham’s minimum fee for U.S. engagements as an average of $50,000 to $75,000, far in excess of usual physician speaking fees (6). Denham even boasted his own webpage on Wikipedia and had a contract with Celebrity Talent International (2,4). Although Denham's biography in Wikipedia claims over 100 scientific publications a quick check of PubMed reveals only 25 with nearly all published in the last 5 years in the Journal of Patient Safety where Denham was editor.

In his article in Forbes, Michael Millenson quotes an accomplished patient safety advocate who left her first meeting with Denham convinced she had met with one of the most brilliant individuals of her life (4). Those who know Denham suspect that he would agree (6). The tendency of very smart and successful individuals to boss others is well known because in their own minds they are smarter and better, even when the evidence says otherwise. Some can even blur the boundaries between what they have done, what they are doing and what they hope to do-convincing themselves that it is in the patients' best interests. Like Watergate did to the Nixon White House, Denham has tainted many in the quality movement. Hence the title of this editorial-"Qualitygate". A lot of money is involved in patient safety and there are undoubtedly some willing to sacrifice principles for personal gain. This will probably not be the last scandal in the quality movement. As we have noted previously, there are probably too many guidelines based on expert opinion and some are wrong (7). Physicians need to exercise their own best judgment in deciding which guidelines need to be implemented.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Department of Justice Office of Public Affairs. CareFusion to pay the government $40.1 million to resolve allegations that include more than $11 million in kickbacks to one doctor". Available at: http://www.justice.gov/opa/pr/2014/January/14-civ-021.html (accessed 2/21/14).
2. Wikipedia. Charles Denham. Available at: http://en.wikipedia.org/wiki/Charles_Denham (accessed 2/21/14). 
3. Newswise. Dr. Charles Denham named editor of Journal of Patient Safety. Available at: http://www.newswise.com/articles/dr-charles-denham-named-editor-of-journal-of-patient-safety (accessed 2/21/14).
4. Allen M. Hidden financial ties rattle top health quality group. Propublica. Available at: http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-quality-group (accessed 2/21/14).
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7. Robbins RA. What's wrong with expert opinion? Southwest J Pulm Crit Care. 2014;8(1):71-3. [CrossRef]

*The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. Qualitygate: the quality movement's first scandal. Southwest J Pulm Crit Care. 2014;8(2):132-4. doi: http://dx.doi.org/10.13175/swjpcc022-14 PDF