Department of

Veterans Affairs Memorandum

May 31, 2017
Program Manager, VA National Center for Patient Safety (10E2E)
Summary of Marion, IL VAMC Site Visit
I;
VHA Chief Patient Safety & Risk Awareness Officer and Director, VA National Center for Patient
Safety (10E2E)

L The VA Medical Center in Marion. Illinois, is a general medical and surgical facility that
operates 55 acute care beds and a 50 bed Community thing Center. Ten Outpatient
Clinics that provide primary care and behavioral medicine services are located in
Harrisburg; Carbondale; Effingham; and Mt. Vernon, IL; Paducah; Hanson; Owensboro; and
Mayfield. Kenteic;Vncrr. and Cvar.r4iLe; IN.

2. In 2008, the Inspector General in the Department of Veterans Affairs found that the
Marion VAMC continued to be plagued by quality management and patient care problems
some two years after a suspicious spike in the number of post-surgical patient deaths
there. The report also found that at least nine patients died because of surgical mistakes
and poor post-surgical care. That report made recommendations to improve conditions at
the facility to include improving quality management oversight, consistency in the way
patient deaths are reported and continuing problems with ensuring patient safety.

Hospital culture is a vical component In the productivity and performance of its workforce.
heavily impacting both quality and access to care. The Marion VAMC completed their
biennial Culture Survey in 2014 and only three of the IS dimension averages for the facility
were below the overall VA averages. This means that based on the 2014 survey sample,
Marion was likely to have a healthier patient safety culture than the VHA norm. To their
credit, some of the facility averages were notably above the overall 2014 VHA averages
including:

Dlm2 Non-punitive Response to Error

Oim3: Education I Training / Resources
DimE: Teamwork within Hospital Units

4. Since 2015 serving as the NCPS progiam manager for Marion VAMC, I have been actively
monitoring their patient safety culture at the suggestion of the facility Patient Safety
Manager. Early in 2015, I received a significant number of phone calls and emaiis from
Marion staff regarding that the culture was in significant decline. Thus, an immediate on-
site visit was conducted to explore the root causes or contributing factors for the decline
In the overall patient safety culture. As a result of the site visit which included VACO staff
from NCPS, Risk Management, and NCOD it was recommended that reailgnmant of Patient
Safety and Quality management was paramount. We Interviewed over 15 employees
during the visit and all were concern with commitment of leadership to address patient

VA FORM
MAR 19*9 2105
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Summary of Marion ;L VAMC Site Visit $13 l/2c11 Pg 2

and environment safety Issues. It was additionally recommended that the VISN intervene
to assure staff complaints were fully investigated and addressed. However, after that visit
in 2015, it appears that no transparent actions were Implemented.

S. In 2016, Marion VAMC staff completed the VA Patient Safety Culture Survey which
unfortunately validated the concerns of the staff. Drastically different from 2014, the
results showed that Marion VAMC were below the VA average in all categories. This
means that based on the 2016 survey sample, Marion VAMC now Is likely to have a less
healthy patient safety culture than the VHA norm, Some of the Marion VAMC dimension
averagcs were notably below the overall 2016 VHA averages including:

Facility 657A5 Percent Positive Responses

by Survey Time Period

60.0 -j

10.0 4
Dim 96 Dim #7 01m08 Dim *9 Dim #14

02005 132005 92011 92014 132016

Dim 6: Teamwork within Hospital Units

Dim 7: Teamwork across Hospital Units
Dim 8: Organizational Learning --Continuous Improvement
Dim 9: feedback & Communication about Error
Dim 14: Frequency of Event Reporting

U
 Summary ofMarion, IL VAMC Site Visit 5131/2017 Page

6. As such, the culture has led to personnel problems across staff areas at Marion VAMC that
are seriously impacting morale and, by extension, the timeliness of health care. The
problems were exacerbated by alleged poor management and communication structures,
distrust between some Marion employees and management, a history of retaliation
toward employees raising Issues, and a lack of accountability across all grade levels.

7. In 2016 and 2017 more complaints and/or whistleblowers were identified. In fact over 26
employees contacted NCPS to request our office to revisit Marion. Like in 2015, due to
number of safety concerns raised by staff, NCPS in collaboration with VACO CLC Director
visited Marion on February 7, 2017. During the course of the visit, we interviewed 13 staff
from the CLC and other areas with the hospital to Include engineering, human resources,
and senior leadership. While conducting those inteMews, a significant number of
additional staff requested to be interview. After the February 7, 2017, I continued my
interview of staff all areas of the facility via conference calls over a period of several
weeks.

8. Observations:

There is a stre agsentiment among many staff at the Marion VAMC that in general that
the facility provides high quality health care. All of the employees interviewed are
dedicated, hardworking, and committed to the Veterans they serve. Marion doctors,
nurses, and staff could choose to work at other facilities, often for greater compensation.
They choose to work at Marion because they believe In this Nation's promise to Its
Veterans, and they work each day to realize that promise and deliver the quality care
Veterans have earned and deserve. However, they also believe th6t It is clear that there
are significant and chronic systemic failures that must be addressed by facility, VISN, and
VACO leadership. I have attached a number of their comments as Appendix A.

it is a rarely possible to grasp much of reason for positive or negative culture during a
short visit or conference call. However, serious quality management and care problems
were found throughout the facility but particularly in the CLC
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Swnrnrny of Marion, IL. VAMC Sit Visit S/fl/loll Page 4

9. Recommendations:

The new Director Jo Ann Ginsberg arrived at the Marion VAMC in November 2016 and
seems very competent but will need assistance In assuring proactive changes are initiated.
During my visit to Marion VAMC, Director Ginsberg intimated that she would thoroughly
uncover why she had not received a number of reports of contact from staff, re-assess the
culture of the facility (especially within CIC), and evaluate all her senior staff for
competency. However, in follow-up phone calls with Individuals interviewed it appears
that none of the concerns have addressed since my site visit, it 15 also perceived by staff
that tha VISN Director is well aware of the behaviors and has elected to dismiss concerns;
thus, condoning the negative culture at the Marion VAMC. Thus, I recommend the
following:

a. In order for VACO to get ahead of this Issue (appears that several events have gained
media attention), request that a VACO team should be sent sack to Mai Ion with the
authority to lnvestgate and taKe immediate appropriate action to assure that the staff
received the necessary protections when rahkig signitcant patient safety issues
(Whistlebiower Proteccions).

b. A number of Individuals interviewed Indicated that they submitted report of contacts

on patient safety and/or environmental issues but all have either disappeared or were
not appropriately submitted to new Director by leadership staff, this should also be
investigated

c. Request that Use Minor send her team to determine if the CLC Is appropriate staffed
and aligned.

d. A review of the appropriateness of A1B process.

e. Determine why several key recommendations from the 2008 DiG were not initiated
(i.e. individuals name in that report appear to still be in leadership positions)

Rodney Williams, JD, LLM

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Summary of Marion, IL VAMCSILc Visit 54112017 Page 5

Appendix A. Comments from Individuals interviewed:

The Marion VAMC leadership culture is difficult to understand as it continues to undermine the
employees to help our Veterans. The Leadership is more interested in bonuses for themselves and
"blaming" the employees rather than supporting the VA Mission. "Just Culture" sounds good but
is not being followed here. The Leadership is a gong or rnofia type system inside the Marion
VAMC. The Mafia members are Frank Kehu5, Tim Hartwell KR, Cheryl Sherrill QM, Mar, Beth
Sniderwln acting SW Chief, Dr. Henry Davis Associate Chief of Staff, Mel Gutiterez, Rose Buck
nursing and our newest member Joan Gins gerg Director.

Hospitalist Medical Director shared Information that he is having difficulty placing Hospitalists on
the April schedule. He/shoving difficulty getting Providers to work at Mqrion VAMC. He has been
given task of "Detail/no" providers to cover the hospital apparer'tly with suggestions of taking two
NP providers though he has declined to detail them 'i/c trick of experience and he does not feel
they will be successful there. He states he can detail the acting EcS chief and/or CLC Director
though he is speaking against this because he does not wont to take the sole full time physician
from CLC. He/eels certain that Marion will be on diversion multiple days in April b/clack of
providers to work here.

Providers do not want to work at Marion. ft appears to a number of the Individuals interviewed
that since Ms. Ginsberg has arrived, she has empowered Cheryl Sherrill in Quality, Mary Beth
Snideiwin in Social Work, Dr. Henry Davis assistant chief of Scoff, and Tim Hartwell HR to be
stronger negative Influences over the entire campus She has empowered the very people that are
dragging the employees down on this campus. This is not what Marion needs and they believe
the Unsafe Culture is degrading even further. Word on the VA streets is that Mr. Frank

Kehus will be returning as Associate Director to our campus in April ...not good news for improving
the culture.

Since October 1, 201 6,flfteen (15) Veterans that were at the Marion acfor Rehab have
died. Staff believes this includes about 4 that convened from Rehab to Hospice, one unexpected
death at CLC and the remainder had been discharged from our CLC and then passed. It has been
brought to the attention of our acting Chief of EC Dr. Bowman, CLC Quality person Elaine Hoogue,
Nursing ACN Matthew Ngati RN, and Maria Honschen RN Nurse Manager.

Frank Kehus is a bully to employees as reported to you by SusAnc;a Cook when she was Bullied
openly in a meeting with the Quad. Some day Mel Guiterez approached SusAnne's supervisor Dr.
Ranch asking-him to speak with SusMna asking her not to make Report of contact on Frank
Kehus. Mel also spoke with SusAnno. Mel wonted the incident covered up and not be
transparent. I sent you a news report from Poplar Bluff of a physician being o3signed to a room
without seeing Veterans as retaliation. Mt Frank Kehus has been detailed to Poplar Bluff about a
year or so ago. He Is a commonality to both VAMC's leadership culture, both facilities being In
VISN 15 with Dr. Patterson. Tim Hartwell HR openly offers supervisors adv!ce how to treat
employees so they will quit
Summary of Marion, II.. VAMC Site Visit 5131'2017 Page 6

Sent a TV report of Lisa Alexander NP in Evanstiille, Indiana being placed in a room without CPP.S
access and having seen no Veterans for over two years as ordered by Dr. Henry Davis. She states to
me that she and Henry used to "dote" and now he is using his position in VA to retaliate against
her. She is on approximate 10 year employee of VHA and her career has had a negative turn since
Dr. Davis joined Marion VAMC. land others have submitted ROC's about Or. Davis "verbally
attacking" Individuals in Huddle.

Mel Guiterez wife was working in front fflce and when Mel was going to be acing Director his
wife mysteriously became the best candidate to be AO in Surgery Dept. So Mel could be acting
Director as he could not supervise his own wife. Mel is known for lack of transparency and having
very 'close reictionships" with females at our facility and a man well versed in cover ups.

Cheryl Sherrill Is known for her c/ace relationship with Frank Kehus. it Is said on campus that she
had an ABS afew yea.s ago in which she could not be a upervIso: though Dr. Paters cm aver ruled
this and supported her to be in charge of Quallty Management. Similar situation exists with Mary
O'Shea having ABl and not allowed to supervise and again Dr. Paterson has supported putting her
bock in her present supervisory role. Cheryl isa Bully and now empowered by new Director
Ginsberg to seemingly do anything she wants pushing employees with her Bullying techniques.
Cheryl is known not to be trusted, passive aggressive behavior and demeaning to employees.

Mary Beth Snidevwin is a Bully empowered by Cheryl Sherrill and supported by Ms.
Ginsberg. Mary Beth S. has been openly adding employees under her supervision as she says
she needs this to be advanced to the next ES leveifor o raise as she iso single parent and needs a
raise.

The issue at Marion Is that it is like a cult, if you "belong' to the Wgrou p'/, you can do no wrong and
are supported by each other, to cover, lie, intimidate, bully, retaliate against anyone that speaks
up about anything. It Is gang like activity. Many have joined or gone along in order to be safe and
to be pan of the "group".

It is UNIFIED bullying. Right now people In management automatically support one another
regardless of the actual circumstances that are taking place.

No one should have to come to work every day worrying about what is oic; to happen to them
that daj'. Zero toleror4 ce for this type of behavior from management should be the goal within a
short period of time.

I would like to think that people could change, but fear that they won't and the only solution is for
them to be removed from rngmt. positions - a Leopard cannot change Its spots.

Determine how did Cheryl SherrillABl agreement disappear and why/how did Dr. Paterson
overrule it after It was Implemented?

How did Mary O'Shea get back into her role, did Dr. Paterson overrule any recommendations?
Summary of
of Marion, IL VAMC Site Visit 541/2017 Page?

Who is safe for staff to do exit interviews? NO ONE! I was in the room once when It was a Joke
that the person leaving wonted and exit and comments were mode that her opinion was of no
value and that meeting will Just be dumped in the trash. This person was a good person and she
had things to say and they did not core.

Management is not held accountable/or their actions with zero tolerance implemented for any.
type of bullying behavior. They evaluate themselves so that won't work (fit continues that way.

Management should be monitored by people at this facility who could be trusted to report
continued bullying without management knowing who these people ore.

If the culture continues, then people should be removed from their management positions quickly
and decisively - not shifted into another management position or promotion. but actually removed
from management or the ability to be in management for the rest of their careers with the
government.

Review use of AS! and Peer Review (get input from those who have suffered tis retaliatory
process). And notionally look at the process.

Nationally look at FO!A request process and timeline, con use min as on example is 15 months
actually acceptable?

Hire EEC person to be on site, which does not answer to Management here, the acting does not
know what he is doing. He was placed in that role by default.