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Veterans deserve better from VA facility

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Saturday, April 27, 2013, 12:01 a.m.

Some lessons are hard to learn.

When I asked Director and CEO Terry Wolf this week what she learned from the Legionnaires' outbreak at the VA Pittsburgh Healthcare System she oversees, she simply grinned, looked around the room and took a deep breath.

She didn't say a word.

Earlier in the conversation, Wolf took responsibility for the outbreak that sickened 21 patients and was linked to five deaths.

“Me,” she said when I asked a group of VA officials who was accountable for the fiasco.

Wolf said she took immediate action when she learned about the problems.

“You can't fix something that you don't know about,” she said.

Wolf's words were disarmingly honest, even though she's had a really bad past few months. Not only did something go terribly wrong at the VA Oakland and O'Hara facilities intended to help veterans, a VA inspector general report this week cited the failures. The mistakes that caused water to become contaminated with deadly bacteria were caused by human error, rather than by any malfunction in the hospital's special water treatment system.

The report found not one but rather a series of blunders that really makes you wonder what was going on. There was no routine flushing of hot water faucets and showers. Some water outlets that tested positive for Legionella were flushed in ways not consistent with recommended guidelines. What's worse, many of these problems weren't being documented and some staffers weren't properly communicating with each other.

Clearly, there's a lesson in there.

“You can never over-communicate,” Dr. Ali Sonel, the VA's chief of staff interjected when Wolf couldn't find words to answer my question about lessons learned. “In health care, you clearly need a lot of redundancies.”

Wolf nodded. I found her a pleasant person despite the circumstances. I told the group, which included other executives who gathered to talk about the inspector general's report, they should be more forthcoming about what's happening inside their walls. No one disagreed.

“We're a very transparent organization,” said David Cord, the Pittsburgh VA's deputy director.

Why then, did the public and employees have to wait more than two weeks after the local VA had outside confirmation it had a problem to hear about the outbreak? The VA notified the public and its workers on Nov. 16, when they knew in late October that the federal Centers for Disease Control and Prevention had connected Legionella in the water to Legionnaires' in a patient.

Sonel did his best to explain that infection-control workers smelled something funny and were eager to get to the bottom of the problem.

Were local VA leaders unable to say much because someone higher up the food chain prevented them from doing so, I asked.

More silence, more looks around the room.

“We can't function on our own,” Sonel finally said. “(The VA) is a large organization. What we say does affect the larger organization. We have to make sure there's a coordinated effort.”

And there you have it, the biggest lesson of them all: Sometimes you can function on your own. Indeed, sometimes you need to function on your own. Take the lead and set the example.

Show the bosses in the Pittsburgh regional office and in Washington that when it comes to veterans, transparency is not something that can wait for weeks and weeks.

Luis Fábregas is a staff writer for Trib Total Media. He can be reached at 412-320-7998 or

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