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Regional director Moreland's response to serious Legionnaires' outbreak is cheesy at best

About Luis Fábregas
Picture Luis Fábregas 412-320-7998
Medical Editor
Pittsburgh Tribune-Review

Luis Fábregas is an award-winning reporter who specializes in medical and healthcare issues as a member of the Tribune-Review’s investigations team.

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By Luis Fábregas

Published: Saturday, Aug. 24, 2013, 12:01 a.m.

Michael Moreland wants our nation's veterans to believe he's watching out for them.

That much is evident in the latest newsletter produced by the regional director of the Veterans Integrated Region Service Network 4, which oversees VA medical facilities in almost all of Pennsylvania and all or portions of five other states.

That includes the VA Pittsburgh Healthcare System Moreland once headed, where at least five veterans died and at least 16 others got sick because of a deadly outbreak of Legionnaires' disease between February 2001 and November 2012. And those are the ones we know about.

But fear not, Mr. Moreland is in charge.

There he is on the second page of the colorful newsletter, a full-blown picture of him in a suit, showing us how to use a hand-held control for a patient lift. Moreland is doing this even though he is an administrator with no clinical background other than a master's degree in social work.

The best part of the newsletter is Moreland's message to veterans, employees, volunteers and friends of the VA. It's nothing short of confusing and contradictory.

Certainly, the families of veterans affected by the outbreak will have a hard time believing that the VA is “a leader in developing new, innovating ways to keep patients and employees safe,” as Moreland writes.

To his credit, Moreland acknowledges that the VA “cannot eliminate all errors.” Yet, he fails to mention the Legionnaires' outbreak at all, wasting an opportunity to add credibility to his message. Instead, he tells us the VA is guided by the “Swiss cheese” model of system failure, an old principle used in aviation and hospitals to examine errors. The holes in the cheese represent the many holes in the system that can cause an error.

Moreland says he wants to turn the Swiss cheese into a solid block of cheddar — no holes. As cheesy as that sounds, Moreland is onto something. We already know too many holes prompted the Legionnaires' outbreak, as explained in a detailed report by the VA Office of the Inspector General. Among the holes: inadequate flushing of water faucets and showers, inadequate maintenance of the water system used to prevent Legionella bacteria and inconsistent communication among VA departments.

Those holes can be avoided with more layers of cheese — or protection — or so the theory goes. Those who embrace the Swiss cheese model don't like to place blame on individuals. Rather, they believe in rearranging the layers so the holes aren't lined up and the problem can be stopped.

I'm no management expert, but I think Moreland is giving us more whine than cheese. His choice of this model to address patient safety, and presumably the Legionnaires' outbreak, almost seems to say: “The VA is a bureaucracy that has all these holes, I didn't cause all these problems. All I can do is try to plug the holes.”

The holes at the VA are pretty huge. Yet, VA Secretary Eric Shinseki is still looking at them. This week, he deployed a team of medical investigators to the VA campus in Oakland to question workers about Legionnaires'. Apparently, seven government investigations — that's how many times they've probed the outbreak — aren't enough to convince the VA's top guy that leadership change is needed.

These guys clearly like their cheese.

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

 

 

 
 


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