Regional director Moreland's response to serious Legionnaires' outbreak is cheesy at best
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 email@example.com.
Show commenting policy
TribLive commenting policy
You are solely responsible for your comments and by using TribLive.com you agree to our Terms of Service.
We moderate comments. Our goal is to provide substantive commentary for a general readership. By screening submissions, we provide a space where readers can share intelligent and informed commentary that enhances the quality of our news and information.
While most comments will be posted if they are on-topic and not abusive, moderating decisions are subjective. We will make them as carefully and consistently as we can. Because of the volume of reader comments, we cannot review individual moderation decisions with readers.
We value thoughtful comments representing a range of views that make their point quickly and politely. We make an effort to protect discussions from repeated comments either by the same reader or different readers.
We follow the same standards for taste as the daily newspaper. A few things we won't tolerate: personal attacks, obscenity, vulgarity, profanity (including expletives and letters followed by dashes), commercial promotion, impersonations, incoherence, proselytizing and SHOUTING. Don't include URLs to Web sites.
We do not edit comments. They are either approved or deleted. We reserve the right to edit a comment that is quoted or excerpted in an article. In this case, we may fix spelling and punctuation.
We welcome strong opinions and criticism of our work, but we don't want comments to become bogged down with discussions of our policies and we will moderate accordingly.
We appreciate it when readers and people quoted in articles or blog posts point out errors of fact or emphasis and will investigate all assertions. But these suggestions should be sent via e-mail. To avoid distracting other readers, we won't publish comments that suggest a correction. Instead, corrections will be made in a blog post or in an article.
- NHL violence concerns former Penguins’ pest Cooke
- Depleted Penguins knock off Wild, run home winning streak to nine
- Pittsburgh scam changed American hustler’s game
- Starkey: What did Super loss signify for Steelers?
- Steelers rookie receiver Wheaton is waiting for chance to contribute
- Steelers’ Foster has definitive role this year
- Steelers notebook: Snow awaits in Green Bay
- State Supreme Court rules municipalities can limit what gas drillers can do
- Penguins notebook: Sochi hopefuls have played well against Penguins
- Gateway’s Nicholson picks Michigan State over Pitt
- Greensburg community rallying to support former basketball standout