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The VA Puget Sound Health Care System’s quality reviews have lagged far behind those of the top performers in the Department of Veterans Affairs health-care network, according to internal evaluations.

During six reviews spread across an 18-month period that ended in June, the Puget Sound VA has never received more than two out of a possible five stars for overall quality, according to documents obtained by The Seattle Times.

Three times, including the three-month period that ended June 30, the Puget Sound VA received the lowest possible level of only one star.

The Puget Sound VA was one of 127 hospitals around the country included in the reviews. They were evaluated using two dozen measurements, including rates of patient mortality and hospital infections, as well as employee turnover and staff response times to calls.

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The Department of Veterans Affairs, despite a push for increased transparency, does not disclose these starred reviews on public websites that display many other hospital-performance indicators.

VA Puget Sound officials over the past year also did not disclose these reviews to U.S. Rep. Jim McDermott, D-Seattle, whose staff periodically meets with VA officials to review performance.

“Transparency is essential to accountable government, and I urge administrators to implement more open reporting on the quality and efficiency of its work,” McDermott said after reviewing the evaluations obtained by The Seattle Times.

VA Puget Sound officials downplay the importance of these reviews. They say that the five-star assessments are an internal “learning tool” and not intended to rank facility performance.

“We are continually creating challenging benchmarks that allow us to find opportunities to improve,” said Megan Streight, a VA regional official.

In the VA evaluation system, 12 of the 127 hospitals earned five stars for quality during the three-month period that ended in March, according to Streight. Under the review system, all the other hospitals were assessed on each measurement on how they compared to a five-star facility.

The Puget Sound VA received some of the worst scores in a measurement that monitors how many patients die in the hospital while receiving acute care. The Puget Sound facility often had a mortality ratio more than twice that of the five-star facilities, and in the most recent quarter was nearly 75 percent higher.

The Puget Sound VA also had far higher rates of pneumonia associated with the use of hospital ventilators. During the quarter that ended in June, that rate was more than 300 percent higher than the average for the five-star hospitals.

Despite the overall low reviews, the Puget Sound VA did have some standout reviews in important patient safety areas. For both urinary-tract infections associated with catheters and antibiotic-resistant infections known as MRSA, Puget Sound had rates far lower than the five-star facilities.

The Puget Sound VA, during the six quarters of reviews, also received three stars for efficiency.

VA officials also say the Puget Sound VA has been assessed in other, broader evaluations and scored high on many important clinical measurements.

William Campbell, VA Puget Sound’s chief of staff, said the Puget Sound VA compares “very favorably” with Seattle-area hospitals such as the University of Washington Medical Center and Swedish Medical Center.

“There’s always room for improvements, but I am proud of what we have done here,” Campbell said.

Coping with growth

The hospital’s poor showing in the starred reviews comes after a decade of rapid growth to accommodate Afghanistan and Iraq war veterans, as well as those from earlier generations who have turned in increasing numbers to the government-run health service.

During the last fiscal year, VA Puget Sound offered service to more than 88,800 patients at its Seattle and American Lake campuses or one of its seven outpatient clinics. That’s a 40 percent surge since 2007, growth that outstrips the average increase for other VA health- care facilities.

The VA also has received a big boost in staff and other resources.

But the Puget Sound VA has had a harder time retaining workers than the top-ranked hospitals. During the last quarter, the turnover rates were more than 20 percent higher than at the facilities that received five stars.

“The turnover is bad,” said Tim Strako, president of Local 3198 of the American Federation of Government Employees, which represents VA Puget Sound employees. “Workloads and lack of staff is probably the biggest thing I hear from our people on the front lines.”

Some longtime patients also have noticed changes.

“This used to be one of the best places in the world to go to,” said Cyril Miller, an Army veteran who has received care at the Beacon Hill hospital since 1992. “But now they often don’t have the staffing to keep up with demand.”

Terry Rogers, chief executive for the Seattle-based Foundation for Health Care Quality, said some of the issues cited in the evaluations could be aggravated by staffing shortfalls.

Several former Puget Sound VA employees interviewed by The Seattle Times say the hospital’s problems are aggravated by a management that sometimes ignores employee concerns and retaliates against those who push to get them addressed.

In a resignation letter submitted Aug. 6, Jeffery Pecoraro, an operating-room nurse educator, wrote that the Puget Sound VA “ … chastises those whom enforce and advocate for policies that protect Veterans and those that serve them.”

Pecoraro says he called attention to problems he noted, including problems with safety procedures for staff assisting in emergency surgical procedures for patients suspected or confirmed to have tuberculosis.

In July, the federal Occupation Safety and Health Administration cited the Puget Sound VA for serious violations related to its safety procedures with these patients.

Those violations included failing to ensure that employees used properly fit-tested, face-piece respirators when operating. Corrective actions were ordered.

Previous struggles

This is not the first time the Puget Sound VA has struggled in its evaluations. In 2009, the Puget Sound VA ranked 137th out of 139 VA hospitals in clinical quality, access and patient satisfaction, according to documents obtained by The Times.

That year, that ranking and other poor performance marks prompted Campbell, the facility’s chief of staff, to prepare a presentation that decried “a rapidly declining performance.”

He tagged 2009 as “one of the worst years in the history of this once storied organization.”

In the presentation, he decried a “doom loop” that included “quick fixes” to inspection findings that did not lead to sustained improvements.

In an interview with The Times, Campbell said the Puget Sound VA has made a major turnaround since 2009.

He noted that in 2010, the Joint Commission on Accreditation of Hospital Organizations gave the hospital one of its strongest reviews of the decade.

“From my perspective, it’s a real success story and something that the staff worked on here collaboratively and diligently,” Campbell said. “We are not the same health-care system today as we were back then. Not by a longshot.”

But the one- and two-star quality reviews over the 18-month period indicate the facility still falls behind the top-tier VA performers in other major urban areas.

Within the VA system, 35 large hospital systems offer services equivalent to the Puget Sound VA. Five of those large VA hospitals were among those that received five stars earlier this year, according to Streight, the VA regional official.

During the past half decade, the Puget Sound VA also has struggled in some areas not specifically tracked in the evaluations.

A 2009 survey examined care of pressure ulcers and wounds — a critical function that often involves treating diabetics and trying to prevent more serious infection problems that eventually can require amputations.

That survey found the program lacked clear leadership and coordination, and noted a general feeling that “power struggles” within the organization would affect development of a comprehensive wound-care program.

That same year, a second evaluation found amputation rates for diabetics and other patients were substantially above the national average.

Campbell said that since those reports were issued, the wound-care clinic has improved and amputation rates have declined.

But Miller, a diabetic who receives care at the clinic, believes the problems have continued.

He said the clinic lost several wound-care specialists during the past year and staff who stayed have had problems getting needed supplies.

Last year, McDermott’s office, acting on a tip from an employee, investigated reports that the wound-care clinic had a shortage of sterilized scissors, a problem that cropped up after the clinic switched from disposable to reusable scissors.

On a visit earlier this summer, Miller said the wound-care clinic lacked a Dremel, a specialized tool that could help grind down the fungus on his big toe, the only one left on his right foot.

“I told them, ‘Don’t touch it if you don’t have the right tool,’” Miller said.

Hal Bernton: 206-464-2581 or

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