The Augusta VA health system, which should be a “flagship” healthcare center for the U.S. Department of Veterans Affairs, has instead had three directors in three months.
Secretary of Veterans Affairs Doug Collins testified last week that the VA is “looking for permanent” leadership at the Augusta hospitals, stating that the facility “should be one of our flagship” centers.
Responding to questions from Georgia Sen. Jon Ossoff at a Senate VA appropriations committee hearing, Collins said a prior Augusta VA leader had “failed up” into an administrative role. Without naming the employee, Collins said he was put on administrative leave. But then, another acting leader intended as a replacement for the first, “has been removed as well.”
Collins linked the moves to a VA Office of Inspector General report that cited many issues at the Augusta medical center. These included a “toxic workplace” that was “putting our VA employees in a bad place,” he said.
The issues appear to predate Collins, who was confirmed in February and has since revealed plans to cut the VA workforce by about 15%. The Augusta VA facilities serve approximately 50,000 veteran patients and employ around 2,700.
The leadership shifts began in March, when Augusta VA Executive Director Robin Jackson and Interim Deputy Director Kimberley Booker were reassigned to another facility in Atlanta, according to prior reports.
At that time, Oscar Rodriguez was named acting director and Lovetta Ford acting deputy director. However, Rodriguez was placed on administrative leave in June amid an investigation into the “leadership climate.” Ford has since been named acting medical center director.
The OIG onsite inspection was conducted Sept. 24-26, 2024. The report, based on an all-employee survey and staff interviews, was published on May 22. It revealed numerous critical issues:
- Culture of fear and toxic workplace: The OIG found “concerning behavior and communication problems among facility leaders.” Interviews and a facility-wide questionnaire revealed facility leaders’ threatening and abusive communication style, retaliation for employees sharing concerns with leaders and a toxic workplace that led to a culture of fear and employees feeling psychologically unsafe.” The findings echoed a 2019 OIG report that described similar concerns.
- Persistent supply deficiencies: The inspection identified “continued supply chain management concerns,” which were repeat findings from prior 2020 and 2023 reports. Staff reported ongoing issues requiring them to leave their units to search for supplies, which delayed patient care. Examples included delayed care inserting a Foley catheter while one was located, a lack of pulse oximetry monitors, delayed dialysis due to unavailable cartridges and a lack of lancets for administering insulin.
- Patient safety and communication: The OIG found inconsistent and low compliance in communicating test results to patients. Nursing leaders lacked access to patient safety reports. There were “missed opportunities” for providing institutional disclosures for adverse patient events, the report said.
- Primary care staffing: The facility faced challenges with staff retention in primary care, with 36 vacant positions, 19 of which had been open for over 12 months, while most primary care team panels were at or above 100% capacity.
- Veteran-Centered Safety Net: While the facility’s programs effectively identified and enrolled veterans into homeless programs, challenges remained. The Freedom’s Path apartments at the uptown division did not accept Housing and Urban Development–Veterans Affairs Supportive Housing program vouchers.
Augusta VA Health Care System OIG Report by Susan McCord on Scribd
