Legionnaires' debacle: VA officials must take ownership of their missteps

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The first step in any recovery program is taking responsibility for the problem, but it doesn't seem like the U.S. Department of Veterans Affairs has embraced that concept, even though it's been two years since local officials became concerned about Legionnaires' disease at its Pittsburgh Healthcare System.

Robert Petzel, the VA's undersecretary for health, participated in a U.S. House Committee on Veterans Affairs hearing Downtown on Monday, but critics -- including Republican Rep. Tim Murphy of Upper St. Clair -- found some of his comments less than satisfying.

Particularly irksome was Dr. Petzel's insistence that a regional administrator keep a $63,000 bonus that was awarded just as the VA's inspector general was releasing a report that said the outbreak occurred because employees in Pittsburgh failed to follow water treatment protocols. That conclusion refuted what the local VA said when it first acknowledged that some veterans had acquired the infection in its facilities; officials initially had blamed the state-of-the-art copper-silver ionization water disinfection system installed at the Oakland University Drive hospital in 1993 specifically to prevent the water-borne disease.

Besides his failure to agree that giving a big bonus to regional director Michael Moreland was wrong, as he presided over the debacle Dr. Petzel further irritated his audience by attempting to characterize the Legionnaires' incident in the context of conditions at VA hospitals nationwide.

The well-informed audience -- which included relatives of some of the six veterans who were killed and 15 other patients sickened at the Pittsburgh facilities -- knew that the inspector general reported in August that problems with the water purification process in 2011 and 2012 were isolated in Pittsburgh and not found in the VAs nationwide.

The only way for the VA to reclaim the trust and confidence of the public in Pittsburgh is to acknowledge fully what went wrong and explain fully what's being done to prevent life-threatening outbreaks in the future.



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