The Veterans Healthcare Systems of the Ozarks (VHSO) is located in Northwest Arkansas and serves a Veteran’s population in three states. Mr. Kelvin Parks developed networks and alliances with the Federal Delegations for Arkansas, Missouri and Oklahoma, to include state and local government officials. He also met quarterly with all Veteran’s Service Organizations to provide facility updates and seek advice and council on how to improve processes to ensure excellent healthcare is provided to all Veterans in his catchment area.
However, his relationship with these stakeholders was recently challenged when he had to advise them that his hospital had an impaired pathologist that may have caused harm to 5,250 now deceased Veterans, and potential harm to 14,544 living Veterans currently receiving care within his healthcare system and also impacted over 5K deceased Veterans. The initial reviews of cases completed by this pathologist revealed errors and misdiagnoses that caused four patient’s deaths and 13 cases resulting in institutional disclosures to inform the patients about the adverse event.
Kelvin Parks, Performance Optimization C-Level Executive
“To meet the commitment of honesty, transparency, and respect to the over 19,000 impacted Veterans and family members, I decided to have an external review team conduct a thorough review of all 33,806 cases read by this pathologist since the time of their employment,” Parks said. To show the severity of this concern, many of the stakeholders also receive care and/or serves as volunteers for our healthcare system. “As a result, I knew it was my obligation and duty to notify them, and all stakeholder groups of this tragic situation.”
Drawing upon his strong alliances with this group, he then called upon these same potentially impacted Veterans for assistance and support as the hospital went through this crisis, which they graciously provided. To accomplish this monumental task, he then personally contacted the congressional offices in Arkansas, Oklahoma and Missouri to advise them of what occurred with this provider and the impact on their constituents and our Veteran population. “ I had a one-on-one meeting with the Senior Senator of the Arkansas Delegation to provide an update on the event, and my plan of action was to notify Veterans, family members and the public.”
Kelvin then formed an onsite Incident Command Center to oversee all aspects of the Pathology Lookback, to include the establishment of a call center, mailing of impact letters to all 19,794 Veterans and/or their family members, and logistical operations to support the lookback of the 33,806 cases. In addition, he partnered with the Federal Delegation of Arkansas, Veteran Health Administration, Veterans Integrated Service Network 16, and Veterans Service Organization Leaders at a joint-press conference to notify the public of misdiagnosed cases by the impaired pathologist. During the press conference, he was transparent and shared all facts surrounding the case, and clearly outlined the external review process designed to review all cases read by this pathologist. He then answered all questions from the audience and media outlets present.
“Keeping my commitment of transparency and honesty to our stakeholders, I conducted monthly public Veterans Town-halls for 52 weeks to provide an operational update on the progress of the reviews, then answered all questions and concerns raised because of this tragic event. Each townhall was attended by more than 200 people, to include Veterans, their families, Veteran Service Organizations and the media. I also partnered with a local media outlet to live stream the event, so that Veterans unable to attend would have access to the information shared during the Townhall. I also travelled to Washington, DC and provided an update to the U.S. House Committee of Veteran’s Affairs, Subcommittee on Oversight and Investigations regarding the progress of the lookback.”
To ensure this process was completed in a timely manner, he also facilitated efforts to acquire external contract pathology support from the University of Arkansas Medical School, the University of Oklahoma, Baylor University, Keesler Air Force Medical Hospital, and the U.S. Airforce Academy.
The magnitude of this Pathology Lookback is the first of its kind in the history of the Veterans Health Administration (and perhaps, modern day medicine), and is being used as a case study to prevent future occurrences. The results of this lookback will be implemented in Pathology and Laboratory Departments across the VA healthcare enterprise. “In addition, Congress introduced a bill, which will require the Veteran Affairs Administration to utilize the operational processes I implemented for all catastrophic notification events.
Watch full video interview below.
Contact Kelvin Parks via LinkedIn or his Career WebFolio.
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