Review of VISN 10 and Facility Leaders’ Response to Recommendations from a VHA Office of the Medical Inspector Report, John D. Dingell VA Medical Center in Detroit, Michigan

Report Information

Issue Date
Report Number
22-04099-153
VISN
1
State
Michigan
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
In response to a congressional request, the VA Office of Inspector General (OIG) inspected the John D. Dingell VA Medical Center in Detroit, Michigan (facility) to assess leaders’ progress toward implementation of recommendations from the VHA Office of the Medical Inspector (OMI). The OIG evaluated facility leaders’ actions related to High Reliability Organization (HRO) goals and Veterans Integrated Service Network (VISN) 10 leaders’ oversight of, and support provided to, the facility leaders. The OIG found concerns related to VISN and facility leaders’ corrective actions in response to 6 of the 10 OMI recommendations. (1) Facility leaders did not meet VHA requirements related to the supervision of post-graduate year -1 residents. (2) Facility leaders delayed taking a privileging action and missed opportunities for state licensing board (SLB) reporting. (3) The interim chief of surgery’s facilitation of morbidity and mortality (M&M) conferences was inconsistent. (4) The facility corrective action plan was deficient for the OMI recommendation regarding the reassessment of a Peer Review Committee member. (5) The VISN academic affiliations officer was not made aware of the OMI recommendation related to resident supervision, did not provide oversight to the facility’s surgical residency program, and did not ensure compliance with VHA policy. (6) The VISN surgical workgroup did not document vital information from the facility, which could have ramifications across other VISN facilities. The OIG identified additional concerns regarding stable and continuous leadership in the facility, the impact of leaders’ actions on HRO principles, and VISN oversight of, and support to, facility leaders. The OIG made four recommendations to VISN leaders and five recommendations to facility leaders. Recommendations addressed resident supervision, National Surgery Office review, National Practitioner Data Bank and SLB reporting, M&M conferences, VISN academic affiliations officer roles and responsibilities, VISN surgical workgroup, VISN oversight and support to the facility, and continued efforts towards HRO.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director evaluates and ensures all Veterans Integrated Service Network 10 facilities comply with Veterans Health Administration requirements regarding resident supervision, specifically related to post-graduate year one on-site direct supervision.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2024

The John D. Dingell VA Medical Center Director reviews the March 2023 National Surgery Office program review as referenced in the Office of the Medical Inspector report and ensures a comprehensive and sustainable response to the recommendations noted in the National Surgery Office memorandum.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2024

The John D. Dingell VA Medical Center Director and facility leaders meet all Veterans Health Administration requirements for National Practitioner Data Bank and State Licensing Board reporting for healthcare providers that meet reporting criteria.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2024

The John D. Dingell VA Medical Center Director ensures the chief of surgery facilitates and provides oversight of morbidity and mortality conferences.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2024

The John D. Dingell VA Medical Center Director ensures that initial level 3 peer review results of Peer Review Committee members’ cases are reassessed by another neutral VA facility Peer Review Committee for final level determination.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2024

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network academic affiliations officer maintains awareness of and performs assigned roles and responsibilities per Veterans Health Administration requirements.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2024

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network surgical workgroup reviews applicable Veterans Health Administration policies, and documents discussion and action plans to reflect facilities’ compliance with Veterans Health Administration policy and surgical complexity level.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2024

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director provides continued oversight and structured support to executive and service line leaders during key leader transitions, and monitors actions taken to ensure completion of action plans.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2024

The John D. Dingell VA Medical Center Director reviews organizational communication channels and ensures consistency with Veterans Health Administration High Reliability Organization goals and considers the use of Veterans Health Administration resources such as the Veterans Health Administration National Center for Organization Development.