Mismanaged Surgical Privileging Actions and Deficient Surgical Service Quality Management Processes at the Hampton VA Medical Center in Virginia

Report Information

Issue Date
Report Number
23-00995-211
VISN
6
State
Virginia
District
Northeast
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Clinical Care Services Operations
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review surgical service and quality management concerns at the Hampton VA Medical Center (facility) in Virginia.

The OIG found facility leaders conducted three focused clinical care reviews (FCCRs) in response to concerns about the assistant chief of surgery’s surgical care. However, facility leaders failed to report the results of two FCCRs and delayed reporting the results of one FCCR to the Medical Executive Committee, and did not use multiple reviewers for interrater reliability in any of the FCCRs to ensure the reviews were “fair and objective.” Facility leaders took several privileging actions against the assistant chief of surgery. However, the OIG found multiple deficiencies with notification letters and processes, including failure to adhere to VHA policy, send extension letters, include required language within the letters, and use clear terminology. Leaders also failed to report the assistant chief of surgery to the state licensing board after identifying six cases of substandard care.

Surgical staff did not complete required patient safety reports. Morbidity and mortality conferences were held in a manner that compromised the formal peer review process and resulted in negative staff experiences. The chief of surgery did not recognize the need for three substandard cases to be considered for peer review. The VISN Chief Medical Officer and the facility chief of quality, safety, and value failed to prevent a management review from including two cases that were being peer reviewed concurrently. The OIG determined that facility leaders generally did not communicate and document required institutional disclosure elements.

Eleven recommendations were made to the facility director regarding FCCRs, privileging actions, state licensing board reporting, professional practice evaluations, patient safety reporting, morbidity and mortality conferences, peer review, and institutional disclosures. One recommendation was made to the VISN Director.

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 Hampton VA Medical Center Director conducts focused clinical care reviews in accordance with Veterans Health Administration requirements, and monitors for compliance.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director ensures that summary suspensions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director confirms that proposed reduction or revocation of privileges complies with Veterans Health Administration policies and procedures, and monitors for compliance.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director complies with Veterans Health Administration requirements when reporting licensed independent practitioners to state licensing boards.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director completes a review of Medical Executive Committee meeting minutes and ensures recommendations made for focused professional practice evaluations for cause for licensed independent practitioners have been completed according to Veterans Health Administration requirements.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director ensures that, when providers are transitioned from an initial focused professional practice evaluation to an ongoing professional practice evaluation, the transition is reported and documented as required by Veterans Health Administration policy, and monitors for compliance.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director ensures that ongoing professional practice evaluations include documentation of all conclusionary outcomes required by Veterans Health Administration policy.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2024

The Hampton VA Medical Center Director ensures surgical staff have an understanding of Veterans Health Administration Joint Patient Safety Reporting submissions and tracks submissions specific to Surgical Service, and monitors for compliance.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2024

The Hampton VA Medical Center Director completes a comprehensive review of surgical morbidity and mortality conferences and ensures facility policy and practice is in alignment with Veterans Health Administration policy and, as necessary, consults with Veterans Health Administration’s National Surgery Office and Veterans Integrated Service Network leaders, and monitors for compliance.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2025

The Hampton VA Medical Center Director ensures that the chief of surgery has a process to identify potential cases for peer review and communicates those cases to the appropriate program staff.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2025

The Mid-Atlantic Veterans Integrated Service Network Director confirms the Hampton VA Medical Center Director ensures that management reviews and peer reviews, if both indicated for the same incident of care, are conducted in accordance with Veterans Health Administration policy, and are not conducted concurrently.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2024

The Hampton VA Medical Center Director considers seeking guidance from the Office of General Counsel to determine the appropriate time frame for ensuring all required elements for previously completed institutional disclosures have been met.