Leaders Failed to Ensure a Dermatologist Provided Quality Care at the Carl T. Hayden VA Medical Center in Phoenix, Arizona

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess facility leaders’ responses to a dermatologist’s deficiencies in quality of care and documentation. The OIG found supervisory staff and senior leaders failed to adequately address patient care concerns outlined by staff in 48 patient safety reports and two consecutive unsatisfactory proficiency reports. Specifically, supervisory staff failed to correct the dermatologist’s delays in performing biopsies and misuse of copy and paste in electronic health records, and did not comprehensively review whether the dermatologist documented procedures not performed. 

The Chief of Staff (COS) reported being unaware of the extent of the dermatologist’s deficiencies, despite attending meetings where the information was shared. The Facility Director did not ensure timely initiation of the State Licensing Board (SLB) reporting process after facility leaders had evidence to support the dermatologist’s failure to meet standards of clinical practice and the Medical Executive Board’s recommendation to not renew clinical privileges.

The COS told the OIG that reviews of the dermatologist’s care were completed, and disclosures were not warranted because no patient harm was identified. However, the OIG found that the reviews were neither comprehensive nor conducted by a dermatologist. Additionally, after the OIG site visit, the chief of dermatology reviewed electronic health records and identified that two patients should have received alternative treatments, one patient did not have all identified lesions addressed, and four patients experienced biopsy delays. Therefore, the OIG concluded that further reviews of the care provided by the dermatologist and reconsiderations for disclosures are warranted. 

The OIG made eight recommendations related to delays in the SLB reporting process, and leaders not adequately addressing clinical deficiencies, misuse of copy and paste, documentation of procedures, and the need for follow-up care and disclosure.