Management at the Biloxi VA hospital knew about issues with a surgeon’s medical license and hired him anyway, staff realized years later, which triggered an investigation into oversight and practices at the Gulf Coast Veterans Health Care System, a new report says.
The Office of the Inspector General issued a report last week on its findings after trying to determine if the incident was isolated or more systemic. It’s called “Facility Leaders’ Oversight and Quality Management Processes at the Gulf Coast VA Health Care System.”
The OIG in 2017 received reports of three allegations against the hospital: that patients had died because there was not full-time coverage of the ICU by a doctor with critical care training, also called an intensivist; that an inspection by regional leaders had not remedied the situation; and that a thoracic surgeon provided poor care to five patients.
The first two allegations were addressed in a March 2018 report, which said that on the intensivist’s off weeks, other doctors only authorized to perform standard surgeries were performing intermediate surgeries, and one hospice-care patient with complications had to be transferred to a private hospital and died. The death wasn’t directly attributed to the lack of staffing.
The 2018 report also found communication and documentation issues, and recommended the regional Veterans Integrated Service Network 16 (which covers Louisiana, Arkansas, Mississippi, parts of Texas and coastal Alabama and Florida) oversee the ICU and surgeries.
A new report issued Aug. 28 addresses the third allegation. The OIG initially investigated an unnamed thoracic surgeon “under its jurisdiction for potential criminal actions” but closed that in November 2017, and expanded the scope of the investigation to include management practices at the hospital.
“Due to concerns for patient safety and potential effects of oversight failures, the OIG team expanded the scope of the review from the surgeon-related oversight processes to include a facility-wide oversight process review,” the report said.
When the surgeon was hired in 2013, the report said “facility leaders were aware of licensure and malpractice issues, including the relinquishing of a state medical license in October 2006 to prevent continued prosecution in a disciplinary case.”
But by the time that was discovered in 2017, none of the current staff knew how those hiring decisions had been made, and they were not documented.
However, “when interviewed, facility leaders did not have a clear understanding of the requirements for reviewing the surgeon’s care provided.”
They “granted and continued the surgeon’s privileges without the required evidence of all competencies.”
Concerns about the surgeon first arose in 2014, when the chief of staff requested the Professional Standards Board review one of the surgeon’s cases, during which privileges were suspended. All allegations were found to be “without merit” and the surgeon resumed duties in April.
In October 2017, leaders placed the surgeon on a “surgical pause,” which is not an official designation, and tried to get a doctor from outside the VA to independently evaluate the surgeon as he worked, called an external proctor. However, the surgeon instead resigned, effective December 2017.
“Facility leaders also removed the surgeon in October 2017 from the clinical care setting without following required processes, including notifications to external reporting agencies,” the report said. Because of that, the surgeon could not be reported to the federal malpractice database, the National Practitioner Data Bank, and there was a delay in reporting to a state licensing board.
The OIG team visited in April 2018, and also found the surgeon still had an active VetPro file. “The delay of action indicated an unclear understanding of the significance of the quality of care issues and required subsequent actions,” the report said.
The OIG then reviewed documentation related to the hiring of 50 doctors and found more deficiencies.
Surgeons who are first granted privileges, or who are granted new privileges, are required to be evaluated (called an FPPE) within a certain time period. An FPPE can also be requested “for cause,” or if there is a concerning incident.
Of the 50 doctor files inspected, 14 files did not contain documentation of a defined or completed FPPE, three of four providers who requested modified or new privileges did not have an FPPE, and three of seven “for cause” FPPEs were not presented to the Executive Committee of the Medical Staff for approval.
The OIG also found “multiple instances of quality management failures,” such as documenting CPR certifications for staff and properly reviewing patient deaths and “adverse events and close calls.”
The report made 19 recommendations for the local VA director to follow, and put the regional VISN director in charge of overseeing implementation.
“Due to changes in leadership and facility leaders’ multiple instances of quality management failures that appeared to be due to a lack of knowledge or understanding of VHA policies, the OIG recommended that the VISN Director oversee implementation of facility recommendations.”
The Gulf Coast Veterans Health Care System has issued a statement in response to the report:
“We appreciate the Office of Inspector General’s (OIG) oversight, which focuses on an individual who no longer works for VA and events that occurred more than two years ago. Since then, the Gulf Coast VA Health Care System has taken action on all of the OIG’s recommendations, and made the following improvements:
- Conducted top-to-bottom reviews in 2018 and again this year to ensure all providers are in good standing.
- Implemented a process — which the OIG named a best practice — to ensure providers have disclosed all licenses, active and inactive, into their credentialing profiles.
- Established an internal tracking tool to keep close tabs on all licensure/certification/registration/malpractice actions for providers.”