Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

A Review of Facility Capabilities
 

Where Veterans Received
 

Complex Surgical Care
 

Report No. 10-02302-225 July 14, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted a 

retrospective review to characterize where seven complex and intermediate surgical 

procedures were performed at Veterans Health Administration (VHA) facilities and at 

non-VHA facilities through fee basis arrangements prior to VHA’s release of Directive 

2010-018, Facility Infrastructure Requirements To Perform Standard, Intermediate, Or 

Complex Surgical Procedures, on May 6, 2010. 

We identified high-risk surgeries performed at VHA facilities and at non-VHA facilities 

through fee basis arrangements during the 2nd and 3rd quarters of fiscal year 2010. We 

then compared VHA facility infrastructure designations (standard, intermediate, or 

complex) to the selected surgical procedures performed at each facility and determined 

whether facilities had the infrastructure to support complex surgical procedures. To 

evaluate the infrastructure of fee basis facilities, we reviewed trauma level and cancer 

center designations. 

We also performed medical record reviews to determine the outcomes of patients whose 

procedures were performed at VHA facilities with infrastructure designations less 

complex than would have been required by the Directive had they been performed after 

the Directive’s effective date. 

We found that VHA facilities had appropriate infrastructure to support surgeries 

performed. Although some surgeries were performed at VHA facilities with designations 

of lower complexity than required by the Directive, these surgeries were performed prior 

to publication of the Directive, and we identified no adverse patient outcomes clearly 

attributable to facility infrastructure. We also found that VHA referred complex 

surgeries to non-VHA facilities with sufficient capabilities to support the surgeries 

performed. Although these facilities did not have the same criteria in place as VHA 

facilities for infrastructure complexity designation, they met similar requirements through 

trauma level and specialty designations. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO: Under Secretary for Health 

SUBJECT: Healthcare Inspection – A Review of Facility Capabilities Where 

Veterans Received Complex Surgical Care 

Purpose 

The VA Office of Inspector (OIG) General Office of Healthcare Inspections conducted a 

retrospective review to characterize where selected complex and intermediate surgical 

procedures were performed at VHA facilities and at non-VHA facilities through fee basis 

arrangements prior to VHA’s release of Directive 2010-018, Facility Infrastructure 

Requirements To Perform Standard, Intermediate, Or Complex Surgical Procedures 

(Directive) on May 6, 2010. The review provides an independent analysis of where 

select complex surgical procedures were performed within the VHA and by fee-forservice providers prior to publication of the Directive. 

Background 

In 2007, the National Surgical Quality Improvement Program (NSQIP)1 identified an 

increase in surgical mortality at a VHA medical center. A subsequent OIG review 

concluded that, independent of physician expertise, availability of support services might 

limit where certain operations should be performed.2 

OIG recommended that the Under Secretary for Health develop and implement a 

mechanism to ensure that each facility’s diagnostic and therapeutic interventions are 

appropriate to the facility’s capabilities. Consequently, the Under Secretary established a 

working group to analyze infrastructure and surgical procedures performed at VHA 

facilities. 

1 In 2009, NSQIP combined with a related cardiac surgery program to form the VA Surgical Quality Improvement
 

Program (VASQIP).

2 Healthcare Inspection – Quality of Care Issues, Marion VA Medical Center, Marion, Illinois,
 

Report No. 07-03386-65, January 28, 2008.
 

VA Office of Inspector General 1 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

The Directive, which resulted from the group’s analysis and recommendations, became 

effective in May 2010. It established an Operative Complexity Matrix (OCM) and 

assigned complexity levels (standard, intermediate, or complex) to each procedure 

identified by Current Procedure Terminology (CPT) codes. The Directive also includes a 

Procedure Infrastructure Matrix (PIM), which establishes the infrastructure requirements 

to perform standard, intermediate, or complex procedures at a VHA facility (see 

Appendixes B–I, Tables 1–10). 

Researchers have evaluated various approaches for decreasing surgical mortality. These 

include limiting complex procedures to high-volume facilities,3 prospective monitoring of 

risk-adjusted outcomes,4 and prompt recognition and management of complications once 

they occur.5 In general, research findings endorse the need for sufficient perioperative 

support services (infrastructure). 

Scope and Methodology 

We identified the following high-risk surgeries performed at VHA facilities and at nonVHA facilities through fee basis arrangements during the 2nd and 3rd quarters of 

fiscal year 2010 (the review period). These surgeries are considered high-risk because 

they are associated with an increased risk for complications or death. The Directive 

designates these surgeries as intermediate or complex. 

	 aortic aneurysm surgery (inclusive of thoracic and abdominal)6 

	 colectomy (removal of all or a part of the large intestine) 

	 craniotomy (removal of part of the skull to expose the brain) 

	 esophagectomy (removal of all or part of the esophagus, part of the upper 

gastrointestinal tract) 

	 open heart surgery 

	 pancreatectomy (removal of all or part of the pancreas) 

	 pneumonectomy (removal of all or part of a lung) 

3 Sonneday CJ, Birkmeyer, JD. A tale of two provinces: Regionalization of pancreatic surgery in Ontario and
 

Quebec. Ann Surg Oncol. 2010; 17:2535-6.
 4 Khuri SF, Henderson, WG. The case against volume as a measure of quality of surgical care. World Journal of
 

Surgery. 2005; 29:1222-9.

5 Dimick JB, Osborne NH, Hall, BL, Clifford YK, Birkmeyer JD. Risk adjustment for comparing hospital quality
 

with surgery: How many variables are needed? J Am Coll Surg. 2010;210:503-8.

6 This surgery involves the removal of a weakened portion of blood vessel (aneurysm), which is then replaced by a
 

man-made graft.
 

VA Office of Inspector General 2 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

We then compared VHA facility infrastructure designations (standard, intermediate, or 

complex)7 to the surgical procedures performed at each facility during the review period 

(see Appendix J, Table 11). 

We also reviewed the outcomes of patients whose procedures were performed at VHA 

facilities with infrastructure designations less complex than would have been required by 

the Directive had they been performed after the Directive’s effective date. For example, 

we reviewed the outcomes of complex surgical procedures performed at intermediate and 

standard facilities. 

To evaluate the infrastructures of fee basis facilities, we obtained trauma level8 

designations from state health department websites, and cancer center designations from 

the National Cancer Institute and the American College of Surgeons. 

We conducted the inspection in accordance with the Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Findings 

VHA Facilities9 

Aortic Aneurysm Surgery 

VHA physicians performed 46 complex aortic aneurysm procedures during the review 

period. All but one of these were performed at complex facilities. The remaining 

procedure was performed at an intermediate Midwest facility. We did not identify 

adverse patient outcomes. 

VHA physicians performed 368 intermediate aortic aneurysm procedures during the 

review period. All the procedures were performed at complex or intermediate facilities. 

Colectomy 

VHA physicians performed 1,178 intermediate colectomy procedures during the review 

period. All but 10 were performed at complex or intermediate facilities. Of these 

10 colectomy procedures: 

7 Patient Care Services: VA Medical Centers Designated for Surgical Complexity http://www.patientcare.va.gov/
 

20100518a1.asp (accessed November 12, 2010)

8 Hospital trauma designations are determined by individual state law provisions. Trauma capabilities are identified
 

by Level: Level-I (Level-1) being the highest, to Level-III (Level-3) being the lowest (some states have five
 

designated levels, in which case Level-V (Level-5) is the lowest).

9 See Appendixes B–I, Tables 1–10. For purposes of clarity, VHA Directive 2010-018, Facility Infrastructure
 

Requirements To Perform Standard, Intermediate, Or Complex Surgical Procedures (Directive) was used as a point
 

of reference. The Directive was not implemented until May 6, 2010.
 

VA Office of Inspector General 3 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

	 All were performed prior to publication of the Directive. 

	 One was performed at an East Coast facility, with no identified adverse outcomes. 

	 Four were performed at a Southern facility. Three of the four patients had no 

adverse outcomes. The fourth patient was an 82 year old with diabetes, obesity, 

and renal insufficiency who died eight days after surgery. We identified no 

aspects of the care provided which could be clearly attributed to the facility’s 

infrastructure. 

	 Five were performed at a Northwest facility. Four of the five patients had no 

adverse outcomes. The fifth patient developed a deep vein thrombosis and a slow 

gastrointestinal bleed 2 weeks after surgery. We did not attribute this patient’s 

surgical complications to the facility’s infrastructure. 

Craniotomy 

VHA physicians performed 237 complex craniotomy procedures during the review 

period. All but one were performed at complex facilities. The remaining procedure was 

performed at an intermediate facility on the East Coast. This procedure, performed by an 

ophthalmologist, was a transcranial10 exploration of an orbit (eye socket). We identified 

no adverse outcomes. 

Esophagectomy 

VHA physicians performed 54 complex and 6 intermediate esophagectomy procedures 

during the review period. All the procedures were performed at complex facilities. 

Open Heart Surgery 

VHA physicians performed 1,608 complex open heart procedures during the review 

period. All the procedures were performed at complex facilities. 

Pancreatectomy 

VHA physicians performed 34 complex and 25 intermediate pancreatectomy procedures 

during the review period. All the procedures were performed at complex facilities. 

Pneumonectomy 

VHA physicians performed four complex pneumonectomy procedures during the review 

period. All but one were performed at complex facilities. The remaining procedure was 

10 Transcranial is a surgical approach through the cranium (skull). 

VA Office of Inspector General 4 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

performed at a Mid-Atlantic intermediate facility prior to publication of the Directive. 

We identified no adverse outcomes. 

VHA physicians performed 97 intermediate pneumonectomy procedures during the 

review period. Ninety-one of the procedures were performed at complex facilities and 

six were performed at intermediate facilities. We identified no adverse outcomes. 

Fee Basis Facilities 

If a service cannot be provided in a timely manner due to capability, capacity, or 

accessibility, the service may, with approval, be provided outside of the VA through fee 

basis,11 which is governed by Federal law. However, fee basis care is not an entitlement 

program or a permanent treatment option.12,13 

We examined the characteristics of facilities performing esophagectomy, 

pancreatectomy, and pneumonectomy procedures. We reviewed each case to determine 

if the infrastructure provided by the fee basis provider was comparable or exceeded 

required VHA infrastructure (see Appendix K, Table 12). 

Trauma designations are given to facilities that meet requirements of government or other 

authorized entities.14 Level I designation requires around-the-clock availability of 

surgeons in addition to emergency care, respiratory therapy, diagnostic imaging, and 

laboratory and blood-component services. 

The National Cancer Institute designates 66 cancer centers as “state-of-the-art cancer 

research and patient care facilities.”15 The American College of Surgeons Commission 

on Cancer grants accreditation “to those facilities that have voluntarily committed to 

provide the best in cancer diagnosis and treatment and are able to comply with their 

established standards.”16 

Esophagectomy 

VHA approved nine complex or intermediate fee basis esophagectomies. All were 

referred to a Level I trauma-designated facility or cancer center. 

Pancreatectomy 

11 VHA Directive 2008-056, VHA Consult Policy, September 16, 2008.
 12 National Fee Program Office, http://www.nonvacare.va.gov, accessed February 16, 2011.
 13 OIG Office of Audits & Evaluation (2010, August 18), Veterans Health Administration: Audit of Non-VA
 

Inpatient Fee Care Program, Report No. 09-03408-227.
 14 American College of Surgeons: Trauma Programs, http://www.facs.org/trauma.verified.html, accessed
 

February 2, 2011.

15 http://cancercenters.cancer.gov/cancer_centers, accessed May 9, 2011.
 16 American College of Surgeons: Cancer Program Accreditation, http://www.facs.org/cancerprogram, accessed
 

May 9, 2011.
 

VA Office of Inspector General 5 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

VHA approved 14 complex or intermediate fee basis pancreatectomies. All but one were 

referred to a Level I or II trauma-designated facility or a cancer center. The remaining 

patient presented to a local hospital emergency department and required emergency 

surgery. 

Pneumonectomy 

VHA approved eight complex or intermediate fee basis pneumonectomies. Six of these 

patients were referred to a Level I trauma facility and one to a cancer center. The 

remaining patient was referred to a regional hospital. The hospital was not a designated 

trauma or cancer center; however, it did have thoracic surgeons on staff and complex 

surgeries, such as open heart surgeries, were performed there. We identified no adverse 

outcomes. 

Conclusions 

This review found that in response to OIG’s 2008 recommendation to the Under 

Secretary for Health, VHA has successfully implemented a mechanism to ensure that 

each facility’s diagnostic and therapeutic interventions are appropriate to the facility’s 

capabilities. 

The complex surgeries identified for this review were supported by the infrastructure at 

VHA facilities. Although some surgeries were performed at VHA facilities with 

designations of lower complexity than required by the Directive, these surgeries were 

performed prior to publication of the Directive, and we identified no adverse patient 

outcomes clearly attributable to facility infrastructure. 

VHA referred complex surgeries to non-VHA facilities with infrastructures that 

supported the complexity of the surgeries performed. Although these facilities did not 

have the same criteria in place as VHA facilities for infrastructure complexity 

designation, they met similar requirements through trauma level and specialty 

designations. 

Comments 

The Under Secretary for Health agreed with our findings. We made no recommendations 

and plan no further actions. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 6 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix A 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 June 24, 2011 

From:	 Under Secretary for Health (10) 

Subject:	 OIG Draft Report: Review of Facility Capabilities Where 

Veterans Received Complex Surgical Care (VAIQ 7118631) 

To:	 Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the Office of Inspector General (OIG) draft report, and I 

concur with its findings. I am pleased to learn that OIG’s analysis confirms 

that the Veterans Health Administration (VHA) is providing complex 

surgical care within facilities with adequate resources and competence. 

This report indicates that VHA has successfully implemented a mechanism 

to ensure that each facility’s diagnostic and therapeutic interventions are 

appropriate to each facility’s capabilities as was recommended in a 

2008 OIG report recommendation. 

2. In response to the 2008 OIG report recommendation, VHA conducted 

detailed analyses of facility infrastructure and surgical procedures 

performed in each VHA Surgical Program. VHA’s analyses concluded that 

any gaps between surgical complexity and infrastructure requirements were 

resolved prior to the publication of VHA Directive 2010-018, Facility 

Infrastructure Requirements to Perform Standard Intermediate, or Complex 

Surgical Procedures. This report confirms VHA’s conclusions. 

3. Per policy, VHA monitors all surgical procedures performed and 

identifies any procedure performed in a facility which exceeds the 

infrastructure complexity designation. The National Surgery Office reports 

all surgical procedures performed beyond facility complexity designation 

through the VA Surgical Quality Improvement Program thereby ensuring 

ongoing policy compliance. 

VA Office of Inspector General 7 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

4. Thank you for the opportunity to review the draft. If you have any 

questions, please contact Linda H. Lutes, Director, Management Review 

Service (10A4A4) at (202) 461-7014. 

Robert A. Petzel, M.D. 

VA Office of Inspector General 8 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix B 

Tables 1–10 are summaries of VHA Directive 2010-018, Facility Infrastructure 

Requirements to Perform Standard, Intermediate, or Complex Surgical Procedures, with 

each section designated as a separate table. 

Table 1. Perioperative Diagnostic Evaluation Requirements. 

Standard Intermediate Complex 

EKG: In-house weekdays dayshift, available on-call 

24 hours a day, 7 days a week, 365 days a year (24/7) 

within 30 minutes 

X 

EKG: In house 24/7. 

X X 

Basic Laboratory: (includes in house weekdays 

dayshift, available on call 24/7 within 30 minutes) X 

Basic Laboratory: In-house 24/7. X 

Basic Radiology: (includes in house weekday dayshift, 

available on call 24/7 within 30 minutes). X 

Basic Radiology: In-house 24/7 X X 

Cardiac Stress Testing: Available in-house during day 

tour, may be through fee or contract. 

X X 

Pulmonary Function Test (PFT) Studies: Available 

in-house during day tour, may be through fee or contract. 

X X 

Computerized Tomography (CT) Scan: In-house 

weekdays dayshift, on-call 24/7 within 30 minutes 

X X 

Vascular Ultrasound: In-house weekdays dayshift X X 

Radiology Interpretation: In-house weekdays dayshift, 

on-call 24/7 within 30 minutes 

X X 

Magnetic Resonance Imaging (MRI) and Magnetic 

Resonance Angiography (MRA): In-house weekday 

dayshift, on-call24/7 within 30 minutes if necessary for 

specialized programs. 

X 

Interventional Cardiology: To be provided 24/7 within 

30 minutes, if necessary, for specialized programs. 

X X 

Vascular Interventional Radiology: To be provided 

24/7 in-house or by fee or contract within 60 minutes. 

X X 

Non-vascular Interventional Radiology: To be 

provided 24/7 in-house or by fee or contract within 

60 minutes. 

X 

Interventional Neuroradiology: In-house or written 

plan and/or policy for fee or contract, 24/7 within 

60 minutes. 

X 

VA Office of Inspector General 9 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix C 

Table 2. Perioperative Consultation Requirements. 

Standard Intermediate Complex 

Preoperative Medical Consultation: (elective) Inhouse weekdays dayshift; (emergency) In-house 

weekday dayshift, available on-call 24/7 within 

15 minutes by phone or 60 minutes in person 

X X X 

Postoperative Medical Consultation: In-house 

weekdays dayshift, available on call 24/7 within 

15 minutes by phone or 60 minutes in person 

X X X 

Specialty Consultants: Cardiology, Pulmonary 

Gastroenterology, Hematology, Infectious Disease, 

Interventional Radiology, Nephrology, Neurology, 

Orthopedic Surgery, Pathology, Thoracic Surgery, 

Urology, Vascular Surgery within 15 minutes by phone 

and 60 minutes in person. 

For specialty services, such as PFT's and cardiac 

catheterization provided by fee or contract, the patient 

may be seen either on-site or off-site 

X 

Specialty Consultants: The following consultants must 

be available 24/7 within 15 minutes by phone or 

60 minutes in person: Cardiology, Gastroenterology, 

Hematology, Infectious Disease, Interventional 

Radiology, Nephrology, Neurology, Orthopedic Surgery, 

Otolaryngology, Pathology, Pulmonary, Thoracic 

Surgery, Urology, Vascular Surgery on staff; 

X 

Cardiovascular Surgeon, Interventional Neuroradiologist, 

Neurosurgeon as indicated by approved clinical 

programs; on staff or by fee or contact, availably within 

15 minutes by phone or 60 minutes in person. X 

Anesthesia Preoperative Assessment: In-house 

weekdays dayshift, available on call 24/7 within 

15 minutes by phone or 60 minutes in person may be 

provided by Certified Registered Nurse Anesthetist 

(CRNA) or mid-level provider. 

X X X 

VA Office of Inspector General 10 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix D 

Table 3. Surgeon Staffing Requirements. 

Standard Intermediate Complex 

General Surgeon: One Full-time Equivalent (FTE) 

employee, who may be provided by contract. X 

General Surgeon: There must be a two or more FTE 

employees who may be provided by contract. X 

General Surgeon: There must be a three or more FTE 

who may be provided by contract. X 

Specialty Surgeons: Variable depending upon in-house 

clinical services offered X X X 

Surgical Assistant: Available 24/7 on call within 

60 minutes X X X 

Call Schedule: Formal General Surgery and Specialty 

Service Call Schedule, availability 24/7 within 

60 minutes. The call schedule must incorporate only 

board certified or board eligible surgeons. 

X X 

Inpatient Coverage: Written plan or policy for the 

availability of a qualified surgeon 24/7 on-call within 

60 minutes. Service may be provided by fee or contract 

at the facility. 

X 

Inpatient Coverage: There must be coverage by surgical 

staff, resident, or fellow 24/7 within 15 minutes by phone 

or 60 minutes in person. X 

Inpatient Coverage: There must be a dedicated inpatient coverage in-house available 24/7, which may be 

provided by resident, fellow, hospitalist, critical care 

specialist, or mid-level provider without responsibility to 

another institution (cannot be provided by physician 

assigned to the Emergency Department or the Medical 

Officer of the Day). 

X 

VA Office of Inspector General 11 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix E 

Table 4. Operating Room (OR) Staffing and Equipment Requirements. 

Standard Intermediate Complex 

Staffing: There must be a minimum of staffing to include 

a circulating Registered Nurse (RN) and scrub technician 

or RN. A policy or protocol defining training and 

competencies consistent with the Association of 

Operating Room Nurses (AORN) and the Association of 

Surgical Technicians (AST) must be maintained. 

X X X 

Staff competencies for specialty specific surgery. 

X X 

A plan or policy for staffing based upon procedural 

complexity. X X 

A plan or policy for supplemental staffing for 

intraoperative emergencies X X 

Instrument Sets: There must be a duplication of all major 

instrument sets including one vascular set available for 

emergency purpose. 

X X X 

Equipment required in each OR: There must be an 

anesthesia machine; the OR must have the capability for 

basic physiological monitoring including EKG, end-tidal 

Carbon Dioxide (CO2), and an electrocautery unit. 

X X X 

Equipment required for the OR Area: There must be a 

code cart and defibrillator, flash sterilizer, and 

intraoperative c-arm. 

X X X 

Equipment required in each OR: Includes monitoring 

equipment for central venous pressure, and arterial 

pressure 

X X 

Equipment required for the OR Area: Must include a 

cell saver. X X 

Coverage: Nursing and operating room must be 

available 24/7 within 60 minutes. X X X 

Radiology: There must be a technician available for 

intraoperative radiology in-house weekdays dayshift, oncall 24/7 within 60 minutes. X X X 

VA Office of Inspector General 12 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix F 

Table 5. Anesthesia Requirements. 

Standard Intermediate Complex 

Provider: There must be an Anesthesiologist, or CRNA 

available for all cases 24/7 within 60 minutes 

X X X 

Chief of Anesthesia: The anesthesia service must be 

managed by a board certified or board eligible 

anesthesiologist. 

X X 

Assistance: Written plan or policy for physician provider 

skilled in airway management as necessary. X X X 

Coverage: In-house weekday dayshift, on-call 

24/7 within 60 minutes. X X X 

Table 6. Post Anesthesia Care Unit (PACU) Requirements. 

Standard Intermediate Complex 

Area: There must be a designated PACU or equivalent; 

local policy may require specific specialty procedures or 

after-hours care to be directly transferred to the Intensive 

Care Unit (ICU). 

X X X 

Staffing: Minimum staffing of two licensed providers 

with a 1:1 provider-to-patient ratio as required, consistent 

with the American Society of PeriAnesthesia Nursing 

(ASPAN) guidelines. 

X X X 

Staffing Outside the PACU: There must be a RN with 

demonstrated competencies available when the patient is 

recovered outside the PACU, consistent with ASPAN 

guidelines. 

X X X 

Competencies for Recovery of Specialty Patients: 

There must be specific competencies for recovery of 

specialty patients as indicated. X X 

Skills: There must be ventilator management, and 

management of physiologic monitoring. X X 

Discharge Guidelines: Patients must be discharged from 

the PACU based upon defined protocol. X X X 

VA Office of Inspector General 13 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix G 

Table 7. Intensive Care (ICU) Requirements. 

Standard Intermediate Complex 

ICU Level: Level 4 or Level 3 without intensivist (for 

explanation of Levels see Web site at: 

http://chestjournal.chestpubs.org/content/132/5/1455.full. 

pdf+html). 

X 

ICU Level: Level 2 o4 Level 3 with intensivist (for 

explanation of Levels see Web site at: 

http://chestjournal.chestpubs.org/content/132/5/1455.full.l 

pdf+html). 

X 

ICU Level: Level 1 or Level 2 (for explanation of Levels 

see website at: 

http://chestjournal.chestpubs.org/content/132/5/1455/full. 

pdf+html). 

X 

Medical Co-management of Surgical Patients: There 

must be a written policy or plan for co-management 24/7. X X 

Table 8. Ward Staffing and Equipment Requirements. 

Standard Intermediate Complex 

Nurse competencies must be in alignment with the types 

of surgical procedures being performed. X X X 

Specialty specific competencies must be defined. 

X X 

Monitored Beds (EKGS): Capability and defined 

criteria for the use of beds remotely monitored by EKG. X X X 

Monitored Beds (Pulse Oximetry): Capability and 

defined criteria for the use of beds remotely monitored by 

pulse oximetry. 

X X X 

VA Office of Inspector General 14 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix H 

Table 9. Requirements for Support Services. 

Standard Intermediate Complex 

Respiratory Therapy: In-house weekday dayshift, oncall 24/7 within 60 minutes, service must be provided by 

a credentialed respiratory therapist. X 

Respiratory Therapy: In-house 24/7; service must be 

provided by a credentialed respiratory therapist. X X 

Pharmacy: Pharmacy services in-house 12 hours a day 

within 15 minutes by telephone and 60 minutes on site. X 

Pharmacy: Pharmacy services in-house 16 hours a day; 

on-call or available within 15 minutes by telephone and 

60 minutes on site. 

X X 

Pharmacy: Pharmacy services in-house 24/7, clinical 

pharmacy services can be available off tour on-call within 

15 minutes by telephone and 60 minutes on site. X 

Blood Bank: There must be packed red blood cells, fresh 

frozen plasma and platelets available within 60 minutes 

weekday dayshift. 

X 

Blood Bank: There must be packed red blood cells, fresh 

frozen plasma, and platelets available within 60 minutes 

24/7. X X 

Physical Therapy: In-house weekday’s dayshift. 

X 

Physical Therapy: In-house weekday dayshift; 

weekends if necessary for specialty specific recovery. X X 

Dialysis: In-house weekdays dayshift; it must be 

available on-call 24/7 within 6 hours X X 

Pathology: There must be capacity for frozen section 

studies in-house weekdays dayshift; on-call 24/7 within 

60 minutes. X X 

Biomedical Engineering: In-house weekday dayshift. 

X X 

VA Office of Inspector General 15 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix I 

Table 10. Sterile Processing and Distribution (SPD) Requirements. 

Standard Intermediate Complex 

Availability: There must be a re-processing capability 

on-site or immediately available appropriate sterile 

instrument sets should be on-site for all scheduled 

procedures 

X 

Availability: There must be processing onsite; personnel 

in-house weekdays dayshift; on-call 24/7, or materials 

available within 15 minutes by written policy or protocol X X 

Equipment: There must be a flash sterilizer available 

24/7 with competent personnel. X X X 

VA Office of Inspector General 16 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix J 

VHA Facilities 

Table 11. The number and complexity of surgeries performed at VHA facilities and 

the complexity of the infrastructure where they were performed. 

Infrastructure Complexity Operative Complexity 

AORTIC ANEURYSM SURGERY 

Complex Intermediate 

Complex 45 345 

Intermediate 1 23 

COLECTOMY 

Complex Intermediate 

Complex 0 879 

Intermediate 0 289 

Standard 0 10 

CRANIOTOMY 

Complex Intermediate 

Complex 236 0 

Intermediate 1 0 

ESOPHAGECTOMY 

Complex Intermediate 

Complex 54 6 

Intermediate 0 0 

OPEN HEART SURGERY 

Complex Intermediate 

Complex 1,608 0 

Intermediate 0 0 

PANCREATECTOMY 

Complex Intermediate 

Complex 34 25 

Intermediate 0 0 

PNEUMONECTOMY 

Complex Intermediate 

Complex 3 91 

Intermediate 1 6 

VA Office of Inspector General 17 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix K 

Fee Based Facilities 

Table 12. The number of complex or intermediate surgical procedures referred for 

fee based care with an assessment of the fee base infrastructure complexity. 

Fee Based Facility Designation ESOPHAGECTOMY PANCREATECTOMY PNEUMONECTOMY 

Level I Trauma 9 9 6 

Level II Trauma 0 1 0 

NCI Cancer Center 0 3 0 

American College of Surgeons (ACS) Cancer 

Center 

0 0 1 

Community Hospital 0 1 0 

Regional Hospital 0 0 1 

VA Office of Inspector General 18 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix L 

OIG Contact and Staff Acknowledgments 

OIG Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments Ann Ver Linden, RN, Team Leader 

Laura Dulcie, BS 

Matt Frazier, MPH 

Stephanie Hensel, RN, JD 

Jerome Herbers, MD 

Clarissa Reynolds, MBA 

Virginia Solana, RN 

VA Office of Inspector General 19 
Review of Facility Capabilities Where Veterans Received Complex Surgical Care 

Appendix M 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Under Secretary for Health (10) 

Veterans Integrated Service Network Directors (1–23) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 20