Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Surgeon Privileging and
 

Resident Supervision Issues
 

W. G. (Bill) Hefner VA Medical Center
 

Salisbury, North Carolina
 

Report No. 11-01993-281 September 16, 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)
 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Executive Summary
 

The VA Office of Inspector General, Office of Healthcare Inspections conducted an 

inspection to determine the validity of allegations of surgeon privileging and resident 

supervision issues at the W. G. (Bill) Hefner VA Medical Center (the facility), Salisbury, 

North Carolina. 

The complainant made the following allegations: 

	 Surgeons at the facility were performing operations that they did not have the 

clinical privileges to perform, which resulted in poor surgical outcomes. 

	 Residents were not supervised appropriately. 

We substantiated the allegation that some surgeons performed certain operative 

procedures without the appropriate corresponding privileges; however, we did not find 

evidence that poor surgical outcomes resulted. We substantiated the allegation that 

residents in Surgical Service were not supervised as required by VHA policy. We found 

that there was no surgeon on site 2 days per week while residents were seeing patients in 

the Clinic. Local policy did not define timeframes for the documentation of resident 

supervision as required by VHA. We also found that resident authored progress notes 

were not consistently co-signed by a supervising surgeon in the timeframe verbalized as 

acceptable by clinical leadership. 

VHA policy requires an “interval note” be entered into the medical record by a physician 

immediately prior to operative procedures. This note documents that the information in 

the previous progress notes was still accurate, an appropriate assessment was completed 

prior to surgery, the patient still required the procedure, and that the patient’s condition 

had not changed. We found that interval notes were not consistently entered into the 

medical record by the attending surgeon. 

We recommended that the Medical Center Director ensure that surgeons have current 

privileges for the procedures they perform and that Surgical Service residents have 

supervision onsite in accordance with VHA policy. We also recommended that the 

facility resident supervision policy define timeframes for the documentation of resident 

supervision and that pre-operative documentation be completed as required by VHA 

policy. The Veterans Integrated Service Network and Medical Center Directors 

concurred with our findings and recommendations and provided acceptable action plans. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO: Director, VA Mid-Atlantic Health Care Network (10N6) 

SUBJECT: Healthcare Inspection – Surgeon Privileging and Resident Supervision 

Issues, W.G. (Bill) Hefner VA Medical Center, Salisbury, North 

Carolina 

Purpose 

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

an inspection to determine the validity of allegations of surgical privileging issues and 

inadequate resident supervision at the W. G. (Bill) Hefner VA Medical Center (the 

facility), Salisbury, NC. 

Background 

The facility is a level 2 tertiary care medical center within Veterans Integrated Service 

Network (VISN) 6, which offers inpatient and outpatient medical, surgical, and 

rehabilitative services. The facility has an academic affiliation with Wake Forest 

University and an active residency program in multiple specialties. The facility operating 

room (OR) is classified by Veterans Health Administration (VHA) as an Intermediate 

Complexity OR. 

In February 2011, the OIG received an anonymous complaint alleging that: 

	 Surgeons at the facility were performing operations that they did not have clinical 

privileges to perform, which resulted in poor surgical outcomes. 

	 Surgical Service residents were not supervised appropriately 

Scope and Methodology 

We conducted a site visit May 9–11, 2011. We interviewed the facility Chief of Staff, as 

well as other clinical, administrative, and management staff with knowledge relevant to 

the allegations. We interviewed the VISN 6 Chief Medical Officer and Quality 

Management staff, as well as the VA Central Office Director of Credentialing and 

VA Office of Inspector General 1 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Privileging, and the Senior Medical Officer, Office of Quality and Safety, regarding 

oversight of privileging processes. We reviewed VHA and local policies, electronic 

medical records, committee meeting minutes, credentialing and privileging folders, and 

reviews completed by the facility and VISN. We also reviewed staff and clinic 

schedules, OR reports, National Surgical Quality Improvement Project data, American 

Council for Graduate Medical Education Guidelines, and other related documents. 

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

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

Efficiency. 

Inspection Results 

Issue 1: Surgeons Performing Procedures Without Privileges 

We substantiated the allegation that surgeons were performing procedures in the OR 

without having the clinical privileges to do so. We identified four surgeons who did not 

have privileges for one or more procedures they performed. 

VHA policy1 addresses the privileging process for providers to practice at a VHA facility. 

Privileges are granted and approved by a facility Professional Standards Board (PSB) 

comprised of medical leaders who have reviewed and discussed the provider’s training 

and practice information. After a provider is hired and approved for initial privileges, a 

Focused Professional Practice Evaluation is conducted, in which the Service Chief and 

PSB review practice patterns and confirm that the provider demonstrates clinical 

competence. 

We reviewed all of the operative procedures performed at the facility between 

October 1, 2009 and March 31, 2011. We compared the procedures performed by each 

surgeon with his/her PSB approved privilege list. Where there were discrepancies, we 

reviewed the medical records of the patients involved. 

A surgeon performed cholecystectomies2 using a laparoscopic technique3 without having 

privileges to do so. The surgeon also performed creation of arteriovenous fistulas4 and 

lower extremity amputations without having clinical privileges to do so. We reviewed 

the medical records for these patients and did not find evidence of poor surgical outcomes 

1 VHA Directive 2006-067, Credentialing of Healthcare Professionals, December 22, 2006. Clinical privileges are 

specific skills and procedures a provider is allowed to perform at a facility, determined by a review of the provider’s 

qualifications, education, experience, and practice history in order to determine competence to perform particular 

skills and techniques.

2 A cholecystectomy is the surgical removal of the gallbladder. 

3 Laparoscopic technique is a minimally invasive surgery involving multiple small incisions and a camera in lieu of 

the traditional long open incision.

4 Arteriovenous fistula is a surgical procedure in which an artery is connected to a vein in the forearm for the 

purpose of using this site for hemodialysis access. 

VA Office of Inspector General 2 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

from these procedures. The VISN identified this problem in November 2010, and by the 

time of our visit, the facility had addressed the issue and taken action. 

Radical prostatectomies5 may be performed in VHA designated Intermediate Complexity 

ORs when the attending surgeon has the clinical privileges for that procedure.6 However, 

the facility had a statement on their privileging form that “facility constraints prevent 

privileges for radical prostatectomy.” Clinical staff and leadership told us that radical 

prostatectomies had not been performed at the facility because nursing staff did not have 

the necessary training to provide post-operative care following this procedure. We found 

that a surgeon performed a radical prostatectomy at the facility in 

May 2010, despite this exclusionary statement. In September 2010, the facility provided 

radical prostatectomy post-operative care training to the nursing staff. Two weeks later, 

another surgeon performed a radical prostatectomy; however, the privilege lists were not 

updated to reflect approval for the surgeons to perform this procedure. In late December 

2010, the facility’s PSB approved the revised urology privilege list, which included 

radical prostatectomy. We reviewed the medical records for these patients and did not 

find poor surgical outcomes as a result of these procedures. 

A surgeon had privileges to perform closed reduction internal fixation of fractures, but 

performed an open reduction internal fixation of a fracture7

, which was not on the 

surgeon’s list of approved privileges. This surgeon was practicing at the time under a set 

of general surgeon privileges with additional orthopedic privileges handwritten in 

margins of the form. The orthopedic surgery privilege list has since been revised to be 

specific to that discipline. We reviewed the medical records for this patient and did not 

find a poor surgical outcome as a result of the procedure. 

OR nurses were to validate and document prior to surgery that the procedures to be 

performed were on the surgeon’s approved privilege list. This was not being done. The 

OR Nurse Manager told us that this process is now being enforced and closely monitored. 

Clinical staff and leadership also told us that, to further improve the privileging process, 

privilege forms for each surgical specialty are being re-written by an interdisciplinary 

team. The forms will not go to the PSB for approval until there is agreement on content 

and clarity between the Chief of Surgery, section chiefs, surgeons, OR Nurse Manager, 

and the facility’s Office of Performance and Quality. 

5 Radical prostatectomy is a surgery to remove all of the prostate gland and some of the tissue around it, to treat
 

prostate cancer.

6 VHA Directive 2010-018, Facility Infrastructure Requirements to Perform Standard, Intermediate, or Complex
 

Surgical Procedures, May 6, 2010.
 7 A closed reduction internal fixation of fractures is a technique where the fracture is set with physical manipulation,
 

without an incision. An open reduction internal fixation of fractures involves an incision and the use of screws
 

and/or plates to set the fracture.
 

VA Office of Inspector General 3 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

To further evaluate the allegation of poor surgical outcomes, we reviewed National 

Surgical Quality Improvement Project data, internal reviews, and other documents, and 

found no adverse patient outcomes related to these procedures that were performed 

without approved privileges. 

The facility had received recommendations from previous reviews regarding the 

privileging of physicians. OIG conducted a scheduled site visit in 2009 and 

recommended that ongoing professional practice evaluations, provider profiles, and 

privileges comply with VHA requirements. 

As a result of their site visit in November 2010, the VISN required that surgeons not be 

allowed to perform procedures they had not been granted privileges for, and that action 

be taken to improve the privileging processes at the facility. The VISN also provided 

education regarding privileging processes to the facility. VISN staff conducted another 

site visit in July 2011, and recommended that surgical core privileges be reviewed and 

revised. 

Issue 2: Resident Supervision 

We substantiated the allegation that a specialty surgery service’s residents were not 

supervised appropriately. We found that residents were seeing patients at the facility 2 

days per week without a supervising attending physician (SA) with them in the clinic. 

We also found that the facility policy did not define the timeframe for documentation of 

resident supervision by the SA in the patients’ medical records. 

Onsite Supervision 

In the outpatient setting, surgeons see patients in the clinic for consultation, follow-up, 

and invasive procedures. The facility currently employs one full-time and three part-time 

surgeons in the specialty service to meet patient care needs, including supervision of 

residents rotating through this specialty. While there are two residents at the facility 

during an academic year, the residents rotate monthly so there is only one resident 

assigned at a time. 

VHA Policy8

requires that when residents are working in an outpatient clinic, a 

supervising practitioner must be physically present during clinic hours. We reviewed the 

specialty service surgeons’ work schedules for the last 24 months. The only full-time 

specialty surgeon on staff has been on extended leave for several months. One part-time 

surgeon works at a Community Based Outpatient Clinic and is onsite at the facility 1 

half-day per month. The remaining two part-time surgeons work at the facility on 

Mondays, Tuesdays, and Thursdays. There is no SA present in the clinic when residents 

are seeing patients on Wednesdays and Fridays. 

8 VHA Handbook 1400.1, Resident Supervision, July 27, 2005. 

VA Office of Inspector General 4 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

The facility’s attempts to recruit additional specialty service surgeons were unsuccessful. 

As a result, on the days in which a surgeon was not on site, procedure clinics were 

cancelled and the residents were only allowed to perform pre-operative assessments 

(history and physicals) and post-operative follow-up visits. Both of the specialty service 

residents currently assigned to the facility are 2nd year residents and clinical leadership 

told us they thought these arrangements would be commensurate with the residents’ level 

of training and experience. Although changes were made in services offered on days in 

which no surgeon was onsite, the facility was not in compliance with the VHA resident 

supervision policy. 

Documentation of Resident Supervision 

VHA policy9 permits four ways to document resident supervision in the medical record: 

1. The SA writes a progress note of his own along with the resident’s note. 

2. The SA writes an addendum to the resident’s note. 

3. The SA co-signs the resident’s note, which implies that the SA is in agreement 

with the content (absent an addendum to the contrary). 

4. The resident includes specific verbiage in the note, such as, “I have seen and 

discussed the patient with my supervising practitioner Dr. [X], and Dr. [X] agrees 

with my assessment and plan.” 

Facilities are also required to determine acceptable timeframes for documentation of 

resident supervision and this should be included in local policy. We reviewed the 

facility’s local policies and found that no such timeframes were defined. However, the 

Chief of Surgery told us that she expected documentation of resident supervision to occur 

within 24 hours. The Chief of Staff and Associate Chief of Staff for Education stated that 

they expected this documentation to occur within 48 hours, or 72 hours if over a 

weekend. 

We found that, generally, the facility relied on SA co-signature of residents’ entries into 

the medical record to document resident supervision. We randomly selected 50 patients 

seen in the Specialty Resident Clinic between October 1, 2010 and March 31, 2011. We 

reviewed the 50 progress notes associated with these clinic appointments. Only 25 of the 

50 notes were co-signed within 48–72 hours; 5 of the 25 notes were not co-signed for 

over a week. These progress notes were not visible in the medical record until they were 

co-signed; therefore, other staff involved in the care of these patients could have 

experienced delays in accessing important clinical information. 

9 VHA Handbook 1400.1. 

VA Office of Inspector General 5 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

VHA policy10 states that when pre-operative assessments are completed by residents, a 

co-signature by the SA is not sufficient. The SA must write his own note or addendum 

describing findings, diagnosis, plan for treatment, and/or choice of procedure to be 

performed. We found that the specialty SAs did not complete pre-operative 

documentation in the patients’ medical records as required. Of the 50 medical records we 

reviewed, 31 had a pre-operative assessment (history and physical report) completed by a 

specialty resident. We found that none of the 31 records contained the required SA 

progress note or addendum. 

Issue 3: Pre-Operative Documentation 

Although not one of the complainant’s allegations, we found deficiencies in required preoperative documentation by the specialty surgeons. 

Per VHA policy11 and Joint Commission standards, an “interval note” must be completed 

immediately prior to any operative procedure by a physician indicating that the 

information in the previous notes is still accurate, an appropriate assessment was 

completed prior to surgery, the patient still requires the procedure, and that the patient’s 

condition has not changed. 

We reviewed the medical records of 31 patients who had surgery in the OR between 

October 1, 2010 and April 30, 2011. In 15 (48 percent) of the 31 records we reviewed, 

there was no interval note as required. 

Conclusions 

We substantiated the allegation that some surgeons performed operative procedures that 

were not on their PSB approved privilege list. We substantiated the allegation that 

residents were not supervised as required while they were seeing patients in the clinic. 

We found that facility policy did not define timeframes for documentation of resident 

supervision as required, and progress notes were not co-signed in a timely manner. We 

also found that required additional pre-operative assessment documentation was not 

completed by attending surgeons. We found that surgeons did not complete interval 

notes immediately prior to an operative procedure as required. 

Recommendations 

Recommendation 1. We recommended that the Medical Center Director ensure that 

privileges are appropriate for the procedures being done and that compliance with this be 

monitored. 

10 VHA Handbook 1400.1 and VHA Handbook 1907.01, Health Information Management and Health Records,
 

August 25, 2006.

11 VHA Handbook 1400.1 and VHA Handbook 1907.01
 

VA Office of Inspector General 6 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Recommendation 2. We recommended that the Medical Center Director ensure that 

residents have onsite supervision as required. 

Recommendation 3. We recommended that the Medical Center Director ensure that the 

resident supervision policy defines timeframes for the documentation of supervision as 

required. 

Recommendation 4. We recommended that the Medical Center Director ensure that 

pre-operative documentation is completed as required and that compliance with this be 

monitored. 

Comments 

The Veterans Integrated Service Network and Medical Center Directors concurred with 

our findings and recommendations and provided acceptable action plans. See 

Appendixes A and B, pages 8–13, for the full text of the Directors’ comments. We will 

follow up on the planned actions until they are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 7 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 17, 2011 

From: Director, VA Mid-Atlantic Health Care Network (10N6) 

Subject: Healthcare Inspection – Surgeon Privileging and Resident 

Supervision Issues, W. G. (Bill) Hefner VA Medical Center, 

Salisbury, North Carolina 

To: Associate Director, Bay Pines Office of Healthcare 

Inspections (54SP) 

Thru: Director, VHA Management Review Service (10A4A4) 

1. The attached subject report is forwarded for your review and 

further action. I have reviewed the responses and concur with the 

facility’s recommendations. 

2. Please contact Paul Russo, Director, W. G. (Bill) Hefner VA 

Medical Center at (704) 638-3344 if you have any further questions. 

DANIEL F. HOFFMAN, FACHE 

Network Director, VISN 6 

VA Office of Inspector General 8 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 4, 2011 

From: Director, W. G. (Bill) Hefner VA Medical Center (659/00) 

Subject: Healthcare Inspection – Surgeon Privileging and Resident 

Supervision Issues, W. G. (Bill) Hefner VA Medical Center, 

Salisbury, North Carolina 

To: Director, VA Mid-Atlantic Healthcare Network (10N6) 

1. I have reviewed the draft report of the Office of Inspector General 

and I concur with the recommendations. 

2. I have included my response in the attached Director’s Comments. 

3. Please contact me if you have any questions or comments. 

Paul M. Russo, MHSA, FACHE, RD
 

Director, W. G. (Bill) Hefner VA Medical Center (659/00)
 

VA Office of Inspector General 9 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation 1. We recommended that the Medical Center Director 

ensure that privileges are appropriate for the procedures being done and that 

compliance with this be monitored. 

Concur Target Completion Date: August 19, 2011 

Facility’s Response: 

Based upon recommendations from the VISN review of Surgery Service 

that occurred in November 2010, and in consultation with the VHA 

Director of Quality Standards, privilege forms for general surgery, urology 

and orthopedics were revised. The two surgeons identified operating 

outside of approved privileges in this time frame were appropriately 

suspended until cases were reviewed and surgeons cleared to return to duty. 

All surgical section chiefs reviewed these revised privilege forms with the 

surgeons to ensure understanding and clarity. 

Completed 

Under the direction of the Chief of Staff, the Professional Standards Board 

(PSB) was restructured to include critical stakeholders and ensure a 

quorum. At the request of the Medical Center Director, all PSB members 

completed re-education on credentialing & privileging and the quality of 

the PSB minutes has been improved to accurately and comprehensively 

address actions and decisions made by the PSB. 

Completed 

In May 2011, the new Chief of Surgery arrived at Salisbury VAMC. To 

further improve the privilege form, the Medical Center Director directed the 

Chief of Surgery to re-write the privilege forms for each surgical specialty. 

To ensure accuracy, these forms will be reviewed and concurred upon by 

the Chief of Surgery, section chiefs, surgeons, the OR Nurse Manager, and 

the Office of Performance and Quality prior to being presented to the PSB 

for approval. 

Target Date: August 19, 2011 

VA Office of Inspector General 10 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

To ensure compliance, each morning the Chief of Surgery reviews the 

surgery schedule with the OR Nurse Manager and signs the schedule to 

indicate concurrence. Prior to each surgery, the OR Nurse Manager 

validates that the procedure to be performed is on the surgeon’s approved 

privilege list. This is then documented and maintained in the Surgery 

Clinic. In addition, the Medical Center Director instructed the Office of 

Performance and Quality staff to conduct random audits of this process to 

monitor compliance. Random audits have been completed since January 

2011 and any questions are immediately discussed with the Chief of 

Surgery. To date, no outliers have been identified and all surgeons have 

been fully compliant. 

Completed/Ongoing 

The primary surgeon of concern with 17 instances of performing 

procedures outside of his privileges is currently under a 120-day Focused 

Professional Practice Evaluation (FPPE) that was established in 

consultation with the VHA Director of Quality Standards. The PSB is 

reviewing the FPPE documentation at 30 day intervals. 

Target Date: September 30, 2011 

The Medical Center Director has also instructed leadership to evaluate and 

strengthen staff performance standards related to credentialing and 

privileging requirements in order to maintain accountability for adherence 

to relevant policy and procedures. 

Target Date: October 30, 2011 

Recommendation 2. We recommended that the Medical Center Director 

ensure that surgical service residents have onsite supervision as required. 

Concur Target Completion Date: September 15, 2011 

Facility’s Response: 

On May 12, 2011, immediately following receipt of guidance from the OIG 

inspectors, clinical leadership assigned a supervising attending physician 

(SA) to provide onsite supervision of the residents in the clinic. The 

surgeon who had been on military leave returned to work and since July 6, 

2011, has provided onsite supervision of the residents in the clinic. 

Completed 

Should a situation arise where the SA is unavailable, resident supervision 

will be halted and patients will be reassigned to another provider if possible 

and fee basis authorization will be considered based upon clinical urgency. 

If another provider is not available and there is no clinical urgency, clinics 

will be cancelled until such time that a SA is available to provide onsite 

VA Office of Inspector General 11 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

supervision. Staff from the Office of Performance and Quality will conduct 

weekly random audits in all areas with residents to determine the presence 

of an onsite supervisor with the residents. Any instance of non-compliance 

will immediately be reported to the Chief of Staff and the Medical Center 

Director. This will be monitored for 6 months at which time the process 

will be reassessed for continuation or modification. 

The Medical Center Director has instructed the Chief of Staff and Associate 

Chief of Staff for Research and Education to review compliance with 

resident supervision requirements with all clinical department chiefs. All 

clinical department chiefs will review these requirements with their staff. 

Target Date: September 15, 2011 

Recommendation 3. We recommended that the Medical Center Director 

ensure that the resident supervision policy defines timeframes for the 

documentation of supervision as required. 

Concur Target Completion Date: Completed 

Facility’s Response: 

The Medical Center Director has ensured that the documentation of 

supervision of residents is in compliance with VHA Handbook 1400.1, 

“Resident Supervision.” According to Handbook 1400.1, the timeframe 

given to the supervising attending physician for co-signing the residents’ 

progress notes, consultations, and reports is delineated in local facility 

policy or local medical staff bylaws. The timeframe for documentation of 

resident supervision has been added to the Salisbury VA Medical Center 

medical staff bylaws and these bylaws were approved on June 30, 2011. 

To monitor compliance, Research and Education staff will perform fifteen 

monthly reviews of surgical residents’ and thirty quarterly reviews of all 

non-surgical residents’ documentation to determine timeliness of the SA 

physician’s co-signature. Results of this monitoring will be reported to the 

Clinical Executive Board. This will be monitored for 6 months at which 

time the process will be reassessed for continuation or modification. 

Recommendation 4. We recommended that the Medical Center Director 

ensure that pre-operative documentation is completed as required and that 

compliance with this be monitored. 

Concur Target Completion Date: Completed 

Facility’s Response: 

VA Office of Inspector General 12 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

The Medical Center Director has directed the Chief of Surgery to instruct 

all surgeons to complete all pre-operative documentation for all cases. The 

Chief of Surgery sent an electronic memorandum to all surgeons on August 

8, 2011, with a read receipt. The topic of completing pre-operative 

documentation was discussed at the May 19, 2011 surgery staff meeting 

and was also added to the agenda for the surgery staff meeting scheduled 

August 11, 2011. 

Monitoring is completed by peers during the clinical pertinence reviews, of 

which 10 are completed each quarter. The results of these reviews are 

reported to the PSB every 6 months. In addition, the Chief of Surgery will 

complete medical record reviews for 50 percent of all surgical cases for the 

History and Physical update and 50 percent of all urology cases to validate 

compliance with weekly reports to the Chief of Staff and monthly reports to 

the Clinical Executive Board. This monitor will continue for 6 months to 

ensure compliance and will be reported to the Chief of Staff. At that time, 

the monitoring will be reassessed for continuation or modified if needed. 

Should there be a lack of compliance with pre-operative documentation, the 

Chief of Surgery will identify the outliers and meet with those individuals 

to review the importance of this documentation. The results of individual 

surgeons’ pre-operative documentation will be reflected in their 

performance appraisals. 

VA Office of Inspector General 13 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix C 

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	 Carol Torczon, ACNP, Associate Director, Project Leader 

Karen McGoff-Yost, LCSW, Team Leader 

Robert Yang, MD 

VA Office of Inspector General 14 
Surgeon Privileging and Resident Supervision Issues, W. G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Mid-Atlantic Health Care Network (10N6) 

Director, W. G. (Bill) Hefner VA Medical Center (659/00) 

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 

US Senate: Richard Burr, Kay Hagan 

U.S. House of Representatives: Virginia Foxx, Larry Kissell, Patrick T. McHenry, 

Melvin L. Watt 

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

VA Office of Inspector General 15