Office of Healthcare Inspections

HEALTHCARE INSPECTION REPORT #19-00004-187 AUGUST 8, 2019

VETERANS HEALTH ADMINISTRATION 

Alleged Delay in Surgical 

Care, Lack of Resident 

Oversight, and Improper 

Physician Pay at the Edward 

Hines, Jr. VA Hospital

Hines, Illinois
In addition to general privacy laws that govern release of medical 

information, disclosure of certain veteran health or other private 

information may be prohibited by various federal statutes including, but not 

limited to, 38 U.S.C. §§ 5701, 5705, and 7332, absent an exemption or other 

specified circumstances. As mandated by law, the OIG adheres to privacy 

and confidentiality laws and regulations protecting veteran health or other 

private information in this report.

Report suspected wrongdoing in VA programs and operations 

to the VA OIG Hotline:

www.va.gov/oig/hotline

1-800-488-8244

The mission of the Office of Inspector General is to 

serve veterans and the public by conducting effective 

oversight of the programs and operations of the 

Department of Veterans Affairs through independent 

audits, inspections, reviews, and investigations.
``

VA OIG 19-00004-187 | Page i | August 8, 2019

Alleged Delay in Surgical Care, Lack of Resident 

Oversight, and Improper Physician Pay at the Edward 

Hines, Jr. VA Hospital, Hines, Illinois

Executive Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the 

validity of allegations regarding a delay in surgical care, lack of resident oversight, and improper 

physician pay at the Edward Hines, Jr. VA Hospital, Hines, Illinois (facility).

On June 25, 2018, the OIG received allegations from a confidential complainant. The 

complainant alleged a delay in performing an appendectomy, that the delay in performing this 

appendectomy was caused in part by inadequate resident oversight, and that surgeons paid by the 

VA were unavailable because they were also working for other institutions.

1

The OIG substantiated that a delay of approximately three hours occurred in performing an 

appendectomy on a patient, but the delay did not result in an adverse event.

2 The OIG team 

determined the delay was due to another patient requiring surgery more urgently and poor

communication.

In spring 2018, the patient presented to the facility’s emergency department at 9:00 p.m. (Day 1) 

with uncomplicated appendicitis, and an operative intervention was planned for the following 

day as an add-on to the surgical schedule.

3 The OIG determined that the patient received 

appropriate preoperative monitoring and care and found no evidence of an adverse event.

During the working week, the number of operating rooms (ORs) at the facility decreases from 

six to two at 3:00 p.m. and from two to one at 5:00 p.m. After 3:00 p.m., the scheduling of 

surgical cases is determined by the requesting surgeon and anesthesiologists and is based on the 

patient’s condition. Around 3:00 p.m. on Day 2, one of the two ORs was occupied with a 

scheduled surgery. The other OR was needed for an unscheduled urgent surgery. This resulted in 

a surgical delay of approximately three hours for the patient with appendicitis. At 6:45 p.m., the 

patient underwent an appendectomy in the available OR.

From admission to surgery, there were two hand-offs in the patient’s care that involved the Chief 

Resident and three general surgery attendings.4 The first hand-off was between the on-call 

surgeon, Chief Resident, and day surgeon. The day surgeon informed the OIG that the Chief 

 

1 An appendectomy is the surgical removal of an infected appendix. An appendix is a finger-like sac attached to the 

lower end of the large intestine.

2 The Joint Commission defines an adverse event as a as “a patient safety event that resulted in harm to a patient.”

3 Appendicitis is infection of the appendix.

4 The three general surgery attending physicians involved in the patient’s care were the on-call surgeon who worked 

from 6:00 p.m. Day 1 until 6:00 a.m. Day 2; the day surgeon who worked from 6:00 a.m. to approximately 6:00 p.m. 

Day 2; and the surgeon of record who started work at 6:00 p.m. Day 2. Attending surgeons are senior physicians 

who provide supervision to physician’s trainees. https://www.merriam-webster.com/dictionary/attending. VHA 

Handbook 1400.01, Resident Supervision, December 19, 2012.
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Resident did not discuss the add-on surgery, and the day surgeon reported being unaware that the 

surgical case had been added to the schedule.5 The second hand-off was between the Chief 

Resident and surgeon of record. The surgeon of record informed the OIG that the Chief Resident 

initially stated that the urgent surgery would last approximately three hours and to arrive around 

8:00 p.m. for the appendectomy. Later, the surgeon of record stated being informed by the Chief 

Resident that the urgent surgery ended early, but the surgeon of record did not need to come in 

earlier than planned. Poor communication between the residents and the surgeons contributed to 

the delay in surgery.

The Joint Commission requires that processes be in place to communicate patient information 

when transitioning the patient from one clinical area to another clinical area.6 Although not an 

allegation and not a Veterans Health Administration requirement, the OIG identified that the 

facility’s practice for scheduling surgeries did not address communication among key staff 

during the multiple steps between identifying the need for surgery and the time of surgery. The 

OIG noted that opportunities existed for facility leaders to evaluate the need for, and implement 

as necessary, communication improvements between residents and surgeons.

The OIG did not substantiate that the patient’s appendectomy was delayed because of inadequate 

resident oversight. Staff interviews and electronic health record documentation confirmed that

general surgery attendings were available at all hours to provide resident supervision, discuss 

patients, and were present in the OR during surgeries.

While most facility surgeons on staff also worked at other institutions, the OIG team was unable 

to determine the availability of surgeons or if they were working at other institutions while being 

paid to work at the facility. The facility had a process in place to document physician hours 

worked; however, a staff member reported there was no verification process to monitor if 

surgeons’ timecards matched actual hours worked. The OIG confirmed that discrepancies existed 

during a review of the general surgeons’ reported hours worked and their timecards for May 

2018. When asked, the facility indicated that documentation was not maintained detailing parttime physicians’ tours of duty or responsibilities.

The Veterans Integrated Service Network (VISN) Fiscal Quality Assurance Manager also 

conducted a review of part-time physician hours and written agreements and determined that the 

facility did not maintain appropriate documentation to verify and validate individual physician

work schedules and payments. The VISN Fiscal Quality Assurance Manager made two 

 

5 The OIG could not confirm this statement as at the time of the site visit. The Chief Resident had completed 

residency training, was no longer employed by the facility, and was not available for an interview. 

6 The Joint Commission is an independent, not-for-profit organization that accredits and certifies nearly 21,000 

health care organizations and programs in the United States. 

https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx. (This website was accessed on 

March 7, 2019.)
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recommendations for the facility to address within six months but did not provide a date for 

VISN follow-up.

The OIG made two recommendations to the Facility Director to evaluate the surgery scheduling 

practices and processes, and to ensure documentation for part-time physicians’ tours of duty and 

responsibilities for time and attendance.

Comments

The Veterans Integrated Service Network and Facility Directors concurred with the 

recommendations and provided an acceptable action plan. (See appendixes A and B, pages 11–

14 for the Directors’ comments.) The OIG considers all recommendations open and will follow 

up on the planned and recently implemented actions to ensure that they have been effective and 

sustained.

JOHN D. DAIGH, JR., MD

Assistant Inspector General

for Healthcare Inspections
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Contents

Executive Summary......................................................................................................................... i

Abbreviations...................................................................................................................................v

Introduction......................................................................................................................................1

Scope and Methodology ..................................................................................................................3

Patient Case Summary .....................................................................................................................4

Inspection Results............................................................................................................................5

1. Delay in Performing an Appendectomy on a Patient..............................................................5

2. Alleged Delay in Patient’s Surgery Related to Resident Oversight........................................7

3. Surgeons Allegedly Paid by VA while Working for Other Institutions .................................8

Conclusion .......................................................................................................................................9

Recommendations 1–2...................................................................................................................10

Appendix A: VISN Director Comments........................................................................................11

Appendix B: Facility Director Comments.....................................................................................12

OIG Contact and Staff Acknowledgments ....................................................................................15

Report Distribution ........................................................................................................................16
Alleged Delay in Surgical Care, Lack of Resident Oversight, and Improper Physician Pay

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VA OIG 19-00004-187 | Page v | August 8, 2019

Abbreviations

EHR electronic health record

OIG Office of Inspector General

OR operating room

VHA Veterans Health Administration

VISN Veterans Integrated Service Network
Alleged Delay in Surgical Care, Lack of Resident Oversight, and Improper Physician Pay

at the Edward Hines, Jr. VA Hospital, Hines, Illinois

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Introduction

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the 

validity of allegations regarding a delay in surgical care, lack of resident oversight, and improper 

physician pay at the Edward Hines, Jr. VA Hospital, Hines, Illinois (facility).

Facility Background

The facility is part of Veterans Integrated Service Network (VISN) 12, and offers inpatient and 

outpatient primary, specialty, and surgical care services. VA classifies the facility as a Level 1a

high complexity, with an assigned operative complexity level of complex.

7 From October 2017 

through September 2018, the facility served 58,208 patients and had a total of 483 hospital 

operating beds, including 248 inpatient beds, 210 community living center beds, and 25 

domiciliary beds. The facility operates six VA community based outpatient clinics located in 

Bourbonnais (Kankakee Clinic), Oak Lawn, Aurora, Hoffman Estates, Peru (LaSalle Clinic), and 

Joliet, Illinois. The facility is affiliated with Loyola University of Chicago, Stritch School of 

Medicine (Loyola), and University of Illinois College of Medicine, Chicago.

Appendicitis

Appendicitis refers to infection of the appendix, a finger-like sac attached to the lower end of the 

large intestine.8

If left untreated, appendicitis can progress, resulting in perforation of the 

appendix and spread of infection into the abdomen. This is known as complicated appendicitis. 

Treatment of uncomplicated (non-perforated) appendicitis is controversial. The current standard 

approach to appendicitis requires surgery to prevent uncomplicated appendicitis from developing 

into complicated appendicitis. However, emerging literature suggests that some patients treated 

with antibiotics may improve without needing an appendectomy.

 

7 The VHA Facility Complexity Model categorizes medical facilities based on “patient population, clinical services 

offered, educational and research missions, and administrative complexity.” Complexity Levels include 1a, 1b, 1c, 

2, or 3, with Level 1a facilities being the most complex and Level 3 facilities being the least complex. Office of 

Quality, Safety, and Value. 2012 VHA Facility Quality and Safety Report. 

https://www.va.gov/health/docs/2012_vha_facility_quality_and_safety_report_final508.pdf. (The website was 

accessed February 27, 2019.)

8 National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases, NIH Publication 

No. 13-4547, Appendicitis, September 2013.
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The timing of surgery for patients with uncomplicated appendicitis is dependent on the stability 

of the patient and the availability of a staffed operating room (OR). The literature varies in terms 

of the optimal timing of surgery for uncomplicated appendicitis.9

Allegations

On June 25, 2018, the OIG received allegations from a confidential complainant regarding a 

delayed surgery at the facility in spring 2018. The complainant made three allegations:

· There was a delay in performing an appendectomy on a patient.

· The delay in the patient’s surgery was due in part to inadequate oversight processes for 

residents.

· Surgeons are paid by the VA while working for other institutions.

 

9 Smink, Douglas et al, Management of Acute Appendicitis in Adults, UpToDate, December 5, 2018, 

https://www.uptodate.com/contents/management-of-acute-appendicitis-in-adults. (The website was accessed on 

February 14, 2019.) Kim, Maru, et al, Effect of Surgical Timing and Outcomes for Appendicitis Severity, ASTR, July 

21, 2016 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4961891/. (The website was accessed on November 26, 

2018.) Drake, Fredrick Thurston et al, Time to Appendectomy and Risk of Perforation in Acute Appendicitis, JAMA 

Surgery, August 2014, Vol. 149, Number 14, https://www.ncbi.nlm.nih.gov/pubmed/24990687. (The website was 

accessed on November 26, 2018.) Bhangu, Aneel et al, Safety of Short, In-Hospital Delays Before Surgery for Acute 

Appendicitis, Annals of Surgery, Volume 259, Number 5, May 2014, www.annalsofsurgery.com. (The website was 

accessed on November 26, 2018.) Eko, Frederick et al, Ideal Timing of Surgery for Acute Uncomplicated 

Appendicitis, January 2013, North American Journal of Medical Sciences, volume 5(1), 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560134/. (The website was accessed on November 26, 2018.) 

Abou-Nukta, Fadi et al, Effects of Delaying Appendectomy for Acute Appendicitis for 12 to 24 Hours, May 2006, 

AMA. https://jamanetwork.com/journals/jamasurgery/fullarticle/398369. (The website was accessed on November 

26, 2018.)
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Scope and Methodology

The OIG initiated the healthcare inspection on September 28, 2018, and conducted an onsite visit 

November 13–16, 2018.

The OIG team interviewed the complainant; VISN Fiscal Quality Assurance Manager; Chief of 

Staff; Associate Director for Patient Care Services; Chiefs of Surgery, Anesthesiology, and 

emergency department; Director of Academic Affiliations; general surgery attendings and

residents; the OR Nurse Supervisor and nurses; and other relevant staff.

The period of data review for this report was May 2018 through March 2019. The OIG team 

reviewed the patient’s electronic health record (EHR), relevant medical literature, relevant 

Veterans Health Administration (VHA) and facility policies, relevant Joint Commission

standards, patient safety reports, physician timecards and schedules, OR schedules, and 

applicable committee meeting minutes.

In the absence of current VA or VHA policy, the OIG considered previous guidance to be in 

effect until superseded by an updated or recertified directive, handbook, or other policy 

document on the same or similar issue(s).

The OIG substantiates an allegation when the available evidence indicates that the alleged event 

or action more likely than not took place. The OIG does not substantiate an allegation when the 

available evidence indicates that the alleged event or action more likely than not did not take 

place. The OIG is unable to determine whether an alleged event or action took place when there 

is insufficient evidence.

The OIG conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and Efficiency.
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Patient Case Summary

The patient, in their 30s, presented to the facility’s emergency department at 9:00 p.m. on Day 1, 

complaining of lower abdominal pain of several hours.10 The emergency department physician 

noted the patient had right lower abdominal tenderness on palpation but did not have a fever. A 

computerized tomography (CT) scan was obtained and showed “early acute appendicitis” 

without perforation of the appendix.11

The patient was admitted to the facility at 12:33 a.m. on Day 2, under the care of the General 

Surgery Service. A general surgery resident (initial surgical resident) evaluated the patient at 

1:55 a.m. and noted an elevated white blood cell count and a CT finding consistent with 

non-perforated appendicitis. The initial surgical resident documented the surgery was

“non-emergent.”12

The initial surgical resident discussed the risks and benefits for antibiotic therapy versus 

appendectomy with the patient. The patient opted for appendectomy, which included the 

administration of preoperative antibiotics.

13 The initial surgical resident reviewed the patient’s 

case with the Chief Resident and the general surgery on-call surgeon (on-call surgeon), with a 

plan for an “early add-on appendectomy.”

14 Overnight, the patient remained without a fever and 

reported pain scores in the mild to moderate range, requiring only one dose of pain medication.

A second general surgery resident (day surgical resident) completed a preoperative scheduling 

worksheet at 7:44 a.m. on Day 2. This worksheet noted discussion and approval by the oncoming 

general surgeon (day surgeon) to add the patient to the day surgeon’s OR surgery schedule for 

that day with the Chief Resident assisting in the surgery.15

Throughout the day, the patient remained without fever and did not require pain medication. The 

patient was transferred to the preoperative surgical area (pre-op) at 2:30 p.m.

16 Concurrently to 

the patient arriving in the pre-op area, an unscheduled urgent surgery was added to the schedule 

 

10 The OIG uses the singular form of they (their/them) to protect the patient’s privacy.

11 CT is radiographic imaging using cross sectional images. https://www.merriamwebster.com/dictionary/computerized%20tomography. (The website was accessed on February 26, 2019.)

12 Non-emergent means not needing immediate attention. https://www.merriamwebster.com/dictionary/emergent#synonyms. (The website was accessed on February 14, 2019.)

13 Pre-operative or prophylactic antibiotics are important for preventing wound infection and abscesses following an 

appendectomy. https://journals.sagepub.com/doi/10.1177/1457496913497433. (The website was accessed on March 

7, 2019.)

14 The on-call surgeon was on call from 6:00 p.m. Day 1 to 6:00 a.m. Day 2.

15 The day surgeon had three scheduled surgeries on the day in question beginning at 7:30 a.m., 9:46 a.m., and 12:45 

p.m.

16 Pre-op is a holding area where patients are prepped for surgery.
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at 2:24 p.m. for the available OR. The unscheduled urgent surgery took precedence over the nonemergent appendectomy and was expected to take approximately three hours. At 6:45 p.m., the 

patient underwent an appendectomy. The surgery was performed by an on-call general surgeon

(surgeon of record).

17 No complications were noted. The patient did well post-operatively and 

was discharged to home on Day 3.

Inspection Results

1. Delay in Performing an Appendectomy on a Patient

The OIG substantiated that a delay occurred in performing an appendectomy on a patient, but the 

delay did not result in an adverse event.18 The OIG team determined the delay was due to another 

patient requiring surgery more urgently and poor communication between residents and 

attending surgeons. The OIG determined that the patient received appropriate preoperative 

monitoring and care. However, the OIG found that opportunities existed for facility leaders to 

evaluate the need for, and implement as necessary, communication improvement between 

residents and attending surgeons.

Urgent Surgery

Facility staff informed the OIG team that OR availability and staffing changed from 

accommodating six ORs to two ORs at 3:00 p.m. and from two ORs to one OR at 5:00 p.m. 

Surgeries starting after 3:00 p.m. are scheduled as determined by the requesting surgeon and 

anesthesiologists and are scheduled based on the patient’s condition.

The OIG confirmed that on Day 2, a scheduled surgery began at 3:09 p.m. and was completed at 

4:16 p.m. in one of the two available ORs.19 Concurrently to the patient with appendicitis 

arriving in the pre-op area at 2:20 p.m., an unscheduled urgent surgery was added to the schedule 

at 2:24 p.m. for the other available OR. The unscheduled urgent surgery took precedence over 

the non-emergent appendectomy and was expected to take approximately three hours. This 

postponed the start time for the appendectomy until an OR and staff became available.

Communication Concerns

Although the Joint Commission requirements are not specific to the OR, the Joint Commission 

requires that processes be in place to communicate patient information, and during transitions in 

 

17 The surgeon of record started work at 6:00 p.m. on Day 2.

18 The Joint Commission defines an adverse event as “a patient safety event that resulted in harm to a patient.”

19 Although the surgery ended at 4:16 p.m., the OR would have had to be cleaned, reconfigured, and staffed prior to 

initiating the next surgery.
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care, hand-off communication allows for discussions between the giver and the receiver.20

Communication among healthcare providers is essential to delivering quality care. The OIG team 

identified poor communication between the residents and attending surgeons.

Communication between Residents and Attending Surgeons

According to the EHR, the initial surgical resident assessed the patient and documented on Day 

2, at 1:55 a.m. that the patient’s condition was consistent with “early acute appendicitis.” The 

initial surgical resident documented that the on-call surgeon and the Chief Resident agreed to add

the patient to the surgery schedule for an appendectomy. At 7:44 a.m., the day surgical resident

completed the preoperative scheduling worksheet and documented that the patient’s surgery was 

discussed with and approved by the day surgeon and the Chief Resident, both of whom would be 

performing the appendectomy. A nurse stated that the preoperative scheduling worksheet was 

printed to the OR where the charge nurse and anesthesiologist added the appendectomy to the 

schedule for approximately 2:15 p.m., to follow the day surgeon’s scheduled surgeries.

Contrary to both the initial and day surgical residents’ documentation in the EHR, the day

surgeon reported to the OIG being unaware that the patient’s appendectomy had been listed as an 

add-on surgery. The day surgeon stated that the Chief Resident did not discuss the add-on 

surgery. The day surgeon reported leaving the OR around 3:30 or 4:00 p.m.21 The day surgeon 

told the OIG that another surgery could have been “bumped” [moved to a later time] to 

accommodate the patient's add-on appendectomy. The OIG found no evidence that the OR staff 

tried to contact the day surgeon about the add-on appendectomy. Also contrary to the EHR 

documentation, the OR schedule and interviews with staff indicated that the Chief Resident was

performing another surgery and was unavailable to perform the add-on appendectomy. The poor 

communication between the residents and the attending surgeons about the add-on surgical case,

as well as the lack of a closed loop communication in which the day surgeon would have 

acknowledged the add-on surgical case, contributed to the delay in surgery.

22

 

20 The Joint Commission is an independent, not-for-profit organization that accredits and certifies nearly 21,000 

health care organizations and programs in the United States. 

https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx. (This website was accessed on 

March 7, 2019.)

21 The OIG could not confirm this statement as, at the time of the site visit, the Chief Resident had completed 

residency training, was no longer employed by the facility, and was not available for an interview. 

22 According to The Joint Commission, closed loop communication is the exchange of information between a sender 

and a receiver and usually includes acknowledging the receipt of information and verifying with the sender that 

information received is the same as the intended information. David P. Baker, Ph.D. et al, “The Role of Teamwork 

in the Professional Education of Physicians: Current Status and Assessment Recommendations,” The Joint 

Commission Journal on Quality and Patient Safety 31, no.4 (April 2005): 185-202.
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Surgery Scheduling

The OIG team requested a copy of the facility policy for OR scheduling and received an 

unsigned copy of a document titled Operating Room Policy and Procedure: Scheduling. The 

document provided was not a facility-wide policy but labeled an OR policy and procedure with a 

signature line for the clinical nurse manager; it was dated/revised in May 2007 and last reviewed 

in 2009. The document provided guidelines for requesting add-on elective surgeries stating 

“complete the add-on scheduling worksheet and print to the OR office. The OR scheduler, CN 

[charge nurse] or clinical director must be contacted by the service...the request will be either 

denied or accepted. If the case [surgery] is accepted, the add-on will be added to the OR 

schedule.”

The OIG substantiated through interviews that the add-on process was consistent with the above 

policy guidelines. When scheduling a surgery, surgical residents were responsible for evaluating 

the patient, discussing the surgery with the Chief Resident and attending surgeon, completing the 

preoperative scheduling worksheet, and sending it to the OR. The Chief Resident was 

responsible for identifying and coordinating with an available attending surgeon.

23 The OR 

charge nurse and anesthesiologist determined the room and staff availability before adding the 

surgery to the schedule.

The OR scheduling document provided by the facility does not address a closed loop 

communication to confirm or notify the identified attending surgeon of the acceptance and time 

of the add-on surgery.

2. Alleged Delay in Patient’s Surgery Related to Resident Oversight

The OIG did not substantiate that the patient’s appendectomy was delayed because of inadequate 

resident oversight.

The VHA handbook on resident supervision states “[i]n a health care system where patient care 

and the training of health care professionals occur together, there must be a clear delineation of 

responsibilities to ensure that qualified practitioners provide patient care, whether they are 

trainees or full-time staff. As resident trainees acquire the knowledge and judgment that accrue 

with experience, they are allowed the privilege of increased authority for patient care.”24

 

23 Attending surgeons are senior physicians who provide supervision to physician’s trainees. https://www.merriamwebster.com/dictionary/attending. VHA Handbook 1400.01, Resident Supervision, December 19, 2012. This VHA 

Handbook was scheduled for recertification on or before the last working day of December 2017 but has not been 

recertified.

24 VHA Handbook 1400.01.
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VHA requires that the patient’s EHR contain documentation of resident supervision by the 

attending physician. This is achieved through a progress note in the patient’s EHR written by the 

attending physician; an addendum to the resident note by the attending physician; the attending 

physician co-signing a resident’s note; or the resident documenting in the progress note the name 

of the attending physician with whom the resident discussed the patient and that the attending 

physician is agreeable with the assessment and treatment plan.

25 In addition, VHA requires 

attending physicians to be physically present in the OR.

26

The OIG confirmed that the EHR of the patient at issue contained the co-signatures of the 

attendings to the residents’ notes, and the attendings entered an addendum to the residents’ notes 

verifying agreement with the care documented and provided by residents.

3. Surgeons Allegedly Paid by VA while Working for Other Institutions

While most facility surgeons on staff also worked at other institutions, due to discrepancies in 

timecards and lack of documentation outlining the tour of duty for part-time physicians, the OIG 

team was unable to determine the availability of surgeons or whether they were paid consistent 

with the hours reflected on their timecards. The facility did not maintain documents outlining 

tours of duty.

VHA allows for part-time physicians to work either fixed or adjustable work hours.

27 Part-time 

physicians on fixed tours have an agreed upon tour of duty that remains constant. Although the 

facility reported not having any part-time physicians with adjustable work hours in the Surgery 

Service, the OIG concluded that the general surgery part-time physicians were functioning as if 

they had adjustable work schedules. The part-time physicians did not consistently work specific 

days or hours.

Upon review of the Surgical Service May 2018 schedules and timecards, the OIG noted the days 

worked per the schedules did not match the reported days worked on the timecard for two of the 

part-time attending physicians. Because of this discrepancy, the OIG was unable to determine if 

surgeons were available when they were scheduled.

The OIG team discovered that the facility had a process in place to document part-time physician 

hours worked; however, a staff member reported the facility did not have a verification process 

 

25 VHA Handbook 1400.01.

26 VHA Handbook 1400.01.

27 VHA Directive 1035, Oversight and Improvement of the Part-Time Physician Program, November 29, 2013. This 

directive expired November 30, 2018 and has not been updated. Part-time physicians use adjustable work hours 

when their duties “routinely make it difficult or inappropriate for them to adhere to a regular tour of duty.” An 

adjustable work hours schedule should be documented and monitored quarterly.
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to monitor if surgeons’ timecards matched their actual work hours.28 Because of the lack of 

monitoring, the OIG could not determine what hours the part-time physicians actually worked or 

if they had received pay consistent with those hours. 

VISN Review

When interviewed, the VISN Fiscal Quality Assurance Manager reported conducting a review of 

part-time physician hours for all VISN 12 facilities in response to the OIG issued report in March 

2018.

29 The Fiscal Quality Assurance Manager stated not being to determine if facility 

physicians were meeting their assigned tours of duty because the facility did not maintain 

required documents showing schedules for part-time physicians working a fixed schedule.30 The 

VISN completed its review in April 2019 and determined that the facility does not maintain 

appropriate documentation to verify and validate individual physician work schedules and 

payment. The VISN made two recommendations for the facility to address within six months, 

but did not provide a date for VISN follow-up.

31

Conclusion

The OIG substantiated that the patient’s appendectomy was delayed approximately three hours. 

The delay was due to another patient needing surgery more urgently and poor communication, 

rather than inadequate resident oversight. The patient received appropriate preoperative 

monitoring and care. The OIG found no evidence of an adverse event to the patient related to the 

delay.

The OIG team identified poor communication between the residents and the attending surgeons.

The facility lacked an updated, signed OR scheduling policy. The unsigned policy did not 

address the communication process when a surgery has been accepted and scheduled.

The OIG did not substantiate the patient’s surgery was delayed because of inadequate resident 

oversight. Staff interviews confirmed the availability of general surgery attendings to residents;

documentation in the patient’s EHR confirmed that attendings were supervising the residents’ 

work and were present in the OR during surgeries.

The OIG team was unable to determine if surgeons were available or paid appropriately due to 

discrepancies in timecards, lack of documentation of the part-time physicians fixed work 

 

28 VHA Directive 1035.

29 VA Office of Inspector General, Review of Resident and Part-Time Physician Time and Attendance at Oklahoma 

City VA Health Care System, Report No. 17-00253-93, March 28, 2018. https://www.va.gov/oig/pubs/VAOIG-17-

00253-93.pdf. (The website was last accessed on February 27, 2019.)

30 The facility reported in February 2019 that they are working to obtain documentation of work schedules for 

part-time surgeons.

31 VISN Audit Report of the Hines VAMC, received April 11, 2010.
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VA OIG 19-00004-187 | Page 10 | August 8, 2019

schedules, and the lack of a verification process to monitor if surgeons’ timecards matched their 

actual work hours. The VISN Fiscal Quality Assurance Manager also conducted a review of 

part-time physician hours and determined that the facility did not maintain appropriate 

documentation to verify and validate individual physician work schedules and payments.

Recommendations 1–2

1. The Edward Hines, Jr. VA Hospital Director evaluates the current surgery scheduling

practices to determine if changes are required to improve communication processes, and 

takes action as necessary.

2. The Edward Hines, Jr. VA Hospital Director ensures that documentation is in place that 

determines part-time physicians’ tours of duty and responsibilities for time and attendance 

and monitors compliance.
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Appendix A: VISN Director Comments

Department of Veterans Affairs Memorandum

Date: July 12, 2019

From: Director, VA Great Lakes Health Care System (VISN 12)

Subj: Healthcare Inspection—Alleged Delay in Surgical Care, Lack of Resident Oversight, and 

Improper Physician Pay at Edward Hines, Jr. VA Hospital, Hines, Illinois

To: Director, Office of Healthcare Inspections (54HL08)

Director, GAO/OIG Accountability Liaison (GOAL) office (VHA 10EG GOAL Action)

1. I have reviewed and concur with the findings and recommendations in the OIG report entitled 

Healthcare Inspection—Alleged Delay in Surgical Care, Lack of Resident Oversight, and 

Improper Physician Pay at Edward Hines, Jr. VA Hospital, Hines, Illinois.

2. Hines concurs with all recommendations. Evidence of the corrective action plan with quality 

improvements to address the recommendations are provided for review.

3. I would like to thank the OIG inspections team for comprehensive review at Edward Hines, Jr. 

VA Hospital, Hines, IL. 

(Original signed by:)

Victoria P. Brahm, MSN, RN, VHA-CM

Acting Network Director, VISN 12
Alleged Delay in Surgical Care, Lack of Resident Oversight, and Improper Physician Pay

at the Edward Hines, Jr. VA Hospital, Hines, Illinois

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Appendix B: Facility Director Comments

Department of Veterans Affairs Memorandum

Date: July 12, 2019

From: Director, Edward Hines, Jr. VA Hospital (578)

Subj: Healthcare Inspection—Alleged Delay in Surgical Care, Lack of Resident Oversight, and 

Improper Physician Pay at Patient at Edward Hines, Jr. VA Hospital, Hines, Illinois

To: Director, VA Great Lakes Health Care System, (VISN 12)

1. Thank you for the opportunity to review and comment on the draft report, Alleged Delay in 

Surgical Care, Lack of Resident Oversight, and Improper Physician Pay at Patient at Edward 

Hines, Jr. VA Hospital, Hines, Illinois.

2. I have reviewed and concur with the status of the actions and recommendations as 

submitted. Most importantly, the OIG concluded that patient care was appropriate and 

residents had adequate supervision.

(Original signed by:)

Steve E. Braverman, M.D.

Medical Center Director
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at the Edward Hines, Jr. VA Hospital, Hines, Illinois

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Comments to OIG’s Report

Recommendation 1

The Edward Hines, Jr. VA Hospital Director evaluates the current surgery scheduling practices to 

determine if changes are required to improve communication processes, and takes action as 

necessary.

Concur. 

Target date for completion: December 31, 2019

Director Comments

The Chief of Surgery completed an evaluation of the surgery scheduling practice to determine 

process changes needed to improve communication. Upon completion, it was determined that a 

new surgery policy will be developed to include key personnel with defined responsibility and 

accountability for communicating scheduling changes and issues, focused communication with 

staff during the perioperative time frame and day of surgery, a provision for enhancing 

communication with the veteran and other support persons designated by the veteran, and a 

process to enhance effective communication among provider and veteran. Surgical Service Staff 

will be educated on the new policy through the monthly Surgical Service Staff Meeting. Chief of 

Staff will monitor and track policy completion and staff education completion through the 

Medical Executive Board (MEB).

Recommendation 2

The. Edward Hines, Jr. VA Hospital Director ensures that documentation is in place that 

determines part-time physicians’ tours of duty and responsibilities for time and attendance and 

monitors compliance.

Concur. 

Target date for completion: February 29, 2020

Director Comments

The Chief of Surgery conducted an evaluation of the time and attendance compliance for parttime physicians’ tours of duty. Upon completion, it was determined that all personnel should 

have an up to date tour of duty that complies with VA regulation format that is accessible for 

review and audit. The Surgery Section Chiefs will review and approve each provider’s tour of 

duty. The Chief of Surgery will review and approve the tour documents. The Surgical Service 

Line Administrative Staff will conduct random internal audits for time and attendance 

compliance for part-time physicians’ tours. Audit results will be reported at the monthly Medical 
Alleged Delay in Surgical Care, Lack of Resident Oversight, and Improper Physician Pay

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Executive Board (MEB) meeting until a 90% compliance is achieved for 3 consecutive months 

and then quarterly thereafter. 
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OIG Contact and Staff Acknowledgments

Contact For more information about this report, please contact the 

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

Inspection Team Joanne Wasko, MSW, LCSW, Director

Erin Butler, LCSW

Craig Byer, MS

Christopher Dong, JD

Jennifer Kubiak, MPH, RN

Carol Lukasewicz, BSN, RN

Robin Moyer, MD

Other Contributors Josephine Andrion, MHA, RN

Alicia Castillo-Flores, MBA, MPH

Dawn Rubin, JD

Natalie Sadow, MBA

Glen Trupp, MHSM, RN
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Report Distribution

VA Distribution

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, VA Great Lakes Health Care System (10N12) 

Director, Hines VA Hospital (578/00)

Non-VA Distribution

House Committee on Veterans’ Affairs

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies

House Committee on Oversight and 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

U.S. Senate: Tammy Duckworth, Richard J. Durbin

U.S. House of Representatives: Mike Bost, Cheri Bustos, Sean Casten, Danny K. Davis, 

Rodney Davis, Bill Foster, Chuy Garcia, Robin Kelly, Adam Kinzinger, Raja 

Krishnamoorthi, Darin LaHood, Daniel Lipinski, Mike Quigley, Bobby L. Rush, Jan 

Schakowsky, Bradley Schneider, John Shimkus, Lauren Underwood 
OIG reports are available at www.va.gov/oig.

The OIG has federal oversight authority to review the programs and operations of VA medical 

facilities. OIG inspectors review available evidence to determine whether reported concerns or 

allegations are valid within a specified scope and methodology of a healthcare inspection and, if 

so, to make recommendations to VA leadership on patient care issues. Findings and 

recommendations do not define a standard of care or establish legal liability.