Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Alleged Resident Supervision Issues 

VA North Texas Health Care System 

Dallas, Texas 

Report No. 09-02024-222 September 21, 2009

VA Office of Inspector General 

Washington, DC 20420 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas 

Executive Summary 

The purpose of the review was to determine the validity of allegations regarding resident 

supervision and attending physicians’ presence at the VA North Texas Health Care 

System (the system). The complainant alleged: 

• Widespread false documentation of resident supervision, 

• Contractual obligations not fulfilled by the University of Texas Southwestern 

Medical Center at Dallas (the university), and 

• Attending physician’s (attending) absence during a Code Blue event. 

We did not substantiate the allegation of widespread false documentation of resident 

supervision. We found that a resident failed to document the correct attending name in 

one medical record in 2007. 

We did not substantiate the allegation that the university failed to meet its contractual 

obligations. We found that attendings provided adequate resident supervision and 

surgical care services. Although we substantiated the allegation that an attending was not 

present during the Code Blue (cardiorespiratory arrest), we found that the patient was 

managed appropriately and that the attending was available by phone. 

During the course of our review, we found that system staff failed to consistently 

document discharge summaries in the medical record, as required. We recommended 

that the system comply with VHA policy regarding documentation of discharge 

summaries. The Veterans Integrated Service Network and System Directors agreed with 

the findings and recommendation and provided an acceptable action plan. Since the 

system had already addressed the issue identified in the recommendation, we consider 

this recommendation closed.

VA Office of Inspector General i 
VA Office of Inspector General 1 

DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Service Network 17 

SUBJECT: Healthcare Inspection – Alleged Resident Supervision Issues, VA North 

Texas Health Care System, Dallas, Texas 

Purpose 

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

allegations of false documentation by resident physicians (residents) and inadequate 

attending physicians’ (attendings) presence at the VA North Texas Health Care System 

(the system), Dallas, TX. The purpose of this review was to determine whether the 

allegations had merit. 

Background 

The system, which is part of Veterans Integrated Service Network (VISN) 17, is a tertiary 

care facility in Dallas, TX. It provides a broad range of services. Surgical specialty care 

is provided by attendings and residents affiliated with the University of Texas 

Southwestern Medical Center at Dallas (the university). The system supported 

671 residents and medical students during the 2008 academic year. The residents rotate 

between the university and the system, providing care for VA patients under the direct 

supervision of attendings. 

Veterans Health Administration (VHA) resident supervision policy is detailed in a 

handbook that establishes requirements for attending involvement in the care provided by 

residents and documentation of that involvement.1

 Documentation of supervision must 

be entered into the medical record by the attending or reflected within the resident 

progress note. The physical presence of the attending is required in the following patient 

settings: (a) outpatient clinic; (b) emergency department; (c) operating room (OR), and 

(d) specialty non-OR (e.g., cardiac catheterization laboratory, angiography suite) 

procedure areas. 

 

1

 VHA Handbook 1400.1, Resident Supervision, July 27, 2005. 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas 

VA Office of Inspector General 2 

The system’s critical care services for surgical patients are carried out in the 15-bed 

surgical intensive care unit (SICU), where care management and resident supervision are 

provided by intensivists2

 from two university groups of contract physicians with surgery 

and anesthesia expertise. The services alternate attending responsibilities on a weekly 

basis. Timesheets are maintained to validate that contracted services are provided. 

In April 2009, a complainant contacted the VA OIG Hotline. Allegations included false 

documentation of resident supervision in 2007 and inadequate performance of SICU 

attending responsibilities. The complainant alleged that: 

• There is widespread false documentation of attending presence even when the 

attending is not at the bedside or in the hospital. 

• System managers said that the VA is not entitled to a monetary refund because 

despite problematic documentation, the university has met its contractual 

obligations. 

• An SICU attending did not fulfill responsibilities during an SICU Code Blue 

(cardiorespiratory arrest) event.

Scope and Methodology 

We interviewed the complainant prior to a site visit conducted June 30–July 1, 2009. We 

interviewed system senior leaders, physician managers, administrators, attendings, 

residents, and nurse managers. We reviewed medical records and facility documents, 

including policies, meeting minutes, call schedules, time and attendance records, contract 

agreement with the university, and various reports. We also reviewed VHA policies and 

procedures. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency.

Inspection Results 

Issue 1: Widespread Resident Supervision Documentation Issues 

We did not substantiate the allegation of widespread false documentation of resident 

supervision in the medical record. 

For the one medical record entry in 2007, we confirmed that a resident incorrectly 

documented attending involvement. The wrong attending was named in the progress 

note, and neither the attending nor the resident entered an addendum to correct the 

 

2

 Intensivists are physicians trained in critical care medicine. 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas 

information. The complainant did not provide additional documentation or information 

to support the allegation that thousands of patient records were falsely documented. 

System physician managers agreed that discrepancies in the medical record must be 

corrected as soon as the error is known and that this was the responsibility of the resident 

as well as the attending. Physician managers stated that it is emphasized during new 

resident orientation that resident supervision information in the medical record must be 

accurate. The residents we interviewed confirmed this information. 

We reviewed the medical records of 29 patients who were admitted to the SICU during 

the 2nd quarter of fiscal year (FY) 2009. We found documentation of resident supervision 

to be correct and adequate and to correlate with the timesheets of the attendings. We 

determined that residents correctly reflected attending involvement in the medical record. 

Issue 2: Contractual Obligations

We did not substantiate the allegation that the university failed to meet its contractual 

obligations. We found that attendings provided adequate resident supervision and 

surgical care services. 

We reviewed the contract related to SICU attending responsibilities and resident 

supervision. We determined that the provision of 1.0 full-time employee equivalent 

hours of critical care surgical services by the university was satisfied for the 6-month 

timeframe reviewed. We examined the “Alternate Hire – Time Record” and the “VA 

Intensive Care Unit Call Schedule for the 2nd and 3rd Quarters of FY 2009.” We found 

evidence of contract physician coverage for the SICU and resident supervision, as 

stipulated in contract agreements between the system and the university. We also 

reviewed the system’s admission and discharge oversight monitors for resident 

supervision. The monitors documented compliance with VHA resident supervision 

requirements. We determined that contract attendings provided the required SICU 

coverage. 

Issue 3: Attending Presence During Code Blue

We substantiated the allegation that the attending was not present during the Code Blue 

event. 

The assigned SICU attending had appropriately documented in the time record that he 

was away from the system at the time of the Code Blue. There was no requirement for 

the attending to be physically present in the unit to fulfill resident supervision 

responsibilities. The residents we interviewed confirmed that attendings are generally 

available by phone for consultations. During this code, the attending spoke with the 

resident by phone and did not return to the system because two other attendings (from 

Medicine and Anesthesia) were already present and managing the patient. Resuscitation 

was successful, but the patient expired the following day due to factors unrelated to the 

VA Office of Inspector General 3 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas 

VA Office of Inspector General 4 

Code Blue. The SICU Medical Director stated that the presence of the SICU attending 

during the Code Blue would not have changed the ultimate outcome for the patient. The 

Chief of Surgery confirmed this information. Based on our review of the patient’s 

medical record, we determined that the patient was managed appropriately. 

Issue 4: Discharge Summaries 

We identified an additional issue that required management attention. VHA policy 

requires that a discharge summary be documented within 24 hours of death.3

 

We reviewed the medical records of 15 SICU patients who died 

January 1–March 31, 2009. We noted appropriate death notes, but discharge summaries 

were missing in 5 (33 percent) of the 15 records. We brought this deficiency to the 

attention of physician managers who agreed that a discharge summary must be completed 

when there is a patient discharge or death. By the end of our onsite visit, three of the five 

discharge summaries had been documented. The remaining two discharge summaries 

were awaiting transcription. We recommended that system managers ensure compliance 

with VHA policy regarding documentation of discharge summaries. 

Conclusions 

We did not substantiate widespread false documentation of resident supervision. We 

found one instance in 2007 where a resident documented the name of an incorrect 

attending in the medical record. We did not substantiate that the university failed to meet 

contractual obligations. The contract attendings provided adequate resident supervision 

and surgical care services. Although we substantiated that an SICU attending was not 

present during a Code Blue event, we determined that the patient was managed 

appropriately. We found that the system needed to comply with VHA discharge 

summary documentation requirements. 

 

3

 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas 

Recommendation 

Recommendation 1. We recommended that the VISN Director ensure that the System 

Director complies with VHA policy regarding discharge summary documentation 

requirements. 

Comments 

The VISN and System Directors agreed with the findings and recommendation and 

provided acceptable corrective actions. (See Appendixes A and B, pages 6–9, for the full 

text of the Directors’ comments.) Since the system has already implemented actions to 

address the findings, we consider this recommendation closed. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 5 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas

Appendix A 

VISN Director Comments 

VA Office of Inspector General 6 

Department of 

Veterans Affairs Memorandum

Date: August 31, 2009 

From: Director, VA Heart of Texas Network (10N17) 

Subject: Healthcare Inspection – Alleged Resident Supervision Issues, VA 

North Texas Health Care System, Dallas, Texas

To: Associate Director, Los Angeles Regional Office of Healthcare 

Inspections (54LA) 

Thru: Director, Management Review Service (10B5) 

I concur with the response by the Medical Center Director and with the 

recommendation for improvement identified in the report. 

 (original signed by:)

Timothy P. Shea, FACHE 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas

Appendix B 

System Director Comments 

VA Office of Inspector General 7 

Department of 

Veterans Affairs Memorandum

Date: August 31, 2009 

From: Director, VA North Texas Health Care System (549/00) 

Subject: Healthcare Inspection – Alleged Resident Supervision Issues, VA 

North Texas Health Care System, Dallas, Texas

To: Associate Director, Los Angeles Regional Office of Healthcare 

Inspections 

We concur with OIG’s findings and recommendation. Please note that the 

five discharge summaries that were found to be missing during the OIG’s 

review for patients who died from January 1, 2009–March 31, 2009, have 

been transcribed and placed in the patients’ medical records. 

Attached is our response to the OIG’s recommendation. 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas

Director’s Comments 

to Office of Inspector General’s Report 

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

recommendation in the Office of Inspector General’s report. 

Recommendation 1. We recommended that the VISN Director ensure that 

the System Director complies with VHA policy regarding discharge 

summary documentation requirements. 

Concur 

A reminder notice was sent to all VA North Texas Health Care System 

(VANTHCS) surgeons on VHA’s policy regarding documentation of 

discharge summaries when there is a patient discharge or death. In 

addition, VANTHCS has re-trained all residents on the policy and will 

continue to train all future incoming residents on this policy to ensure 

compliance. 

Quality Management will conduct chart audits of all deaths that occur in the 

ICU to determine if documentation of discharge summaries is completed 

with 24 hours of death. This data will be collected and analyzed quarterly 

and reported to the Executive Committee of the Medical Staff (ECMS) as a 

recurring agenda item. Minutes from the ECMS will be submitted to the 

VISN 17 Office to monitor and ensure compliance with the VHA Policy 

concerning documentation of discharge summaries within 24 hours of 

death. 

VA Office of Inspector General 8 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Virginia L. Solana, RN, MA 

Director, Denver and Los Angeles Regional Offices of 

Healthcare Inspections 

(213) 253-2677 ext. 4936 

Daisy Arugay, Coordinator 

Mary Toy, Team Leader 

VA Office of Inspector General 9 
Alleged Resident Supervision Issues, VA North Texas Health Care System, Dallas, Texas

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heart of Texas Health Care Network (10N17) 

Director, VA North Texas Health Care System (549/00) 

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 

U.S. Senate: John Cornyn, Kay Bailey Hutchison 

U.S. House of Representatives: Joe Barton, Michael Burgess, Chet Edwards, 

Louie Gohmert, Kay Granger, Ralph M. Hall, Jeb Hensarling, Eddie Bernice Johnson, 

Sam Johnson, Kenny Marchant, Randy Neugebauer, Pete Sessions, Mac Thornberry 

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

VA Office of Inspector General 10