Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Quality of Care Issues 

at a VA Healthcare System 

Report No. 08-01362-03 October 6, 2008

VA Office of Inspector General 

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

Call the OIG Hotline – (800) 488-8244 
Quality of Care Issues At A VA Healthcare System 

Executive Summary 

The purpose of the inspection was to determine the validity of an anonymous allegation 

that “a number of patients” died while under the care of a board certified surgeon 

employed by a VA healthcare system. We concluded that the system took appropriate 

actions to ensure patient safety and to review the provider’s quality of care prior to and 

during the Office of Inspector General’s review of the allegations. We also concluded 

that the system’s Regional Counsel needed to determine whether reporting the provider to 

the NPDB and to appropriate licensing boards was warranted 

We recommended that Regional Counsel review all pertinent documentation and actions 

taken by the system and determine whether the system had a legal obligation to report the 

provider to the National Practitioner Data Bank and/or the appropriate state licensing 

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

VA Office of Inspector General i 
a.

DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Service Network 

SUBJECT: Healthcare Inspection – Quality of Care Issues at a VA Healthcare 

System 

Purpose 

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

reviewed allegations regarding quality of care issues at a VA healthcare system (the 

system). The purpose of this inspection was to determine the validity of the allegations. 

Background 

On March 6, 2008, OIG received an anonymous complaint alleging that “a number of 

patients” died while under the care of a board certified surgeon employed by the system. 

However, the complainant identified only one patient who had recently died intraoperatively. 

Scope and Methodology 

We reviewed the credentialing and privileging folder of the provider and interviewed 

appropriate senior managers during a site visit in March 2008. We also evaluated results 

of reviews of the provider’s care conducted through the system’s internal processes and 

the results of case reviews conducted by a panel of surgeons independent of Veterans 

Health Administration (VHA). We reviewed VHA regulations governing credentialing 

and privileging,1

 reporting to the National Practitioner Data Bank (NPDB),2 and 

reporting to state licensing boards.3

 Additionally, we reviewed pertinent Joint 

 

1

 VHA Handbook, 1100.19, Credentialing and Privileging, October 2, 2007. 2

 VHA Handbook 1100.17, National Practitioner Data Bank Reports, November 13, 2002. 3

 VHA Handbook 1100.18, Reporting and Responding to State Licensing Boards, February 17, 2004. 

VA Office of Inspector General 1
Quality of Care Issues at a VA Healthcare System 

Commission (JC) standards4 and made a second site visit in May. Because the 

complainant was anonymous, we were unable to interview that individual or get any 

further information. We conducted the inspection in accordance with Quality Standards 

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

Inspection Results 

We found that system clinical managers took appropriate actions to ensure patient safety 

and to review the surgeon’s clinical care prior to our March visit. Clinical managers took 

the following actions: 

• Consulted Regional Counsel and notified the surgeon in writing of plans to review 

cases for quality of care issues and to have a second surgeon assist on all major 

procedures during the period of the review. 

• Completed an internal review of the surgeon’s cases from September 1, 2006 – 

August 9, 2007. That review showed that the surgeon’s post-operative mortality and 

morbidity rates were lower than the national averages.5

 

• Arranged for an independent review of a select number of the provider’s mortality 

cases (seven) during the period of January 2006 to January 2008. Two of these cases 

were intra-operative deaths (the third intra-operative death identified by the 

complainant had not occurred at the time this external review was arranged). 

Surgeons from a community medical facility functioned as an independent review 

panel and completed the review. 

• Planned to arrange for a second independent review of the same cases, including the 

third intra-operative death. 

The independent panel’s conclusions were available while we were onsite in March. The 

panel concluded that all seven patients were challenging and that five of the seven 

patients had severe co-morbidities that directly contributed to their fatal outcomes. In 

four of these cases, the review showed that the families requested only comfort measures 

be provided because of the patients’ critical medical conditions. The remaining two 

patients suffered from advanced cancer. While the panel did not criticize the provider’s 

clinical decisions, it made several recommendations designed to improve overall care for 

patients requiring surgery. The system either implemented or was in the process of 

implementing the recommendations at the time of the May site visit. The following is a 

summary of the recommendations. 

• Patient selection should involve a multi-disciplinary review of cases by a tumor board 

comprised of Medical Oncology, Radiation Oncology, and Surgery. 

 

4

 The Joint Commission, Comprehensive Accreditation Manual for Hospitals, September 2007. 5

 Information from the system’s National Surgical Quality Improvement Program data, FY 2007. 

VA Office of Inspector General 2 
Quality of Care Issues at a VA Healthcare System 

• Deconditioned patients should be exposed to preoperative conditioning programs in 

an effort to decrease postoperative complications. 

• Two surgeons should perform high-risk resections. 

• Postoperative care must involve nursing and resident staff experienced in respiratory 

care and high risk pulmonary patients. 

• Administratively, the panel offered the option of a designation of first assistant for the 

surgeon for a period of 6–12 months that would allow for ongoing technical 

assessments and weekly morbidity and mortality reviews. 

The panel also had the opportunity to review the third intra-operative death that occurred 

after it completed its initial case reviews. The results of that review and the result from 

the second independent review were available at the time of our May site visit. Based on 

the panel’s recommendations and the conclusions from the second independent review, 

clinical managers implemented the following action plan. 

• The surgeon would continue to see patients in the clinic, care for patients in the 

hospital, consult on cases, and share in emergency call including performing 

necessary emergency surgeries. 

• Specific cases would be presented at the multi-disciplinary weekly conference, and 

tumor cases would be presented to the tumor board. 

• Assistance by a second surgeon would be required on all procedures deemed major 

and/or high-risk surgeries. 

• The surgeon’s technical skills and intra-operative judgment would be monitored and 

evaluated weekly for 6 months. If satisfactory, the surgeon could perform major 

cases with a surgical fellow or the chief surgical resident. 

• The surgeon could perform non-major cases with surgical residents. 

The JC Medical Staff standard (MS.4.30) allows the medical staff to define the 

circumstances requiring monitoring and evaluation of a practitioner’s professional 

performance and states that a decision to assign a period of performance monitoring 

should not affect other existing privileges in good standing. 

VHA Handbook (HB) 1100.19 (page 40) also allows for the restriction of performance of 

selected specific procedures, if the restriction is time limited and restoration is contingent 

upon on particular conditions or criteria. However, the HB also states (italicized note on 

pages 39–40) that “any situation that results in a practitioner being proctored, where the 

proctor is assigned to do more than just observe, but rather exercise control or impart 

knowledge, skill, or attitudes to another practitioner...may constitute supervision. If this 

occurs after initial privileges have been granted, it is considered a restriction on the 

practitioner’s privileges and as such is a reduction of privileges and is reportable to the 

NPDB if proctorship lasts longer than 30 days....” 

VA Office of Inspector General 3 
Quality of Care Issues at a VA Healthcare System 

The system’s position was that the surgeon was not restricted from performing major 

surgeries because he could function as primary operative surgeon, could do non-major 

procedures that did not require a second surgeon, and could fulfill all other duties in 

accordance with granted privileges including emergency call. Therefore, the system 

believed that the surgeon’s privileges were not restricted or reduced; and the system was 

not obligated to report the surgeon to the NPDB or the State Licensing Board. 

Ultimately, the decision to report a practitioner is a legal decision; and the system’s 

Regional Counsel needed to make that determination. 

Conclusions 

We concluded that the system took appropriate actions to ensure patient safety and to 

review the provider’s quality of care prior to and during OIG’s review of the allegations. 

Regional Counsel needed to determine whether reporting the provider to the NPDB and 

to appropriate licensing boards was warranted 

Recommendation 

We recommended that the VISN Director ensure that the System Director requires that 

Regional Counsel review all pertinent documentation and actions taken and determine 

whether the system has a legal obligation to report the provider to the NPDB and/or the 

appropriate state licensing boards. 

OIG Comments 

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

provided an acceptable action plan. (See Appendixes A and B, pages 5–7, for the full 

text of the Directors’ comments.) 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 4 
Quality of Care Issues at a VA Healthcare System 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 5 

Department of 

Veterans Affairs Memorandum

Date: September 12, 2008 

From: Director, Veterans Integrated Service Network 

Subject: Healthcare Inspection – Quality of Care Issues at a VA 

Healthcare System

To: Regional Director, Office of Healthcare Inspections 

The Network Director concurs with the findings of the Healthcare 

Inspection. 

Network Director 
Quality of Care Issues at a VA Healthcare System 

Appendix B 

System Director Comments 

Department of 

Veterans Affairs Memorandum

Date: September 12, 2008 

From: Director, Healthcare System 

Subject: Healthcare Inspection – Quality of Care Issues at a VA 

Healthcare System

To: Regional Director, Office of Healthcare Inspections 

We concur with findings of the Healthcare Inspection review of the VA 

Healthcare System 

System Director 

VA Office of Inspector General 6 
Quality of Care Issues at a VA Healthcare System 

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

We recommended that the VISN Director ensure that the System Director 

requires that Regional Counsel review all pertinent documentation and 

actions taken and determine whether the system has a legal obligation to 

report the provider to the NPDB and/or the appropriate state licensing 

boards. 

Concur 

The documents and actions taken have been referred to Regional Counsel 

to determine whether the System has a legal obligation to report the 

provider to the NPDB and/or the appropriate state licensing boards. 

VA Office of Inspector General 7 
Quality of Care Issues at a VA Healthcare System 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Katherine Owens, MSN 

Regional Director, Office of Healthcare Inspections 

(603) 222-5871 

Acknowledgments Jerome Herbers, M.D. 

George Wesley, M.D. 

VA Office of Inspector General 8 
Quality of Care Issues at a VA Healthcare System 

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Veterans Integrated Service Networks 

VA Healthcare Systems 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

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

VA Office of Inspector General 9