Report No. 11-00163-109 March 2, 2011

VA Office of Inspector General 

Washington, DC 20420 

Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Alleged Quality of Care Issues 

Captain James A. Lovell 

Federal Health Care Center, 

North Chicago, Illinois
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)
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois 

Executive Summary 

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

review to determine the validity of allegations made by a confidential complainant 

regarding graduate medical education physician trainee (trainee) supervision and the 

quality of care provided by a physician at the Captain James A. Lovell Federal Health 

Care Center (the facility) in North Chicago, IL. 

The complainant alleged that the physician did not review patient imaging tests prior to 

co-signing physician trainee report documentation and that the physician co-signed a 

misinterpreted imaging report. Additional allegations included the physician neglects 

patient care duties by not carrying a pager and not returning calls or electronic mail in a 

timely manner, trainees worked prior to the contract start date, the physician is not 

clinically competent to perform or supervise a specific procedure (the procedure), and the 

physician creates an intimidating work environment. We did not address the allegation of 

an intimidating work environment due to an ongoing Equal Employment Opportunity 

investigation. 

We did not substantiate that the physician failed to review patient imaging tests prior to 

co-signing trainee documentation. We did not substantiate that the physician co-signed a 

misinterpreted imaging report. A Veterans Health Administration (VHA) consultant who 

reviewed the image that was allegedly misinterpreted stated the interpretation was not a 

misdiagnosis. We did not substantiate that the physician neglected patient care duties due 

to lack of a pager and rarely responding to electronic mail and telephone calls. The 

physician carries an encrypted BlackBerry® that receives both telephone calls and 

electronic mail. 

We substantiated that a trainee worked prior to the contract start date. However, there 

was no harm to patients, and senior managers took appropriate actions to ensure trainees 

are scheduled according to their contract. We could neither confirm nor refute that the 

physician was competent to perform or supervise the procedure because the physician 

had not performed the procedure in the past 2 years. However, we found that senior 

mangers did not grant privileges based on documented clinical competence. We also 

found that the Executive Committee of the Medical Staff meeting minutes did not reflect 

the rationale used to support the physician’s reprivileging. 

We recommend that the facility’s senior managers ensure compliance with VHA 

physician credentialing and privileging requirements as given in VHA Handbook 

1100.19, Credentialing and Privileging, November 14, 2008. 

The Veterans Integrated Service Network and Facility Directors concurred with the 

findings and recommendations. We will follow up to assure managers grant privileges 

based on documented clinical competence. 

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, VA Great Lakes Health Care System (10N12) 

SUBJECT: Healthcare Inspection – Alleged Quality of Care Issues James A. Lovell 

Federal Health Care Center, North Chicago, Illinois 

Purpose 

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

review to determine the validity of allegations made by a confidential complainant 

regarding graduate medical education physician trainee (trainee) supervision and the 

quality of care provided by a physician at the Captain James A. Lovell Federal Health 

Care Center (the facility) 1

 in North Chicago, IL. 

Background 

The facility provides care to all eligible veterans, and to active duty service members and 

their dependents. It consists of 199 hospital beds, 195 community living center beds, 

149 Mental Health Residential Rehabilitation Treatment Program beds, and 

3 community based outpatient clinics. Trainees work and receive training at the facility, 

which is part of Veterans Integrated Service Network (VISN) 12. 

The complainant alleged the physician: 

• Did not review patient imaging results prior to co-signing a physician trainee 

report documentation, which resulted in the co-signing of a report that contained 

an incorrect interpretation. 

• Neglected patient care duties by not carrying a pager and having a delayed 

response to electronic mail or telephone calls 

During interviews, the complainant additionally alleged: 

• A trainee worked prior to the contract start date. 

• The physician was not clinically competent to perform or to supervise trainees 

performing a specific procedure (the procedure). 

 

1

 In October 2010, the North Chicago VA System and Great Lakes Naval Training Center integrated health care 

services and became the Captain James A. Lovell Federal Health Care Center, North Chicago, IL. 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

• The physician created an intimidating work environment. 

We did not address the allegation of an intimidating work environment because of an 

ongoing Equal Employment Opportunity investigation. 

Scope and Methodology 

We interviewed the complainant by telephone and in person. We conducted a site visit 

on October 27–28. We interviewed senior managers, physician managers and other 

physicians familiar with the physician, and physician trainees. We also interviewed 

general counsel, Human Resources (HR) staff, the physician trainee program director, 

and a Veterans Health Administration (VHA) physician consultant. 

We reviewed patient medical records, physician trainee supervision policies, Executive 

Committee of the Medical Staff (ECOMS) reprivileging meeting minutes, time and 

attendance records, and available administrative data. We also reviewed physician 

trainee program information, and quality management and physician credentialing and 

privileging data. Additionally, we consulted with a VA specialist who reviewed an 

imaging test result. 

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: Trainee Supervision 

We did not substantiate that the physician failed to review imaging test results prior to 

co-signing physician trainee report documentation, or that the physician co-signed an 

imaging test report that contained an incorrect interpretation. 

Local policy requires that qualified, privileged physicians supervise all physician trainees 

and document concurrence with their assessments and observations. There are varying 

levels of supervision, which range from being physically present with the physician 

trainee to being available for telephone consultation, and co-signing their documented 

assessments. The level of supervisory involvement is dependent upon the experience and 

skill of the physician trainee. In the case of the imaging results, the supervising physician 

must review the images prior to co-signing physician trainee documentation. 

We found no evidence that the physician did not review patient imaging test results prior 

to co-signing physician trainee documentation. We reviewed attendance records and 

identified 2 days when the physician was the only supervisor on duty. The physician cosigned all imaging reports written on those days, and physician trainees told us the 

physician reviewed the images prior to co-signing their documentation. 

VA Office of Inspector General 2 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

VA Office of Inspector General 3 

We did not find that the imaging test report, co-signed by the physician, contained an 

incorrect diagnosis. Another facility physician documented that the physician trainee’s 

interpretation, which was based on a patient’s test images, was incorrect. The other 

physician also documented a different diagnosis. Therefore, we requested a VHA 

consultant to review the images. In November, the consultant reviewed the patient’s 

medical history and the imaging test results. The consultant did not believe the physician 

trainee’s documented imaging report was a misdiagnosis. The consultant noted either 

diagnosis would not pose a significant risk for the patient’s long-term prognosis. 

Issue 2: Communication 

We did not substantiate that the physician neglected patient care duties due to lack of a 

pager and rarely responding to electronic mail and telephone calls. 

To assure continuity of care, physicians must be available by telephone, electronic mail, 

or pager unless they are on leave and have assigned another physician to care for patients 

in their place. The physician carries an encrypted BlackBerry® that receives both 

telephone calls and electronic mail. We learned of one instance where the physician 

responded 3 days after another physician’s electronic mail request to change a patient’s 

medication. The patient had a 2-week supply of the required medication, and we 

determined an immediate response was not necessary to assure quality care. 

We interviewed supervisors, staff, and physician trainees regarding the physician’s 

response to electronic mail and telephone calls. All told us that when an immediate 

response was necessary, the physician responded either in person or by telephone in a 

timely manner. 

Issue 3: Physician Trainee Start Date 

We substantiated that a physician trainee worked prior to the contract start date. 

The physician trainee affiliation agreement was between the facility and another medical 

center, which was associated with the physician trainees’ medical school. 

Two new physician trainees began work in the facility a few days before their contract 

date. One of the physician trainees observed patient testing and did not provide patient 

care. The second physician trainee provided night call coverage2

 and responded to one 

call. The physician trainee’s supervising physician reviewed and agreed with the 

physician trainee’s response to the call. 

On June 29, staff alerted managers when they learned human resources (HR) staff had 

not cleared the physician trainees to begin before their contract date. Managers then 

 

2

 Night call refers to a health care provider who is readily available to respond to patient medical needs during the 

evening and night hours, either in person or by telephone. 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

VA Office of Inspector General 4 

immediately removed the physician trainees from duty. Because there was no harm to 

patients, and senior managers took appropriate actions to ensure the physician trainees’ 

program manager schedules physician trainees according to their contract, we made no 

recommendations. 

Issue 4: Clinical Competence 

We could not confirm or refute whether the physician was competent to perform the 

procedure. Interviews and record reviews revealed the physician had not performed the 

procedure at the facility during the prior 2-year period; however, facility senior managers 

granted the physician privileges to perform the procedure in 2010. We found the senior 

managers did not evaluate clinical competency data prior to granting privileges to 

perform the procedure. We also found the ECOMS minutes did not reflect the rationale 

used to support granting of the physician’s requested privileges. 

VHA Handbook 1100.193

 requires that the physician’s service chief reviews the 

requested privileges and recommends continuing the privileges after evaluating the 

physician’s demonstrated clinical competence. The ECOMS then determines whether 

clinical competence is adequately demonstrated to support granting the requested 

privileges. The ECOMS meeting minutes must reflect the rationale used to support 

granting requested privileges. We found senior managers did not grant privileges based 

on documented clinical competence and documentation was not included in the ECOMS 

minutes. 

Conclusions 

We did not substantiate that the physician failed to review patient imaging tests prior to 

co-signing physician trainee documentation. A VHA physician consultant reviewed the 

imaging test results that contained an alleged misdiagnosis. The consultant stated the 

documented diagnosis would not be considered a misdiagnosis. 

We did not substantiate that the physician neglected patient care duties due to not 

carrying a pager and to delayed response to electronic mail or telephone calls. The 

physician responded to most communications in a timely manner. The one incident 

provided for our review did not affect patient care. 

We substantiated that a physician trainee worked prior to the contract start date. There 

was no harm to patients and senior managers took appropriate actions to ensure physician 

trainees are scheduled according to their contract. 

We could not confirm or refute that the physician was not competent to perform or 

supervise physician trainees performing the procedure because the physician had not 

performed the procedure in the past 2 years. We found senior mangers granted privileges 

 

3

 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

VA Office of Inspector General 5 

that were not based on documented clinical competence. We also found the ECOMS 

meeting minutes did not reflect the rationale used to support the physician’s reprivileging 

for the procedure. 

Recommendation 

We recommend that facility senior managers ensure compliance with VHA physician 

credentialing and privileging requirements as given in VHA Handbook 1100.19, 

Credentialing and Privileging, November 14, 2008. 

Comments 

The VISN and Facility Directors agreed with the findings and recommendation (see 

Appendixes A and B, pages 6–9, for the Director’s comments). We will follow up to 

assure managers grant privileges based on documented clinical competence. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

Appendix A 

VISN Director Comments 

VA Office of Inspector General 6 

Department of 

Veterans Affairs Memorandum

Date: January 10, 2011 

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

Subject: Healthcare Inspection – Alleged Quality of Care Issues at James 

A. Lovell Federal Health Care Center, North Chicago, Illinois

To: Director, Denver Office of Healthcare Inspections (54DV) 

Thru: Director, Management Review Service (10B5) 

Attached please find the [Captain James A. Lovell Federal 

Health Care Center] FHCC response to the alleged quality of 

care issues. I have reviewed and concur with the response 

and request for closure. 

Network Director, VA Great Lakes Health Care System (10N12) 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

Appendix B 

Facility Director Comments 

VA Office of Inspector General 7 

Department of 

Veterans Affairs Memorandum

Date: January 10, 2010 

From: Director, James A. Lovell Federal Health Care Center (556/00) 

Subject: Healthcare Inspection – Alleged Quality of Care Issues at James 

A. Lovell Federal Health Care Center, North Chicago, Illinois

To: Director, VISN 

1. This is to acknowledge receipt and review of the 

findings and recommendation of the Office of the Inspector 

General Healthcare Inspection referenced above. 

2. Attached is our response and request for closure. 

 (original signed by:) 

Patrick Sullivan, Director 

Captain James A. Lovell Federal Health Care Center (556/00) 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

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 Recommendation

Recommendation 1. We recommend that the facility senior managers 

ensure compliance with VHA physician credentialing and privileging 

requirements as given in VHA Handbook 1100.19, Credentialing and 

Privileging, November 14, 2008. 

Concur 

Target Completion Date: Ongoing monitoring

Facility’s Response: Although this facility cannot disagree that 

compliance with all handbooks is required, this recommendation seems to 

be based on the handbook requirement for renewal (vs. new) clinical 

privileges. In addition, the special and unique situation related to the 

merger with the Navy needs to be taken into consideration. The approach 

used for the medical staff privileging at the point of integration for the new 

Federal Health Care Facility (FHCC) is a new approach that was endorsed 

by the VHA Office of Quality and Performance and falls under the 

handbook for new credentialing and privileging. 

Specifically, within 30–60 days prior to October 1, 2010, all 480 former 

North Chicago VA System (NCVAMC) and Naval Clinic Great Lakes 

providers had to apply for credentialing and privileging in the newly 

established Captain James A. Lovell FHCC, and for that purpose they were 

all considered and processed as new providers for the FHCC. 

Given the above approach, all the providers whose privileges were in good 

standing in the “former” facilities as of September 1, 2010, were granted 

the same (facility specific) privileges, and their appropriate chiefs were 

required to have Focused Professional Practice Evaluation on all of them. 

The [specialist] in question had privileges that were granted at NCVAMC 

to cover the period October 26, 2008 through October 25, 2010, and was in 

good standing. His privileges as a new provider to FHCC were then 

granted for September 22, 2010 through September 21, 2012. All 

providers, including this [specialist], will undergo Focused Professional 

VA Office of Inspector General 8 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

VA Office of Inspector General 9 

Practice Evaluation to demonstrate competencies of all the privileges 

requested. At that point, any competency that is not current will be reevaluated and removed per VHA Handbook 1100.19 procedures. Closure 

of this recommendation is requested due to additional clarification 

provided. 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

OIG Contact and Staff Acknowledgments 

OIG Contact Virginia L. Solana, RN 

Director, Denver Office of Healthcare Inspections 

Acknowledgments Cheryl Walker, NP, Team Leader 

Laura Dulcie, BS 

Stephanie Hensel, RN, JD 

VA Office of Inspector General 10 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center North Chicago, Illinois

Appendix C 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

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

Director, Captain James A. Lovell Federal Health Care Center (556/00) 

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: Richard J. Durbin, Mark Kirk 

U.S. House of Representatives: Robert J. Dold 

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

VA Office of Inspector General 11