Report Summary

Title: Healthcare Inspection – Quality of Care, Management Controls, and Administrative Operations, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
Report Link: http://www.va.gov/oig/pubs/VAOIG-13-00872-71.pdf
Report Number: 13-00872-71
Issue Date: 2/6/2014
City/State: Columbia, SC
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: OIG conducted a review in response to allegations concerning quality of care, clinical oversight, management controls, and administrative operations in the Surgery Service at the William Jennings Bryan Dorn VA Medical Center (the facility) in Columbia, SC. We could not substantiate high general and vascular surgery complication rates or that contaminated surgical equipment contributed to surgical site infections. We substantiated improper use of hard-copy logbooks, insufficient staffing in surgery clinic, and several vacancies in Anesthesia Service. We did not substantiate patients being placed under extended anesthesia so residents could be trained in laparoscopic techniques, or that a power outage negatively impacted surgical patients. We determined that deficient surgical scheduling processes had a direct impact on operating room scheduling and caused case delays resulting in the use of overtime. The facility’s Infection Control program was fragmented and inconsistent, surveillance data were rarely analyzed or trended, and Infection Control Sub-Council minutes lacked evidence of preventive and corrective measures. Also, Reusable Medical Equipment Oversight Committee minutes did not include required elements.
We confirmed that the University affiliate had removed general and orthopedic surgery residents from the VA training rotation at different times; after some improvements, the general surgery residency program is again in jeopardy. The Quality Management program did not provide the necessary monitoring and oversight to assure that some patient care processes were safe and effective. High-level oversight and subordinate committees did not consistently receive required reports, act on identified conditions, or follow-up to resolution. The facility’s Patient Safety and Peer Review Programs did not comply with VHA requirements, and many of the facility’s key leaders were functioning in “acting” capacities. We made 12 recommendations.