Healthcare Inspection – Alleged Patient Safety Concerns in the Operating Room, VA Maine Healthcare System, Augusta, Maine

OIG conducted an inspection to assess the merit of allegations concerning operating room (OR) staffing, pre-operative anesthesia evaluations of complex patients and the surgical mortality rate at the VA Maine Healthcare System, Augusta, ME. We substantiated that the OR did not have a front desk clerk and/or a nurse scheduled to work in the clean core area. However, due to the absence of a master staffing plan, we could not substantiate that the current staff was inadequate to support OR staff. We did not substantiate that pre-operative anesthesia evaluations of complex patients are inadequate because providers frequently evaluate patients just prior to surgery. Our review of the surgical mortality data did not identify obvious outliers or negative trends that would indicate systemic quality of care issues in the OR and require further review. In addition to the allegations, we identified weaknesses in the surgical and OR quality improvement processes. We recommended that the VA Maine Healthcare System Director develop and implement a master staffing plan for the OR, ensure that the Surgical Work Group and OR Committee are functioning in accordance with VHA and local policies, and that the recommendations made pursuant to a recent protected VHA Surgical Program review are implemented.