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Healthcare Inspection – Administrative Irregularities, Leadership Lapses, and Quality of Care Concerns, VA Central Iowa Health Care System, Des Moines, Iowa

Report Information

Issue Date
Report Number
13-02073-106
VISN
State
Iowa
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection in response to a request by Senators Charles Grassley and Tom Harkin, both of whom received allegations of administrative irregularities, leadership lapses, and quality of care concerns at the VA Central Iowa Health Care System. We did not substantiate that a physician was not qualified for his/her position; however, the physician did not meet Accreditation Council for Graduate Medical Education’s (ACGME) standards for a position he/she filled temporarily. We did not substantiate that a physician had inappropriately performed skin biopsies, that a physician obstructed the cardiology consult process, nor that the nursing staff turnover rate was high and due to discontent with facility leadership. We substantiated that a physician did not follow ACGME standards in the selection process of physician staff whose duties would include teaching, the facility did not complete Focused Professional Practice Evaluations as required, and there was a decline in staff morale. We also substantiated that staff were unclear as to who was authorized to perform out of Operating Room airway management. We recommended that the VISN Director ensure that staff meet ACGME requirements and that the facility Director ensure (a) that the selection of physicians participating in medical educational activities is within the standards of the ACGME’s Residency Review Committee, (b) a standardized process for the management of cardiology consults is implemented, (c) Focused Professional Practice Evaluations are consistently completed, and (d) a comprehensive list of staff authorized to perform out of Operating Room airway management is maintained.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated System Network Director ensure that the Chief of Staff appoints a director of the specific unit of the subject Service Line, who meets the qualification standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that selection of physicians who will be participating in medical educational activities is conducted within the standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure the implementation of a standardized process for the management of cardiology consults, consistent with VHA policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure processes be strengthened so that Focused Professional Practice Evaluations for licensed independent practitioners are consistently conducted as required, and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the Chief of Staff maintain a comprehensive list of staff that is authorized to perform out of Operating Room airway management in compliance with facility policy.