Report Summary

Title: Healthcare Inspection – GI Fellowship Program Issues, New Mexico VA Health Care System, Albuquerque, New Mexico
Report Link:
Report Number: 14-00612-167
Issue Date: 5/23/2014
City/State: Albuquerque, NM
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The OIG conducted an inspection in response to complaints about the supervision of fellows in the Gastroenterology (GI) Department at the New Mexico VA Health Care System (facility), Albuquerque, NM. We did not substantiate the allegation that the ACGME requires that patients seen by fellows must also be seen in person within 24 hours by a credentialed attending physician, and this is not being done in the facility GI Department. Although VHA requires a supervising practitioner to physically meet, examine, and evaluate a patient within 24 hours of an inpatient admission, it is not required for inpatient or outpatient consultations in a specialty service. We did not substantiate the allegation that the Chief of GI was co-signing GI Fellow consult notes with “in lieu of” for UNM GI attending physicians who were not seeing patients. We found that UNM GI fellows appropriately documented that patients were discussed with their UNM GI supervising practitioner, or alternatively, we found an addendum to the original GI consult note was entered by the UNM GI supervising practitioner. We also found that the Chief of GI was adding an addendum to the GI consult note and signing for administrative purposes to authenticate and complete the GI consult notes so they would be accessible by other clinical staff. We did not substantiate the allegation that UNM GI attending physicians were not credentialed at the facility. We found that all four without compensation UNM GI attending physicians who provided coverage at the facility were appropriately credentialed and privileged. We did not substantiate the allegation that senior leadership was unwilling or unable to take corrective action. We found that facility leadership was aware of the complaint and had initiated appropriate follow-up prior to our site visit. We made no recommendations.