Report Summary

Title: Healthcare Inspection – Administrative Irregularities, Leadership Lapses, and Quality of Care Concerns, VA Central Iowa Health Care System, Des Moines, Iowa
Report Number: 13-02073-106
Issue Date: 3/31/2014
City/State: Des Moines, IA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
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.