Report Summary

Title: Healthcare Inspection – Alleged Mismanagement and Quality of Care Issues in Surgical Service, John D. Dingell VA Medical Center, Detroit, Michigan
Report Number: 15-02994-269
Issue Date: 6/19/2017
City/State: Detroit, MI
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: OIG conducted a healthcare inspection regarding alleged Surgical Service mismanagement and quality of care issues at the John D. Dingell VA Medical Center (facility), Detroit, MI.
We substantiated that the Surgical Service Associate Chief of Staff (ACOS) had negative interactions with operating room (OR) staff; however, this did not result in adverse patient outcomes. We did not substantiate that the ACOS had unprofessional behavior unaddressed by leadership. We substantiated that the ACOS reduced general surgeons’ access to surgical cases and OR time. The ACOS performed most of the general surgery cases; however, the Chief of Staff supported the ACOS’ actions. We substantiated that the ACOS altered the daily surgical schedule over a 2-year timeframe (2013–2015) to accommodate his elective cases, which resulted in patient delays for previously scheduled cases and patient complaints. The facility developed a policy to minimize disruption in the surgical schedule; however, the new policy was not consistently followed. We substantiated that the ACOS did not adhere to VHA and facility policy regarding certain aspects of the supervision of surgical residents including correct documentation of the ACOS’ presence during surgeries, communication of a designated back-up surgeon when absent from the OR, and ensuring completion of post-operative notes.
We substantiated that the ACOS performed elective colonoscopy procedures in the OR. These procedures increased OR utilization time, but the practice did not violate VHA or facility policy. We did not substantiate that performing these procedures in the OR diluted morbidity and mortality data. We did not substantiate that the ACOS performed colonoscopy examinations without the appropriate equipment available. We did not substantiate that the ACOS exercised poor clinical decision making that resulted in negative outcomes for many patients including patient deaths. However, we reviewed 53 cases with quality of care concerns and found 3 instances where clinical judgement may have affected patients’ adverse outcomes. We also found that a requested autopsy was not done and facility staff did not fully comply with VHA peer review requirements. We recommended that the Facility Director ensure that OR communication and interpersonal dynamics are improved; providers follow processes for scheduling add-on OR cases; ACOS’ post-operative notes are completed; ACOS’ OR presence during surgeries is documented; ACOS’ backup OR surgeons are designated; staff review adverse outcome cases and consider institutional disclosures; an unperformed autopsy is reviewed; and VHA peer review requirements are followed.