Report Summary

Title: Alleged Access Delays and Surgery Service Concerns, VA Roseburg Healthcare System, Roseburg, Oregon
Report Number: 15-00506-535
Issue Date: 7/11/2017
City/State: Roseburg, OR
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: At Representative Peter A. DeFazio’s request, OIG conducted a healthcare inspection of the VA Roseburg Healthcare System (system), Roseburg, OR, to assess allegations regarding access delays, surgery service quality of care concerns in 2014, and complaints that the Chief of Surgery (COS) performed colonoscopies in an unsafe manner. We substantiated access delays in some surgery and gastroenterology service areas; however, system leaders had implemented actions to reduce wait times. We did not substantiate surgeons were unable to maintain surgical skills; surgeons could be detailed to other facilities to perform procedures not done at the system. We did not substantiate that surgeries were performed without intensive care unit back up. We did not substantiate a surgeon (COS) performed colonoscopies unsafely, but found he practiced in an outdated manner. Soon after arriving at the system, gastroenterology staff voiced concerns about the COS’s competency although he had performed colonoscopies at another VHA facility. The COS underwent proctoring. Four physician proctors concluded the COS met or exceeded expectations. We reviewed the COS’s system cases. We found no complications such as over sedation, bleeding, perforation, or missed cancers. However, we found his documentation often did not include data such as polyp size or quality of bowel preparation. We also found the COS fulgurated (burnt) polyps, a practice that has fallen out of favor and that he made recommendations for surveillance colonoscopies without waiting for pathology results. We identified one patient for whom the COS took timely follow-up action on the biopsy results but did not inform the patient of a cancer diagnosis for 15 days. The COS stopped performing colonoscopies at the system. While we did not identify system patients with poor outcomes, we were concerned that the COS’s system documentation may have implications for the colonoscopies he performed at a prior VA facility. We found that VHA’s Colorectal Cancer Screening directive does not require documentation of many of the established quality indicators for monitoring the practice of providers who perform colonoscopies. We recommended the Acting Under Secretary for Health perform a quality review of the COS’s colonoscopies performed in a prior VHA facility, revise VHA’s Colorectal Cancer Screening directive to include standardized documentation of quality indicators and consider adding photodocumentation of cecal intubation and withdrawal time to the Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation criteria. We recommended that the System Director ensure patient notification of diagnostic test results according to required time frames.