Breadcrumb

Healthcare Inspection – Alleged Access Delays and Surgery Service Concerns, VA Roseburg Healthcare System, Roseburg, Oregon

Report Information

Issue Date
Report Number
15-00506-535
VISN
State
Oregon
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
At the request of Representative Peter DeFazio, OIG conducted an evaluation of the VA Roseburg Healthcare System (system), Roseburg, OR, in response to allegations regarding access delays and surgery service quality of care concerns. We substantiated access delays in some surgery and gastrointestinal service areas; however, system leadership and clinical program managers knew of the delays, implemented action plans to reduce wait times, and recorded the number of patients waiting per Veterans Health Administration (VHA) policy. We did not substantiate the allegation that a surgeon with questionable competence was performing colonoscopies. The surgeon was detailed to another VA facility where three board certified surgeons and one board certified gastroenterologist observed the surgeon during 16 endoscopy procedures and concluded the surgeon’s competency met or exceeded standards. We did not substantiate the allegation that surgeons were unable to maintain surgical skills. According to multiple providers at the system and Veterans Integrated Service Network level, surgeons could be detailed to other facilities to perform procedures not normally done at the system in order to maintain their surgical skills. We did not substantiate the allegation that surgeries are performed inappropriately without intensive care unit back-up. All surgical cases were monitored to ensure procedures were performed within the capabilities of the system’s designated complexity level. We made no recommendations.

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 Acting Under Secretary for Health perform a quality review of the Chief of Surgery's colonoscopies performed in the prior Veterans Health Administration facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Under Secretary for Health revise the Veterans Health Administration Colorectal Cancer Screening directive to include standardized documentation of quality indicators based on professional society guidelines and published literature (including but not limited to photodocumentation of anatomical landmarks establishing cecal intubation and documentation of cecal withdrawal times).
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Under Secretary for Health consider adding photodocumentation of cecal intubation and cecal withdrawal time to the standardized criteria for quality colonoscopy for Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure patient notification of diagnostic test results within the required timeframe, particularly for critical results, and that clinicians document notification.