Report Summary

Title: Healthcare Inspection – Alleged Women’s Health Care Issues, Gulf Coast Veterans Health Care System, Biloxi, Mississippi
Report Number: 16-03705-60 Download
Issue Date: 1/4/2018
City/State: Biloxi, MS
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection Report
Release Type: Unrestricted

OIG conducted an inspection in response to allegations regarding gynecology and women’s health primary care services at the VA Gulf Coast Veterans Health Care System (system), Biloxi, MS. Specifically, the allegations were that a system gynecologist turned away patients by cancelling their consults for routine cancer screenings; did not order the correct test for a patient who was contemplating a hysterectomy; refused to perform two tubal ligations; refused to reorder medications for a patient; failed to document gynecology procedures correctly; and failed to use a colposcope to perform colposcopies. Additional allegations were that a Women’s Health Clinic physician assistant was not addressing a patient’s medical care and that system gynecologists lived too far away to be on-call for surgical patients. We did not substantiate the above allegations, except that a system gynecologist did not reorder a medication for another gynecologist’s patient. However, we determined that it was reasonable for the covering gynecologist to defer reordering to the regular gynecologist. During the inspection, we identified several issues under the responsibility of medical leadership: providers did not always follow Veterans Health Administration cervical cancer screening guidelines; loop electrosurgical excision procedures were performed in the operating room with general anesthesia; communication and collaboration was lacking between gynecologists and providers and between providers and patients that may have affected safe and effective patient care; a care coordination agreement was outdated; and one gynecologist’s privileges were not in compliance with system required experience to perform surgical procedures.

We also found that the Patient Advocacy Program, under the responsibility of system leadership, was not tracking complaints as required by Veterans Health Administration. We made six recommendations.