Report Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations that the Samuel S. Stratton VA Medical Center’s peer review processes did not follow Veterans Health Administration (VHA) policy; the surgeon performed intraoperative radiofrequency ablation (IORFA) surgery for hepatocellular carcinoma and “completely missed” tumors in patients; a surgeon told a patient there was a recurrence of a tumor although it was “completely missed” during IORFA surgery; the surgeon performed cancer surgery on patients who did not have cancer; and adverse events occurred during and after the surgeon’s other cancer surgeries.

The OIG substantiated the facility’s peer review process did not follow VHA policy, and the facility did not meet credentialing and privileging requirements.

The OIG substantiated the surgeon completely or partially missed tumors when performing IORFA in three patients and told patients they had residual tumors when tumors were not initially ablated. The OIG determined that facility leaders did not provide disclosures for the patients reviewed. The OIG did not substantiate the surgeon performed surgery on patients who did not have cancer or that adverse events occurred during cancer surgeries.

The OIG made nine recommendations related to reviewing quality oversight and quality data for professional practice evaluations; improving peer review programs; including accurate performance data for Surgery Service’s professional practice evaluations; developing and implementing processes to document, report, and track discussed patient cases; implementing processes to track, monitor, and report IORFA outcomes; consulting with Office of General Counsel on patients with missed tumors to institutionally disclose if appropriate; assessing the Surgeon’s IORFA outcomes; performing external reviews of IORFA processes; and evaluating actions for relevant staff.