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Alleged Issues in the Cardiology Department at the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana

Report Information

Issue Date
Report Number
19-07090-90
VISN
10
State
Indiana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Staffing
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations concerning delays in interpreting electrocardiograms (ECGs) and event monitor tracings, failure to schedule cardiac procedures for over one year, failure to scan pacemaker data into the electronic health record (EHR), high cardiologist turnover, and the lack of proper supervision in the Device Clinic at the Richard L. Roudebush VA Medical Center (facility). The OIG reviewed an additional allegation that Surgery Service maintained an unauthorized wait list for an electrophysiology procedure. The OIG did not substantiate that ECG or cardiac event tracings reports were not interpreted timely, patients requiring cardiac surgery procedures were not scheduled for over a year, or improper supervision of the Device Clinic. Pacemaker tracings were not scanned into the EHR; however, the facility’s practice of entering tracing information as EHR notes was acceptable according to the VA Director of the National Cardiology Program. After the OIG’s site visit, the Cardiology Department initiated a process to scan pacemaker tracings into the EHR despite the lack of a requirement. The OIG substantiated that cardiologist turnover has been high at the facility but did not find evidence of adverse clinical outcomes resulting from staff turnover. The OIG substantiated that Cardiology and Surgery Services staff did not utilize the required consult process and maintained an unauthorized wait list for the electrophysiology procedure. The OIG found electrophysiology providers were not using the Veterans Health Administration consult process for electrophysiology procedures prior to February 2019. The OIG did not find evidence of adverse clinical outcomes related to the use of wait lists or failure to use the consult process. The OIG made four recommendations related to cardiologist turnover, staff understanding of authorized and unauthorized patient wait lists, and the training of staff on consult process and wait list policies.

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)
The Richard L. Roudebush VA Medical Center Director reviews and develops cardiology recruitment and retention processes to reach the approved staffing level.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Richard L. Roudebush VA Medical Center Director explores the possible reasons for difficulties recruiting and retaining cardiologists and takes action to resolve identified issues.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Richard L. Roudebush VA Medical Center Director ensures that facility staff understand the Veterans Health Administration policy regarding authorized and unauthorized patient wait lists, and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Richard L. Roudebush VA Medical Center Director ensures facility managers train staff regarding the consult process and wait list policies, and monitors compliance.