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Facility Oversight and Leaders’ Responses Related to the Deficient Practice of a Pathologist at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia

Report Information

Issue Date
Report Number
19-07600-215
VISN
6
State
Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Patient Safety
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted an inspection to evaluate facility oversight and leaders’ response to a pathologist’s practice at the facility. The OIG found the Pathology and Laboratory Medicine Chief (Chief) followed VHA policy and performed a quality review of surgical pathology cases and reported the pathologist’s initial misdiagnosis. Facility leaders ensured the required comprehensive clinical care reviews were conducted, resulting in the discovery of 10 additional misdiagnoses. The pathologist also misdiagnosed a skin biopsy. The Chief followed Veterans Health Administration (VHA) policy for secondary reviews of the misdiagnoses, completed supplemental reports, and documented provider notification. The OIG found no documentation that providers informed three patients of their misdiagnoses. The OIG learned one patient experienced an adverse clinical outcome and did not have any documented disclosures. Also, facility staff and leaders did not report any of the misdiagnoses as adverse events. Facility leaders summarily suspended the pathologist; however, the OIG found no documentation renewing the suspension. The Facility Director then terminated the pathologist. The pathologist appealed the termination through the VHA Disciplinary Appeals Board, which recommended a reinstatement. The pathologist was reinstated, and clinical privileges were restored. Facility leaders did not comply with VHA’s mandated privileging processes and were unaware of who was responsible for state licensing board reporting. Quarterly retrospective reviews of all pathology reports exceeded the 10 percent standard; however, the Chief and staff pathologists did not consistently review 10 percent of each pathologist’s cases. The Chief and staff pathologists reviewed 9.4 percent of the pathologist’s cases, below the 10 percent requirement. The OIG made 10 recommendations related to test results, disclosure and reporting of adverse events, issue briefs, the summary suspension process, the credentialing and privileging process, state licensing board reporting, and quality reviews of the pathologists’ work.

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 Hunter Holmes McGuire VA Medical Center Director ensures that the Pathology and Laboratory Medicine Services actionable supplemental test results are communicated timely in accordance with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hunter Holmes McGuire VA Medical Center Director ensures that facility leaders adhere to Veterans Health Administration policy that outlines the processes for the disclosure of adverse events, including clinical and institutional disclosures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hunter Holmes McGuire VA Medical Center Director reviews the treatment course for the identified dermatology patient who experienced an adverse clinical outcome and takes action, including disclosures, if appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hunter Holmes McGuire VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to reporting of all adverse events to the patient safety manager.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hunter Holmes McGuire VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to reporting adverse events to the VA Pathology Regional Commissioner.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hunter Holmes McGuire VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to issue briefs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hunter Holmes McGuire VA Medical Center Director ensures that facility leaders adhere to Veterans Health Administration policy that outlines the summary suspension process for licensed independent practitioners.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hunter Holmes McGuire VA Medical Center Director verifies that facility leaders adhere to Veterans Health Administration policy that outlines the credentialing and privileging process as related to the subject pathologist.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hunter Holmes McGuire VA Medical Center Director and facility leaders meet all Veterans Health Administration requirements for state licensing board reporting.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hunter Holmes McGuire VA Medical Center Director ensures that the Pathology and Laboratory Medicine Service Chief ensures the required Veterans Health Administration and facility quality reviews of the Pathology and Laboratory Medicine Services’ pathologists are performed.