Management of the Ophthalmology Clinic and Patient Safety Reporting Concerns at the VA Central Iowa Health Care System in Des Moines

The VA Office of Inspector General (OIG) conducted an inspection in response to multiple allegations related to Ophthalmology Clinic management, quality of care, oversight, medication management, and facility leaders’ failures at the VA Central Iowa Health Care System (facility) in Des Moines. The OIG team did not substantiate that the facility hired a new physician right out of residency to be Chief of Ophthalmology, there was a lack of appropriate supervision of ophthalmology residents, the quality of cataract surgeries decreased while the number of complications increased, cataract surgery outcomes were not reviewed by an oversight group, and surgery managers and facility leaders were told about complications and other concerns and did not take action. Facility audit report findings identified inappropriate storage and labeling of medications in the Ophthalmology Clinic. The OIG found facility leaders took actions to resolve the findings. The OIG identified deficits in Ophthalmology Clinic staff members’ knowledge and use of the required patient safety event reporting system. The OIG also identified issues with the management and impact of ongoing personnel conflicts within the Ophthalmology Clinic. Leaders at multiple levels had difficulty managing the impact of interpersonal conflicts in the Ophthalmology Clinic that adversely affected the culture of the clinic. The OIG made four recommendations to the Facility Director related to training staff on reporting patient safety incident events and close calls, entering patient safety events and close calls into the Joint Patient Safety Reporting system, addressing the Ophthalmology Clinic culture, and the oversight and management of the Ophthalmology Clinic.