Report Summary

Title: Thoracic Surgery Quality of Care Issues and Facility Leaders’ Response at the C.W. Bill Young VA Medical Center in Bay Pines, Florida
Report Number: 18-01321-56 Download
Issue Date: 1/13/2021
City/State: Bay Pines, FL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the facility to evaluate allegations related to a thoracic surgeon’s surgical complications including patient deaths and misrepresentations of operative note documentation and the facility’s inappropriate reporting of the thoracic surgeon’s complication rate.

The surgeon, board certified in thoracic and cardiac surgery, began clinical practice in 2009, started working at the facility in 2013 as a staff thoracic surgeon, and was selected to become Chief of Surgery in July 2014.

On November 9, 2017, the OIG received a complaint about the surgeon’s competency and quality of care in five patient cases. The OIG consulted with a non-VA thoracic surgeon, who reviewed the care of the five patients as well as 19 patient cases from a previous OIG evaluation.

The non-VA consultant identified quality of care concerns with 16 of the 24 patient cases. The facility completed external management reviews and found five cases of concern. In February 2019, the surgeon was reassigned to a nonclinical care setting. Veterans Health Administration (VHA) and Veterans Integrated Service Network leaders established a panel of VHA cardiothoracic surgeons who reviewed 22 of the 24 cases evaluated by the non-VA consultant as well as other, additional cases. In December 2019, the panel determined that the surgeon delivered thoracic surgical care within quality expectations and the surgeon resumed patient care.

The OIG did not substantiate that the facility failed to appropriately report surgical errors and complications.

The OIG made five recommendations to the Under Secretary for Health related to a thoracic specialty leader, operative documentation, the National Surgery Office’s surgery assessments, and peer review processes. The OIG made an additional five recommendations to the Facility Director related to operative documentation, professional communications, Surgical Work Group oversight, privileging, and institutional disclosures.