Report Summary

Title: VHA’s Response following Cardiac Catheterization Lab Closure at the Samuel S. Stratton VA Medical Center in Albany, New York
Report Number: 19-09129-76 Download
Issue Date: 2/17/2021
City/State: Albany, NY
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 an inspection to assess an allegation that the Cardiac Catheterization Lab (CCL) was closed due to concerns of risk to patients at the Samuel S. Stratton VA Medical Center (facility) in Albany, New York. The OIG did not receive a response from Veterans Integrated Service Network (VISN) 2 staff following an inquiry and subsequently opened the healthcare inspection.

The OIG substantiated that the CCL was closed due to concerns of risk to patients and determined the closure was in response to issues including use of improper clinical procedural techniques, personnel disputes, and a hostile work environment. A facility fact-finding review identified concerns with communication and team dynamics among staff and suspended CCL procedures.

The OIG found that VISN and facility leaders acted promptly to obtain unbiased assessments when they arranged for an external review of the CCL by the National Cardiology Program Office (NCPO). The NCPO made recommendations addressing the clinical judgment and technical skills of the CCL cardiologists. Facility leaders convened an administrative investigation board and initiated management reviews. Clinicians independent of the facility and well versed in interventional cardiology assessed the CCL cardiologists’ clinical competence. VISN and facility leaders decided that the CCL should remain closed indefinitely.

According to the NCPO, its role is typically confined to advising the Veterans Health Administration (VHA) and facilities on policy matters. In this instance, the offering of recommendations by NCPO extended beyond policy matters and addressed operations, including the safe resumption of interventional cardiology at the facility.

The OIG made three recommendations: two recommendations to the Under Secretary for Health regarding the designation of a VHA specialty leader in interventional cardiology and one recommendation to the VISN Director to review the circumstances that led to the failure to respond to an OIG inquiry.