Breadcrumb

VHA’s Response following Cardiac Catheterization Lab Closure at the Samuel S. Stratton VA Medical Center in Albany, New York

Report Information

Issue Date
Report Number
19-09129-76
VISN
2
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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.

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 Under Secretary for Health should publish written guidance that clarifies roles and responsibilities of the national Cardiology program office, Veterans Integrated Service Networks, and Chief Medical Officers to review and opine on interventional cardiologist applicant’s qualifications for employment in those cases when facilities lack local interventional cardiology expertise and the facility’s Chief of Staff seeks subject matter expert opinion.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network Director reviews circumstances that led to the failure to respond to an OIG request for additional information and alters the person-dependent process accordingly to ensure future OIG referrals are responded to timely and completely.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network Director reviews circumstances that led to the failure to respond to an OIG request for additional information and alters the person-dependent process accordingly to ensure future OIG referrals are responded to timely and completely.