Chief of Staff’s Provision of Care Without Privileges, Quality of Care Deficiencies, and Leaders’ Failures at the Montana VA Health Care System in Helena

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Montana VA Health Care System to assess allegations of the Chief of Staff (COS) providing pregnancy care without privileges, deficient care, and leadership failures. The OIG found that the COS practiced without privileges when providing pregnancy care for a patient during her second and third trimesters. The COS evaluated the patient for potential severe pregnancy-related conditions at the facility on two occasions instead of directing the patient to a community facility equipped to evaluate and manage obstetric care. The COS’s failure to follow evidence-based clinical standards for care placed the patient and fetus at risk. The OIG also identified opportunities for improvement in the COS’s management of another patient whose post-operative treatment included provision of an inadequate antibiotic and a delayed consultation. However, the OIG was unable to determine whether alternate management strategies would have resulted in a different clinical outcome. The OIG also found that the COS failed to perform expected preoperative testing for surgical procedures in 32 of 35 cases. The OIG found deficiencies in leaders’ oversight, resulting in a failure to detect quality of care concerns and act on known and substantiated concerns. Required ongoing professional practice evaluations were not completed for the COS, and privileging processes were not followed. The Facility Director did not initiate state licensing board reporting for the COS on two separate occasions, and failed to complete state licensing board reporting timely on a third, when reportable deficiencies were identified. The OIG made 10 recommendations related to ensuring alignment with VHA and facility policies, including those related to privileging, and maternity and pregnancy care; a review of care deficiencies to identify follow-up needs; processes for ongoing professional practice evaluations; timely completion of administrative actions; and state licensing board reporting.