Deficiencies in Facility Leaders’ Summary Suspension of a Provider and Patient Safety Reporting Concerns at the VA Black Hills Health Care System in Fort Meade, South Dakota

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate facility leaders’ response to an alleged impairment of a general surgeon (subject provider) and assess concerns with patient safety event reporting at the VA Black Hills Health Care System (facility) in Fort Meade, South Dakota. The OIG found facility leaders failed to issue a summary suspension of the subject provider’s privileges when removing the provider from patient care. Factors that may have contributed to the facility leaders’ failure to issue a summary suspension included misunderstandings of policy regarding summary suspensions; an initial presumption that the subject provider’s actions were conduct related and that privileging actions were not indicated; and facility leaders were waiting for upcoming changes to the Veterans Health Administration’s (VHA’s) privileging policy for privileging actions. Because the concern for patient safety reached the level of removing the subject provider from patient care, the Facility Director was obligated to issue a summary suspension when the concerns were identified. The OIG is concerned that the misunderstanding of policy and failure to suspend privileges allowed the subject provider to engage in patient care, potentially placing patients at risk of harm. The OIG found that facility leaders failed to complete a focused clinical care review. Since facility leaders did not conduct a comprehensive review of the care provided by the subject provider, there were limited opportunities to identify additional incidents of potential clinical care concerns and to assess for harm. It was also determined by the OIG that facility surgical staff did not consistently report patient safety events in the joint patient safety reporting system. The OIG made three recommendations to the Facility Director related to VHA policy for conducting summary suspensions and related privileging actions, focused clinical care reviews, and evaluation of patient safety reporting processes.