Concern Regarding a Patient Death and Alleged Conflicts of Interest at the VA Western Colorado Health Care System, Grand Junction

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations regarding a patient death following a urology procedure and conflicts of interest in hiring urologists at the facility. A facility urologist performed extracorporeal shock wave lithotripsy (ESWL) on a patient who died 25 days later. The patient did not have significant risk factors and was a suitable candidate for ESWL. The OIG found an abnormal pathology blood smear result in the electronic health record for the patient. The ordering provider failed to consult with the facility pathologist and address the abnormal pathology blood smear result with the patient. Several urologists were hired from a private practice that was associated with the Associate Chief of Staff for Acute Care Services (ACOS), which could be considered a violation of standards of ethical conduct for VA employees. However, the OIG determined that facility leaders other than the ACOS approved the hiring of the urologists to meet the needs of the facility and patients. The ACOS did not sign recruitment requests for the urologist positions. Urologists hired by the facility had ownership in a company associated with ESWL rental equipment. The OIG was unable to determine an increase in ESWL procedures was due to the urologists’ ownership interest in the company. Facility leaders were aware of the potential conflict of interest and sought guidance from the VA Office of General Counsel. Although the General Counsel found “no actual conflict of interest” given the facts offered, the OIG found that these facts may have contained inaccurate statements. The OIG found no evidence that facility urologists failed to respond when on call. The OIG made two recommendations relating to abnormal blood smear results and conflicts of interest.