Deficiencies in Credentialing, Privileging, and Evaluations for Surgeons at the St. Cloud VA Medical Center in Minnesota

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate facility leaders’ response to surgical care concerns related to two facility surgeons at the St. Cloud VA Medical Center (facility) in Minnesota.

The OIG found facility leaders generally met the Veterans Health Administration requirements for summary suspension notifications and initiation of focused clinical care reviews (FCCR) for the surgeons. However, the OIG identified concerns related to clinical privileges and professional practice evaluations for the medical staff.

The OIG determined that the surgical service chief failed to ensure that one surgeon’s application for privileges included recent surgical case volume and case mix as required. Additionally, although the focused professional practice evaluation plan for monitoring the surgeon included direct observation, the surgeon was not directly observed to ensure competency with surgical procedures. The OIG determined that facility leaders failed to initiate reporting of the surgeon to the state licensing board (SLB) when clinical care concerns were identified in the surgeon’s FCCR.

The OIG found facility surgeons’ ongoing professional practice evaluations reviewed only procedures completed in the surgical outpatient clinic and did not include the evaluation of operating room surgical procedures. The OIG is concerned that the failure to include all aspects of the surgeons’ practice limited facility leaders’ ability to ensure the effectiveness of the professional evaluation processes and processes used to monitor the quality of surgical care.

The OIG found that the surgical service chief was clinically inactive for the first two years of employment. As a result, facility leaders had no ability to ensure the competent clinical performance of the surgical service chief.

The OIG made four recommendations to the Facility Director related to comprehensive review of surgical service credentialing and privileging processes, professional practice evaluations, and SLB reporting processes.