Deficiencies in Invasive Procedure Complexity Infrastructure, Surgical Resident Supervision, Information Security, and Leaders’ Response at the Lieutenant Colonel Charles S. Kettles VA Medical Center in Ann Arbor, Michigan

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to surgical services, information security, and facility leaders’ response to patient safety concerns.

The OIG substantiated the facility lacked services required to support the assigned inpatient invasive procedure complexity designation. Waivers for these services were approved; however, the OIG found delays with waiver requests and a concern with failing to monitor timeliness of patient transfers. The OIG did not substantiate a failure to meet blood bank or surgical coverage requirements but identified concerns with surgical service leaders’ engagement with the blood utilization committee and facility leaders’ failure to consider an institutional disclosure.

The OIG was unable to determine if facility leaders failed to ensure on-site supervision of postgraduate year one (PGY-1) surgery residents. The OIG found inconsistencies with interpretation of Veterans Health Administration (VHA) policy and is concerned that the Office of Academic Affiliations guidance given to Veterans Integrated Service Network (VISN) 10 leaders regarding PGY-1 surgery resident supervision does not meet the policy’s intent.

The OIG substantiated facility leaders failed to ensure information security when physicians provided unauthorized VA computer access to residents.

The OIG did not substantiate surgeons failed to meet standards for postoperative documentation or that facility leaders were unresponsive to patient safety concerns. However, the OIG found concerns with the monitoring and sustainment of related action plans.

The OIG made three recommendations to the Under Secretary for Health regarding invasive procedure complexity infrastructure, supervision of PGY-1 surgery residents, and processes related to health profession trainee computer access; three recommendations to the VISN Director regarding invasive procedure waiver requests and resolution of patient safety concerns; and six recommendations to the Facility Director regarding facility surgical infrastructure and waiver requirements, blood utilization committee participation, institutional disclosure, operative documentation compliance, and information security.