The VA Office of Inspector General (OIG) conducted a healthcare inspection after receiving a referral from OIG inspectors regarding facility leaders’ response to a report that a urologist had severe hand tremors and possibly low vision. The OIG identified two adverse clinical outcomes in 121 of the urologist’s surgical patients, neither of which required an increased level of care and did not result in long-term impact. The OIG determined the two complications were appropriately managed by the urologist, reported through the patient safety reporting system, and acted upon. Facility leaders failed to adequately oversee the urologist’s performance by not formally evaluating a report of the urologist’s physical impairments that could have posed a risk to patient safety. The facility conducted management reviews of the urologist, but deficiencies were identified in the processes used. Failures in facility leaders’ privileging processes led to delays in removing the urologist’s privilege to perform open procedures and a failure to inform the urologist of active privileges. Facility leaders were noncompliant with VHA directives that require reporting adverse privileging actions to the National Practitioner Data Bank and reporting patient safety concerns to state licensing boards. Consequently, patient safeguards intended to be achieved through reporting did not occur. Frequent personnel changes in facility-leader positions may have contributed to failures in oversight, privileging, and practitioner reporting processes. The noncompliance with facility and VHA policies likely occurred due to poor communication regarding the urologist’s practice and privileging status, a lack of knowledge of position responsibilities, and inexperienced support staff. The deficiencies found in the focused professional practice evaluation processes and National Practitioner Data Bank reporting were consistent with issues previously identified by the OIG. Duplicative recommendations were not made regarding these issues. The OIG made six recommendations to the Veterans Integrated Service Network 7 and facility directors.
Dublin, GA
United States
