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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Other Participating OIGs
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
23-02179-189
Report Description

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review how facility leaders’ actions may have impacted intensive care unit (ICU) coverage, patient care, and resident education at the VA Eastern Colorado Health Care System in Aurora (facility).The OIG was unable to determine whether facility leaders implemented surgical ICU changes without adequate planning in April 2022. However, the OIG found that the subsequent lack of ICU provider coverage for surgical patients adversely affected the provision of cardiothoracic (CT) surgical services. CT surgeries were paused from September 2022 through August 2023 and the newly appointed Chief of Staff failed to notify VA Central Office through the Veterans Integrated Service Network (VISN) of the pause. The OIG substantiated that leaders’ actions to change the medical ICU from an open to a closed model were made without adequate planning and input from service and section leaders and staff. The OIG substantiated that the sudden implementation of a closed ICU model resulted in a lack of ICU resident supervision and an ineffective teaching environment for residents. The OIG did not substantiate that the medical ICU model change resulted in patient harm; however, the OIG identified a deficiency in the facility’s completion of a root cause analysis.The OIG made one recommendation to the Under Secretary for Health to evaluate the VISN leaders lack of awareness of the CT surgical pause; three recommendations to the VISN Director related to CT surgeries, facility high reliability organization implementation, and residents’ education needs; and two recommendations to the Facility Director related to call escalation and root cause analysis training.

Report Type
Inspection / Evaluation
Location

CO
United States

Number of Recommendations
0
Questioned Costs
$0
Funds for Better Use
$0

Open Recommendations

This report has 4 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The Under Secretary for Health evaluates the circumstances that led to Veterans Integrated Service Network leaders lack of awareness of the 11-month curtailment of cardiothoracic surgeries and takes action as needed to ensure effective Veterans Integrated Service Network oversight of facility clinical operations.

03 No $0 $0

The Veterans Integrated Service Network Director ensures facility leaders implement high reliability organization principles to plan for clinical operation changes that include stakeholders, service and section leaders, and staff input.

04 No $0 $0

The Veterans Integrated Service Network Director ensures that the educational needs of the facilitys residents are evaluated and maintained during service and program changes, including on-site supervision, as required by Veterans Health Administration directive.

06 No $0 $0

The VA Eastern Colorado Health Care System Director reviews root cause analysis requirements for interviewing individuals relevant to root cause analyses and ensures staff are trained accordingly.

Department of Veterans Affairs OIG

United States