Heart Transplant Program Review: Facility Leaders Failed to Ensure a Culture of Safety and the Section Chief Engaged in Unprofessional Conduct at the Richmond VA Medical Center in Virginia

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review allegations regarding the heart transplant program and the performance and behavior of the cardiothoracic section chief (section chief). The OIG also reviewed the temporary inactivation of the heart transplant program and factors associated with reactivation, and Veterans Integrated Service Network (VISN) and facility leaders’ responses to staff concerns about the heart transplant program.

The OIG did not substantiate that the section chief’s surgical patient outcomes, including morbidity and mortality rates, and the facility’s readmission rates statistically varied from national averages to warrant further assessment by the National Surgery Office.

The OIG was unable to determine whether the section chief had “incredibly long” cardiopulmonary bypass times and was not able to draw a conclusion regarding current versus historical cardiopulmonary bypass times for the section chief. The OIG noted facility staff performed a low volume of transplants, which may contribute to variations in outcomes.

The OIG substantiated the section chief repeatedly exhibited unprofessional conduct toward staff, and determined facility and surgical leaders failed to create a culture of safety to ensure staff felt comfortable reporting concerns.

The OIG found VISN leaders failed to ensure a timely quality of care review of cardiothoracic cases; however, the VISN Chief Medical Officer identified further concerns in the heart transplant program that were addressed promptly.

The OIG made two recommendations to the Under Secretary for Health related to a comprehensive review of the transplant program and oversight of quality measures; one recommendation to the VISN Director regarding completion of facility leaders’ requests for clinical care reviews; and three recommendations to the Facility Director including a clinical care review, a review of the section chief’s conduct, and a review of staff’s concerns and development of a culture of safety.