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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
24-00194-42
Report Description

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess facility leaders’ responses to a dermatologist’s deficiencies in quality of care and documentation. The OIG found supervisory staff and senior leaders failed to adequately address patient care concerns outlined by staff in 48 patient safety reports and two consecutive unsatisfactory proficiency reports. Specifically, supervisory staff failed to correct the dermatologist’s delays in performing biopsies and misuse of copy and paste in electronic health records, and did not comprehensively review whether the dermatologist documented procedures not performed. 

The Chief of Staff (COS) reported being unaware of the extent of the dermatologist’s deficiencies, despite attending meetings where the information was shared. The Facility Director did not ensure timely initiation of the State Licensing Board (SLB) reporting process after facility leaders had evidence to support the dermatologist’s failure to meet standards of clinical practice and the Medical Executive Board’s recommendation to not renew clinical privileges.

The COS told the OIG that reviews of the dermatologist’s care were completed, and disclosures were not warranted because no patient harm was identified. However, the OIG found that the reviews were neither comprehensive nor conducted by a dermatologist. Additionally, after the OIG site visit, the chief of dermatology reviewed electronic health records and identified that two patients should have received alternative treatments, one patient did not have all identified lesions addressed, and four patients experienced biopsy delays. Therefore, the OIG concluded that further reviews of the care provided by the dermatologist and reconsiderations for disclosures are warranted. 

The OIG made eight recommendations related to delays in the SLB reporting process, and leaders not adequately addressing clinical deficiencies, misuse of copy and paste, documentation of procedures, and the need for follow-up care and disclosure.

Report Type
Inspection / Evaluation
Location

AZ
United States

Number of Recommendations
8
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No

Open Recommendations

This report has 8 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The Carl T. Hayden Medical Center Director ensures that supervisory staff take effective actions to correct clinical deficiencies.

02 No $0 $0

The Carl T. Hayden Medical Center Director identifies electronic health records containing the dermatologists misuse of copy and paste and takes action as warranted to ensure the safety of patients.

03 No $0 $0

The Carl T. Hayden Medical Center Director ensures that service chiefs and patient safety staff report instances of misuse of copy and paste to Health Information Management System staff.

04 No $0 $0

The Carl T. Hayden Medical Center Director ensures a comprehensive review is conducted to determine if the dermatologist documented electrodesiccation and curettage procedures that were not performed and takes action as warranted, including providing patients with clinical care and disclosures if needed, and notifying the Office of Inspector General.

05 No $0 $0

The Carl T. Hayden Medical Center Director ensures that the Chief of Staff is aware of and addresses pervasive deficiencies, when they exist, in clinical care provided at the facility.

06 No $0 $0

The Desert Pacific Healthcare System Network Director evaluates reasons for noncompliance with the state licensing board reporting policy with regard to the dermatologist, and takes action as needed.

07 No $0 $0

The Carl T. Hayden Medical Center Director ensures that a dermatologist conducts a review of the dermatologists patients with consideration of the concerns laid out in this report, to identify patients who may need follow-up care and disclosures, and takes action as warranted.

08 No $0 $0

The Carl T. Hayden Medical Center Director reviews with facility leaders, disclosure requirements outlined in VHA Directive 1004.08, Disclosure of Adverse Events to Patients.

Department of Veterans Affairs OIG

United States