Leadership Failures Related to Training, Performance, and Productivity Deficits of a Provider at a Veterans Integrated Service Network 10 Medical Facility

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to concerns from the U.S. Office of Special Counsel involving a Veterans Integrated Service Network (VISN) 10 medical facility. A complainant alleged an ophthalmologist lacked training, provided substandard care, and failed to meet productivity expectations. Further, despite reported concerns, the Chief of Staff (COS) intended to reappoint the surgeon following the probationary period. The OIG substantiated the surgeon lacked adequate training to perform cataract and laser surgery as the surgeon did not satisfactorily complete an approved residency training program, was ineligible for board certification in ophthalmology, and did not meet the facility’s ophthalmologist hiring requirements. Several credentialing and privileging activities did not comply with Veterans Health Administration requirements and included inadequate primary source verification from foreign educational institutions and insufficient references attesting to the surgeon’s suitability to perform cataract surgeries. The surgeon was hired regardless. Staff concerns about the surgeon’s productivity, competency, and technical skills began within months of hire. The surgeon did not consistently demonstrate the skills to assure good outcomes, was unable to meet surgical productivity expectations, and surgery times exceeded norms. Retrospective clinical reviews by two VISN ophthalmologists reflected deficits. Despite these ongoing concerns, the COS endorsed the surgeon’s reappointment as the facility’s sole ophthalmologist. Multiple system and leadership failures allowed the surgeon to perform cataract surgery and clinic laser procedures without the required training and competency to do so. Once the surgeon’s deficits were identified, facility leaders were slow to respond. As a result, over a two year period, patients were placed at unnecessary risk for potential surgical complications. The surgeon’s employment was subsequently terminated. The OIG made five recommendations related to credentialing and privileging, professional practice evaluations, management of performance deficits, and the actions of the COS.