Review of Clinical Care and Behavior Concerns about Two Surgeons at the Martinsburg VA Medical Center in West Virginia

The VA Office of Inspector General conducted a healthcare inspection of the Martinsburg VA Medical Center (facility) to assess leaders’ response to clinical care and behavioral concerns involving two surgeons. The inspection was initiated after staff raised concerns about the two surgeons’ surgical competency, outcomes, and behavior. 

The OIG found that leaders generally followed required procedures when clinical care concerns were raised about both surgeons. Leaders initiated privileging action, conducted quality and clinical reviews, and restored privileges when indicated. One surgeon underwent a focused clinical care review that identified substandard care and resulted in a focused professional practice evaluation. That surgeon later completed the evaluation and moved to ongoing monitoring.

Although leaders carried out required privileging actions, the OIG found delays in the peer review process. Veterans Health Administration policy requires timely designation of peer reviews as confidential quality management activities, but the time between identifying cases and completing the necessary documentation by the facility exceeded required limits. These delays reduced opportunities for timely assessment and improving the quality of patient care.

Leaders complied with requirements for institutional disclosures. They conducted an electronic health record lookback of hundreds of surgeries performed by one surgeon, identified cases involving serious adverse events, and completed institutional disclosures when required.

The OIG also reviewed the two surgeons’ behavior concerns. The chief of surgery addressed disruptive behavior associated with one surgeon but did not assess an allegation involving the second surgeon, contrary to VA policy and facility bylaws. 

The OIG made two recommendations, and the Facility Director concurred with both. The Facility Director reported a process to ensure timely initiation of peer reviews will be implemented and stated that appropriate action was taken after assessing the allegations regarding the second surgeon’s behavior.