Review of VISN 10 and Facility Leaders’ Response to Recommendations from a VHA Office of the Medical Inspector Report, John D. Dingell VA Medical Center in Detroit, Michigan

In response to a congressional request, the VA Office of Inspector General (OIG) inspected the John D. Dingell VA Medical Center in Detroit, Michigan (facility) to assess leaders’ progress toward implementation of recommendations from the VHA Office of the Medical Inspector (OMI). The OIG evaluated facility leaders’ actions related to High Reliability Organization (HRO) goals and Veterans Integrated Service Network (VISN) 10 leaders’ oversight of, and support provided to, the facility leaders.The OIG found concerns related to VISN and facility leaders’ corrective actions in response to 6 of the 10 OMI recommendations. (1) Facility leaders did not meet VHA requirements related to the supervision of post-graduate year -1 residents. (2) Facility leaders delayed taking a privileging action and missed opportunities for state licensing board (SLB) reporting. (3) The interim chief of surgery’s facilitation of morbidity and mortality (M&M) conferences was inconsistent. (4) The facility corrective action plan was deficient for the OMI recommendation regarding the reassessment of a Peer Review Committee member. (5) The VISN academic affiliations officer was not made aware of the OMI recommendation related to resident supervision, did not provide oversight to the facility’s surgical residency program, and did not ensure compliance with VHA policy. (6) The VISN surgical workgroup did not document vital information from the facility, which could have ramifications across other VISN facilities.The OIG identified additional concerns regarding stable and continuous leadership in the facility, the impact of leaders’ actions on HRO principles, and VISN oversight of, and support to, facility leaders. The OIG made four recommendations to VISN leaders and five recommendations to facility leaders. Recommendations addressed resident supervision, National Surgery Office review, National Practitioner Data Bank and SLB reporting, M&M conferences, VISN academic affiliations officer roles and responsibilities, VISN surgical workgroup, VISN oversight and support to the facility, and continued efforts towards HRO.