BILOXI, Miss. (WLOX) - What started as an investigation into a claim of improper care against a VA surgeon ended with authorities finding multiple infractions by facility leaders at the Biloxi VA.
That led the Office of the Inspector General to expand its investigation from the surgeon to the entire Gulf Coast facility and its oversight process. Ultimately, the OIG would make 18 recommendations for the Biloxi veterans hospital to follow.
The OIG began investigating after five allegations involving the quality of care given by the thoracic surgeon in question were made. After two of those allegations were addressed, the OIG focused on the third claim, opening its first investigation in 2017. No criminal action was taken at that time, but just five months later, an investigation into the VA’s overall management processes found deficiencies.
The OIG determined that the thoracic surgeon in question did not have the proper credentials when he was hired in August 2013. However, facility leaders were aware of those licensure issues and that the surgeon had previously relinquished his medical license in 2006 after facing a malpractice lawsuit.
Despite those red flags, the VA's facility director and credentialing committee approved the surgeon's medical staff appointment. Furthermore, the hiring board did not keep any written records or documentation that noted those occurrences and why they moved forward with giving him medical privileges, clearly going against the credentialing and privileging procedures governing all Veterans Health Administration facilities.
Facility leaders also did not have a clear understanding of the requirements for reviewing the surgeon’s care provided when interviewed by the OIG.
The surgeon was removed from clinical care in October 2017, which was also done without following the required processes, such as reporting the change to external agencies like the state licensing board and the National Practitioner Data Bank. In December of that same year, he resigned, leading to more violations of policies put in place to maintain quality care and generally accepted standards of practice.
The investigation led the OIG to review service files for 50 new physicians who were hired between October 2016 and December 2017. In doing so, the OIG found, among other things, that that 14 of the 50 service files lacked documentation. Several other weaknesses were identified, as well.
Many of the issues were attributed to changes in leadership and multiple instances of quality management failures by facility leaders that appeared to be due to lack of knowledge or understanding of the VHA policies. The OIG set forth 18 recommendations to be implemented by the facility in regards to professional practice evaluations, reporting to external agencies, documenting committee meeting minutes in detail, reporting events to the Patient Safety Committee, reporting surgery patients' deaths as required, completing proactive risk assessments, and institutional disclosure and review processes.
The Gulf Coast Veterans Health Care System said they have since taken action on all of the recommendations made by the OIG.
“We appreciate the Office of Inspector General’s (OIG) oversight, which focuses on an individual who no longer works for VA and events that occurred more than two years ago," said the VA’s acting public affairs officer Cindy Dorfner in a written statement.
Since the investigation, Dorfner said the Biloxi facility has made many improvements, including: conducting top-to-bottom reviews for 2018 and again in 2019 to ensure all providers are in good standing, implementing a best-practice process to ensure that providers have disclosed all licenses into their credentialing process; and, establishing an internal tracking tool to keep close tabs on all licensure/certification/registration/malpractice actions for providers.
To read the 53-page report from the OIG in full, click HERE.