The Department of Veterans Affairs says the Hampton VA Medical Center is working to address a string of failures identified in a recent federal watchdog report.
In a report released last week, the Office of the Inspector General (OIG) for the U.S. Department of Veterans Affairs identified problems at the medical center related to surgical services and how leadership there addressed quality management concerns.
“We take allegations of oversight and misconduct seriously and have strengthened our policies and procedures to ensure consistent, high-quality care from licensed professionals,” said Terrence Hayes, the VA’s press secretary, in a Tuesday statement. “We plan to fully implement all recommendations by December.”
The Hampton facility recently confirmed it was replacing several top officials, including its director, chief of staff and chief of surgery.
The OIG launched its review following multiple complaints it received about the center in 2022.
“We got some concerns about surgical quality so we engaged with the facility trying to get some response,” said Julie Kroviak, the department’s principal deputy assistant inspector general for health care inspections. “We then sent further questions to the regional office — and after that we just became more concerned about the quality review processes.”
Kroviak said the report can get a “little bit technical” but shouldn’t be dismissed.
“I think it can be written off as ‘Oh just some detailed processes weren’t followed by clinical leaders.’ But those processes are so critical to the foundation of a patient’s safety program,” she said. “If the highest levels of leadership are not aware of them, truly not aware of them, there are so many places for things to go seriously wrong.”
For example, the report found that after concerns were raised about patient safety, facility leaders issued a summary suspension of the assistant chief of surgery’s clinical privileges in January 2023. But it says the surgeon’s clinical privileges were restored after facility leaders failed to follow required protocol. The surgeon transferred to another VA health facility in June 2023, which “precluded facility leaders from correcting the process, including initiating additional actions,” the report states.
The Hampton center serves southeastern Virginia and northeastern North Carolina. From Oct. 1, 2021, through Sept. 30, 2022, the center served more than 66,000 patients.
The report states OIG received a complaint, which included five patient case examples, in December 2022 that the assistant chief of surgery provided poor surgical care and that the chief of staff was aware of the concerns but did not address them.
After OIG requested additional information, the Veterans Integrated Service Network responded and said the facility conducted a focused clinical care review of 15 cases performed by the assistant chief of surgery. It found six cases did not meet the standard of care and four of those had intraoperative complications, including one patient who experienced a laceration of the liver and another who underwent surgery in concerningly close proximity to having received chemoradiation therapy.
The report states OIG opened its hotline inspection in May 2023. During this review, widespread failures and deficiencies were identified related to facility leaders’ responses to care concerns and subsequent privileging actions involving the assistant chief of surgery, professional practice evaluations of surgeons, surgical service quality management and institutional disclosures.
“The findings identified through this inspection highlight not only failures of facility leaders to ensure that the required processes were appropriately implemented, but also a lack of leaders’ basic understanding of the processes that support delivery of safe health care,” the report states.
The report provided a dozen recommendations, including that summary suspensions, clinical care reviews and proposed revocation of privileges are conducted in accordance with the requirements and policies of the Veterans Health Administration. It further advised the center to ensure that ongoing professional practice evaluations include documentation of all conclusionary outcomes.
In his statement, Hayes said the VA fully supported OIG’s findings.
Hayes said a new team is meeting bi-weekly to address OIG’s recommendations with a target year-end completion goal. He said the facility has introduced a new reporting tool to track clinical care metrics, suspensions, privilege changes, state board reports and ongoing evaluations. Additionally, the facility has initiated monthly patient risk meetings in surgery services.
Hayes noted Michael Harper is taking on the role of acting medical center director until Aug. 5. Harper will then be replaced by Walt Dannenberg, who currently serves as the medical center director of the Long Beach VA Medical Center in California. Hayes said the leadership changes were done to “align with the VA’s commitment to high-reliability principles” but were not directly related to the report.
The House of Representatives’ Committee on Veterans’ Affairs also recently completed an investigation into the Hampton VA Medical Center after lawmakers said they received credible complaints about patient safety concerns and medical incompetence. As a result of the investigation, the committee announced last week that the center was making a series of personnel changes.
Katie King, katie.king@virginiamedia.com
