Facility Leaders’ Oversight and Quality Management Processes at the Gulf Coast VA Health Care System in Biloxi, Mississippi

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to an allegation that a thoracic surgeon (surgeon) provided poor quality of care to five patients. Two other allegations received were addressed in an OIG report published in 2018, Inadequate Intensivist Coverage and Surgery Service Concerns (Report No. 17-03399-150). The surgeon was no longer at the facility. Care concerns identified in two of the five patients had been addressed. The OIG determined that before hiring the surgeon, facility leaders were aware of licensure and malpractice issues, including the relinquishing of a state medical license to prevent continued prosecution in a disciplinary case. Facility leaders were deficient in granting and continuing the surgeon’s clinical privileges without required evidence of competency. Errors during the removal process for the surgeon prevented reporting to the National Practitioner Data Bank and delayed reporting to state licensing boards. The OIG noted weaknesses in quality management processes including the credentialing and privileging of other providers, documentation of basic and advanced cardiac life support certification, administrative closure of electronic health record notes, posting of confidential data to the facility’s internal website, adverse event reporting, completion of institutional disclosure, and administrative investigation board timeliness. The OIG made 18 recommendations related to professional practice evaluation processes, National Practitioner Data Bank and state licensing board reporting, documenting sufficient detail in committee meeting minutes to reflect decision-making, and protecting certain confidential information. Recommendations also centered on reporting events to the Patient Safety Committee, reporting surgery patients’ deaths as required, completing proactive risk assessments, and institutional disclosure and administrative investigation board review processes.