Haley VA center error cost patient's life, report says
The VA inspector general also cites flies in
operating rooms and contract
issues with USF
10/28/06
By PAUL DE LA GARZA, Times Staff Writer
TAMPA – One patient died at James A. Haley VA Medical Center because of an
error during surgery and some surgeries were canceled because doctors didn’t
show up, according to a report issued Thursday.
The findings also said the hospital’s operating room was closed twice because
of fly infestations and that staff responded by installing “suspended
electric flying insect traps.’’
In addition, the 31-page report by the Inspector General of the Department of
Veterans Affairs raised questions about the legality of a contract for
surgical services between the University of South Florida and Haley, the
nation’s
busiest VA hospital.
Investigators recommended that Haley review all contracts with USF to ensure
that the contracts are properly administered.
VA spokesman Phil Budahn said Thursday the agency already was taking
appropriate actions to address problems identified in the Haley investigation.
“We will continue to monitor the situation to ensure timely implementation of
these actions,” he said.
The inspector general began its investigation in February after stories in
the St. Petersburg Times revealed several allegations contained in an anonymous
four-page letter.
Separately, the VA recently completed an internal review of hospital director
Forest Farley. Results of that investigation have not been made public.
Investigators did not substantiate all of the allegations in the letter but
documented multiple problems. For example, investigators confirmed that a
patient died at the hospital during surgery in 2002 because of an employee
error.
The report provided neither the identity of the patient nor specifics of the
case. It did say Haley responded appropriately after the death.
“The medical center conducted an internal quality review; in addition, they
took appropriate actions based on their findings to prevent further occurrence,”
the report said. “The medical center also disclosed the event to the family.”
Investigators substantiated that surgeries routinely were delayed because
surgeons were not in the operating room.
In 2005, 5,423 surgical procedures were conducted. Haley recorded 1,040
surgical delays totaling 22,918 minutes, or about 15 days. In at least two cases
surgeries were canceled because the surgeon was not available.
The inspector general found that on two occasions managers closed the
operating room “because of the presence of flies.”
“Timely sanitary and pest control procedures were implemented, including
temporarily closing the OR to protect patient safety,” the report said. “The
Pest
Control Technician also responded immediately.”
Haley serves 435,442 veterans in a seven-county area. According to
investigators, it cannot meet patient demand with its eight operating rooms.
To improve operating room efficiency, Haley brought in a VA consulting team
from outside the region. The team “noted that the demand for services exceeded
the medical center’s capacity, signaling a rapidly approaching crisis.”
“We concluded that the surgical service was constrained by a staffing model
intended for an 8-hour day, an OR suite built to sustain a much lower case
load, and bed availability for a much smaller veteran population,” the report
said.
Haley is in the process of expanding to 10 operating rooms.
Investigators documented other problems in the operating room. They concluded
that some staff members were completing forms for monitoring anesthesia
before surgery instead of during surgery, as is required.
In addition, investigators substantiated that Haley’s anesthesiology service
was understaffed because Haley was unable to recruit anesthesiologists. The
problem was a shortage of anesthesiologists nationwide and low pay at the VA.
In the private sector, an anesthesiologist can earn between $282,212 to
$453,000 a year. At Haley, the pay scale ranges from $90,000 to $255,000.
Investigators concluded that the heart surgery program at Haley has a high
death rate but did not say what would be considered normal. To address the
problem, the inspector general recommended that the hospital perform surgeon
peer
reviews.
In the case of the contract with USF, the investigation concluded that the
workload at Haley was not sufficient to justify a $300,000 cardiovascular
services agreement with the university.
According to the report, Haley has entered into contracts with USF to provide
cardiovascular surgery services, including pre- and post-surgical
evaluations, treatment, and followup since 1995.
Since 1999, however, the hospital has hired staff surgeons, decreasing the
workload for USF physicians.
Investigators said that should have resulted in a decrease in the level of
services required under the contract with USF, but it didn’t.
“We concluded that the medical center was not receiving the level of services
paid for under the contract. We concluded that these contracts were not
awarded and administered properly for many years, which resulted in VA paying
for
services that were not needed and not provided,” the report said.
Investigators said the practice by Haley of paying USF physicians for
part-time work, in addition to the money they were getting under the contract,
amounted to “an improper supplementation of salary.”
Investigators said records show that the medical center was aware as early as
1996 that it was not receiving – and may not have needed – the level of
services paid for under the contract with USF.
“Nonetheless, the contract requirements remained unchanged,” the report said.
In response to the investigation, George Gray, the St. Petersburg-based VA
director for the southeast United States, said all three contracts between Haley
and USF would be reviewed.
In comments contained in the report, Gray also said Haley had taken a series
of steps to correct the problems identified by the inspector general, such as
hiring a scheduler to improve operations in the operating room and
implementing peer reviews.
In a statement late Thursday, USF spokeswoman Anne DeLotto Baier said USF
will cooperate with any review the VA conducts of contracts with USF.
Paul de la Garza can be reached at
delagarza@sptimes.
------------
VA Watchdog dot Org - VA NEWS FLASH - 10-28-06 #3
TAMPA VA ERROR LED TO VETERAN'S DEATH -- Plus: VAOIG report
tells of canceled surgeries because doctors didn't show up,
flies in the operating rooms and other issues.
Background here...
http://www.vawatchd
20newsflashes%
There are two VAOIG reports...
Here...
http://www.va.
And, here...
http://www.va.
Today's story here...
http://www.sptimes.
10/26/Tampabay/