Following allegations of threats to patient safety and a lack of quality care from the former chief of surgery at the John D. Dingell VA Medical Center in Detroit, the VA Office of Inspector General published findings July 18 from its recent inspection highlighting 10 areas with deficiencies that require improvement.
"During the inspection, the OIG identified concerns surrounding past facility leaders' failure to incorporate High Reliability Organization practices, including bi-directional communication, governance and policy management, and promoting a psychologically safe environment…," the report reads.
It also found "additional concerns related to instability in facility leadership, the impact of leaders' actions on HRO principles, and [Veterans Integrated Service Network] oversight of, and support to, facility leaders."
Specifically, regarding concerns and allegations surrounding the former chief of surgery, Gamal Mostafa, MD, the Detroit News reported there were 16 separate instances of substandard care in which other leaders at the facility could have reported him — but failed to do so — to the medical boards he is licensed by, thus delaying the revocation of his licenses.
The latest report follows two others conducted in 2021 and 2022 by the Office of the Medical Inspector that at the time resulted in multiple recommendations related to oversight of surgical services, and quality reviews.
The new report features multiple recommendations to bring the facility back into compliance with completion dates ranging from Oct. 31, 2023, to early 2024. The report says that the facility must:
- Comply with adequate resident supervision, specifically of post-graduate year one on-site direct supervision.
- Review the reports to develop and implement a comprehensive and sustainable response to the recommendations outlined.
- Ensure all leaders at the facility meet data bank and licensing requirements outlined by national and state boards.
- Ensure that the chief of surgery has oversight of morbidity and mortality conferences.
- Have any level three peer review cases reviewed by a neutral VA peer review committee.
- Create a way for the academic affiliations officer to be fully aware of all assigned roles and responsibilities of leaders.
- Undergo surgical workplace reviews and subsequently implement action plans to bring the facility back into compliance.
- Develop plans for adequate oversight and leadership even during transitions.
- Review and revise organizational communication channels and practices.