Veteran Oversight Now

Fred Baker:
Welcome back to another episode of Veteran Oversight Now an official podcast of the VA Office of Inspector General. I'm your host, Fred Baker.
Each month on this podcast, we'll bring you highlights of the OIG’s recent oversight activities and interview key stakeholders in the office's critical work for veterans. This is a special hotline edition of Veteran Oversight Now and joining us today is Trina Rollins. Trina is the director for Hotline Coordination within the VA IG's Office of Healthcare Inspections. Trina is a board-certified physician assistant who worked at the VA North Texas Health Care system for eight years prior to joining the VA OIG in 2011.
Welcome, Trina.
Trina Rollins:
Thanks, Fred. I'm glad to be here.
Fred Baker:
Well, thank you again and we appreciate your insight and we're excited to be here for another hotline edition of this podcast. Today we're here to talk about the report Leaders Failure to Resolve Cardiology Department Challenges at the VA Medical Center in Indianapolis, Indiana. As we normally do, Trina, if you don't mind, please describe the size of the facility, the services it provides, and then kind of how it compares to other VA facilities.
Trina Rollins:
Okay. So, this facility is part of VISN 10 and is classified as a level one, a high complexity facility. It provides acute inpatient, medical surgical and rehabilitation care as well as outpatient primary and specialized services such as comprehensive cardiac care. I do want to point out this facility is affiliated with over 59 academic institutions, including the Indiana University School of Medicine. And that's going to be important as we talk about that.
Fred Baker:
We’re going to talk about that.
Trina Rollins:
Yeah, and it provides education to more than 2500 students each year.
Fred Baker:
Wow. So, this is not our first inspection specific to this department, correct?
Trina Rollins:
Unfortunately, not. It's not our first and this facility has had other officers also do some work related to the cardiology department.
Fred Baker:
So, talk about some of the previous chronic issues with this department and how far they go back.
Trina Rollins:
Yeah, I mean, we can go back to October of 2019. The Office of Medical Inspector conducted an inspection at that time in designating allegations about the facility's leadership. And what they did identify regarding cardiology was that it was very concerning about the number of losses—meaning the providers losses—and they were having recruitment difficulties and then concerns with leadership training amongst the cardiology leadership and excessive on call hours, which was limiting the ability to maintain a cardiology practice.
You know, part of those long call hours can be detrimental to hiring. In 2020, OIG was there, and we published a report showing that there were continued staffing challenges within the cardiology department and identified high levels of cardiology turnover. Later in 2020, the National Cardiology Program Office from VACO actually did a site visit and again noted that the facility had been faced with evolving leadership, chronic turnover, and severe physician understaffing in the cardiology program and had also had temporary loss of their cardiothoracic surgery program at that time.
We, as an OIG, came back again in January of 2023 and while doing an inspection, noted that the cardiology department still had these issues, including ineffective leadership and cardiology staffing shortages.
Fred Baker:
So, these are very significant challenges then. Two questions before we get into why we initiated the new inspection and what we found. First of all, what was the size of this cardiology department?
Trina Rollins:
So, yeah, when the National Program Office came and did their site visit, they recommended a staff of seven full time cardiologists, in that seven is three general cardiologists and then four specialty cardiologists, which would be electrophysiologist and interventional cardiologist. On top of that, there would be a cardiology chief and then four nurse practitioners that specialized in cardiology care. So, a total of 12 staff.
Fred Baker:
With these repeated challenges over time. Before we get into what caused those and what we found, how can these challenges in leadership and staffing affect patient care?
Trina Rollins:
So, again, you know, with this, the staffing turnover makes the stability of the department unstable, and it causes increased workload for those staff that are still present and causes low morale. You know, when the cardiology positions are low, then the services they provide are low. They're not able to do these interventional cardiology procedures or do the cardiac cath and if they're not able to do that, that impacts the nursing staff that staff those areas. Those staff they're there full time. If there's no procedures to do, then they're pulled to other departments within the facility in order to keep their full-time staff working. And then again that impacts their morale as well because they're cardiology specialists. They want to work in cardiology and they're not as comfortable working in other areas of the hospital. But, so again, as that ripple effect happens, it overall impacts the care that the patients receive. Some of the care just wasn't available anymore because they didn't have the cardiologist available.
Fred Baker:
Well, yes. So, what initiated this new inspection that we did and what was behind this turnover and lack of permanent leadership.
Trina Rollins:
So really, the reason we opened it up is just because of the continued problem. From 2019 forward to 2023, we're seeing this continued issue with the cardiology departments. So, we felt it was a good time to just take another in-depth look at it. As the inspectors were doing their work speaking with some of the former cardiologist, the staff at work, their high turnover was an impacting factor because that increased their workload. And, you know, in some aspects, the salary was lower than what it was in the community. If the national Cardiology Program Office noted that the veteran care would not be sustainable because of the continued turnover in that department. And they recommended and tried to suggest to the facility leadership long term that they needed to find a way of making this department more stable.
Fred Baker:
So let me ask one point of clarity. So, it's well known that VHA has staffing issues, the same as in the many facilities in the community have. Everyone's you know, fighting for the same medical staff? Is this a problem at this facility or do other cardiologists, facilities at other VHA medical facilities have the same problem?
Trina Rollins:
It is. You know, cardiology is a subspecialty of medicine. And again, these specialists take a lot of time to train, and their resources are scarce and so when cardiologists are available, like you said, you've got multiple hospitals competing to try and get them to come on board.
Fred Baker:
So then is so if everyone has the same kind of competition, was it just really a leadership issue that made it so bad here?
Trina Rollins:
Well, we can partly tie it back to the breakdown in the relationship with the university affiliate.
Fred Baker:
I was going to ask that. So, let's talk about that then first. What is the purpose, the nature of those affiliates and then what happened to cause it to break down?
Trina Rollins:
Yeah, it's as I pointed out, the facility trains a lot of students each year. And part of that helps with recruitment of medical staff moving forward. So, again, if you've got this really positive relationship with the university affiliate who are sending over staff to be trained, you know, there's a good possibility that they can help recruit those same staff to come and work for the facility after their training is over. I do want to point out that federal law requires VA to develop and carry out programs of education and training for health personnel for its own needs, as well as the needs of the nation. And it's one of the statutory missions of VA to conduct education and training programs for students and residents from a variety of health care professions. Again, that enhances the quality and timeliness of health care provided to veterans.
Fred Baker:
So, didn't we also cite a lack of permanent leadership?
Trina Rollins:
Yes, the leadership turnover impacted this whole situation as well. You know, executive leadership is the chief of staff, for instance, is responsible for the care under the chief of staff's umbrella. They need to have awareness of it. But if that person is rotating out, how much background information are they getting about the problems that have occurred or that could still be brewing in the department?
Fred Baker:
And let's back up real quick to the affiliate issue. How did that break down? We didn't discuss that. We got the importance of it. But how did it break down?
Trina Rollins:
Yeah, you know, the affiliate some of the explanation that we were getting was it was related to the previous chief of cardiology and the relationship there was not productive. And so, the affiliate started backing out when the fellowship learners, the actual students, started complaining to the university affiliate, about problems such as loss of providers and the decreased number of services available, the university pulled their students because they had to guarantee a proper training for those students. So, you can see the ripple effect of the loss of the cardiologists, the loss of number of services and then now the loss of the actual students.
Fred Baker:
So, what were our findings?
Trina Rollins:
All right. So, with this, we made, again, recommendations to both the VISN and the facility for the VISN, we wanted them to, you know, to strengthen their oversight of the cardiology department and any actions taken and then assure the sustainability of those actions. VISN 10 reported to the OIG that they would be providing oversight of the facilities plan to strengthen and maintain the cardiology department's relationship with the university affiliate, and they would be getting those updates quarterly in committee. And then we also made recommendations to the facility director to reconcile the national Cardiology Program Office to do another site visit, because, again, the needs have changed since their site visit back in 2020. And then that in turn would help the facility determine what additional support or resources is needed now.
Fred Baker:
Have they put any new permanent leadership back in place?
Trina Rollins:
Yes. So, the chief of staff is stable. The new chief of cardiology is in place. And so, again, that part has shown some stability now.
Fred Baker:
So, were they responsive to our recommendations?
Trina Rollins:
They were. I mean, they admitted there have been issues. Obviously, you know, we had four different reports from different entities showing there were problems. And they admitted that, yes, this was a sustained issue. But again, I think, you know, with the VISN overseeing part of this, the National Program Office being part of the solution as well, by doing another site visit and making recommendations on what type of support the cardiology department would need to be successful in the future, it looks like they're on the right track to make a positive change.
Fred Baker:
So that's what I was going to bring up. We track these recommendations, and we keep them open until we're satisfied that they're met. What are their plans of action. Are we confident that the same problems won't be repeated or that will be.
Trina Rollins:
You can't say, yeah, I can't give you any level of confidence, but I will let you know. You know that OIG, we will not close a recommendation until the facility and the VISN has shown sustainable change and progress. Again, it's not just putting something into place, that doesn't take care of the recommendation. You've actually got to show data to us that there is sustainability to that change.
Fred Baker:
And finally, are there any broader lessons learned here for maybe the other VISNs?
Trina Rollins:
I mean, overall, I think it shows the importance of having stable leadership, you know, with stable leadership comes the ability to assess problems in the departments that you're running and to predict some of those problems and head them off before they actually occur. I think, you know, everyone or every facility can take a look and say, you know, if they're having turnover in a department, really take a look at it and find out why. How is that impacting the staff that are still at your facility? And, you know, and in this case, how did it impact the university affiliate?
Fred Baker:
Right. That seems like it was very significant with respect to that turnover.
Trina Rollins:
It is. I mean, because, again, once the relationship was repaired, that university affiliate actually helped recruit additional cardiologists for the facility. So, they're continuing to help find a cardiologist to staff the department. And so, again, you know, if you've got that positive relationship with your university affiliate, it's going to be positive for the facility.
Fred Baker:
And that's good news for the veteran.
Trina Rollins:
Exactly.
Fred Baker:
Well, Trina, as always, thank you very much for your insight. We appreciate it. Is there anything else you would add?
Trina Rollins:
No, just thank you so much for the opportunity.
Fred Baker:
All right. Thanks, Trina. As mentioned in this podcast, you can submit a complaint to the VA OIG by phone 1-800-488-8244 or you can go to our website www.vaoig.gov/hotline and fill out a hotline complaint there. However, if you are a veteran in crisis or someone who is concerned about one, please call the Veterans Crisis line. Dial 988 and then press one. Now let's go to Lauren for the highlights of our oversight work for this past month.
Lauren O’Connor:
Thanks, Fred. The VA OIG stayed busy in February as work related to VA's electronic health record modernization efforts continued. Our Deputy Inspector General, David Case, testified before the House Committee on Veterans Affairs on February 15th. Speaking to members of the Subcommittee on Technology Modernization, he focused on VA's progress toward resolving issues with the pharmacy functions of the new electronic health record, or EHR. He previously previewed the findings in three upcoming OIG reports about the system, including shortcomings in pharmacy related patient safety issues and the EHR’s appointment scheduling package.
David Case:
As of September 2023, there have been approximately 250,000 veterans who either received medication orders and or had medication allergies documented in the new EHR. They may be unaware of the potential risk for a medication or allergy related event if they visit a legacy EHR site.

Lauren O’Connor:
He also discussed the OIG’s concern that the Veterans Health Administration is requiring mental health staff at new EHR sites to make fewer attempts to contact no show patients than required at EHR sites using the legacy system. Visit our website to review all published EHR related reports and stay tuned for upcoming reports covering this topic.
Also, testifying before Congress was Brent Arronte, our deputy assistant inspector general for audits and evaluations. He spoke to members of the House Veterans Affairs Subcommittee on Disability Assistance and Memorial Affairs on February 14th. Dana Sullivan, a director of the OIG Claims and Appeals Division, joined him.
Mr. Arronte’s testimony focused on the OIG findings and recommendations regarding overpayments, underpayments, and other improper payments in VA's compensation and pension programs.

Brent Arronte:
Despite the dedicated work of VA personnel, the OIG body of work on VA's compensation and pension programs has found that improper payments are often caused by ineffective internal controls and inadequate technology or human error resulting from complicated and unclear policies and guidance.

Lauren O’Connor:
Find both written statements as well as recordings of their opening statements on our website under the Congressional Relations tab.
Turning to investigations, the Department of Justice announced that an opioid manufacturer Endo Health Solutions Inc. will pay a criminal fine of over $1 billion, a civil settlement of $475 million and criminal forfeiture of $450 million. The manufacturer also agreed to plead guilty to a misdemeanor charge of violating the Federal Food, Drug, and Cosmetic Act by introducing misbranded drugs into interstate commerce. A multi-agency investigation determined that the manufacturers sales representatives marketed their opioid drug to prescribers by touting the medication’s purported abuse deterrence, tamper resistant, and crush resistance despite a lack of clinical data supporting those claims. The manufacturer also partnered with a consulting company to devise a marketing scheme that targeted healthcare providers that the company knew were prescribing their opioid for nonmedically accepted purposes. The loss to federal healthcare programs is approximately $208.5 million, of which the loss to VA is approximately $8.5 million. This investigation was conducted by the VA OIG, FBI, and several other federal agencies.
In another case, the VA OIG and Social Security Administration OIG investigated a defendant who allegedly stole the identity of an Army veteran for over 20 years, fraudulently obtaining more than $800,000 in VA healthcare and compensated benefits. VA terminated benefit payments several times after the veteran passed away in 2018, but each time the defendant reached out to VA, purporting to be the veteran, and requested that the benefits continue. The defendant was charged in the Eastern District of Washington with wire fraud, aggravated identity theft, false representation of Social Security number, and theft of government funds.
Last month, the VA OIG published 16 reports. From the Office of Audits and Evaluations comes a report on inconsistent ratings scheduling updates for hip and knee replacement benefits. The VBA uses a rating schedule to assess veterans’ service-related disabilities and reviews medical documentation to determine benefits. The OIG examined VBA's implementation of the 2021 changes to the disability rating schedule for hip and knee replacements or resurfacing and found that VBA rating specialists did not always apply the correct convalescence periods or ensure accurate special monthly compensation benefits.
The system used to determine convalescence benefits requires dates to be manually entered and lacks functionality to calculate proper periods. About 38 percent of reviewed claims yielded improper payments, with questioned costs of about $3.3 million in overpayments and underpayments. Further, VBA did not sufficiently monitor claims decision accuracy, and 75 percent of staff required retraining on disability ratings schedule changes. VBA concurred with OIG’s four recommendations to improve the accuracy of claims decisions.
The VA OIG’s Office of Healthcare Inspections assessed allegations that facility staff delayed ordering medications following a patient's discharge from a community hospital in Las Vegas. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in the facility staff's response to the patient's subsequent death by suicide. The OIG made five recommendations related to reviewing the patient's care, community care coordination, primary care, and actions required following a patient death by suicide.
We also published 10 Comprehensive Healthcare Inspection Program reports focused on VA medical facilities in Kansas, South Carolina, Wisconsin, New York, Michigan, Florida, Alaska, Minnesota, and Vermont. To read these reports, visit our website at vaoig.gov and select the reports tab.
Thank you for listening to February's highlights. Visit our website for all VA podcast episodes.
This has been an official podcast of the VA Office of Inspector General. Veteran Oversight Now is produced by the Office of Communications and Public Affairs and is available at va.gov/oig. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers through meaningful, independent oversight. Check out the website for more on the VA OIG oversight mission. Read current reports and keep up to date on the latest criminal investigations, report potential crimes related to VA waste or mismanagement, potential violations of laws, rules or regulations or risks to patients, employees, or property to the OIG online or call the hotline at 1-800-488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at one 800-273-8255. Press one and speak with a qualified responder now.