VA Hospitals:

Surgical Residents Need Closer Supervision

HRD-86-15: Published: Jan 13, 1986. Publicly Released: Jan 13, 1986.

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In response to a congressional request, GAO reviewed Veterans Administration (VA) hospitals' supervision of surgical residents to determine whether: (1) the supervision is adequate; (2) VA is monitoring this supervision; and (3) the supervision in VA hospitals is comparable to that in non-VA hospitals.

GAO reviewed surgical resident supervision at 10 VA and 15 non-VA hospitals and sent questionnaires to supervising surgeons and residents at 28 VA hospitals. GAO noted that, since VA supervision criteria were too broad, it developed its own more specific criteria establishing the minimum supervision needed to ensure quality patient care and effective resident training. GAO found that: (1) compliance with GAO intraoperative criteria was generally adequate; (2) compliance with the preoperative and postoperative criteria was insufficient; (3) hospital enforcement of VA criteria varied, affecting residents' supervision; and (4) only 34 percent of the 148 surgical cases reviewed were in compliance with all the GAO criteria. VA primarily monitors supervision by reviewing annual audits that VA hospitals submit; however, GAO found that: (1) 33 percent of the hospitals did not submit the results of their audits for fiscal year 1984; (2) only one of the reports submitted contained enough information to monitor preoperative, intraoperative, and postoperative supervision; (3) VA headquarters had not told the regional directors responsible for enforcing the audit requirement which VA hospitals had not complied; and (4) VA hospitals had not issued specific requirements for monitoring supervision, causing the quality to vary. GAO also found that the level of VA hospital supervision was slightly lower than that at non-VA hospitals, perhaps due to lack of incentives such as reimbursement requirements.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: VA revised its manual to include this recommendation.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to revise VA criteria on supervision of surgical residents so that the criteria are no less specific than GAO criteria. The revised criteria should define the appropriate actions for preoperative and postoperative supervision.

    Agency Affected: Veterans Administration

  2. Status: Closed - Implemented

    Comments: VA modified its manual to indicate that, generally, one supervising surgeon would supervise all three phases of surgery and, if this is not possible, the supervising surgeons should communicate.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to require that VA hospital chiefs of surgery enforce criteria for surgical resident supervision. This enforcement should include not allowing surgeons whose schedules do not permit supervising all three phases of surgery to supervise residents.

    Agency Affected: Veterans Administration

  3. Status: Closed - Implemented

    Comments: A circular was issued in March 1987.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to designate either the Office of Quality Assurance or the Surgical Service office within the Department of Medicine and Surgery as having the primary responsibility for monitoring supervision of residents and indicate that all pertinent information on such supervision should be given to that office.

    Agency Affected: Veterans Administration

  4. Status: Closed - Implemented

    Comments: VA modified its manual to standardize the reports on supervision of residents.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to specify and standardize the systems VA hospitals should use to monitor and report on the supervision of surgical residents.

    Agency Affected: Veterans Administration

  5. Status: Closed - Implemented

    Comments: A circular was issued in March 1987.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to ensure that the VA hospitals send the Surgical Service the results of their annual audits of the adequacy of surgical resident supervision.

    Agency Affected: Veterans Administration

  6. Status: Closed - Implemented

    Comments: VA modified its manual to relate the level of the resident to the level of supervision.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to revise VA criteria on supervision of surgical residents so that the criteria are no less specific than GAO criteria. The revised criteria should relate the five levels of intraoperative supervision to the level of the resident and complexity of the case.

    Agency Affected: Veterans Administration

  7. Status: Closed - Implemented

    Comments: VA revised its manual in response to the recommendation that its criteria address the credentials of the supervising surgeon.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to revise VA criteria on supervision of surgical residents so that the criteria are no less specific than GAO criteria. The revised criteria should address the credentials of the supervising surgeon.

    Agency Affected: Veterans Administration

  8. Status: Closed - Implemented

    Comments: VA modified its manual to clarify this exemption.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to revise VA criteria on supervision of surgical residents so that the criteria are no less specific than GAO criteria. The revised criteria should clarify the provision exempting certain residents from the criteria.

    Agency Affected: Veterans Administration

  9. Status: Closed - Implemented

    Comments: VA concurred with the recommendation and implemented it through a change to the manual.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to require that VA hospital chiefs of surgery enforce criteria for surgical resident supervision. This enforcement should include not allowing scheduled surgery to proceed unless the preoperative criteria are met.

    Agency Affected: Veterans Administration

 

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