top of page

The Section Chief of the Richmond VA’s Medical Center Heart Transplant Program Failed to Ensure a Culture of Safety and Engaged in Unprofessional Conduct


The Department of Veterans Affairs Office of Inspector General (OIG) recently released a report detailing concerning findings about the Richmond VA Medical Center in Virginia. The investigation, prompted by multiple complaints, focused on the facility's heart transplant program and the conduct of its cardiothoracic section chief, Dipesh Shah, MD. 


From March 16–August 11, 2023, the Department of Veterans Affairs Office of Inspector General (OIG) received multiple complaints about the section chief’s unprofessional conduct, cardiac surgical patient outcomes, and patient care practices. In response to the allegations, the Richmond VA’s transplant program had been suspended for more than a year, beginning in August 2023. 


In September 2023, the OIG initiated an investigation of these allegations. On October 24, 2024, the OIG issued a report concluding that facility leaders failed to ensure a culture of safety, and the section chief of cardiac surgery engaged in unprofessional conduct.  


The report identified two operations where two of Dr. Shah’s patients were on a cardiac bypass machine for eight hours. Both patients later died, one within hours and another within a month. 


The OIG said it was unable to draw a conclusion regarding Dr. Shah’s “pump times,” as they are known in the medical world, because they could not validate the numbers shared by the hospital. 


The OIG’s key findings included the following: 


The Section Chief Engaged in Unprofessional Conduct 

  • The OIG substantiated that the section chief repeatedly exhibited unprofessional conduct toward staff. This conduct included instances of rudeness and even a threat to tape a staff member’s mouth shut. 

  • Despite leadership counseling for the section chief and verbal counseling from the chief of surgery, this unprofessional behavior continued. 


Evaluation of Cardiac Surgery Quality Outcomes 

  • The heart transplant program had consistently low patient volume. National guidelines recommend a minimum of 10 heart transplants per year to maintain team proficiency, but the facility only performed 17 transplants over a three-year period.  


Facility Leaders Failed to Ensure a Culture of Safety 

  • Facility and surgical leaders failed to create a culture of safety where staff felt comfortable reporting their concerns. Although facility leaders conducted leadership rounding and facilitated discussions on psychological safety and conflict resolution, these efforts were not successful. 

  • The facility's staff reported fear of retaliation for voicing concerns about the section chief. Surgical staff reported to the OIG that they:  

  • Did not report threats or concerns due to fear of retaliation. 

  • Felt that their complaints were “turned around on [them].” 

  • Escalated concerns by making their complaints “louder than in the past where [they] were more fearful.” 

  • Sought other employment to leave the situation. 


The OIG made several recommendations based on its findings: 

  • Improve Culture of Safety: The Veterans Integrated Service Network Director should ensure that facility leaders take action to improve the culture of safety within the heart transplant program. 

 

  • Evaluate Program Viability: The Veterans Integrated Service Network Director should evaluate the long-term viability of the heart transplant program, considering factors such as patient volume and surgical team proficiency. 

 

  • Address Unprofessional Conduct: The Facility Director should address the cardiothoracic section chief’s unprofessional conduct and take appropriate corrective action. 

 

  • Review Surgical Cases: The Facility Director should ensure that the Chief of Surgery reviews surgical cases with prolonged cardiopulmonary bypass times to determine if peer review is warranted. 

 

  • Enhance Communication: The Facility Director should implement processes to improve communication between facility leaders and staff regarding patient safety concerns. 


This OIG report serves as a reminder of the critical importance of maintaining a strong culture of safety in medical facilities and ensuring proper oversight and accountability for medical providers leadership roles. Healthcare organizations, particularly those serving vulnerable populations like veterans, must prioritize these areas to provide the highest quality of care and maintain public trust.  

Comments


bottom of page