VA Assigns Levels of Inpatient Surgery Services

Janice Simmons, for HealthLeaders Media , May 10, 2010

The Department of Veterans Affairs (VA) has become the first hospital system nationwide to develop and implement a new method of monitoring and classifying where complex and difficult inpatient surgeries should be performed—based on specific criteria among its 112 surgery programs—to promote quality care and safer surgeries.

The VA, the country's largest hospital system, began in 2007 to look for ways to "close and prevent gaps in surgical care," said Robert Petzel, MD, the VA's undersecretary of health.

Following an expert work group's review of surgical standards, the VA conducted onsite studies of its hospitals between June 2009 and March 2010. Using this information, the VA assigned each of its medical centers an inpatient "surgical complexity" level: complex, intermediate, or standard.

Using criteria developed by 16 surgical advisory boards, including 80 experts, VA has authorized 66 hospitals to conduct "complex" inpatient surgeries, 33 hospitals to conduct "intermediate" inpatient surgeries, and 13 to conduct "standard" inpatient surgeries.

Those hospitals with a "complex" rating were designated as requiring special infrastructure—such as facilities, equipment and staff—to allow intricate operations, such as cardiac surgery, craniotomies, and total pancreatectomies.

Those facilities with an "intermediate" rating may perform surgeries such as colon resections, repairs of abdominal aortic aneurysms, and complete joint replacement. And, those with a "standard" complexity rating may perform inpatient surgeries requiring limited infrastructure—such as hernia repair, cholecystecomy, urologic procedures, and ear, nose, and throat surgeries.

"If a patient requires a surgical procedure that exceeds the facility's complexity rating, VA will ensure that the patient receives the required care from another provider," Petzel said.

The initiative is expected, though, to affect only a small number of surgical procedures. The VA provided over 357,000 inpatient surgeries for veterans during 2009. Based on 2009 figures, the VA anticipates that 0.1% of "intermediate" or "complex" surgeries (approximately 364 patients) would now be referred to another provider. The VA healthcare system currently provides services to 6 million veterans annually.

Five facilities that have previously conducted some "intermediate" surgeries will now perform "standard" surgeries in house and ensure that patients obtain other procedures nearby from the best qualified providers. These are the surgery programs at VA hospitals in Alexandria, LA; Beckley, WV; Fayetteville, NC; Illiana at Danville, IL; and Spokane, WA.

The VA's surgical review program is expected to be expanded to include standards for outpatient surgery. Each of the VA's 21 hospital networks has developed a surgical strategic plan to ensure that veterans receive needed care during the implementation process.

Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at

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