Officials with VA medical centers often failed to report health care providers who faced review after questions were raised about their clinical care, according to a report released by the Government Accountability Office, or GAO.
Further, reviews of privileged providers – independent physicians and dentists approved to provide specific services for the VA – frequently went undocumented and were conducted months or even years after the initial complaint, the GAO reported.
“In 2015, GAO put the VHA on our high-risk list for a number of reasons, including ambiguous policies and a lack of oversight and accountability. Our just-released report (GAO-18-63), along with a rather large body of work over many years, demonstrates that the VHA needs to improve in certain areas,” Randall B. Williamson, a director with the GAO’s health care team who is responsible for the agency’s work on VA health care-related issues, told Healio.com. “An area that needs attention is oversight and accountability. In GAO-18-63, we found once again that oversight was lacking to better ensure that VA medical centers are doing what they are supposed to do in protecting the safety of some of the veterans they serve.”
The GAO evaluated five VA medical centers, which had 148 providers who required a review between October 2013 and March 2017. All five medical centers lacked at least some of the necessary documentation of their reviews, and the facilities could not produce documentation of reviews in nearly half of cases, per the GAO’s report. In 16 cases, medical centers did not begin the review process for anywhere between 3 months to “multiple years” after questions of the providers’ competence or conduct first arose.
Of nine professionals who had adverse actions taken on their privileges or who resigned during an investigation, the medical centers failed to report eight to the National Practitioner Data Bank, which tracks medical malpractice payments and other adverse actions against health care providers. None of them were reported to their state licensing boards, according to the GAO. Both failures are violations of VHA policy.
The report found that “officials … misinterpreted or were not aware of VHA policies and guidance,” which led to reporting failures. In one incident, the GAO said, a medical facility failed to report a provider who resigned rather than face adverse privileging action. Two years later, the same provider had their privileges revoked by a non-VA hospital in the same city.
“By not promptly reviewing the quality of care providers give when concerns are raised, and not reporting adverse events to the National Practitioner Data Base and state medical boards as required in VA policy, some veterans (albeit a small number) could be exposed to substandard and unsafe care,” Williamson said.
The VA announced a series of improvements in response to the report.
“We appreciate GAO’s review and agree with its conclusions. As a result, we are rewriting policies and updating procedures to comply with all of GAO’s recommendations,” Curtis Cashour, VA press secretary, told Healio.com. “Under Secretary Shulkin, VA’s new direction is to hold employees accountable and to be transparent with our findings and actions.”
The VA will publish all disciplinary actions on a weekly basis, streamline the processes for reporting actions to state licensing boards and the National Practitioner Data Bank and require a senior-level approval on all employee settlements of more than $5,000. Those settlements will also be published on a quarterly basis, Cashour said.
USA Today reported that Rep. Phil Roe, R-Tenn., chairman of the House Veterans Affairs Committee, will oversee a hearing on the report’s findings Wednesday. – by Andy Polhamus
U.S. Government Accountability Office. Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns. GAO-18-63. http://www.gao.gov/products/GAO-18-63. Publicly released November 27, 2017. Accessed November 27, 2017.