A new Government Accountability Office report raises new and troubling concerns about the quality of care delivered by medical centers associated with the Department of Veterans Affairs. In many cases, the VA failed to report potentially dangerous doctors to a national database that would have prevented the clinicians from practicing elsewhere.
The report (PDF) looked at five VA medical centers and their actions after concerns were raised about clinical care delivered by their physicians and dentists. Although they were required to review 148 providers from October 2013 through March 2017, the GAO found that the VA failed to document or conduct reviews in a timely manner. In addition, they didn’t report the conduct of eight of the nine providers to state licensing boards or the National Practitioner Data Bank, which collects information about the competence of providers.
In one case, the GAO learned that one medical center failed to report a provider who resigned to avoid an adverse privileging action. That provider found a job at a non-VA hospital in the same city and two years later that organization took adverse privileging action against the clinician for the same reason. The VA’s failure to conduct adequate oversight of these reporting practices hinders the agency’s ability to provide safe, high-quality care to veterans, the GAO said.
Unless the VA strengthens its oversight of these processes, the GAO determined that veterans are at risk of receiving unsafe care through the health system.
The report calls for the VA to include in its policies the need to use a standardized auditing tool to conduct timely reviews and document these reviews when concerns are raised about a provider’s clinical care. In addition, officials with Veterans Integrated Service Networks must establish a process to oversee medical centers to ensure they are reporting providers to the national database and state licensing boards in a timely manner.
The House Committee on Veterans Affairs will hold a hearing about quality and safety concerns at the VA on Wednesday.
The report is just the latest to reveal problems at the VA. FierceHealthcare reported on Monday that one VA neurosurgeon has continued to collect a six-figure salary for years even though he has been barred from performing surgeries at a VA medical center in Mississippi. And it’s not an isolated case. VA medical centers across the country have paid doctors millions in paid administrative leave.
Last month USA Today reported hundreds of instances in which the VA covered up employee mistakes and withheld information from patients about medical errors. Indeed, that investigation revealed the VA signed secret settlement deals with clinicians and healthcare workers across the country to cover up serious mistakes, including dangerous medical errors. In the wake of the report, VA Secretary David Shulkin said the agency would review its patient safety procedures and policies of reporting medical professionals to the national data bank.