Medical providers that offered suboptimal care and, sometimes, abuse to veterans were often never reported to agencies charged with overseeing their practices.
The Government Accountability Office (GAO) issued an audit of the Veterans Health Administration (VHA) on Monday, revealing procedural failures that allowed health care practitioners to continue seeing patients, despite being accused of serious wrongdoing.
Concluding that veterans may be “at increased risk of receiving unsafe care,” the report calls into question the management of the nearly 40,000 doctors and nurses that staff Department of Veterans Affairs (VA) hospitals.
According to department procedures cited by the GAO, when a Veterans Affair’s medical center (VAMC) is made aware of a problem with a provider, it is required to conduct a review. If warranted, leadership and the credentialing committee at the clinic may then take an “adverse privileging action,” which could include revoking the doctor or nurse’s ability to offer care at the facility.
If action is taken against the provider, then the VAMC is also required to report the individual to the state licensing board and the National Practitioner Data Bank (NPDB)—a government-backed repository tracking negative information about health care workers.
Those procedures, however, are rarely followed, the GAO found.
The watchdog reviewed five VA medical centers, looking at records from October 2013 to March 2017. It found that those VAMCs took adverse action against nine providers, yet not a single one was reported to a state licensing board. And eight of the nine practitioners sanctioned weren’t logged into the NPBD.
“As a result,” GAO concluded, “VHA’s ability to provide safe, high quality care to veterans is hindered because other VAMCs, as well as non-VA health care entities, will be unaware of serious concerns raised about a provider’s care.”
GAO stated that, in most cases, officials were “generally not familiar with or misinterpreted” VHA policies.
In once case identified by inspectors, a provider who had their privileges revoked from a medical center due to patient abuse, was never reported to the state licensing board or NPBD, and was then later able to get a job working for a different VA clinic.
Another instance highlighted by the GAO involved a VAMC director choosing not to report a provider for wrongdoing, after the individual promised to retire. Two years later, the practitioner was working at a different non-VA hospital where they ultimately had their privileges revoked for the exact same reason that got them in trouble at the previous clinic.
“The director’s decision not to report the provider as required left patients in that community vulnerable to adverse outcomes because problems with the provider’s performance were not disclosed,” the report stated.
The VA concurred with a series of recommendations offered by the GAO to bolster its oversight systems. They included a call to create a process to ensure that problematic providers are reported to appropriate agencies in a timely fashion.