A new GAO report exposes that Veterans Affairs shamefully put veterans lives at risk by failing its duty to report bad doctors and other clinicians.
The GAO report confirms a USA Today report exposing VA has concealed and avoided investigations and mandated reporting of bad health care workers for many years. Maybe if VA had followed its own mandatory reporting guidelines, veterans like Charles Ingram, the veteran who burned himself alive, would still be with us.
GAO Report Exposes Veterans Affairs Bad Doctor Reporting
The GAO report in question evaluated only 5 locations and found VA failed to report 8 of 9 clinicians. Unfortunately, the report fails to tell readers which facilities were evaluated. Obviously, one would expect one star rated facilities like Phoenix VA to have more failures than five star rated facilities like Minneapolis VA.
Providers at the unnamed facilities were not reported because “officials were generally not familiar with or misinterpreted” the policies.
“At one facility, we found that officials failed to report six providers to the (national database) because the officials were unaware that they had been delegated responsibility for…reporting,” the GAO said.
GAO also found VA failed to maintain adequate documentation on almost half the investigations.
Per USA Today, “a total of 148 providers required clinical reviews after concerns were raised about their care between October 2013 and March 2017. But in nearly half those cases, the hospitals could not provide documentation that the reviews occurred.”
“We found that all five (hospitals) lacked at least some documentation of the reviews they told us they conducted, and in some cases, the required reviews were not conducted at all,” GAO concluded.
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USA Today and other mainstream media left out the specific procedures GOA said VA was supposed to follow. It included it straight from the GAO report italicized below for your review. Veterans should be able to track this to help guide them when reporting wrongdoing by a clinician.
Below are those proceedures and their findings:
Download: GAO Report Bad Doctors
Veterans Affairs Clinician Care Review Requirements And Results
Triggers Requiring VA To Evaluate For Possible Adverse Reporting
As part of the credentialing and privileging process, VAMC officials are responsible for monitoring each provider’s performance on an ongoing basis and identifying any concerns about clinical care that may warrant further review. VAMCs can identify concerns about providers’ clinical care in a variety of ways, including the following:
- Ongoing monitoring. VHA requires VAMCs to conduct and document ongoing monitoring of each provider’s performance at least twice a year through an ongoing professional practice evaluation. During this evaluation, a provider’s performance is evaluated against benchmarks established by VAMC leadership that define acceptable performance, such as documenting patient visits appropriately and achieving specific patient outcomes.
- Peer review triggers. VHA has a separate process, called peer review, that VAMCs may use to review adverse events. While information collected as part of peer review is protected for quality improvement purposes and may not be used to take action against a provider, VAMCs can identify concerns about a provider’s clinical care based on a trend of certain peer review outcomes over a specified period of time, referred to as triggers. VHA requires VAMCs to establish peer review triggers. An example of a peer review trigger is when a provider has two or more episodes of patient care within a 12-month period for which a peer determined that most experienced, competent providers would have managed the episodes differently.
- Complaints or incident reports. Concerns about a provider’s clinical care can also be identified through complaints and incident reports.17 These can come from any individual with a concern, including patients, providers, or VAMC leadership.
- Tort claims. Filed or settled tort claims or malpractice claims can raise a concern about a provider not identified through ongoing monitoring or peer review.
Types Of Review VA Is Supposed To Do (But Won’t)
Once a concern about a provider’s clinical care is identified, VHA policy and guidance establish processes for VAMC officials to use to review the concern and determine whether an action should be taken against the provider’s clinical privileges. VHA policy states that if allowing a provider under review to continue delivering patient care could result in imminent danger to veterans, VAMC officials should remove the provider from delivering patient care through a summary suspension of privileges. VAMC officials have flexibility to determine the most appropriate process to use to review a provider’s clinical care depending on the specific concerns and the situation. These processes include the following:
- Focused professional practice evaluation (FPPE) for cause. This is a prospective review of the provider’s care over a specified period of time, during which the provider has the opportunity to demonstrate improvement in the specific area of concern. Failure to improve could result in further review or action.
- Retrospective review. This is a review of the provider’s delivery of patient care focused on a specific period of time in the past, a specific area of practice, or both, based on an identified concern.
- Comprehensive review. This is a more extensive retrospective review, generally performed by a panel of experts to ensure fairness and objectivity. In addition to reviewing the provider’s past patient care, these reviews may also include interviews with the provider, patients, and staff. These reviews generally result in conclusions about whether care delivered by the provider met the standard of care and may include recommendations about the provider’s privileges.
Steps VA Might Take (But Doesn’t) To Protect Veterans
Once a review is completed, VAMC leadership officials and the VAMC credentialing committee make decisions about next steps, which could include the following:
- Do nothing, if the review did not substantiate the concerns;
- Conduct further review (such as an FPPE for cause to allow the provider an opportunity for improvement or a comprehensive review if more information is needed); or
- Take an adverse privileging action, including limiting one or more privileges (such as prescribing medication or performing a certain procedure) or revoking all of the provider’s privileges.
If the VAMC’s credentialing committee recommends an adverse privileging action, it is the VAMC director’s responsibility to weigh all available information, including recommendations, and take an action. After a permanent provider is notified of the director’s decision, the provider can appeal the decision to the Disciplinary Appeals Board as part of their due process rights. The adverse privileging action is considered final once the Disciplinary Appeals Board reaches a decision and the Deputy Under Secretary for Health executes the Board’s decision. If a permanent provider does not make use of the offered due process procedures within 7 days, the provider waives his or her right to due process and the adverse privileging action is considered final.
Reporting VA Is Required To Follow
VHA policy requires VAMCs to alert certain entities if there are serious concerns with regard to a provider’s clinical performance. VHA policy assigns reporting responsibility and authority to the VAMC director, who generally delegates the task of reporting to other VAMC officials. VHA makes this information available to other health care entities through two distinct reporting processes:
NPDB. Under VHA policy, VAMC directors must report to the NPDB any adverse privileging action the facility takes that 1) affects the clinical privileges of a provider for a period longer than 30 days and 2) is related to professional incompetence or professional misconduct. VHA policy requires VAMCs to submit these NPDB adverse action reports within 15 calendar days of the date the adverse privileging action is made final— that is, when all applicable internal due process procedures have been completed and the VAMC director has signed off on the action. VAMC directors are also required to report to the NPDB providers who resign or retire while under investigation or in return for the VAMC not conducting such an investigation or proceeding. To avoid any errors in the facts of the report, the VAMC director must notify any provider who is about to be reported to the NPDB and give the provider an opportunity to discuss the content of the report before it is submitted.
SLBs. VHA policy requires VAMC directors to report providers—both current and former employees—when there are serious concerns about the providers’ clinical care to any SLB where the providers hold an active medical license. Specifically, VHA policy requires VAMCs to report providers who so substantially failed to meet generally accepted standards of clinical practice as to raise reasonable concern for the safety of patients. According to VHA policy and guidance, the SLB reporting process should be initiated as soon as it appears that a provider’s behavior or clinical practice fails to meet accepted standards. VAMC officials are directed not to wait to report to SLBs until adverse privileging actions are taken because an SLB conducts its own investigation of the provider to determine whether licensure action is warranted. This reporting process comprises five stages as established in VHA policy, and VHA policy states that the process should be completed in around 100 days (see figure 1).
Clinical Care Quality May Impact Performance Pay
Performance pay—a component of VA provider compensation—is an annual lump sum payment based on the extent to which an individual provider achieves specific goals. The goals may vary for providers across VA, at the same VAMC, or within a particular specialty. VA policy establishes minimum performance pay eligibility criteria, including being employed by VA from July 1 through September 30 of the fiscal year being reviewed.
Clinical Care Findings
Documentation frequently lacking. We found that the five selected VAMCs collectively required reviews of 148 providers’ clinical care after concerns were raised from October 2013 through March 2017, but VAMC officials were unable to provide documentation that almost half of these reviews were conducted. We found that all five VAMCs lacked at least some documentation of the reviews they told us they conducted, and in some cases the required reviews were not conducted at all. We also found VHA does not adequately oversee these reviews, as discussed later in this report.
- FPPEs for cause. FPPEs for cause accounted for most of the missing documentation of clinical care reviews, despite VHA policy requiring VAMCs to document FPPEs for cause in the providers’ files. Specifically, of the 112 providers for whom the selected VAMCs required FPPEs for cause from October 2013 through March 2017, the VAMCs were unable to provide documentation of the FPPEs for nearly a quarter (26) of the providers. Additionally, VAMC officials confirmed that FPPEs for cause that were required for another 21 providers were never conducted.
- Other reviews. The selected VAMCs were also unable to provide documentation of some retrospective reviews. Specifically, of the 27 providers for whom the selected VAMCs conducted a retrospective review, 8 were missing documentation. While VHA guidance recommends that VAMCs document these reviews, VHA policy does not require that VAMCs document retrospective or comprehensive reviews. VHA officials told us that they expected VAMCs to document these types of reviews so that the information could be used to support adverse privileging actions, if necessary. Without clearly stated documentation requirements in VHA policy, VAMC officials inconsistently document their results, preventing VAMC directors and VISNs from properly evaluating the effectiveness of its retrospective and comprehensive reviews, which are used to, among other things, ensure patient safety. Additionally, we found that key officials from two VAMCs were not aware of the VHA guidance and that 5 of the 8 missing retrospective reviews were from these two VAMCs. We also found that one VAMC was missing documentation of clinical care reviews for 12 providers who met the VAMC’s peer review trigger. In the absence of this documentation, we were unable to identify the type of reviews that were missing for these 12 providers.
The selected VAMCs’ failure to document reviews of providers’ clinical care after concerns were raised is inconsistent with federal internal control standards for monitoring and documentation, which state that management should conduct and document separate evaluations, when necessary. In the absence of VAMC documentation of such separate evaluations of providers, VAMC leadership officials lack key information needed to make decisions about whether providers’ privileges are appropriate, and they also lack reasonable assurance that appropriate reviews are conducted.
Reviews not always timely. We found that the five selected VAMCs’ reviews of providers’ clinical care were not always conducted in a timely manner after concerns were raised. Specifically, of the 148 providers, the VAMCs’ initiation of reviews of 16 providers’ clinical care was delayed by more than 3 months, and in some cases for multiple years, after the concern was raised. At one VAMC, service chiefs were not instructed to conduct reviews of 14 providers until 4 to 13 months after these providers met the VAMC’s peer review trigger. Before the service chiefs were notified of the concerns, 3 of these providers had at least one additional concerning episode of care—that peer reviewers judged would have been handled differently by most experienced providers—identified through the peer review process. As pointed out in VHA guidance, earlier intervention could prevent additional patients from receiving substandard care. Officials from another VAMC did not conduct retrospective reviews on 2 providers until we requested documentation of the reviews, approximately 3 and a half years after the credentialing committee had initially requested a review.
While VHA officials told us that clinical care reviews should be conducted as expeditiously as reasonably possible, VHA policy does not specify a timeliness requirement. Allowing more time to elapse before a clinical care review is initiated weakens the intended purpose behind clinical care reviews and further increases risk to patient safety. Federal internal control standards for monitoring state that management should evaluate issues and remediate identified deficiencies in a timely manner. A clinical care concern could represent a potential deficiency in providing medical care, and as a result, VHA increases its risk further without establishing a policy that sets timeframes for conducting clinical care reviews.
VHA oversight is inadequate. We also found that VHA does not adequately oversee VAMC reviews of providers’ clinical care after concerns have been raised, including ensuring that these reviews are completed and documented in a timely manner. Under VHA policy, VISNs are responsible for overseeing the credentialing and privileging processes at their respective VAMCs. While reviews of providers’ clinical care after concerns are raised are a component of credentialing and privileging, we found that the VISNs with responsibility for overseeing the selected VAMCs through routine audits do not include these reviews in their audits. While the standardized tool VHA requires the VISNs to use for these audits instructs the VISNs to identify and review providers who were on an FPPE for cause, none of the VISN officials we spoke with described any routine oversight of FPPEs or any other reviews of identified clinical care concerns. This may be in part because some VISN officials are not using VHA’s standardized audit tool as required. Officials from one VISN said they had developed their own audit tool and officials from another VISN said that they were not conducting the audits due to multiple instances of turnover in a key position at the VISN. Further, VHA’s standardized audit tool does not direct the VISN to oversee any other types of reviews of clinical care concerns, such as retrospective or comprehensive reviews. The tool also does not require VISN officials to look at documentation of the FPPEs for cause; instead, it calls for reviewing credentialing committee meeting minutes. Without reviewing documentation, VISN officials would be unable to identify the incomplete documentation that we identified in our review. Both VHA and VISN officials described instances of assisting VAMC officials with reviews of providers’ clinical care after concerns had been raised, but VHA and VISN officials told us that their involvement in these reviews is typically consultative and not routine. (For example, the VISN may assist by identifying providers outside of the VAMC to conduct the review.) As a result, VHA and the VISNs are not conducting routine oversight to ensure that VAMC reviews of providers’ clinical care after concerns are raised are conducted appropriately, including adequately ensuring that the reviews are completed and documented in a timely manner, in accordance with VHA policy.
The lack of routine VHA oversight, through the VISNs, of VAMC reviews of providers’ clinical care after concerns are raised is inconsistent with federal internal control standards for monitoring, which state that management should establish and operate monitoring activities. In the absence of routine monitoring of VAMCs’ evaluations of providers after concerns have been raised, VHA lacks reasonable assurance that VAMCs adequately review all identified concerns about providers’ clinical care and take appropriate privileging actions to ensure that VA is providing safe, high quality care for veterans.