Donovan Slack, USA TODAY Nov. 27, 2017
A months-long USA TODAY Network investigation reveals that for years, the U.S. Department of Veterans Affairs concealed mistakes and misdeeds by staff members entrusted with caring for veterans.
The Department of Veterans Affairs failed to report 90% of potentially dangerous medical providers in recent years to a national database designed to prevent them from crossing state lines and endangering patients elsewhere, according to the Government Accountability Office.
The watchdog’s conclusions in the report to be released Monday confirm findings of a recent USA TODAY investigation that found theVA has for years concealed medical mistakes and misconduct by health care workers. In response to that story published in October, the VA vowed to overhaul its policies for reporting clinicians to authorities.
The GAO also found that VA officials didn’t report any of the problem clinicians to state medical boards that could have yanked their licenses.
The findings are based on a sampling of five VA hospitals, where only nine health care workers warranted reporting since 2014. But if those findings hold true across all of the VA’s roughly 150 hospitals, potentially hundreds of medical providers weren’t reported.
In one case examined by the GAO, a VA hospital director failed to report a clinician who went on to work at a private sector hospital, which revoked the worker’s privileges two years later, suggesting patients were endangered.
In response to the GAO report, VA officials reiterated that pledge, concurred with its findings and said they planned to increase oversight of reporting by regional officials. In the past, reporting decisions have been left mainly to local hospital directors.
USA TODAY had found oversight was so lax, the VA had no idea how many medical workers had been reported or if they had been reported at all.
Rep. Phil Roe, R-Tenn., chairman of the House Veterans Affairs Committee, asked GAO to investigate and is chairing a hearing on the findings Wednesday.
Under VA policies, hospitals are supposed to report to the national database doctors and dentists who leave while under investigation for medical mistakes or when their clinical credentials are curtailed or revoked because of poor care. They are also supposed to report medical providers to state licensing authorities if they “raise reasonable concern for the safety of patients.”
But at the five unidentified hospitals examined by GAO, providers weren’t reported as required because VA “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.
The office also found VA hospitals did not adequately document investigations of medical care that can lead to reports.
In all, 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,” investigators concluded.
The GAO recommended the VA ensure reviews are documented, that they are conducted more quickly and that they are overseen by regional officials, who can ensure problem medical workers are reported. The VA said it would have those fixes in place within a year.