On Monday, the Government Accountability Office (GAO) reported that the Veterans Administration (VA) were slow to act or failed to report on 90 percent of its doctors within the system when concerns were raised about the performances of those doctors.
The five VAMCs GAO selected for review collectively required review of 148 providers from October 2013 through March 2017 after concerns were raised about their clinical care. The GAO found that these reviews were not always documented or conducted in a timely manner and identified these providers by reviewing meeting minutes from the committee responsible for requiring these types of reviews at the respective VAMCs, and through interviews with VAMC officials.
The selected VAMCs were unable to provide documentation of these reviews for almost half of the 148 providers. Additionally, the VAMCs did not start the reviews of 16 providers for 3 months to multiple years after the concerns were identified.
“The Department of Veterans Affairs requires its medical centers to review a doctor’s care if quality or safety concerns arise. If VA medical center officials decide a doctor should no longer provide care to veterans, they are required to inform hospitals and other health care entities by reporting to a national database and to the states where the doctor is licensed, “the GAO stated.
“However, at the 5 VA medical centers we reviewed, we found that these reviews were not always timely. We also found that VA officials did not report 8 of the 9 doctors who should have been reported.”
The GAO also found that the Veterans Health Administration (VHA) does not adequately oversee these reviews at VAMCs through its Veterans Integrated Service Networks (VISN), which are responsible for overseeing the VAMCs.
“Without documentation and timely reviews of providers’ clinical care, VAMC officials may lack information needed to reasonably ensure that VA providers are competent to provide safe, high quality care to veterans and to make appropriate decisions about these providers’ privileges,” the GAO said.
GAO found that after one VAMC failed to report to the NPDB or SLBs a provider who resigned to avoid an adverse privileging action, a non-VA hospital in the same city took an adverse privileging action against that same provider for the same reason 2 years later.
GAO stated that they making four recommendations, including for VA to direct VHA to require VAMCs to document reviews of providers’ clinical care after concerns are raised, develop timeliness requirements for these reviews, and ensure proper VISN oversight of such reviews as well as timely VAMC reporting of providers to the NPDB and SLBs. VA concurred with GAO’s recommendations and described steps it will take to implement them.
Read the full GAO report.
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