The U.S. Department of Veterans Affairs failed to report 90 percent of poor-performing providers to state and national databases, which are designed to prevent those doctors from practicing in other states and endangering patient lives, according to a new Government Accountability Office report.

In fact, from October 2013 to March 2017, the five VA medical centers audited by GAO didn’t report any of the poor-performing providers to state licensing boards -- which could have pulled their licenses. VA policy mandates the reporting of providers who have adverse reports on their record.

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Concerns ranged from inconsistent or unsafe practices to providers who incorrectly record patient visits.

VA officials were also slow to investigate when concerns were raised over some doctors, the report found. Of the 148 providers from these medical centers, VA leaders delayed reviews for 16 providers for more than three months -- and sometimes reviews took years to initiate.

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And three providers had at least one further concerning episode after the initial complaint was filed. In some situations, those VA leaders instructed the review to be held between four to 13 months after a concern was raised.

“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,” according to the report. “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.”

The report also found that oversight of VA healthcare is inadequate. The VA requires leaders to use audits to identify and review providers who have complaints against them. None of the reviewed VA medical centers describe any routine oversight or reviews based on clinical concerns.

The concern is real. In one case highlighted by the report, a poor-performing provider, who the VA did not report, went on to work in the private sector, where the worker’s privileges were pulled two years later as their actions could have endangered patient lives.

What’s most alarming is that the GAO only audited five of the VA’s care centers, but the agency has over 150 hospitals. If these findings are true for all of the VA’s hospitals, there are still many providers who haven’t been reported.

GAO is recommended the VA specify in its policy that reviews of raised concerns should be documented and ensure that timeliness for initiating reviews are required for all medical centers. 

Further, VA Undersecretary of Health should require officials to oversee reviews of care concerns and make sure audits are conducted with a standardized tool.

A bipartisan bill was introduced early this month that would require the VA to report adverse actions to the National Practitioner Data Bank and state licensing boards. A move designed to prevent the adverse events revealed in this new GAO report.

The proposed bill came on the heels of a USA Today report that found VA pushed aside firing orders in secret settlement deals. If passed, the legislation would prevent disciplined medical providers from crossing state lines to keep practicing.

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com