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GAO Review: VA Failed to Report 90% of Potentially Dangerous Health Care Workers

Veterans Affairs
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November 27, 2017

The Government Accountability Office (GAO) released a report Monday revealing the Department of Veterans Affairs (VA) has failed to report 90 percent of potentially dangerous medical providers to a national database in recent years.

Reports to the national database are designed to prevent medical providers from jumping from state to state and potentially endangering patients in the locations they relocate, USA Today reports.

The GAO found VA officials failed to report a single problematic clinician to state medical boards, bodies that have the power to revoke licenses.

The audit was conducted throughout five unidentified VA hospitals, and found nine cases where health care workers should have been reported in 2014. With just over 150 hospitals, if the rate of failed reporting held consistent, potentially hundreds of medical providers were not reported.

The oversight was so flawed that the VA had no efficient way to identify the number of medical workers who had been reported or if those workers were reported in the first place, according to USA Today.

In one particular instance of failed reporting examined by the GAO, a clinician's privileges were revoked after leaving the VA and continuing to practice medicine in a private sector hospital for two years, suggesting patients were endangered.

"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.

Under VA policies, hospital directors are responsible for their hospitals reporting doctors and dentists who leave in poor standing due to medical mistakes, investigations into their practice, and falsifying clinical credentials or not disclosing they were revoked because of inadequate care. But, this was not occurring at the five hospitals examined by GAO.

"Officials were generally not familiar with or misinterpreted" the policies, investigators concluded.

The GAO also found the VA hospitals did not adequately document investigations that assist the reports of problematic clinical.

Of the 148 VA health care providers who required clinical reviews between October 2013 and March 2017, the hospitals were unable to provide documentation of reviews in nearly half the cases.

"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.

Chairman of the House Veterans Affairs Committee, Rep. Phil Roe (R., Tenn.) has asked the GAO to investigate thoroughly and will chair a hearing Wednesday on the findings.

VA officials responded to the report by reiterating a pledge that they plan to increase oversight in the reporting by regional officials due to local hospitals directors are left responsible for filing the reports.

The VA said it will have fixes in place within a year.