GAO Finds Quality Concerns About Specific Clinicians at VA Often Go Unreported

The Department of Veterans Affairs (VA) has a multilayered process to deal with providers if concerns are raised about their care, but too often those mechanisms go unused, according to a report released Monday by the Government Accountability Office (GAO).

In fact, in the sample GAO evaluated, which covered 5 VA medical centers over a period of more than 3 years, officials at the facilities were unable to produce documentation for about half the reviews that were required after complaints were raised. Then, medical centers often failed to adequately oversee the ones that were done, according to the report.

The report covers a period from October 2013 to March 2017, which bridged a public scandal at the VA that forced the resignation of former Secretary Eric Shinseki over reports of long wait times and inadequate resources for returning veterans, particularly in the area of mental health care.

The new report does little to alleviate these concerns about the Veterans’ Health Administration (VHA). It finds, “VHA’s inadequate oversight of these processes calls into question the extent to which VAMCs are held accountable for ensuring that veterans receive safe, high quality care.”

The issue covered in the new report concerns whether the VA is following its own processes for the following: 1) conducting scheduled reviews of the doctors and dentists who work at VA medical centers, and 2) following up on reports to help providers improve on areas of weakness, which is among the methods the VA uses to ensure the providers in its facilities are delivering good clinical care. Most of the missing reports the GAO survey uncovered were in this category.

A report of this type, called a “focused professional practice evaluation (FPPE) for cause,” is described in the report as 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.” Thus, if a doctor failed to improve, the VA might lack proof, and poor care would continue.

The GAO’s report focused on 148 providers across 5 medical centers whose clinical care had raised concerns. Of the 112 providers who required FPPEs for cause during the review period, the 5 VA centers could not provide documentation for 26, and officials at the centers confirmed there were another 21 providers who should have had these evaluations but they were never conducted. These same facilities were also missing documentation from other types of reviews.

Ongoing reviews were often behind schedule, so that some clinicians were well past the “trigger point” for a peer review, in which supervisors would have addressed concerning episodes of care to make recommendations on how they should have been done differently. As the report noted, these delays meant more patients may have received substandard or low-value care.

The report even found that officials at 1 VA center didn’t start retrospective reviews on 2 providers until the GAO asked for the documentation, “approximately 3 and a half years after the credentialing committee had initially requested a review.”

GAO made several recommendations, which the VA did not contest:

• The VA’s undersecretary for Health should specify that reviews of clinical care after concerns have been raised should be documented, including retrospective and comprehensive reviews, with a timeliness requirement and the use of auditing tools to keep the process on schedule.
• Oversight should include reviewing documentation in order to ensure that these reviews are documented appropriately and conducted in a timely manner.
• The undersecretary for Health should require key VA medical center officials to establish a process for making sure that their findings get to state licensing boards and the National Provider Data Bank in a timely manner.