VA Promises Changes After Widespread Failure to Report Clinician Safety Issues

By Sandra Basu

WASHINGTON—VA officials sought to reassure lawmakers that the agency is responding appropriately to an oversight report finding that several medical providers who gave harmful care to patients were never reported to the National Practitioner Data Bank (NPDB) or state licensing boards (SLB).

One step, according to Gerard Cox, MD, MPH, VA acting deputy under secretary for health for organizational excellence, is that the range of clinical occupations that VA will report to the NPDB will be voluntary expanded.

“We are doing this because we feel this is the right thing to do for veterans,” Cox said.

While the NPDB only requires reporting physicians and dentists for adverse privileging actions and resignation while under investigation, VA plans to report “all privileged providers to the NPDB for privileging actions resulting from substandard care, professional misconduct or professional incompetence,” he testified at a House subcommittee hearing titled, “Examining VA’s failure to address provider quality and safety concerns.”


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An Overview of the Stages of the Veterans Health Administration’s (VHA) State Licensing Board Reporting Process
A case is considered sensitive if (a) it includes a previous history of licensure action against the provider; (b) it includes the death of a patient; (c) the provider has retained legal counsel in anticipation of litigation; (d) there has been media attent ion related to some aspect of the case; or (e) the provider has a clinical diagnosis, or is under the care of a physician, and that information is part of the review or provider response includes the provider’s personal health information.

Government Accountability Office (GAO) officials talked about the bigger issue. “VA’s failure to report the providers to the databank or state licensing boards makes it possible for providers to obtain privileges at other VAMC or non-VA healthcare entities that serve veterans,” explained Randall Williamson, the oversight group’s director of healthcare.

Specifically, the GAO looked at five VAMCs, finding that clinical care by 148 providers required reviews after concerns were raised about quality, but no documentation was available for about half of those reviews to prove they had been conducted.

Even many reviews that had been performed were not done so in a timely manner, the report added. Of the 148 providers, the VAMCs did not initiate reviews of 16 providers for three months, and in some cases, “for multiple years, after concerns had been raised about the providers’ care.”

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