WASHINGTON, DC – A recent investigation by the VA Office of the Inspector General (OIG) found widespread noncompliance by VA facilities in reporting healthcare professionals whose conduct or incompetence led them to be fired to state licensing boards (SLB) or the National Practitioner Data Bank (NPDB).
This failure to report could result in healthcare providers who are let go for misconduct or poor performance to get jobs elsewhere without new employers knowing about blots on their records.
The investigation was sparked when two healthcare inspections involving terminated physicians revealed that the VAMCs involved were noncompliant with SLB and NPDB reporting.
One investigation involved the quality of care issues at the community living center and emergency department at the Dayton, OH, VAMC. The second was the more widely publicized investigation into the Hunter Holmes McGuire VAMC in Richmond, VA, where a pathologist who had been terminated for failing to diagnose or misdiagnosing cancer in at least a dozen patients was rehired. In both instances, inspectors found deficiencies in the facility’s reporting practices and questioned whether the problem might be systemic across VA.
VA requires facility directors to submit SLB reports regarding healthcare professionals when substantial evidence supports a conclusion that there is a reasonable concern for the safety of patients or the community. It’s left to the SLBs to determine what, if any, action to take based on the report.
The OIG discovered that in the majority of cases involving separated healthcare practitioners, VA medical facility directors failed to follow the agency’s mandatory processes for SLB reporting, finding that in only 41% of cases were facilities fully compliant. For the remaining 59%, investigators found issues throughout the reporting process, from initial review to final report submission.
Nearly half of the cases did not lead to a comprehensive review to determine whether a report to an SLB was necessary. Of those cases that did have a comprehensive review, facility directors failed to complete a required decision memorandum in nearly 25% of cases. Of the 46 clinicians facility staff decided should be reported to an SLB, only 41 were actually reported.
The OIG report places the blame for such widespread noncompliance on an incomplete understanding of the reporting process and on poor internal processes at facilities.
Pending Personnel Action
“Examples of facility staffs’ misunderstanding of policy included staff explaining to the OIG the initiation of the SLB reporting process was not started due to pending personnel action, which was contrary to policy,” investigators wrote in the report. “Another facility staff described a facility director not completing decision memorandums regarding SLB reporting because the healthcare professional was under the auspices of nursing.”
The same lack of compliance exists when it comes to NPDB reporting. The OIG found that facility directors failed to submit NPDB reports in 15 of 35 physician or dentist cases appealing a separation from employment. In this instance, the investigators placed much of the blame on contradictory VA policies.
Federal regulation and VHA policy require facility directors to file an NPDB report on any physician whose privileges were impacted for more than 30 days due to professional competence or conduct, or who resign during an investigation. Federal regulation specifies that NPDB reports are intended to be filed within 15 days after a facility director’s privileging action. VHA reporting guidelines also state that physicians must be offered “appropriate internal VA medical center due process procedures” as outlined in VHA credentialing policy. That policy states that NPDB reports be submitted after all appeals have been exhausted–a process that could take months.
Of the 35 cases OIG looked at that required an NPDB report, only 20 cases were reported. Of those, OIG found only one that was submitted in under 15 days following a facility director’s privileging action.
Again, poor understanding of the reporting process was also to blame.
“One staff [member] reported awaiting the conclusion of a federal district court proceeding to decide whether to report a physician,” the report states. “Another staff [member] misstated policy by stating that physicians are only reported for paid tort claims.”
The report goes on to state, “The failure of this important safeguard could lead to current and future employers not being aware of concerns regarding competence or conduct of physicians and dentists. As a result, these physicians and dentists are enabled to continue to practice without the heightened level of scrutiny intended to be triggered by an NPDB report.”
In both SLB and NPDB reporting, facility staff blamed their lack of knowledge of proper processes on the infrequency of adverse actions requiring such reporting. Some staff members reported having made two or fewer adverse action reports in their career.
As for how this problem became a systemic one, OIG notes that VA has failed to assign any programmatic oversight to ensure facility leaders’ compliance with the mandatory reporting processes. This lack of oversight contributed to VA leaders’ failure to detect the problem and intervene sooner. OIG’s recommendations include ensuring programmatic oversight, as well as for VA leaders to review reporting processes at the facility level.