Veterans Affairs officials do not routinely notify state medical boards when department doctors are fired for malpractice or incompetence, a situation that could put the public at risk, according to a new investigation by the VA Inspector General. .
In a report released last week, the Oversight Office found that “for the majority of cases involving separated healthcare professionals, VA medical facility managers did not follow required reporting processes. [those individuals] to state licensing boards.
Officials warned that “failure to follow these reporting processes leaves [state officials] unaware of the shortcomings of a medical professional’s practice and ultimately violates an important VA commitment to protect the health of veterans and the public,” the report states.
The review was prompted by a series of cases in 2020 involving the firing of underperforming VA medical staff. Officials from the inspector general’s office said the cases revealed broader concerns about how facility managers understood and followed rules about notifying external medical review boards.
Under current rules, the Veterans Health Administration requires these leaders to submit a report to state licensing boards or the National Practitioner Data Bank “when substantial evidence supports a reasonable conclusion that the professional’s clinical practice raises a reasonable concern for patient or community safety.”
VA rules only cover doctors and dentists, not other medical professionals. The reports allow outside officials to ban problematic doctors from working in other public or private sector positions where they could repeat the same mistakes.
But of 107 cases reviewed by the Inspector General, only 44 were found to fully comply with these reporting rules.
In some cases, the inaction was the result of confusion about who was responsible for generating the report to state officials. In about a third of cases, facility officials did not conduct an initial review to determine whether such reporting was necessary.
“The Inspector General found that the non-compliance was related to facility staff’s misunderstanding of VHA policy and poor facility processes,” the report said.
“The non-compliance has resulted in gaps in reporting practices that have resulted in delays or failures in reporting healthcare professionals whose clinical practice or behavior did not meet generally accepted standards.”
In response to the report, Veterans Health Administration officials promised changes to the process in the coming months. They include new oversight of the issue by the Office of Quality and Patient Safety and new training for healthcare facility managers on the subject so that they better understand their responsibilities.
This work should be completed by the end of this year.
The full report is available on the VA Inspector General’s website.
Leo covers Congress, Veterans Affairs and the White House for Military Times. He has covered Washington, DC since 2004, focusing on military personnel and veterans policies. His work has earned him numerous accolades, including a 2009 Polk Award, a 2010 National Headliner Award, the IAVA Leadership in Journalism Award, and the VFW News Media Award.