The Veterans Affairs Department has fallen short in ways that put veterans and the public "at risk [of] receiving unsafe medical care" by failing to report potentially dangerous doctors, a government watchdog concluded after an investigation.
The Government Accountability Office report, issued Monday, reveals issues with the VA's handling of complaints made against doctors and other health care professionals. The VA says the report will lead to changes at the department.
In some cases, reviews did not take place "for 3 months to multiple years after the concerns were identified." Nearly half of the reviews the GAO looked into had no paper trail.
The report found that the VA dropped the ball in the most serious cases, when it concluded a doctor's behavior should be reported to state licensing authorities and a national database. A report to state licensing officials was made in only one instance out of nine analyzed by the GAO. Reporting to state licensing authorities should occur in instances when doctors' behavior raises "reasonable concern for the safety of patients," GAO wrote.
The report gave several examples of how the shortcomings left doctors with serious complaints against them working for the VA or in the community:
In one case, a "provider whose services were terminated related to patient abuse subsequently held privileges at another" Veterans Administration medical center.
Another struck a deal to resign instead of being reported as a VA credentialing committee had decided. "The director's decision not to report the provider as required left patients in that community vulnerable to adverse outcomes because problems with the provider's performance were not disclosed," GAO concluded.
A third left the VA but continues to work for "a network of providers that provides care for veterans in the community."
"By failing to report providers, the VA was basically creating an environment where these poor performers could go and practice in other VA medical centers or even outside the VA health care system," said Sharon Silas, one of the report's authors.
The VA agrees with the report's conclusions and is "rewriting policies and updating procedures to comply with all of GAO's recommendations," spokesman Curt Cashour told CNN. The department has stepped up reporting, and now posts online a summary of its disciplinary actions each week.
Rep. Phil Roe, a physician, veteran and Tennessee Republican who requested the report, said he was "alarmed by the findings."
"During my medical career, my colleagues and I took pride in meeting and exceeding quality standards, and took comfort in knowing that anyone who failed to meet these standards could be held accountable," said Roe, who is chairman of the House Committee on Veterans' Affairs. "The fact that this accountability is lacking in VA is entirely unacceptable and disturbing, to say the least."
The GAO picked five of the country's 170 VA medical centers for the investigation.