Patients at Department of Veterans Affairs hospitals are not being adequately protected from doctors who have histories of providing substandard treatment, according to a new report from the Government Accountability Office.
None of the four Veterans Affairs hospitals examined by the GAO complied with all of the requirements for peer review of patient care that results in a bad outcome, which could include patient deaths.
Cases that warranted possible disciplinary action also were not always followed up on properly, according to the report.
The Veterans Health Administration has procedures in place to ensure quick reviews in cases that have bad outcomes.
Those can range from a confidential review by senior doctors to more formal investigations that can lead to discipline.
Among the standards the hospitals failed to meet were timely completion of the reviews and development of clear triggers that would signal the need for more in-depth investigation of the patient’s care, according to GAO.
“Failure of VAMCs (Veterans Affairs medical centers) to adhere to the protected peer review policy elements may result in missed opportunities to identify providers who pose a risk to patient safety,” GAO concluded.
“VHA cannot provide reasonable assurance that VAMCs are using the peer review triggers as intended, as a risk assessment tool. This weakens VAMC’s ability to ensure they are identifying providers that are unable to deliver safe, quality patient care,” GAO said.
Investigations by VA's inspector general and media reports have documented at least 21 preventable deaths and a series of sanitary and safety lapses at VA hospitals.
Recent reports have linked poor patient care, maintenance issues and unsanitary practices to at least six preventable deaths in Columbia, S.C., five in Pittsburgh, four in Atlanta, and three each in Memphis and Augusta, Ga.
There are three levels of review after an adverse incident at a VA hospital. The most informal is peer review in which experienced medical providers examine the treatment a patient received to determine whether it was appropriate.
That process is considered “protected,” meaning it is confidential and the results cannot be used in disciplinary proceedings.
The other two levels examine the doctor’s competence and determine whether the adverse outcome is due to misconduct. They are not protected, and the results can be used to discipline the health care provider.
If an investigation in a protected review uncovers evidence that the doctor or dentist’s actions put patients at risk, the case can be forwarded to the higher level of unprotected examination. There are supposed to be clear triggers to make that determination.
The initial review must be completed within 45 days under VA policies. If it is determined the case should have been handled differently, it is supposed to be sent to a higher-level panel, which is supposed to make a final determination within 120 days.
Other VA policies require cases in which patient care or doctor competence are questioned to be sent to an unprotected review, and that each hospital develop clear triggers that would flag a case for further investigation.
But when GAO studied the peer review processes at VA hospitals in Dallas, Nashville, Seattle and Augusta, Maine, it found none met all four requirements.
Only one hospital completed all initial reviews within the required 45 days. It also completed final reviews within the 120-day deadline in 97 percent of the cases.
Two other veterans’ hospitals met the 45-day deadline less than 80 percent of the time. Final reviews at those two hospitals were done within the required 120 days in 89 percent of the cases.
The last hospital could not be assessed because its records were incomplete.
The hospitals were not identified by name.
All four hospitals did have standards to trigger a higher level of review if the quality of care or doctor competence was questioned.
Three of them appropriately sent questioned cases for further examination between 96 and 100 percent of the time.
But the same hospital that had the sloppy records sent only 79 percent of the cases that should have been given more scrutiny to a higher level of review.
VA officials generally agreed with the GAO findings and said the agency plans to implement the recommended changes.