The report found that complaints against doctors were not reviewed in a timely fashion, paperwork was not properly filed and doctors who had resigned to avoid disciplinary action were allowed to go work elsewhere without facing any consequences.
The government watchdog looked into five VA medical centers where concerns had been raised about 148 independent health care professionals. The report examined complaints that had been made over a period of about three and a half years. There are 170 VA medical centers in the U.S.
In the case of 16 doctors, the medical centers took months, even years, to start the review process, well after concerns about them were first raised.
The report also found that medical centers fell short of documenting their reviews of complaints, and five medical centers couldn’t provide the GAO with paperwork for nearly half of the 148 complaints they investigated.
If VA medical centers take disciplinary action against a doctor, it is the center’s responsibility to report the complaint to both state licensing boards (SLB) and the National Practitioner Data Bank (NPDB), a database that prevents medical offices from unknowingly hiring a doctor with a history of poor performance.
The GAO report detailed what had happened in the cases of nine doctors who had either resigned to avoid disciplinary action or had actions taken against them for misconduct or work incompetence. Only one had been reported to the NPDB, and none of the doctors had been reported to state licensing boards, which could have suspended or revoked their license to practice.
In another case described in the GAO report, a medical center failed to report a doctor who had resigned to avoid disciplinary action. As a result, a non-VA hospital in the same city hired the doctor and ultimately was forced to take the same disciplinary action two years later because of the same issue.
But the GAO also noted that the medical centers “misinterpreted or were not aware” of the correct procedures for reporting a health care professional to the NPDB or SLB.
"We appreciate GAO’s review and agree with its conclusions, although many of the events highlighted in the report occurred several years ago prior to Dr. [David] Shulkin taking over as VA secretary," the Department of Veterans Affairs said in a statement. "In response to GAO’s review, we are rewriting policies and updating procedures to comply with all of GAO’s recommendations."
Shulkin, a doctor and the former undersecretary for health at the VA, was sworn in as secretary in February.
"Under Secretary Shulkin, VA’s new direction is to hold employees accountable and to be transparent with our findings and actions," the statement said.
Among some of the changes it's making in light of the report, the VA announced that it would create a new policy that will expedite reporting doctors who have had disciplinary actions taken against them to SLBs. The VA said the new policy is undergoing final revisions. The VA said it's complying with reporting the doctors to the NPDB after they're terminated or resigned.
The department also plans publish on a weekly basis the disciplinary actions taken against offending doctors.