The U.S. Department of Veterans Affairs (VA) failed to report disciplinary action taken against providers and delayed reviews of complaints against physicians, according to a report from the Government Accountability Office (GAO).

In the report, the GAO looked at five VA medical centers. Between October 2013 and March 2017, review would have been required of 148 providers after concerns were raised about their clinical care. The GAO found that:

• No documentation was provided for almost half of the 148 reviews.
• 16 reviews weren’t started for three months to multiple years after the initial complaints.
• Of the nine providers who “had adverse privileging actions taken against them or who resigned during an investigation related to professional competence or conduct,” only one was reported to the National Practitioner Data Bank (NPDB) and none were reported to state licensing boards.

This meant other VA medical centers and non-VA healthcare facilities were unaware of past complaints against a provider. The GAO found one of the nine providers who should have been reported went on to work at a non-VA hospital in the same city. Two years later, an adverse privileging action was taken against the physician.

In another case, a provider terminated over concerns “related to patient abuse subsequently held privileges at another" VA medical center.

The reasons for these shortcomings, the GAO report said, were often lack of awareness about the reporting requirements. It also found that the department has “inadequate oversight” of the review process, resulting in reviews either not be fully documented or not being completed in a timely manner.

Until the department “strengthens its oversight of these processes, veterans may be at increased risk of receiving unsafe care through the VA health care system,” the report said.

The GAO recommended several steps to address these problems, including refining policies for when reviews of providers’ clinical care should be conducted and how long they should take. It also recommended Veterans Integrated Service Networks (VISNs), which are responsible for overseeing VA centers, should update its auditing tools and make sure providers are reporting the state licensing boards and the NPDB.

The VA concurred with all of the GAO’s recommended actions, promising to issue interim guidance on addressing clinical care concerns by the end of the year.