Veterans Affairs officials are failing to consistently notify state medical boards when department physicians 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 watchdog office found that “for a majority of cases involving separated healthcare professionals, VA medical facility directors failed to follow mandatory processes for reporting [those individuals] to state licensing boards.”

Officials warned that “failure to comply with these reporting processes leaves [state officials] unaware of a healthcare professional’s practice deficiencies 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 dismissal of poor-performing VA medical staffers. Officials from the Inspector General’s Office said those cases revealed broader concerns about how well facility directors understood and followed rules regarding notification to outside medical review boards.

Under current rules, the Veterans Health Administration requires those 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 the safety of patients or the community.”

VA rules only cover physicians and dentists, and not other health care professionals. The reports allow outside officials to bar the problematic physicians from working in other public-sector or private-sector posts where they might repeat the same mistakes.

But in 107 cases reviewed by the inspector general, only 44 were deemed fully compliant with those reporting rules.

In some cases, the lack of action was a result of confusion over who was responsible for generating the report to state officials. In about one-third of the cases, facility leaders failed to conduct an initial review to see if such reporting was necessary.

“The inspector general found that the noncompliance was linked to facility staff misunderstanding of VHA policy and poor facility processes,” the report states.

“The noncompliance led to lapses in reporting practices that resulted in delays or failures in reporting healthcare professionals whose clinical practice or behavior substantially failed to meet generally accepted standards.”

In response to the report, Veterans Health Administration officials promised changes to the process in coming months. They include new oversight of the issue by the Office of Quality and Patient Safety and new training of health facility leaders on the topic so they better understand their responsibilities.

That work is expected to 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, D.C. since 2004, focusing on military personnel and veterans policies. His work has earned numerous honors, including a 2009 Polk award, a 2010 National Headliner Award, the IAVA Leadership in Journalism award and the VFW News Media award.

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