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VA must tighten physician peer reviews, GAO says

Dec. 6, 2013 - 01:03PM   |  
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The Veterans Affairs Department fails to follow its own policies on monitoring sub-par doctors whose treatment — or lack thereof — may harm patients, a new government review finds.

In a report released Monday, the Government Accountability Office reviewed four VA medical facilities and found they did not always follow established guidance for doctors to review fellow physicians involved in “adverse events” such as an incorrect surgical procedures, treatments or misdiagnoses that may have jeopardized patient health.

VA hospitals have various levels of peer review to examine physicians’ actions following a treatment issue. The reviews range from determining whether a peer’s actions were clinically appropriate to full investigations of whether a provider’s care was grossly negligent.

Of the four VA medical centers GAO reviewed for its audit — in Dallas, Nashville, Seattle and Augusta, Maine — none complied with all the policies for review, although several adhered to certain portions of the guidance.

“Failure of [VA 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,” the GAO said.

From 2006 to 2009, there were 101 surgical adverse events alone, according to GAO — incorrect surgical procedures such as performing a procedure on the wrong patient, inserting an incorrect implant or performing an incorrect procedure.

In the past several months, the VA IG also has published reports of at least 21 preventable deaths at VA health facilities, including three at the Memphis VA Medical Center, five at the VA Pittsburgh Healthcare System, three at the Charlie Norwood VA Medical Center, Augusta, Ga., and four at the Atlanta VA Medical Center.

In Columbia, S.C., 52 malignancies were linked to delayed colonoscopies; six deaths have been linked to the delays, according to the Associated Press.

The GAO said VA must ensure that all medical centers are following their peer review policies and require the facilities to report information on how they are implementing “triggers” that set off further reviews.

Auditors also said VA regional offices and the VA Inspector General, which both have oversight for monitoring the hospitals’ peer review processes and ensuring the medical centers have needed flags for additional review, failed to monitor implementation at the medical center level.

“As such, the Veterans Health Administration cannot provide reasonable assurance that Veterans Affairs medical centers are using peer review triggers as intended,” according to GAO.

In its response to the report, VA agreed to the report’s findings as well as its recommendations.

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