[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
BROKEN PROMISES: ASSESSING VA'S
SYSTEMS FOR PROTECTING
VETERANS FROM CLINICAL HARM
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HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, OCTOBER 16, 2019
__________
Serial No. 116-38
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
40-994 PDF WASHINGTON : 2022
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COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tennessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
CHRIS PAPPAS, New Hampshire, Chairman
KATHLEEN M. RICE, New York JACK BERGMAN, Michigan, Ranking
MAX ROSE, New York Member
GILBERT RAY CISNEROS, JR., AUMUA AMATA COLEMAN RADEWAGEN,
California American Samoa
COLLIN C. PETERSON, Minnesota MIKE BOST, Illinois
CHIP ROY, Texas
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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WEDNESDAY, OCTOBER 16, 2019
Page
OPENING STATEMENTS
Honorable Chris Pappas, Chairman................................. 1
Honorable Jack Bergman, Ranking Member........................... 3
Honorable Mark Takano............................................ 9
Honorable Aumua Amata Coleman Radewagen.......................... 16
Honorable Gilbert Ray Cisneros, Jr............................... 16
Honorable Carol Miller........................................... 18
Honorable Joe Cunningham......................................... 20
Honorable Scott Peters........................................... 22
Honorable Jennifer Wexton........................................ 24
WITNESSES
Ms. Sharon Silas, Director, Health Care Team, U.S. Government
Accountability Office.......................................... 4
Dr. John Daigh, Assistant Inspector General for Healthcare
Inspections, Office of Inspector General, U.S. Department of
Veterans Affairs............................................... 6
Dr. Steven Lieberman, Acting Principal Deputy Under Secretary for
Health, Veterans Health Administration, U.S. Department of
Veterans Affairs............................................... 8
Accompanied by:
Dr. Gerald Cox, Deputy Under Secretary for Health for
Organizational Excellance, Veterans Health
Administration, U.S. Department of Veteran Affairs
Ms. Jessica Bonjorni, Acting Assistant Deputy Under Secretary
for Health for Workforce Services, Veterans Health
Administration, U.S. Department of Veterans Affairs
APPENDIX
Prepared Statements of Witness
Ms. Sharon Silas Prepared Statement.............................. 33
Dr. John Daigh Prepared Statement................................ 57
Dr. Steven Lieberman Prepared Statement.......................... 64
Submissions For The Record
Honorable Rick Crawford (AR-1) Prepared Statement................ 71
Honorable French Hill (AR-2) Prepared Statement.................. 71
Honorable John Lewis (GA-5) Prepared Statement................... 72
Honorable David McKinley (WV-1) Prepared Statement............... 75
Honorable Carol Miller (WV-1) Prepared Statement................. 75
Honorable Bruce Westerman (AR-4) Prepared Statement.............. 75
Honorable Steve Womack (AR-3) Prepared Statement................. 77
The National Council of State Boards of Nursing Prepared
Statement...................................................... 78
BROKEN PROMISES: ASSESSING VA'S SYSTEMS FOR PROTECTING.
VETERANS FROM CLINICAL HARM
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WEDNESDAY, OCTOBER 16, 2019
U.S. House of Representatives
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
Washington, DC.
The subcommittee met, pursuant to notice, at 2:48 p.m., in
room 210, House Visitors Center, Hon. Chris Pappas (chairman of
the subcommittee) presiding.
Present: Representatives Pappas, Rose, Cisneros, Peterson,
Wexton, Peters, Cunningham, Takano, Bergman, Radewagen, Bost,
Roy and Miller.
OPENING STATEMENT OF CHRIS PAPPAS, CHAIRMAN
Mr. Pappas. Good afternoon. I call this hearing to order.
Without objection, the chair is authorized to declare a recess
at any time.
Before we begin, I would like to ask unanimous consent for
our colleagues, Representatives Cunningham, Lewis, Miller,
Peters and Wexton to participate in today's hearing should they
all be able to attend.
Without objection, so ordered.
I would like to also welcome our full committee chair, Mark
Takano. Thank you for being here, Mr. Chair.
Approximately 8 weeks ago the media began reporting on a
string of concerning incidents of patient harm and professional
misconduct in VA medical facilities. In August, a former VA
pathologist in Fayetteville, Arkansas was charged with
involuntary manslaughter, fraud and making false statements in
an attempt to conceal years of substance abuse. Over his 11-
year tenure with VA he is believed to have botched diagnoses
for an estimated 3,000 veterans, some of whom died.
Authorities are also investigating at least a dozen
suspicious deaths at the VA hospital in Clarksburg, West
Virginia. Medical examiners have now determined that 3 of these
veterans died of homicide by insulin injection.
Early in September a veteran receiving end of life care at
a VA nursing home in Atlanta was bitten by ants more than 100
times before facility staff finally moved him to a new room and
took action to address this infestation. These reports are
sickening.
Over the last 2 months we have also received a steady
stream of reports from VA's Inspector General (IG) identifying
appalling VA quality management failures in several other
locations.
For example, last month the IG reported on multiple
leadership failures at a VA facility in Veterans Integrated
Services Network (VISN) 10 in the Midwest which allowed an
opthalmologist to perform substandard surgery and laser
procedures for 2 years. This doctor regularly took hours to
complete cataract surgeries that should have taken less than 30
minutes. The facility director and chief of staff repeatedly
dismissed concerns that were raised by other staff members.
Although these 2 facility level leaders had the
responsibility and the authority to remove the provider, they
instead chose to disregard the patient safety risks. The
reason, according to the IG the ophthalmologist's spouse was
also a surgeon at the facility and leaders worried that
terminating one would entice the other to resign, leaving
several veterans--leaving the facility with 2 physician
vacancies.
In the end, as a result, several veterans were referred to
community care for further treatment to resolve complications
arising from this surgeon's care.
It would be easy to dismiss any one of these cases as just
an isolated incident or just one bad apple. Collectively, these
cases speak to wider problems with VA's ability to identify
clinicians who are negligent, abusive or committing criminal
acts and prevent them from practicing. The VA has got to do
better.
Today's hearing will explore several critical questions:
What red flags are VA facilities missing, overlooking or
choosing to ignore when they hire and employ clinicians; when
concerns arise, why are not medical center officials
investigating in a timely manner; and when concerns are
substantiated, why isn't VA reporting them to the National
Practitioner Data Bank, the NPDB, and to State licensing boards
in a timely fashion.
As today's hearing will make clear, far too much
responsibility and authority has been placed at the local
level. The Veterans Health Administration and its VISNs are
doing far too little oversight to ensure that facility level
leaders understand and are complying with policies for ensuring
proper patient care and safety.
Instead, VA's pervasive lack of accountability is leading
to patient harm. That is why we have convened today's hearing.
Veterans and their families deserve answers. They need to know
that the VA is upholding its moral and ethical obligation to
deliver world class health care. This is the promise our Nation
made to those who have served, and our heroes deserve nothing
less than that.
This is not new territory for VA or for this subcommittee.
In fact, 2 years ago General Bergman shared a subcommittee
hearing on this very topic. One of our witnesses. Dr. Gerard
Cox, testified at that hearing. Among other things, Dr. Cox
promised that the VA would update its policies related to
credentialing and privileging, improve the timeliness and
reporting to the NPDB and State licensing boards, expand NPDB
reporting to nurses and other types of clinicians instead of
just physicians and dentists, and establish a new VISN level
compliance process.
As you will hear today, none of these actions have been
made since our subcommittee's last hearing on this topic. I
will say that again. The VA has not taken any of the actions
that it promised during that hearing in 2017. The string of
incidents over the last 8 weeks should serve as a wake up call.
No one here would deny veterans deserve any less than that, but
we must do better for VA employees who are brave enough to
speak up when they are concerned that a colleague's clinical
incompetence, their impairment, negligence or misconduct is
putting veterans' lives at risk.
As the IG found in the case of the ophthalmologist in VISN
10, facility leaders repeatedly ignored concerns raised by
other clinicians at the facility. The indictment of the VA
pathologist in Arkansas states that colleagues complained to
facility leaders repeatedly that the doctor appeared to be
intoxicated while on duty, both before and after he completed
an inpatient treatment program.
In both cases it took years for facility leaders to remove
these providers, and in the meantime our veterans suffered. It
is not enough for VA leaders to sit here today and pledge
policy changes. They have done that before. We need to see that
VA is as outraged as we are and that leaders at all levels will
be willing to walk the walk. We must see a fundamental cultural
transformation. Something must be done to make VA a place where
employees at all levels feel they have psychological safety and
to be able to sound the alarm.
Employees need to know that their concerns will be taken
seriously, that there is a sense of urgency to address these
concerns as soon as they arise and that VA is acting swiftly to
guarantee these issues do not occur again in the future. Their
lives depend on it.
With that I would like to recognize our ranking member,
General Bergman, for 5 minutes for any opening remarks he may
have.
OPENING STATEMENT OF JACK BERGMAN, RANKING MEMBER
Mr. Bergman. Thank you, Mr. Chairman. As you stated on the
front end, in 2017 as chair of this subcommittee I held a
hearing on VA provider competency, which focused on VA's
handling of providers who were found to deliver substandard
care.
Sadly, we are holding another hearing on this vitally
important topic in the wake of several new reports of serious
patient harm involving VA providers. Our veterans deserve
better and we collectively must give them our best effort
because they have given us their best effort through their
service.
When problems arise, we must take a long, hard look at what
went wrong, why it went wrong, and what we can do to mitigate
the risk of future failures.
The unfortunate reality is that this is a retrospective
process. No congressional hearing or legislation can change
what happened. It has been said that there are 3 things that
you can never get back in this world: The spent arrow, the
spoken word, and the missed opportunity.
Mr. Chairman, we have before us an opportunity to
significantly improve the department for veterans and their
loved ones. The committee has received several reports recently
from the VA Inspector General and the Government Accountability
Office (GAO) that identified failures in credentialing,
privileging and quality management. It appears to me that there
are polices in place that, if followed, could mitigate and/or
avoid many of these issues.
However, an organization's policies and procedures alone do
not make for success. It is the leadership of the organization
that establishes the culture, empowers individuals to think and
act autonomously, and drives the organization toward a more
improved version of itself. It appears that many of these
problems are, in a large part, leadership failures.
For example, one of the glaring issues following a recent
GAO report was the lack of consistent and standard
credentialing, privileging and quality management oversight
from VISN Chief Medical Officers. The report found that the
VISN CMOs assessments of credentialing, privileging and quality
of care were often incomplete with inconsistent use of the
``standardized assessment tool.'' In fact, some VISN officials
stated that they were not using the standardized tool, but
rather developing their own auditing tool.
You cannot manage what you do not measure. It seems that
there is little about the VISN's oversight of credentialing and
privileging that is actually measured.
Another area of concern that the inspector general has
raised is the lack of direct observation of providers on
Focused Professional Practice Evaluations or FPPEs. Instead, VA
facilities rely on documents to evaluate the provider's
performance.
Though documents may show performance to be within
acceptable ranges, they may not capture a practitioner's
behavior while operating, responding during a crisis or
confidence with a procedure. I am interested in hearing more
about this issue from our witnesses.
As a military commander, I know that there is always the 10
percent who are not with the program and can sully the
reputation of the rest of the organization. While hundreds of
thousands of veterans receive quality health care from tens of
thousands of VA providers every day, VA is not immune to this
10 percent problem.
When issues are identified, VA must act swiftly to address
them. Therefore, I want to know what VA is doing to correct the
identified failures and most importantly what it has learned
from these failures and what systems and people have been put
in place to ensure that VA avoids similar failures in the
future.
To kind of sum up, the observation is no clear chain of
command, no structured review process and no requirement for
direct observation.
I thank all of our witnesses for being here today and I
look forward to a productive hearing.
With that, Mr. Chairman, I yield back.
Mr. Pappas. Thank you, Ranking Member Bergman.
I will now recognize our first witness. First we have Ms.
Sharon Silas, a director of the U.S. Government
Accountability's Office Health Care Team.
Thank you for appearing with us today, and you are
recognized for 5 minutes.
STATEMENT OF SHARON SILAS
Ms. Silas. Thank you.
Chairman Pappas, Ranking Member Bergman, and members of the
subcommittee, I am pleased to be here today to discuss our
recent body of work on provider qualifications and competence
in VA's health care system.
My testimony today is summarized as findings and
recommendations from 2 recent reports on VA's response to
adverse information when credentialing providers, and the
reviews and reporting of VA providers when concerns are raised
about the quality of their clinical care.
Based on our findings from these 2 reports, we made 11
recommendations, 9 of which remain open.
Like other health care facilities, VA medical centers are
responsible for ensuring that their providers deliver safe care
to patients. VA has processes and policies in place to help
ensure that providers have the qualifications and competence to
deliver quality care to veterans.
First, as part of credentialing and renewing clinical
privileges for a provider, Veterans Health Administration (VHA)
policy requires VA medical centers to review the NPDB which is
a data base that collects and releases information on providers
who, for example, have been disciplined by a State licensing
board or other health care entity.
Review of NPDB reports are used to verify that the
provider's medical licenses are current and in good standing.
However, in our 2019 report we found inconsistent adherence to
VHA policies that disqualified providers from employment at VA
medical centers.
Specifically, we found that some VA medical center
officials were not aware of key policies that govern
credentialing reviews and that gaps exist in VHA policy that
allow for inconsistent interpretation.
For example, VHA did not have policies in place regarding
Drug Enforcement Agency (DEA) registrations and the
circumstances in which waivers may be required.
Last, VHA's oversight of VA medical centers' reviews of
adverse information was inadequate.
Second, VA medical center officials are also required to
review and, if warranted, address any concerns that may arise
about a privileged provider's clinical care. Depending on the
nature of the concern and the review's findings, take
appropriate actions including limiting or preventing the
provider from delivering care to veterans.
VA medical center officials are also required to report the
providers against whom they take adverse privileging actions to
the NPDB and State licensing boards. If VA medical centers fail
to properly review, address and report concerns that have been
raised about the provider's performance, they may be exposing
veterans, and potentially the public, to unsafe care.
In our 2017 review, we found that for 148 providers that
required clinical reviews at 5 VA medical centers, VA officials
were unable to provide any documentation for about half of
them. In fact, officials acknowledged that in some cases the
required reviews were not conducted at all.
Furthermore, VA medical centers did not always conduct
reviews of providers' clinical care in a timely manner, some
taking longer than 3 months and in some cases years to initiate
reviews of a provider's performance.
We also found that the 5 VA medical centers did not alert
the NPDB or State licensing boards if there were serious
concerns with regard to a provider's clinical performance as
required by VHA policy.
Specifically, we found that only 1 of 9 providers was
appropriately reported to the NPDB and none of these providers
were reported to the State licensing boards. We found that 1 of
these providers was later fired and reported to the State
licensing board by a non-VA facility for the same reason
several years later.
The causes of these deficiencies that we identified in this
review can again be attributed to gaps in policy and inadequate
oversight. For example, we found that VHA policy does not
require VA medical centers to document all types of reviews of
providers' clinical care. We also found that while VISN
officials are responsible for overseeing the credentialing and
privileging processes of the respective VA medical centers,
none of the VISN officials we spoke with describe any routine
oversight.
In the last few months a number of high profile incidents
involving quality and safety concerns with VA providers have
been covered in the media. While these cases each have their
own specific circumstances, many appear to illustrate the
potential impact of the deficiencies we identified in our
reviews and highlight the importance of VA implementing GAOs
recommendations.
Strengthening policies and oversight of VA medical center's
credentialing and reviews of provider clinical care when
concerns are raised are key to decreasing the risks that our
veterans and the general public will be exposed to unsafe care.
This concludes my prepared statement. I would be happy to
answer any questions that you may have.
[The Prepared Statement Of Sharon Silas Appears In The
Appendix]
Mr. Pappas. Thank you very much, Ms. Silas.
Our second witness is Dr. John Daigh. He is the Assistant
Inspector General for Health Care Inspections at the VA Office
of Inspector General.
Dr. Daigh, thanks for joining us, and you are recognized
for 5 minutes.
STATEMENT OF DR. JOHN DAIGH
Dr. Daigh. Chairman Pappas, Ranking Member Bergman, members
of the subcommittee, I thank you for the opportunity to testify
regarding Office of Inspector Generals (OIG's) work on the
important topic of credentialing and privileging of licensed
and independent practitioners.
I am privileged to represent the OIG's Office of Health
Care Inspections and the staff that prepared the reports
discussed in our written testimony.
I would like to begin by affirming that our work supports
the fact that VHA usually provides quality health care to
veterans, and that the overwhelming majority of clinical
administrative staff at VA hospitals are committed to their
mission.
However, it is clear that credentialing and privileging
processes along with the patient safety program and quality
assurance must be improved to provide appropriate assurance
that veterans will continue to receive high quality medical
care.
In numerous reports over the last few years my office has
detailed incidents where physician care did not meet VHA
standards and episodes where veterans were placed at risk or
harmed as a result of too many months of unchecked substandard
care.
We have made recommendations to VHA to address the lapses
in provider credentialing and privileging practice evaluations
and a to ready acceptance by VHA privileging committees that a
provider has the clinical skills and thought processes required
to provide high quality care.
We are also concerned that it takes too long for the
leadership at a hospital to act to address poor performing
providers.
In particular, an August 2019 report highlights many of
these failures with the VISN 10 medical center's decision to
hire an opthalmologist. The individual that was hired was not
board eligible in ophthalmology. The submitted clinical
references did not provide comfort that the physician could
perform cataract surgery, a surgery for which the physician was
subsequently given privileges by the facility leadership. He
was not adequately assessed through the FPPE process with
respect to the ability to perform cataract surgeries. When
concerns about the quality of this provider's surgical care
were raised by nurses and other members of the staff, hospital
leadership was far too slow to respond.
Simply put, it should not be a challenge to determine there
is a problem when cataract surgery that should take less than
30 minutes takes hours, and it should not be a challenge to
remedy that problem.
While VHA needs to improve their efforts to collect and
review all required documents for the credentialing process,
more emphasis should be given to understanding the quality of
the provider's prior practice through interviews and references
from appropriate sources.
VHA needs to look for opportunities to adopt a show me
attitude when granting privileges. For example, observing a
colonoscopy or reviewing the interpretation of scans and
pathology slides should be comprehensively adopted in early
stages of a provider's employment.
Direct observation of clinical procedure performance and
increased use of simulation centers could better demonstrate
that a clinician will be more likely to provide high quality
medical care.
More concerning to me than the credentialing and
privileging issues we uncover is the finding that substandard
care was provided for months without VHA leadership action.
Technicians and nurses tell my staff that they have no reason
to speak up about poor provider care when they see inaction
from providers themselves or from facility leadership.
I am unsure if providers and staff are not making
themselves heard or if leadership is not listening. This
problem speaks to the need to consider changes to the patient's
safety and quality assurance programs. They must work together
to ensure that veterans receive quality medical care.
While we generally believe VHA policies are reasonable, it
is time for VHA to conduct a serious review of how it
implements these policies. Our recent reports should not be
discounted as isolated events that would be expected to occur
across a large system.
In addition to challenging how providers are evaluated in
order to reduce variance across the system, VHA should consider
appointing a national leader for each speciality whose primary
responsibility is to ensure that the quality practice of that
speciality across VA is at an outstanding level.
A change in how local, regional and national leaders
conduct evaluations and communicate about practitioners who
should not be providing care to veterans is paramount given
these missteps and delays. Many of the failures we identify can
be traced to what is, at best, ineffective oversight from
regional and national leaders.
Mr. Chairman, that concludes my statement and I will be
pleased to answer any questions.
[The Prepared Statement Of Dr. John Daigh Appears In The
Appendix]
Mr. Pappas. Thank you very much, Dr. Daigh.
Finally, I will recognize our VA witnesses, Dr. Steven
Lieberman, the Acting Principal Deputy Under Secretary for
Health at the Veterans Health Administration or VHA. He is
accompanied by Dr. Gerard Cox, VHA's Deputy Under Secretary For
Health For Organizational Excellence. Finally we have Ms.
Jessica Bonjorni who is VHA's Acting Assistant Deputy Under
Secretary For Health For Work Force Services.
Thank you all for joining us today and, Dr. Lieberman, you
are recognized for 5 minutes.
STATEMENT OF DR. STEVEN LIEBERMAN
Dr. Lieberman. Good afternoon, Chairman Pappas, Ranking
Member Bergman and members of the subcommittee.
I appreciate the opportunity to discuss the Veterans Health
Administration's process for credentialing, privileging and
quality management. I am joined today by Dr. Gerard Cox, Deputy
Under Secretary For Health For Organizational Excellence, and
Ms. Jessica Bonjorni, Acting Assistant Deputy Under Secretary
For Health For Work Force Services.
VA is committed to ensuring that veterans receive safe,
high quality health care. We know that some staff do not uphold
VA's values and we will hold accountable anyone that provides
poor care or commits crimes in our facilities.
Some recent events are deeply disturbing. It is extremely
troubling that the actions of a few flawed staff might
overshadow the great work of the nearly 348,000 employees who
provide quality care every day to veterans and their families.
During Fiscal Year 2019, VA clinical staff engaged patients
more than 121 million times, completed 1.7 million more
outpatient appointments at VA facilities over Fiscal Year 2018,
and saw an additional 73,000 more veterans over Fiscal Year
2018. We are proud that veterans are continuing to choose VA
for their health care as the quality of care and access in VA
continues to improve.
Research studies highlight that the quality of care in VA
is better than care in the private sector. The public does not
often hear about the overwhelming majority of our patient
encounters where VA staff works hard every day to optimize
care. Our internal surveys from veterans who receive VA care
show that their trust in our system continues to improve, most
recently at 88 percent.
As we grow, we are undergoing a transformation into a high
reliability organization. This new initiative to eliminate harm
to patients includes remedying the culture in which mistakes
may happen. Research confirms that most errors in health care
are unintentional. Our goal is to embrace a just culture where
staff feel comfortable speaking up if something has gone wrong
or could go wrong if a concern is not addressed. This creates a
system that reduces mistakes and prevents errors from harming
the patient.
It is important to note that a just culture still ensures
accountability, immediate discipline and prosecution, when
appropriate, for those who act with maliciousness, willful
negligence or intent to cause harm. VA demonstrated our
commitment to that accountability with the recent incidents
when staff did not live up to VA's high standards.
VA removes people who willfully cause harm from patient
care immediately.
We learn from the mistakes that cause harm and we welcome
investigations to ensure that we are doing everything we can to
create a safe health care environment. We have not found a
common thread between the recent incidents. Instead, there are
a small number of people whom acted inappropriately.
VA has a robust set of processes to screen all applicants
before they join VA that includes background screening. For
health care providers we follow the joint commission standards
for credentialing and privileging, including checking with the
provider's State licensing board and the National Practitioner
Data Bank to determine if an applicant has been reported due to
substandard care, professional misconduct or professional
incompetence.
VA continues to monitor provider's performance and the
external reporting bodies to ensure they remain fit for
service, and we react quickly when a new issue is found.
Unfortunately, there is no way in health care to predict
every human failing. We establish strong systems in the way
industry standards to respond quickly and comprehensively
whenever a patient's safety might be in jeopardy.
In conclusion, I want to emphasize that I am sorry for any
pain that any veteran or their families have experienced as a
result of our employees acting inappropriately. When something
goes wrong we learn from those experiences. As a result of
that, we get stronger. We get stronger because of the nearly
348,000 employees who come to work every day to provide
excellent care to veterans.
That completes my opening statement and we are prepared to
answer your questions.
[The Prepared Statement Of Dr. Steven Lieberman Appears In
The Appendix]
Mr. Pappas. Thank you, Dr. Lieberman.
We will now turn to questions and I will begin by
recognizing Chairman Takano for 5 minutes.
Mr. Takano. Thank you, Chairman Pappas.
About a month ago the full committee held a member day
hearing where colleagues presented their veterans policy
priorities and I was alarmed to hear from Representative Womack
that VA either failed to provide or was slow to provide
relevant information to his office and to other members of the
Arkansas delegation after firing the pathologist whose botched
diagnoses allegedly contributed to the death or harm of
numerous veterans.
Representative Westerman submitted a statement for the
record for today's hearing that echos those concerns. According
to Mr. Westerman, the VA for months ignored his request to
convene an administrative investigation board to examine
possible medical center leadership failures. The investigation
was convened only after several of the facilities senior
leaders, including the director, had retired or quit.
I have also heard from members of the Arkansas delegation
that VA originally only proposed reviewing the final year of
cases handled by this individual. That is right. VA did not
plan to fully review all 11 years of this pathologist's
diagnoses until after Members of Congress and the IG applied
pressure to do so.
Dr. Lieberman, has VA now finished reviewing all 11 years
of this provider's practice?
Dr. Lieberman. Yes, they have, sir.
Mr. Takano. Great. How has VA gone about informing veterans
whose health may have been affected who might have been
misdiagnosed by this doctor?
Dr. Lieberman. They have reached out to every veteran or
their family, if the veteran was no longer available, to
disclose to them what had happened with their loved one.
Mr. Takano. Approximately how many veterans have been
contacted, veteran families?
Dr. Lieberman. Approximately 30.
Mr. Takano. 30. Are there more to be contacted because we
are talking about 11 years worth of cases.
Dr. Lieberman. Those are the cases where harm may have
occurred as a result of the provider.
Mr. Takano. All right. I will be interested to hear more
from your office about how you arrived at those 30 and how you
could eliminate all of the other cases.
Dr. Lieberman. We would be happy to meet with you to
discuss that further.
Mr. Takano. Thank you.
Dr. Lieberman, when and how did the VA medical center, the
VISN and VA headquarters become aware that at least a dozen--I
am turning now to the question of Clarksburg, West Virginia, at
least a dozen veterans died under suspicious circumstances over
the course of about a year and a half. How did you become
aware? How and when did the VA medical center, the VISN, the VA
headquarters become aware that at least a dozen veterans died
under suspicious circumstances?
Dr. Lieberman. As you know this is still under criminal
investigation and we have not had confirmed the numbers. We
have not been informed on any specific numbers. We certainly
were informed of what had trans--that there was a concern----
Mr. Takano. I just want to know how you all became aware.
How did any of the medical centers, the VISN, how did you
become aware?
Dr. Lieberman. The facility had concerns that this was
going on and did a review over a year ago and they informed
their facility leadership who, once they became aware,
immediately called leadership at the time in VA headquarters
and then the OIG was immediately notified also.
Mr. Takano. My question is, is it true that they only
became aware after the IG brought it to their attention or are
you saying that they became aware before that--the IG got
involved?
Dr. Lieberman. Right before the IG became involved. The IG
was notified very soon after leadership in VA headquarters was
made aware.
Mr. Takano. How did you become aware of these deaths?
Dr. Lieberman. Personally, I heard about it without any
details, just that there was a concern at the facility from the
OIG.
Mr. Takano. This is after the OIG was brought into this?
Dr. Lieberman. I was not the leadership at the time when
the concerns were first brought forward. When I assumed my
leadership role is when I was notified about this.
Mr. Takano. Okay. What actions, if any, has VA taken to
inform veterans or their next of kin who may have suffered
unexplained hypoglycemic events or even death at the Clarksburg
Veterans Affairs Medical Center (VAMC)?
Dr. Lieberman. We have not reached out to anyone as this is
an active investigation.
Mr. Takano. Fair enough.
Are veterans and their families expected to rely on the
news media for this information?
Dr. Lieberman. They certainly have the OIG available to
answer any of their questions.
Mr. Takano. All right. VA is not--because of the ongoing
investigation, you have not pro-actively made any notifications
of the families?
Dr. Lieberman. That is correct.
Mr. Takano. Mr. Chairman, my time is out and I yield back.
Mr. Pappas. Thank you, Chairman Takano.
I would now like to recognize Ranking Member Bergman for 5
minutes.
Mr. Bergman. Thank you, Mr. Chairman.
Dr. Lieberman, according to the VHA handbook, 1100.19, the
Principal Deputy Under Secretary for Health or designee is
responsible for ensuring oversight of VHA's credentialing and
privileging for licensed providers.
However, the handbook also says, ``The ultimate
responsibility for credentialing and privileging resides with
the facility director.''
Can you please help me reconcile who has the ultimate
responsibility because you are higher in the chain, the chain
of command that is, than a medical center director, correct?
Dr. Lieberman. Correct, sir.
Mr. Bergman. Okay. Who is at the top?
Dr. Lieberman. Ultimately the Principal Deputy Under
Secretary and the Under Secretary for Health have the ultimate
responsibility for the organization to ensure that it is done
correctly.
Mr. Bergman. Okay. Let me ask you a question. If you are at
the top, you know, what are your expectations as they related
to credentialing, and privileging, and when was the last time
that you personally laid out your expectations?
Dr. Lieberman. Credentialing and privileging is a critical
aspect of screening to ensure we get the right candidates for
our positions, although there is no perfect way to predict when
an employee is going to be problematic. There are many checks
and balances in this process. It starts with the H.R.
department actually, takes a look at suitability, looks for--
every employee undergoes a background check, gets
fingerprinted.
Then the credentialing office begins their part of the
review, which is what is called primary source verification
where they double check that whatever the applicant says in
their application is correct. They will check directly to make
sure that they got the correct diploma, the correct training,
the----
Mr. Bergman. Okay. Well, you know, you could talk for a lot
because there is a lot to do there. To use the example of the
cataract surgery taking 2 hours when we know it should take
somewhere between 15 and 30 minutes, depending on what type of
procedure, whether it is a temporal incision or wherever it is.
But the point is, you know, the ASCRS, the American Society
for Cataract and Refractive Surgery, as well as other medical
disciplines have, you know, have criteria for performance.
Does the VA look to these speciality groups like the
cataract surgeons to make sure that in the end you are doing--I
hear you are doing the paperwork, but who is doing truly the
hands on to make sure that the surgeon can hold the
phacoemulsification, you know, hand piece correctly so that it
does not suck the iris out as opposed to the lens?
Dr. Lieberman. Dr. Cox, do you want to just talk about that
issue?
Dr. Cox. Sure. Thank you very much for the opportunity to
be here today.
Each clinical community establishes its own standards for
quality. Ultimately, to answer your question, sir; it is the
immediate supervisor, that surgeon, the service chief in
ophthalmology or general surgery or dermatology or whatever
service it is that is responsible for assuring the competency
and the quality of the practice of the people providing that
care in that medical center.
As you heard, there are processes in place for ongoing
professional performance evaluation and for peer review to
conduct that assurance.
Mr. Bergman. When is the last time that somebody got called
before a board of their peers for review and was, shall we say,
given a thumb's down based on performance?
Dr. Cox. Well, in the surgery community, the idea of having
a sort of peer review or local review of one another's care is
commonplace. Morbidity and mortality conferences are routine in
every medical facility, including VA medical facilities, to
review cases where there is an unexpected outcome or something
that could have been done differently. That has helped
providers learn from one another and assure the higher quality
of care.
Dr. Lieberman. Yes, just to respond, peer reviews get a
thumb's down. Everyone has the responsibility to do these
objectively. If the standard of care was not met, that is
pointed out.
Mr. Bergman. Is there, I hate to say, re-mediation or
retraining?
Again, in my time as a commercial pilot, if you could not
pass your check ride you did not fly the line. You were not
certified safe to operate that aircraft. You had to go back
through training and you got a couple of chances before you
lost your job.
Is there such, if you will, an exact set of re-
qualification training or standards that will allow people who
are good folks, but maybe their skill sets are not up to where
they need--they must be to, again, to handle surgical
instruments, is there a process?
Dr. Cox. Well, you are exactly right, sir. It is a
requirement that everybody be monitored in this way and the
process depends on the specifics of each case. Each one is
handled individually.
It may be determined that additional training or retraining
is the remedy. It may be something like a lesser remedy, more
close scrutiny or more frequent oversight. As Chairman Pappas
suggested earlier, having another surgeon directly observe the
care of that surgeon under scrutiny in the operating room.
Then in egregious cases where the provider's performance
can not be improved after additional training or scrutiny of
that type, then that is when we get into the question of taking
action against the person's privileges to suspend them, limit
them, or even to revoke them.
Mr. Bergman. Well, again, what this committee looks for,
subcommittee looks for is examples of oversight on your part.
These are tough decisions and tough things to have to tell
professionals, you did not make the cut. There is no pun
intended in that at all. I mean, the idea is that you need to
get better before we let you into an operating room or into
whatever level of care you are providing.
Dr. Daigh, you have raised to my staff that there is a lack
of direct observation of providers when they are under a focus
professional practice evaluation, the FPPE. What could be
missed if a provider's documents are reviewed, but they are not
directly observed?
Dr. Daigh. Thank you, sir, for the question.
I think in the ophthalmologist's case I think it is pretty
clear that if at the beginning of this individual's practice
one had simply gone to the OR, if they were already a competent
ophthalmologist, and observed this individual provide surgery
for a day or 2, you would probably come to the conclusion that
this person should not be privileged to practice medicine at
the hospital that they practiced.
I think it is a missed opportunity, whether we are talking
about colonoscopies or surgical procedures or the
interpretation of slides or images to not test whether an
individual new to your hospital with the prior practice coming
in to test how well they actually can perform, as opposed to
saying, you have wonderful degrees, you have been to great
places, we are going to assume you can do this procedure.
Thank you, sir.
Mr. Bergman. Okay. I know my time is up.
To relate it to a check ride, you just do not welcome a new
pilot into your squadron without giving him a check ride first.
Thank you, Mr. Chairman. I yield back.
Mr. Pappas. Thank you.
I will now recognize myself for 5 minutes of questioning.
I would like to start with Ms. Silas. One of the things
that I hope we can address today at this hearing is the status
of the corrective actions that VA promised it would take in our
last subcommittee hearing on this 2 years ago.
I just want to reflect a little bit on your testimony. You
indicated that the GAO made 11 recommendations. Among these
recommendations include updating credentialing policies to
establish a timeliness requirement reviewing quality of care
concerns and to make clear that facilities must document these
reviews.
GAO also recommended that VHA direct its VISNs to audit
facilities' compliance with requirements for preparing
credentialing files, initiating and completing timely reviews,
documenting those reviews and reporting adverse actions to NPDB
and State licensing boards.
Is it true that almost all of these recommendations remain
unimplemented? If so, what are the status in getting VA where
they need to be?
Ms. Silas. Thank you for that question.
Yes. Out of the 11 recommendations that we have made
between the 2 reports, 9 of those recommendations remain open.
The 2 recommendations that have been closed is the
recommendation that the VISN chief medical officer document
evidence that the VISNs are overseeing compliance with
policies.
When we did a recommendation follow up with the Veterans
Health Administration in August 2019 they let us know that Vet
Pro was modified to allow for documentation of the VISN chief
medical officer reviews.
The other recommendation that has been closed is the
recommendation that QSV office should compile and disseminate
best practices to the facilities. The Veterans Health
Administration let us know that they had compiled best
practices and codified some of those best practices at the
time.
Mr. Pappas. Well, thank you for that.
It is my understanding that VHA's credentialing and
privileging policies, the directive and handbook, were due for
re-certification at the end of October 2017.
Dr. Cox, I am wondering if I can ask you, you testified
before the subcommittee almost 2 years ago pledging to update
these policies and establish a VISN level oversight process.
Can you reflect on those comments and where things stand
today and why we have not gotten to implementation?
Dr. Cox. Thank you, Mr. Chairman. I would be happy to.
Since 2 years ago when I sat before this committee, there
have been a number of steps that we have taken to strengthen
and improve our credentialing and privileging and quality
oversight.
First of all, as you read in the GAO report, we completed a
review; a focused review of over 70,000 providers in our system
who had been improperly--to identify any who had been
improperly hired because they had previously had a license that
was revoked. That is a prohibition that we corrected. We
removed 11 out of the 70,000 as a result of that review, and we
reinforced the prohibition by providing additional training for
our chiefs of staff and our credentialing officials at medical
centers.
We developed and piloted that standard auditing tool for
VISN Chief Medical Officers (CMOs). This is now an automated
tool that will be fully implemented before the end of this
calendar year. It will not only provide a standard for all CMOs
to use, but also automatically provide information about the
summary of those reviews to the VHA Central Office Medical
Staff Affairs office that is responsible for these policies.
We strengthened the Focused Professional Practice
Evaluation (FPPE) and Ongoing Professional Practice Evaluation
(OPPE) monitoring practices by mandating that only a specialist
from within the same specialty community can review the work of
another provider. That had not been standard prior to 2016. Now
it is the standard. Those specialty-specific criteria must be
used at each facility, rather than having a boiler plate set of
criteria for those reviews.
We also, in cases where there is only one type of
specialist, a solo physician, let us say the only general
surgeon or the only anesthesiologist, in those cases we have
put policy in place to make sure that their work is reviewed by
somebody who is a true peer, somebody in the same specialty
from a different facility rather than having a non-peer from
within the same facility, even a clinical supervisor such as
the chief of staff, for example, conduct those reviews.
Mr. Pappas. I appreciate these steps. When do you expect
that these policy updates will be completed?
Dr. Cox. Well, the policy updates are in progress and one
of the reasons that they have not been completed is because we
are rewriting and expanding them to incorporate some of these
strengths and strengthening activities.
For example, we are separating the credentialing policy
from the privileging policy and in the privileging policy
adding additional information and guidance on how to conduct
FPPE and OPPE.
In the case of the credentialing policy, we are
incorporating requirements now for telemedicine which add
another level of complexity for assessing the credentials of
somebody who might practice in one State, but via telehealth be
taking care of veterans in another State.
I expect both of these would be published by next summer.
Mr. Pappas. By next summer of 2020?
Dr. Cox. Yes, sir.
Mr. Pappas. Okay. That is well beyond the date that you had
indicated in the 2017 hearing, and I understand that these
things can take months of review to actually get to the
implementation stage. So----
Dr. Cox. That is correct.
Mr. Pappas.--we are going to continue to do follow up on
that. I think this continues to be a critical area that
requires our attention.
My time is expired, so I would like to recognize the next
member for questioning.
Ms. Radewagen, you are recognized for 5 minutes.
Ms. Radewagen. Hello for Mr. Chairman and Ranking Member.
Thank you for holding this hearing. Thank you also to the panel
for being here today.
Dr. Lieberman or Dr. Cox, VHA Handbook 1100.19 states that
the VISN CMO is responsible for oversight of the credentialing
and privileging process of the facilities within the VISN using
standardized assessment tool.
Would you please explain what this tool is, and what data
does this tool provide, and how are these data points utilized
in oversight?
Dr. Cox. The auditing tool is basically an electronic form
that has standard criteria that will be used across all 18
VISNs by each of the Chief Medical Officers. They will use it
to review any clinical or competency reviews that are conducted
at the facilities within that VISN.
Just to put this in perspective, Dr. Lieberman mentioned
there were 348,000 or so VA employees. 180,000 of them are
licensed providers. We have 180,000 providers in our
credentials data base. Of those, 65,000 of them are independent
providers such as physicians and dentists and advanced practice
nurses.
One of the reasons that you do not hear about the 64,990-
plus providers that are not getting into trouble that are not
providing substandard care is because they are caring, and they
are competent, and they are committed to the care of veterans.
Ms. Radewagen. Ms. Silas, in your written testimony you
referenced a standardized audit tool that VA developed to help
VISNs oversee reviews of clinical concerns. It appears to me
that many of the problems are a result of facilities not
appropriately using the tools that VHA has provided.
I would like to hear your opinion as to what VHA needs to
do to make sure that the tool is employed properly.
Ms. Silas. That is correct. There is an audit tool that has
been developed for the VISNs to oversee or at least conduct
audits of the VA facilities.
What we found was that during our review from 2017 that
none of the VISN officials that we spoke with described any
type of routine oversight. They were not using the audit tool
consistently.
We did make a recommendation that the Veterans Health
Administration ensure that the VISNs were consistently using
that tool to conduct their audits because currently right now
the VISN or the VHA policy does not require VISNs to oversee
the directors reporting to the National Practitioner Data Base
or to the State licensing boards. This could also be
incorporated into the tool and help to better ensure that there
is oversight of the VA medical centers.
Ms. Radewagen. Thank you, Mr. Chairman. I yield back.
Mr. Pappas. Thank you.
I would like to recognize Mr. Cisneros for 5 minutes.
Mr. Cisneros. Thank you, Mr. Chairman. Thank you all for
being here today.
Dr. Lieberman, in your testimony you State that the VA has
an obligation to notify State licensing boards of any
substantial findings in substandard care performed at the VA by
current or former licensed health care professionals. However,
in instances in which faulty clinicians are still able to
practice to the detriment of veterans still occurs.
In your opinion what are the barriers in place that prevent
the VA from reporting a clinician to the State licensing board?
Dr. Lieberman. I will start and then perhaps Dr. Cox will
have items to add.
First of all, when we fail to do something in a timely
manner, if we do not--any issues with any of the cases we are
discussing, we study what went wrong and we identify the
problems and we look in the given facility. But then we also
look nationally at what we can do to improve it.
Often, issues involved with failure for this would have to
do with training of our staff and making sure that they are
aware of the right way to proceed, and the timeliness and how
they are supposed to proceed. Dr. Cox.
Dr. Cox. First of all, let me clarify that reporting to the
State licensing board is a separate process from reporting to
the National Practitioner Data Bank (NPDB) and with different
thresholds.
Reporting to the licensing board is done whenever we have
enough evidence that a provider may have failed to meet the
acceptable standard of care and could have put patients at
risk.
The VA has no authority to take action against any
provider's license. That authority resides with the licensing
board. We provide them the evidence that we collect and then it
is up to the board to determine whether to open their own
investigation and whether to use that evidence to take actions
such as restricting, removing or suspending a provider's
license.
The standard for National Practitioner Data Bank reporting
is much higher. That can only be done after a complete
investigation as well as all the due process that providers do,
including a fair hearing where they can present their own
evidence and call their own witnesses to defend themselves.
At that point the National Practitioner Data Bank report is
submitted by the Medical Center Director. To answer a question
that came up earlier, it is the Medical Center Director who is
the privileging authority and who has the sole and ultimate
responsibility for making these decisions.
In fact, VA does a pretty good job of policing itself. The
basis for that statement is that over the last 3 and a half
years, from January 2016 until June of this year we reported
over 1,000 of those 65,000 licensed independent providers to
the NPDB. We have reported over 1,000 people in that 3 and a
half year span.
These actions are taken all the time. They are difficult
and complex cases. They require judicious decision-making on
the part of that Medical Center Director. But that is what we
need to do to protect the safety of Veterans.
Mr. Cisneros. In the 2017 GAO report found that the VA
medical center selected for their investigation did not report
any of the providers with adverse privileges actions taken
against them to State licensing boards despite it being
required by VHA policy.
Therefore, GAO recommended it be required that the VISN
officials establish a process for oversight in ensuring the VA
medical centers were reporting providers to the State licensing
board and to the National Practitioner Data Banks.
My understanding, to this date, the recommendation has
still not been taken up even 2 years later. Why is this the
case and why are there obstacles that prevent the VA from
implementing this necessary oversight?
Dr. Cox. Well, we agreed with the recommendation that it is
the responsibility of the VISN to conduct that oversight. One
of the reasons is, as I mentioned, 65,000 providers, 170 or so
medical centers, so it is just not feasible to expect that any
one person or office in Washington, DC. can do that. We have
regional governance for that reason.
Regarding the open GAO recommendations that Ms. Silas
talked about, I just wanted to indicate that, you know, across
the 2 GAO reports in question, the 2017 report had 4
recommendations. It is true they are all still open. But it
would not be fair to say that they have not been acted upon.
That report was published in November 2017 and within 2 months,
by January 2018 we had issued additional interim guidance to
the field in lieu of a formal policy change, which is still in
the works, and took the recommended actions.
Two of those 4 open recommendations have to do with putting
this in policy, so they can not be closed until we have
published that formal policy as Chairman Pappas asked me about.
The other 2 have to do with finalizing this automated auditing
tool for chief medical officers which we will be rolling----
Mr. Cisneros. Yes. I am running out of time here, but I
would like to, if you could, Mr. Lieberman, or Dr. Lieberman,
sorry, submit for the record, one of the things that you said
was training. There was a lack of training as to why this was
not happening.
If you could submit for the record what that training
program is and how are we going about training these directors
of the medical centers to make sure that these requirements are
met, that they do need to report these to the licensing boards
and to the National Practitioner Data Bank, I would appreciate
that.
Dr. Lieberman. I would be happy to do that. I can just want
to reemphasize what Dr. Cox was speaking about. Our VISN chief
medical officers take this responsibility incredibly seriously
and they have been going into the facilities and doing direct
reviews and auditing, and we see this as really making a
difference.
Mr. Cisneros. All right. Thank you. I yield back my time.
Mr. Pappas. Thank you.
I would like to recognize Ms. Miller for 5 minutes.
Ms. Miller. Thank you, Chairman Pappas, and Ranking Member
Bergman, and thank you all for being here today.
It is of utmost importance that we continue to provide and
maintain the highest quality of care for the men and women who
have served our country so bravely. The deaths at Lewis A.
Johnson VA Medical Center in Clarksburg, West Virginia, and the
sexual assault allegations in Beckley, West Virginia VA Medical
Center are not only troubling, but they are unacceptable.
As Members of Congress, it is our job to support swift and
proper investigations to ensure that such instances never
happen again. There have been considerable progress that has
been made with the quality of care that our veterans are
receiving following the enactment of the MISSION Act and
efforts to address the veterans' suicide epidemic.
Our service members should feel safe and comfortable
seeking care at the VA and these events show that there needs
to be additional oversight of clinicians, proper removal of bad
actor and monitoring of care.
The tragic deaths of our veterans at the Lewis A. Johnson
VA Medical Center in Clarksburg and the sexual assault
allegations at the Beckley VA Medical Center, once again, are
unacceptable. We must work together to ensure the families of
our Nation's heroes get the answers that they deserve and that
we can work to prevent these tragic events in the future.
I fully support the investigation into this matter and I
appreciate the committee's interest and oversight.
Dr. Lieberman, many of the veterans in my district are
extremely faithful to the VA and the quality of care that they
receive there. Do you have any suggestions on how we can take
VA policies that are made here in D.C. and ensure that they
make it down through the leadership ladder to guarantee that
the individuals are aware of the policies and are implementing
them correctly?
Dr. Lieberman. Thank you for that question, a very
important question.
We take this very seriously when we implement policies. We
are in the process of modernizing and that is a big part of our
modernization is to ensure that we are adequately communicating
to all levels of the organization. We start at the top and have
national meetings, but ultimately it is spread through the
VISNs and then down to the facilities.
We also have through our clinical leadership, we expect
them to communicate. We expect the communication to be 2 way.
We have national calls by specialty, by different parts of the
organization, nursing, clinical areas, and we talk about what
are the challenges that the field is facing, what are their
concerns if we are implementing a policy, making sure we get
their input.
We do not want everything to be, decisions to be made
always at the top. We want to make sure that we get input from
front line staff so that our policies can be most effective.
Ms. Miller. I am glad to hear that.
Dr. Daigh, what are the concerns and/or benefits of
incorporating a direct observation policy?
Dr. Daigh. Thank you for that question.
I think that the direct observation in many instances
allows an expert, for example, going back to the eye surgeon,
to observe whether or not it is a go, no go using the airline
language as to whether a surgeon could actually do that job or
not.
If you have an individual that you are going to give
privileges to do a colonoscopy to, and you watch that person do
the colonoscopy, and you see the same images that that person
doing the colonoscopy is seeing, you can have a conversation,
are they recognizing the right landmarks, are they seeing
pathology and biopsying it appropriately or marking it
appropriately, did they get to where they want to go to the
cecum to call it a complete colonoscopy.
I think that by observing and watching an individual do the
skills they are being hired to do, you can learn a great deal.
There are other areas where it is much more difficult. It
is an expensive process, but I think it is one that should be
considered and applied much more freely than it is currently in
the VA.
Ms. Miller. If we were to incorporate this policy, what
would it look like in terms of staffing, timeliness and quality
of care?
Dr. Daigh. I do not have an answer to that. I think that
that would require work I have not done to try to figure out
what the staffing requirements be or what the actual
implementation strategy would be.
But by observing and reporting on the cases that we have
seen recently, we are seeing evidence now that physicians are
making errors that we did not used to see in terms of making it
through the system and impacting a large number of veterans.
I think it is time to consider that we start to look at the
quality of care provided at the beginning when we hire someone
and do a more forceful job there observing their practice in
addition to monitoring them with not just paperwork, but with a
data collection system that is relevant to the care they
provide.
For example, monitoring how much blood loss a surgeon has
during a surgery is important, but that may not really inform
as to whether they can do their surgery well.
Ms. Miller. But it also is not just the physicians.
Dr. Daigh. I agree. There are many providers in the
hospital who--well, let me answer it this way. Nurses in
general are required to show me that they--prove that they can
do a skill. You are asked to suction here, suction this. You
are asked to put a piece of equipment together to start an IV
or to set up an IV bag.
Physicians are often given credit for their training and
education and experience, and I think there should be more of a
show me attitude as they are granted the privileges to do
skills as other people who work in the hospital are often
required to do.
Ms. Miller. Because there are many other people that work
in the hospitals.
Dr. Daigh Absolutely.
Ms. Miller. Thank you. I yield back my time.
Mr. Pappas. Thank you, Ms. Miller.
I would like to recognize Mr. Cunningham for 5 minutes.
Mr. Cunningham. Thank you, Mr. Chair, and thank you to each
and every one of you all for coming here today. I appreciate
it.
Dr. Lieberman, in 2017 a constituent of South Carolina's
first congressional district who was also a VA patient with a
service-related mental health disability died by asphyxiation
while under supervision of the Doran VA Medical Center. Are you
familiar with that case?
Dr. Lieberman. I have heard about it. Yes.
Mr. Cunningham. Okay. I mean, speaking more generally here
I want to use my time to discuss the VA's approach toward
ensuring patient safety in a mental health setting,
particularly for those patients who have been diagnosed with a
serious mental illness.
Can you speak briefly about the policies or safeguards that
the VA has in place to protect mental health patients from harm
by hospital staff?
Dr. Lieberman. We take this very seriously, patient safety.
We talk about this. If there is any events that go wrong, we
are going to take a look at it and see what happened in these
situations. Certainly, if there is a suicide, but in this case
it was not a suicide. It was----
Mr. Cunningham. Physical restraint.
Dr. Lieberman.--physical restraint. Correct. We look at
physical restraints. We monitor for that also with--under the
recommendation of the joint commission we are supposed to take
a look at that. We are supposed to minimize use of physical
restraint. When something goes wrong, we have to take a look at
it. Our mental health leadership take this very seriously, and
do look at this, and do talk about this in national forums
about how we can do better when something goes wrong.
Mr. Cunningham. Are you familiar with how personnel are
trained under these circumstances when they have an encounter
with someone with a serious mental health issue as was in this
case?
Dr. Lieberman. I would like to take that for the record and
get back to you and make sure I get you an accurate answer of
all the details. But we do extensive training in this area.
Mr. Cunningham. Yes. I would like to know some more details
about the training and also who or what department in
particular is charged with making sure that the restraint
protocols meet certain standards. You do not have that
information either handy I do not suppose, do you?
Dr. Lieberman. Not today, no. We will be happy to get you
that.
Mr. Cunningham. Okay. As far as the personnel thing, you
touched on this briefly before, but what processes are in place
to ensure the personnel are screened, they are credentialed,
and they are retrained periodically to certify that they are
aware of VHA policy requirements relating to the safe use of
such techniques?
Dr. Lieberman. When we first hire people we certainly do
extensive background checking, doing fingerprinting, making
sure that no one has a criminal background. Depending on the
level of the staff, if it is licensed staff we are going to
validate that they have the correct licenses.
We are certainly going to check their references, important
things like that, to make sure that they do not have any
history in the workplace showing any concern. Then we go very
deep for our providers, making sure that everything they put on
their application is accurate. If there is a lapse in time that
they work, why did that have that lapse, are they physically
and mentally healthy. We ask for--to have a medical
recommendation about that.
Mr. Cunningham. Okay. I appreciate it. You will supplement
the record and provide that information as far as who is tasked
with training them and what that protocol is and how often it
is reviewed, correct?
Dr. Lieberman. Absolutely.
Mr. Cunningham. You know, obviously as we are seeing when
our men and women return home from service, so many of their
scars we can not see. This is becoming, you know, a difficult
issue to deal with. But they deserve the best care that we can
give them. I applaud the VA for what they have done, and we are
just seeking the areas in which they can improve upon. I
appreciate your service.
My question to you is, what else can we as Members of
Congress, specifically this committee, do to ensure that this
growing area of concern, men and women with mental health
issues, Post Traumatic Stress Disorder (PTSD), after coming
back from doing so much for our country are awarded the care
that they deserve and the care that they need? Are there any
other tools from us that you would request?
Dr. Lieberman. I really want to emphasize how dedicated,
how well trained most of our staff are that do the right thing
every day.
I have a concern when we just focus on the negative that it
actually harms the veteran who is on the fence about whether
they should come to the VA. We have to tell both sides. We have
to tell the good stories because we hear that veterans hear
about these issues, which are certainly concerning, and we
certainly have to learn from them and improve. But we also have
to talk about the quality of care that VA has to offer and
especially for mental healthcare. I apologize for what happened
at Doran. That is a very upsetting issue there for that
particular case.
But we have to get our veterans to be willing to come to
us, and I just get worried when we just focus on negative in
forums that it is harming the veteran.
Mr. Cunningham. Yes. I would say in Charleston we have a 5-
star facility and----
Dr. Lieberman. Uh-huh.
Mr. Cunningham.--are very proud of that facility there in
Charleston. I think overall that that is the impression there.
Unfortunately, though, we do have to focus on some of the
terrible situations we are confronted with and how to make
things better and to ensure that they do not become a pattern.
I think that is the purpose of being here today.
Again, I thank you for your service, each and every one of
you all, and I would yield back.
Mr. Pappas. Thank you.
Mr. Peters, you are recognized for 5 minutes.
Mr. Peters. Thank you, Mr. Chairman, and Ranking Member
Bergman. Also, thank you for letting me waive on this
committee. I was pleased to serve on it in the last Congress.
As a San Diegan I really want to say how much I appreciate the
work you all do and appreciate your commitment to our veterans.
I also want to acknowledge that there is a lot of fine work
going on at the VA and that the nature of our business is that
as oversight we are going to look at some of the things that
are not going as well.
I wanted to come today just to get into a little bit of a
troubling story from the San Diego VA. I recently detailed this
story at the VA committee member day last month, but wanted to
summarize the story here.
The San Diego VA participated in a study examining
alcoholic liver disease, which was one site among other
institutions of a larger National Institutes of Health (NIH)
funded study led by the Pittsburgh Liver Research Center at
University of North Carolina (UNC) Chapel Hill.
Nine patients diagnosed with alcoholic hepatitis received
transjugular biopsies, and according to whistleblower's
disclosures this was not the standard of care and reported this
to the VA's Office of Medical Inspector or OMI.
Following OMI's report the Office of the Special Counsel,
or OSC, conducted an independent investigation and found that
the VA's internal report was unsatisfactory.
The Special Counsel report alleges that these samples were
collected improperly, sometimes without patient consent, and
could have put patients in harm's way, not that there was
evidence that anyone was harmed, but that was their conclusion.
The Special Counsel urged the VA to revisit its findings in the
matter and take a truly critical look at the research being
conducted at the San Diego VA.
Now we know this is not the first time that OMI has
investigated wrongdoing and has come up short in answers
according to the Special Counsel. According to data provided by
inewsource, which is a San Diego news outlet who has broke the
story, when the Office of Special Counsel reviews OMI report,
16 percent of them are found unreasonable, which is more often
than other executive agencies.
My colleagues here will remember the clinical neglect at
the Manchester VA which has been mentioned. The Special Counsel
also find OMI's reports in that instance to be unsatisfactory.
Again, no recorded cases of risking patient safety in this
instance. This story presents a case, though, that could have
consequences in other settings, especially for VA medical
centers that conduct research onsite. We want them to do that.
We want them to pair with academic institutions. My goal is to
strengthen the investigatory bodies that handle these types of
allegations so that these things do not come up.
Dr. Cox, maybe I will ask you, since you served as the
director of the Office of Medical Inspector, how often does OMI
review and report on medical research issues like these?
Dr. Cox. Thank you, Congressman. I would be happy to answer
your question.
First of all, it is not often that the Office of the
Medical Inspector is involved with research oversight. VA is
unique in having a separate and independent Office of Research
Oversight (ORO) which participated with the Office of the
Medical Inspector in that San Diego review.
If I may, I just would like to clarify the sequence of
events that you described about the liver research case.
The 2 whistleblowers at the San Diego VA Medical Center, to
whom we are very grateful for bringing these concerns forward,
went to the Office of the Special Counsel (OSC). They asserted
themselves as whistleblowers with OSC. Through the standard
statutorily guided process, the Special Counsel of the United
States referred the matter to the Secretary of the VA, who had
then assigned it to the Office of the Medical Inspector (OMI)
for Investigation.
OMI completes dozens of these whistleblower investigations
every year. They are part of our independent internal assurance
and oversight capability. They are the entity that can go into
any VA medical center and conduct an investigation and collect
evidence to determine whether the whistleblower's allegations
are substantiated or not.
As you indicated, when OMI did the initial investigation,
and wrote a report of that investigation at San Diego, they
failed to substantiate the whistleblowers' concerns. The reason
for that, it later became apparent, is that at least 1 key
witness was not truthful--
Mr. Peters. Okay.
Dr. Cox.--was not forthcoming with information. When we
later found out about that ourselves, we took it upon ourselves
to go back, conduct a second visit, a second investigation.
This is after OSC had closed the initial case and said it was
not reasonable. On the second occasion we substantiated those
findings, substantiated that there was egregious research
misconduct, and voluntarily submitted that second report to the
Special Counsel of the United States, and they are now
considering it.
Mr. Peters. Great. I appreciate that.
In general, do you think that OMI has enough resources to
thoroughly handle whistleblower complaints?
Dr. Cox. I do. You mentioned the inewsource article and we
were able to answer questions from the investigative reporter
before she published the article. We conducted our own analysis
of the rate at which the Special Counsel of the United States
finds OMI's reports not reasonable and we came up with a very
different number.
She asserted 16 percent. Our number is about 5 percent.
That track record actually has substantially improved from 2014
when the Office of the Medical Inspector was restructured, and
we have added additional staff since then. I believe that the
staffing levels are now at--
Mr. Peters. I am out of time, but to the extent you would
like to supplement your answers in writing, I would certainly
appreciate that. Again, I appreciate you all being here.
Thank you.
Dr. Cox. I would be very happy to. Thank you.
Mr. Peters. I yield back.
Mr. Pappas. Thank you.
I would now like to recognize Ms. Wexton for 5 minutes.
Ms. Wexton. Thank you, Mr. Chairman, and thank you to Mr.
Chairman and Ranking Member for allowing me to participate in
today's hearing.
I represent Northern Virginia here in Congress and my
district begins just outside of Washington D.C. and goes about
100 miles west all the way to West Virginia. Veterans in my
district, because we do not have a VA facility of our own, they
have the option of either going east into the D.C. VA or west
to Martinsburg. Both of these facilities are in VISN 5 and so
obviously the allegations or the substantiated issues at VISN 5
are very important to me and to my constituents.
I was really troubled to learn about the deaths at the
Johnson Medical Center in Clarksburg, West Virginia, and the
sexual assault allegations at Beckley, West Virginia's VA
medical center. I am very concerned about the serious
allegations of wrongdoing by medical personnel at the VA
facilities in Arkansas and Georgia.
Our veterans have sacrificed so much for our country and
they deserve the highest quality of care, and at a minimum they
should feel safe in our VA facilities. I think we can all agree
about that. Unfortunately, these facilities have failed on both
counts.
With the benefit of hindsight we are able to see some of
the things that went wrong, but what I am hoping we are able to
do with today's hearing is make sure that we have the
protections and protocols in place to make sure that these
things do not happen again.
I would like to focus for a moment on the role of VISNs in
oversight of wrongdoing at these VISN 5 facilities. There have
been reports, Dr. Lieberman, that VA employees are hesitant to
report suspected wrongdoing in these and other incidents. I was
pleased to hear you talk a little bit about, you know, from top
down, but also from bottom up to make sure that the reports are
made.
Are VA employees trained on the appropriate chain of
command in reporting suspected wrongdoing at the VA medical
center level?
Dr. Lieberman. Thank you for that question, Congresswoman.
This is a really critical issue and that is why we are
undertaking this high reliability organization journey where,
as a part of being a just culture staff feel comfortable coming
forward. They are not concerned that they are going to get in
trouble for this, and so we are working on this.
At the Atlanta facility, one of the biggest failures with
that unfortunate case was the culture there was such that it
did not come up the chain of command of what was going wrong
there. As a response to that, we really emphasized in a variety
of different forums, including Dr. Stone, our executive in
charge, sent out a letter to every employee talking to them
about the importance, that they have an obligation, a
responsibility to speak up when they see an unsafe situation,
that we will protect them if they come forward.
Certainly, if some employees will never trust their
leadership, and so we always have the backup, there are
hotlines, OIG. We have the compliance hotline, OSC. There is
always that. But, really, we want to get to the point in our
own organization where everybody feels comfortable in speaking
up.
Ms. Wexton. It would also be good for them to feel
comfortable that their complaints will make it up the chain of
command and be acted upon, and they will find out what the
results of the investigation----
Dr. Lieberman. Absolutely. We have to lead by example and
show them that they are making a difference in the workplace
when they speak up.
Ms. Wexton. Thank you.
Ms. Silas, I was pleased to hear you talk about the GAOs 11
recommendations and ones that are being implemented, and
particularly with regard to the standardized audit tool.
Now am I to understand from your answer to an earlier
question that there are issues with the tool that is being
rolled out right now? Is it lacking in some way?
Ms. Silas. No. I was not commenting that there was an issue
with the audit tool. We are still waiting for validation that
the tool has been rolled out.
Ms. Wexton. Have you had an opportunity to see how this
tool works?
Ms. Silas. I have not personally had an opportunity to see
how the tool works.
Ms. Wexton. Has someone with GAO had an opportunity to see
how this tool works?
Ms. Silas. Yes. The team that conducted the review had
opportunity.
Ms. Wexton. Is it your understanding from that team that
the tool that is going to be implemented will address the
oversight concerns that were announced in the report?
Ms. Silas. Yes. That is correct.
Ms. Wexton. Okay.
Dr. Cox, I guess you were talking about the fact that this
tool is going to be rolled out before the end of the year; is
that correct?
Dr. Cox. Yes, ma'am.
Ms. Wexton. What kind of training do you have for staff in
order to ensure that they are properly using the oversight tool
and that it will be a part of any sort of initial intake?
Dr. Cox. Training of both the Chief Medical Officers at the
VISNs who are going to be the primary ones to use this tool,
and of the credentialing officials at every VA medical center,
is a part of the implementation strategy. That is built into
the roll out process.
The tool was developed and has been piloted. There were, as
with many new electronic things, some IT glitches. We had to
step back a little bit and fix those bugs, and that is the
reason that it has not already been implemented. But it is on
track to be rolled out this year.
Ms. Wexton. You expect that for the year 2020 it will be
fully operational and be used in the entire facility all
throughout the VISN?
Dr. Cox. We do.
Ms. Wexton. Okay. Thank you very much.
I see my time has expired. I appreciate it. I yield back.
Mr. Pappas. Thank you very much.
I just have a few additional questions before we close and
I am wondering, Dr. Daigh, if I can ask one of you.
In your testimony you talk a little bit about the
decentralized nature of VHA and how this places significant
responsibility, if not all the responsibility, in the hands of
local leaders to ensure they are employing highly qualified,
highly competent professionals.
But time and again your teams have discovered that leaders
have failed to carry out certain responsibilities related to
reviewing the quality of care concerns and taking action to
limit or revoke privileges and reporting clinicians to
licensing boards and the NPDB.
In your opinion should all of these responsibilities
inherently reside at the local level? Do we have that balance
right, or is there an opportunity here to get VISNs and VHA
more involved in the process?
Dr. Daigh. I think that VISNs and VHA should be more
involved in the process. I think that sometimes there is a lack
of knowledge as to what an evaluation would be that is proper.
If you hire a medical specialist who is the only person in the
hospital who does that specialty, the chief of staff may, in
fact, know very little about the technical aspects of that job.
I think getting larger involvement or more specific
involvement by national leaders would be important.
Mr. Pappas. Thank you.
Dr. Lieberman or the VA, would you like to comment on that
at all?
Dr. Lieberman. I think we are, or we are moving in that
direction. As we mentioned before, the chief medical officers
are having much more involvement with oversight and auditing of
the process as well as our national offices are. Certainly a
lot of the suggestions that Dr. Daigh has mentioned we are
taking under serious consideration and taking a look at.
Mr. Pappas. Okay. Dr. Lieberman, one more thing before we
close, and this has to do with the situation with the
pathologist in Arkansas.
One of the things that really does not sit well with me is
that this individual completed a 3-month inpatient rehab
program and then was returned to his position as the chief of
pathology. He went on not only to conceal his continued
impairment, but was also changing, you know, recommendations
and he was believed to have falsified veterans' medical records
in that process.
I am wondering if you could talk broadly about the
acceptability of an individual returning to a supervisory
position. Shouldn't we have individuals watching this person's
work as opposed to this individual being tasked with watching
the work of other folks?
Dr. Lieberman. Thank you for that question.
In this country about 10 to 15 percent of American citizens
will have a problem with alcohol or other forms of substance
abuse during their lifetimes, and that is no different than
health care providers. It is an unfortunate fact, but that is
part of our society.
It has been shown that for physicians that they actually
have a very high long-term success rate with rehabilitation,
upwards of 80 to 90 percent abstain from alcohol. It is thought
that those individuals truly love what they do in their
careers, and they are committed to this and they are
successful.
In health care, in society, individuals are given a chance.
This individual went through rehab. Most people who go through
rehab will not--if the allegations are true about what the OIG
has said about this individual, this person was very trained
and skilled and found a substance that most people in health
care have not even heard of, and knew that this could cause
intoxication and also would not be detectable on screening.
I was not there or not involved with the decision, but
certainly one could look at the decision to immediately put
this individual back as the service chief. You might have
decided to observe them in a non-leadership position for a
while just to confirm.
Again, this individual was getting repeated alcohol tests
and they were turning out to be negative. There were no obvious
warning signs about that initially.
Mr. Pappas. Well, I certainly believe in second chances and
supporting an individual's recovery is crucial, especially in
the workplace. But I think that additional steps should have
been taken in this case.
I am wondering, Dr. Daigh, if you have any thoughts on that
particular case.
Dr. Daigh. I would like not to talk about the case at hand,
but talk more generally. I certainly do believe in second
chances. I do think, though, when someone has a physical
impairment or a mental impairment, be it Hepatitis or drug
abuse or substance abuse, and they are brought back on to
practice medicine that there should be close oversight of the
quality of the work they do. Whether or not they are a manager
or not, I think that is more of a local decision. But I think
that the care they provide post-whatever the event was ought to
be critical and be focused.
Mr. Pappas. Well, thank you. Thank you to our panel.
I would like to see if General Bergman has any additional
questions or if he would like to close.
Mr. Bergman. The answer is both.
Mr. Pappas. Okay.
Mr. Bergman. One quick question. Ms. Bonjorni, you have
been sitting there very quiet and patient for this entire time.
I noticed that in your bio that you are certified both in human
resource and project management.
It is my understanding that there are organizations that
certify credentialing specialists. Does VHA require
credentialing personnel to be certified and, if not, has VA
explored the benefits of requiring certification and, if so,
what did it find?
Ms. Bonjorni. Well, thank you for your question, sir.
I do not believe that we have explored that, but we are
actually in the beginning stages of a process to look at the
organizational structure and the position and career paths for
people who do credentialing work within VHA. That is absolutely
a concept that we could explore to determine whether that would
make a significant positive impact.
Mr. Bergman. Well, you know, we are all here. You know,
several of us have used the word just recently within the last
minute or so we believe in second chances. We also believe that
if--we have to look inside ourselves as an organization and
what is it we are trying to achieve, and are our tactics,
techniques and procedures or processes that we would use for
ensuring that, number 1, the best quality outcome for the
veterans, and that starts with providers who are credentialed,
certified, re-certified from time to time to ensure that they
are up to standard.
I would just like to, if I can just incorporate my closing
into this, Mr. Chairman.
Mr. Pappas. Sure.
Mr. Bergman. You know, again, thanks for the hearing. You
know, it has been about 2 years since I chaired the
subcommittee hearing on this topic. I guess to say I am not
troubled would not be true. I am troubled that we continue to
have the same conversations about leadership and policy
implementation. We can and we must do better.
I intend to work with all of you and all our other
witnesses to leverage your experience, because you are where
the rubber meets the road, to leverage your experiences, your
responsibilities, to improve VA's processes for credentialing,
privileging and quality management.
That said, I am encouraged by the fact that several of the
incidents referenced today reached OIG through VA employees who
were willing to stand up and call out what they believed to be
substandard care, substandard practitioning, if you will.
We have had a series of hearings on the process for VA
staff to report serious concerns, and with another one on the
horizon I wanted to take a moment just to thank these
individuals who have utilized the system to bring attention to
these serious, serious issues.
With that, Mr. Chairman, I yield back.
Mr. Pappas. Thank you very much, General Bergman.
Thank you as well to our panel for being here today.
I think it is critical that we understand that we are all
looking out for the veteran, the end-user of the care offered
by the VA to ensure that it is top notch and to ensure that
their health safety is always protected.
Veterans need to trust that the VA is fulfilling its
responsibilities for credentialing and privileging. They also
need to know that this department is taking appropriate action
to investigate concerns that arise about clinical care and
remove clinicians who deliver substandard care or engage in
misconduct.
We as a subcommittee have a duty to ensure that VA fulfills
all of its responsibilities and, unfortunately, I think today's
testimony means that we have some more work to do. I am
committed to working alongside General Bergman and to the
members of this subcommittee as well as our congressional
colleagues on both sides of the aisle to continue our oversight
work and to continue to encourage the VA to be moving in the
right direction.
I thank you for all of your efforts. I thank the workforce
at the VA and its providers for the care that they offer for
our veterans day in and day out. I just hope we can continue
this conversation and continue to understand that there is a
sense of urgency that is there for our veterans to make sure
that the steps that have been outlined today are implemented as
quickly as possible.
Members have 5 legislative days to revise and extend their
remarks, and include any extraneous material.
Again, thank you all for joining us today. Without
objection, the subcommittee stands adjourned.
[Whereupon, at 4:16 p.m., the subcommittee was adjourned.]
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A P P E N D I X
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Prepared Statements of Witnesses
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Prepared Statement of Ms. Sharon Silas
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
------
Prepared Statement of Dr. John D. Daigh
Chairman Pappas, Ranking Member Bergman, and members of the
Subcommittee, thank you for the opportunity to discuss the Office of
Inspector General's (OIG's) oversight of Veterans Health Administration
(VHA) efforts to ensure its medical facilities are effectively
implementing their provider credentialing and privileging (C&P)
processes. The mission of the OIG is to oversee the efficiency and
effectiveness of VA's programs and operations through independent
audits, inspections, reviews, and investigations. For many years, the
OIG has conducted reviews and investigations that have identified
concerns with VHA's C&P operations.
This statement focuses on barriers and challenges to VHA's efforts
to implement programs that ensure licensed independent healthcare
practitioners have the appropriate qualifications to provide medical
care services within the scope of their license. The need for VHA to
properly manage and oversee these programs cannot be understated, as
they are key to ensuring veterans receive health care from highly
qualified providers. Although VHA has national policies governing the
C&P process, the decentralized structure of VHA puts significant
responsibility on local leaders and physicians to actually execute the
C&P process. The OIG has completed several reports recently in response
to allegations of inappropriate or incomplete C&P processes. While the
OIG has found general compliance with C&P processes during the course
of recurring comprehensive healthcare inspections,\1\ other focused OIG
healthcare reviews related to specific incidents have identified
concerning lapses in protocols that could have or have led to patient
harm.
---------------------------------------------------------------------------
\1\ The OIG's Comprehensive Healthcare Inspection Program and the
Comprehensive Healthcare Inspection Summary Report Fiscal Year 2018 are
discussed in the background section of this statement.
---------------------------------------------------------------------------
After providing some context for the discussion of C&P
deficiencies, several reports are highlighted to provide examples of
failures the OIG has identified in the C&P process.
background on credentialing, privileging, and skill assessment
VHA has defined procedures for credentialing and privileging ``all
health care professionals who are permitted by law and the facility to
practice independently--without supervision or direction, within the
scope of the individual's license, and in accordance with individually
granted clinical privileges.'' \2\ These healthcare professionals are
also referred to as licensed independent practitioners (LIPs).
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\2\ VHA Handbook 1100.19, Credentialing and Privileging, October
15, 2012 (This VHA Handbook was scheduled for recertification on or
before the last working date of October 2017 and has not been
recertified.) Healthcare professionals such as clinical pharmacists,
nurses, and technologists are evaluated on their competency to perform
core and specific skills and techniques, often using objective
assessments, such as test-taking and completing simulations. These
processes are entirely separate from the C&P process and are not
addressed in this statement.
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Credentialing ``refers to the systematic process of screening and
evaluating qualifications.'' \3\ Credentialing involves ensuring an
applicant has the required education, training, experience, and mental
and physical health. This process also ensures that the applicant has
the skill to fulfill the requirements of the position and to support
the requested clinical privileges.
---------------------------------------------------------------------------
\3\ VHA Handbook 1100.19.
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Clinical privileging is the process by which an LIP is permitted by
law and the facility to provide medical care services within the scope
of the individual's license. Clinical privileges are specific to the
medical procedure performed. They are based on the individual's
clinical competence, recommendations by service chiefs (typically the
LIP's supervisor) and the Medical Staff Executive Committee, and with
approval by the facility director. Peer references, professional
experience, health status, education, training, and licensure inform
decisions about a provider's clinical competence and ability to
successfully accomplish clinical privileges. Clinical privileges are
granted for a period not to exceed 2 years, and LIPs must undergo
reprivileging prior to expiration.\4\
---------------------------------------------------------------------------
\4\ VHA Handbook 1100.19.
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VHA also mandates processes to check the skills of providers during
their term of employment. A Focused Professional Practice Evaluation
(FPPE) is a time-limited process conducted in three instances: (1) for
all new LIPs who are requesting initial privileges or scope of
practice; (2) when a provider requests a new clinical privilege or
scope of practice; and (3) when issues affecting the provision of safe,
high-quality patient care are identified. VHA requires that all LIPs
new to the facility have FPPEs completed, documented in the provider's
electronic profile, and reported to an appropriate committee of the
medical staff.\5\ The process involves evaluating the provider's
privilege-specific competencies. This may include periodic chart
review, direct observation, monitoring diagnostic and treatment
techniques, or discussion with other individuals involved in the care
of patients.\6\
---------------------------------------------------------------------------
\5\ VHA Handbook 1100.19.
\6\ VHA Handbook 1100.19.
---------------------------------------------------------------------------
To monitor an LIP's performance during his or her service and help
assist in determining whether a provider will be reprivileged, VHA uses
the Ongoing Professional Practice Evaluation (OPPE). This oversight
process involves the service chief's evaluation of the provider's
professional performance and includes data specific to the provider's
practice, such as reviews of surgical cases, electronic health records,
infection control, and drug usage evaluation. Data must be provider-
specific, reliable, easily retrievable, timely, justifiable, and
comparable. The OPPE includes data from direct observation and reviews
and confirms the quality of care delivered by privileged providers.
OPPEs allow the facility to identify professional practice trends
affecting patient safety and quality of care. The service chief is
responsible for establishing whether a provider does or does not meet
established criteria.
the oig's comprehensive healthcare inspection program focus on
evaluating credentialing and privileging processes
The OIG uses its Comprehensive Healthcare Inspection Program (CHIP)
to provide cyclical, focused evaluation of the quality of care
delivered in the inpatient and outpatient settings of VHA facilities.
Each inspection covers a consistent and predetermined set of key
clinical and administrative processes that are associated with
promoting quality care across facilities. These inspections are one
element of the overall efforts of the OIG to ensure that the Nation's
veterans receive high-quality and timely VA healthcare services.
OIG CHIP teams evaluate areas of clinical and administrative
operations that reflect quality patient care, with focused review areas
changing every fiscal year.\7\ C&P processes were evaluated in Fiscal
Year (FY) 2018, whereas Fiscal Year 2019 and Fiscal Year 2020 have
focused on privileging.
---------------------------------------------------------------------------
\7\ The eight areas for Fiscal Year 2018 were quality, safety, and
value; credentialing and privileging; environment of care; medication
management; mental health; long-term care; women's health; and high-
risk processes. The nine areas for Fiscal Year 2019 were leadership and
organizational risks; quality, safety, and value; medical staff
privileging; environment of care; medication management; mental health;
long-term care; women's health; and high-risk processes. The ten areas
for Fiscal Year 2020 are leadership and organizational risks; quality,
safety, and value; medical staff privileging; environment of care;
medication management; care coordination; mental health; women's
health; high risk processes; and veterans integrated service networks.
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comprehensive healthcare inspection summary report fiscal year 2018.
In Fiscal Year 2018, OIG staff completed 51 CHIP reports, which are
rolled-up in an Fiscal Year 2018 Summary Report. Those reports were
based, in part, on OIG staff interviews with facility leaders and
reviews of C&P documentation for LIPs initially hired within 18 months
before site visits and LIPs reprivileged within 12 months before the
visits.\8\ The OIG evaluated
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\8\ Comprehensive Healthcare Inspection Summary Report Fiscal Year
2018, October 10, 2019.
performance indicators for credentialing processes, such
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as current licensure and verification of primary source information;
privileging processes, such as verifying existing
privileges and the details of the recommendations and approvals for
requested privileges;
FPPEs; and
OPPEs.
The Fiscal Year 2018 CHIP Summary Report generally found compliance
with requirements for C&P processes but identified concerns with the
FPPE and OPPE processes.
The Summary Report made four recommendations to the Under Secretary
for Health to improve the C&P process nationally, based upon aggregate
data collected during the Fiscal Year 2018 CHIP site visits. The first
recommends that VHA ensure that the FPPEs are reported properly to
committees for review. The second recommends that the FPPEs clearly
delineate timeframes for review in compliance with VHA policy. The
third recommends that VHA verify that clinical managers include
service-specific data in ongoing professional practice evaluations and
monitor clinical managers' compliance. The fourth recommends VHA verify
that clinical managers include specialty-specific elements in
gastroenterology, pathology, nuclear medicine, and radiation oncology
providers' OPPEs and monitor clinical managers' compliance. The
Executive in Charge for VHA concurred with the first, third, and fourth
recommendations and in principle with the second recommendation.\9\ The
Executive in Charge projected that these recommendations would be fully
implemented by June 2020. OIG staff will monitor VA's progress.
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\9\ VHA concurred in principle to our recommendation that FPPEs
have clearly delineated timeframes, noting that the Joint Commission
describes FPPEs as focusing on either a period of time or a certain
number of procedures for infrequent activities.
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credentialing & privileging process breakdowns
Ensuring that VHA providers have the training and education to care
for the veterans they serve is imperative in the delivery of high-
quality health care. Without effective implementation of the
credentialing process, veterans are at risk of receiving care from
providers who are not appropriately licensed, adequately skilled, or
trained. Despite the importance of credentialing, OIG reports, such as
the following, have documented breakdowns when VHA staff have not
actually verified and obtained the required documentation or confirmed
the accounts of job applicants' references.
leadership failures related to training, performance, and productivity
deficits of a provider at a veterans integrated service network 10
medical facility.
In December 2018, the OIG became aware of allegations of
mismanagement, waste of funds, and safety risks at a Veterans
Integrated Service Network (VISN) 10 medical facility.\10\ A
complainant alleged an ophthalmologist lacked training, provided
substandard care, and failed to meet productivity expectations. In
spite of these reported concerns, the facility's chief of staff
intended to reappoint the surgeon following the probationary period.
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\10\ Leadership Failures Related to Training, Performance, and
Productivity Deficits of a Provider at a Veterans Integrated Service
Network 10 Medical Facility, September 24, 2019.
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The OIG substantiated the surgeon lacked adequate training to
perform cataract and laser surgery as the surgeon did not
satisfactorily complete an approved residency training program, was
ineligible for board certification in ophthalmology, and did not meet
the facility's ophthalmologist hiring requirements. Additionally, the
OIG found several C&P activities that did not comply with VHA policy.
Facility staff could not explain to the OIG why primary source
verification was not obtained from all foreign educational institutions
the surgeon listed in the credentialing paperwork, and staff did not
document when attempts to do so were unsuccessful. In addition to
documentation to support claims of education and training, VHA requires
physician applicants to provide the names of references with knowledge
of the applicant's ability to perform the work for which they are being
hired. Specifically, information is sought about the individual's level
of performance, number and type of procedures performed,
appropriateness, and outcomes of care provided. The four references the
surgeon at issue provided were all flawed. Two non-VHA references had
no direct knowledge of the surgeon's ability to perform cataract
surgeries. The third could not provide actual numbers of surgeries or
describe outcome quality. And, the fourth could not describe the
surgeon's technical performance.
Facility leaders continued to employ the surgeon despite
substandard performance and staff in associated specialties expressing
concerns about the surgeon's quality within months of hire. The surgeon
did not consistently demonstrate the skills to assure good outcomes,
was unable to meet surgical productivity expectations, and surgery
times exceeded norms. For example, the chief of staff was told that the
surgeon was taking one-to-two hours to complete a cataract surgery, as
compared with VHA's average of 26 minutes. Retrospective clinical
reviews by two other ophthalmologists within the same VISN reflected
these deficits.
Despite these ongoing concerns, the chief of staff endorsed the
surgeon's reappointment as the facility's sole ophthalmologist. At the
time of the interviews, facility staff told the OIG that they believed
the surgeon would be reappointed because facility leaders needed the
services of the surgeon's spouse, who was also a surgeon, and facility
leaders described them as a ``package set,'' admitting that
relationship was a consideration. As a result, for 2 years before the
surgeon was terminated, patients were placed at unnecessary risk for
potential surgical complications. The OIG made five recommendations
related to C&P processes, professional practice evaluations, management
of performance deficits, and the chief of staff's actions. OIG staff
continue to monitor VA's progress until all proposed actions are
complete.
professional practice evaluation breakdowns
In addition to being credentialed, before rendering services, the
facility's medical leaders must determine if a provider meets the
specific criteria for conducting procedures. Importantly, the facility
considers the provider to be privileged only for particular medical
procedures and must repeat the privileging process if the provider
wishes to conduct different patient care services. Therefore, VHA
policy dictates that providers are privileged using identified
provider-, service-, and facility-specific privileges. A critical
feature of ensuring that providers are delivering high-quality care is
the focused evaluation (FPPE) and the ongoing evaluation (OPPE). Once a
provider begins rendering care to veterans, proper use of the FPPE to
monitor performance at the start of employment or if a question of the
provider's skills is raised can mitigate risks. A properly executed
OPPE is critical for VHA's determination whether it wishes to retain
the services of a current provider. However, numerous OIG reports have
identified a lack of diligence across VHA facilities in executing FPPEs
and OPPEs as the following examples demonstrate.
intraoperative radiofrequency ablation and other surgical service
concerns at the samuel s. stratton va medical center in albany, new
york.
The OIG conducted a healthcare inspection in response to
confidential allegations regarding lack of quality oversight of the
facility's Surgery Service, including communications to patients about
surgery complications; the peer review process; and surgery outcomes
for a surgical oncologist.\11\ OIG's inspection revealed the facility
did not meet VHA's C&P requirements. A lack of documentation regarding
the surgical oncologist's supervision and competencies during the
initial FPPE period may have contributed to the facility later not
recognizing that the surgeon had missed diagnosing and removing tumors
from veterans. The OIG could not determine if the surgeon was
supervised when conducting the intraoperative radiofrequency ablation
procedures, and there were no written evaluations of the procedures.
The surgery manager's use of the FPPE was ineffective for practice
evaluation.
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\11\ Intraoperative Radiofrequency Ablation and Other Surgical
Service Concerns at the Samuel S. Stratton VA Medical Center Albany,
New York, August 29, 2018.
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Additionally, the surgeon's OPPE was flawed. The forms contained
incomplete data and did not address specific competencies related to
the surgical specialty. Further complicating matters, the chief of
surgery failed to collect sufficient data to evaluate the surgeon's
practice and surgical outcomes. The quarterly data used by the chief of
surgery to evaluate the surgeon's competency also contained errors over
a 2-year period, thus failing to trigger a focused review of the
surgeon. OIG staff could not determine if healthcare quality data or
patient safety trends were affected by poor FPPE/OPPE processes because
of the unreliable data. The OIG also found failures related to the
facility's quality management. Patients were not timely notified that
the surgeon did not completely remove tumors. Nine recommendations were
made, and one recommendation related to establishing a process to
track, monitor, and report on intraoperative radiofrequency ablation
outcomes remains open.
This report underscores the need for adherence to VHA policy that
ongoing assessments of a provider's competence must focus on the
specific provider and examine his or her particular skills and judgment
as they relate to the requested privilege. To ensure thorough and
accurate evaluations, VHA policy has appropriately mandated that
reviews be conducted by a physician with similar training and
privileges.
quality of care concerns in thoracic surgery, bay pines va healthcare
system in florida.
This healthcare inspection focused on anonymous allegations
regarding the quality of care provided by a thoracic surgeon at the Bay
Pines VA Healthcare System.\12\ While the review did not substantiate
that the thoracic surgeon was incompetent, the OIG identified a
deficiency in the system's process for evaluating a surgeon's
competency. Contrary to policy, the criteria used in the surgeon's
initial FPPE were not privilege-specific and was inadequate to fully
assess a practitioner's skills. The OIG recommended that the system's
director ensure that FPPE review criteria are sufficient to evaluate
the privilege-specific competence for thoracic surgeons.
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\12\ Quality of Care Concerns in Thoracic Surgery Bay Pines VA
Healthcare System Bay Pines, Florida, August 16, 2017.
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The surgeon had been employed with VA long enough to have undergone
a routine recredentialing OPPE, which was conducted by an
administrative psychiatrist. New VHA guidance had been issued, but was
not yet in force, mandating OPPEs be conducted by a provider with
similar training and privileges. Based on the OIG's recommendation made
during the site visit, the system arranged for the surgeon to be
proctored in order to confirm whether the surgeon had the ability and
skills. A thoracic surgeon from another VA facility directly observed
the thoracic surgeon's operative skills and did not have concerns
regarding his surgical technique. VHA has satisfactorily completed
action on OIG recommendations. This report highlights the benefit of
having performance determinations made with specificity and by an
independent peer.
credentialing and privileging process failures have patient care
impacts
Additional reports from the OIG further demonstrate that failures
to execute C&P processes properly occur across the VHA system and
affect its provision of patient care and quality management.
facility leaders' oversight and quality management processes at the
gulf coast va health care system in biloxi, mississippi.
The OIG conducted a healthcare inspection to examine the C&P
process, as well as the facility's understanding of quality management
practices, in response to multiple allegations of another thoracic
surgeon's poor quality of care.\13\ A review of the surgeon's C&P files
revealed that before hiring the surgeon in August 2013, facility
leaders knew of malpractice issues as well as the surgeon having
relinquished a State medical license in October 2006 to prevent
prosecution in a disciplinary case. Still, the facility director hired
the surgeon after the Credentialing Committee recommended the
appointment.
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\13\ Facility Leaders' Oversight and Quality Management Processes
at the Gulf Coast VA Health Care System, August 28, 2019. Two other
allegations received were addressed in the OIG report, Inadequate
Intensivist Coverage and Surgery Service Concerns, VA Gulf Coast
Healthcare System Biloxi, Mississippi, March 29, 2018.
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Process failures continued after the surgeon's hiring. Facility
leaders did not complete components of the surgeon's focused and
ongoing evaluations. In addition, the OIG team found that facility
leaders were deficient in granting and continuing the surgeon's
clinical privileges without required evidence of competency. During the
OIG's April 2018 site visit, the OIG team found that although the
surgeon resigned from VHA in December 2017, the chief of surgery did
not provide C&P staff with details regarding an exit-interview
statement about the surgeon's failure to meet standards of practice
until June 2018. This information was needed to inactivate the
surgeon's C&P file.
Facility leaders removed the surgeon in October 2017 from clinical
care without following required processes, including notifications to
external reporting agencies. As a result, facility leaders were unable
to report the surgeon to the National Practitioner Data Bank and were
delayed in reporting to State licensing boards.
The failures to follow C&P processes with the surgeon led the OIG
to review service file documentation for 50 other facility care
providers who were newly appointed to the medical staff from October
2016 through December 2017. The following table reflects deficiencies
in facility oversight responsibilities.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Additionally, the OIG noted weaknesses in quality management,
documentation of basic and advanced cardiac life support certification,
administrative closure of electronic health record notes, posting of
confidential data to the facility's internal website, adverse event
reporting, completion of institutional disclosures, and administrative
investigation board timeliness.
The OIG made 18 recommendations related to professional practice
evaluation processes, National Practitioner Data Bank and State
licensing board reporting, documenting sufficient detail in committee
meeting minutes to reflect decisionmaking, and protecting certain
confidential information. Recommendations also centered on reporting
events to the Patient Safety Committee, reporting surgery patients'
deaths as required, completing proactive risk assessments, and
institutional disclosure and administrative investigation board review
processes. OIG staff will monitor VA's progress until all proposed
actions are complete.
facility hiring processes and leaders' responses related to the
deficient practice of a radiologist at the charles george va medical
center in asheville, north carolina.
An OIG healthcare inspection team evaluated concerns regarding
deficiencies identified in the practice and oversight of a fee-basis
radiologist during a 6-month tenure in 2014.\14\ The concerns were
identified during the facility's 2018 CHIP review in response to
questions related to the radiologist's initial C&P, the radiologist's
deficient delivery of care, and the facility's delayed evaluation of
the deficient care.\15\
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\14\ Facility Hiring Processes and Leaders' Responses Related to
the Deficient Practice of a Radiologist at the Charles George VA
Medical Center Asheville, North Carolina, September 30, 2019.
\15\ Comprehensive Healthcare Inspection Program Review of the
Charles George VA Medical Center, Asheville, North Carolina, October
16, 2018.
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The OIG determined that facility leaders did not complete the C&P
of the radiologist in line with VHA and facility requirements. First,
the references used to approve the radiologist's request for privileges
did not include a reference from peers and a most recent employer. In
fact, the references were from three non-radiologist physicians and a
non-physician radiology technician. These are individuals who are not
``qualified to provide authoritative information regarding training/
experience, competence, [and] health status.'' The failure to secure a
reference from the radiologist's last employer is notable given the
radiologist had been working at a VA medical center in Altoona,
Pennsylvania (Altoona VAMC). Second, in June 2014, the radiologist
denied having been notified of any malpractice-related judicial
proceedings. However, the radiologist was sent notification by the
Altoona VAMC in January 2014 that they were named in a tort claim, with
a separate notice sent a later in June. VHA Central Office and
Asheville VAMC leaders explained to the OIG that they were unaware of
these tort claims and would not have known before final adjudication of
the claims unless the radiologist disclosed them.
As the radiologist began providing medical services in 2014, there
was inadequate oversight of the radiologist, most vividly demonstrated
by the facility's failure to complete an FPPE within VHA-established
timelines. The chief of imaging, the radiologist's supervisor, did not
complete the FPPE for 174 days, well past the 90-day deadline. This
failure was undetected because facility managers did not have a
tracking system to monitor such action items. When the chief of imaging
did finally review the radiologist's work, it was noted as
``unsatisfactory'' with concerns about diagnostic interpretations. The
facility also did not complete a review of the radiologist's work until
after 2016 and did not submit an issue brief to VISN 6 leaders alerting
them to the clinical failures until 2018, after the OIG identified the
concerns in the CHIP review. If the facility had conducted the FPPE
within required timelines, the radiologist could have been removed from
service more quickly. As it happened, two patients received disclosures
resulting from the radiologist's deficient practices. The facility also
received help from VHA's National Teleradiology Program to assist with
reviews of the radiologist's work, identifying dozens of other images
that were not read to standard.
Facility leaders failed to take proper actions to curtail the
radiologist's practice after not renewing the radiologist's contract in
December 2014 and did not promptly complete the subject radiologist's
exit memorandum within 7 days as required by VHA to comply with State
licensing boards' reporting requirements. The results were not made to
the facility professional standards board until August 2018, 3 years
after the required date. Due to the failure to complete the exit
memorandum, the patient safety manager was not promptly notified to
trigger mandated administrative reviews. After the OIG review
commenced, the facility director issued notices in January 2019 to
eight State licensing boards stating that the radiologist failed to
meet generally accepted standards of clinical practice. The OIG
subsequently made four recommendations to the facility and VISN related
to C&P requirements, State licensing board reporting, reporting of
adverse events, and potential administrative actions. OIG staff will
monitor VA's progress until all proposed actions are complete.
alleged inappropriate anesthesia practices at the james e. van zandt
vamc in altoona, pennsylvania.
In 2018, the OIG reported on C&P concerns also involving the
Altoona VAMC in response to a complainant's allegations about the
services provided by an anesthesiologist at the facility.\16\ The
anesthesiologist allegedly did not follow VHA and facility policies for
controlling medication waste and did not individualize patient
medication dosing and used more anesthetic/sedation medication than the
recommended guidelines for outpatient procedures. The OIG found the
anesthesiologist used more anesthetic/sedation medication for
outpatient procedures than the FDA-approved manufacturer's instructions
for 17 of 20 identified patients. This OIG-directed review was
conducted by the chief of anesthesiology at the Corporal Michael J.
Crescenz VA Medical Center in Philadelphia, Pennsylvania. While the OIG
found issues with dosing above the recommended guidance, OIG staff did
not find that the reviewed patients suffered related adverse outcomes.
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\16\ Alleged Inappropriate Anesthesia Practices at the James E.
Van Zandt VAMC, Altoona, Pennsylvania, July 5, 2018.
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The OIG examined the facility's adherence to VHA and facility-level
privileging policies as well as reporting the provider's conduct to
oversight bodies. Although the facility did not identify issues to
report to the National Practitioner Data Bank or the anesthesiologist's
pertinent State licensing board upon the anesthesiologist's discharge
from employment, the OIG recommended that the facility should
reevaluate if the provider should be reported for the practice of
administering medications inconsistent with FDA-approved manufacturer's
instructions.
Facility leaders did not provide oversight of the anesthesiologist
according to VHA and facility privileging and ongoing monitoring
policies. When facility leaders renewed the anesthesiologist's
privileges in 2017, the privileges were not facility-specific, which is
a key component of privileging. The anesthesiologist's privileges
included management of patients under general anesthesia during
surgical and certain other medical procedures and supervision of
critically ill patients in special care units, which the facility does
not have. Therefore, facility leaders should not have granted those
privileges to the anesthesiologist.
Additionally, the anesthesiologist's OPPE did not include
monitoring of drug usage, which is a relevant, provider-specific data
element. The reason for this was unclear; however, a review of drug
usage data may have identified a pattern of the anesthesiologist
prescribing anesthesia medications inconsistent with FDA-approved
manufacturer's instructions, which increased the patients' risks of
respiratory and cardiac arrest and/or failure. The OIG made four
recommendations, which are now closed. The facility subsequently
reported the anesthesiologist to the National Practitioner Data Bank
and State licensing board.
national and local oversight weaknesses
Many of the issues identified in the cited OIG reports are united
with common themes of management and programmatic failures. Many of
these failures are due to ineffective oversight from regional and
national leaders. The OIG has not found evidence that national leaders
are actively engaged in the determination, collection, and analysis of
standardized quality-related data. The OIG has also found that local
leaders do not always have tools to track and follow-up on completion
of provider evaluations. These gaps can lead to situations in which
local leaders receive actionable information later than desired to
promptly resolve problems.
Additionally, because VHA first uses a local peer to review a
clinician's performance, smaller facilities that have few specialists
can be at a disadvantage. The reviewing clinician may be placed in the
awkward position of attempting to review medical decision-making
without the requisite skills or education. When VHA medical facilities
face physician staffing shortages, this problem intensifies as the
clinician is required to devote time to conducting the review in
addition to their daily tasks, such as accomplishing their patient care
duties.
The C&P issues reported by OIG should not be discounted as isolated
events expected across a large system. Rather, changes should be
considered to the C&P processes by requiring LIPs to demonstrate the
skills required to perform specific clinical activities. For example,
during the FPPE process, the regular use of direct observation of
clinical procedure performance and increased use of simulation centers
would better demonstrate that a clinician will provide high-quality
medical care. VHA should also consider appointing a national leader for
each specialty whose primary responsibility is to ensure the highest
quality practices across all facilities, with active involvement in
overseeing the FPPE and OPPE processes. The need for changes in how
local, regional, and national leaders conduct evaluations and
communicate about practitioners who should not be providing care to
veterans could not be more urgent given the missteps and delays the OIG
has observed.
conclusion
VHA's goal is to deliver high-quality, timely health care to
veterans. To achieve this objective, it is clear that VHA must improve
its efforts to ensure physicians have the training, skills, and
techniques they claim to possess. The OIG has repeatedly identified
deficiencies in the management and execution of the C&P processes that
inevitably lead to mistakes and failures in the delivery of health care
to veterans. To more efficiently use its resources in delivering health
care, VHA must continue to implement OIG and other oversight
recommendations and properly staff clinical positions to provide the
capacity needed for properly conducting the C&P processes.
Mr. Chairman, this concludes my statement. I would be happy to
answer any questions you or other members of the Subcommittee may have.
______
Prepared Statement of Dr. Steven Lieberman
Good morning, Chairman Pappas, Ranking Member Bergman, and Members
of the Subcommittee. I appreciate the opportunity to discuss VA's
processes for ensuring the competency and quality administration of
care by the health care professionals we employ. I am accompanied today
by Dr. Gerard Cox, Deputy Under Secretary for Health for Organizational
Excellence (VHA) and Ms. Jessica Bonjorni, Acting Assistant Deputy
Under Secretary for Health for Workforce Services.
introduction
VA is committed to ensuring that Veterans receive safe, high-
quality health care. VA serves over 320,000 Veterans every day. The
vast majority of VA employees are committed to doing the right thing
while serving America's Veterans. In fact, as VA recently testified,
many of VA's providers are called to serve in our medical facilities
not because of money or acclaim, but because of their commitment to
VA's mission to care for Veterans.
As in any large health care system, we must also face the
unfortunate reality that some individual employees have not upheld that
commitment. The actions of those few are deeply troubling. It is also
deeply troubling that those actions might taint the reputations and
undermine the good work of the nearly 348,000 VHA employees who run our
medical facilities and take care of Veterans every day. These few
people do not represent VA's values, and we will continue to hold
accountable those who would commit crimes or provide poor care in our
facilities.
VA takes great care to screen employees for their character and
suitability and for their eligibility for a personal identity
verification credential before bringing them on duty, including
conducting criminal background checks. We also conduct extensive
scrutiny of prospective health care providers' medical credentials, and
after hiring, we monitor those providers to ensure they are clinically
competent and are providing safe, high-quality care. While we must do
everything we can to make sure our employees are well-qualified and
suitable for their jobs, we also recognize that we cannot guarantee
that VA will never hire another person who fails to uphold VA's
commitment to Veterans. What we have done in the face of that reality
is establish a system in which wrongdoing can be identified quickly and
swift action can be taken to minimize the harm to Veterans. We will
learn everything we can from the problems that have given rise to this
hearing to strengthen our system. We have also found in our reviews of
recently publicized cases that the monitoring and reporting systems we
have in place typically work well in identifying potential
inappropriate behavior or inadequate care earlier than before, and that
VA's leaders do, in fact, take quick action to ensure that patients are
safe.
screening: background checks
VA requires that all individuals working directly with Veterans are
thoroughly and properly vetted. For all potential employees, this
starts with a background screening before entering on duty. The
background screening process applies to all applicants, appointees,
employees, contractors, affiliates, and other individuals who require
physical or electronic access to VA information or information systems
to perform their jobs.
VA conducts different levels of background checks on employees
based on their position description, function, and scope of practice,
as required by Office of Personnel Management (OPM) rules. Most front-
line facility-level positions, including direct patient care positions,
require a Low-Risk/Non-Sensitive Investigation. Upon receiving a
conditional offer of employment, selected applicants undergo pre-
screening for an interim suitability and personal identity verification
(PIV) credentialing determination consisting of a review of their FBI
criminal check results and employment history. If this review is
favorable, the applicant is given a firm offer of employment. If
derogatory information exists and cannot be mitigated, the subject's
job offer is normally rescinded.
Following the pre-screening and interim suitability and
credentialing determination, a full background investigation, that
includes work and criminal history, etc., is initiated. DoD's Defense
Counterintelligence and Security Agency (DCSA) conducts these
background investigations and returns them to the local VA facility for
adjudication. An OPM-trained suitability adjudicator in the facility
Human Resources Office reviews all investigative information and must
establish a reasonable expectation that the person's employment or
continued employment either would or would not protect the integrity
and promote the efficiency of the Department. When there is a
reasonable expectation that a person's employment would not do so, the
person is found unsuitable. The process to remove an unsuitable VA
employee varies depending on the length of the subject's employment
(probationary vs. non-probationary).
credentialing and privileging
The next step in hiring a health care professional is the
credentialing process. VHA's medical credentialing and privileging
policies apply to all licensed health care professionals, including
physicians, dentists, advanced practice nurses, physician assistants,
and clinical pharmacists who work in any VA health care facility, as
well as those in Veterans Integrated System Network (VISN) offices and
the VHA Central Office.
Medical Credentialing is the process of obtaining and
verifying documents related to the applicant's professional education,
licensure, and certification, (such as copies of medical licenses,
medical or nursing school diplomas, board certification certificates,
etc.). The medical credentialing process also includes a review of the
applicant's health status; previous experience, including any gaps in
training and employment longer than 30 days; professional references;
malpractice history and adverse actions; and/or criminal violations, as
appropriate. These requirements are established by The Joint
Commission, which accredits most health care facilities across the
U.S., including all VA Medical Centers (VAMC). VA does not make firm
employment offers to health care professionals until the medical
credentialing process is completed.
Privileging is the process by which the authorized
official at an individual VAMC (generally the Medical Center Director)
determines whether to grant clinical privileges to permit a licensed
independent practitioner to provide medical care services within the
scope of his or her licensure, training, and experience. According to
The Joint Commission's standards, the decision whether to grant
clinical privileges to an applicant to the medical facility's medical
staff must be made at the local facility level.
Every applicant for a position on the medical staff of a VA
facility is required to disclose information about any history of
malpractice claims, adverse actions taken against licensure or
privileges held in a previous position, prior misdemeanor or felony
convictions, etc. VA's mandatory screening procedures also require
queries of the appropriate State Licensing Board (SLB), the Federation
of State Medical Boards, and the National Practitioner Data Bank (NPDB)
to determine whether an applicant has been reported to any of these
entities due to substandard care, professional misconduct, or
professional incompetence. VA verifies the information disclosed by the
provider to ensure the hiring official has a full picture of the
applicant from an objective source.
All information obtained through the medical credentialing process
must be carefully considered before appointment and privileging
decision actions are made. Hiring officials take this process very
seriously when considering a potential employee. The local Medical
Center Director has the ultimate decision authority about whether an
employee should be hired and whether clinical privileges should be
granted, based on the outcome of the medical credentialing process.
monitoring and investigations
VA has an obligation to reasonably ensure that its health care
staff meet or exceed generally accepted professional standards for
patient care and has the obligation to alert those entities charged
with licensing health care professionals when there is serious concern
about a licensed health care professional's clinical practice.
This obligation includes monitoring the care that our providers
deliver in medical facilities. It also includes notifying SLBs of any
substantiated findings of substandard care performed at VA by current
or former licensed health care professionals and responding to
inquiries from SLBs concerning the clinical practice of those
professionals.
Whenever concern arises about a privileged provider's ability to
deliver safe, high-quality patient care, the first consideration is
whether that provider presents an imminent danger to the health and
safety of any individual based upon the knowledge at hand. If there is
an imminent danger, the VAMC Director invokes a summary suspension of
clinical privileges which immediately removes the provider from patient
care to ensure patient safety. Summary suspension can range from
suspending a single privilege to perform a specific procedure to
suspension of all clinical privileges; however, the purpose of summary
suspension is to afford time for a focused review of the clinical care
concern or issue. This action can be taken by a facility Medical Center
Director immediately, allowing VA to ensure Veterans' safety without
delay to conduct an investigation. Providers receive a notice of
suspension that includes their due process rights to respond.
The focused clinical care review generally takes the form of a
retrospective review of the care that has been provided in the clinical
care area of concern. Retrospective reviews are completed by
independent health care professionals of the same specialty who hold
privileges in the area being reviewed. These specialists provide an
expert opinion regarding whether the provider under scrutiny has met
the standard of care. The facility's clinical leaders then decide on
whether action should be taken based on the findings of the review. If
a review of the findings does not identify a risk to patients,
appropriate action may involve intensive monitoring of the provider's
practice for a defined period. In more serious cases, an adverse
privileging action may be warranted, such as reducing, restricting, or
denying privileges or, in the most egregious cases, revoking all
privileges and terminating employment with VA.
npdb screening and ongoing monitoring
As described above, all applicants are thoroughly screened,
including a review of any reports made to NPDB. Each report is
individually reviewed in detail and primary source information is
obtained from the reporting entity to outline the circumstances that
led to the report. If information obtained through this process calls
into question the professional competence or conduct of an individual
applying to VA, the selecting official and facility leadership review
the facts and circumstances to determine what action would be
appropriate, possibly including non-selection.
After being appointed to the medical staff of a VA facility, all
privileged providers are enrolled in and monitored through the NPDB
Continuous Query Program. VA mandated this voluntary, proactive measure
so that we receive immediate alerts whenever any privileged provider is
reported by any entity to the NPDB, including reports that arise from
problems that occurred prior to VA employment. Once the alert is
received, VA expeditiously obtains primary source information related
to the report entered and takes immediate action as needed. For
example, if an NPDB report is entered by an SLB, VA can review the
information obtained from the reporting licensing board and determine
if a licensure action has been taken which would immediately disqualify
a provider from a VA appointment in accordance with section 7402(f) of
title 38, United States Code. The review of licenses and determination
of qualification for employment is made by the facility Human Resources
Officer in consultation with the District Counsel Attorney. VA takes
the matter of license revocation very seriously, as we continue to keep
sight of the well-being of our Veterans in our care.
We note that VA is like all other health care systems in this area.
All accredited VAMCs and systems adhere to Joint Commission standards
for medical credentialing and monitoring care. If there were some way
of entirely avoiding misconduct or poor clinical care, there would be
no need for the industry to use an NPDB, or for SLBs to have review
procedures. We are, unfortunately, unable to predict and account for
every issue that may arise, which is why we must respond quickly and
comprehensively whenever Veterans' safety might be in jeopardy.
In 1980, VA established the Office of the Medical Inspector (OMI)
to assess and report on quality of care issues within VHA. In Public
Law 100-322, Veterans' Benefits and Services Act of 1988, Congress
expanded the functions of OMI and assigned the VA Inspector General an
oversight role. This law addressed the Department's quality assurance
activities, upgraded and expanded OMI, and increased its number of
employees to ensure independence, objectivity, and accountability.
As an integral element of VHA's oversight and compliance program,
OMI is responsible for assessing the quality of VA health care through
independent, objective, and thorough health care investigations. In
2014, following the VA wait times crisis, the Acting Secretary of
Veterans Affairs appointed Dr. Cox as the Interim Medical Inspector.
Under his leadership, we restructured the policies, procedures, and
human resources of OMI.
conclusion
VA remains committed to earning Veterans' trust in our system and
will continue to do everything we can to ensure that our patients
receive appropriate and safe health care. Although VA cannot always
foresee and prevent wrongdoing, we will continue to monitor patient
care diligently and take quick action when Veterans' safety is at risk.
Mr. Chairman this concludes my testimony. My colleagues and I are
prepared to respond to any questions you may have.
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Additional Submissions for the Record
=======================================================================
Submissions for the Record
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Prepared Statement of The Honorable Rick Crawford (AR-1)
Chairman Pappas and Ranking Member Bergman, thank you for holding
this hearing regarding the Veterans Affairs health system.
I would like to thank the committee for its attention to the
disturbing matter that occurred in the Fayetteville VA Hospital from
2015 to 2018.
Due to the failure of leadership within the Veterans Health Care
System of the Ozark (VHSO), Dr. Robert Morris Levy's irresponsible
actions have resulted in over 3,000 misdiagnoses and 15 deaths.
Our great Veterans deserve the best care and should have never been
exposed to the personal tragedies that resulted from Mr. Levy's
malpractice.
We should all use this terrible situation as an opportunity to
review and amend rules and regulations within the Department of
Veterans Affairs to ensure that our Veterans receive quality healthcare
and accurate diagnoses.
While I am not a member of the Committee on Veterans Affairs, I am
committed to providing support for any proposals that will help the
Department of Veterans Affairs avoid similar tragic situations in the
future.
One important change to consider would be to prohibit individuals
from taking supervisory roles immediately after being rehabilitated
from substance abuse.
I believe that many common-sense changes can be made to ensure that
this never happens again.
I would especially like to thank the Department of Veterans Affairs
Office of Inspector General for its extensive investigation that
resulted in Federal charges.
Again, thank you Chairman Pappas and Ranking Member Bergman for
your time and attention to this matter.
______
Prepared Statement of The Honorable French Hill (AR-2)
Chairman Pappas, Ranking Member Bergman, and Members of the
Committee:
I appreciate the opportunity to submit this statement in support of
this critical hearing today examining patient harm at U.S. Department
of Veterans Affairs (VA) medical facilities.
As you may be aware, in my home State, Dr. Robert Morris Levy was
chief pathologist at the VA Medical Center of the Ozarks in
Fayetteville, Arkansas, and was recently indicted for allegedly
botching diagnoses for an estimated 3,000 veterans between 2005 to
2017, and responsible for at least 15 deaths.
This alleged gross negligence by a physician charged with caring
for our veterans is a disturbing revelation and a clear failure to
uphold the VA's mission to the men and women who served our Nation in
uniform.
Congress has provided the VA with the necessary tools to remove bad
actors, such as Dr. Levy. Failing to dismiss physicians and any other
employees whose work is unsatisfactory does a disservice to our
veterans.
Dr. Levy's case is especially troubling, as his history of issues
with substance abuse and run ins with the law were evident for years.
Nine years before VA even hired him in 2005, he was arrested and
convicted of drunken driving. He hid his abuse at VA for a decade until
an employee reported him to supervisors as intoxicated in 2015, but Dr.
Levy denied the allegation and no further action was taken.
In 2016, Dr. Levy was found to be intoxicated when he was called to
the radiology department to assist with a biopsy. His blood alcohol
level was at 0.4, five times the legal limit in Arkansas of 0.08. He
was suspended and entered a 3-month inpatient treatment program, at
taxpayer expense.
After completing treatment, Dr. Levy returned to his work at VA, as
if nothing happened.
In 2017, Dr. Levy was sent home after appearing drowsy and
``speaking nonsense phrases'' when he arrived to chair an October 2017
meeting of the hospital's tumor board. The hospital was forced to
cancel multiple surgeries and medical procedures that required a
pathologist.
His clinical privileges were suspended but he was allowed to return
to nonclinical work. Again, allowing this reckless behavior to
continue.
It would be almost an entire year before VA began a deeper dive of
his work, finding a number of misdiagnoses.
In March 2018, Dr. Levy was arrested for driving under the
influence after local police spotted him driving erratically in a post
office parking lot. He was finally fired by VA the next month.
I was proud to support the VA Accountability and Whistleblower
Protection Act of 2017, which was signed into law on June 23, 2017, and
instituted necessary reforms at the VA by providing the Secretary with
the authority to remove, demote, or suspend any VA employee, including
Senior Executive Service (SES) employees, for performance or
misconduct.
This would have proved vital to Dr. Levy's case, who had a
staggering record of being impaired on the job and yet continued to
evaluate patients even after numerous complaints against him.
My district is home to many of our brave veterans and service
members at Little Rock Air Force Base and Camp Robinson, and they
deserve to know that VA is giving them the best possible care.
I share your commitment to rigorous oversight to protect the men
and women who sacrificed and served our country and will hold those who
break the law and undermine the mission of the VA accountable.
Thank you again for holding this critical hearing and putting the
care of our Nation's veterans above all else.
______
Prepared Statement of The Honorable John Lewis (GA-5)
Good afternoon, Chairman Pappas, Ranking Member Bergman, and
Members of the Subcommittee.
Thank you for inviting me to testify on this important matter. I am
grateful that the Subcommittee is holding this hearing. It is critical
that safe, quality, consistent, compassionate patient care become a top
priority at all VA Medical Centers. A United States Veteran should
never experience what Airman Joel Marrable and his family endured.
The Atlanta Veterans Affairs Health Care System (VAMC) is one of
the largest in the country. In Atlanta alone, there are more 18,000
Veterans, who may rely on the services provided at VA medical
facilities. The Atlanta VAMC is one of eight Department of Veterans
Affairs (VA) medical facilities that comprise the VA Southeast Network.
This expansive network serves 1.4 million Veterans in Georgia, South
Carolina, and Alabama. This is the third largest veteran population in
the country.
Many Veterans throughout the region rely on the Atlanta VAMC to
provide general and service-related health care. Located in Decatur,
Georgia, the Atlanta VAMC oversees community-based clinics and health
facilities throughout Metro Atlanta and surrounding areas. The Eagle's
Nest Community Living Center is one of several facilities in the VA
Southeast Network responsible for providing Veterans with long term
care. Fulfilling their mission should require the highest level of
attentive and empathetic care.
The importance of these facilities and the expectation of quality,
safe care are the reasons that Air Force Veteran, and cancer patient,
Joel Marrable's case is so horrific. When news broke last month
detailing how Airman Marrable endured more than 100 ant bites while in
care at the VAMC's Eagles Nest Community Living Center, a facility in
my district, I was disgusted and heartbroken.
I want you to close your eyes. Imagine that after serving your
nation around the world, you face the greatest battle of your life--the
fight against cancer. It is a constant struggle, and the pain seems
insurmountable. When you feel as if the suffering could not get any
worse, you are attacked by an infestation of ants--covering your body
and your room, biting you constantly-- as you fight for your life.
This is what Airman Marrable endured. This is how a daughter
discovered her father. This was their lasting memory of Atlanta VAMC.
The staff told his daughter, Ms. Laquana Ross, that they thought her
father passed away because of the magnitude of ants covering his body.
I cannot comprehend how a person could be so neglected that the staff
could not tell if he was still alive.
The record should be clear--the Atlanta VAMC failed Airman Marrable
in his final days. It was Ms. Ross who discovered that her father was
still alive and still fighting for his life. It was Ms. Ross who
insisted that her father to receive the care and dignity that he
deserved in his final hours. A clean room, a bathed body, a bed without
biting bugs, and regular health checks are not extraordinary
expectations. These are the basics, and the VAMC failed to provide
them.
In Airman Marrable's last days, his family could not even comfort
him without causing pain. Ms. Ross recalled that her father was in so
much agony from the ant bites that he would flinch whenever she touched
his swollen hands. Mr. Chairman, these were his final moments. This was
the care that his government gave Airman Marrable as he transitioned
from this world.
When something is not right, it is our duty as Members of Congress
to speak up and speak out. We have a moral obligation to do what is
just and what is fair. Mr. Chairman, I shared my concerns with
Department of Veterans Affairs Secretary, Robert Wilkie, and Ms. Ann
Brown, the Director of the Atlanta VA healthcare system in a letter,
which I would like to submit for the record. I am here today, because I
want to ensure that what Airman Marrable endured never occurs again. He
deserved better, and his country failed him and his family in their
time of need.
The men and women who serve and sacrifice for our country deserve
exceptional care from an agency and their contractors whose sole
purpose is to care for those who valiantly protected our Nation. I am
grieved by the inept response and negligence surrounding Airman
Marrable's care. It is appalling to know that in his last days, Airman
Marrable and his family were left to resolve this crisis when they
should have been afforded the opportunity to cherish their last
precious moments together.
Throughout my congressional district, Veterans are an integral part
of the fabric of our community. These patriots put their lives on the
line and their family, friends, and personal ambition on the back
burner as they serve our Nation. They work, live, and contribute to the
vibrancy of our country and deserve the highest level of respect and
care.
Mr. Chairman, similar to many congressional offices, the majority
of my office's constituent casework concerns Servicemembers, Veterans,
and their families.. Upon hearing of this horrific case, my District
Office caseworkers began a desperate search to provide support and
solace to Airman Marrable and his. family. We extended our deepest
condolences and ensured that the Marrable family knew that our office
was a resource in their darkest hour.
The challenge of timely, quality, consistent service at VA
facilities remains constant and widespread. My caseworkers are
constantly fielding stories from frustrated and distraught constituents
and their families. There is a sense of disarray and a lack, of
appreciation for the important work of VA patient advocates, who are
key intermediaries between congressional offices, the VA, and the
Veterans. Responses to congressional inquiries languish, and those
caseworkers and advocates who dedicate their careers to serving United
States' Veterans and Servicemembers increasingly feel hopeless.
I believe that the commitment to the health and well-being of our
Veterans takes priority over politics and party lines. We must
demonstrate that the sacrifices made by these brave men and women were
not in vain. These women and men sacrificed selflessly, and their
country's appreciation should be proudly displayed by the quality of
care at every VA Medical Facility.
As a nation and as a people, we can do better, and we must do
better. The care our Veterans receive is a direct reflection of how our
Nation shows gratitude to those who fight bravely to preserve our
freedoms. Compassion, empathy, and respect should be our compass, our
mission, and our mandate. At every opportunity, we should work
tirelessly to correct the errors and shortcomings of the systems upon
which they rely and strengthen the agency to support future generations
of Veterans and their families.
Again, I thank you, Mr. Chairman, for the opportunity to testify
this afternoon.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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Prepared Statement of The Honorable David McKinley (WV-1)
We cannot begin to understand the grief and anger the families of
those killed at the Clarksburg VA Medical Center have felt this last
year. To find out that your loved ones were killed while in the care of
a hospital is unimaginable.
The investigation into the suspicious deaths at the Clarksburg VA
Medical Center has now gone on for more than 16-months and has left
families with more questions than answers. It is imperative that the
authorities conclude this investigation as soon as possible and provide
answers to the public, closure to the families and justice to those who
lost loved ones.
While hindsight is 20/20, we now know that several red flags should
have been raised soon after the deaths. At the time, many of these
deaths did not raise suspicions, and family members trusted the VA
hospital when they were told the deaths were natural.
While it is clear several missteps were made, we would be remiss if
we did not give credit to the Clarksburg VA Medical Center, for self-
reporting the suspicious deaths once a pattern was noticed.
This incident has damaged the trust veterans and their families'
have in the VA, and we owe it to them to find out what happened. I hope
the committee will use today's hearing to find solutions that will
protect our veterans and restore their belief that they are receiving
the best quality of care possible.
______
Prepared Statement of The Honorable Carol Miller (WV-3)
Thank you, Chairman Pappas and Ranking Member Bergman for holding
this hearing today.
It is of utmost importance that we continue to provide and maintain
the highest quality of care for the men and women who have bravely
served our country.
The deaths at Louis A. Johnson VA Medical Center in Clarksburg,
West Virginia and the sexual assault allegations at Beckley, West
Virginia VA Medical Center are troubling and unacceptable. As Members
of Congress, it is our job to support swift and proper investigations
to ensure that such instances never happen again.
There has been considerable progress with the quality of care that
our veterans receive following the enactment of the MISSION Act and
efforts to address the veteran's suicide epidemic. Our service members
should feel safe and comfortable seeking care at the VA, and these
events show that there needs to be additional oversight of clinicians,
proper removal of bad actors, and monitoring of care.
The tragic deaths of our veterans at the Louis A. Johnson VA
Medical Center in Clarksburg and the sexual assault allegations at the
Beckley VA Medical Center are unacceptable. We must work together to
ensure the families of our Nation's heroes get the answers that they
deserve, and that we can work to prevent these tragic events in the
future. I fully support the investigation into this matter and
appreciate the Committee's interest and oversight.
______
Prepared Statement of The Honorable Bruce Westerman (AR-4)
Chairman Pappas and Ranking Member Bergman, distinguished Members
of the Committee, and today's witnesses, thank you for hosting today's
hearing and allowing me to submit a statement for the record.
As many of you now know, the Veterans Health Care System of the
Ozarks (VHSO) suffered a catastrophic failure to hold one of their
highest-ranking providers accountable, Chief Pathologist Dr. Robert
Morris Levy.
Since his firing in 2018, only after he was arrested for a DUI, it
has been uncovered that his malpractice resulted in the death of 15 of
our Nation's veterans and 15 others whose health was irreparably
harmed.
An additional 3,007 errors and misdiagnosis date back to 2005. It's
now been uncovered that Dr. Levy had a misdiagnosis rate of 9 percent.
Over 12 times the average pathology error rate.
In total, Dr. Levy diagnosed over 21,000 individuals and viewed
33,902 total cases during his tenure.
We may never know the true extent of the damage he caused, but the
systemic problems that allowed it to occur in the first place must be
addressed, and that starts with leadership.
When I first learned of the issues with Dr. Levy in May 2018, I
immediately requested more information on how veterans and their
families would be notified of the lookback process, and what resources
would be made available to those seeking more information.
The VA did set up a dedicated phone line for patients, but when my
staff tested it, they sat on hold for over 22 minutes.
Imagine learning from a televised press conference that you may
have had your cancer misdiagnosed, and you call a number to learn more
about what you can do, only to wait almost half an hour before you can
talk to anyone.
That's simply unacceptable, and the problems didn't end there.
We requested for months that the VHSO put together an
Administrative Investigative Board (AIB) to internally review the
processes and problems that enabled this to happen, but it wasn't
completed until September 17, 2018, almost 4 months after first
learning of the problems with Dr. Levy.
At that time, many of the senior leadership staff had retired or
quit, limiting the ability for the Board to conduct a substantive
investigation.
Furthermore, we were told that the AIB was limited to assessing the
validity of the allegations against Dr. Levy related to quality of
care, and that they could not investigate the quality of care and
oversight because the Office of the Inspector General (OIG) was
investigating these issues.
My staff inquired with the OIG's office to assess if this was in
fact true, and we were told the OIG does not believe they would have
directed the VHSO to avoid those topics.
I would like to know why the AIB took so long to be commenced and
completed and why, or if, it was limited in scope per the VHSO's
communication to my office?
I also have concerns regarding the VHSO's decision to first only
conduct a short retrospective review of Dr. Levy's cases.
It took the VA Inspector General requesting a full, comprehensive
review to be done instead of the VA making this decision on their own--
potentially harming the health of veterans who received care from Dr.
Levy at other stages of his career.
The lookback process seems as if it was made up as it went along
without any proven and tested systems in place to ensure each and every
case was reviewed in depth and in a timely manner.
Does the VA have a standard lookback or review process for cases
involving medical malpractice, and if so, was it properly followed?
Additionally, why was Dr. Levy allowed to immediately return to a
position of authority after rehabilitating from substance abuse?
This allowed Dr. Levy to conceal misdiagnosis that may have been
caused by his substance abuse. He was able to remove and delete cases
that may have shown evidence of misdiagnosing patients, and even
falsely claim a second physician had reviewed his cases for quality
control.
The VA must look at the processes and procedures for reinstating
physicians after substance abuse issues to ensure they do not relapse
or hide medical mistakes without proper oversight.
Another issue we discovered was the length of time it took for VISN
Director Skye McDougall to put a permanent Medical Center Director in
place following the retirement of Dr. Worley in June 2018, the previous
Medical Center Director and supervisor to Dr. Levy.
From communications my staff had with Director McDougall, she
stated that a replacement candidate had been submitted for approval in
May 2018--yet this makes no sense because Dr. Worley was still there at
the time.
That candidate, Mr. Kelvin Parks, was not formally approved until
the end of November 2018.
Why did it take 6 months to hire a permanent director, one who had
been serving as an Interim Medical Center Director the whole time,
during a time when strong leadership was needed?
And was a proper interview process followed that included other
candidates to assess who may serve the VHSO best?
Additionally, what processes are in place to ensure a timely and
efficient hiring process is in place, and what can be done, whether
administratively or legislatively, to ensure the hiring process can be
improved?
Although more issues were uncovered, the examples I present here
today show a pattern of leadership failures when problems arise, and we
need to ensure these failures don't happen again.
The members of America's Armed Forces are promised care for life
due to the sacrifice they make to serve our Nation. We owe it to them
to ensure that promise is kept, and that the care they receive is of a
high quality.
The men and women that work at the VA are honorable, hard-working
and highly qualified medical personnel who provide our Nation's
veterans with great care, but that care can always be improved.
And when malpractice like this happens, it's imperative we do
everything we can to ensure it's made right and corrected so it may
never happen again.
As Members of Congress, how can we support the VA, and are there
legislative changes we need to make to help stem leadership and
accountability failures and ensure our veterans get the best care
possible?
Again, thank you Chairman Pappas and Ranking Member Bergman for
allowing me this opportunity, and I trust that we will all work
together to ensure this may never happen again.
______
Prepared Statement of The Honorable Steve Womack (AR-3)
Chairman Pappas, Ranking Member Bergman, distinguished members of
the subcommittee, thank you for holding this important hearing focused
on the Veterans Affairs health system.
As many of you know, Robert Levy, a former employee of the Veterans
Health System of the Ozarks (VHSO), was recently indicted in the
Western District of Arkansas on three counts of involuntary
manslaughter and 28 counts of mail fraud, wire fraud, and making false
statements to law enforcement.
These charges stem from Mr. Levy's conduct while serving as Chief
of Pathology and Laboratory Medical Services for the VHSO, which is
located in my district in Fayetteville, Arkansas.
While he was serving as Chief of Pathology, Mr. Levy was
responsible for diagnosing veterans after examining their fluid and
tissue samples. He repeatedly showed up to work intoxicated, first from
alcohol and then, in order to pass mandated alcohol tests, from a
substance called 2M-2B. This compound produces a sensation like alcohol
but cannot be detected on normal alcohol screenings. Mr. Levy was
finally fired from the VA in April 2018 following 2M-2B being detected
in a fluid sample.
This was not Mr. Levy's first time failing an alcohol test. He was
required to pass mandatory alcohol screenings because in 2016 he was
found to be intoxicated while on duty. His blood alcohol content was
0.396--almost 5 times the legal limit--during the time he was scheduled
to consult on a biopsy for a patient.
I was given the opportunity to speak about this situation at your
committee's Member Day Hearing last month. During my testimony, I asked
your committee to investigate the circumstances surrounding Mr. Levy's
reinstatement, specifically how he was allowed to return to duty as a
supervisor. I want to thank each and every one of you for responding to
my request by holding this hearing.
While I understand this hearing is intended to look broadly at the
VA's credentialing system, I would ask you to pay special attention to
the physician reinstatement process. Particularly, the process for
determining whether a physician should be returned to a supervisory
position.
As Mr. Levy's indictment clearly shows, he was able to conceal
misdiagnoses that may have occurred because of his intoxication due to
his supervisory position. This position allowed him to ensure any
conflicting diagnoses were removed or deleted and, in some cases, he
was able to falsely claim a second physician conducted a review when no
review was completed.
As I previously stated, I do not understand why, at the very least,
an independent review procedure was not put in place to ensure Mr.
Levy's subordinates were able to submit their reviews without
interference. I think this committee and the VA should look at the
procedures for reinstating a physician following a substance abuse
issue. Furthermore, I hope you will look at whether or not those
physicians should be returned to supervisory positions.
I truly appreciate your attention to these matters. The people of
Northwest Arkansas and across the country are well-served by your
diligence and knowledge. I look forward to any solutions that come from
this hearing and stand ready to help you in any way.
Our veterans stepped forward to defend our country and our values.
They answered the call of duty, and it is now up to us to support these
patriots. This hearing is the first step to ensuring the VA's
credentialing system is appropriate for that mission.
Thank you again for your time and attention.
______
Prepared Statement of The National Council of State Boards of Nursing
Thank you for the opportunity to provide input on the House
Committee on Veterans' Affairs, Subcommittee on Oversight and
Investigations hearing: Broken Promises: Assessing VA's System for
Protecting Veterans from Clinical Harm. The National Council of State
Boards of Nursing (NCSBN) commends the Subcommittee for holding this
hearing and addressing provider accountability issues within the
Veterans Health Administration (VHA).
NCSBN is an independent, non-profit association comprising 59
boards of nursing (BONs) from across the U.S., the District of Columbia
and four U.S. territories. BONs are responsible for protecting the
public through regulation of licensure, nursing practice, and
discipline of the 4.9 million registered nurses (RNs), licensed
practical/vocational (LPN/VNs), and advanced practice registered nurses
(APRNs) in the U.S. with active licenses.
NCSBN has a longstanding relationship with the VA, including
working extensively with the Office of Nursing Services and Telehealth
Services in support of regulatory changes that improve veterans' access
to providers and the care they deliver. We strongly support VA as they
endeavor to care for our Nation's veteran population and seek to serve
as a partner and resource in the Department's efforts to improve
quality of care and patient safety. With those goals in mind, our
comments focus on two issues that we believe are critical to improving
patient safety in the VA.
reporting to state licensing boards (slbs) and the national
practitioner data bank (npdb)
In November 2017, the Government Accountability Office (GAO)
released a study entitled, ``Improved Policies and Oversight Needed for
Reviewing and Reporting Providers for Quality and Safety Concerns.''
\1\ The report found that between October 2013 and March 2017, the five
VA Medical Centers under review had taken adverse privileging actions
against nine providers that should have been reported to SLBs and NPDB.
Of those nine providers, only one was reported to NPDB and none of them
were reported to SLBs. The report exposed a major gap in public
protection that exposes veterans and other patients to potentially
risky care providers. GAO made four recommendations in the report,
which included making sure that proper VISN oversight was in place to
ensure timely reporting of providers to NPDB and SLBs.
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\1\ GAO, VA Health Care: Improved Policies and Oversight Needed
for Reviewing and Reporting Providers for Quality and Safety Concerns,
GAO-18-63 (Washington, DC.: Nov. 15, 2017). https://www.gao.gov/assets/
690/688378.pdf.
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VA concurred with GAO's recommendations, and set September 2018 as
a targeted completion date for the first two recommendations and
October 2018 for the second two recommendations. NCSBN is pleased that
VA concurred with GAO's recommendations and developed plans to address
them. However, we were disappointed to learn, according to testimony
before this Subcommittee by Comptroller General Gene L. Dodaro on May
22, 2019, that all of GAO's recommendations remain open and that VA
revised completion dates to August 2019 and August 2020, respectively.
We encourage the VA to provide additional updates related to
implementing these recommendations.
As a means to further address these ongoing patient safety issues,
NCSBN encourages the passage of the Department of Veterans Affairs
Provider Accountability Act (S. 221), which would require VHA
facilities to report any covered major adverse action taken against a
VHA provider, particularly those that affect patient safety, to the
NPDB and the appropriate SLBs. The Senate Committee on Veterans Affairs
has already held a hearing on the bill and introduction of a House
companion is likely in the coming months.
Additionally, NCSBN strongly encourages VHA, in consultation with
SLBs, to revise and update VHA Handbook 1100.18-Reporting and
Responding to SLBs, which outlines procedures that VHA facilities must
follow when reporting providers to and interacting with SLBs. This
section of the Handbook was originally drafted in 2005 and was
scheduled for recertification in 2010, however no action has been
taken. The current handbook language is both antiquated and complex,
leading to VHA employee confusion about reporting responsibilities and
limiting communication between SLBs and VHA facility staff.
ongoing monitoring of provider credentials
In February 2019, GAO released a report entitled, ``Greater Focus
on Credentialing Needed to Prevent Disqualified Providers from
Delivering Patient Care.'' \2\ The report identified several issues
with how VHA reviews provider credentials, and highlighted a need for
ongoing monitoring of provider licensure. In response, GAO made the
following recommendation and VA concurred.
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\2\ GAO, Broken Promises: Assessing VA's System for Protecting
Veterans from Clinical Harm, GAO 19-6, (Washington, DC.: February 28,
2019). https://www.gao.gov/assets/700/697173.pdf.
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Recommendation 6-The Under Secretary for Health should direct the
VHA facilities to periodically review provider licenses using NPDB
adverse-action reports, similar to recent VHA-wide reviews. Facility
officials should take appropriate action on providers who do not meet
the licensure requirements, and report the findings to VHA VISN and
Central Office officials for review.
NCSBN supports ongoing verification of VHA provider licensure to
ensure that our Nation's veterans are being treated by safe, competent
providers. Over the past 2 years, NCSBN has had a tremendous
partnership with the VA Office of Nursing Services, helping them better
monitor the license status of VA nurses in real-time by offering direct
assistance to several VHA facilities in implementing Nursys e-Notify, a
free service for institutions who want to receive automated nurse
license status updates. Nursys e-Notify informs a VHA facility if one
of its employed RNs or LPN/VNs receives public discipline or alerts
from their licensing jurisdiction(s). It also notifies the facility if
licenses are expiring. Pilot sites for implementing Nursys e-Notify
include: Baltimore, Maryland VAHCS, Beckley, WV VAMC, Dallas (North),
TX VHCS, and Marion, IL VAMC. Nearly 20 VHA facilities have implemented
Nursys e-Notify to date.
NCSBN is pleased with ongoing efforts to implement Nursys e-Notify
at all VHA facilities and encourages VA to require its implementation
at every VHA facility nationwide. This will enable nurse leaders at
every facility across the country to have real-time information
regarding the license and discipline status of their entire nursing
workforce.
conclusion
NCSBN and State boards of nursing look forward to continued
partnership with the VHA, Congressional VA Committees, VA providers,
and our Nation's veterans. We aim to help ensure that veterans seeking
care from the VHA enjoy the same patient safety protections as patients
in the private sector.
NCSBN appreciates the opportunity to share our perspective and
expertise with the Subcommittee on this important matter. If you have
any questions or would like any additional information, please do not
hesitate to contact us. Elliot Vice, NCSBN's Director of Government
Affairs, can be reached at [email protected] and 202-624-7781. We look
forward to continuing the dialog on these important issues.
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