FAYETTEVILLE, Ark. (KNWA/KFTA) — The Department of Veterans Affairs OIG (Office of the Inspector General) released a report detailing pathology oversight failures in 2017 during Dr. Robert Levy’s tenure at the Veterans Health Care System of the Ozarks in Fayetteville.
- Deficiencies in quality management processes.
- Inadequate management of an impaired provider
- Failure of facility leaders to foster a culture of accountability
The OIG found that deficiencies in the facility’s management processes contributed to thousands of diagnostic errors that occurred throughout Dr. Levy’s tenure.
OIG also acknowledged that an impaired provider should be offered assistance when appropriate in recognizing and managing the causes of impairment. The process of assistance must be, “consistent with the protection of patients.”
The report states that a failure of facility leaders to explore or take action may promote perceptions that reporting will have no effect. Not aggressively addressing reports can also discourage staff from complying with the facility’s policy to report subsequent observations of possibly unsafe treatment, according to the report.
The OIG concluded that facility leaders did not meet VHA’s goal to establish an “environment in which staff act with integrity to achieve accountability.”
The Veterans Health Care System of the Ozarks released a statement to KNWA/FOX24 on the OIG report. You can read that statement in full below:
The Veterans Health Care System of the Ozarks (VHSO) and the Department of Veterans Affairs is truly saddened at the pain victims and families endured at the hands of this pathologist. The Department assures Veterans that we are fully committed to improving our processes and systems moving forward to prevent a situation like this from happening again. VA has begun the process of addressing many of the OIG’s recommendations and expects to complete the remainder by May 2022.
In October 2017, VHSO leadership received reports of possible impairment of a staff pathologist, immediately removed him from clinical practice and subsequently terminated him in April 2018, independent from the OIG investigation. An external review team conducted a thorough review of all cases read by the pathologist and sent a letter to all Veterans included in the review. Veterans or their family members who had a serious misdiagnosis were notified in person; others were notified through the clinical disclosure process.
In January 2021, the pathologist was sentenced to 20 years in prison followed by three years supervised release, and ordered to pay approximately $498,000 in restitution to VA.
The investigations into this matter revealed that the pathologist sought to deceive the government, and VA was not aware of the actions he took to conceal his errors. Once the full extent of his actions was known, VA worked immediately to enact process changes at VHSO and nationally that would prevent any provider from causing tragic patient harm.
VA has strengthened internal controls by ensuring no provider can review his or her own work and by providing more stringent oversight, policy and processes, including:
- Implementing a VA-wide policy requiring facilities with two or less providers in any given specialty to have provider reviews performed at an alternate VA facility with similarly qualified specialty providers, ensuring independent and objective oversight.
- Evaluating current guidance related to impaired healthcare workers and exploring the possibility of a mandatory alcohol testing policy.
- Ensuring processes are in place in the new electronic health record to alert relevant staff and leadership when clinically significant changes to pathology reports are made.
- Evaluating quality management processes related to external, non-VHA pathology consultant assessments, a process that is encouraged and helps maintain high quality patient care standards for Veterans, and defining procedures that ensure relevant parties are notified of significant discrepancies in interpretation that might affect patient care decisions.
- Creating a quality analyst position at VHSO dedicated to Pathology and Laboratory Medicine service.
- Increasing oversight and monthly reporting by VHSO Pathology and Laboratory Medicine services to the Medical Executive Council, VA’s governing body for all clinical services, to prevent future fraudulent documentation by any Pathology and Laboratory employees and ensure the integrity of information provided to governing or accrediting bodies such as the College of American Pathologists or The Joint Commission.
Note, this OIG report is based on findings from the OIG Office of Healthcare Inspections, which delayed its inspection in deference to the OIG Office of Investigations’ criminal case. With the closure of the Office of Investigations case, the OIG Office of Healthcare Inspections issued its report.
Representative Steve Womack (R-AR) released a statement regarding the report:
The report details an abject failure of leadership that led to the misdiagnosis and subsequent harm to hundreds of veterans who rely on the VA health system for care. It is unacceptable to limit accountability to the criminal conduct of Dr. Levy. I am disturbed by the complicit nature of the leadership chain that permitted a climate to exist that led to the horrific outcomes affecting these victims. Numerous signs of impairment were ignored, proper institutional controls were absent, and the end result was a terrible tragedy impacting our American heroes.Congressman Steve Womack
U.S. Senator John Boozman (R-AR) also released the following statement in response to the report.
Negligence and a total lack of accountability by leaders at the Fayetteville VA Medical Center resulted in the misdiagnosis of veterans. While steps have been taken to prevent the inexcusable failures from continuing in the VA, I will be working with my colleagues to ensure the recommendations made in this report are implemented and veterans get the quality care they deserve from the VA.Senator John Boozman