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Several weaknesses have been identified in VA and DOD programs and processes that could compromise patients’ safety.

• VA did not collect and analyze aggregate data on administrative investigation boards’ (AIB) investigations. These data could provide VA with valuable information to systematically gauge the extent to which matters investigated by AIBs may be occurring throughout VA’s health care system and allow VA to assess the causes and take corrective action, and then share information about any improvements made as a result of the corrective actions with all VA medical facilities and networks. This could improve VA’s overall operations, and in some instances, help to reduce risks to veterans’ safety.

• DOD lacked a systematic process to address inconsistencies between its physician credentialing and privileging requirements and the military services’ requirements. Such differences may result in military services’ noncompliance with requirements that DOD deems important. Credentialing and privileging requirements help ensure that physicians who work in DOD medical facilities have the appropriate credentials and clinical competence to provide health care services to patients. Select Army facilities did not fully comply with all of the Army’s physician credentialing and privileging requirements. For example, credentials files did not consistently contain documents required to support the physician’s clinical competence and complete practice history. This is important in light of the Fort Hood tragedy where an Army physician allegedly shot and killed 13 people.

• VA did not review 16 percent of the total paid tort claims involving VA practitioners from fiscal years 2005 through 2010, as required by VA policy, to determine whether these practitioners delivered substandard care to veterans. Practitioners who deliver substandard care are to be reported to a national data bank that is queried by VA and non-VA hospitals as part of their hiring process and when they are deciding what privileges to grant practitioners who deliver care to patients. This requirement helps VA and non-VA hospitals to identify practitioners who may not be qualified to deliver care to patients.

• Many of the nearly 300 sexual assault incidents reported to the VA police were not reported to VA leadership officials and the VA OIG. Several factors may have contributed to this underreporting, including unclear guidance and deficiencies in VA’s oversight. VA also did not have risk assessment tools designed to examine sexual assault-related risks veterans may pose. VA needs to identify and address these vulnerabilities in its medical facilities to help ensure veterans’ and VA employees’ safety.

• VA’s training guidance for cleaning; disinfecting; and sterilizing reusable medical equipment (RME), which is designed to be used on multiple patients, has gaps and contains conflicting information. This can result in staff not cleaning; disinfecting; and sterilizing RME correctly, which poses potential risks to the safety of veterans.

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