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Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas

Report Information

Issue Date
Report Number
18-02496-157
VISN
16
State
Arkansas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) initiated a healthcare inspection in spring 2018 after receiving allegations that former Pathology and Laboratory Medicine Service Chief Dr. Robert Levy misdiagnosed pathological specimens and altered quality management documents to conceal errors at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas. The inspection was completed after the OIG Office of Investigations conducted a criminal investigation. In January 2021, Dr. Levy was sentenced to 20 years in prison for manslaughter and mail fraud. The OIG substantiated the allegations. After a comprehensive, retrospective review of cases Dr. Levy interpreted over his 12-year tenure (almost 34,000 cases), clinical reviewers identified more than 3,000 diagnostic errors. The need for disclosures of errors causing serious injury was identified for 34 patients. As service chief of a specialty care department with only one other pathologist and chairperson of three pathology quality management committees, Dr. Levy had the opportunity to subvert the quality process. Facility leaders failed to recognize his manipulation of quality data. Dr. Levy admitted to long-term alcohol use. The OIG found that facility leaders missed opportunities to address signs of an impairment. The failure of facility leaders to promote a culture of accountability likely led to minimal reporting of Dr. Levy’s signs of impaired behaviors. The OIG made 10 recommendations to the Under Secretary for Health related to competency and pathology quality management processes, pathology reports, and the consulting process with external pathologists. The OIG also recommended the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security & Preparedness be consulted about administrative actions for VHA leaders, as appropriate. Two recommendations focused on alcohol testing and management of impaired healthcare workers. Two recommendations to the Facility Director addressed peer references during reappraisal and evaluation of the facility’s psychological safety climate.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures that the Veterans Health Administration competency process for locum tenens, newly hired specialty care providers, and newly hired service chiefs is evaluated to confirm that the results of the assessment accurately reflects the clinical competency of providers who are privileged, and takes action, as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health reviews current Veterans Health Administration credentialing and privileging policies to assess guidance related to service chiefs’ ongoing professional practice evaluation and takes action, as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health reviews Veterans Health Administration policies to ensure that if facility leaders elect to incorporate pathology 10 percent peer reviews into the performance evaluations of a Pathology and Laboratory Medicine Service Chief, those reviews are performed by a peer without a conflict of interest and takes action, as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates the use and methodology of the Pathology and Laboratory Medicine Service 10 percent peer review for effectiveness as a quality management tool, and takes action, as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates Veterans Health Administration guidance related to amended pathology reports’ terminology, use, and entry of such reports into patients’ electronic health records, and revises guidance, as appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health confirms that provisions are included in the Veterans Health Administration record modernization program that ensure amended pathology report alerts are directed to designated facility staff and leaders.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates Veterans Health Administration quality management processes related to external, non-VHA pathology consultant assessments and ensures that facility leaders, the specialty care provider, and requesting providers are notified of the results of such reviews and a tracking process is in place.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, & Preparedness to determine whether administrative action is warranted for Veterans Health Administration leaders who did not adequately perform their duties with respect to the issues within this report, and takes action, as appropriate.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health explores the development of a mandatory alcohol testing policy for individuals including healthcare workers who perform functions that would put patients at risk should the employee work while impaired.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates Veterans Health Administration’s guidance related to impaired healthcare workers and ensures that it addresses the circumstances under which alcohol and or drug testing may be performed; the extent of a retrospective review of care if one is indicated; and the availability of advisors who are knowledgeable on the management of an impaired provider, and takes action, as indicated.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Health Care System of the Ozarks Director verifies that peer references obtained during the reappraisal and reprivileging processes are in alignment with VHA Handbook 1100.19, Credentialing and Privileging.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Health Care System of the Ozarks Director evaluates the psychological safety climate to ensure facility staff, patients, and the general public are empowered to report concerns and unsafe patient care without fear of reprisal and takes action, as needed.