The VA Office of Inspector General (OIG) evaluated allegations related to inappropriate language and conduct toward women veterans by a gynecological provider; a nurse chaperone’s failure to provide patient support; and three additional concerns related to compliance with patient complaint processes, facility leaders’ response to the gynecological provider’s misconduct, and deficiencies in reporting misconduct to state licensing board(s) and the National Practitioner Data Bank.
The OIG substantiated that the gynecological provider’s conduct was unprofessional, unethical, and insensitive. The nurse chaperone did not provide support to, or advocate on behalf of, the patients. The OIG found the Veterans Health Administration (VHA) has not incorporated key best practice strategies, such as trauma-informed care and sensitive examination policies, into training, policy, and practice. Further, VHA policies fall short in outlining expected chaperone responsibilities, duties, training, or competencies.
Although facility patient advocates and quality management leaders tracked and trended patient complaints, the data was incomplete, limiting the accuracy and value of identified trends.
Facility leaders had prior knowledge of the gynecological provider’s misconduct; however, leaders failed to effectively address misconduct for years by not timely performing informal or formal investigations and not reporting the provider to state licensing board(s) or the National Practitioner Data Bank despite evidence that the conduct may have met the reporting standards.
The OIG made two recommendations to the Under Secretary for Health related to the role and training of providers and chaperones who conduct or provide support to patients during sensitive exams. The OIG made one recommendation to the Veterans Integrated Service Network Director related to facility processes for recording and tracking patient complaints.
The OIG made three recommendations to the Facility Director regarding staff education on misconduct policies, administrative investigation policies, and review of the subject gynecologist’s conduct and quality of care provided.