VA policy to disclose errors in medical care not always followed

A system designed to disclose failures in treatment was not always followed.
The C.W. Bill Young VA Medical Center Campus, part of the Bay Pines VA Healthcare System. [CHERIE DIEZ   |   Times]
The C.W. Bill Young VA Medical Center Campus, part of the Bay Pines VA Healthcare System. [CHERIE DIEZ | Times]
Published December 13 2014
Updated December 13 2014

BY WILLIAM R. LEVESQUE

Department of Veterans Affairs leaders often talk proudly about how the agency polices itself when medical mistakes occur, saying they inform veterans who are seriously harmed, apologize and even tell them how to file a financial claim for damages.

But a VA report to Congress in April showing the agency made 76 "institutional disclosures" involving veterans who were hurt by delays in treatment of gastrointestinal cancers might reveal that this confession policy is often not followed, according to interviews and congressional records obtained by the Tampa Bay Times.

Those disclosures, which included 24 veterans who died, were made only after an extraordinary, one-time investigation of consultation delays by the VA and not in the ordinary course of business, records show. That raises the question of whether any disclosures would have been reported without the VA's unprecedented inquiry.

"This is why we don't allow people to investigate themselves," said Anthony Hardie, a board member of Veterans for Common Sense, a Washington, D.C., veterans advocacy group. "The VA continues to have serious transparency issues."

A study published in February by researchers with VA ties might provide further evidence that the agency often fails to disclose errors to veterans. It examined seven VA hospitals in the Midwest, and identified 45 cases of patients who were seriously harmed in 2009 and 2010. Yet the facilities only reported 13 of those as institutional disclosures.

The study in the Journal of Healthcare Risk Management admitted that the sample of VA hospitals was small. But the study said "discussions with disclosure stakeholders within (VA) confirm similar low numbers on institutional-level disclosures being performed nationwide."

VA officials in Washington declined requests for an interview on disclosure policy.

In a written statement, the VA said its policy of disclosing errors in care "is consistent with the practices of a transparent organization. This . . . transparency is a best practice in the U.S. medical community. Our transparency is based in a respect for our patients, America's veterans, and a philosophy that transparency improves the care we provide."

The VA acknowledged "obstacles" in reporting mistakes despite its intent of openness.

"Some harms that results from care do not present immediately," the VA said. "Others are not known until a complaint is brought forth or a concern raised. . . . The VA has been a leader in disclosing harm. But like many new and leading programs, we still have much to learn about the process."

Without providing figures, the VA said it has seen an increase in the number of disclosures made in the past three years.

In May, the Times reported how Pinellas County resident Horace Lalley, 76, died in 2012 of bladder cancer that his doctors at the C.W. Bill Young VA Medical Center near Seminole had repeatedly diagnosed as a urinary tract infection, his family said.

No institutional disclosure was made in that case before the article's publication, Young VA officials said, because the family did not complain to them about allegations of inadequate care. Family members said they found that rationale hard to believe.

"They took the doctor (who failed to make the proper diagnosis) off my father's case when they found out he had cancer," said Denise Voyles, Lalley's daughter. "So the VA knew."

Young VA officials said they attempted a disclosure to family members after the article. But the family declined to meet with them.

When the VA released a "fact sheet" to Congress in April saying 76 veterans had been seriously harmed or killed by treatment delays for gastrointestinal cancers in 2010 and 2011, the news made national headlines.

Two senior VA leaders also privately met with congressional staff to look at the massive and unprecedented review of consultation delays in the VA system, an assessment they said involved looking at 250 million patient appointments nationally.

In the meeting, VA officials talked with pride about their institutional disclosure policy, a recording of the meeting shows.

"This is unique to" the VA, said Carolyn Clancy, who was then the VA's assistant undersecretary for health, quality safety and value. "There are private sector systems that are struggling to do this . . . We ask people who have been harmed, and it was avoidable, what do they want? They want an apology. . . . And they want to know that you're not going to do it again. And I think every system, and every clinician in the country, wants to make that last commitment, that we won't do this again. But we are the only system that really has the capacity to make good on that."

A congressional staffer asked if the disclosures resulted from the VA investigation on consult delays and otherwise wouldn't have been revealed.

"That's correct," said Dr. Tom Lynch, a senior VA health administrator. "We wouldn't had known about them had we not done the look back."

It's a fine point, but an important one. And it was lost in the barrage of media coverage about the report. In congressional testimony later, no VA official would be asked whether this fact provided evidence that the VA often failed to disclose mistakes.

Contact William R. Levesque at [email protected] or (813) 226-3432.

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