Fierce Healthcare News –
Poor quality management processes, fear of reprisal and other failures at a Veterans Affairs hospital allowed a pathologist with a substance abuse condition to misdiagnose thousands of cases over 13 years, several of which led to suboptimal treatments and patient deaths, according to an investigation.
A report released this week by the VA Office of Inspector General (OIG) outlined the managerial, structural and workforce culture failures by leadership at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas.
Hospital leaders “failed to promote a culture of accountability” that would have led to more staff members coming forward to report the pathologist’s behavior, according to the report. This lack of accountability led to consequences that were “devastating, tragic and deadly,” the OIG said in the report.
He was removed from service in 2018, faced criminal charges in 2019 and was sentenced to 20 years in prison and nearly $500,000 in restitution this January. Levy has appealed that sentence.
The OIG’s investigation included a full review of all Levy’s cases during that time. Among nearly 34,000 diagnoses, outside pathologists identified more than 3,000 errors and 589 “major diagnostic discrepancies.”
These diagnostic errors were obscured by a quality management process developed and controlled by Levy and just one other subordinate pathologist, “which made the process susceptible to subversion,” the OIG wrote.
Peer reviews of a supervisor by a subordinate are “an inherent conflict of interest,” and informal communications by the two through sticky notes “provided Dr. Levy the opportunity to alter or ignore the results” of the peer reviews, according to the report.
Among various quality management committees that Levy chaired or participated, other members and leaders failed to dispute data or review major diagnostic discrepancies when opportunities arose.
Further, the OIG found that the facility had received multiple reports from staff and others that Levy was impaired during work.
He was temporarily removed from clinical care in 2016 and allowed to return to work following the completion of a treatment program. He was permanently removed in 2018, following an arrest on suspicion of driving while intoxicated.
The OIG wrote that although impaired providers should be offered assistance “when appropriate,” the investigation revealed “multiple lapses” in leadership’s response to reports occurring prior to 2016 that endangered patients.
“Had facility leaders taken the opportunities that presented as early as March 2014 to vigorously address allegations of impairment and adequately review Dr. Levy’s clinical competency, his removal may have occurred sooner,” the OIG wrote.
In addition, the facility staff who had reported Levy’s impairment told the OIG during interviews that they were afraid of potential reprisal for flagging his behavior.
“Deficiencies in quality management processes and managing a potentially impaired provider, as well as facility leaders’ failure to foster a culture of accountability that encouraged reporting without reprisal contributed to Dr. Levy’s errors continuing for many years,” the OIG wrote. “Any one of these breakdowns could cause harmful results. Occurring together and over an extended period of time, the consequences were devastating, tragic and deadly.”
The OIG’s report came with 12 recommendations for the Arkansas facility and the broader Veterans Health Administration’s policies. Among these was a review of the vetting process for temporary and newly hired staff, new policies to prevent conflicts of interest during peer review, development of a mandatory alcohol testing policy for healthcare workers and efforts to empower the facility’s staff when reporting concerns.
The OIG also recommended discussions as to whether administrative action is warranted for leadership “who did not adequately perform their duties with respect to the issues within this report.”
VA Press Secretary Terrence Hayes told the Washington Post that Levy ”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 [the Arkansas facility] and nationally that would prevent any provider from causing tragic patient harm.”
Rep. Steve Womack, R-Missouri, who had previously testified before the House Veterans Affairs Committee on the Fayetteville facility’s oversight, said the OIG report outlines “an abject failure of leadership” harming hundreds of veterans and makes the case for broader disciplinary action.
“It is unacceptable to limit accountability to the criminal conduct of Dr. Levy,” the representative said in a statement. “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.”
Tags: Arrests Healthcare Diversion Impaired Opioid Crisis Patient Harm Provider Arrest
