The Department of Veterans Affairs OIG (Office of the Inspector General) released a report detailing pathology oversight failures in 2017 during Dr. Robert Levy’s tenure at the Veterans Health Care System of the Ozarks in Fayetteville.
The 102 page report released on June 2 details many factors that contributed to Dr. Robert Levy misdiagnosing patients such as:
- Deficiencies in quality management processes.
- Inadequate management of an impaired provider
- Failure of facility leaders to foster a culture of accountability
The OIG found that deficiencies in the facility’s management processes contributed to thousands of diagnostic errors that occurred throughout Dr. Levy’s tenure.
OIG also acknowledged that an impaired provider should be offered assistance when appropriate in recognizing and managing the causes of impairment. The process of assistance must be, “consistent with the protection of patients.”
The report states that a failure of facility leaders to explore or take action may promote perceptions that reporting will have no effect. Not aggressively addressing reports can also discourage staff from complying with the facility’s policy to report subsequent observations of possibly unsafe treatment, according to the report.
The OIG concluded that facility leaders did not meet VHA’s goal to establish an “environment in which staff act with integrity to achieve accountability.”
Representative Steve Womack (R-AR) released a statement regarding the report:
The report details an abject failure of leadership that led to the misdiagnosis and subsequent harm to hundreds of veterans who rely on the VA health system for care. It is unacceptable to limit accountability to the criminal conduct of Dr. Levy. 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.
CONGRESSMAN STEVE WOMACK
(by: Gary Gilbert, KNWA/KFTA/Ozarks First)
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