**GAO-12-6R**                      Published: Oct 28, 2011. Publicly Released: Oct 28, 2011.                  

-   
-   
-   
-   

    Jump To:  
-  Elder Abuse 
-  Services for Older Adults 
-  State and Local-Level Drivers and Trends 
-  State and Local Fiscal Projections 
-  Federal Borrowing 
-  Managing the Debt 
-  Summary of Funding Provisions 
-  Auditing the Government's Books 
-  Unpacking the Financial Report 
-  Highlights 
-  Recommendations 
-  Background 
-  About This Work 
-  About This Work 
-  Trends 
-  About the Center 
-  Why It's High Risk 
-  What Remains To Be Done 
-  Key Reports 
-  Newest COVID-Related Reports 
-  AI Use Cases 
-  Flood Insurance 
-  Past Pandemic-Related Reports 
-  CARES Act Oversight Reports 
-  All COVID-19 Reports 
-  Report Suspected Fraud 
-  Subjects 
-  How to Get Notified 
-  Past Reports 
-  Public Health Threats 
-  Explore the FY 2022 and 2023 Funds 
-  Lessons Learned 
-  Agency Reports 
-  Recent Reports 
-  Recommendations 
-  Supplemental Material 
-  Full Report 
-  Additional Data 
-  View Decision 
-  Downloads 
-  Previously Identified Actions 
-  Related Pages 
-  Associated Agencies 
-  Tough Choices and Opportunities Ahead 
-  Americas Fiscal Future Key Areas 
-  Retirement Security Key Areas 
-  Current List 
-  About The High Risk List 
-  Area Ratings 
-  Previous High Risk Products 
-  Search Federal Vacancies 
-  Past Federal Vacancies 
-  Violation Letters 
-  About the Yellow Book 
-  Advisory Council 
-  Related Resources 
-  Comment Letters 
-  Related Publications 
-  Contacts and Resources 
-  Major Issues Facing the Nation 
-  Meeting Strategic Challenges 
-  Additional Resources 
-  Resources 
-  GAO Contacts 
-  Mission Teams 
-  Operations and Staff Offices  
-  Organization Chart  
-  Why a Career at GAO? 
-  Am I Qualified? 
-  Company Culture 
-  Reasonable Accommodations 
-  Video Gallery 
-  Paid Internships 
-  Student Volunteers 
-  Professional Development Program 
-  Advancement 
-  Executive Candidate Program 
-  Summer Associates 
-  Externships 
-  Benefits 
-  Contacts 

Skip to Highlights

## Highlights

	The Department of Veterans Affairs (VA) operates one of the largest health care delivery systems in the nation--providing health care services to more than 5 million veterans each year in over 1,000 facilities. These health care services are delivered by physicians, nurses, and other types of practitioners and range from routine examinations to complex surgical procedures. As in any health care setting, veterans receiving health care services at VA facilities may be at risk of incurring medical injury as a result of substandard care. Recent incidents have heightened concern about the quality of care provided to veterans by VA facilities. For example, in 2010 we reported that one VA facility discovered in 2009 that medical equipment had been improperly cleaned, thus posing safety risks to 2,526 veterans. In the event that an injury occurs as a result of care rendered by a VA practitioner, a veteran alleging medical malpractice may seek compensation by filing a tort claim with one of VA's 22 regional counsel offices. The offices, which operate under VA's Office of General Counsel (OGC), are responsible for initially investigating and, to the extent possible, resolving the tort claims through administrative review. After undergoing administrative review, claims may proceed to litigation in federal court, in which the Department of Justice (DOJ) defends the United States. During either VA's administrative review or litigation, the government may resolve tort claims by making payments to veterans. When such payments are made to veterans, VA's Office of Medical-Legal Affairs (OMLA) uses medical information from these paid tort claims, as well as related medical records and other relevant information, to assess the quality of care provided to veterans. In 1995, we reported that data on tort claims provided opportunities for VA to identify concerns with individual providers and decrease the risk of future tort claims. Specifically, we recommended that VA use available data on tort claims to help identify problem-prone areas in VA's delivery of care and initiate programs that could help prevent the types of incidents that generate tort claims for medical injuries. VA generally concurred with our 1995 recommendation and implemented a process to analyze and use available tort claims data to assess the quality of veterans' care. In light of recent concerns about the quality of veterans' care provided in some VA facilities, Congress asked us to examine the resolution of tort claims filed against VA in the context of VA's efforts to improve the quality of veterans' care at its facilities. In this report, we (1) describe the number of tort claims that were resolved through VA's administrative review and through litigation from fiscal years 2005 through 2010 and (2) examine how OMLA uses paid tort claims data to assess the quality of veterans' care.

	From fiscal years 2005 to 2010, the number of tort claims filed against VA rose by 33 percent, from 1,251 to 1,670. Most tort claims filed against VA in fiscal years 2005 through 2010 were resolved through VA's administrative review, rather than through litigation. Specifically, VA resolved more than 80 percent of tort claims through administrative review during this 6-year period, and the remainder were resolved through litigation. Additionally, the amount paid for tort claims during fiscal years 2005 through 2010 was lower for claims resolved through administrative review than for claims resolved through litigation. For example, in fiscal year 2010, about $30 million was paid for the 277 tort claims that were resolved through VA's administrative review, while about $49 million was paid for the 114 claims that were resolved through litigation. Further, in fiscal year 2010 the average number of days to resolve tort claims administratively was considerably less than the average number of days it took to resolve claims through litigation. VA policy requires OMLA to review tort claims that result in payments to veterans in order to determine whether VA practitioners provided substandard care. For each medical injury-related tort claim paid, OMLA is required to collect medical records related to the incident that prompted the claim and convene a review panel of medical practitioners to determine whether the claim was associated with substandard care. If the panel determines that a practitioner rendered substandard care, OMLA notifies the director of the VAMC involved in the claim of the panel's conclusion and the director must report the practitioner to the National Practitioner Data Bank (NPDB). VAMCs and VA networks utilize NPDB data in overseeing the practitioners who deliver services in their facilities. Although VA's regional counsel offices are required to notify OMLA about all paid tort claims to initiate OMLA's review of VA practitioners involved in the claims, we found that this notification does not always occur because VA lacks an internal control to help ensure that regional counsel offices comply with this requirement. Specifically, we found that the regional counsel offices did not report to OMLA 16 percent of the total number of paid tort claims involving VA practitioners from fiscal years 2005 through 2010. VA OGC officials told us that this occurred for several reasons, such as lack of administrative oversight and staff turnover. As a result, OMLA did not have the opportunity to review all paid tort claims for this time period to determine whether VA practitioners associated with these claims rendered substandard care, thus limiting the number of practitioners who should have been reported to the NPDB. To help ensure the quality of care provided to veterans by VA practitioners, including that information about all paid tort claims is reported and used appropriately to improve patient care, we recommend that the Secretary of Veterans Affairs direct the General Counsel to take the following three actions: (1) Ensure that regional counsel offices notify OMLA about all paid tort claims resolved through VA's administrative review and through litigation. (2) Develop and implement an internal control process to verify the completeness of the notifications of paid tort claims that regional counsel offices provide to OMLA. (3) Review all paid tort claims related to medical injuries at VA facilities in prior years to ensure that all of these claims are reported to OMLA.

## Recommendations

## Recommendations for Executive Action

## Full Report

Full Report (21 pages)

Accessible Text 

## Office of Public Affairs

Sarah Kaczmarek
kaczmareks@gao.gov

(202) 512-4800

## Topics

Veterans

ClaimsClaims processingFederal courtsHealth care facilitiesHealth care programsHealth care servicesInternal controlsLitigationMedical care evaluationMedical equipmentMedical recordsPolicy evaluationQuality of careTortsVeteransVeterans benefitsVeterans hospitalsAdministrative proceduresAssessmentsMalpracticeVeterans medical care