Oversight Review of Specialty Service Issues at the VA Montana Health Care System, Fort Harrison, Montana

This is a review of actions taken by the Veterans Health Administration (VHA) to address allegations that a physician at the VA Montana Health Care System was providing substandard care and engaging in improper medical record documentation practices. We found that management officials were initially impeded in fully addressing these allegations due to an Administrative Board of Investigation product that did not sufficiently address the complainant’s allegations. However, ultimately, we found that managers complied with existing VHA policy in obtaining appropriate external peer reviews of care provided by the subject physician, and in taking the personnel actions described in this oversight review, including separation from VA employment of the subject physician. In the course of performing this oversight review, we had numerous additional concerns regarding the provision of care to veterans beyond the allegation about a single physician’s practice. These concerns referred to the overall operation of a clinical service. We recommend that the Acting Under Secretary for Health empanel a team of relevant specialists and administrators to perform a comprehensive review of all aspects of the referenced specialty care for veterans served by the medical center.