New Peters' bill responds to leaders' misconduct at Detroit VA hospital

Washington — A new bipartisan bill introduced Tuesday in the U.S. Senate aims to ensure accountability and neutrality in the peer review process used by the Department of Veteran Affairs to investigate concerns about the quality of medical care provided at VA hospitals across the country.

The legislation by Sen. Gary Peters, D-Bloomfield Township, is in response to findings of misconduct and a pattern of substandard surgical care last year at the John D. Dingell VA Medical Center in Detroit that now-former leaders tried to conceal by manipulating or altering external peer reviews. 

Those findings were part of a report by the Veterans Health Administration’s Office of the Medical Inspector (OMI) last year. A follow-up evaluation by the VA Office of the Inspector General raised concerns in July about whether the Midtown hospital had sufficiently addressed a problem with how the peer reviews were being conducted.

Peters said his aim with the bill is to ensure that members of a VA facility's Peer Review Committee should not be participating in peer reviews of cases that they directly took part in or for cases in which they have a conflict of interest or that could suggest even the appearance of a conflict.

"This bill codifies VA policy that really needs to be put into law to ensure that the process is actually effective. It's requiring that if you have any kind of direct involvement in a case or if you have a conflict of interest, you have to recuse yourself from the review process," Peters said in an interview.

"If you're on the committee and you have a complaint against you, it must be evaluated by another VA facility to ensure that the assessment is neutral and objective and that it's outside of the board completely."

The OIG report over the summer found that Detroit had altered it's peer review process to have a neutral party initially review the case under investigation, but the OIG said a neutral party should also conduct a final review of cases that involved any members of the Peer Review Committee.

Peters' bill is co-sponsored by Sen. Debbie Stabenow, D-Lansing, and Sen. John Boozman, R-Arkansas.

The legislation also responds to the string of three interim leaders that were temporarily installed at the Detroit VA after the medical director, Dr. Pamela Reeves, was reassigned to another role while under investigation in July 2022. Acting Director Chris Cauley was officially appointed as the medical center's permanent leader on Aug. 28.

The bill would require the VA to have a plan in place to fill a medical director vacancy within 180 days, Peters said.

"You need to have permanent leadership in place, and you can't have gaps. When you have gaps, things fall through the cracks, and that's bad," Peters said.

The bill also requires VA facilities to alert Congress within 90 days after temporarily reassigning or detailing a director of a VA hospital to a different post and to include specific information about the detail, including location.

"I was just absolutely appalled to learn of the misconduct that occurred at the medical center in Detroit and even more outraged that members of the leadership team at the center failed to take immediate action," Peters said. "In fact, some folks even tried to cover up this incident, so it's important for us to get to the bottom of it.

The legislation has the support of the nonprofit organization Disabled American Veterans, Vietnam Veterans of America, the American Legion, the Iraq and Afghanistan Veterans of America and the Project on Government Oversight (POGO), according to Peters' office.

"Hopefully, this never happens again to anybody else, and it doesn't happen in any other VA hospital in the country, which is why we need to put the recommendations that the IG made the into law," Peters said.

Peters and other Michigan lawmakers in the congressional delegation previously had asked Secretary Denis McDonough to install a permanent director at the Detroit VA "as soon as permissible," saying leadership and managerial failures following the "crisis of care" at the facility led to a culture of "distrust" and low patient and employee morale.

Inspector General Michael Missal has said that past leadership failures at the hospital resulted in a "poor" culture that did not prioritize patient safety or the delivery of high-quality health care, and in which employees felt psychologically unsafe to speak up about concerns. Missal said that Reeves was "exclusive, non-collaborative and hostile," and that the hospital suffered from recurring turnover in senior leadership positions, as well as people in acting roles.

Reeves was fired in June nearly a year after she was removed from the role she'd held at the Detroit VA since 2008. The hospital has also seen the sudden retirement in May of Dr. Scott Gruber, the chief of staff who had served on the Peer Review Committee, according to the OMI investigation.

The turmoil at the 106-bed hospital drew the attention of McDonough, who visited Detroit in July with Missal to meet with staff and veterans. McDonough has said he is demanding leaders "redouble" efforts to improve the workplace culture and flow of information.  

Cauley told The Detroit News that he's seeing some positive signs of culture change as a result of those efforts, including "very, very promising" results from the annual all-employee survey. He's also opened new lines of communication with facility staff, whose ranks have increased by 15% since September 2022, Cauley said.

"We've given them a channel directly to the medical center director and leadership to ask questions of us, and that has helped quite a bit," Cauley said. "We've increased our communications with our stakeholders, for instance, our congressional and veteran service organizations."

The OMI report last year had substantiated a whistleblower's allegation that processes for ensuring quality of care at the medical center were being "manipulated at multiple points, preventing action from being taken to address a quality concern or provide knowledge of this concern to higher leadership members or the National Surgery Office (NSO)."

OMI investigators concluded that external peer reviews ? used to evaluate if a medical provider’s handling of a harmful “adverse event” was clinically appropriate ? had been changed “with little or no documented rationale.”

“These external reviews from multiple sources showed a pattern of substandard care across at least 2 years and multiple procedures,” the OMI report stated.

The responsible committee had altered the peer review ratings 11 times since 2018 for a particular provider at the hospital whose name was redacted by the VA in the OMI report.

The ratings were changed from a so-called Level 3 designation ? which flags that a clinician diverged from how most “experienced and competent” clinicians would have managed a case ? to Level 1, which is the category for more typical case management.

The separate OIG report revealed in July that facility leaders had delayed fully revoking clinical privileges last year for the hospital's former chief of surgery and reporting him to outside entities that track alleged physician misconduct, despite findings of substandard care and a potential "imminent threat to patient safety."

The OIG report said facility leaders in Detroit had "missed opportunities" for reporting the former chief of surgery, Dr. Gamal Mostafa, to licensing boards in states where he's licensed, saying two clinical reviews in 2021 and 2022 had identified 16 episodes of substandard care by Mostafa that met the requirements to initiate reporting to the state entities.

Mostafa retired from the VA as of April 5, though he had performed no surgeries at the facility since August 2021. Mostafa's attorneys have said the OIG report contained inaccuracies, and that "no harm came to any patients and no complaints or tort claims were ever filed by any of these patients."