Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures.
Washington DC: VA Office of the Inspector General; January 4, 2024; Report no. 22-02294-42.
System fragmentation is known to enable clinicians with performance issues to remain in practice and risk patient safety. This report examines credentialing practices at a community care network weakened by interorganizational communication gaps, data inconsistencies, and information failures. The investigators also noted patient safety reporting problems that could be addressed through enhanced communication and staff training.