Malpractice or Missing Systems? Rethinking How VHA Names Physicians in NPDB Reports
Is it always the physician's fault — or is VHA naming individuals for failures in systems it was responsible for maintaining?
Are malpractice payments made by the Veterans Health Administration (VHA) always the result of the physicians involved — or does the pattern call for a closer look at systems? A trend is showing up with enough regularity in NPDB and credentialing work that it deserves scrutiny: a federal facility settles or pays a claim under the Federal Tort Claims Act (FTCA), and in the process, an individual practitioner is identified and subsequently reported to the National Practitioner Data Bank — even where the underlying failure looks less like individual negligence and more like a breakdown in the systems the facility was responsible for maintaining.
This isn't a hypothetical concern, and it isn't the first time it's surfaced. I've encountered this dynamic more than once — including in a Medical Executive Committee discussion where the committee and the facility's medical director both raised the same objection: that a practitioner had been named and reported to the NPDB following a VA-related tort claim in circumstances the group felt didn't reflect that individual's actual conduct. When a Medical Executive Committee is independently raising the same concern in a peer review setting, it's worth asking whether this is a recurring structural problem rather than an isolated dispute.
1. The FTCA is the mechanism — and it puts a name on the claim
The Federal Tort Claims Act allows individuals to bring negligence claims against federal agencies, including the VA, for harm caused in the course of care. The claim itself is against the government, not the individual provider. But underlying malpractice claims and settlements typically identify the treating practitioner or practitioners whose care is at issue — and that identification is exactly what can trigger a report to the NPDB once a payment is made for that practitioner's benefit under 45 CFR 60.7. In other words: the government is the defendant, but the individual clinician's name travels with the claim and can end up permanently attached to a federal database.
2. Quality of care is a systems problem, not just an individual one
Decades of patient safety research have converged on a simple point: most preventable harm in healthcare doesn't trace back to a single clinician's bad judgment — it traces back to broken handoffs, unclear ownership of a task, and information that didn't move from one caregiver to the next. Communication failures, and specifically failed handoffs between providers, are consistently identified as a leading and largely preventable driver of adverse events and malpractice claims. When a patient's care crosses institutional lines — VA to community provider, specialist to primary care, one covering physician to another — the risk of a dropped handoff rises accordingly. That's a design problem, not a character flaw.
3. Joint Commission standards require hospitals to have these systems — it isn't optional
This is where the standard gets concrete. The Joint Commission has long required hospitals to have a real process for hand-off communication — one that provides the opportunity for actual discussion between the giver and receiver of patient information, not just a form that gets filled out. This requirement traces back to a 2006 National Patient Safety Goal mandating a standardized approach to handoff communications, including the chance to ask and answer questions before responsibility for a patient transfers. Following the Joint Commission's 2025 accreditation manual reorganization, this requirement now lives under the National Patient Safety Goals chapter (Hand-Off Communication, NPG.01.04.01) rather than its former home in the Provision of Care chapter — a relocation, not a relaxation, of the same underlying obligation. In plain terms: accredited hospitals are required to have a real system for making sure critical information — like whether a patient was told to resume a blood thinner — doesn't fall through the cracks. This is an institutional obligation, not an individual one.
4. The VA has documented, acknowledged gaps in exactly this kind of system
This isn't speculation about the VA — it's the VA's own oversight record. The Government Accountability Office has found that VA's own initiative to coordinate referrals between VA facilities and community providers lacked clear program direction, with staff in some cases uncertain where to even go for guidance after a reorganization that wasn't clearly communicated. Separately, GAO has reported that VA's electronic health record system is decades old and requires new records from outside providers to be manually loaded in — a basic interoperability gap that makes it harder, not easier, for information to move cleanly between a community specialist and the VA team managing the rest of a veteran's care. When a veteran chooses to receive care outside the VA network — increasingly common and increasingly encouraged under community care expansion — the odds that a piece of that care doesn't make it back into the VA record rise accordingly.
5. So — is it fair to name the individual practitioner?
Put the pieces together: a federal statute that attaches a practitioner's name to a claim against the government; a body of patient-safety evidence showing that most of these breakdowns are systemic rather than individual; an accreditation standard that makes handoff communication a hospital-level requirement; and a documented, acknowledged gap in the VA's own systems for making that handoff work. When all four of those are true, and a claim is paid, and the individual is the one who ends up permanently reported to the NPDB — with no requirement that the reporting entity first determine whether the failure was actually attributable to that practitioner's own conduct rather than the system around them — something in that chain isn't lining up.
None of this means individual accountability should disappear. Some cases genuinely do involve a specific clinician's judgment. But where the record shows a communication or handoff failure between systems the institution was responsible for maintaining — and where that institution's own oversight body has acknowledged gaps in exactly those systems — practitioners and the committees that oversee them are right to ask whether the NPDB report reflects what actually happened, or simply reflects who was easiest to name.
Claudia M. Rausch provides regulatory, policy, and operational consulting on NPDB compliance and healthcare credentialing matters. Nothing in this post constitutes legal advice.
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Sources
- 45 CFR § 60.7 — Reporting medical malpractice payments. eCFR. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-60/subpart-B/section-60.7
- The Joint Commission — Hand-Off Communication, NPG.01.04.01 (formerly Provision of Care standard PC.02.02.01, Element of Performance 2). https://digitalassets.jointcommission.org/api/public/content/a05e74ef89484e2084b6511189b73a99?v=279f39cc
- U.S. Government Accountability Office, Veterans Health Care: Referral Coordination Initiative for Specialty Care Needs Improved Program Direction and Guidance, GAO-25-106678 (Jan. 21, 2025). https://www.gao.gov/products/gao-25-106678
- U.S. Government Accountability Office, Veterans Affairs' Ongoing Struggle to Modernize Its Electronic Health Record System, WatchBlog. https://www.gao.gov/blog/veterans-affairs-ongoing-struggle-modernize-its-electronic-health-record-system
