Review of the Peer Review Process at the VA Caribbean Healthcare System in San Juan, Puerto Rico

The VA Office of Inspector General (OIG) initiated a healthcare inspection on September 2, 2025, in response to anonymous allegations received regarding the integrity of the peer review process at the VA Caribbean Healthcare System (facility) in San Juan, Puerto Rico. The OIG conducted an unannounced site visit from December 2–4, 2025, followed by virtual interviews through January 21, 2026.

The OIG determined the facility met Veterans Health Administration (VHA) Directive 1190(1), Peer Review for Quality Management, requirements for peer review process management including alignment with committee structure, documentation of initial and final levels of care, recommendations for education and quality improvement, and required quarterly reporting to the clinical executive committee. The OIG found that peer review committee members assigned final levels of care based on a majority vote. Additionally, peer review committee members described having discussions to forget the patient outcome and focus on the episode of care under review in an effort to avoid hindsight or outcome bias. However, the OIG identified that the peer review committee made decisions regarding completing institutional disclosures, which is not part of the committee’s quality management process, that should have been made by facility leaders. The OIG made one recommendation to the Facility Director to address this issue. The Facility Director provided an action plan to ensure all discussion related to the disclosure of adverse events is removed from Peer Review Committee proceedings.