Institutional Disclosure Policy Requirements Should Be Clarified

The VA Office of Inspector General’s (OIG’s) oversight function includes interpretation of Veterans Health Administration (VHA) policies. Unclear policies create challenges for oversight and may impact the services veterans receive. The purpose of this memorandum is to highlight concerns with facility-level expectations described in the VHA policy for conducting institutional disclosures of adverse events. The OIG identified unclear language and inconsistent application of VHA Directive 1004.08, Disclosure of Adverse Events to Patients, during various healthcare inspections that took place during fiscal years 2022 and 2023.

The OIG determined that VHA policy language is unclear as to whether a sentinel event automatically triggers the need for institutional disclosure, in part because of The Joint Commission’s (TJC’s) evolving definition of a sentinel event, which now includes non-patient-care events. Based on a fiscal year 2023 hotline inspection involving a sentinel event, the OIG also discovered unclear criteria regarding the definition of suicide as a sentinel event, and whether all sentinel events require institutional disclosure.

Unclear requirements may have resulted in VHA medical facility leaders’ confusion about when to make institutional disclosures. Additionally, the OIG found that VHA Directive 1004.08 does not provide leaders with discretion on whether to make an institutional disclosure of an event based on a delay in discovery of a serious adverse incident when, according to 1004.08, an institutional disclosure would otherwise be implemented.

The OIG requested the Under Secretary for Health (1) more clearly specify in an amended or updated policy when a sentinel event, as defined by TJC, should trigger an institutional disclosure; (2) reinforce to VHA staff the indications for institutional disclosure; and (3) reinforce to staff that the present policy requires institutional disclosure for specific events, regardless of timeliness of discovery.