VA Health Care
Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement Gao ID: GAO-06-648 May 25, 2006The Department of Veterans Affairs (VA) is responsible for determining that over 36,000 physicians working in its facilities have the appropriate professional credentials and qualifications to deliver health care to veterans. To do this, VA credentials and privileges physicians providing care at its medical facilities. In this report, GAO determined the extent to which selected VA facilities complied with (1) four VA credentialing requirements and five VA privileging requirements and (2) a requirement to submit information on paid malpractice claims. GAO also determined (3) whether VA has internal controls to help ensure the accuracy of information used to renew clinical privileges. GAO reviewed VA's policies, interviewed VA officials, and randomly sampled 17 physician files at each of seven VA medical facilities.
GAO found that the files reviewed at seven VA medical facilities complied with four of VA's credentialing requirements selected for review, and all but one of five privileging requirements. Credentialing is the process of verifying that a physician's professional credentials, such as state medical licenses, are valid and meet VA's requirements for employment. Privileging is the process for determining which health care services a physician is allowed to provide to veterans. For the files GAO reviewed, compliance with the fifth privileging requirement was problematic at six facilities because officials used performance information when renewing clinical privileges but collected all or most of this information through their facility's quality assurance program. This is prohibited under VA policy. In general, VA quality assurance information is confidential, according to federal law and VA policy. According to VA officials, if quality assurance information is used outside of a facility's quality assurance program, it could be used for other purposes, including litigation. The information is protected to encourage physicians to participate in quality assurance programs by reporting and discussing adverse events to help prevent such events from occurring in the future. VA has not provided guidance to help medical facilities find ways to efficiently collect performance information outside of a facility's quality assurance program. At the seventh medical facility, officials did not use performance information to renew clinical privileges, as required. Three of the seven medical facilities did not meet VA's requirement to submit, within 60 days after being notified that the claim was paid, any information on paid VA medical malpractice claims involving facility practitioners, including physicians, to VA's Office of Medical-Legal Affairs. This office reviews the information and determines whether practitioners involved in the claims delivered substandard care, displayed professional incompetence, or engaged in professional misconduct. The office informs facilities of its determinations. When facilities do not submit all relevant VA malpractice information in a timely manner, VA medical facility officials lack complete information that would allow them to make informed decisions about the clinical privileges that their physicians should be granted. VA has not required its medical facilities to establish internal controls to help ensure that privileging information managed by medical staff specialists--who are responsible for obtaining and verifying the information used in the credentialing and privileging processes--is accurate. One facility GAO visited did not identify 106 physicians whose privileging process had not been completed by facility officials for at least 2 years because of inaccurate information provided by the facility's medical staff specialist. As a result, these physicians were practicing at the facility without current clinical privileges. Without accurate information on the privileges that have been granted to physicians and the dates for renewing those privileges, VA medical facility officials will not know if they have failed to renew clinical privileges for any of their physicians in accordance with VA policy.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-06-648, VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement
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Report to the Chairman, Committee on Veterans' Affairs, House of
Representatives:
United States Government Accountability Office:
GAO:
May 2006:
VA Health Care:
Selected Credentialing Requirements at Seven Medical Facilities Met,
but an Aspect of Privileging Process Needs Improvement:
VA Credentialing and Privileging:
GAO-06-648:
GAO Highlights:
Highlights of GAO-06-648, a report to the Chairman, Committee on
Veterans' Affairs, House of Representatives.
Why GAO Did This Study:
The Department of Veterans Affairs (VA) is responsible for determining
that over 36,000 physicians working in its facilities have the
appropriate professional credentials and qualifications to deliver
health care to veterans. To do this, VA credentials and privileges
physicians providing care at its medical facilities. In this report,
GAO determined the extent to which selected VA facilities complied with
(1) four VA credentialing requirements and five VA privileging
requirements and (2) a requirement to submit information on paid
malpractice claims. GAO also determined (3) whether VA has internal
controls to help ensure the accuracy of information used to renew
clinical privileges. GAO reviewed VA‘s policies, interviewed VA
officials, and randomly sampled 17 physician files at each of seven VA
medical facilities.
What GAO Found:
GAO found that the files reviewed at seven VA medical facilities
complied with four of VA‘s credentialing requirements selected for
review, and all but one of five privileging requirements. Credentialing
is the process of verifying that a physician‘s professional
credentials, such as state medical licenses, are valid and meet VA‘s
requirements for employment. Privileging is the process for determining
which health care services a physician is allowed to provide to
veterans. For the files GAO reviewed, compliance with the fifth
privileging requirement was problematic at six facilities because
officials used performance information when renewing clinical
privileges but collected all or most of this information through their
facility‘s quality assurance program. This is prohibited under VA
policy. In general, VA quality assurance information is confidential,
according to federal law and VA policy. According to VA officials, if
quality assurance information is used outside of a facility‘s quality
assurance program, it could be used for other purposes, including
litigation. The information is protected to encourage physicians to
participate in quality assurance programs by reporting and discussing
adverse events to help prevent such events from occurring in the
future. VA has not provided guidance to help medical facilities find
ways to efficiently collect performance information outside of a
facility‘s quality assurance program. At the seventh medical facility,
officials did not use performance information to renew clinical
privileges, as required.
Three of the seven medical facilities did not meet VA‘s requirement to
submit, within 60 days after being notified that the claim was paid,
any information on paid VA medical malpractice claims involving
facility practitioners, including physicians, to VA‘s Office of Medical-
Legal Affairs. This office reviews the information and determines
whether practitioners involved in the claims delivered substandard
care, displayed professional incompetence, or engaged in professional
misconduct. The office informs facilities of its determinations. When
facilities do not submit all relevant VA malpractice information in a
timely manner, VA medical facility officials lack complete information
that would allow them to make informed decisions about the clinical
privileges that their physicians should be granted.
VA has not required its medical facilities to establish internal
controls to help ensure that privileging information managed by medical
staff specialists”who are responsible for obtaining and verifying the
information used in the credentialing and privileging processes”is
accurate. One facility GAO visited did not identify 106 physicians
whose privileging process had not been completed by facility officials
for at least 2 years because of inaccurate information provided by the
facility‘s medical staff specialist. As a result, these physicians were
practicing at the facility without current clinical privileges. Without
accurate information on the privileges that have been granted to
physicians and the dates for renewing those privileges, VA medical
facility officials will not know if they have failed to renew clinical
privileges for any of their physicians in accordance with VA policy.
What GAO Recommends:
GAO recommends that VA provide guidance to its medical facilities on
how to collect physician performance information in accordance with
VA‘s policy that can be used to renew clinical privileges, enforce the
timely submission of VA medical malpractice information, and instruct
facilities to establish internal controls for privileging information.
VA concurred with the findings and recommendations and provided an
action plan to implement the three recommendations.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-648].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Laurie E. Ekstrand at
(202) 512- 7101 or ekstrandl@gao.gov.
[End of Section]
Contents:
Letter:
Results in Brief:
Background:
Selected Physician Files at Medical Facilities Demonstrated Compliance
with Four VA Credentialing and Four Privileging Requirements;
a Fifth Privileging Requirement Was Problematic:
Not All Medical Facilities Submitted Paid Malpractice Claim Information
in a Timely Manner:
VA Has Not Established Internal Controls to Help Ensure the Accuracy of
Medical Facilities' Privileging Information:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Table:
Table 1: Average Number of Months Taken by Three VA Medical Facilities
to Submit VA Medical Malpractice Claim Information to VA's Office of
Medical-Legal Affairs (as of December 2005):
Figures:
Figure 1: Steps Taken in VA's Physician Credentialing Process:
Figure 2: Steps Taken in VA's Physician Privileging Process:
Figure 3: Medical Malpractice Claim Information Not Submitted by Three
VA Medical Facilities to the Office of Medical-Legal Affairs within 60
Days:
Abbreviations:
FSMB: Federation of State Medical Boards
NPDB: National Practitioner Data Bank
VA: Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
May 25, 2006:
The Honorable Steve Buyer:
Chairman Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Chairman:
The Department of Veterans Affairs (VA) has over 36,000 physicians
working at more than 1,300 facilities in its health care system. To
help ensure the quality of the health care these physicians deliver and
the safety of veterans, VA is responsible for determining that its
physicians have the appropriate professional credentials and clinical
experience to provide health care to VA's patients.[Footnote 1] To do
this, VA credentials and privileges physicians providing care at VA
medical facilities. Credentialing is the process of verifying that a
physician's professional credentials, such as licensure, education, and
training, are valid and meet VA's requirements for employment.
Privileging is the process for determining--based in part on a
physician's credentials--which health care services a physician should
be allowed to provide to VA patients without supervision.[Footnote 2]
These health care services are known as a physician's clinical
privileges. Physicians are granted initial clinical privileges when
they begin their employment at a VA medical facility. Physicians'
professional credentials and clinical privileges must be reviewed and
renewed at least every 2 years.[Footnote 3] VA's credentialing and
privileging policy describes the information that VA medical facility
officials are required to review and verify in order to credential and
grant clinical privileges to VA physicians. In addition to the
requirements outlined in VA's credentialing and privileging policy,
medical facility officials are required to submit information to VA
headquarters on any VA physicians who are involved in paid VA medical
malpractice claims. This malpractice information is used by VA
headquarters to make decisions about the appropriateness of the care
delivered to veterans and should be used by medical facility officials
when making decisions about the clinical privileges to grant
physicians.
You expressed interest in the credentialing and privileging of VA
physicians and how this helps VA ensure the delivery of safe care to
veterans. In response to your request, we (1) determined the extent to
which selected VA medical facilities complied with four of VA's
credentialing requirements and five of VA's privileging requirements in
relation to individual physicians, and (2) determined the extent to
which selected VA medical facilities complied with the requirement to
submit information to VA headquarters on paid VA medical malpractice
claims involving VA physicians. Also, during the course of our work, we
learned about a medical facility where inaccuracies in privileging
information resulted in 106 physicians providing care to veterans in
the facility without the required clinical privileges. According to VA
officials, the individual responsible for privileging data
inappropriately changed the privileging dates for some of these
physicians to a later date in order to delay work needed to complete
the credentialing and privileging requirements on these physicians.
This led us to add to our review a reporting objective related to
internal controls. Specifically, in this report we also (3) determined
whether VA has internal controls to help ensure the accuracy of
information medical facilities use to renew physicians' clinical
privileges.
To determine the extent to which selected VA medical facilities
complied with four of VA's credentialing requirements and five of VA's
privileging requirements in relation to individual physicians, we
reviewed VA's policies to identify the requirements that VA medical
facility officials must follow when credentialing and granting clinical
privileges to physicians. We selected four of VA's credentialing
requirements for review because they are requirements that--unlike
others--address information about physicians that can change or be
updated with new information periodically. As a result, VA requires
that this information be verified by medical facility officials when a
physician initially applies for employment at VA and at least every 2
years thereafter. Other VA credentialing requirements are not subject
to change or updating and are required by VA to be verified when the
physician initially applies for employment.[Footnote 4] Under the four
requirements we reviewed, VA medical facility officials must:
1. verify that all state medical licenses held by physicians are valid;
2. query the Federation of State Medical Boards (FSMB) database to
determine whether physicians had disciplinary action taken against any
of their licenses, including expired licenses;
3. verify information provided by physicians on their involvement in
medical malpractice claims at a VA or non-VA facility;
and:
4. query the National Practitioner Data Bank (NPDB) to determine
whether a physician was reported to this data bank because of
involvement in VA or non-VA paid medical malpractice claims, display of
professional incompetence, or engagement in professional misconduct.
Of the privileging requirements in VA's credentialing and privileging
policy, we selected four requirements that VA identifies as general
privileging requirements. In addition, we selected another privileging
requirement about the use of individual performance information because
of its importance in the renewal of clinical privileges. The five VA
privileging requirements we selected are:
1. verify that all state medical licenses held by physicians are valid;
2. verify physicians' training and experience;
3. assess physicians' clinical competence and health status;
4. consider any information provided by a physician related to medical
malpractice allegations or paid claims, loss of medical staff
membership, loss or reduction of clinical privileges at a VA or non-VA
facility, or any challenges to a physician's state medical license;
and:
5. use information on a physician's performance when making decisions
about whether to renew the physician's clinical privileges.
Two of the five privileging requirements--verify all state medical
licenses and consider medical malpractice information--are also VA
credentialing requirements we reviewed.
To determine the extent to which selected VA medical facilities
complied with four of VA's credentialing requirements and five of VA's
privileging requirements, we conducted site visits to seven VA medical
facilities that were chosen based on the diversity of their size and
geographic location. The medical facilities are located in Boise,
Idaho; Kansas City, Missouri; Las Vegas, Nevada; Lexington, Kentucky;
Martinsburg, West Virginia; Miami, Florida; and San Antonio, Texas. For
each of the seven medical facilities, VA officials provided a list of
medical facility physicians grouped by their clinical specialty. Using
this list, at each medical facility we randomly selected 17 physicians
and obtained files with their credentialing and privileging
information. Our sample included physicians working in VA medical
facilities full-time and part-time, through a contract,[Footnote 5] or
without direct compensation from VA. In some cases, these physicians
also worked at non-VA medical facilities. Eight of the 17 physician
files at each medical facility represent eight clinical specialties
that are offered at most VA medical facilities: anesthesiology,
gastroenterology, neurology, oncology, ophthalmology, orthopedics,
radiology, and urology. Four of the 17 represent general surgery and
internal medicine and 5 of the 17 had no specialty identified on the
list provided by VA. To determine whether the files we reviewed
demonstrated compliance with the four VA credentialing requirements and
VA's privileging requirements at each of the seven VA medical
facilities, we reviewed paper copy credentialing and privileging files
for our sample of physicians to determine whether these files included
documentation demonstrating that medical facility officials had
complied with the credentialing and privileging requirements. We also
reviewed credentialing information on these physicians stored in
VetPro, a Web-based credentialing system VA implemented in March 2001.
Based on the sample of physician files we reviewed at each of the seven
medical facilities, we can discuss a medical facility's compliance for
the physician files we reviewed; we cannot draw conclusions about the
remaining physician files at the medical facilities we visited or about
the compliance of other VA medical facilities. In collecting
information on the credentialing and privileging requirements from
physician files at each facility, we employed standard data collection
techniques to ensure the accuracy and reliability of the data used in
this report.
Finally, we included in our review a requirement that is related to the
privileging process. Under this requirement, medical facility officials
must submit to VA's Office of Medical-Legal Affairs any information on
VA practitioners, including physicians, who were involved in a paid VA
medical malpractice claim. The Office of Medical-Legal Affairs
determines whether the physicians involved in these claims delivered
substandard care to veterans.[Footnote 6] We collected information
about the extent to which each of the seven medical facilities in our
review submitted malpractice information to the Office of Medical-Legal
Affairs.
To determine whether VA has internal controls to help ensure the
accuracy of information medical facilities use to renew physicians'
clinical privileges, we interviewed the director of VA's credentialing
and privileging program, as well as other VA headquarters and medical
facility officials. We identified the internal controls VA has in place
for its privileging process and, using GAO's standards for internal
controls in the federal government, determined whether these controls
are adequate.[Footnote 7] For a complete description of our scope and
methodology, see appendix I. We conducted our work from July 2005 to
May 2006 in accordance with generally accepted government auditing
standards.
Results in Brief:
The physician files we reviewed at the seven VA medical facilities
demonstrated compliance with the four credentialing requirements we
reviewed and four of the five privileging requirements. The files we
reviewed showed that compliance with the fifth privileging requirement-
-to use information on a physician's performance in making privileging
decisions--was problematic at six of the seven VA medical facilities we
visited. At these six medical facilities, officials obtained this
information from their facility's quality assurance program. In
general, information that is collected as part of VA's quality
assurance program is confidential according to federal law, and VA by
policy prohibits the use of such information in connection with
privileging. This information is protected, in large part, to encourage
physicians to participate in quality assurance programs by reporting
and discussing openly the causes of adverse patient events to help
prevent such events from occurring in the future. According to VA
officials, if quality assurance information is used outside of a
facility's quality assurance program, it could be available for other
purposes, including litigation. VA has not provided guidance to help
medical facilities find alternative ways to efficiently collect
performance information, outside of a facility's quality assurance
program, that could be used in the renewal of clinical privileges. At
the seventh medical facility, officials did not use performance
information to renew clinical privileges, as required.
Three of the seven medical facilities we visited did not meet the
requirement to submit, within 60 days, information on paid VA medical
malpractice claims involving their practitioners, including physicians,
to VA's Office of Medical-Legal Affairs. This office reviews the claims
information and makes a determination of whether practitioners,
including physicians, involved in the claims delivered substandard care
to veterans. If it is determined that the physician delivered
substandard care to veterans, the medical facility must report the
physician to NPDB. When VA medical facilities do not submit all
relevant information to the Office of Medical-Legal Affairs in a timely
manner, facility officials make privileging decisions without the
advantage of determinations on whether VA physicians delivered
substandard care. In addition, substandard care determinations that are
required to be reported to the NPDB go unreported or reporting is
delayed when VA medical facilities do not send information in a timely
manner to the Office of Medical-Legal Affairs. This delay or lack of
reporting to NPDB prevents other VA and non-VA facilities where the
physician may also practice from having complete information on the
physician's medical malpractice history.
VA has not required its medical facilities to establish internal
controls to help ensure that privileging information managed by medical
staff specialists--employees responsible for obtaining and verifying
the information used in the credentialing and privileging processes--is
accurate. One facility we visited did not identify 106 physicians whose
privileging process had not been completed by facility officials for at
least 2 years because of inaccurate information provided by the
facility's medical staff specialist. As a result, these physicians were
practicing at the facility without current clinical privileges.
Subsequent to our visit, this facility implemented internal controls to
reduce the risk of a similar situation occurring in the future. During
our site visits, we did not identify any medical facilities that had
established such internal controls. Without accurate information on the
privileges that have been granted to physicians and the dates for
renewing those privileges, VA medical facility officials will not know
if they have failed to renew clinical privileges for any of their
physicians in accordance with VA policy.
To better ensure that VA physicians are qualified to deliver care
safely to veterans, we recommend that VA provide guidance to medical
facilities on how to collect individual physician performance
information in accordance with VA's credentialing and privileging
policy to use in the renewal of physicians' clinical privileges, and
that VA enforce the requirement that medical facilities submit
information on paid VA medical malpractice claims to VA's Office of
Medical-Legal Affairs within 60 days after being notified that the
claim is paid. Additionally, we recommend that VA instruct its medical
facilities to establish internal controls to ensure the accuracy of
their privileging information. In commenting on a draft of this report,
VA agreed with our findings and conclusions and concurred with our
recommendations. VA also provided an action plan to address the three
recommendations.
Background:
Physicians who work at VA medical facilities are required to hold at
least one current and unrestricted state medical license. Current and
unrestricted licenses are those in good standing in the states that
issued them, and licensed physicians may hold licenses from more than
one state. State medical licenses are issued by state licensing boards,
which generally establish state licensing requirements governing their
licensed practitioners.[Footnote 8] To keep a license current,
physicians must renew their licenses before they expire and meet
renewal requirements established by state licensing boards, such as
continuing education. Renewal procedures and requirements vary by
state. When state licensing boards discover violations of licensing
practices--such as the abuse of prescription drugs or the provision of
substandard care--that result in adverse health effects, they may place
restrictions on licenses or revoke them. Restrictions issued by a state
licensing board can limit or prohibit a physician from practicing in
that particular state. Generally, state licensing boards maintain a
database that contains information on any restrictions or revocations
of physicians' licenses.
VA requires its medical facility officials to credential and privilege
facility physicians periodically in order to work at VA. VA physicians
must be credentialed and privileged prior to their initial appointment
to a facility's medical staff and then again at least every 2 years
when they must reapply for a position on the facility's medical staff.
The latter is known as the process of reappointment.
VA's Credentialing Process:
Prior to working at VA, physicians initiate the credentialing process
for their initial appointment by completing VA's application process,
which includes entering into VetPro information used by VA medical
facility officials in the credentialing process. Among the
credentialing information that VA requires physicians enter into
VetPro, for their initial appointment, is information on all the
medical licenses they have ever held and the states where they have
obtained these licenses, including any licenses they have held that
have expired. For their reappointments, physicians must update this
credentialing information in VetPro.
Once physicians enter their credentialing information into VetPro, a
facility's medical staff specialist--an employee who is responsible for
obtaining and verifying the information used in the credentialing and
privileging processes--performs a data check on the information to be
sure that all required information has been entered. In general, the
medical staff specialist at each VA medical facility manages the
accuracy of VetPro's credentialing data. The medical staff specialist
verifies, with the original source of the information, the accuracy of
the credentialing information entered by the physicians. This type of
check is known as primary source verification. For example, the medical
staff specialist contacts state licensing boards in order to verify
that physicians' state medical licenses are valid and unrestricted.
Medical staff specialists are required, at initial appointment and at
reappointment, to verify the status of the state medical licenses
physicians disclose to VA by listing them in VetPro. The medical staff
specialists can obtain information on the status of physicians' state
medical licenses by accessing the information on state licensing
boards' Web sites or by contacting the boards directly.
At initial appointment only, VA requires medical staff specialists to
query FSMB, which contains information from state licensing boards.
This query enables officials to determine all the state medical
licenses a physician has ever held, including those not disclosed by a
physician to VA, and whether a physician has had any disciplinary
actions taken against these licenses. VA does not require this query at
reappointment because VA headquarters regularly receives reports from
FSMB on any VA physician whose name appears on FSMB's list, indicating
that disciplinary action has been taken against the physician's state
medical license. When VA headquarters receives a report from FSMB, it
notifies the appropriate VA medical facility.
VA's credentialing process requires VA medical staff specialists to
verify medical malpractice claims at initial appointment and at
reappointment. These claims may be verified by contacting a court of
jurisdiction or the insurance company involved in the medical
malpractice claim, or by obtaining a statement of claims status from
the attorney representing the physician in the medical malpractice
claim. In addition, VA requires medical staff specialists to query
NPDB, which contains reports by state licensing boards, hospitals, and
other health care entities on unprofessional behavior on the part of
physicians or adverse actions taken against them. This query enables
officials to determine whether physicians fully disclosed to VA any
involvement they might have had in paid medical malpractice
claims.[Footnote 9] Once a physician's credentialing information has
been verified, the medical staff specialist sends the information to
the physician's supervisor, who is known as a clinical service
chief.[Footnote 10] The clinical service chief reviews this information
along with the physician's privileging information. Figure 1
illustrates VA's credentialing process.
Figure 1: Steps Taken in VA's Physician Credentialing Process:
[See PDF for image]
Note: This credentialing process takes place at VA medical facilities.
[End of figure]
Privileging Process:
At the same time physicians enter credentialing information into
VetPro, they complete a written request for clinical privileges. The
facility medical staff specialist provides the physician's clinical
service chief with the requested clinical privileges and information
that indicates that the credentialing information entered by the
physician into VetPro has been verified with the appropriate primary
sources. The medical staff specialist also provides the physician's
clinical service chief with information on the physician's ability to
perform the clinical privileges requested, including whether the
physician has had a physical examination performed for initial
appointment. For reappointment, documentation is required by another
physician stating that the physician is able to perform both physically
and mentally the clinical privileges requested. In addition, the
medical staff specialist provides the clinical service chief with
information on medical malpractice allegations or paid claims, loss of
medical staff membership, loss or reduction of clinical privileges, or
any challenges to the physician's state medical licenses.
The requested clinical privileges are reviewed by a clinical service
chief, who recommends whether a physician should be appointed or
reappointed to the facility's medical staff and which clinical
privileges should be granted. When deciding to recommend clinical
privileges, a clinical service chief considers whether the physician
has the appropriate professional credentials, training, and work
experience to perform the privileges requested. For reappointment only,
a clinical service chief is to consider observations of the physician's
delivery of health care to veterans, and VA's policy requires that
information on a physician's performance, such as a physician's
surgical complication rate, be used when deciding whether to renew a
physician's clinical privileges. Based on the clinical service chief's
observations and the physician's performance information, the clinical
service chief recommends that clinical privileges previously granted by
the facility remain the same, be reduced, or revoked, and whether newly
requested privileges should be added.[Footnote 11]
Clinical service chiefs forward their recommendations and the reasons
for the recommendations to the next level of a medical facility's
privileging review process, which may be a professional standards board
or a medical executive committee.[Footnote 12] A medical facility
professional standards board or the medical executive committee reviews
the recommendations of the clinical service chief and recommends to the
facility director whether the physician should be appointed to the
facility's medical staff and which clinical privileges should be
granted to the physician. The 2-year time period for renewal of
clinical privileges and reappointment to the medical staff begins on
the date that the privileges are approved by the medical facility's
director. The list of approved clinical privileges with the date of
approval is maintained in paper copy files at VA medical facilities and
the initial appointment or reappointment date is entered into VetPro.
Figure 2 illustrates VA's privileging process.
Figure 2: Steps Taken in VA's Physician Privileging Process:
[See PDF for image]
Note: This privileging process takes place at VA medical facilities.
[End of figure]
According to VA's policy and a VA memorandum, information concerning
individual physician performance that is used as part of the
privileging process to either reduce, revoke, or support[Footnote 13]
granting clinical privileges must be collected separately from a
medical facility's quality assurance program.[Footnote 14] VA's policy
is based on a federal law that restricts the disclosure of documents
produced in the course of VA's quality assurance program.[Footnote 15]
In general, documents created in connection with such a program are
confidential and may not be disclosed except in limited
circumstances.[Footnote 16] Individuals who willfully disclose
documents that they know are protected quality assurance documents are
subject to fines up to $20,000. Although the law states that it is not
intended to limit the use of documents within VA, VA's policy expressly
prohibits the use of such documents in connection with the privileging
process. VA's use of separate information sources for quality assurance
and privileging decisions is intended to maintain the confidential
status of documents produced in connection with quality assurance
programs. According to VA, the confidentiality of individual
performance information helps ensure provider participation, including
physicians, in a medical facility's quality assurance program by
encouraging providers to openly discuss opportunities for improvement
in provider practice without fear of punitive action.
VA has another requirement that is related to the renewal of
physicians' clinical privileges. Medical facility officials are
required to submit to VA's Office of Medical-Legal Affairs information
on malpractice claims. This information must be submitted within 60
days after being notified about a paid malpractice claim. The Office of
Medical-Legal Affairs is responsible for convening a panel of
clinicians to determine whether a VA facility physician involved in the
claim delivered substandard care. The Office of Medical-Legal Affairs
notifies the medical facility director of the results of its review. If
it is determined that the physician delivered substandard care to
veterans, the medical facility must report the physician to NPDB within
30 days of being notified of the decision. VA medical facility
officials also would use this determination to decide whether to grant
clinical privileges to the physician involved in the VA medical
malpractice claim.
Selected Physician Files at Medical Facilities Demonstrated Compliance
with Four VA Credentialing and Four Privileging Requirements;
a Fifth Privileging Requirement Was Problematic:
The physician files we reviewed at the seven VA medical facilities
demonstrated compliance with the four credentialing requirements we
selected for review and four of five VA privileging requirements. The
files we reviewed showed that six of the seven medical facilities had
problems complying with a fifth privileging requirement--to use
information on a physician's performance when renewing clinical
privileges. Compliance with that requirement was problematic largely
because in their privileging decisions facility officials used
performance information obtained from their facility quality assurance
program. Information contained in documents created in the course of a
VA quality assurance program is protected by VA policy that expressly
prohibits the agency from using that documentation in the privileging
process. VA has not provided guidance to help facilities find
alternative ways to efficiently collect performance information,
outside of a facility's quality assurance program, that could be used
in privileging decisions. At the seventh medical facility, officials
did not use performance information to renew clinical privileges, as
required.
Physician files at all seven medical facilities demonstrated compliance
with the four credentialing requirements we selected for review. In all
cases, the VA facility medical staff specialists contacted state
licensing boards--a form of primary source verification--to ascertain
the status of the state medical licenses held and disclosed by their
physicians.[Footnote 17] Based on the physician files we reviewed,
medical staff specialists also queried the FSMB database as required to
obtain additional information on the status of physicians' medical
licenses, including those that may not have been disclosed by
physicians. Medical staff specialists complied with the requirement to
contact primary sources, such as courts of jurisdiction, to verify
information on involvement in medical malpractice claims, including
ongoing claims, disclosed by physicians. Additionally, in all cases
medical staff specialists queried NPDB to identify those physicians who
have been involved in paid medical malpractice claims, including any
physicians who failed to disclose involvement in such claims.
The physician files at the seven medical facilities also demonstrated
compliance with four of the five VA privileging requirements we
reviewed. We found that medical staff specialists contacted state
licensing boards to verify the status of all state medical licenses
held by their physicians and to determine whether any of these licenses
had any action taken against them. Medical staff specialists also used
primary sources to verify that physicians had the necessary training
and experience to deliver health care and perform the clinical
privileges they requested. We found that after medical staff
specialists performed their verification, clinical service chiefs
reviewed this information as required, along with information on
physicians' health status and information disclosed by the physicians
about their involvement in medical malpractice allegations or cases in
which claims were paid.
While we found evidence demonstrating compliance with four of the five
privileging requirements, the files we reviewed also showed that there
were problems complying with the fifth privileging requirement--to use
information on a physician's performance in making privileging
decisions. VA requires that during the renewal of a physician's
clinical privileges, VA clinical service chiefs use information on a
physician's performance to support, reduce, or revoke the clinical
privileges the physician has requested. However, the performance
information cannot be collected as part of a medical facility's quality
assurance program. Although medical facility clinical service chiefs
must use performance information in making decisions about renewal of
clinical privileges, VA has not provided guidance on how facility
officials can obtain such information in accordance with VA policy--
that is, outside of a quality assurance program.
VA's credentialing and privileging policy states that facilities cannot
use information collected as part of a facility's quality assurance
program to reduce or revoke the clinical privileges requested by
physicians, but the initial policy guidance was silent about the use of
this information to support granting the clinical privileges requested
by physicians. Officials at six medical facilities told us that they
used quality assurance information to support the granting of clinical
privileges requested by their physicians, but collected all or most of
this information through facility quality assurance programs. In
contrast, facility officials at one medical facility did not use
individual physician performance information to renew physicians'
clinical privileges.
VA issued a directive in September 2004 and a memorandum in October
2004 which VA headquarters officials told us were intended to clarify
for medical facility officials the circumstances under which physician
performance information could not be used in the credentialing and
privileging process. The September 2004 directive explained the
specific types of information that are protected, such as information
that identifies an individual physician, and the October 2004
memorandum explained that information on a physician's performance that
is collected as part of a medical facility's quality assurance program
could not be used to support, reduce, or revoke a physician's clinical
privileges. The directive and the memorandum did not identify the ways
in which medical facility officials could efficiently collect physician
performance information outside of a facility's quality assurance
program that would provide information for renewing physicians'
clinical privileges. According to facility officials, collecting the
same information twice--once for quality assurance and once for
privileging--is resource-intensive and limits the time they have to
address other issues.
Without guidance from VA, officials from four facilities told us that
they do not know how to collect this information in accordance with
VA's policy. Facility officials from two other medical facilities said
they believed that they were complying with VA's requirement because
they stored performance information in such a way that the identity of
individual physicians could not be easily retrieved. Quality assurance
staff at these two medical facilities assigned a code to each physician
and filed the performance information by assigned code rather than
under an individual physician's name. These staff could then retrieve
an individual physician's performance information using the code. At
one facility, quality assurance staff said their regional legal counsel
told them that the confidentiality of the information would be
maintained with this type of coding system and would allow them to use
the information to renew physicians' clinical privileges. However,
according to both VA headquarters legal counsel and the director of
VA's credentialing and privileging program, coding quality assurance
information in this manner and using it to renew clinical privileges
could make this information available for other purposes, including
litigation, and therefore does not comply with VA policy. A VA
headquarters official told us that the medical facilities need further
education on how to collect individual physician performance
information that can be used in the renewal of physicians' clinical
privileges.
Not All Medical Facilities Submitted Paid Malpractice Claim Information
in a Timely Manner:
We found that three of the seven VA medical facilities we visited did
not comply with the requirement to submit paid VA medical malpractice
claim information in a timely manner.[Footnote 18] These facilities had
not submitted information on 52 paid medical malpractice claims that
may have involved their physicians to VA's Office of Medical-Legal
Affairs within the 60-day required time frame for information requested
as of December 2005.[Footnote 19] See figure 3 for the number of paid
VA medical malpractice claims for which information was not submitted
in a timely manner by the three facilities from 2001 through 2005.
Figure 3: Medical Malpractice Claim Information Not Submitted by Three
VA Medical Facilities to the Office of Medical-Legal Affairs within 60
Days:
[See PDF for image]
Note: We considered claim information submitted 14 days after the 60-
day time frame to be on time, while information submitted 15 or more
days after the 60-day time frame, we considered to be delinquent.
[End of figure]
The Office of Medical-Legal Affairs is responsible for reviewing
information on paid VA medical malpractice claims submitted by VA
medical facilities by forming panels of clinicians to determine whether
VA practitioners, including physicians, delivered substandard care to
veterans in these claims.[Footnote 20] When VA medical facilities do
not submit all relevant claim information to the Office of Medical-
Legal Affairs, facility clinical service chiefs may make privileging
decisions without the knowledge of physician peer determinations on
whether VA physicians delivered substandard care to veterans. In
addition, substandard care determinations that are required to be
reported by facility officials to the NPDB go unreported or reporting
is delayed when VA medical facilities do not send claim information in
a timely manner to the Office of Medical-Legal Affairs. This delay or
lack of reporting to NPDB prevents other VA and non-VA facilities where
the physician may also practice from having complete information on the
physician's malpractice history. For example, at one facility we
visited, we found that from 2001 through 2005, information on 21 of the
facility's 26 paid medical malpractice claims had not been submitted
within the 60-day time frame to VA's Office of Medical-Legal
Affairs.[Footnote 21] Moreover, on average this medical facility took
30 months to submit information to VA's Office of Medical-Legal
Affairs, whereas the other two facilities averaged about 5 months to
submit information. See table 1 for the average number of months it
took for these VA medical facilities to submit paid VA medical
malpractice claim information to VA's Office of Medical-Legal Affairs.
Table 1: Average Number of Months Taken by Three VA Medical Facilities
to Submit VA Medical Malpractice Claim Information to VA's Office of
Medical-Legal Affairs (as of December 2005):
Calendar year: 2001;
Average number of months to submit information on VA medical
malpractice claims: Facility A: 4;
Average number of months to submit information on VA medical
malpractice claims: Facility B: 57;
Average number of months to submit information on VA medical
malpractice claims: Facility C: 3.
Calendar year: 2002;
Average number of months to submit information on VA medical
malpractice claims: Facility A: 3;
Average number of months to submit information on VA medical
malpractice claims: Facility B: 47;
Average number of months to submit information on VA medical
malpractice claims: Facility C: 6.
Calendar year: 2003;
Average number of months to submit information on VA medical
malpractice claims: Facility A: 9;
Average number of months to submit information on VA medical
malpractice claims: Facility B: 34;
Average number of months to submit information on VA medical
malpractice claims: Facility C: 7.
Calendar year: 2004;
Average number of months to submit information on VA medical
malpractice claims: Facility A: 6;
Average number of months to submit information on VA medical
malpractice claims: Facility B: 3;
Average number of months to submit information on VA medical
malpractice claims: Facility C: 4.
Calendar year: 2005;
Average number of months to submit information on VA medical
malpractice claims: Facility A: 3;
Average number of months to submit information on VA medical
malpractice claims: Facility B: 3;
Average number of months to submit information on VA medical
malpractice claims: Facility C: 6.
Source: GAO analysis of VA data.
[End of table]
VA Has Not Established Internal Controls to Help Ensure the Accuracy of
Medical Facilities' Privileging Information:
VA has not required its medical facilities to establish internal
controls to help ensure that privileging information managed by medical
staff specialists is accurate. One facility we visited did not identify
106 physicians whose privileging process had not been completed by
facility officials for at least 2 years because of inaccurate
information provided by the facility's medical staff specialist. As a
result, these physicians were practicing at the facility without
current clinical privileges. Subsequent to our visit, this facility
implemented internal controls to reduce the risk of a similar situation
occurring in the future. During our site visits, we did not identify
any medical facilities that had established such internal controls.
Without accurate information on the privileges that have been granted
to physicians and the dates for renewing those privileges, VA medical
facility officials will not know if they have failed to renew clinical
privileges for any of their physicians in accordance with VA policy.
For at least 2 years, one VA medical facility did not identify 106
physicians whose privileging process had not been completed by facility
officials because of inaccurate information provided by the facility's
medical staff specialist. According to facility officials, the medical
staff specialist changed the reappointment dates on some of these
physicians to a later date in order to delay work she needed to perform
to complete the credentialing and privileging requirements on these
physicians. For other physicians, the medical staff specialist removed
the physicians' names from the VetPro database so that the physicians
would not show up on VetPro lists as needing to be reappointed to the
facility's medical staff. Facility officials further told us that the
medical staff specialist changed appointment dates and removed names
from VetPro in order to conceal the fact that these physicians no
longer had current privileges. As a result, these physicians were
practicing at the facility without current clinical privileges. The
clinical service chiefs, members of the professional standards board
and the medical executive committee, and the facility director were
unaware that these physicians were working without current clinical
privileges, and learned of the problem only after it was brought to
their attention by an individual newly hired to help the facility's
medical staff specialist. Medical facility officials told us that after
becoming aware of the problem, they confronted the medical staff
specialist responsible for the data inaccuracies, who then resigned.
Medical facility officials then began to check the clinical privileges
of all of their physicians and identified inaccuracies in the
privileging information for 106 physicians. After reviewing the 106
physician files, facility officials told us they did not find any
problems that would have warranted the physicians' removal from the
facility's medical staff or that placed veterans at risk.
Although this medical facility did not identify any problems with the
106 physicians' clinical privileges or with their clinical competence
to deliver care to veterans, the potential exists for problems to occur
at other VA medical facilities. During our site visits, we did not
identify any facilities that had established internal controls that
would help ensure the accuracy of the information used to renew
clinical privileges. A VA headquarters official told us that there is
no requirement for VA medical facilities to have such internal controls
in place. While VA does not require facilities to establish these
internal controls, the facility that identified inaccuracies in its
privileging information subsequently implemented internal controls to
reduce the risk of a similar situation occurring in the future.
Facility officials have taken steps to help ensure that a similar
situation does not recur. For example, the facility now provides each
facility clinical service chief with a list of physicians on a
quarterly basis and asks the clinical service chiefs to verify that the
listed physicians are currently working at the medical facility and to
identify those physicians working at the facility who are not on the
list. This allows medical facility officials to know if physicians have
been inappropriately deleted from VetPro and are working at the
facility without current clinical privileges. Without internal controls
such as this for their privileging information, VA's medical facilities
may not know whether they have allowed some of their physicians to
practice with expired privileges.
Conclusions:
VA is responsible for ensuring that its physicians are qualified to
deliver health care to veterans at VA medical facilities and has
requirements in place that medical facility officials are to use to
help ensure that physicians meet these qualifications. VA medical
facilities we visited complied with the four VA credentialing
requirements we reviewed and all but one of five privileging
requirements--to use information on a physician's performance when
renewing clinical privileges. While officials at six of the seven
facilities we visited made an attempt to comply with VA's requirement
to use performance information, these officials deviated from VA's
policy by collecting all or most of the performance information through
their facilities' quality assurance programs. This occurred, in part,
because VA has not provided guidance on how to collect this information
in accordance with VA's policy. In addition, VA medical facility
officials did not have all the information they needed on physicians
involved in paid VA medical malpractice claims, because the facilities
had not submitted such information to VA's Office of Medical-Legal
Affairs in a timely manner. This could have placed veterans at risk of
receiving care from physicians who did not have adequate clinical
skills. Finally, VA has not required its medical facilities to
establish internal controls to help ensure the accuracy of their
privileging information. Until VA requires its medical facilities to
establish internal controls to ensure the accuracy of privileging
information, facilities are at risk for allowing physicians to practice
with expired clinical privileges.
Recommendations for Executive Action:
To better ensure that VA physicians are qualified to deliver care
safely to veterans, we recommend that the Secretary of Veterans Affairs
direct the Under Secretary for Health to take the following three
actions:
* provide guidance to medical facilities on how to collect individual
physician performance information in accordance with VA's credentialing
and privileging policy to use in medical facilities' privileging
processes,
* enforce the requirement that medical facilities submit information on
paid VA medical malpractice claims to VA's Office of Medical-Legal
Affairs within 60 days after being notified that the claim is paid,
and:
* instruct medical facilities to establish internal controls to ensure
the accuracy of their privileging information.
Agency Comments and Our Evaluation:
In commenting on a draft of this report, VA agreed with our findings
and conclusions and concurred with our recommendations. VA also
provided an action plan to address the three recommendations. VA
acknowledged that we identify a challenge faced not only by VA
facilities, but by all health care facilities, to incorporate physician-
specific performance information into the credentialing and privileging
processes. In addition, VA recognized the need to improve facility
compliance with submitting information on paid VA medical malpractice
claims to the Office of Medical-Legal Affairs in a timely manner.
Further, VA agreed that internal controls are needed to ensure the
accuracy of information used to renew physicians' clinical privileges
and has begun the work necessary to establish these internal controls
at all VA facilities. VA also provided details of actions it plans to
take to implement the three recommendations in the draft report. VA's
written comments are reprinted in appendix II.
As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its date. We will then send copies of this report to the
Secretary of Veterans Affairs and other interested parties. We also
will make copies available to others upon request. In addition, the
report will be available at no charge at the GAO Web Site at Hyperlink,
http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7101 or ekstrandl@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff members who made major
contributions to this report are listed in appendix III.
Sincerely yours,
Signed by:
Laurie E. Ekstrand:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
To determine the extent to which selected Department of Veterans
Affairs' (VA) medical facilities complied with VA's credentialing and
privileging requirements, we reviewed policies, procedures, and
guidance on VA's credentialing and privileging processes. We also
interviewed the director of VA's credentialing and privileging program,
as well as officials responsible for credentialing and privileging at
the VA medical facilities we visited. We selected four credentialing
requirements for review because they are requirements that--unlike
others--address information about physicians that can change or be
updated with new information periodically. As a result, VA requires
that this information be verified by facility officials at least every
2 years. Other credentialing requirements, such as where a physician
attended medical school or previous employment history, are not subject
to change or updating and are required by VA to be verified when the
physician initially applies for employment. The four credentialing
requirements are:
1. verify that all state medical licenses held by physicians are valid;
2. query the Federation of State Medical Boards (FSMB) database to
determine whether physicians had disciplinary action taken against any
of their licenses, including expired licenses;
3. verify information provided by physicians on their involvement in
medical malpractice claims at a VA or non-VA medical facility;
and:
4. query the National Practitioner Data Bank (NPDB) to determine
whether a physician was reported to this data bank because of
involvement in VA or non-VA paid medical malpractice claims, display of
professional incompetence, or engagement in professional misconduct.
Of the privileging requirements in VA's credentialing and privileging
policy, we selected four requirements that VA identifies as general
privileging requirements. In addition, we selected another privileging
requirement about the use of individual performance information because
of its importance in the renewal of clinical privileges. The five VA
privileging requirements we selected are:
1. verify that all state medical licenses held by physicians are valid;
2. verify physicians' training and experience;
3. assess physicians' clinical competence and health status;
4. consider any information provided by a physician related to medical
malpractice allegations or paid claims, loss of medical staff
membership, loss or reduction of clinical privileges at a VA or non-VA
facility, or any challenges to a physician's state medical license;
and:
5. use information on a physician's performance when making decisions
about whether to renew the physician's clinical privileges.
Two of the five privileging requirements--verify all state medical
licenses and consider medical malpractice information--are also VA
credentialing requirements.
We conducted site visits to seven VA medical facilities that were
chosen based on size and geographic location. The medical facilities
selected for review were located in Boise, Idaho;
Kansas City, Missouri; Las Vegas, Nevada; Lexington, Kentucky;
Martinsburg, West Virginia; Miami, Florida; and San Antonio, Texas. For
each medical facility visited, we obtained from VA a list of physicians
and their specialties. Using this list, at each facility we randomly
selected 17 physicians and obtained files with their credentialing and
privileging information. Our sample included physicians working in VA
facilities full-time and part-time, through a contract, or without
direct compensation from VA. In some cases, these physicians also
worked at non-VA medical facilities. At each facility we visited, we
selected one file from the following clinical specialties that are
offered at most VA medical facilities: anesthesiology,
gastroenterology, neurology, oncology, ophthalmology orthopedics,
radiology, and urology. We also selected two physician files from
general surgery and internal medicine, and five files from physician
names that had no specialty identified on the list provided by VA. At
some facilities, we found that the physician specialty indicated on the
list provided by VA was incorrect. We replaced these files by random
selection with physician files in the specialty needed.
To determine whether the files we reviewed demonstrated compliance with
the selected VA credentialing requirements and privileging
requirements, we compared the documentation found in our sample files
against the credentialing and privileging requirements. During our site
visits, we reviewed the documentation in VetPro and in a physician's
paper copy credentialing file to determine whether the facility
complied with each of the four VA credentialing requirements that we
reviewed. If documentation was present either in VetPro or the paper
copy file, we determined that the medical facility complied with VA's
requirement. For each physician, we reviewed the three most recent
appointment cycles--the period from one appointment process to the next
appointment process, which occurs every 2 years. Some of the physicians
in our sample had not been through three appointment cycles. For those
physicians, we reviewed only the number of cycles that had been
completed. We documented our findings from these reviews on a data
collection instrument.
At each medical facility, we reviewed a physician's paper copy
privileging file to determine whether the physician's file contained
documentation that the medical facility met the five VA privileging
requirements we examined. For the fifth requirement--use of information
on a physician's performance when making decisions about whether to
renew physicians' clinical privileges--we also interviewed facility
officials, including the facility quality assurance manager, to
determine whether the facility collected this physician performance
information outside of the facility's quality assurance program. For
some physician files we reviewed, the physician had only been through
initial appointment and therefore did not have individual physician
performance information in the privileging file.
Based on the sample of physician files we reviewed at each of the seven
medical facilities, we can discuss a medical facility's compliance for
the physician files we reviewed; we cannot draw conclusions about the
remaining physician files at the medical facilities we visited or about
the compliance of other VA medical facilities. In collecting
information on the credentialing and privileging requirements from
physician files at each facility, we employed standard data collection
techniques to ensure the accuracy and reliability of the data used in
this report, such as interviewing medical facility officials about the
accuracy and timeliness of the information contained in the physician
files we reviewed and taking steps to have a consistent interpretation
of VA's credentialing and privileging requirements for the physician
files we reviewed at each medical facility.
To determine the extent to which the selected VA medical facilities
complied with a requirement to submit information on paid VA medical
malpractice claims, we obtained data from VA's Office of Medical-Legal
Affairs in Buffalo, New York to identify the VA medical facilities that
were delinquent--more than 60 days had passed since the facility was
notified that a claim had been paid--in submitting medical malpractice
claim information to this office.[Footnote 22] The data included the
name of the VA medical facility, the veteran who was named in the
claim, the date the Office of Medical-Legal Affairs was notified that a
claim had been paid, and the date the Office of Medical-Legal Affairs
notified the facility that a VA medical malpractice claim had been
paid. VA's Office of Medical-Legal Affairs determines whether a
physician who was involved in a VA medical malpractice claim delivered
substandard care to veterans, and if so, was reported to NPDB. We
interviewed officials at this office to obtain information about VA's
process and requirements for determining if substandard care was
delivered.
To determine whether VA has internal controls to help ensure the
accuracy of medical facility information that is used to renew
physicians' clinical privileges, we interviewed the director of VA's
credentialing and privileging program, as well as other VA officials.
We identified the internal controls VA has in place for its privileging
process and used GAO's standards for internal controls in the federal
government to determine whether these controls were adequate. During
our site visits, we determined if any of the seven medical facilities
had internal controls in place to help ensure the accuracy of the
information used to support the renewal of clinical privileges. We
conducted our work from July 2005 to May 2006 in accordance with
generally accepted government auditing standards.
[End of section]
Appendix II: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
May 12, 2006:
Ms. Laurie Ekstrand:
Director:
Health Care Team:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Ekstrand:
The Department of Veterans Affairs (VA) has reviewed your draft report,
VA HEALTH CARE: Selected Credentialing Requirements at Seven Medical
Facilities Met, but an Aspect of Privileging Process Needs Improvement
(GAO-06-648) and agrees with your findings and conclusions. VA also
concurs with your recommendations.
The Government Accountability Office's (GAO) report identifies a
challenge faced not only by VA facilities but by all health care
facilities: incorporating provider specific performance information
into the credentialing and privileging process. Since privileging is
performed at the facility level, a major focus of VA's approach to
ensuring compliance with our policies on this process has been and
continues to be providing education and information to medical facility
staff. VA also recognizes the need to improve compliance with VA policy
that requires medical facilities to submit any information on paid VA
medical malpractice claims to the Office of Medical-Legal Affairs
(OMLA) in a timely manner. OMLA will educate, monitor, and followup
with networks on the reporting process requirements. Additionally, OMLA
is implementing a new initiative to notify network directors of any
reporting delinquencies by facilities under their jurisdiction.
Finally, facilities will be required to establish internal controls to
ensure the accuracy of their privileging information. Network directors
will monitor compliance and report back to the Deputy Under Secretary
for Health for Operations and Management.
The enclosure details actions planned and taken to implement GAO's
recommendations. VA appreciates the opportunity to comment on your
draft report.
Sincerely yours,
R. James Nicholson:
Enclosure:
DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT VA HEALTH CARE: Selected
Credentialing Requirements at Seven Medical Facilities Met, but an
Aspect of Privileging Process Needs Improvement (GAO-06-648):
To better ensure that VA physicians are qualified to deliver care
safely to veterans, GAO recommends that the Secretary of Veterans
Affairs direct the Under Secretary for Health to take the following
three actions:
* provide guidance to medical facilities on how to collect individual
physician performance information in accordance with VA's credentialing
and privileging policy to use in medical facilities' privileging
process;
Concur - VA has developed and continues to refine methods to provide
education and information to medical facility staff to address this
recommendation. Presentations were made on provider-specific data at
the Office of Quality and Performance (OQP) and Employee Education
System (EES) co-sponsored VHA credentialing conference in July 2004 as
well as on a VHA national credentialing conference call sponsored by
the OQP in November 2004. Primarily, medical staff support specialists
attended both these conferences. Recognizing that this is an on-going
issue, the OQP is preparing a series of educational presentations to be
done via conference call with the medical facilities, and completed
this fiscal year. One module titled, "Provider Profiling and
Competency," gives a detailed description of the type of provider
specific information that is and is not acceptable for use in the
renewal of clinical privileges of medical staff. Attendance at these
educational conference calls will be taken and medical staff support
specialists will be encouraged to invite facility quality managers,
service chiefs, and other involved in the privileging process.
Additionally, the OQP is developing a request for proposal (RFP) for a
web-based training program for medical staff processes directed towards
the medical staff support specialists. One of the web-based training
modules defined in the RFP will be directed to all staff involved in
the reappraisal and privileging process incorporating provider
profiling, the use of provider specific performance information. This
RFP will be awarded this fiscal year with training modules developed
and delivered by April 1, 2007.
DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT VA HEALTH CARE: Selected
Credentialing Requirements at Seven Medical Facilities Met, but an
Aspect of Privileging Process Needs Improvement (GAO-06-648)
(Continued):
* enforce the requirement that medical facilities submit information on
paid VA medical malpractice claims to VA's Office of Medical-Legal
Affairs within 60 days after being notified that the claim is paid;
and:
Concur - To improve compliance with the above requirement, the Office
of Medical-Legal Affairs (OMLA) has instituted the plan below. This
plan will be communicated to the networks and medical facilities
through participation by the Director, OMLA in the network director and
chief medical officer (CMO) conference calls as well as by
electronically informing all VA medical center risk managers through
OMLA's "VA Med-Legal RM Contacts" listserve prior to June 1, 2006.
* For information not received within 60 days, the Director, OMLA will
notify the network director of the delinquency, and copy the facility
director on the notification.
* After 90 days, the Director, OMLA will notify the network director of
the delinquency, and copy the facility director and the Associate Chief
Patient Care Services (PCS) Officer on the notification.
* On a quarterly basis, beginning July 1, 2006, the OMLA will send to
the Associate Chief PCS Officer, a list of paid tort claims for which
the OMLA has not received the requested records and the date the
information was requested. Copies of pertinent correspondence will also
be included.
In addition, by June 1, 2006, the Deputy Under Secretary for Health for
Operations and Management (DUSHOM), will issue a memorandum to the
network directors outlining the new initiative of the OMLA and
reinforce that each medical center must comply with VA policy regarding
submitting information to the OMLA in a timely manner. The Director,
OMLA will also provide briefings to the chief medical officers and to
the medical center directors on their weekly call.
DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT VA HEALTH CARE: Selected
Credentialing Requirements at Seven Medical Facilities Met, but an
Aspect of Privileging Process Needs Improvement (GAO-06-648)
(Continued):
* instruct medical facilities to establish internal controls to ensure
the accuracy of their privileging information.
Concur - Internal controls at VA medical facilities have been discussed
several times on the OQP VHA credentialers' national conference call,
most recently during the April 4, 2006 call. Following that conference
call OQP sent an e-mail to the VHA credentialers' mail group describing
initiatives identified by various facility credentialing and
privileging staff to better ensure the accuracy of the provider
appointment paperwork and to track those on the medical staff who have
active privileges. In addition, the Chief OQP will issue a memorandum
by June 1, 2006, through the DUSHOM, to the network directors
indicating that each medical facility in the network must establish
internal controls and report back to the network that such controls
have been established. Examples of current internal controls used by
facilities will be provided so each facility can assess what internal
controls address the facility's needs. Network leadership will be
responsible for the continued monitoring of the use of internal
controls.
To further strengthen internal controls in the privileging process,
modifications to VetPro, delivered June 28, 2005, display the medical
staff appointment on the "Search" screen either as "Appointed" or
"Expired." This allows for a quick reference of the status of a
practitioner's appointment. Staff at the medical facilities continues
to be trained in using this as a tool that may assist the monitoring of
provider appointments and possibly be incorporated into the facility's
internal control process. Additionally, the VetPro design does not
allow appointments to exceed the 2 years VA policy allows. The need for
internal controls to ensure the accuracy and timeliness of the
privileging process will continue to be emphasized to VA staff and
leadership.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Laurie E. Ekstrand at (202) 512-7101 or ekstrandl@gao.gov:
Acknowledgments:
In addition to the contact named above Marcia A. Mann, Assistant
Director; Kelly Barar; Mary Ann Curran; Martha A. Fisher; and Krister
Friday made key contributions to this report.
[End of section]
Related GAO Products:
VA Health Care: Steps Taken to Improve Practitioner Screening, but
Facility Compliance with Screening Requirements Is Poor. GAO-06-544.
Washington, D.C.: May 25, 2006.
VA Health Care: Improved Screening of Practitioners Would Reduce Risk
to Veterans. GAO-04-566. Washington, D.C.: March 31, 2004.
VA Health Care: Veterans at Risk from Inconsistent Screening of
Practitioners. GAO-04-625T. Washington, D.C.: March 31, 2004.
FOOTNOTES
[1] We have performed other work related to this subject. See Related
GAO Products listed at the end of this report.
[2] Health care services could include, for example, surgical
procedures and administering anesthesia.
[3] Physicians' clinical privileges are also reviewed whenever a
physician requests that a health care service be added or removed from
the list of approved clinical privileges. This may occur before the 2-
year renewal period.
[4] Physicians may also possess credentials that VA does not require to
work in a VA facility, such as a Drug Enforcement Administration
certificate, which allows a physician practicing outside of a VA
facility to prescribe controlled substances. If a physician does have
these other credentials, then VA requires medical facility officials to
verify these credentials since they may change or be updated
periodically.
[5] VA medical facilities can contract with local or national companies
in order to obtain physician services.
[6] In this report, determinations of substandard care may also include
determinations of professional incompetence or professional misconduct.
[7] GAO, Internal Control Management and Evaluation Tool, GAO-01-1008G
(Washington, D.C.: August 2001).
[8] State licenses are issued by offices in states, territories, or the
District of Columbia, collectively referred to as state licensing
boards.
[9] NPDB includes information on medical malpractice claims that are
paid, but does not include information on ongoing claims.
[10] Clinical services may include surgery, medicine, and radiology.
[11] Reduction of privileges may include restricting or prohibiting a
physician from performing certain procedures or prescribing certain
medicines. Revocation of privileges refers to the permanent loss of all
clinical privileges at that facility.
[12] At some VA medical facilities, the professional standards board
and the medical executive committee represent the medical staff, have
the same members, and perform the same functions so are considered to
be one committee. If the committees are separate, the professional
standards board is generally comprised of three to five physician peers
and the medical executive committee is generally comprised of all
facility clinical service chiefs.
[13] Support granting clinical privileges means that the clinical
privileges previously held by the physician will be maintained as well
as adding newly requested clinical privileges.
[14] VA requires its medical facilities to have a quality assurance
program. In general, the VA quality assurance program consists of
specified systematic health care reviews carried out by or for VA for
the purpose of improving the quality of medical care or the utilization
of health care resources in VA facilities. See 38 C.F.R. § 17.500
(2005). These programs collect data on various clinical process and
outcome measures involving physicians and other types of practitioners.
The measures may include a surgeon's complication rate or a physician's
prescribing of medications. Medical facility officials use these
measures to look for undesirable patterns and trends in performance.
[15] 38 U.S.C. § 5705 (2000).
[16] See Department of Veterans Affairs, VHA Handbook 1100.19 (Mar. 6,
2001).
[17] VA medical facility officials may also perform primary source
verification of physicians' licenses by querying a state licensing
board's Web site for information on the licenses.
[18] At the time of our review, the remaining four VA facilities did
not have any medical malpractice claim information that had not been
submitted within VA's 60-day time frame.
[19] VA medical malpractice claims may involve physicians or another
type of licensed health care practitioner, such as a nurse.
[20] The panel must include at least one reviewer who is a member of
the profession of the practitioner under review.
[21] As of March 31, 2006, this medical facility had sent all
delinquent medical malpractice claims to VA's Office of Medical-Legal
Affairs.
[22] We considered claim information submitted 14 days after the 60-day
time frame to be on time, while information submitted 15 or more days
after the 60-day time frame, we considered to be delinquent. At the
time of our review, four of the seven facilities did not have any
medical malpractice claim information that had not been submitted
within VA's 60-day time frame.
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