VA Health Care
Improved Oversight and Compliance Needed for Physician Credentialing and Privileging Processes Gao ID: GAO-10-26 January 6, 2010VA has policies to ensure that physicians have appropriate qualifications and clinical abilities through the processes of credentialing, privileging, and continuous monitoring of performance. Results of a VA investigatory report in 2008 cited deficiencies in the Marion, Illinois, VA medical center's (VAMC) credentialing and privileging processes and oversight of its surgical program. This report examines VA's policies and guidance to help ensure that information about physician qualifications and performance is accurate and complete, VAMCs' compliance with selected VA credentialing and privileging policies, and their implementation of VA policies to continuously monitor performance. The Government Accountability Office (GAO) reviewed VA's policies, interviewed VA officials, and reviewed a judgmental sample of 30 credentialing and privileging files at each of six VAMCs that GAO visited. GAO selected the files to ensure inclusion of highly paid specialties, newly hired physicians, and other physician characteristics. GAO selected the judgmental sample of six VAMCs based on geographic balance and other factors.
VA's policies and guidance on credentialing, privileging, and continuous monitoring help ensure the collection of accurate and complete information about physician professional qualifications, clinical abilities, and clinical performance. These policies and guidance address or exceed relevant accreditation standards. Following events at the Marion VAMC, VA made policy changes to allow VAMCs to collect more complete and timely information on physician licensure, malpractice, and disciplinary actions. GAO did not find problems at the six VAMCs visited that mirrored the extent of those reported by investigators at the Marion VAMC. However, GAO found that VAMC staff did not consistently follow VA's credentialing and privileging policy requirements selected for review. GAO selected requirements that must be verified each time a physician goes through the credentialing process and must be recorded in VA's Web-based credentialing database. For example, 29 of the 180 credentialing and privileging files reviewed lacked proper verification of state medical licensure. In addition, the VAMCs did not identify instances when physicians appeared to have omitted required information on their applications. For example, GAO identified 21 files where required malpractice information was not disclosed by physicians and was not detected by VAMCs. GAO identified several of these cases in an external database of malpractice settlements and judgments that VAMCs should review. Finally, VA policies lacked sufficient internal controls, such as specifying how compliance should be assessed, to identify and correct problems with VAMCs' noncompliance with credentialing and privileging policies. The six VAMCs GAO visited also exhibited gaps in implementing VA policies and guidance to continuously monitor physician performance. All six VAMCs either failed to document the collection of physician performance information or collected data that were insufficient to adequately gauge performance. In addition, despite VA guidance, confusion over the proper usage of protected physician performance information persisted at the VAMCs GAO visited. Four of the six VAMCs inappropriately used protected information in privileging decisions--a violation of VA policy that may result in public disclosure and render some privileging decisions subject to challenge.
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-10-26, VA Health Care: Improved Oversight and Compliance Needed for Physician Credentialing and Privileging Processes
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Report to Congressional Addressees:
United States Government Accountability Office:
GAO:
January 2010:
VA Health Care:
Improved Oversight and Compliance Needed for Physician Credentialing
and Privileging Processes:
GAO-10-26:
GAO Highlights:
Highlights of GAO-10-26, a report to congressional addressees.
Why GAO Did This Study:
VA has policies to ensure that physicians have appropriate
qualifications and clinical abilities through the processes of
credentialing, privileging, and continuous monitoring of performance.
Results of a VA investigatory report in 2008 cited deficiencies in the
Marion, Illinois, VA medical center‘s (VAMC) credentialing and
privileging processes and oversight of its surgical program. This
report examines VA‘s policies and guidance to help ensure that
information about physician qualifications and performance is accurate
and complete, VAMCs‘ compliance with selected VA credentialing and
privileging policies, and their implementation of VA policies to
continuously monitor performance. GAO reviewed VA‘s policies,
interviewed VA officials, and reviewed a judgmental sample of 30
credentialing and privileging files at each of six VAMCs that GAO
visited. GAO selected the files to ensure inclusion of highly paid
specialties, newly hired physicians, and other physician
characteristics. GAO selected the judgmental sample of six VAMCs based
on geographic balance and other factors.
What GAO Found:
VA‘s policies and guidance on credentialing, privileging, and
continuous monitoring help ensure the collection of accurate and
complete information about physician professional qualifications,
clinical abilities, and clinical performance. These policies and
guidance address or exceed relevant accreditation standards. Following
events at the Marion VAMC, VA made policy changes to allow VAMCs to
collect more complete and timely information on physician licensure,
malpractice, and disciplinary actions.
GAO did not find problems at the six VAMCs visited that mirrored the
extent of those reported by investigators at the Marion VAMC. However,
GAO found that VAMC staff did not consistently follow VA‘s
credentialing and privileging policy requirements selected for review.
GAO selected requirements that must be verified each time a physician
goes through the credentialing process and must be recorded in VA‘s
Web-based credentialing database. For example, 29 of the 180
credentialing and privileging files reviewed lacked proper
verification of state medical licensure. In addition, the VAMCs did
not identify instances when physicians appeared to have omitted
required information on their applications. For example, GAO
identified 21 files where required malpractice information was not
disclosed by physicians and was not detected by VAMCs. GAO identified
several of these cases in an external database of malpractice
settlements and judgments that VAMCs should review. Finally, VA
policies lacked sufficient internal controls, such as specifying how
compliance should be assessed, to identify and correct problems with
VAMCs‘ noncompliance with credentialing and privileging policies.
Table: Compliance with Credentialing and Privileging Requirements at
Six VAMCs:
Proper verification of information provided by physicians:
Type of information: State medical licenses;
Files with proper verification: 151;
Files lacking proper verification: 29;
Total files reviewed: 180.
Type of information: Malpractice;
Files with proper verification: 52;
Files lacking proper verification: 38;
Total files reviewed: 90.
Identification of nondisclosures on physician applications:
Type of information: State medical licenses;
Apparent disclosure: 168;
Evidence of nondisclosure: 12;
Total files reviewed: 180.
Type of information: Malpractice;
Apparent disclosure: 159;
Evidence of nondisclosure: 21;
Total files reviewed: 180.
Source: GAO analysis of documentation in VAMCs‘ credentialing and
privileging files.
Note: Only 90 of 180 physicians reported a malpractice allegation or
claim.
[End of table]
The six VAMCs GAO visited also exhibited gaps in implementing VA
policies and guidance to continuously monitor physician performance.
All six VAMCs either failed to document the collection of physician
performance information or collected data that were insufficient to
adequately gauge performance. In addition, despite VA guidance,
confusion over the proper usage of protected physician performance
information persisted at the VAMCs GAO visited. Four of the six VAMCs
inappropriately used protected information in privileging decisions”a
violation of VA policy that may result in public disclosure and render
some privileging decisions subject to challenge.
What GAO Recommends:
GAO recommends that VA develop a formal mechanism to systematically
review VAMC credentialing and privileging files and performance
monitoring for compliance with VA policies. VA agreed with GAO‘s
findings and recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-10-26] or key
components. For more information, contact Randall B. Williamson at
(202) 512-7114 or williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
VA's Policies and Guidance Help Ensure Accurate Information on
Physician Qualifications, but One Policy May Not Be an Effective Use
of Resources:
Credentialing and Privileging at Selected VAMCs Lacks Consistent
Compliance with VA Policy, Clear Documentation in VetPro, and
Comprehensive Oversight by VISN Officials:
Gaps in Continuous Monitoring of Physician Performance Existed at
Selected VAMCs and Officials Continued to Use Performance Information
Inappropriately:
VA Has Begun to Implement Its Plan to Improve Oversight for VAMC
Surgical Programs by Creating Resource Standards for Surgical
Procedures:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Selected Joint Commission Standards, and Corresponding VA
Policies, for Physician Credentialing:
Table 2: Selected Joint Commission Standards and Corresponding VA
Policy and Guidance for Continuous Monitoring of Physician Performance:
Table 3: Compliance with Selected VA Documentation Requirements Used
for Physician Credentialing and Privileging at Six VA Medical Centers
(VAMC):
Table 4: Identification of Compliance with VA Policy Regarding
Physician Disclosure of Information Prior to Service Chief
Recommendation at Six VA Medical Centers (VAMC):
Table 5: Service Chief Compliance with VA Documentation Policies for
Reprivileging Recommendations at Six VA Medical Centers (VAMC):
Table 6: Service Documentation of Compliance with Continuous
Monitoring of Physician Performance at Six VA Medical Centers (VAMC):
Table 7: Factors of Clinical Performance Included in Continuous
Monitoring at Six VA Medical Centers (VAMC), by Service:
Table 8: Steps in VA's Plan to Implement the Operative Complexity and
Infrastructure Standards Workgroup's Recommendations Regarding
Surgical Resource Standards:
Figures:
Figure 1: Select VA Organization, Roles, and Responsibilities:
Figure 2: Illustration of How VetPro Displays Summary Information:
Abbreviations:
ACOS: associate chief of staff:
CMO: chief medical officer:
FPPE: Focused Professional Practice Evaluation:
FSMB: Federation of State Medical Boards:
NPDB: National Practitioner Data Bank:
NSQIP: National Surgical Quality Improvement Program:
OIG: Office of Inspector General:
OPPE: On-Going Professional Practice Evaluation:
VA: Department of Veterans Affairs:
VAMC: Department of Veterans Affairs medical center:
VISN: Veterans Integrated Service Network:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
January 6, 2010:
Congressional Addressees:
To help ensure the quality of care provided by its approximately
36,000 physicians, the Department of Veterans Affairs (VA) requires
each VA medical center (VAMC) to take specific steps to determine
whether physicians have the appropriate professional qualifications
and clinical abilities to care for VA's patients. This begins with the
processes of credentialing and privileging before physicians are
appointed to a VAMC's medical staff. During the credentialing process,
VAMC staff collect and review information such as a physician's
professional training, malpractice history, peer references, and other
components of professional background to determine whether physicians
have suitable abilities and experience for appointment to a VAMC's
medical staff. During the privileging process, VAMCs determine which
health care services--known as clinical privileges--the physician
should be allowed to provide. After a physician is hired, the
credentialing and privileging processes are repeated at least every 2
years.[Footnote 1] VA also requires that VAMCs monitor physicians'
clinical performance through the collection and analysis of physician-
specific clinical performance information. VA requires that VAMCs
assess this clinical performance information to evaluate physicians'
clinical competence as they reevaluate physicians' lists of privileges
during the reprivileging process.
Patient deaths between October 2006 and March 2007 at the VAMC in
Marion, Illinois, prompted an investigation by the VA Office of
Inspector General (OIG) into the VAMC's processes for monitoring
physician quality. The Marion VAMC had experienced a number of deaths
after surgical procedures; specifically, VA's surgical quality
monitoring program reported that seven patients died out of 180
surgical cases between October and December 2006. This mortality rate
was more than four times greater than expected when considering the
patients' physical conditions prior to surgery. The VA OIG issued a
report in January 2008 that identified deficiencies at the facility
related to credentialing and privileging of physicians and the process
of monitoring surgical care.[Footnote 2] For example, the VA OIG found
multiple instances where physicians had privileges to perform
procedures without evidence of competence to perform the procedures,
and that the surgical program was expanded to include complex surgical
procedures even though sufficient clinical support services, such as
24-hour respiratory therapy, pharmacy, and radiology, were not
available at the VAMC. Marion VAMC officials also failed to adequately
address information that a surgeon entered into a voluntary agreement
with one state medical board to stop practicing medicine in that
state.[Footnote 3] The VA OIG recommended that VA make several
improvements to its credentialing and privileging processes, and
implement an oversight mechanism to ensure that appropriate clinical
support services are available for all surgical procedures performed
at VAMCs.
We have also reported on problems with VA's process for evaluating
physician performance. In May 2006, we found that six of seven VAMCs
we visited had problems complying with a privileging requirement
[Footnote 4] because officials inappropriately used protected
physician performance information collected through the facility's
quality management program when renewing clinical privileges.[Footnote
5] This is prohibited under VA policy because information collected as
part of a facility's quality management program is protected to
encourage physicians to report and discuss adverse events without fear
of punitive action. We recommended that VA provide guidance to its
VAMCs on how to collect physician performance information that can be
used to renew clinical privileges in accordance with VA's policy. In
November 2007, we testified that VA had implemented our recommendation
to provide VAMCs with additional guidance on how to collect
performance information, but that we did not know the extent of
compliance at VAMCs.[Footnote 6]
Based on events at the Marion VAMC, questions have been raised about
physician credentialing and privileging processes at VAMCs and whether
VAMCs are performing surgical procedures that are adequately supported
by the capabilities of the clinical support services. Explanatory
material accompanying the fiscal year 2008 appropriation directed that
we assess VA facilities' compliance with credentialing and privileging
standards.[Footnote 7] In this report we assess (1) the policies and
guidance VA has in place to help ensure that information about
physician professional qualifications, clinical abilities, and
clinical performance is accurate and complete; (2) the extent to which
selected VAMCs comply with selected VA credentialing and privileging
policies for physicians, and the extent to which VA helps ensure
compliance; (3) the extent to which selected VAMCs have implemented VA
policies and guidance to continuously monitor physician performance;
and (4) the extent to which VA has oversight mechanisms in place to
track that VAMCs are performing surgical procedures that match their
capabilities.
To determine the policies and guidance VA has in place to help ensure
that information about physician professional qualifications, clinical
abilities, and clinical performance is accurate and complete, we
reviewed VA policies and guidance on credentialing and privileging and
monitoring of physician performance, and interviewed VA headquarters
officials, including the Director, Credentialing and Privileging, who
is responsible for VA credentialing and privileging policy. We
reviewed 2008 credentialing and privileging accreditation standards
issued by The Joint Commission ("Joint Commission"), a nonprofit
organization that evaluates and accredits more than 16,000 health care
organizations in the United States, including hospitals. Because state
medical boards are responsible for the licensure and discipline of
physicians, we also conducted a Web-based survey of medical boards in
all 50 states and the District of Columbia in order to obtain
information on the policy of each medical board related to the
disclosure of physician licensure information.[Footnote 8] We opened
the survey on March 19, 2009, and closed it on April 9, 2009, with a
final response rate of 76 percent.
To determine the extent to which selected VAMCs comply with selected
VA credentialing and privileging policies, we visited six VAMCs and
reviewed credentialing and privileging files for a judgmental sample
of 30 physicians at each VAMC, a total of 180 physician files. For
each physician file, we examined credentialing and privileging
documentation for compliance with selected VA policies. We reviewed
four credentialing and privileging requirements about proper
documentation: verification of all state medical licenses ever held by
a physician, verification of malpractice claims, receipt of the
minimum number of references, and queries to an external database
about disciplinary actions taken against physician licenses. We also
reviewed whether VAMCs reprivileged physicians within 2 years of the
previous privileging process, as required by VA policy. We looked for
evidence of omissions by physician applicants related to medical
licenses and malpractice, as well as gaps in background greater than
30 days. We also looked for documentation by physician service chiefs--
officials responsible for physicians providing particular clinical
services--of the rationale for credentialing and privileging
recommendations for physicians as is required by VA policy. In
addition, we interviewed staff responsible for verifying physician-
supplied information and staff responsible for recommending physician
appointments or privileges.
We visited the following VAMCs: Alexandria VAMC (Pineville,
Louisiana); Edward Hines, Jr. VA Hospital (Hines, Illinois); Lebanon
VAMC (Lebanon, Pennsylvania); Hunter Holmes McGuire VAMC (Richmond,
Virginia); Togus VAMC (Augusta, Maine); and VA Montana Health Care
System (Fort Harrison, Montana). We chose these VAMCs based on a
variety of factors, including location in metropolitan and
nonmetropolitan areas and geographic balance. We conducted the site
visits between August 2008 and February 2009. On the basis of the
sample of credentialing and privileging files we reviewed at each of
the six VAMCs, we can discuss a facility's documented compliance for
the physician files we reviewed; we cannot draw conclusions about the
remaining physician files at the VAMCs we visited or about the
compliance of other VAMCs.
To determine the extent to which VA helps ensure compliance with its
credentialing and privileging policies, we reviewed VA policies and
GAO internal control standards to determine criteria for management
oversight.[Footnote 9] To obtain information about the processes in
place to oversee compliance, we interviewed officials at each of the
six Veterans Integrated Service Networks (VISN) where we conducted a
VAMC site visit.[Footnote 10] We also reviewed documents describing
the criteria VISNs use to evaluate facilities' credentialing and
privileging processes. We analyzed how VetPro, VA's Web-based
credentialing database, displays information for users and analyzed
the information that physicians are asked to input directly into
VetPro. The information from our site visits cannot be used to make
generalizations about practices at all VAMCs, and the information from
our interviews with VISN officials cannot be used to generalize about
VISN-level oversight. Because our credentialing and privileging file
review included reviewing information in VetPro, we also assessed the
database's reliability. To do this, we examined relevant documentation
and interviewed VA headquarters officials about measures VA takes to
ensure the reliability of information in VetPro. On the basis of our
review, we determined that the information in VetPro was sufficiently
reliable for the purposes of our report.
To determine the extent to which selected VAMCs implemented VA
policies and guidance to continuously monitor physician performance,
we reviewed VA policies and guidance relating to credentialing and
privileging. We interviewed VA headquarters officials and officials in
the six VISNs that include the VAMCs we visited. To evaluate VAMC
implementation of VA policies and guidance pertaining to physician
performance monitoring, we interviewed physician service chiefs at
each VAMC we visited about efforts to monitor physician performance.
Finally, at each VAMC we collected documents demonstrating how
continuous monitoring of physician performance was conducted. To
determine the possible effects of the inappropriate use of physician
performance information, we reviewed federal law and interviewed VA
general counsel staff. The information from our site visits cannot be
used to generalize about all monitoring practices at the selected
VAMCs, or about the practices at all VAMCs.
To examine the extent to which VA has oversight mechanisms in place to
track that VAMCs are performing surgical procedures that match their
capabilities, we reviewed VA policies. To obtain information on VA's
plans for implementing an oversight mechanism for VAMCs' surgical
programs, we reviewed the work of VA's Operative Complexity and
Infrastructure Standards Workgroup and conducted a series of
interviews with VA headquarters officials. While on site visits at the
selected VAMCs, we conducted interviews with chiefs of surgery, and
after the site visits, we conducted follow-up interviews to obtain
information on the facility-level implementation of the National
Surgical Quality Improvement Program (NSQIP)--which is VA's noncardiac
surgical quality monitoring program--and other VAMC reviews of
surgical program quality. We also reviewed copies of facility-level
NSQIP reports, NSQIP training materials, and articles on NSQIP in peer-
reviewed journals. The information we obtained through our site visits
and interviews with chiefs of surgery cannot be generalized to all
VAMCs.
Further details on our scope and methodology can be found in appendix
I. We conducted this performance audit from July 2008 through January
2010 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Background:
VA Organization, Roles, and Responsibilities:
VA provides health care services at 153 VAMCs, which are grouped by
region into 21 VISNs. Responsibilities for physician credentialing,
privileging, and continuous monitoring of physician performance exist
in all three levels of VA: VA headquarters, VISNs, and VAMCs. (See
figure 1.)
Figure 1: Select VA Organization, Roles, and Responsibilities:
[Refer to PDF for image: illustration]
VA headquarters:
Headquarters offices are responsible for efforts to ensure quality of
care, for Veterans Integrated Service Network (VISN) oversight, and
for the creation of policy.
Under Secretary for Health:
* Deputy Under Secretary for Health for Operations and Management;
* Office of Quality and Performance.
Veterans Integrated Service Networks (VISN):
There are 21 VISNs, organized by region, and each VISN is responsible
for managing and overseeing facilities located within its region.
* VISN Director;
* VISN Chief Medical Officer.
VA medical centers (VAMC):
Each VAMC is responsible for implementing the credentialing,
privileging, and physician monitoring processes consistent with VA
policy. This figure generally describes the organization of the six
VAMCs we visited.
VAMC Director;
* Chief of Staff;
- Credentialer;
* Chief of Medicine;
* Chief of Mental Health;
* Chief of Surgery;
* Other Physician Service Chiefs.
Source: GAO analysis of VA documents and interviews with VAMC
officials.
[End of figure]
VA headquarters develops VA-wide policies and oversight approaches for
the VISNs to execute. The Office of Quality and Performance is
responsible, at the direction of the Under Secretary for Health, for
overseeing VA-wide credentialing and privileging policy, which
includes requirements for the continuous monitoring of physician
performance. The Deputy Under Secretary for Health for Operations and
Management is responsible for assuring that all 21 VISNs implement a
credentialing and privileging process at each VAMC consistent with VA
policy. Each VISN has a VISN director, who reports to the Deputy Under
Secretary for Health for Operations and Management, and a VISN chief
medical officer (CMO), who reports to the VISN director. The VISN CMO
is responsible for the oversight of the credentialing and privileging
process of VAMCs in the VISN. Within each VAMC, the VAMC director has
the ultimate responsibility for physician credentialing and
privileging at the facility. The chief of staff is the highest ranking
medical officer in the VAMC, and is responsible for the quality of
clinical care provided at the facility, including maintaining the
credentialing and privileging process. VAMCs are generally organized
by clinical service. The six VAMCs that we visited were divided into
services--such as medicine, mental health, and surgery--which provide
specialized health care services.[Footnote 11] Services are led by
physician service chiefs, who are responsible for the physicians
within the service, including monitoring the quality of care being
delivered to patients by physicians in the service. Generally, service
chiefs report to the chief of staff.
Credentialing and Privileging Processes:
Initial credentialing and privileging for physicians occurs before
physicians are permitted to practice medicine at a VAMC. VA policy
requires physician applicants to enter information about medical
licensure, board certification, and other relevant credentials into
VetPro. Applicants also complete requests for privileges which
describe the specific health care services that they would like to
provide. Once the required credentialing information is provided by
the physician, an employee of the VAMC--usually a credentialer--
collects documentation from the original source for each credential,
in order to confirm the factual accuracy of the physician-provided
information. For example, the credentialer would typically contact
medical schools and medical residency programs to confirm dates of
participation and program completion by the physician. This is
referred to as primary source verification. New physician applicants
must also provide three professional references. These references must
provide specific information about physicians' scope of practice and
clinical performance.[Footnote 12]
Service chiefs must review this information about a physician's
professional training and experience, as well as input from
references, before determining whether to recommend both the
physician's appointment to the VAMC medical staff and the appropriate
clinical privileges. VA requires its physicians to possess at least
one full, active, current, and unrestricted license to practice
medicine. VA also prohibits the employment of physicians who have or
have had more than one license and had any license terminated, or
voluntarily relinquished any license after written notification by the
state of possible termination, for reasons of substandard care,
professional misconduct, or professional incompetence, unless such
license is fully restored. Service chiefs are expected to review
applicants' files to identify inconsistencies or omissions in
information and then require physicians to enter the omitted
information. For physicians going through the reappointment and
reprivileging processes, service chiefs also must review and consider
physician-specific clinical information collected at the VAMC that is
related to professional performance, judgment, or clinical or
technical competence.
Service chiefs' recommendations for both new applicants and
reappointments are considered by a committee of VAMC physicians who
forward medical staff appointment and privileging recommendations to
the VAMC director, who is the final approving official. Appointments
and privileges are typically granted for 2 years, and VAMCs must
reappoint physicians and renew their privileges at least every 2 years.
Continuous Monitoring of Physician Performance:
VA requires VAMCs to continuously monitor the performance of
physicians providing care at VAMCs. Continuous monitoring allows VAMCs
to identify professional practice trends that impact the provision of
high-quality patient care. While continuous monitoring can take many
forms, VA requires that during the reprivileging process, service
chiefs consider such factors as procedure volume, complication rates,
and comparison of physician-specific data with aggregate data of
physicians holding comparable privileges when available. Service
documentation of continuous monitoring is kept in individual physician-
specific performance profiles. A physician's performance profile can
be used by the service chief to assess the physician's performance at
the time of reprivileging. Monitoring of physician performance
includes On-Going Professional Practice Evaluations (OPPE), which are
a way to document and evaluate physician performance using available
data.
One other specific type of continuous monitoring is Focused
Professional Practice Evaluations (FPPE). The FPPE is a process where
the VAMC evaluates the privilege-specific competence of a physician
who does not have documented evidence of competently performing the
privilege requested at the VAMC. VAMCs must consider performing FPPEs
at initial appointment or when granting new privileges. FPPEs may also
be used if a question arises about a physician's ability to provide
safe, high-quality patient care. FPPEs can take a number of forms,
including direct observation of physician skills or periodic chart
reviews. VAMC officials must specify the evaluation criteria to be
used prior to performing the FPPE.
National Surgical Quality Improvement Program (NSQIP):
NSQIP collects data on selected surgical procedures performed by each
VA facility and the outcomes within 30 days of those procedures.
[Footnote 13] The NSQIP analysis uses risk adjustment to control for
patient risk factors that might affect surgical outcomes by estimating
the expected number of deaths and complications. By comparing these
estimates to the actual number of deaths and complications the
facilities experienced, VA can assess the quality of surgical care at
each VAMC. NSQIP uses statistical estimates to determine if facilities
are outliers when they have higher than expected numbers of deaths and
complications within 30 days of a sample of surgeries, given known
patient risk factors. These outlier VAMCs must evaluate all deaths
that occurred during the reporting period.[Footnote 14] If the VAMC is
an outlier for two consecutive reporting periods, a VA surgical site
visit team is sent to evaluate the VAMC's surgical program. Between
1991 and the end of fiscal year 2004, deaths within 30 days of major
surgery in the VA decreased by 37 percent, and complications decreased
by 42 percent.[Footnote 15]
VA's Policies and Guidance Help Ensure Accurate Information on
Physician Qualifications, but One Policy May Not Be an Effective Use
of Resources:
VA's policies and guidance on credentialing, privileging, and
continuous monitoring help ensure the collection of accurate and
complete information about physician professional qualifications,
clinical abilities, and clinical performance. Following events at the
Marion VAMC, VA made several policy changes to allow VAMCs to collect
more complete and timely information on physician licensure,
malpractice, and disciplinary actions. However, VA's new policy
requiring facilities to obtain written verification of licensure
information from state medical boards--which previously could be
obtained by telephone or through a state medical board's Web site--may
not be an effective use of VA resources.
VA Policies and Guidance on Credentialing, Privileging, and Continuous
Monitoring Address or Exceed Joint Commission's Accreditation
Standards:
VA's policies on credentialing address relevant Joint Commission
standards. (See table 1.) For example, the Joint Commission requires
that facilities verify a physician's education and relevant training.
Correspondingly, VA's policy states that each VAMC must verify
information about medical school graduation, residencies, and
fellowships.
Table 1: Selected Joint Commission Standards, and Corresponding VA
Policies, for Physician Credentialing:
Licensure:
Joint Commission standard[A]: Verify current physician licensure with
the relevant state medical board(s) at specified times, including when
the license expires;
VA policy: Verify with the state medical board(s) all licenses
currently or previously held that are disclosed by the physician at
appointment, reappointment, and upon lapsing.
Education, training, and experience:
Joint Commission standard[A]: Verify education and relevant training;
VA policy: Verify information about medical school graduation,
residencies, fellowships, and board certification. Physician must
disclose information on all education, training, and employment
experience, including all gaps greater than 30 days.
Malpractice history and adverse actions against licensure, medical
staff membership, and clinical privileges:
Joint Commission standard[A]: Evaluate any evidence of an unusual
pattern or number of malpractice judgments;
VA policy: Efforts must be made to obtain primary source verification
of the issues and facts related to physician involvement in any
administrative, professional, or judicial proceedings in which
malpractice is or was alleged. Documentation must include a statement
of adjudication by an insurance company, court of jurisdiction, or
attorney's statement of claim status. Unsuccessful good faith efforts
to obtain this information must be documented. The facility must
document evaluation of the facts of malpractice case resolution. VA
policy sets specific thresholds for additional review. A VA chief
medical officer, who is responsible for oversight of the credentialing
and privileging processes of the facilities within the region, must
review, to ensure the appointment is appropriate, of each physician
with (1) three payments made, (2) two payments totaling $1 million or
more, or (3) one payment of at least $550,000.
Joint Commission standard[A]: Query the National Practitioner Data
Bank (NPDB)[B] at specified times, including before granting new
privileges;
VA policy: Enroll the physician in NPDB's Proactive Disclosure Service
through VetPro, VA's Web-based credentialing database, before initial
appointment, and renew enrollment annually. This service provides
alerts to the facility any time new information about a physician is
entered into NPDB. Reports from the service are to be verified, and VA
medical centers (VAMC) must document evaluation of the facts of the
report.
Joint Commission standard[A]: Evaluate challenges to, and voluntary
and involuntary relinquishment of, licensure;
VA policy: Obtain disciplinary information prior to initial
appointment through screening the physician, using VetPro, through the
Federation of State Medical Boards (FSMB)[C] Disciplinary Alerts
Service that provides alerts to VA headquarters when a state medical
board reports an action against a license. Within 30 days after
receiving notice of an alert from VA headquarters, VAMC officials must
document primary source verification of the action and review of this
information to determine the impact on the physician's continued
ability to practice within the scope of granted clinical privileges.
Joint Commission standard[A]: Evaluate voluntary or involuntary
termination of medical staff membership and reductions, limitations,
or loss of privileges;
VA policy: Verify any voluntary or involuntary termination of medical
staff membership and loss of, or adverse action against, privileges.
Sources: GAO analysis of 2008 Joint Commission standards and 2008 VA
policy.
[A] Joint Commission standards related to malpractice history and
adverse actions against licensure, medical staff membership, and
clinical privileges are privileging standards. VA policy, however,
classifies them as credentialing standards.
[B] The NPDB is administered by the U.S. Department of Health and
Human Services and includes information on physicians who either have
been disciplined by a state medical board, professional society, or
health care provider or have been named in a medical malpractice
settlement or judgment.
[C] The FSMB is a national organization representing U.S. state and
territory medical boards, as well as the District of Columbia, and 14
state boards of osteopathic medicine. The FSMB maintains a central
repository which includes board-reported information on disciplinary
actions taken against medical licenses.
[End of table]
In addition, VA's credentialing policies include requirements that are
not included in the Joint Commission's standards. For example, Joint
Commission standards require verification of a physician's current
state medical licenses, while VA policy requires verification of both
current and past licenses. VA also requires physicians to disclose and
explain gaps in education, training, and employment greater than 30
days, while the Joint Commission standards contain no such requirement.
VA's privileging policies and guidance also address Joint Commission's
standards. The Joint Commission requires facilities to consider,
during the privileging process, a physician's credentials, such as
licensure and training. The standards also require consideration of
peer references that include information related to clinical
performance, as well as information, when available, on a physician's
clinical performance compared to aggregate data. Correspondingly, for
privileging, VA policy states that VAMCs must consider physician
credentials, attempt to obtain verification of the privileges the
physician currently holds or most recently held at other institutions,
and review three professional references. References need to contain
information about the applicant's medical knowledge, technical skills,
and clinical judgment. For reprivileging, VA requires that VAMCs
review two peer references and consider the physician's clinical
performance at the VAMC, using data such as complication rates. Each
physician's performance must be compared to aggregate data for
physicians with the same or comparable privileges, if available. In
December 2008, VA provided guidance to VAMCs that included specific
types of information that may be used in reprivileging, such as
infection rates.
Finally, VA's policies and guidance on continuous monitoring of
clinical performance also address the Joint Commission's standards, as
described in table 2. In particular, the Joint Commission described in
its 2008 standards how facilities should collect data for OPPEs and
FPPEs. VA's 2008 guidance described how VAMCs should implement these
processes.
Table 2: Selected Joint Commission Standards and Corresponding VA
Policy and Guidance for Continuous Monitoring of Physician Performance:
On-going Professional Practice Evaluations (OPPE):
Joint Commission standard: Facilities must have a clearly defined
process in place for OPPEs. Facilities may evaluate performance using
data such as procedures, outcomes, and length of patient stay in the
facility;
VA policy and guidance: VA guidance states that OPPEs should be
conducted twice a year to comply with Joint Commission standards.
Focused Professional Practice Evaluations (FPPE):
Joint Commission standard: Facilities must implement a process to
evaluate the privilege-specific competence of physicians who do not
have documented evidence of competently performing a requested
privilege at the facility. This process may also be used when a
question arises regarding a currently privileged physician's ability
to provide safe, high-quality, patient care. Facilities must develop
criteria, such as evidence of a clinical performance trend that would
trigger an FPPE of a physician;
VA policy and guidance: VA policy states that VA medical centers must
have a process in place to evaluate the privilege-specific competence
of a physician who does not have documented evidence of competently
performing a requested privilege. Consideration for FPPEs is to occur
at the time of initial appointment or when granting new privileges.
FPPEs may also be used if a question arises regarding a physician's
ability to provide safe, high-quality patient care.
Sources: GAO analysis of 2008 Joint Commission standards and 2008 VA
policy and guidance.
[End of table]
When implemented by VAMCs, VA policies for credentialing, privileging,
and continuous monitoring help ensure that facilities can identify
physicians with insufficient or falsified credentials or questionable
clinical performance. The VA OIG report on the events at the Marion
VAMC identified several deficiencies in the facility's credentialing
and privileging processes that were related to failures--largely on
the part of the VAMC's medical leadership--to comply with VA policies
for credentialing and privileging physicians.
VA Has Changed Policies to Obtain More Complete and Timely Information
about Physician Licensure, Malpractice, and Disciplinary Actions:
Since events at the Marion VAMC, VA has made two changes to its
policies for verifying information about physician credentials. First,
for licensure, VA began using a new service from FSMB that reports all
states where a physician has ever held a license.[Footnote 16] When
VAMCs screen a physician through FSMB, the VAMCs will receive this
report, which they can use to identify state medical licenses not
disclosed by the physician. VA began receiving this service in summer
2008, according to a VA official. VA told us that it has verbally
instructed facilities to verify any discrepancies between the FSMB
report and what the physician has disclosed, and VA policy requires
follow up of any discrepancies found during the verification process.
Second, also included in VA's 2008 policy is a requirement for
facilities to enroll physicians, through VetPro, at initial
appointment in the National Practitioner Data Bank's (NPDB) Proactive
Disclosure Service, and renew enrollment annually.[Footnote 17] This
service provides alerts to VA headquarters any time new information
about a physician is entered into NPDB. Previously, VAMCs obtained new
information from NPDB only when the database was queried every 2 years
after initial appointment or when a physician requested new
privileges. This policy allows VAMCs to obtain more timely information
about malpractice and disciplinary actions than under the previous
policy.
According to VA headquarters officials, in response to events at
Marion VAMC, the November 2008 policy included a new requirement for
VISN oversight of physicians who have unusually high numbers or
amounts of malpractice payments. In cases where a physician has three
malpractice payments, two payments that total $1 million or more, or
one payment equal to or over $550,000, the VISN CMO must review the
physician's appointment to ensure that the appointment is appropriate.
VA Issued a New Requirement for Written Licensure Verification, but It
May Not Be an Effective Use of Resources:
VA's November 2008 policy included a new requirement for VAMCs to
request written verification of state medical licensure, but we found
that this may not be an effective use of facility resources.
Previously, other means of verification--such as telephone
verification or using a state medical board's Web site--were permitted
without a requirement for written verification.[Footnote 18] According
to VA's Director, Credentialing and Privileging, the policy change is
intended to enhance VA's ability to obtain information from state
medical boards about pending board actions against a physician's
license, disciplinary actions under consideration, or open
investigations. VA has implemented this policy to require that VAMCs'
requests to the state medical boards include a waiver, signed by the
physician as a condition of appointment, authorizing the boards to
release this information about pending or ongoing actions. However,
FSMB officials told us that state medical boards, citing state laws or
policies, may not disclose this information even with a waiver.
The results of our state medical board survey confirmed that state
medical boards frequently will not provide information on pending or
ongoing actions, even with a signed waiver. Of the 50 states and
District of Columbia that received the survey, 39 responded (76
percent). Twenty-six states (66 percent of those that responded)
reported that they would not provide information about pending board
actions against a physician's license, disciplinary actions under
investigation, or open investigations. Of the 26 states that said that
they would not provide this information, most (22) cited state law as
the reason. While 13 of the 26 states would provide written
verification of licensure and final actions against licensure, they
would charge a fee for VA to obtain this information. Of the 12 states
that listed a specific fee, the average fee was $20, with 1 state
charging $50. Thirteen of the 39 states responded that they would
provide information about pending board actions against a physician's
license, disciplinary actions under investigation, or open
investigations. However, 2 of these states reported that they would
provide only information that is already publicly available, and 1
state's response was not clear as to whether it would actually
disclose the relevant information. Therefore, VA's current policy may
require VAMCs to expend resources to obtain information about final
actions taken against licensure that is not likely to exceed what is
currently available at no cost. A VA headquarters official told us
that VA is aware that state medical boards may not disclose this
information. VA planned in October 2009 to send each board a letter
asking them whether they will release the information if provided a
signed waiver by the physician.
Credentialing and Privileging at Selected VAMCs Lacks Consistent
Compliance with VA Policy, Clear Documentation in VetPro, and
Comprehensive Oversight by VISN Officials:
At the six VAMCs we visited, we found that VAMC staff did not
consistently follow VA's credentialing and privileging policies.
Credentialers sometimes did not comply with requirements to verify
physician information such as state medical licenses and prior
malpractice claims. Service chiefs did not always adequately review
the information submitted by physicians in order to identify whether
required information had been omitted by physicians. In addition, we
found weaknesses in VetPro's display of summary information and the
wording of questions for physicians, which could inhibit service
chiefs' ability to evaluate physician qualifications. Finally, VA
policies lacked specificity in describing the monitoring activities
that are expected to oversee VAMCs' compliance with credentialing and
privileging policies.
Some VAMC Credentialing and Privileging Files Were Missing Information
Necessary to Determine Whether Physicians Were Adequately Qualified:
Across the six VAMCs we visited, we found inconsistent compliance by
credentialers with verifying required credentialing and privileging
information we selected for review.[Footnote 19] This credentialing
information is necessary to evaluate the qualifications and
credentials of physicians, and the privileging information is
necessary to determine which health care services physicians should be
permitted to independently practice within the facility. The four
credentialing and privileging documentation requirements we reviewed
for compliance were: (1) verification of all state medical licenses
ever held by a physician; (2) verification of malpractice claims; (3)
queries to FSMB about disciplinary actions taken against a physician's
license; and (4) receipt of the required number of references.
Noncompliance with documentation of medical license verification and
malpractice verification accounted for most of the instances where VA
policy was not followed. Table 3 summarizes compliance with VA
policies of the 30 physician files we reviewed at each VAMC.
Table 3: Compliance with Selected VA Documentation Requirements Used
for Physician Credentialing and Privileging at Six VA Medical Centers
(VAMC):
VAMC: A;
State medical licenses: Complied with VA policy: 28;
State medical licenses: Did not comply with VA policy: 2;
Malpractice: Complied with VA policy: 8;
Malpractice: Did not comply with VA policy: 8;
Federation of State Medical Boards database query: Complied with VA
policy: 30;
Federation of State Medical Boards database query: Did not comply with
VA policy: 0;
Physician references: Complied with VA policy: 30;
Physician references: Did not comply with VA policy: 0.
VAMC: B;
State medical licenses: Complied with VA policy: 24;
State medical licenses: Did not comply with VA policy: 6;
Malpractice: Complied with VA policy: 12;
Malpractice: Did not comply with VA policy: 8;
Federation of State Medical Boards database query: Complied with VA
policy: 30;
Federation of State Medical Boards database query: Did not comply with
VA policy: 0;
Physician references: Complied with VA policy: 29;
Physician references: Did not comply with VA policy: 1.
VAMC: C;
State medical licenses: Complied with VA policy: 28;
State medical licenses: Did not comply with VA policy: 2;
Malpractice: Complied with VA policy: 10;
Malpractice: Did not comply with VA policy: 2;
Federation of State Medical Boards database query: Complied with VA
policy: 30;
Federation of State Medical Boards database query: Did not comply with
VA policy: 0;
Physician references: Complied with VA policy: 29;
Physician references: Did not comply with VA policy: 1.
VAMC: D;
State medical licenses: Complied with VA policy: 21;
State medical licenses: Did not comply with VA policy: 9;
Malpractice: Complied with VA policy: 6;
Malpractice: Did not comply with VA policy: 10;
Federation of State Medical Boards database query: Complied with VA
policy: 25;
Federation of State Medical Boards database query: Did not comply with
VA policy: 5;
Physician references: Complied with VA policy: 28;
Physician references: Did not comply with VA policy: 2.
VAMC: E;
State medical licenses: Complied with VA policy: 30;
State medical licenses: Did not comply with VA policy: 0;
Malpractice: Complied with VA policy: 13;
Malpractice: Did not comply with VA policy: 0;
Federation of State Medical Boards database query: Complied with VA
policy: 30;
Federation of State Medical Boards database query: Did not comply with
VA policy: 0;
Physician references: Complied with VA policy: 29;
Physician references: Did not comply with VA policy: 1.
VAMC: F;
State medical licenses: Complied with VA policy: 20;
State medical licenses: Did not comply with VA policy: 10;
Malpractice: Complied with VA policy: 3;
Malpractice: Did not comply with VA policy: 10;
Federation of State Medical Boards database query: Complied with VA
policy: 30;
Federation of State Medical Boards database query: Did not comply with
VA policy: 0;
Physician references: Complied with VA policy: 29;
Physician references: Did not comply with VA policy: 1.
VAMC: Total;
State medical licenses: Complied with VA policy: 151;
State medical licenses: Did not comply with VA policy: 29;
Malpractice: Complied with VA policy: 52;
Malpractice: Did not comply with VA policy: 38;
Federation of State Medical Boards database query: Complied with VA
policy: 175;
Federation of State Medical Boards database query: Did not comply with
VA policy: 5;
Physician references: Complied with VA policy: 174;
Physician references: Did not comply with VA policy: 6.
Sources: GAO analysis of documentation in VAMCs' credentialing and
privileging files.
Notes: We reviewed 30 files at each VAMC. However, results for one
category do not total 30 at each facility because the requirement did
not apply to all physician files. Site visits to these six VAMCs were
conducted from August 2008 through February 2009.
[End of table]
At the six VAMCs, medical licenses were properly verified in 151 out
of 180 files, with five of six VAMCs having 2 or more physician files
that lacked proper verification of medical licenses.
VAMC staff at the six VAMCs properly verified malpractice allegations
or claims for 52 of 90 files in which physicians reported at least one
past allegation of malpractice. However, at three VAMCs malpractice
verification was not completed properly at least half of the time.
We found that VA documentation requirements were followed for querying
the FSMB and collecting physician references in all but a limited
number of instances. Specifically, we found:
* documentation that the FSMB had been queried in 175 out of 180
physician files, and:
* documentation that the required number of references had been
obtained in 174 out of 180 physician files.
In addition to the four credentialing and privileging requirements, we
also examined whether credentialers ensured that reprivileging took
place no more than 2 years after the previous privileging process.
Reprivileging took place no more than 2 years after the previous
privileging process in 123 out of 128 files that had reprivileging
data.
Medical Staff Leadership Did Not Adequately Scrutinize Information or
Document Credentialing and Privileging Decisions at Selected VAMCs:
Although credentialers are generally responsible for collecting
primary-source documentation at the VAMCs we visited, it is service
chiefs who are responsible for reviewing physicians' credentials to
recommend medical staff appointments and privileges and, therefore,
best positioned to identify instances where physicians did not provide
required information. However, some service chiefs at the VAMCs we
visited did not identify those instances when physicians omitted
required information in the 180 files we reviewed--even when evidence
of the omissions was available elsewhere in the physician file.
[Footnote 20] An example would be if a physician disclosed employment
in Pennsylvania but did not list a Pennsylvania medical license.
As part of our review of the 180 physician files at the six VAMCs, we
looked for evidence of omissions by physician applicants related to
medical licenses, malpractice, and gaps in background greater than 30
days. (See table 4 for a summary of our findings related to instances
when service chiefs did not identify omissions made by physicians in
submitted credentialing and privileging information at the six VAMCs
we visited.)
Table 4: Identification of Compliance with VA Policy Regarding
Physician Disclosure of Information Prior to Service Chief
Recommendation at Six VA Medical Centers (VAMC):
VAMC: A;
State medical licenses: Evidence of unreported licenses: 2;
State medical licenses: No evidence of unreported licenses: 28;
Malpractice: Evidence of unreported or underreported malpractice: 2;
Malpractice: No evidence of unreported or underreported malpractice:
28;
Background: Unexplained gaps greater than 30 days: 3;
Background: No unexplained gaps greater than 30 days: 27.
VAMC: B;
State medical licenses: Evidence of unreported licenses: 4;
State medical licenses: No evidence of unreported licenses: 26;
Malpractice: Evidence of unreported or underreported malpractice: 5;
Malpractice: No evidence of unreported or underreported malpractice:
25;
Background: Unexplained gaps greater than 30 days: 1;
Background: No unexplained gaps greater than 30 days: 29.
VAMC: C;
State medical licenses: Evidence of unreported licenses: 2;
State medical licenses: No evidence of unreported licenses: 28;
Malpractice: Evidence of unreported or underreported malpractice: 5;
Malpractice: No evidence of unreported or underreported malpractice:
25;
Background: Unexplained gaps greater than 30 days: 0;
Background: No unexplained gaps greater than 30 days: 30.
VAMC: D;
State medical licenses: Evidence of unreported licenses: 2;
State medical licenses: No evidence of unreported licenses: 28;
Malpractice: Evidence of unreported or underreported malpractice: 4;
Malpractice: No evidence of unreported or underreported malpractice:
26;
Background: Unexplained gaps greater than 30 days: 1;
Background: No unexplained gaps greater than 30 days: 29.
VAMC: E;
State medical licenses: Evidence of unreported licenses: 0;
State medical licenses: No evidence of unreported licenses: 30;
Malpractice: Evidence of unreported or underreported malpractice: 1;
Malpractice: No evidence of unreported or underreported malpractice:
29;
Background: Unexplained gaps greater than 30 days: [Empty];
Background: No unexplained gaps greater than 30 days: [Empty].
VAMC: F;
State medical licenses: Evidence of unreported licenses: 2;
State medical licenses: No evidence of unreported licenses: 28;
Malpractice: Evidence of unreported or underreported malpractice: 4;
Malpractice: No evidence of unreported or underreported malpractice:
26;
Background: Unexplained gaps greater than 30 days: 1;
Background: No unexplained gaps greater than 30 days: 29.
VAMC: Total;
State medical licenses: Evidence of unreported licenses: 12;
State medical licenses: No evidence of unreported licenses: 168;
Malpractice: Evidence of unreported or underreported malpractice: 21;
Malpractice: No evidence of unreported or underreported malpractice:
159;
Background: Unexplained gaps greater than 30 days: 6;
Background: No unexplained gaps greater than 30 days: 144.
Sources: GAO analysis of documentation in VAMCs' credentialing and
privileging files.
Notes: Site visits to these six VAMCs were conducted from August 2008
through February 2009. We did not analyze the background requirement
at VAMC E.
[End of table]
[Sidebar: VAMC File Review: Inadequate review of licensure and an
inadequate reference:
An experienced primary care physician at one VAMC we visited was hired
in 2007. The physician‘s file showed that the only medical license he
reported holding was issued 6 years after he started in private
practice. The VAMC never documented investigating this. Further,
records from one hospital where the physician worked show the
physician held privileges at that facility for just 3 months in the
1990s”not the 31 years he disclosed to the VAMC. Finally, one of the
three required references was an attorney who answered ’no information“
to questions about the applying physician‘s clinical competency and
medical practice. End of sidebar]
During our file review at the six VAMCs, we found that 168 of 180
physician files showed no evidence that physicians had omitted any
state medical licenses currently or previously held. However, 12 of
the 180 files contained evidence that not all medical licenses were
disclosed by the physician. Without full disclosure of medical
licenses, credentialers would not know which states need to be
contacted to obtain primary source verification that would indicate
whether disciplinary action had been taken against a physician's
license. The VA OIG found weakness in the disclosure of medical
licenses by physicians at the Marion VAMC. Its review uncovered
evidence that one physician did not disclose a medical license in
which disciplinary action had been taken. As a result of the VA OIG's
scrutiny, the provider was placed on authorized absence pending an
investigation.
We also found during our review that 159 of 180 physician
credentialing files contained detailed written information about all
malpractice complaints made against physicians as required by VA
policy.[Footnote 21] Several of the 21 cases where the malpractice
disclosure policy was not followed were identified through NPDB
reports in the physician file. These NPDB reports--which VAMCs are
required to collect on each physician during each appointment or
reappointment process--showed malpractice payments had been made on
claims that physicians never disclosed. For example, a surgeon at one
VAMC disclosed no malpractice allegations against him, yet NPDB showed
that two claims, totaling $160,000, had been paid based on care
provided by the physician. This physician's credentialing file
documented that the physician was reappointed in part based on "no
pending or actual malpractice judgments."
VA policy requires that physicians with gaps of greater than 30 days
in their backgrounds and experience document the reasons for these
gaps because this information can be compared with licensure data to
make sure physicians reported all licenses held. We found that 144 of
150 physician files either documented no gaps or contained
explanations for the gaps of greater than 30 days. In the remaining 6
files, gaps were found with no documentation that an explanation was
provided.
[Sidebar: VAMC File Review: A restricted license without documented
review:
A VAMC we visited violated VA policy in 2002 by hiring a surgeon and
keeping him on the medical staff for 3 years without documenting an
investigation about why one of his medical licenses had been
restricted. The restrictions stemmed from an incident”according to a
state medical board finding”in which the physician operated on the
wrong joint of a patient, did not tell the patient‘s family about the
error, and did not record the result on the operative report until
colleagues pressured him to do so. This state‘s medical board revoked
the physician‘s license in 1989. Nine months later the license was
restored to a restricted status, which lasted until April 2006 when
the restrictions were lifted.
We found no evidence in the physician‘s file that an investigation by
VA into the details of the medical license restriction ever took
place, as VA policy required at the time. (The policy has since been
updated to prohibit hiring physicians with restricted licenses.) This
physician resigned from the VAMC in April 2005”and was rehired in June
2006, shortly after the medical license restrictions were lifted.
Prior to rehiring the physician, the VAMC documented a review of the
circumstances surrounding the licensure restrictions. End of sidebar]
Although VA policy requires physician service chiefs--officials
responsible for physicians providing particular clinical services--to
document their rationale for credentialing and privileging
recommendations for physicians, we found such documentation only about
one-third of the time. VA requires service chiefs to document in
VetPro what quality-of-care information they reviewed during the
reprivileging process. Service chiefs must then explain their
rationale for recommending the physicians' privileges. Of the 130
physicians who went through the reprivileging process at least once,
we found that only 45 files--about a third--contained required service
chief documentation in their most recent reprivileging cycle. (See
table 5 for a breakdown of our findings by VAMC visited.)
[Sidebar: VAMC File Review: Inaccurate review of malpractice data:
One VAMC hired a physician in 2003 using a special, abbreviated
privileging process designed for emergency situations. The order
granting privileges was signed by the acting facility director and
acting chief of staff and stated that a query of the National
Practitioner Data Bank (NPDB) showed ’no derogatory information has
been discovered.“ However, NPDB data we reviewed showed at least four
paid malpractice claims before he was hired”including one involving
medical equipment left inside a patient‘s body. End of sidebar]
Table 5: Service Chief Compliance with VA Documentation Policies for
Reprivileging Recommendations at Six VA Medical Centers (VAMC):
VAMC: A;
Rationale for reprivileging documented by service chief: Complied with
VA policy: 6;
Rationale for reprivileging documented by service chief: Did not
comply with VA policy: 12.
VAMC: B;
Rationale for reprivileging documented by service chief: Complied with
VA policy: 2;
Rationale for reprivileging documented by service chief: Did not
comply with VA policy: 21.
VAMC: C;
Rationale for reprivileging documented by service chief: Complied with
VA policy: 17;
Rationale for reprivileging documented by service chief: Did not
comply with VA policy: 5.
VAMC: D;
Rationale for reprivileging documented by service chief: Complied with
VA policy: 6;
Rationale for reprivileging documented by service chief: Did not
comply with VA policy: 17.
VAMC: E;
Rationale for reprivileging documented by service chief: Complied with
VA policy: 8;
Rationale for reprivileging documented by service chief: Did not
comply with VA policy: 11.
VAMC: F;
Rationale for reprivileging documented by service chief: Complied with
VA policy: 6;
Rationale for reprivileging documented by service chief: Did not
comply with VA policy: 19.
VAMC: Total;
Rationale for reprivileging documented by service chief: Complied with
VA policy: 45;
Rationale for reprivileging documented by service chief: Did not
comply with VA policy: 85.
Sources: GAO analysis of documentation in VAMCs' credentialing and
privileging files.
Notes: We reviewed 30 files at each VAMC. However, results do not
total 30 at each facility because the requirement did not apply to all
physician files. Site visits to these six VAMCs were conducted from
August 2008 through February 2009.
[End of table]
Of the 85 files that did not contain required documentation, some
contained no service chief comments at all. Others contained comments
that did not meet VA requirements for service chiefs to explain the
rationale for their decisions and the quality-of-care activities that
were considered. For example, one service chief wrote "outstanding
surgeon," but did not explain what quality data, if any, were used to
reach that conclusion.
Display of VetPro Information May Inhibit VAMCs' Ability to Accurately
Collect and Scrutinize Data:
We identified two VetPro weaknesses--in the display of summary
information and in the wording of questions for physicians--that could
inhibit service chief review of physician qualifications during the
credentialing and privileging process.
VetPro's Information Display May Limit Identification of Inaccurate
Information:
We found weaknesses in the way VetPro displayed credentialers'
corrections to physician-supplied information. VetPro displays
information by category, and each category of information--such as
medical training, medical licensure, and references--is available on
separate VetPro screens. Some of the screens have a table with summary
information at the top of the screen and detailed information about a
single entry at the lower portion of the screen. However, when
information has been corrected by credentialers based on primary
source verification, the corrections do not appear in these summary
tables and there is no notification within these summary tables that
alerts service chiefs that physicians' self-reported information was
found by credentialers to be inaccurate. This corrected information
was available in VetPro, but accessing it required an extra step. In
one instance, we found a discrepancy of 14 months between the dates
when the physician reported obtaining privileges at one hospital and
the privileging information provided directly by the hospital. (See
figure 2, which illustrates a hypothetical example of VetPro's display
of summary information.)
Figure 2: Illustration of How VetPro Displays Summary Information:
[Refer to PDF for image: illustration]
Four specific areas are highlighted with the following information
added:
1) The ’Status“ box on the summary table receives a label ’V,“ for
verified, once credentialers enter information into the ’Verified Data“
section. However, other information in the summary table is based on
what the physician applicant enters, not the information collected by
credentialers – even when there are discrepancies with the primary
source information that credentialers collect.
2) Detail information is only visible for one record at a time. Those
reviewing the VetPro file must click on the other state names to view
details of the primary source information for medical licenses in
those states.
3) There is a discrepancy between the Maine license expiration
reported by the physician and primary source information collected by
the VAMC credentialer. Information from the credentialer shows a 7
month gap between the expiration of the Maine license and the start of
the Idaho license. However, no gap is observable from the summary
table. VA policy requires VAMCs to follow up when discrepancies are
found during the verification process.
4) This area contains links to electronic copies of the primary source
documents collected by the credentialer. Reviewers such as service
chiefs can examine these images to obtain additional detail about the
circumstances of when and why the physician surrendered a medical
license.
Source: GAO analysis of VetPro Web-based credentialing database.
[End of figure]
One service chief told us that he looked at information in VetPro with
his credentialer, who helped him navigate the process; another told us
that the credentialer would identify any information in the
physician's file that needed special attention. A third said that if
the credentialer corrected physician-supplied information in VetPro he
was not aware of it. Such a process--in which service chiefs rely on
credentialers to identify information in the VetPro file that requires
extra attention--requires credentialers, who typically do not have
medical backgrounds, to conduct substantive review of physicians'
credentialing information. One service chief suggested that an alert,
or "flag," would make the review process more useful by drawing
attention to places in VetPro where there were discrepancies between
physician-reported information and verified documentation. Once
discrepancies are identified, service chiefs would need to investigate
further to determine whether these discrepancies should be taken into
account when recommending medical staff appointment or privileges.
Wording of Questions in VetPro May Have Been Confusing to Physicians:
In addition, some physicians may have been confused about the wording
of VetPro questions related to medical licensure and experience with
malpractice allegations. For example, physicians are asked a series of
questions after the following introduction:
"For disciplinary reasons, have any of the following ever been, or are
they in the process of being either on a voluntary or involuntary
basis--conditional, denied, revoked, suspended, reduced, limited,
placed on probation, not renewed, withdrawn, or relinquished while
under investigation or after being notified that investigation would
be conducted?"
What follows is a series of yes-or-no questions including, for
licensure, "Medical License in any State?" and, for malpractice
claims, "Have you ever been involved or notified that the quality of
care you provided is being reviewed as part of an administrative (e.g.
Administrative Tort Claim), or judicial proceeding in which
professional malpractice has been alleged?" (emphasis in original)
[Footnote 22]
During our file reviews, we noted that several physicians answered
"yes" to the question about licensure even though some stated the
licenses were voluntarily surrendered for nondisciplinary reasons.
These cases suggest physician confusion about the meaning of this
question, since the loss of a medical license for disciplinary reasons
could render the physician ineligible to work at a VAMC. Further, one
physician, whose file was among the 21 instances where files contained
evidence of either undisclosed or inadequate disclosure of malpractice
allegations or claims, responded to the question about malpractice, in
part, that the question was too vague and that more specificity was
needed.[Footnote 23] Confusion about the wording of the malpractice
question may have been a factor in some of these 21 instances. This
confusion with respect to VetPro questions related to licensure and
malpractice suggests weaknesses in processes that are intended to help
VAMCs collect complete and accurate credentialing information.
VA Oversight Policies Lack Detail Necessary to Implement Proper
Controls over VAMCs' Credentialing and Privileging Processes:
The oversight policies for credentialing and privileging processes
that were issued by VA in 2008 assign responsibility for oversight to
VISN chief medical officers (CMO) but lack specificity in describing
the monitoring activities that are expected.[Footnote 24] Internal
control standards state that agencies should clearly define key areas
of authority and responsibility, establish appropriate lines of
reporting, assess the quality of performance over time, and include
policies and procedures for ensuring that the findings of audits and
other reviews are promptly resolved.[Footnote 25] VA's 2008 oversight
policies do not specify how CMOs should assess compliance with
credentialing and privileging policies, nor do they specify how CMOs
should follow up to ensure that identified weaknesses have been
promptly resolved. VA also provided guidance in August 2009 that
details specific oversight activities that can be used to evaluate a
VAMC's credentialing and privileging processes; however, the guidance
does not describe a process for follow up to ensure that findings are
resolved.
VISN officials we spoke with described participating in oversight
activities or planning oversight activities that addressed at least
some elements of internal control standards. We interviewed CMOs and
other officials in the six VISNs that were responsible for oversight
of the six VAMCs we visited. The VISN officials described past and
current oversight practices, as well as changes that were planned as a
result of VA's new oversight policies. Activities that VISN officials
described included participating in credentialers' e-mail discussion
groups to track questions that come up about recredentialing and
reviewing three to five credentialing files per site visit for
completeness. Officials at two VISNs said the VA oversight policies
would lead to more frequent site visits. One of these officials also
said the policies led him to become more hands-on during site visits,
and making direct observation of processes and engaging in direct
questioning of VAMC staff about credentialing and privileging.
Some of the practices VISN officials described were insufficient for
identifying key areas of authority and responsibility, assessing the
quality of performance over time, and conducting adequate follow-up to
see that findings had been promptly resolved. For example, one VISN
official we interviewed could not say whether the VISN had staff
assigned to review VAMC credentialing and privileging files, and a
second VISN reported that sometimes the credentialing and privileging
file review process was not conducted if VISN officials determined it
was not warranted. A third VISN official reported that he reviewed 20
to 30 credentialing and privileging files per hour--a pace, at 2 to 3
minutes per file, that provides only a limited ability to assess all
aspects of compliance.[Footnote 26] Officials at a fourth VISN
reported using criteria from the Joint Commission and the VA OIG to
review credentialing and privileging files in preparation for reviews
by these entities. However, these criteria do not fully overlap with
VA's credentialing and privileging policies.[Footnote 27] Of the four
VISNs that systematically conducted file reviews, only one described
engaging in a follow-up process after reviewing credentialing and
privileging files to ensure that findings were resolved.
VA provided guidance in August 2009--after our interviews were
conducted--for evaluating a VAMC's credentialing and privileging
process. The guidance includes provisions for reviewing verification
of state medical licensure and malpractice, completion of an FSMB
query, gaps in work history greater than 30 days, possible omissions
of state medical licenses through reviewing discrepancies between
physicians' work history and state medical licenses reported, and
whether service chiefs documented physician competency and recommended
privileges. However, VA's guidance does not include a process for
ensuring that the findings of the review are promptly resolved by the
VAMC.
Gaps in Continuous Monitoring of Physician Performance Existed at
Selected VAMCs and Officials Continued to Use Performance Information
Inappropriately:
The six selected VAMCs we visited varied in their implementation of VA
policies and guidance to continuously monitor physician performance.
Some VAMCs exhibited gaps in this monitoring by either failing to
document the collection of physician performance information, or by
collecting data that were insufficient to adequately gauge
performance. In addition, despite VA guidance issued after our 2006
report, confusion about the proper use of protected physician
performance information persisted in the VAMCs we visited: four of the
six used this information inappropriately in privileging decisions.
Selected VAMCs Varied in Their Implementation of VA Policies to
Continuously Monitor Physician Performance and Gaps in Monitoring
Processes Existed:
VA policy requires service chiefs to continuously monitor physician
performance. Continuous monitoring of physician performance is
important because VA requires service chiefs to assess all available
information addressing physician performance when recommending
privileges for the physicians in their services. However, all of the
VAMCs we visited exhibited gaps in their efforts to conduct this
monitoring. We reviewed the surgery, mental health, and medicine
services at all six VAMCs visited and found that 6 of these 18
services failed to document compliance with VA policy regarding
continuous monitoring of physician performance. These 6 services could
not provide us with any documentation of continuous monitoring, such
as data collection spreadsheets, standardized forms for assessing
performance, or checklists of performance criteria. Table 6 describes
the documentation of compliance, by service and facility, with VA
policy.
Table 6: Service Documentation of Compliance with Continuous
Monitoring of Physician Performance at Six VA Medical Centers (VAMC):
VAMC: A;
Service: Surgery: [A];
Service: Mental Health: [A];
Service: Medicine: [A].
VAMC: B;
Service: Surgery: [A];
Service: Mental Health: [A];
Service: Medicine: [A].
VAMC: C;
Service: Surgery: [A];
Service: Mental Health: [B];
Service: Medicine: [B].
VAMC: D;
Service: Surgery: [A];
Service: Mental Health: [B];
Service: Medicine: [B].
VAMC: E;
Service: Surgery: [A];
Service: Mental Health: [A];
Service: Medicine: [B].
VAMC: F;
Service: Surgery: [A];
Service: Mental Health: [B];
Service: Medicine: [A].
Sources: GAO analysis of physician performance information obtained
from VAMCs.
Legend:
[A] The service was able to provide us with documentation of
continuous monitoring, such as data collection spreadsheets,
standardized forms for assessing performance, or checklists of
performance criteria.
[B] The service was unable to provide us with any documentation of
continuous monitoring of physician performance.
Note: Site visits to these six VAMCs were conducted from August 2008
through February 2009.
[End of table]
In the reprivileging process, VA requires consideration of such
factors as the number of procedures performed and complication rates,
when available. It also requires the comparison of physician-specific
data to aggregate data of physicians with the same or comparable
privileges, when available. The VA official responsible for
credentialing and privileging policy told us that some mental health
services may not have physicians that perform procedures. Consistent
with this official's statement, one of the three mental health
services that produced documentation of continuous monitoring did not
have information on procedures in its documentation.
While 9 of the 12 services reviewed in surgery and medicine provided
us with documentation of continuous monitoring, 1 of these 9 services
did not include information on procedures or complication rates.
Additionally, 4 of these 9 services did not compare physician-specific
data to aggregate data as required by VA policy. Table 7 summarizes
whether surgery and medicine service documentation of continuous
monitoring included information on these three factors.
Table 7: Factors of Clinical Performance Included in Continuous
Monitoring at Six VA Medical Centers (VAMC), by Service:
Factor of clinical performance: Procedure volume data;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [A].
Factor of clinical performance: Complication rates;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [A].
Factor of clinical performance: Data are compared to aggregate data;
Service: Surgery: VAMC A: [B];
Service: Medicine: VAMC A: [A][C].
Factor of clinical performance: Procedure volume data;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [A].
Factor of clinical performance: Complication rates;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [A].
Factor of clinical performance: Data are compared to aggregate data;
Service: Surgery: VAMC A: [B];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Procedure volume data;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Complication rates;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Data are compared to aggregate data;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Procedure volume data;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Complication rates;
Service: Surgery: VAMC A: [B];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Data are compared to aggregate data;
Service: Surgery: VAMC A: [A][C];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Procedure volume data;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Complication rates;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Data are compared to aggregate data;
Service: Surgery: VAMC A: [A][C];
Service: Medicine: VAMC A: [B].
Factor of clinical performance: Procedure volume data;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [A].
Factor of clinical performance: Complication rates;
Service: Surgery: VAMC A: [A];
Service: Medicine: VAMC A: [A].
Factor of clinical performance: Data are compared to aggregate data;
Service: Surgery: VAMC A: [B];
Service: Medicine: VAMC A: [A].
[End of table]
Sources: GAO analysis of physician performance information obtained
from VAMCs.
Note: Site visits to these six VAMCs were conducted from August 2008
through February 2009.
Legend:
[A] The service efforts to document continuous performance monitoring
included this factor of clinical performance.
[B] The service efforts to document continuous performance monitoring
did not include this factor of clinical performance.
[C] These services compared physician-specific data to benchmark
criteria.
[End of table]
Continuous monitoring varied by service as well as by facility.
Surgical services consistently exhibited efforts to conduct continuous
monitoring of physician performance. All six surgical services
produced documentation of continuous monitoring. Further, all six
surgical services collected information on at least one of the three
factors of clinical practice, with two of the six services collecting
information on all three factors. VA's Acting Chief Quality and
Performance Officer told us that there are areas of clinical practice
that are procedure based, such as surgery, where the types of
procedures performed allow for more opportunities to collect procedure
based data on physician performance than those clinical care areas
that are not procedure based. The variation also existed across
facilities. At VAMC B both services we reviewed--surgery and medicine--
produced documentation of efforts to conduct continuous monitoring of
physician performance, and the documentation produced contained at
least one of the three factors of clinical performance. In contrast,
only one service reviewed at VAMC D provided us with documentation of
continuous monitoring efforts.
In the absence of documentation of continuous monitoring processes, it
is unclear what specific criteria services use to monitor physician
performance on an ongoing basis. Further, if services' continuous
monitoring efforts do not include collection of physician volume and
complication rate data, and comparison of these data with aggregated
data from comparably privileged physicians, service chiefs are less
able to make a meaningful assessment of a physician's clinical
competence and identify negative trends in a physician's care. As a
result, VAMCs and VA cannot ensure that these services are adequately
monitoring the performance of their physicians.
VA has recently issued new policies and guidance on physician
performance monitoring processes in an effort to clarify how services
can monitor physician performance. In December 2008, VA issued
guidance to VAMCs on how to perform On-Going Professional Practice
Evaluations (OPPE), a type of continuous monitoring that involves
formally documenting and evaluating physician performance using
available data.[Footnote 28] The guidance provides suggestions on how
facilities should conduct OPPEs, how often OPPEs should be conducted,
and suggests specific criteria service chiefs can use in assessing
physician performance.
Selected Facilities Continued to Use Protected Physician Performance
Information Inappropriately Despite VA Guidance:
Four of the six VAMCs visited used protected peer review information
in privileging decisions, despite VA guidance and training about the
legal protections granted to certain types of performance information
and appropriate ways to use this information.[Footnote 29] In 2006 we
found that six of seven VAMCs visited used protected quality
management program information in reprivileging, which is prohibited
under VA policy. We recommended that VA issue guidance to facilities
about this topic.[Footnote 30] In October 2007, VA issued additional
guidance, and subsequently provided training to facilities, including
two presentations addressing the proper usage of protected
information. VA requires that during reprivileging, service chiefs use
information on a physician's performance to support, reduce, or revoke
the clinical privileges the physician requested. The performance
information a service chief uses cannot be collected as part of a
VAMC's quality management program. Protected peer review is a quality
management process and information contained in documents created in
the course of a quality management process is protected under VA
policy. The policy explicitly states that information generated by
these peer reviews cannot be used to take personnel actions, such as
changes in privileges. Despite this guidance, our physician file
reviews showed four of the six VAMCs we visited used protected peer
review information in privileging decisions. In one such case, the
physician's VetPro file included a document with brief notes relating
to a protected peer review along with the final outcome of this peer
review. Similar information was found in physician performance
profiles used by service chiefs in their reprivileging decisions.
VAMC officials we interviewed expressed and demonstrated confusion as
to the appropriate use of protected peer review information. At one
VAMC one official told us he thought it was permissible to aggregate
physician-specific peer review information and use this information in
privileging, while another attested to directly using this type of
information in privileging. However, the VA official responsible for
credentialing and privileging policy confirmed that aggregate
physician-specific peer review information was protected and should
not be used in privileging. Another VAMC had policies which clearly
outlined processes generating protected and unprotected physician
performance information and stated that protected information was not
to be used in privileging. However, we found protected peer review
information in materials used for privileging at this facility.
VA officials confirmed that the use of protected information in the
privileging process in violation of VA policy may result in the
information becoming public or in legal challenges to privileging
decisions. According to VA's Director, Credentialing and Privileging,
privileging is considered a human resources function, and therefore
the information used in the privileging process is subject to less
stringent legal protections than information generated as part of a
VAMC quality management program. If protected physician performance
information generated by a VAMC quality management program serves as
the basis for a privileging decision, the decision itself could be
subject to challenge. Further, a physician making such a challenge may
be able to obtain the release of inappropriately used information,
thereby raising the possibility that the information could become
public.
VA Has Begun to Implement Its Plan to Improve Oversight for VAMC
Surgical Programs by Creating Resource Standards for Surgical
Procedures:
In response to a recommendation to improve oversight of VAMC surgical
programs made by the VA OIG in its report on events at Marion VAMC, VA
has created a plan to set resource standards for surgical procedures
and has taken steps towards the implementation of this plan. In
addition to these new oversight plans, VA also uses surgical quality
data to monitor the quality of its surgical programs through NSQIP,
which is an oversight mechanism used to monitor noncardiac surgical
program quality.
VA Has Developed Surgical Resource Standards for VAMCs and Created a
Plan for Implementing These Standards:
In response to the VA OIG recommendation from the report on the Marion
VAMC that VA develop a mechanism to ensure that diagnostic and
therapeutic interventions are appropriate to the capabilities of each
facility, VA chartered an Operative Complexity and Infrastructure
Standards Workgroup in December 2007.[Footnote 31] The Workgroup took
several steps. First, it determined, based on a literature review,
that there were no existing surgical resource standards.[Footnote 32]
Second, it identified the clinical support services and resources
needed before, during, and after the surgeries and procedures
performed at VAMCs and classified each support service as standard,
intermediate, or complex. Third, the Workgroup classified surgeries or
procedures as requiring standard, intermediate, or complex clinical
support services or resources.
A VA headquarters official said that when VA's resource standards are
implemented, each VA facility will be classified as having standard,
intermediate, or complex operative complexity--that is, the ability to
perform standard, intermediate, or complex surgeries and procedures
based on the availability of clinical support services or resources at
the facility. VA conducted a survey of all VAMCs on the clinical
support services and resources available at each facility, and the
VISNs used the results to determine VAMCs' initial operative
complexity designation in February 2009. VA also used the survey to
identify any VAMC that needed additional resources. Facilities with
resource deficiencies were instructed to establish an action plan to
resolve deficiencies and to provide VA with status reports by
September 1, 2009, and December 1, 2009. According to VA headquarters
officials, VA plans to issue the final policy containing these
standards in January 2010.
The Workgroup's final report, signed by the Under Secretary for Health
in October 2008, describes the resource standards and the Workgroup's
recommended steps to implement the standards, including the release of
the policy containing the standards. The steps and VA's anticipated
completion dates are outlined in table 8 below.
Table 8: Steps in VA's Plan to Implement the Operative Complexity and
Infrastructure Standards Workgroup's Recommendations Regarding
Surgical Resource Standards:
Steps: Identification of Veterans Integrated Service Network (VISN)
chief surgical consultant: The Workgroup recommended that each VISN
develop an identified Lead Network Director of Surgical Service,
responsible to the VISN chief medical officer, to facilitate
communication. According to VA officials, a chief surgical consultant
for each VISN was established in February 2009 to help facilities
analyze their capabilities;
Status: Complete.
Steps: Monitoring of compliance through the National Surgical Quality
Improvement Program (NSQIP): The Workgroup recommended the development
of a monitoring method through NSQIP. According to VA officials, in
order to monitor compliance, a facility will be flagged through NSQIP
software if it records a procedure that is more complex than those
procedures in the facility's operative complexity designation;
Status: Complete.
Steps: Response to facility designation: The Workgroup recommended
that VA permit the development of a plan to achieve compliance with an
initial operative complexity designation, and that the VISN address
funding for all facilities that need to achieve compliance. Each
facility was given an initial classification of standard,
intermediate, or complex. VISNs were instructed to develop a plan for
each VAMC to either concur with the designation or identify and
justify an alternative designation. According to VA officials, this
should include the procurement of additional resources if necessary to
fill any resource gaps. All VISNs have submitted an action plan;
Status: Complete.
Steps: Creation of VISN model for surgical services: The Workgroup
recommended that VA facilitate a VISN model for the delivery of
surgical services within the VISN, including an inventory of available
surgical services at each facility within each VISN. According to VA
officials, this model will be finished before the release of the
policy;
Status: Completion anticipated before January 1, 2010.
Steps: Creation of VISN plan to address transfer of patients: The
Workgroup recommended that VA require each VISN to develop a plan for
the transfer of patients to another facility when the initial treating
facility does not have the appropriate resources to handle the
surgical condition. According to VA officials, this is a part of the
VISN model for surgical services, and will be finalized before the
release of the policy;
Status: Completion anticipated before January 1, 2010.
Steps: Release of policy: The Workgroup recommended that VA accept the
resource standards and mandate their use by policy. According to VA
officials, this policy will be effective January 1, 2010;
Status: Completion anticipated before January 1, 2010.
Sources: GAO analysis of VA documents and interviews with VA
headquarters officials.
[End of table]
According to VA headquarters officials, as of July 2009, three of the
six steps in VA's plan to implement resource standards have been
completed. First, in February 2009, a chief surgical consultant was
identified for each VISN. According to these officials, each chief
surgical consultant is responsible for helping facilities analyze
their capabilities, and will receive facility-level information from
within the VISN. Second, these officials said that NSQIP software can
also be used to track VAMC procedures and identify VAMCs that are
performing procedures outside their classification level through codes
recorded in NSQIP. Third, VISNs have responded to the operative
complexity designations. VA headquarters officials told us that the
VISN models for surgical services and patient transfer plans would be
completed by the time the policy is issued, in January 2010.
To further improve surgical program oversight, VA issued a policy in
January 2009 on future restructuring, reduction or augmentation of
VAMCs' clinical programs. The policy would require that a VAMC obtain
approval from the VISN and the Under Secretary for Health before
undertaking any major expansion of a surgical program.[Footnote 33]
When requesting an expansion, the VAMC's chief of staff and VISN CMO
must ensure that a thorough clinical evaluation has been conducted at
the facility to ensure that providers have the required competency and
that an assessment of clinical support services and resources has been
made. The chief of staff and VISN CMO must also ensure that a site
visit, which may include experts in the relevant surgical specialty,
is conducted when applicable by the responsible VA headquarters
program staff.[Footnote 34] Finally, the chief of staff must ensure
processes are in place to provide ongoing review and evaluation of the
quality of care provided for all clinical services. The facility
director must submit a formal business plan to the VISN director for
approval. VA's new policy also provides a mechanism for facilities to
change their operative complexity designation. VA headquarters
officials told us that a facility's formal business plan will also be
used to approve a change in designation. For example, these officials
told us that if a facility is designated as intermediate, but wants to
expand to perform complex surgeries, VA must approve a formal business
plan describing planned clinical and support services.
VA Monitors Surgical Outcome Data and Has Policies Related to
Oversight of VAMC Surgical Programs:
In addition to the oversight activities under development related to
facility capabilities, VA and VAMCs conduct other activities for
oversight of surgical program quality. VA uses NSQIP to monitor
surgical program quality.[Footnote 35] While NSQIP does not directly
consider facility capabilities, VA uses NSQIP to detect problems
within surgical programs and further investigate the potential causes
of those problems, as it did at Marion VAMC when NSQIP identified a
mortality rate over four times higher than the expected rate.
In addition to NSQIP reports, surgery chiefs at all six VAMCs we
visited told us that they also monitor their surgical programs using
other types of facility-level surgical quality oversight.
Specifically, five of six surgery chiefs identified morbidity and
mortality reviews as a mechanism for monitoring their surgical
programs.[Footnote 36] VA policy requires that VAMCs ensure the
trending of mortality data by location, time, and provider[Footnote
37] is implemented, and that VAMCs conduct a review of the data to
identify and address any problematic trends. These data are to be
discussed in a regular forum, such as within quality management or
morbidity and mortality committee meetings. Furthermore, all major
complications and deaths that are related to a surgical procedure at a
VA facility must be peer reviewed within 30 days of the original
surgical procedure.[Footnote 38]
VA policy also provides for VISN and headquarters oversight for all
peer reviews, including those related to patient morbidity and
mortality.[Footnote 39] The VISN director must ensure an annual
inspection of all VAMCs to ensure compliance with peer review
requirements, adequate review of peer review results, and
implementation of follow-up actions. VA policy also requires that
facilities collect and report quarterly to the VISN certain data
related to peer review such as the number and results of reviews. The
VISN must analyze these data and identify any difference in facility
data resulting from the peer review process. The VISN must report on a
quarterly basis its data and analysis to VA headquarters.
Conclusions:
Following events at the VAMC in Marion, Illinois, which identified
weaknesses in the monitoring of physician quality of care, VA has
strengthened several of its credentialing and privileging policies and
guidance and has taken steps to implement a mechanism to help ensure
that VAMCs are not performing surgical procedures beyond their
capabilities. With the exception of the new policy requiring written
verification of licensure--which potentially wastes VA resources--
these policies, if implemented correctly by VAMCs, appear sufficient
to help facilities identify physicians who should not be providing
care to veterans, as well as surgical programs that may be endangering
veterans by authorizing the performance of complex procedures that are
not adequately supported.
We did not find problems at the six VAMCs we visited that mirrored the
extent of those reported by the VA OIG in 2008 at the Marion VAMC.
However, we identified deficiencies in credentialing, privileging, and
continuous monitoring of physicians that suggest a lack of scrutiny in
critical areas, such as awareness of physicians' experience with
malpractice and experience in all states where physicians have
practiced. Activities such as these are the responsibility of VAMCs'
service chiefs, who are the individuals best positioned to scrutinize
the background information provided by physicians seeking appointment
and to identify inconsistencies or missing information. However, the
lack of compliance we found related to service chiefs'
responsibilities suggests that service chief attention to these
activities needs to be made a higher priority. We also found
weaknesses in VetPro which, if corrected, would make it easier for
service chiefs to scrutinize the backgrounds of physicians and allow
them to make decisions based on complete and accurate information.
Absent complete and accurate information, service chiefs may recommend
physicians with inappropriate backgrounds for appointment to VAMC
medical staffs.
The lack of compliance we found at the six VAMCs indicates that
oversight of these activities needs heightened scrutiny at all levels--
VA, VISN, and VAMC. Because credentialing, privileging, and continuous
monitoring are facility-level processes, vigorous VISN oversight is
needed for VA to have reasonable assurance that VAMCs are implementing
these processes adequately. However, oversight of VAMCs' credentialing
and privileging activities was insufficient. VISN officials described
cursory activities, such as spending just 2 to 3 minutes per
credentialing and privileging file. Further, VA's policy for oversight
lacks internal controls, such as a follow-up mechanism to confirm that
identified problems have been properly addressed. In addition, while
VA has provided guidance on continuous monitoring that may be helpful
to facilities, we found gaps in monitoring efforts and that some
facilities continued to use protected information to make privileging
decisions.
Recommendations for Executive Action:
In order to improve oversight of credentialing, privileging, and
continuous monitoring processes at VAMCs, we are making three
recommendations. We recommend that the Secretary of Veterans Affairs
direct the Under Secretary for Health to take the following 3 actions:
* Require VISN directors to develop a formal oversight process to
systematically review credentialing and privileging files and the
information used to support reprivileging of physicians for compliance
with VA policies and document results of reviews and corrective
actions at least annually. The oversight process should include
feedback to VAMC officials about the proper use of legally protected
performance information, if necessary. In order to close the feedback
loop, the oversight process should describe a method of follow up to
measure whether VAMCs corrected identified weaknesses.
* Update VetPro to more effectively display physician credentialing
information. Specifically, VA should improve the display of verified
information on VetPro's summary tables and simplify and clarify
questions related to malpractice and licensure.
* Collect more information about state medical boards' policies on the
release of information, and consider amending VA policy to not require
written verification for states that do not provide additional
information in addition to what is available by phone or on the state
boards' Web sites.
Agency Comments:
VA provided us with comments on a draft of this report, which we have
reprinted in appendix II. In its comments, VA agreed with our
recommendations and described the agency's planned actions to
implement them. Specifically, VA said that a workgroup representing
VISN and VAMC leadership would develop a system of formal oversight
for the credentialing and privileging process. The system will include
documentation of results and corrective actions, with follow up at
least annually. The oversight framework is to be incorporated into a
revision to VA's credentialing and privileging policy, which will be
completed by June 2010. VA also plans revisions to VetPro which are
scheduled to be completed by September 2012. VA noted that these
revisions will include easier VetPro usage and will clarify VetPro's
display. Finally, VA said that its survey of state medical boards to
seek their willingness to provide additional information, initiated in
October 2009, will be analyzed and results considered for inclusion
into the current revision of VA's credentialing and privileging
policy. VA also provided technical comments, which we have
incorporated as appropriate.
We are sending copies of this report to the Secretary of Veterans
Affairs, appropriate congressional committees, and other interested
parties. In addition, the report is available at no charge on the GAO
Web site at [hyperlink, http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact me at (202) 512-7114 or w [Hyperlink, williamsonr@gao.gov]
illiamsonr@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 who made major contributions to this report are
listed in appendix III.
Signed by:
Randall B. Williamson:
Director, Health Care:
[End of section]
List of Congressional Addressees:
The Honorable Tim Johnson:
Chairman:
The Honorable Kay Bailey Hutchison:
Ranking Member:
Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Chet Edwards:
Chair:
The Honorable Zach Wamp:
Ranking Member:
Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies:
Committee on Appropriations:
House of Representatives:
The Honorable Bob Filner:
Chairman:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Richard J. Durbin:
United States Senate:
[End of section]
Appendix I: Scope and Methodology:
To determine what policies and guidance the Department of Veterans
Affairs (VA) has in place to help ensure that information about
physician professional qualifications, clinical abilities, and
clinical performance is accurate and complete, we reviewed VA policies
and guidance on credentialing and privileging and monitoring of
physician performance. To obtain more information about these policies
and guidance, we interviewed VA headquarters officials, including VA's
Director, Credentialing and Privileging. We reviewed 2008
credentialing and privileging accreditation standards issued by The
Joint Commission ("Joint Commission"), a nonprofit organization that
evaluates and accredits more than 16,000 health care organizations in
the United States, including hospitals. We also interviewed officials
from Joint Commission, including the Senior Vice President for
Healthcare Improvement and the Vice President, Standards and Survey
Methods.
To obtain information about the potential effects of VA's policy
requiring written verification of licensure, we interviewed VA's
Director of Quality Standards and two officials from the Federation of
State Medical Boards (FSMB)--the Senior Director of the Federation
Credentials Verification Services and Federation Physician Data Center
and Credentials Verification Service and the Manager of the FSMB
Physician Data Center. To obtain information on medical board policy
related to the disclosure of physician licensure information, we
conducted a Web-based survey of medical boards in all 50 states and
the District of Columbia.[Footnote 40] We opened the survey on March
19, 2009, and closed it on April 9, 2009, with a final response rate
of 76 percent.
To determine the extent to which selected VA medical centers (VAMC)
comply with selected VA credentialing and privileging policies, we
conducted site visits to six VAMCs and reviewed credentialing and
privileging files for a judgmental sample of 30 physicians at each
VAMC, a total of 180 physician records. For each physician, we
examined credentialing and privileging documentation for compliance
with VA policies. The four credentialing and privileging requirements
we selected for review included:
* verification of all state medical licenses ever held by the
physician;
* verification of malpractice claims by contacting a court of
jurisdiction or the insurance company involved in the medical
malpractice claim, or by obtaining a statement of claim status from
the attorney representing the physician in the malpractice claim;
* receipt of the minimum number of references; VA requires that
physicians provide three references prior to their initial appointment
at a VAMC and two references prior to medical staff reappointment; and:
* query the FSMB about disciplinary actions that state medical boards
have taken against physician licenses.
In addition to the four credentialing and privileging requirements, we
also examined whether credentialers ensured that reprivileging took
place within 2 years after the previous privileging process. We looked
for evidence of omissions by physician applicants related to medical
licenses, malpractice, and at five of six VAMCs visited, gaps in
background greater than 30 days. We also looked for documentation by
physician service chiefs--officials responsible for physicians
providing particular clinical services--of the rationale for
credentialing and privileging recommendations for physicians as is
required by VA policy. We interviewed staff responsible for
recommending or granting physician appointment or privileges--
including service chiefs, chiefs of staff, and facility directors--
about their decision-making processes. We also interviewed
credentialers who collect documentation to verify physician-supplied
information about their processes for verifying credentialing and
privileging information.
At each site we identified a judgmental sample of 30 physicians'
files. In selecting the files, we attempted to maximize the number of
physician medical specialties while also having consistency in the
specialties that were reviewed at each site. To identify which medical
specialties were likely to be represented at each site, we identified
a list of "core specialties" using descriptions of hospital services
and lists of designated service chiefs at VAMCs. From this core, we
identified the three highest paying surgical and medicine specialties
as well as the highest paying specialty from imaging services--since
pay is a challenge where VA competes with the private sector to hire
qualified physicians--and chose two physicians from each of these
specialties.[Footnote 41] We reviewed the files of at least five newly
hired physicians at each site to identify whether the facility was
complying with VA's October 2007 credentialing and privileging policy,
which was in effect when we began our work. In addition, at each site
we reviewed the files of at least two psychiatrists--because of VA's
initiative to hire more mental health providers--and all physicians
who were the only specialist in their discipline on the medical staff.
[Footnote 42] In addition, we reviewed the files of at least two
general surgeons, since problems at the Marion VAMC focused on issues
related specifically to the clinical skills of a general surgeon at
that facility. When the VAMC had more than two physicians in each
medical specialty we designated, or more than five newly hired
physicians, we chose files randomly from within the whole group of
specialists or new physicians. On the basis of the sample of physician
files we reviewed at each of the six VAMCs, we can discuss a
facility's documented compliance for the physician files we reviewed;
we cannot draw conclusions about the remaining physician files at the
VAMCs we visited or about the compliance of other VAMCs.
Because our file review included reviewing information in VetPro, we
assessed the database's reliability. To do this, we examined relevant
documentation and interviewed VA headquarters officials about measures
VA takes to ensure the reliability of information in VetPro. On the
basis of our review, we determined that the information in VetPro was
sufficiently reliable for the purposes of our report.
We visited the following facilities: Alexandria VAMC (Pineville,
Louisiana); Edward Hines, Jr. VA Hospital (Hines, Illinois); Lebanon
VAMC (Lebanon, Pennsylvania); Hunter Holmes McGuire VAMC (Richmond,
Virginia); Togus VAMC (Augusta, Maine); and VA Montana Health Care
System (Fort Harrison, Montana). We chose these VAMCs based on a
variety of factors, including location in metropolitan and
nonmetropolitan areas,[Footnote 43] geographic balance,[Footnote 44]
and facilities' procedural complexity level.[Footnote 45] We
eliminated from consideration those facilities that did not perform
inpatient surgery because the VA Office of Inspector General (OIG)
report on the Marion VAMC identified weaknesses in the inpatient
surgery unit. We also excluded the seven facilities we visited in our
2006 report on credentialing and privileging,[Footnote 46] and
facilities in Veterans Integrated Service Network (VISN) 15 because,
during the time of our selection process, a VA official told us that
the VISN was transitioning away from a centralized credentialing
process.[Footnote 47] We conducted our site visits between August 2008
and February 2009. The results from our site visits are not
generalizable to all facilities.
To determine the extent to which VA helps ensure compliance with its
credentialing and privileging policies, we reviewed VA policy changes
in October and November 2008 which contained provisions delegating
credentialing and privileging oversight responsibilities to VISN
officials. We reviewed GAO internal control standards to determine
criteria for management oversight.[Footnote 48] We interviewed the
chief medical officer (CMO) for each of the six VISNs where we
conducted a VAMC site visit to capture information about the review
processes in place to oversee the proper execution of credentialing
and privileging activities. Our interviews with VISN CMOs were
conducted between December 2008 and May 2009, after VA's policies had
been released. We reviewed VA's August 2009 guidance for evaluating
VAMCs' credentialing and privileging processes. Further, we analyzed
how the VetPro database displays information for users and the
information that physicians are asked to input into VetPro, and we
interviewed service chiefs to understand their interpretation of
information in VetPro. The analysis of the VetPro display included an
examination of how corrections made by VAMC staff were displayed for
VetPro users. The information from our site visits cannot be used to
generalize about practices at all VAMCs, and the information from our
interviews with VISN officials cannot be used to generalize about VA
oversight at the VISN level.
To determine the extent to which selected VAMCs implemented VA
policies and guidance to continuously monitor physician performance,
[Footnote 49] we reviewed relevant VA policies, including those for
credentialing and privileging, and interviewed VA headquarters
officials and the CMOs for six VISNs that included the VAMCs we
visited. To clarify our understanding of accreditation standards
relating to physician performance monitoring, we interviewed officials
from The Joint Commission. Finally, we evaluated VAMC implementation
of VA policies and guidance pertaining to physician performance
monitoring on our site visits to six VAMCs. We interviewed service
chiefs about efforts to monitor physician performance at each of the
VAMCs we visited, and collected documents describing how the
individual services conducted continuous monitoring of physician
performance. We spoke with the service chiefs in charge of the
surgery, mental health, and medicine services at each facility
visited.[Footnote 50] We also interviewed service chiefs in primary
care, radiology, and long-term care at some facilities. To determine
the possible effects of the inappropriate use of protected physician
performance information, we reviewed federal law and interviewed VA
general counsel staff. On the basis of the information we gathered, we
can discuss individual VAMC and service compliance with VA policies
and guidance to continuously monitor physician performance. However,
we cannot generalize about the other service practices at the selected
VAMCs, or about the practices at all VAMCs.
To examine the extent to which VA has oversight mechanisms in place to
track that VAMCs are performing surgical procedures that match their
capabilities, we reviewed several VA policies, including policies on
restructuring clinical programs, quality reviews of surgical programs
and outcomes, mortality assessment, and peer review for quality
management. We also reviewed the VA OIG report on the Marion VAMC to
identify issues related to surgical program oversight, and reviewed
and identified relevant accreditation standards from The Joint
Commission. For background information on VA's National Surgical
Quality Improvement Program (NSQIP), we reviewed copies of facility-
level NSQIP reports, NSQIP training materials, and peer-reviewed
journal articles on NSQIP. We reviewed the final report written by
VA's Operative Complexity and Infrastructure Standards Workgroup to
identify recommendations to VA in implementing its oversight
mechanism. We also conducted a series of interviews with the VA
headquarters officials to obtain additional information on
implementation for VA's oversight mechanism. While on site visits at
the selected VAMCs, we conducted interviews with chiefs of surgery,
and after the site visits, we conducted follow-up interviews to obtain
information on the facility-level use of NSQIP and other surgical
program monitors. The information we obtained through our site visits
and interviews with chiefs of surgery cannot be generalized to all
VAMCs.
We conducted this performance audit from July 2008 through January
2010 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
[End of section]
Appendix II: Comments from the Department of Veterans Affairs:
Department of Veterans Affairs:
Office of the Secretary:
December 14, 2009:
Mr. Randall B. Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VA HEALTH CARE: Improved
Oversight and Compliance Needed for Physician Credentialing and
Privileging Process (GAO-10-26) and agrees with the findings and
concurs with GAO's recommendations.
The Veterans Health Administration (VHA) is already moving forward to
enhance physician credentialing and privileging. The enclosure
describes actions taken or that will occur to address each of GAO's
recommendations. The enclosure also provides technical comments. VA
appreciates the opportunity to review and comment on your draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
The Department of Veterans Affairs (VA) Comments To Government
Accountability Office (GAO) Draft Report, VA Health Care: Improved
Oversight and Compliance Needed for Physician Credentialing and
Privileging Process (GAO-10-26):
GAO Recommendation: In order to improve oversight of credentialing,
privileging, and continuous monitoring processes at VAMCs, GAO
recommends that the Secretary of Veterans Affairs direct the Under
Secretary for Health to:
Recommendation 1: Require VISN Directors to develop a formal oversight
process to systematically review credentialing and privileging files
and the information used to support reprivileging of physicians for
compliance with VA policies and document results of reviews and
corrective actions at least annually. The oversight process should
include feedback to VAMC officials about the proper use of legally
protected performance information, if necessary. In order to close the
feedback loop the oversight process should describe a method of follow
up to measure whether VAMCs corrected identified weaknesses.
VA comments to the draft report: Concur. The Office of the Deputy
Under Secretary for Health for Operations and Management will
collaborate with Veterans Health Administration's (VHA) Office of
Quality and Safety, through the Office of Quality and Performance, to
facilitate a work group representing VISN and facility leadership to
develop a system of formal oversight of the credentialing and
privileging process. This oversight process, to be determined by the
Office of the Deputy Under Secretary for Health for Operations and
Management, will provide a systematic approach to a programmatic
review of compliance with VA policy, documenting results and
corrective actions and follow-up at least annually. The framework will
be incorporated into VA credentialing and privileging policy currently
under revision to be completed by June 2010.
Recommendation 2: Update VetPro to more effectively display physician
credentialing information. Specifically, VA should improve the display
of verified information on VetPro's summary tables and simplify and
clarify questions related to malpractice and licensure.
VA comments to the draft report: Concur. The Associate Deputy Under
Secretary for Health for Quality and Safety, through the Office of
Quality and Performance, has already initiated a new service request
for the next generation of VetPro. Requirements for functionality and
display will be developed by system users to enable easier VetPro
usage and clarity of its display.
Depending on approval of the new service request and the extent of
support from VA's Office of Information and Technology, the Office of
Quality and Performance anticipates the completed assessment and plan
for the next generation of VetPro system by September 2010. The
development and deployment of the new VetPro system is estimated to be
completed by September 2012.
Recommendation 3: Collect more information about state medical boards'
policies regarding the release of information, and consider amending
VA policy to not require written verification for states that do not
provide additional information from what is available by phone or on
the state boards' Web sites.
VA comments to the draft report: Concur. The Associate Deputy Under
Secretary for Health for Quality and Safety, through the Office of
Quality and Performance, initiated a survey in October 2009 to the 70
state medical boards, 53 state nursing boards, and 53 state dental
boards, to seek their willingness to provide additional information
for credentialing and privileging purposes. This survey will be
analyzed when completed and the results considered for inclusion into
the current revision to VA's credentialing and privileging policy. Any
amendments to the current credentialing and privileging policy will be
in concurrence by March 31, 2010.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114:
Staff Acknowledgments:
In addition to the contact named above, Marcia A. Mann, Assistant
Director; Susannah Bloch; Lori Fritz; Kaitlin McConnell; Kate Nast;
Steve Robblee; Jessica Cobert Smith; and Rusty Walker made key
contributions to this report.
[End of section]
Footnotes:
[1] Physicians must reapply for a position on a facility's medical
staff at least every 2 years, a process known as reappointment. After
the initial privileging process, each successive episode is known as
"reprivileging."
[2] Department of Veterans Affairs, Office of Inspector General,
Healthcare Inspection: Quality of Care Issues VA Medical Center,
Marion, Illinois, 07-03386-65 (Washington, D.C., Jan. 28, 2008).
[3] VA policy requires physicians to possess at least one full,
active, current, and unrestricted license.
[4] GAO, VA Health Care: Selected Credentialing Requirements at Seven
Medical Facilities Met, but an Aspect of Privileging Process Needs
Improvement, [hyperlink, http://www.gao.gov/products/GAO-06-648]
(Washington, D.C.: May 25, 2006). The other four privileging
requirements we reviewed were: (1) verify that physicians' state
medical licenses are valid; (2) verify physicians' training and
experience; (3) assess physicians' clinical competence and health
status; and (4) consider any information provided by a physician
related to malpractice allegations or paid claims, loss of medical
staff membership, loss or reduction of privileges, or any challenges
to state medical licenses.
[5] While VA requires that VAMCs collect and analyze physician
performance information for use in the reprivileging process, this
performance information must be collected outside of a VAMC's quality
management program. VAMCs' quality management programs consist of
specified systematic health care reviews carried out in order to
improve the quality of medical care or the utilization of health care
resources at VAMCs.
[6] GAO, VA Health Care: Improvements Made in Physician Privileging
Policies, but Medical Facility Compliance Has Not Been Assessed,
[hyperlink, http://www.gao.gov/products/GAO-08-271T] (Washington,
D.C.: Nov. 6, 2007).
[7] H. Committee on Appropriations, 110th Cong., Committee Print on
H.R. 2764/Public Law 110-161, Division I, p. 1956 (2008) (Pub. L. No.
110-161, § 4, directed that the explanatory statement printed in the
Congressional Record on or about December 17, 2007 shall have the same
effect as if it were a joint explanatory statement of a committee of
conference. See 153 Cong. Rec. H15479 (daily ed. Dec. 17, 2007)).
[8] We did not survey state boards of osteopathic medicine.
[9] GAO, Standards for Internal Control in the Federal Government,
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]
(Washington, D.C.: November 1999).
[10] VA's health care system is organized into 21 geographically
defined regions, or VISNs, which have budget and management
responsibilities for VA facilities located within their region.
[11] Examples of other services at VAMCs we visited included primary
care, geriatrics, and radiology.
[12] Physicians applying for reprivileging are expected to provide two
references.
[13] In 1991, VA began a study in 44 VAMCs to validate the methodology
of NSQIP. In 1994, VA established NSQIP as a monitoring mechanism in
all VAMCs.
[14] VHA Directive 2007-008, Quality Reviews of Surgical Programs and
Outcomes, states that any facility that is an outlier during the 6-
month reporting period must perform a written assessment of all
mortalities, and that two consecutive 6-month periods would prompt a
site visit. A VA headquarters official told us that this directive is
currently under revision, and that the current practice includes a
quarterly reporting period.
[15] Shukri F. Khuri, "The NSQIP: A New Frontier in Surgery," Surgery
138(5) (2005): 839.
[16] This information is provided to FSMB by state medical boards.
[17] The NPDB is administered by the U.S. Department of Health and
Human Services and includes information on physicians who either have
been disciplined by a state medical board, professional society, or
health care provider or have been named in a medical malpractice
settlement or judgment.
[18] Under the new policy, VAMCs may initially obtain licensure
verification by Web site or telephone, but must request written
verification within 5 days.
[19] We based this review on VA's 2007 credentialing and privileging
policies, which were the policies in place when we began visiting the
six VAMCs.
[20] We cannot be certain our review reflects all instances in which
omissions by physicians occurred. The data we collected during
physician file reviews captures detail about instances in which
evidence elsewhere in the physician file demonstrated that required
information was missing.
[21] VA policy states: "VA application forms, or supplemental forms,
require applicants to give detailed written explanations of any
involvement in administrative, professional, or judicial proceedings,
including Federal tort claims proceedings, in which malpractice is, or
was, alleged."
[22] VA does not provide a definition in VetPro. A claim against a
federal agency under the Federal Tort Claims Act may be referred to as
an administrative tort claim. See 28 C.F.R. Part 14. Such a claim
could result from injury or death alleged to have been caused by a
physician working for the VA or another federal agency.
[23] We did not find documentation that the facility addressed the
physician's confusion by following up to explain what information was
required.
[24] CMOs were given responsibility for "ensuring a sound process for
granting and renewing clinical privileges" in an October 2008 policy.
They were assigned to oversee credentialing and privileging processes
of VAMCs in their respective VISNs according to the November 2008
revision of VA's credentialing and privileging policy.
[25] GAO, Standards for Internal Control in the Federal Government,
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]
(Washington, D.C.: November 1999).
[26] The VA headquarters official responsible for credentialing and
privileging estimated that a thorough review of a physician file
should take at least 30 minutes.
[27] The Joint Commission standards do not include some VA policy
requirements related to credentialing. For example, the Joint
Commission does not require facilities to collect information about
all medical licenses that have ever been held by a physician, as VA
does. The VA OIG inspection protocol that was in place when we
interviewed VISN officials did not include review of any elements of
credentialing. The OIG revised its review protocol starting in July
2009, and this revised protocol contains some elements for reviewing
credentialing information. However, the revised protocol does not ask
inspectors to look for evidence of required information that physician
applicants have not provided in their credentialing file.
[28] The OPPE process allows clinical leadership to identify
professional practice trends that affect the quality of care and
patient safety. Because this December 2008 guidance was issued in the
middle of our site visits, which occurred from August 2008 to February
2009, we did not evaluate the extent to which the six VAMCs we visited
had implemented the OPPE process.
[29] Peer review is a nonpunitive, critical review of a physician's
clinical interventions performed by a peer or group of peers. The
purpose of peer review is to improve the quality of care or
utilization of resources at a VAMC. A peer is a practitioner of
similar education, training, licensure, and privileges or scope of
practice. A typical peer review involves a single reviewer making a
judgment about the quality of decisions associated with another
physician's clinical intervention. Peer reviews ultimately result in
the case receiving a rating based on whether other experienced,
competent practitioners would have managed the case in a similar
manner.
[30] See [hyperlink, http://www.gao.gov/products/GAO-06-648].
[31] The Workgroup included clinicians from VA headquarters, VISN, and
VAMC levels.
[32] According to a 2008 Joint Commission standard on determination of
organizational resource ability (MS.4.00), medical staff must
determine before granting privileges that the resources necessary to
support the privileges granted are currently available or available
within a specified time frame. The standard does not specify the
resources needed for specific procedures.
[33] Major expansion includes the introduction of a new surgical
procedure which would significantly increase the complexity of
procedures done at the facility, or the introduction of thoracic or
vascular surgery, transplant services, cardiac surgery, bariatric
surgery, neurosurgery, or total joint replacement. This policy also
prohibits any elimination of major clinical programs without approval.
[34] A panel of experts is specifically required when new programs are
desired in robotic surgery, bariatric surgery, transplant surgery,
cardiac surgery, or neurosurgery.
[35] NSQIP oversees the quality of certain noncardiac surgeries; the
Continuous Improvement in Cardiac Surgery Program similarly oversees
cardiac surgical programs, and the Neurologic Surgery Consultants Work
Group oversees neurosurgical programs.
[36] Other types of quality monitoring mechanisms mentioned include
infection control reviews and surgical and other invasive procedure
review.
[37] The policy requires trending data by provider when the provider
can be linked to the care of a specific patient.
[38] VHA Directive 2005-056, Mortality Assessment (Dec. 1, 2005).
[39] VHA Directive 2008-004, Peer Review for Quality Management (Jan.
28, 2008).
[40] We did not survey state boards of osteopathic medicine. The New
York State Education Department, Office of the Professions, is
responsible for updating physician licensure information, while the
Department of Health Office of Professional Medical Conduct maintains
information related to physician discipline. We surveyed each
organization separately and combined their responses into one response
for New York.
[41] Physician pay data came from the American Medical Group
Association's 2007 Medical Group Compensation and Financial Survey.
The surgical specialties selected were orthopedic surgery, urology,
and anesthesiology. The medical specialties selected were cardiology,
gastroenterology, and dermatology.
[42] We chose these sole specialists because for these physicians peer
review often must be done using specialists from outside the facility.
[43] We considered area population in the selection process to ensure
that we included VAMCs in regions that were similar to the Marion VAMC
in terms of rurality or geographic isolation. To identify those VAMCs
in rural and geographically isolated areas, we used the Rural-Urban
Continuum Codes from the 2007 Area Resource File. We deemed a facility
rural or geographically isolated if it was located in a
nonmetropolitan county or the lowest population category for
metropolitan counties in the continuum. Facilities that met this
standard were located in counties in nonmetropolitan areas or in
metropolitan areas of less than 250,000 people. Four of the six
facilities we visited--Lebanon VAMC, VA Montana Health Care System,
Togus VAMC, and Alexandria VAMC--met this standard.
[44] To address geographic balance, the selected VAMCs were from
different VISNs and Census divisions.
[45] To consider facility complexity, we used VA's classification
system that assigns VAMCs to one of three complexity levels. In
descending order of complexity, they are complexity level 1 (further
subdivided into levels 1a, 1c, and 1c), complexity level 2, and
complexity level 3. We selected two hospitals at complexity level 1,
two hospitals at level 2, and two hospitals at level 3. Alexandria
VAMC, a complexity level 2 facility at the time of our site selection,
had been reclassified as a complexity level 3 facility at the time of
our site visit.
[46] The VAMCs were located in Boise, Idaho; Kansas City, Missouri;
Las Vegas, Nevada; Lexington, Kentucky; Martinsburg, West Virginia;
Miami, Florida; and San Antonio, Texas.
[47] Marion VAMC is part of VISN 15.
[48] GAO, Standards for Internal Control in the Federal Government,
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]
(Washington, D.C.: November 1999).
[49] We conducted our site visits between August 2008 and February
2009. Evaluation of VAMC compliance with VA policies on continuous
monitoring of physician performance is based on VA's October 2007
policy on credentialing and privileging. While VA issued a revised
policy in November 2008, we had already conducted several site visits
and therefore evaluated all six VAMCs based on VA's 2007 policy.
[50] We chose surgery because the VA OIG identified problems with the
surgical program at the Marion VAMC, and mental health because of a
recent VA initiative to hire more mental health physicians. At one
VAMC we interviewed the associate chief of staff (ACOS) for acute
care. At this facility, the acute care unit is organized to include
physician staff positions in internal medicine. While the ACOS for
acute care was not the direct supervisor for internal medicine
physicians, the ACOS has ultimate responsibility for the internal
medicine practices of the VAMC.
[End of section]
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