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entitled 'VA Health Care: Selected Credentialing Requirements at Seven 
Medical Facilities Met, but an Aspect of Privileging Process Needs 
Improvement' which was released on June 15, 2006. 

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Report to the Chairman, Committee on Veterans' Affairs, House of 
Representatives: 

United States Government Accountability Office: 

GAO: 

May 2006: 

VA Health Care: 

Selected Credentialing Requirements at Seven Medical Facilities Met, 
but an Aspect of Privileging Process Needs Improvement: 

VA Credentialing and Privileging: 

GAO-06-648: 

GAO Highlights: 

Highlights of GAO-06-648, a report to the Chairman, Committee on 
Veterans' Affairs, House of Representatives. 

Why GAO Did This Study: 

The Department of Veterans Affairs (VA) is responsible for determining 
that over 36,000 physicians working in its facilities have the 
appropriate professional credentials and qualifications to deliver 
health care to veterans. To do this, VA credentials and privileges 
physicians providing care at its medical facilities. In this report, 
GAO determined the extent to which selected VA facilities complied with 
(1) four VA credentialing requirements and five VA privileging 
requirements and (2) a requirement to submit information on paid 
malpractice claims. GAO also determined (3) whether VA has internal 
controls to help ensure the accuracy of information used to renew 
clinical privileges. GAO reviewed VA’s policies, interviewed VA 
officials, and randomly sampled 17 physician files at each of seven VA 
medical facilities. 

What GAO Found: 

GAO found that the files reviewed at seven VA medical facilities 
complied with four of VA’s credentialing requirements selected for 
review, and all but one of five privileging requirements. Credentialing 
is the process of verifying that a physician’s professional 
credentials, such as state medical licenses, are valid and meet VA’s 
requirements for employment. Privileging is the process for determining 
which health care services a physician is allowed to provide to 
veterans. For the files GAO reviewed, compliance with the fifth 
privileging requirement was problematic at six facilities because 
officials used performance information when renewing clinical 
privileges but collected all or most of this information through their 
facility’s quality assurance program. This is prohibited under VA 
policy. In general, VA quality assurance information is confidential, 
according to federal law and VA policy. According to VA officials, if 
quality assurance information is used outside of a facility’s quality 
assurance program, it could be used for other purposes, including 
litigation. The information is protected to encourage physicians to 
participate in quality assurance programs by reporting and discussing 
adverse events to help prevent such events from occurring in the 
future. VA has not provided guidance to help medical facilities find 
ways to efficiently collect performance information outside of a 
facility’s quality assurance program. At the seventh medical facility, 
officials did not use performance information to renew clinical 
privileges, as required. 

Three of the seven medical facilities did not meet VA’s requirement to 
submit, within 60 days after being notified that the claim was paid, 
any information on paid VA medical malpractice claims involving 
facility practitioners, including physicians, to VA’s Office of Medical-
Legal Affairs. This office reviews the information and determines 
whether practitioners involved in the claims delivered substandard 
care, displayed professional incompetence, or engaged in professional 
misconduct. The office informs facilities of its determinations. When 
facilities do not submit all relevant VA malpractice information in a 
timely manner, VA medical facility officials lack complete information 
that would allow them to make informed decisions about the clinical 
privileges that their physicians should be granted. 

VA has not required its medical facilities to establish internal 
controls to help ensure that privileging information managed by medical 
staff specialists—who are responsible for obtaining and verifying the 
information used in the credentialing and privileging processes—is 
accurate. One facility GAO visited did not identify 106 physicians 
whose privileging process had not been completed by facility officials 
for at least 2 years because of inaccurate information provided by the 
facility’s medical staff specialist. As a result, these physicians were 
practicing at the facility without current clinical privileges. Without 
accurate information on the privileges that have been granted to 
physicians and the dates for renewing those privileges, VA medical 
facility officials will not know if they have failed to renew clinical 
privileges for any of their physicians in accordance with VA policy. 

What GAO Recommends: 

GAO recommends that VA provide guidance to its medical facilities on 
how to collect physician performance information in accordance with 
VA’s policy that can be used to renew clinical privileges, enforce the 
timely submission of VA medical malpractice information, and instruct 
facilities to establish internal controls for privileging information. 
VA concurred with the findings and recommendations and provided an 
action plan to implement the three recommendations. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-648]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Laurie E. Ekstrand at 
(202) 512- 7101 or ekstrandl@gao.gov. 

[End of Section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Selected Physician Files at Medical Facilities Demonstrated Compliance 
with Four VA Credentialing and Four Privileging Requirements; 
a Fifth Privileging Requirement Was Problematic: 

Not All Medical Facilities Submitted Paid Malpractice Claim Information 
in a Timely Manner: 

VA Has Not Established Internal Controls to Help Ensure the Accuracy of 
Medical Facilities' Privileging Information: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Comments from the Department of Veterans Affairs: 

Appendix III: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Table: 

Table 1: Average Number of Months Taken by Three VA Medical Facilities 
to Submit VA Medical Malpractice Claim Information to VA's Office of 
Medical-Legal Affairs (as of December 2005): 

Figures: 

Figure 1: Steps Taken in VA's Physician Credentialing Process: 

Figure 2: Steps Taken in VA's Physician Privileging Process: 

Figure 3: Medical Malpractice Claim Information Not Submitted by Three 
VA Medical Facilities to the Office of Medical-Legal Affairs within 60 
Days: 

Abbreviations: 

FSMB: Federation of State Medical Boards 
NPDB: National Practitioner Data Bank 
VA: Department of Veterans Affairs: 

United States Government Accountability Office: 

Washington, DC 20548: 

May 25, 2006: 

The Honorable Steve Buyer: 
Chairman Committee on Veterans' Affairs: 
House of Representatives: 

Dear Mr. Chairman: 

The Department of Veterans Affairs (VA) has over 36,000 physicians 
working at more than 1,300 facilities in its health care system. To 
help ensure the quality of the health care these physicians deliver and 
the safety of veterans, VA is responsible for determining that its 
physicians have the appropriate professional credentials and clinical 
experience to provide health care to VA's patients.[Footnote 1] To do 
this, VA credentials and privileges physicians providing care at VA 
medical facilities. Credentialing is the process of verifying that a 
physician's professional credentials, such as licensure, education, and 
training, are valid and meet VA's requirements for employment. 
Privileging is the process for determining--based in part on a 
physician's credentials--which health care services a physician should 
be allowed to provide to VA patients without supervision.[Footnote 2] 
These health care services are known as a physician's clinical 
privileges. Physicians are granted initial clinical privileges when 
they begin their employment at a VA medical facility. Physicians' 
professional credentials and clinical privileges must be reviewed and 
renewed at least every 2 years.[Footnote 3] VA's credentialing and 
privileging policy describes the information that VA medical facility 
officials are required to review and verify in order to credential and 
grant clinical privileges to VA physicians. In addition to the 
requirements outlined in VA's credentialing and privileging policy, 
medical facility officials are required to submit information to VA 
headquarters on any VA physicians who are involved in paid VA medical 
malpractice claims. This malpractice information is used by VA 
headquarters to make decisions about the appropriateness of the care 
delivered to veterans and should be used by medical facility officials 
when making decisions about the clinical privileges to grant 
physicians. 

You expressed interest in the credentialing and privileging of VA 
physicians and how this helps VA ensure the delivery of safe care to 
veterans. In response to your request, we (1) determined the extent to 
which selected VA medical facilities complied with four of VA's 
credentialing requirements and five of VA's privileging requirements in 
relation to individual physicians, and (2) determined the extent to 
which selected VA medical facilities complied with the requirement to 
submit information to VA headquarters on paid VA medical malpractice 
claims involving VA physicians. Also, during the course of our work, we 
learned about a medical facility where inaccuracies in privileging 
information resulted in 106 physicians providing care to veterans in 
the facility without the required clinical privileges. According to VA 
officials, the individual responsible for privileging data 
inappropriately changed the privileging dates for some of these 
physicians to a later date in order to delay work needed to complete 
the credentialing and privileging requirements on these physicians. 
This led us to add to our review a reporting objective related to 
internal controls. Specifically, in this report we also (3) determined 
whether VA has internal controls to help ensure the accuracy of 
information medical facilities use to renew physicians' clinical 
privileges. 

To determine the extent to which selected VA medical facilities 
complied with four of VA's credentialing requirements and five of VA's 
privileging requirements in relation to individual physicians, we 
reviewed VA's policies to identify the requirements that VA medical 
facility officials must follow when credentialing and granting clinical 
privileges to physicians. We selected four of VA's credentialing 
requirements for review because they are requirements that--unlike 
others--address information about physicians that can change or be 
updated with new information periodically. As a result, VA requires 
that this information be verified by medical facility officials when a 
physician initially applies for employment at VA and at least every 2 
years thereafter. Other VA credentialing requirements are not subject 
to change or updating and are required by VA to be verified when the 
physician initially applies for employment.[Footnote 4] Under the four 
requirements we reviewed, VA medical facility officials must: 

1. verify that all state medical licenses held by physicians are valid; 

2. query the Federation of State Medical Boards (FSMB) database to 
determine whether physicians had disciplinary action taken against any 
of their licenses, including expired licenses; 

3. verify information provided by physicians on their involvement in 
medical malpractice claims at a VA or non-VA facility; 
and: 

4. query the National Practitioner Data Bank (NPDB) to determine 
whether a physician was reported to this data bank because of 
involvement in VA or non-VA paid medical malpractice claims, display of 
professional incompetence, or engagement in professional misconduct. 

Of the privileging requirements in VA's credentialing and privileging 
policy, we selected four requirements that VA identifies as general 
privileging requirements. In addition, we selected another privileging 
requirement about the use of individual performance information because 
of its importance in the renewal of clinical privileges. The five VA 
privileging requirements we selected are: 

1. verify that all state medical licenses held by physicians are valid; 

2. verify physicians' training and experience; 

3. assess physicians' clinical competence and health status; 

4. consider any information provided by a physician related to medical 
malpractice allegations or paid claims, loss of medical staff 
membership, loss or reduction of clinical privileges at a VA or non-VA 
facility, or any challenges to a physician's state medical license; 
and: 

5. use information on a physician's performance when making decisions 
about whether to renew the physician's clinical privileges. 

Two of the five privileging requirements--verify all state medical 
licenses and consider medical malpractice information--are also VA 
credentialing requirements we reviewed. 

To determine the extent to which selected VA medical facilities 
complied with four of VA's credentialing requirements and five of VA's 
privileging requirements, we conducted site visits to seven VA medical 
facilities that were chosen based on the diversity of their size and 
geographic location. The medical facilities are located in Boise, 
Idaho; Kansas City, Missouri; Las Vegas, Nevada; Lexington, Kentucky; 
Martinsburg, West Virginia; Miami, Florida; and San Antonio, Texas. For 
each of the seven medical facilities, VA officials provided a list of 
medical facility physicians grouped by their clinical specialty. Using 
this list, at each medical facility we randomly selected 17 physicians 
and obtained files with their credentialing and privileging 
information. Our sample included physicians working in VA medical 
facilities full-time and part-time, through a contract,[Footnote 5] or 
without direct compensation from VA. In some cases, these physicians 
also worked at non-VA medical facilities. Eight of the 17 physician 
files at each medical facility represent eight clinical specialties 
that are offered at most VA medical facilities: anesthesiology, 
gastroenterology, neurology, oncology, ophthalmology, orthopedics, 
radiology, and urology. Four of the 17 represent general surgery and 
internal medicine and 5 of the 17 had no specialty identified on the 
list provided by VA. To determine whether the files we reviewed 
demonstrated compliance with the four VA credentialing requirements and 
VA's privileging requirements at each of the seven VA medical 
facilities, we reviewed paper copy credentialing and privileging files 
for our sample of physicians to determine whether these files included 
documentation demonstrating that medical facility officials had 
complied with the credentialing and privileging requirements. We also 
reviewed credentialing information on these physicians stored in 
VetPro, a Web-based credentialing system VA implemented in March 2001. 
Based on the sample of physician files we reviewed at each of the seven 
medical facilities, we can discuss a medical facility's compliance for 
the physician files we reviewed; we cannot draw conclusions about the 
remaining physician files at the medical facilities we visited or about 
the compliance of other VA medical facilities. In collecting 
information on the credentialing and privileging requirements from 
physician files at each facility, we employed standard data collection 
techniques to ensure the accuracy and reliability of the data used in 
this report. 

Finally, we included in our review a requirement that is related to the 
privileging process. Under this requirement, medical facility officials 
must submit to VA's Office of Medical-Legal Affairs any information on 
VA practitioners, including physicians, who were involved in a paid VA 
medical malpractice claim. The Office of Medical-Legal Affairs 
determines whether the physicians involved in these claims delivered 
substandard care to veterans.[Footnote 6] We collected information 
about the extent to which each of the seven medical facilities in our 
review submitted malpractice information to the Office of Medical-Legal 
Affairs. 

To determine whether VA has internal controls to help ensure the 
accuracy of information medical facilities use to renew physicians' 
clinical privileges, we interviewed the director of VA's credentialing 
and privileging program, as well as other VA headquarters and medical 
facility officials. We identified the internal controls VA has in place 
for its privileging process and, using GAO's standards for internal 
controls in the federal government, determined whether these controls 
are adequate.[Footnote 7] For a complete description of our scope and 
methodology, see appendix I. We conducted our work from July 2005 to 
May 2006 in accordance with generally accepted government auditing 
standards. 

Results in Brief: 

The physician files we reviewed at the seven VA medical facilities 
demonstrated compliance with the four credentialing requirements we 
reviewed and four of the five privileging requirements. The files we 
reviewed showed that compliance with the fifth privileging requirement-
-to use information on a physician's performance in making privileging 
decisions--was problematic at six of the seven VA medical facilities we 
visited. At these six medical facilities, officials obtained this 
information from their facility's quality assurance program. In 
general, information that is collected as part of VA's quality 
assurance program is confidential according to federal law, and VA by 
policy prohibits the use of such information in connection with 
privileging. This information is protected, in large part, to encourage 
physicians to participate in quality assurance programs by reporting 
and discussing openly the causes of adverse patient events to help 
prevent such events from occurring in the future. According to VA 
officials, if quality assurance information is used outside of a 
facility's quality assurance program, it could be available for other 
purposes, including litigation. VA has not provided guidance to help 
medical facilities find alternative ways to efficiently collect 
performance information, outside of a facility's quality assurance 
program, that could be used in the renewal of clinical privileges. At 
the seventh medical facility, officials did not use performance 
information to renew clinical privileges, as required. 

Three of the seven medical facilities we visited did not meet the 
requirement to submit, within 60 days, information on paid VA medical 
malpractice claims involving their practitioners, including physicians, 
to VA's Office of Medical-Legal Affairs. This office reviews the claims 
information and makes a determination of whether practitioners, 
including physicians, involved in the claims delivered substandard care 
to veterans. If it is determined that the physician delivered 
substandard care to veterans, the medical facility must report the 
physician to NPDB. When VA medical facilities do not submit all 
relevant information to the Office of Medical-Legal Affairs in a timely 
manner, facility officials make privileging decisions without the 
advantage of determinations on whether VA physicians delivered 
substandard care. In addition, substandard care determinations that are 
required to be reported to the NPDB go unreported or reporting is 
delayed when VA medical facilities do not send information in a timely 
manner to the Office of Medical-Legal Affairs. This delay or lack of 
reporting to NPDB prevents other VA and non-VA facilities where the 
physician may also practice from having complete information on the 
physician's medical malpractice history. 

VA has not required its medical facilities to establish internal 
controls to help ensure that privileging information managed by medical 
staff specialists--employees responsible for obtaining and verifying 
the information used in the credentialing and privileging processes--is 
accurate. One facility we visited did not identify 106 physicians whose 
privileging process had not been completed by facility officials for at 
least 2 years because of inaccurate information provided by the 
facility's medical staff specialist. As a result, these physicians were 
practicing at the facility without current clinical privileges. 
Subsequent to our visit, this facility implemented internal controls to 
reduce the risk of a similar situation occurring in the future. During 
our site visits, we did not identify any medical facilities that had 
established such internal controls. Without accurate information on the 
privileges that have been granted to physicians and the dates for 
renewing those privileges, VA medical facility officials will not know 
if they have failed to renew clinical privileges for any of their 
physicians in accordance with VA policy. 

To better ensure that VA physicians are qualified to deliver care 
safely to veterans, we recommend that VA provide guidance to medical 
facilities on how to collect individual physician performance 
information in accordance with VA's credentialing and privileging 
policy to use in the renewal of physicians' clinical privileges, and 
that VA enforce the requirement that medical facilities submit 
information on paid VA medical malpractice claims to VA's Office of 
Medical-Legal Affairs within 60 days after being notified that the 
claim is paid. Additionally, we recommend that VA instruct its medical 
facilities to establish internal controls to ensure the accuracy of 
their privileging information. In commenting on a draft of this report, 
VA agreed with our findings and conclusions and concurred with our 
recommendations. VA also provided an action plan to address the three 
recommendations. 

Background: 

Physicians who work at VA medical facilities are required to hold at 
least one current and unrestricted state medical license. Current and 
unrestricted licenses are those in good standing in the states that 
issued them, and licensed physicians may hold licenses from more than 
one state. State medical licenses are issued by state licensing boards, 
which generally establish state licensing requirements governing their 
licensed practitioners.[Footnote 8] To keep a license current, 
physicians must renew their licenses before they expire and meet 
renewal requirements established by state licensing boards, such as 
continuing education. Renewal procedures and requirements vary by 
state. When state licensing boards discover violations of licensing 
practices--such as the abuse of prescription drugs or the provision of 
substandard care--that result in adverse health effects, they may place 
restrictions on licenses or revoke them. Restrictions issued by a state 
licensing board can limit or prohibit a physician from practicing in 
that particular state. Generally, state licensing boards maintain a 
database that contains information on any restrictions or revocations 
of physicians' licenses. 

VA requires its medical facility officials to credential and privilege 
facility physicians periodically in order to work at VA. VA physicians 
must be credentialed and privileged prior to their initial appointment 
to a facility's medical staff and then again at least every 2 years 
when they must reapply for a position on the facility's medical staff. 
The latter is known as the process of reappointment. 

VA's Credentialing Process: 

Prior to working at VA, physicians initiate the credentialing process 
for their initial appointment by completing VA's application process, 
which includes entering into VetPro information used by VA medical 
facility officials in the credentialing process. Among the 
credentialing information that VA requires physicians enter into 
VetPro, for their initial appointment, is information on all the 
medical licenses they have ever held and the states where they have 
obtained these licenses, including any licenses they have held that 
have expired. For their reappointments, physicians must update this 
credentialing information in VetPro. 

Once physicians enter their credentialing information into VetPro, a 
facility's medical staff specialist--an employee who is responsible for 
obtaining and verifying the information used in the credentialing and 
privileging processes--performs a data check on the information to be 
sure that all required information has been entered. In general, the 
medical staff specialist at each VA medical facility manages the 
accuracy of VetPro's credentialing data. The medical staff specialist 
verifies, with the original source of the information, the accuracy of 
the credentialing information entered by the physicians. This type of 
check is known as primary source verification. For example, the medical 
staff specialist contacts state licensing boards in order to verify 
that physicians' state medical licenses are valid and unrestricted. 

Medical staff specialists are required, at initial appointment and at 
reappointment, to verify the status of the state medical licenses 
physicians disclose to VA by listing them in VetPro. The medical staff 
specialists can obtain information on the status of physicians' state 
medical licenses by accessing the information on state licensing 
boards' Web sites or by contacting the boards directly. 

At initial appointment only, VA requires medical staff specialists to 
query FSMB, which contains information from state licensing boards. 
This query enables officials to determine all the state medical 
licenses a physician has ever held, including those not disclosed by a 
physician to VA, and whether a physician has had any disciplinary 
actions taken against these licenses. VA does not require this query at 
reappointment because VA headquarters regularly receives reports from 
FSMB on any VA physician whose name appears on FSMB's list, indicating 
that disciplinary action has been taken against the physician's state 
medical license. When VA headquarters receives a report from FSMB, it 
notifies the appropriate VA medical facility. 

VA's credentialing process requires VA medical staff specialists to 
verify medical malpractice claims at initial appointment and at 
reappointment. These claims may be verified by contacting a court of 
jurisdiction or the insurance company involved in the medical 
malpractice claim, or by obtaining a statement of claims status from 
the attorney representing the physician in the medical malpractice 
claim. In addition, VA requires medical staff specialists to query 
NPDB, which contains reports by state licensing boards, hospitals, and 
other health care entities on unprofessional behavior on the part of 
physicians or adverse actions taken against them. This query enables 
officials to determine whether physicians fully disclosed to VA any 
involvement they might have had in paid medical malpractice 
claims.[Footnote 9] Once a physician's credentialing information has 
been verified, the medical staff specialist sends the information to 
the physician's supervisor, who is known as a clinical service 
chief.[Footnote 10] The clinical service chief reviews this information 
along with the physician's privileging information. Figure 1 
illustrates VA's credentialing process. 

Figure 1: Steps Taken in VA's Physician Credentialing Process: 

[See PDF for image] 

Note: This credentialing process takes place at VA medical facilities. 

[End of figure] 

Privileging Process: 

At the same time physicians enter credentialing information into 
VetPro, they complete a written request for clinical privileges. The 
facility medical staff specialist provides the physician's clinical 
service chief with the requested clinical privileges and information 
that indicates that the credentialing information entered by the 
physician into VetPro has been verified with the appropriate primary 
sources. The medical staff specialist also provides the physician's 
clinical service chief with information on the physician's ability to 
perform the clinical privileges requested, including whether the 
physician has had a physical examination performed for initial 
appointment. For reappointment, documentation is required by another 
physician stating that the physician is able to perform both physically 
and mentally the clinical privileges requested. In addition, the 
medical staff specialist provides the clinical service chief with 
information on medical malpractice allegations or paid claims, loss of 
medical staff membership, loss or reduction of clinical privileges, or 
any challenges to the physician's state medical licenses. 

The requested clinical privileges are reviewed by a clinical service 
chief, who recommends whether a physician should be appointed or 
reappointed to the facility's medical staff and which clinical 
privileges should be granted. When deciding to recommend clinical 
privileges, a clinical service chief considers whether the physician 
has the appropriate professional credentials, training, and work 
experience to perform the privileges requested. For reappointment only, 
a clinical service chief is to consider observations of the physician's 
delivery of health care to veterans, and VA's policy requires that 
information on a physician's performance, such as a physician's 
surgical complication rate, be used when deciding whether to renew a 
physician's clinical privileges. Based on the clinical service chief's 
observations and the physician's performance information, the clinical 
service chief recommends that clinical privileges previously granted by 
the facility remain the same, be reduced, or revoked, and whether newly 
requested privileges should be added.[Footnote 11] 

Clinical service chiefs forward their recommendations and the reasons 
for the recommendations to the next level of a medical facility's 
privileging review process, which may be a professional standards board 
or a medical executive committee.[Footnote 12] A medical facility 
professional standards board or the medical executive committee reviews 
the recommendations of the clinical service chief and recommends to the 
facility director whether the physician should be appointed to the 
facility's medical staff and which clinical privileges should be 
granted to the physician. The 2-year time period for renewal of 
clinical privileges and reappointment to the medical staff begins on 
the date that the privileges are approved by the medical facility's 
director. The list of approved clinical privileges with the date of 
approval is maintained in paper copy files at VA medical facilities and 
the initial appointment or reappointment date is entered into VetPro. 
Figure 2 illustrates VA's privileging process. 

Figure 2: Steps Taken in VA's Physician Privileging Process: 

[See PDF for image] 

Note: This privileging process takes place at VA medical facilities. 

[End of figure] 

According to VA's policy and a VA memorandum, information concerning 
individual physician performance that is used as part of the 
privileging process to either reduce, revoke, or support[Footnote 13] 
granting clinical privileges must be collected separately from a 
medical facility's quality assurance program.[Footnote 14] VA's policy 
is based on a federal law that restricts the disclosure of documents 
produced in the course of VA's quality assurance program.[Footnote 15] 
In general, documents created in connection with such a program are 
confidential and may not be disclosed except in limited 
circumstances.[Footnote 16] Individuals who willfully disclose 
documents that they know are protected quality assurance documents are 
subject to fines up to $20,000. Although the law states that it is not 
intended to limit the use of documents within VA, VA's policy expressly 
prohibits the use of such documents in connection with the privileging 
process. VA's use of separate information sources for quality assurance 
and privileging decisions is intended to maintain the confidential 
status of documents produced in connection with quality assurance 
programs. According to VA, the confidentiality of individual 
performance information helps ensure provider participation, including 
physicians, in a medical facility's quality assurance program by 
encouraging providers to openly discuss opportunities for improvement 
in provider practice without fear of punitive action. 

VA has another requirement that is related to the renewal of 
physicians' clinical privileges. Medical facility officials are 
required to submit to VA's Office of Medical-Legal Affairs information 
on malpractice claims. This information must be submitted within 60 
days after being notified about a paid malpractice claim. The Office of 
Medical-Legal Affairs is responsible for convening a panel of 
clinicians to determine whether a VA facility physician involved in the 
claim delivered substandard care. The Office of Medical-Legal Affairs 
notifies the medical facility director of the results of its review. If 
it is determined that the physician delivered substandard care to 
veterans, the medical facility must report the physician to NPDB within 
30 days of being notified of the decision. VA medical facility 
officials also would use this determination to decide whether to grant 
clinical privileges to the physician involved in the VA medical 
malpractice claim. 

Selected Physician Files at Medical Facilities Demonstrated Compliance 
with Four VA Credentialing and Four Privileging Requirements; 
a Fifth Privileging Requirement Was Problematic: 

The physician files we reviewed at the seven VA medical facilities 
demonstrated compliance with the four credentialing requirements we 
selected for review and four of five VA privileging requirements. The 
files we reviewed showed that six of the seven medical facilities had 
problems complying with a fifth privileging requirement--to use 
information on a physician's performance when renewing clinical 
privileges. Compliance with that requirement was problematic largely 
because in their privileging decisions facility officials used 
performance information obtained from their facility quality assurance 
program. Information contained in documents created in the course of a 
VA quality assurance program is protected by VA policy that expressly 
prohibits the agency from using that documentation in the privileging 
process. VA has not provided guidance to help facilities find 
alternative ways to efficiently collect performance information, 
outside of a facility's quality assurance program, that could be used 
in privileging decisions. At the seventh medical facility, officials 
did not use performance information to renew clinical privileges, as 
required. 

Physician files at all seven medical facilities demonstrated compliance 
with the four credentialing requirements we selected for review. In all 
cases, the VA facility medical staff specialists contacted state 
licensing boards--a form of primary source verification--to ascertain 
the status of the state medical licenses held and disclosed by their 
physicians.[Footnote 17] Based on the physician files we reviewed, 
medical staff specialists also queried the FSMB database as required to 
obtain additional information on the status of physicians' medical 
licenses, including those that may not have been disclosed by 
physicians. Medical staff specialists complied with the requirement to 
contact primary sources, such as courts of jurisdiction, to verify 
information on involvement in medical malpractice claims, including 
ongoing claims, disclosed by physicians. Additionally, in all cases 
medical staff specialists queried NPDB to identify those physicians who 
have been involved in paid medical malpractice claims, including any 
physicians who failed to disclose involvement in such claims. 

The physician files at the seven medical facilities also demonstrated 
compliance with four of the five VA privileging requirements we 
reviewed. We found that medical staff specialists contacted state 
licensing boards to verify the status of all state medical licenses 
held by their physicians and to determine whether any of these licenses 
had any action taken against them. Medical staff specialists also used 
primary sources to verify that physicians had the necessary training 
and experience to deliver health care and perform the clinical 
privileges they requested. We found that after medical staff 
specialists performed their verification, clinical service chiefs 
reviewed this information as required, along with information on 
physicians' health status and information disclosed by the physicians 
about their involvement in medical malpractice allegations or cases in 
which claims were paid. 

While we found evidence demonstrating compliance with four of the five 
privileging requirements, the files we reviewed also showed that there 
were problems complying with the fifth privileging requirement--to use 
information on a physician's performance in making privileging 
decisions. VA requires that during the renewal of a physician's 
clinical privileges, VA clinical service chiefs use information on a 
physician's performance to support, reduce, or revoke the clinical 
privileges the physician has requested. However, the performance 
information cannot be collected as part of a medical facility's quality 
assurance program. Although medical facility clinical service chiefs 
must use performance information in making decisions about renewal of 
clinical privileges, VA has not provided guidance on how facility 
officials can obtain such information in accordance with VA policy-- 
that is, outside of a quality assurance program. 

VA's credentialing and privileging policy states that facilities cannot 
use information collected as part of a facility's quality assurance 
program to reduce or revoke the clinical privileges requested by 
physicians, but the initial policy guidance was silent about the use of 
this information to support granting the clinical privileges requested 
by physicians. Officials at six medical facilities told us that they 
used quality assurance information to support the granting of clinical 
privileges requested by their physicians, but collected all or most of 
this information through facility quality assurance programs. In 
contrast, facility officials at one medical facility did not use 
individual physician performance information to renew physicians' 
clinical privileges. 

VA issued a directive in September 2004 and a memorandum in October 
2004 which VA headquarters officials told us were intended to clarify 
for medical facility officials the circumstances under which physician 
performance information could not be used in the credentialing and 
privileging process. The September 2004 directive explained the 
specific types of information that are protected, such as information 
that identifies an individual physician, and the October 2004 
memorandum explained that information on a physician's performance that 
is collected as part of a medical facility's quality assurance program 
could not be used to support, reduce, or revoke a physician's clinical 
privileges. The directive and the memorandum did not identify the ways 
in which medical facility officials could efficiently collect physician 
performance information outside of a facility's quality assurance 
program that would provide information for renewing physicians' 
clinical privileges. According to facility officials, collecting the 
same information twice--once for quality assurance and once for 
privileging--is resource-intensive and limits the time they have to 
address other issues. 

Without guidance from VA, officials from four facilities told us that 
they do not know how to collect this information in accordance with 
VA's policy. Facility officials from two other medical facilities said 
they believed that they were complying with VA's requirement because 
they stored performance information in such a way that the identity of 
individual physicians could not be easily retrieved. Quality assurance 
staff at these two medical facilities assigned a code to each physician 
and filed the performance information by assigned code rather than 
under an individual physician's name. These staff could then retrieve 
an individual physician's performance information using the code. At 
one facility, quality assurance staff said their regional legal counsel 
told them that the confidentiality of the information would be 
maintained with this type of coding system and would allow them to use 
the information to renew physicians' clinical privileges. However, 
according to both VA headquarters legal counsel and the director of 
VA's credentialing and privileging program, coding quality assurance 
information in this manner and using it to renew clinical privileges 
could make this information available for other purposes, including 
litigation, and therefore does not comply with VA policy. A VA 
headquarters official told us that the medical facilities need further 
education on how to collect individual physician performance 
information that can be used in the renewal of physicians' clinical 
privileges. 

Not All Medical Facilities Submitted Paid Malpractice Claim Information 
in a Timely Manner: 

We found that three of the seven VA medical facilities we visited did 
not comply with the requirement to submit paid VA medical malpractice 
claim information in a timely manner.[Footnote 18] These facilities had 
not submitted information on 52 paid medical malpractice claims that 
may have involved their physicians to VA's Office of Medical-Legal 
Affairs within the 60-day required time frame for information requested 
as of December 2005.[Footnote 19] See figure 3 for the number of paid 
VA medical malpractice claims for which information was not submitted 
in a timely manner by the three facilities from 2001 through 2005. 

Figure 3: Medical Malpractice Claim Information Not Submitted by Three 
VA Medical Facilities to the Office of Medical-Legal Affairs within 60 
Days: 

[See PDF for image] 

Note: We considered claim information submitted 14 days after the 60- 
day time frame to be on time, while information submitted 15 or more 
days after the 60-day time frame, we considered to be delinquent. 

[End of figure] 

The Office of Medical-Legal Affairs is responsible for reviewing 
information on paid VA medical malpractice claims submitted by VA 
medical facilities by forming panels of clinicians to determine whether 
VA practitioners, including physicians, delivered substandard care to 
veterans in these claims.[Footnote 20] When VA medical facilities do 
not submit all relevant claim information to the Office of Medical- 
Legal Affairs, facility clinical service chiefs may make privileging 
decisions without the knowledge of physician peer determinations on 
whether VA physicians delivered substandard care to veterans. In 
addition, substandard care determinations that are required to be 
reported by facility officials to the NPDB go unreported or reporting 
is delayed when VA medical facilities do not send claim information in 
a timely manner to the Office of Medical-Legal Affairs. This delay or 
lack of reporting to NPDB prevents other VA and non-VA facilities where 
the physician may also practice from having complete information on the 
physician's malpractice history. For example, at one facility we 
visited, we found that from 2001 through 2005, information on 21 of the 
facility's 26 paid medical malpractice claims had not been submitted 
within the 60-day time frame to VA's Office of Medical-Legal 
Affairs.[Footnote 21] Moreover, on average this medical facility took 
30 months to submit information to VA's Office of Medical-Legal 
Affairs, whereas the other two facilities averaged about 5 months to 
submit information. See table 1 for the average number of months it 
took for these VA medical facilities to submit paid VA medical 
malpractice claim information to VA's Office of Medical-Legal Affairs. 

Table 1: Average Number of Months Taken by Three VA Medical Facilities 
to Submit VA Medical Malpractice Claim Information to VA's Office of 
Medical-Legal Affairs (as of December 2005): 

Calendar year: 2001; 
Average number of months to submit information on VA medical 
malpractice claims: Facility A: 4; 
Average number of months to submit information on VA medical 
malpractice claims: Facility B: 57; 
Average number of months to submit information on VA medical 
malpractice claims: Facility C: 3. 

Calendar year: 2002; 
Average number of months to submit information on VA medical 
malpractice claims: Facility A: 3; 
Average number of months to submit information on VA medical 
malpractice claims: Facility B: 47; 
Average number of months to submit information on VA medical 
malpractice claims: Facility C: 6. 

Calendar year: 2003; 
Average number of months to submit information on VA medical 
malpractice claims: Facility A: 9; 
Average number of months to submit information on VA medical 
malpractice claims: Facility B: 34; 
Average number of months to submit information on VA medical 
malpractice claims: Facility C: 7. 

Calendar year: 2004; 
Average number of months to submit information on VA medical 
malpractice claims: Facility A: 6; 
Average number of months to submit information on VA medical 
malpractice claims: Facility B: 3; 
Average number of months to submit information on VA medical 
malpractice claims: Facility C: 4. 

Calendar year: 2005; 
Average number of months to submit information on VA medical 
malpractice claims: Facility A: 3; 
Average number of months to submit information on VA medical 
malpractice claims: Facility B: 3; 
Average number of months to submit information on VA medical 
malpractice claims: Facility C: 6. 

Source: GAO analysis of VA data. 

[End of table] 

VA Has Not Established Internal Controls to Help Ensure the Accuracy of 
Medical Facilities' Privileging Information: 

VA has not required its medical facilities to establish internal 
controls to help ensure that privileging information managed by medical 
staff specialists is accurate. One facility we visited did not identify 
106 physicians whose privileging process had not been completed by 
facility officials for at least 2 years because of inaccurate 
information provided by the facility's medical staff specialist. As a 
result, these physicians were practicing at the facility without 
current clinical privileges. Subsequent to our visit, this facility 
implemented internal controls to reduce the risk of a similar situation 
occurring in the future. During our site visits, we did not identify 
any medical facilities that had established such internal controls. 
Without accurate information on the privileges that have been granted 
to physicians and the dates for renewing those privileges, VA medical 
facility officials will not know if they have failed to renew clinical 
privileges for any of their physicians in accordance with VA policy. 

For at least 2 years, one VA medical facility did not identify 106 
physicians whose privileging process had not been completed by facility 
officials because of inaccurate information provided by the facility's 
medical staff specialist. According to facility officials, the medical 
staff specialist changed the reappointment dates on some of these 
physicians to a later date in order to delay work she needed to perform 
to complete the credentialing and privileging requirements on these 
physicians. For other physicians, the medical staff specialist removed 
the physicians' names from the VetPro database so that the physicians 
would not show up on VetPro lists as needing to be reappointed to the 
facility's medical staff. Facility officials further told us that the 
medical staff specialist changed appointment dates and removed names 
from VetPro in order to conceal the fact that these physicians no 
longer had current privileges. As a result, these physicians were 
practicing at the facility without current clinical privileges. The 
clinical service chiefs, members of the professional standards board 
and the medical executive committee, and the facility director were 
unaware that these physicians were working without current clinical 
privileges, and learned of the problem only after it was brought to 
their attention by an individual newly hired to help the facility's 
medical staff specialist. Medical facility officials told us that after 
becoming aware of the problem, they confronted the medical staff 
specialist responsible for the data inaccuracies, who then resigned. 
Medical facility officials then began to check the clinical privileges 
of all of their physicians and identified inaccuracies in the 
privileging information for 106 physicians. After reviewing the 106 
physician files, facility officials told us they did not find any 
problems that would have warranted the physicians' removal from the 
facility's medical staff or that placed veterans at risk. 

Although this medical facility did not identify any problems with the 
106 physicians' clinical privileges or with their clinical competence 
to deliver care to veterans, the potential exists for problems to occur 
at other VA medical facilities. During our site visits, we did not 
identify any facilities that had established internal controls that 
would help ensure the accuracy of the information used to renew 
clinical privileges. A VA headquarters official told us that there is 
no requirement for VA medical facilities to have such internal controls 
in place. While VA does not require facilities to establish these 
internal controls, the facility that identified inaccuracies in its 
privileging information subsequently implemented internal controls to 
reduce the risk of a similar situation occurring in the future. 
Facility officials have taken steps to help ensure that a similar 
situation does not recur. For example, the facility now provides each 
facility clinical service chief with a list of physicians on a 
quarterly basis and asks the clinical service chiefs to verify that the 
listed physicians are currently working at the medical facility and to 
identify those physicians working at the facility who are not on the 
list. This allows medical facility officials to know if physicians have 
been inappropriately deleted from VetPro and are working at the 
facility without current clinical privileges. Without internal controls 
such as this for their privileging information, VA's medical facilities 
may not know whether they have allowed some of their physicians to 
practice with expired privileges. 

Conclusions: 

VA is responsible for ensuring that its physicians are qualified to 
deliver health care to veterans at VA medical facilities and has 
requirements in place that medical facility officials are to use to 
help ensure that physicians meet these qualifications. VA medical 
facilities we visited complied with the four VA credentialing 
requirements we reviewed and all but one of five privileging 
requirements--to use information on a physician's performance when 
renewing clinical privileges. While officials at six of the seven 
facilities we visited made an attempt to comply with VA's requirement 
to use performance information, these officials deviated from VA's 
policy by collecting all or most of the performance information through 
their facilities' quality assurance programs. This occurred, in part, 
because VA has not provided guidance on how to collect this information 
in accordance with VA's policy. In addition, VA medical facility 
officials did not have all the information they needed on physicians 
involved in paid VA medical malpractice claims, because the facilities 
had not submitted such information to VA's Office of Medical-Legal 
Affairs in a timely manner. This could have placed veterans at risk of 
receiving care from physicians who did not have adequate clinical 
skills. Finally, VA has not required its medical facilities to 
establish internal controls to help ensure the accuracy of their 
privileging information. Until VA requires its medical facilities to 
establish internal controls to ensure the accuracy of privileging 
information, facilities are at risk for allowing physicians to practice 
with expired clinical privileges. 

Recommendations for Executive Action: 

To better ensure that VA physicians are qualified to deliver care 
safely to veterans, we recommend that the Secretary of Veterans Affairs 
direct the Under Secretary for Health to take the following three 
actions: 

* provide guidance to medical facilities on how to collect individual 
physician performance information in accordance with VA's credentialing 
and privileging policy to use in medical facilities' privileging 
processes, 

* enforce the requirement that medical facilities submit information on 
paid VA medical malpractice claims to VA's Office of Medical-Legal 
Affairs within 60 days after being notified that the claim is paid, 
and: 

* instruct medical facilities to establish internal controls to ensure 
the accuracy of their privileging information. 

Agency Comments and Our Evaluation: 

In commenting on a draft of this report, VA agreed with our findings 
and conclusions and concurred with our recommendations. VA also 
provided an action plan to address the three recommendations. VA 
acknowledged that we identify a challenge faced not only by VA 
facilities, but by all health care facilities, to incorporate physician-
specific performance information into the credentialing and privileging 
processes. In addition, VA recognized the need to improve facility 
compliance with submitting information on paid VA medical malpractice 
claims to the Office of Medical-Legal Affairs in a timely manner. 
Further, VA agreed that internal controls are needed to ensure the 
accuracy of information used to renew physicians' clinical privileges 
and has begun the work necessary to establish these internal controls 
at all VA facilities. VA also provided details of actions it plans to 
take to implement the three recommendations in the draft report. VA's 
written comments are reprinted in appendix II. 

As agreed with your office, unless you publicly announce its contents 
earlier, we plan no further distribution of this report until 30 days 
after its date. We will then send copies of this report to the 
Secretary of Veterans Affairs and other interested parties. We also 
will make copies available to others upon request. In addition, the 
report will be available at no charge at the GAO Web Site at Hyperlink, 
http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7101 or ekstrandl@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff members who made major 
contributions to this report are listed in appendix III. 

Sincerely yours, 

Signed by: 

Laurie E. Ekstrand: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

To determine the extent to which selected Department of Veterans 
Affairs' (VA) medical facilities complied with VA's credentialing and 
privileging requirements, we reviewed policies, procedures, and 
guidance on VA's credentialing and privileging processes. We also 
interviewed the director of VA's credentialing and privileging program, 
as well as officials responsible for credentialing and privileging at 
the VA medical facilities we visited. We selected four credentialing 
requirements for review because they are requirements that--unlike 
others--address information about physicians that can change or be 
updated with new information periodically. As a result, VA requires 
that this information be verified by facility officials at least every 
2 years. Other credentialing requirements, such as where a physician 
attended medical school or previous employment history, are not subject 
to change or updating and are required by VA to be verified when the 
physician initially applies for employment. The four credentialing 
requirements are: 

1. verify that all state medical licenses held by physicians are valid; 

2. query the Federation of State Medical Boards (FSMB) database to 
determine whether physicians had disciplinary action taken against any 
of their licenses, including expired licenses; 

3. verify information provided by physicians on their involvement in 
medical malpractice claims at a VA or non-VA medical facility; 
and: 

4. query the National Practitioner Data Bank (NPDB) to determine 
whether a physician was reported to this data bank because of 
involvement in VA or non-VA paid medical malpractice claims, display of 
professional incompetence, or engagement in professional misconduct. 

Of the privileging requirements in VA's credentialing and privileging 
policy, we selected four requirements that VA identifies as general 
privileging requirements. In addition, we selected another privileging 
requirement about the use of individual performance information because 
of its importance in the renewal of clinical privileges. The five VA 
privileging requirements we selected are: 

1. verify that all state medical licenses held by physicians are valid; 

2. verify physicians' training and experience; 

3. assess physicians' clinical competence and health status; 

4. consider any information provided by a physician related to medical 
malpractice allegations or paid claims, loss of medical staff 
membership, loss or reduction of clinical privileges at a VA or non-VA 
facility, or any challenges to a physician's state medical license; 
and: 

5. use information on a physician's performance when making decisions 
about whether to renew the physician's clinical privileges. 

Two of the five privileging requirements--verify all state medical 
licenses and consider medical malpractice information--are also VA 
credentialing requirements. 

We conducted site visits to seven VA medical facilities that were 
chosen based on size and geographic location. The medical facilities 
selected for review were located in Boise, Idaho; 
Kansas City, Missouri; Las Vegas, Nevada; Lexington, Kentucky; 
Martinsburg, West Virginia; Miami, Florida; and San Antonio, Texas. For 
each medical facility visited, we obtained from VA a list of physicians 
and their specialties. Using this list, at each facility we randomly 
selected 17 physicians and obtained files with their credentialing and 
privileging information. Our sample included physicians working in VA 
facilities full-time and part-time, through a contract, or without 
direct compensation from VA. In some cases, these physicians also 
worked at non-VA medical facilities. At each facility we visited, we 
selected one file from the following clinical specialties that are 
offered at most VA medical facilities: anesthesiology, 
gastroenterology, neurology, oncology, ophthalmology orthopedics, 
radiology, and urology. We also selected two physician files from 
general surgery and internal medicine, and five files from physician 
names that had no specialty identified on the list provided by VA. At 
some facilities, we found that the physician specialty indicated on the 
list provided by VA was incorrect. We replaced these files by random 
selection with physician files in the specialty needed. 

To determine whether the files we reviewed demonstrated compliance with 
the selected VA credentialing requirements and privileging 
requirements, we compared the documentation found in our sample files 
against the credentialing and privileging requirements. During our site 
visits, we reviewed the documentation in VetPro and in a physician's 
paper copy credentialing file to determine whether the facility 
complied with each of the four VA credentialing requirements that we 
reviewed. If documentation was present either in VetPro or the paper 
copy file, we determined that the medical facility complied with VA's 
requirement. For each physician, we reviewed the three most recent 
appointment cycles--the period from one appointment process to the next 
appointment process, which occurs every 2 years. Some of the physicians 
in our sample had not been through three appointment cycles. For those 
physicians, we reviewed only the number of cycles that had been 
completed. We documented our findings from these reviews on a data 
collection instrument. 

At each medical facility, we reviewed a physician's paper copy 
privileging file to determine whether the physician's file contained 
documentation that the medical facility met the five VA privileging 
requirements we examined. For the fifth requirement--use of information 
on a physician's performance when making decisions about whether to 
renew physicians' clinical privileges--we also interviewed facility 
officials, including the facility quality assurance manager, to 
determine whether the facility collected this physician performance 
information outside of the facility's quality assurance program. For 
some physician files we reviewed, the physician had only been through 
initial appointment and therefore did not have individual physician 
performance information in the privileging file. 

Based on the sample of physician files we reviewed at each of the seven 
medical facilities, we can discuss a medical facility's compliance for 
the physician files we reviewed; we cannot draw conclusions about the 
remaining physician files at the medical facilities we visited or about 
the compliance of other VA medical facilities. In collecting 
information on the credentialing and privileging requirements from 
physician files at each facility, we employed standard data collection 
techniques to ensure the accuracy and reliability of the data used in 
this report, such as interviewing medical facility officials about the 
accuracy and timeliness of the information contained in the physician 
files we reviewed and taking steps to have a consistent interpretation 
of VA's credentialing and privileging requirements for the physician 
files we reviewed at each medical facility. 

To determine the extent to which the selected VA medical facilities 
complied with a requirement to submit information on paid VA medical 
malpractice claims, we obtained data from VA's Office of Medical-Legal 
Affairs in Buffalo, New York to identify the VA medical facilities that 
were delinquent--more than 60 days had passed since the facility was 
notified that a claim had been paid--in submitting medical malpractice 
claim information to this office.[Footnote 22] The data included the 
name of the VA medical facility, the veteran who was named in the 
claim, the date the Office of Medical-Legal Affairs was notified that a 
claim had been paid, and the date the Office of Medical-Legal Affairs 
notified the facility that a VA medical malpractice claim had been 
paid. VA's Office of Medical-Legal Affairs determines whether a 
physician who was involved in a VA medical malpractice claim delivered 
substandard care to veterans, and if so, was reported to NPDB. We 
interviewed officials at this office to obtain information about VA's 
process and requirements for determining if substandard care was 
delivered. 

To determine whether VA has internal controls to help ensure the 
accuracy of medical facility information that is used to renew 
physicians' clinical privileges, we interviewed the director of VA's 
credentialing and privileging program, as well as other VA officials. 
We identified the internal controls VA has in place for its privileging 
process and used GAO's standards for internal controls in the federal 
government to determine whether these controls were adequate. During 
our site visits, we determined if any of the seven medical facilities 
had internal controls in place to help ensure the accuracy of the 
information used to support the renewal of clinical privileges. We 
conducted our work from July 2005 to May 2006 in accordance with 
generally accepted government auditing standards. 

[End of section] 

Appendix II: Comments from the Department of Veterans Affairs: 

The Secretary Of Veterans Affairs: 
Washington: 

May 12, 2006: 

Ms. Laurie Ekstrand: 
Director: 
Health Care Team: 
U. S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Ekstrand: 

The Department of Veterans Affairs (VA) has reviewed your draft report, 
VA HEALTH CARE: Selected Credentialing Requirements at Seven Medical 
Facilities Met, but an Aspect of Privileging Process Needs Improvement 
(GAO-06-648) and agrees with your findings and conclusions. VA also 
concurs with your recommendations. 

The Government Accountability Office's (GAO) report identifies a 
challenge faced not only by VA facilities but by all health care 
facilities: incorporating provider specific performance information 
into the credentialing and privileging process. Since privileging is 
performed at the facility level, a major focus of VA's approach to 
ensuring compliance with our policies on this process has been and 
continues to be providing education and information to medical facility 
staff. VA also recognizes the need to improve compliance with VA policy 
that requires medical facilities to submit any information on paid VA 
medical malpractice claims to the Office of Medical-Legal Affairs 
(OMLA) in a timely manner. OMLA will educate, monitor, and followup 
with networks on the reporting process requirements. Additionally, OMLA 
is implementing a new initiative to notify network directors of any 
reporting delinquencies by facilities under their jurisdiction. 
Finally, facilities will be required to establish internal controls to 
ensure the accuracy of their privileging information. Network directors 
will monitor compliance and report back to the Deputy Under Secretary 
for Health for Operations and Management. 

The enclosure details actions planned and taken to implement GAO's 
recommendations. VA appreciates the opportunity to comment on your 
draft report. 

Sincerely yours, 

R. James Nicholson: 

Enclosure: 

DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT 
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT VA HEALTH CARE: Selected 
Credentialing Requirements at Seven Medical Facilities Met, but an 
Aspect of Privileging Process Needs Improvement (GAO-06-648): 

To better ensure that VA physicians are qualified to deliver care 
safely to veterans, GAO recommends that the Secretary of Veterans 
Affairs direct the Under Secretary for Health to take the following 
three actions: 

* provide guidance to medical facilities on how to collect individual 
physician performance information in accordance with VA's credentialing 
and privileging policy to use in medical facilities' privileging 
process; 

Concur - VA has developed and continues to refine methods to provide 
education and information to medical facility staff to address this 
recommendation. Presentations were made on provider-specific data at 
the Office of Quality and Performance (OQP) and Employee Education 
System (EES) co-sponsored VHA credentialing conference in July 2004 as 
well as on a VHA national credentialing conference call sponsored by 
the OQP in November 2004. Primarily, medical staff support specialists 
attended both these conferences. Recognizing that this is an on-going 
issue, the OQP is preparing a series of educational presentations to be 
done via conference call with the medical facilities, and completed 
this fiscal year. One module titled, "Provider Profiling and 
Competency," gives a detailed description of the type of provider 
specific information that is and is not acceptable for use in the 
renewal of clinical privileges of medical staff. Attendance at these 
educational conference calls will be taken and medical staff support 
specialists will be encouraged to invite facility quality managers, 
service chiefs, and other involved in the privileging process. 

Additionally, the OQP is developing a request for proposal (RFP) for a 
web-based training program for medical staff processes directed towards 
the medical staff support specialists. One of the web-based training 
modules defined in the RFP will be directed to all staff involved in 
the reappraisal and privileging process incorporating provider 
profiling, the use of provider specific performance information. This 
RFP will be awarded this fiscal year with training modules developed 
and delivered by April 1, 2007. 

DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT 
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT VA HEALTH CARE: Selected 
Credentialing Requirements at Seven Medical Facilities Met, but an 
Aspect of Privileging Process Needs Improvement (GAO-06-648) 
(Continued): 

* enforce the requirement that medical facilities submit information on 
paid VA medical malpractice claims to VA's Office of Medical-Legal 
Affairs within 60 days after being notified that the claim is paid; 
and: 

Concur - To improve compliance with the above requirement, the Office 
of Medical-Legal Affairs (OMLA) has instituted the plan below. This 
plan will be communicated to the networks and medical facilities 
through participation by the Director, OMLA in the network director and 
chief medical officer (CMO) conference calls as well as by 
electronically informing all VA medical center risk managers through 
OMLA's "VA Med-Legal RM Contacts" listserve prior to June 1, 2006. 

* For information not received within 60 days, the Director, OMLA will 
notify the network director of the delinquency, and copy the facility 
director on the notification. 

* After 90 days, the Director, OMLA will notify the network director of 
the delinquency, and copy the facility director and the Associate Chief 
Patient Care Services (PCS) Officer on the notification. 

* On a quarterly basis, beginning July 1, 2006, the OMLA will send to 
the Associate Chief PCS Officer, a list of paid tort claims for which 
the OMLA has not received the requested records and the date the 
information was requested. Copies of pertinent correspondence will also 
be included. 

In addition, by June 1, 2006, the Deputy Under Secretary for Health for 
Operations and Management (DUSHOM), will issue a memorandum to the 
network directors outlining the new initiative of the OMLA and 
reinforce that each medical center must comply with VA policy regarding 
submitting information to the OMLA in a timely manner. The Director, 
OMLA will also provide briefings to the chief medical officers and to 
the medical center directors on their weekly call. 

DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT 
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT VA HEALTH CARE: Selected 
Credentialing Requirements at Seven Medical Facilities Met, but an 
Aspect of Privileging Process Needs Improvement (GAO-06-648) 
(Continued): 

* instruct medical facilities to establish internal controls to ensure 
the accuracy of their privileging information. 

Concur - Internal controls at VA medical facilities have been discussed 
several times on the OQP VHA credentialers' national conference call, 
most recently during the April 4, 2006 call. Following that conference 
call OQP sent an e-mail to the VHA credentialers' mail group describing 
initiatives identified by various facility credentialing and 
privileging staff to better ensure the accuracy of the provider 
appointment paperwork and to track those on the medical staff who have 
active privileges. In addition, the Chief OQP will issue a memorandum 
by June 1, 2006, through the DUSHOM, to the network directors 
indicating that each medical facility in the network must establish 
internal controls and report back to the network that such controls 
have been established. Examples of current internal controls used by 
facilities will be provided so each facility can assess what internal 
controls address the facility's needs. Network leadership will be 
responsible for the continued monitoring of the use of internal 
controls. 

To further strengthen internal controls in the privileging process, 
modifications to VetPro, delivered June 28, 2005, display the medical 
staff appointment on the "Search" screen either as "Appointed" or 
"Expired." This allows for a quick reference of the status of a 
practitioner's appointment. Staff at the medical facilities continues 
to be trained in using this as a tool that may assist the monitoring of 
provider appointments and possibly be incorporated into the facility's 
internal control process. Additionally, the VetPro design does not 
allow appointments to exceed the 2 years VA policy allows. The need for 
internal controls to ensure the accuracy and timeliness of the 
privileging process will continue to be emphasized to VA staff and 
leadership. 

[End of section] 

Appendix III: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Laurie E. Ekstrand at (202) 512-7101 or ekstrandl@gao.gov: 

Acknowledgments: 

In addition to the contact named above Marcia A. Mann, Assistant 
Director; Kelly Barar; Mary Ann Curran; Martha A. Fisher; and Krister 
Friday made key contributions to this report. 

[End of section] 

Related GAO Products: 

VA Health Care: Steps Taken to Improve Practitioner Screening, but 
Facility Compliance with Screening Requirements Is Poor. GAO-06-544. 
Washington, D.C.: May 25, 2006. 

VA Health Care: Improved Screening of Practitioners Would Reduce Risk 
to Veterans. GAO-04-566. Washington, D.C.: March 31, 2004. 

VA Health Care: Veterans at Risk from Inconsistent Screening of 
Practitioners. GAO-04-625T. Washington, D.C.: March 31, 2004. 

FOOTNOTES 

[1] We have performed other work related to this subject. See Related 
GAO Products listed at the end of this report. 

[2] Health care services could include, for example, surgical 
procedures and administering anesthesia. 

[3] Physicians' clinical privileges are also reviewed whenever a 
physician requests that a health care service be added or removed from 
the list of approved clinical privileges. This may occur before the 2- 
year renewal period. 

[4] Physicians may also possess credentials that VA does not require to 
work in a VA facility, such as a Drug Enforcement Administration 
certificate, which allows a physician practicing outside of a VA 
facility to prescribe controlled substances. If a physician does have 
these other credentials, then VA requires medical facility officials to 
verify these credentials since they may change or be updated 
periodically. 

[5] VA medical facilities can contract with local or national companies 
in order to obtain physician services. 

[6] In this report, determinations of substandard care may also include 
determinations of professional incompetence or professional misconduct. 

[7] GAO, Internal Control Management and Evaluation Tool, GAO-01-1008G 
(Washington, D.C.: August 2001). 

[8] State licenses are issued by offices in states, territories, or the 
District of Columbia, collectively referred to as state licensing 
boards. 

[9] NPDB includes information on medical malpractice claims that are 
paid, but does not include information on ongoing claims. 

[10] Clinical services may include surgery, medicine, and radiology. 

[11] Reduction of privileges may include restricting or prohibiting a 
physician from performing certain procedures or prescribing certain 
medicines. Revocation of privileges refers to the permanent loss of all 
clinical privileges at that facility. 

[12] At some VA medical facilities, the professional standards board 
and the medical executive committee represent the medical staff, have 
the same members, and perform the same functions so are considered to 
be one committee. If the committees are separate, the professional 
standards board is generally comprised of three to five physician peers 
and the medical executive committee is generally comprised of all 
facility clinical service chiefs. 

[13] Support granting clinical privileges means that the clinical 
privileges previously held by the physician will be maintained as well 
as adding newly requested clinical privileges. 

[14] VA requires its medical facilities to have a quality assurance 
program. In general, the VA quality assurance program consists of 
specified systematic health care reviews carried out by or for VA for 
the purpose of improving the quality of medical care or the utilization 
of health care resources in VA facilities. See 38 C.F.R. § 17.500 
(2005). These programs collect data on various clinical process and 
outcome measures involving physicians and other types of practitioners. 
The measures may include a surgeon's complication rate or a physician's 
prescribing of medications. Medical facility officials use these 
measures to look for undesirable patterns and trends in performance. 

[15] 38 U.S.C. § 5705 (2000). 

[16] See Department of Veterans Affairs, VHA Handbook 1100.19 (Mar. 6, 
2001). 

[17] VA medical facility officials may also perform primary source 
verification of physicians' licenses by querying a state licensing 
board's Web site for information on the licenses. 

[18] At the time of our review, the remaining four VA facilities did 
not have any medical malpractice claim information that had not been 
submitted within VA's 60-day time frame. 

[19] VA medical malpractice claims may involve physicians or another 
type of licensed health care practitioner, such as a nurse. 

[20] The panel must include at least one reviewer who is a member of 
the profession of the practitioner under review. 

[21] As of March 31, 2006, this medical facility had sent all 
delinquent medical malpractice claims to VA's Office of Medical-Legal 
Affairs. 

[22] We considered claim information submitted 14 days after the 60-day 
time frame to be on time, while information submitted 15 or more days 
after the 60-day time frame, we considered to be delinquent. At the 
time of our review, four of the seven facilities did not have any 
medical malpractice claim information that had not been submitted 
within VA's 60-day time frame. 

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