VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements Is Poor

VA has partially implemented our recommendation--its Office of the Medical Inspector has developed a compliance assessment tool which it planned to pilot test at the Baltimore VA medical center in July 2007, then refine the tool and use it at eight other medical centers. VA's Office of Human Resources Management plans to continue to review facility compliance with VA's personnel screening requirements as part of its on-site HR inspections. However, until VA has completed its pilot and refinement of the assessment tool, we are unable to determine whether this will completely satisfy our recommendation. We have not been given updated information from VA on this recommendation. Update from July 2009: The Office of the Medical Inspector (OMI) reviewed compliance with credentialing requirements in fiscal year 2007 and analyzed the data to publish a White Paper in fiscal year 2009, recommending that a plan of action be developed to ensure compliance with all credentialing requirements. VA's office of Human Resources Management, Oversight and Effectiveness Service (OES) have made compliance with screening requirements a standard part of their review of facilities' human resources programs, and assessed 14 facilities in fiscal year 2006, 16 in fiscal year 2007, and 16 in fiscal year 2008. Additionally, VHA's System-wide Ongoing Assessment Review Strategy (SOARS) program includes background checks, personnel suitability, and credentialing in their site visit assessment process. OES will be giving the responsibility of the suitability program to the Office of Security and Law Enforcement.

VA implemented this recommendation when it issued VA directive and handbook 0710 on May 18, 2007, standardizing operating procedures for its personnel screening process. The requirement includes use of VA's Screening Checklist to document that required screening activities have been completed and to initiate and adjudicate background investigations in a timely manner. VA medical facility officials also are required to establish local policies and procedures to ensure that personnel screenings are properly accomplished and to conduct quarterly file reviews to determine screening compliance.