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

VA has issued guidance to VA medical facilities on how to appropriately collect information on individual physician performance and use that information in VA's privileging process. In addition, VA has completed training for credentialers at all its medical facilities on provider-specific profiles to be used at the time of reappraisal and privileging. VA's Office of Quality and Performance launched three new online training programs on 7/13/2007. This training requires participants to enter their names and facility location so that lists can be developed to determine completion of the training. Training for the three new programs (Medical Staff Leadership and Medical Staff Performance Profiles--Parts I and II) was completed on January 31, 2008. VA reported that over 3,200 staff took each of the 3 modules.

In June 2006, VA's Office of Medical-Legal Affairs began notifying network and VA medical facility directors of delinquencies in reporting this information by the medical facilities. If a medical facility's delinquency in reporting extends longer than 90 days, VA requires the Office of Medical-Legal Affairs to inform not only network and VA medical facility directors but also VA headquarters of the delinquency. Because VA's Office of Medical-Legal Affairs reviews information on paid malpractice claims involving VA physicians to determine whether the physicians delivered substandard care, when VA medical facilities do not submit relevant malpractice claim information to this office, medical facility clinical service chiefs may make privileging decisions without complete information about substandard care provided by physicians.

VA implemented our recommendation by first asking network directors to report on how they tracked the privileging status of VA physicians. In response to a VA memorandum sent on May 16, 2006, network directors provided a report indicating that their medical facilities had one or more mechanisms in place to identify physicians who were currently privileged at their facilities and to track whether their privileges have expired. In addition, VA instructed its network directors to monitor the internal controls at their facilities that ensure that VA medical facilities have accurate clinical privileging information and that physicians are not practicing with expired clinical privileges.