Military Health Care: Improved Procedures and Monitoring Needed to Ensure Provider Qualifications and Competence

What GAO Found

The Defense Health Agency is responsible for ensuring the quality and safety of health care delivered by individual providers at its military medical treatment facilities. However, GAO found that four selected facilities and the Defense Health Agency did not always adhere to the agency's clinical quality management procedures in part because they were unclear.

• Credentialing and privileging. GAO reviewed documentation for 100 providers from four selected facilities and found that the facilities did not always adhere to the Defense Health Agency's procedures for credentialing and privileging—the process of verifying that a provider has the appropriate qualifications and abilities to deliver specific health care services. For example, for about one-sixth of providers reviewed, the facilities did not verify all medical licenses before granting privileges. Additionally, for almost half of the providers reviewed, the facilities did not obtain clinical references from appropriate individuals such as the program director, as required. GAO found this was partly due to the procedures being unclear about which providers must have clinical references.
• Focused evaluations of concerns. The four selected facilities collectively conducted 20 focused evaluations to address clinical performance concerns raised about individual providers. GAO's review showed that these facilities did not always adhere to requirements. For example, for about half of these evaluations, facilities did not document the metrics for evaluating whether providers adequately addressed the concerns raised. GAO found that nonadherence was due in part to unclear procedures, such as inconsistent terminology for these evaluations.
• Patient safety events that resulted in compensation. GAO found that the Defense Health Agency did not always adhere to its own requirements for reviewing patient safety events. Patient safety events, such as the misdiagnosis of a life-threatening condition, can involve compensation because of the potential for patient harm. The four selected facilities had 12 such events that resulted in compensation to patients or their families. Specifically, the Defense Health Agency's reviews of nine of these events exceeded the required time limits for those reviews. Also, the Defense Health Agency did not report providers involved in those nine events to a national database as required.

GAO also found that the Defense Health Agency did not sufficiently monitor facilities' adherence to its clinical quality management procedures. As of May 2022, the Defense Health Agency monitored adherence to some credentialing and privileging requirements by running database reports on expired credentials, but did not monitor adherence to other requirements, such as certain performance evaluations. Defense Health Agency officials told GAO they have developed plans to monitor facilities' documentation of focused evaluations and patient safety events, but had not yet implemented these plans.

Why GAO Did This Study

Since 2014, Congress and the Department of Defense (DOD) have taken steps intended to strengthen patient safety in the Military Health System. As part of those efforts, Congress mandated that the Defense Health Agency, an agency within DOD, be responsible for the military departments' administration of facilities. This responsibility includes ensuring individual providers are qualified and competent to deliver safe, high quality care to patients.

Congress included a provision in statute for GAO to review the Defense Health Agency's clinical quality management procedures. This report addresses facilities' and the Defense Health Agency's adherence to these procedures and the Defense Health Agency's monitoring of facilities' adherence. GAO reviewed documentation from four facilities selected to obtain variation in location and military department. Additionally, GAO reviewed the Defense Health Agency's clinical quality management procedures and interviewed relevant Defense Health Agency officials about these procedures and related monitoring efforts. GAO also evaluated the procedures and monitoring efforts using federal internal control standards.