Veterans Health
 

Administration
 

Follow-Up Audit of
 

Part-Time Physician
 

Time and Attendance
 

OFFICE OF AUDITS AND EVALUATIONS

September 30, 2011 

11-00308-294 
ACRONYMS AND ABBREVIATIONS
 

MSLE Memorandum of Service Level Expectations 

OIG Office of Inspector General 

VA Veterans Affairs 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VistA Veterans Health Information Systems and Technology Architecture 

To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Report Highlights: Follow-Up Audit of 

Part-Time Physician Time and 

Attendance 

Why We Did This Audit 

The VA Office of Inspector General (OIG) 

followed up to assess the effectiveness of 

implementation actions on two prior OIG 

audits that identified weaknesses in the 

Veterans Health Administration’s (VHA) 

management of part-time physician time and 

attendance. The audit determined if controls 

ensured part-time physicians were on duty 

as scheduled. Given the significant salary 

costs associated with acquiring VA parttime physicians’ services, it is important that 

VHA’s controls over these resources 

provide accountability and ensure payments 

are supported by the services provided. 

What We Found 

VHA’s diligence in implementing prior 

audit recommendations helped reduce the 

number of days where evidence indicated 

that part-time physicians might not be 

meeting their employment obligations. In 

response to prior audit findings, VHA 

augmented existing procedures by 

establishing performance monitors, 

requiring written agreements detailing the 

expectations of part-time physicians, and 

developing additional requirements for 

recording actual hours worked. As a result, 

the percentage of days with no evidence of 

VA activity decreased from 33 percent in 

2003 to 11 percent in 2010. In addition, 

only 3 percent of part-time physicians were 

not on duty as required—an improvement 

from our 2003 and 2004 audits that reported 

11 percent and 8 percent respectively. 

However, written service agreements are no 

longer required for all part-time physicians 

and VA medical centers did not fully 

implement other controls. Those controls 

included monitoring part-time physicians’ 

type of time, validating attendance 

according to standard operating procedures, 

and timely and accurately recording actual 

hours worked. 

What We Recommend 

We recommend the Under Secretary for 

Health reinstitute the requirement for written 

agreements with all part-time physicians. In 

addition, he needs to require VA medical 

center management to establish oversight 

procedures on time and attendance controls 

and clarify standard operating procedures 

for time and attendance monitors. 

Agency Comments 

The Under Secretary for Health agreed with 

our findings and recommendations and 

provided an acceptable implementation plan 

for the recommendations. Appendix B 

contains the full text of the Under 

Secretary’s comments. 

BELINDA J. FINN
 

Assistant Inspector General
 

for Audits and Evaluations
 

i 
TABLE OF CONTENTS
 

Introduction......................................................................................................................................1
 

Results and Recommendations ........................................................................................................2
 

Finding VHA Improved Controls, but Additional Accountability and Oversight is
 

Still Needed.........................................................................................................2
 

Appendix A Scope and Methodology................................................................................... 10
 

Appendix B Under Secretary for Health Comments............................................................ 13
 

Appendix C OIG Contact and Staff Acknowledgments....................................................... 17
 

Appendix D Report Distribution .......................................................................................... 18
 

ii 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Objective 

Part-Time 

Physicians 

Prior OIG Audits 

INTRODUCTION 

This Office of Inspector General (OIG) follow-up audit assessed the 

effectiveness of implementation actions on two prior OIG audits and 

determined if the Veterans Health Administration’s (VHA) management 

controls ensured that part-time physicians were on duty as scheduled. 

Appendix A describes the scope and methodology used to answer the audit 

objective. 

VA employs part-time physicians to perform duties on less than a full-time 

basis—a regularly scheduled tour of duty of less than 80 hours in a biweekly 

pay period. Timekeepers and supervisors are required to ensure timecards 

reflect actual time worked by the part-time physicians. Most part-time 

appointments include a regularly scheduled tour of duty that does not 

significantly change (fixed schedule). VA medical centers place part-time 

physicians on an adjustable work schedule if they have varying VA or 

non-VA patient care, research, or educational responsibilities that make 

adherence to the same scheduled tour of duty difficult. As of 

October 2010, VA employed over 6,250 part-time physicians. Given the 

significant salary costs (approximately $660 million in FY 2010) associated 

with acquiring VA part-time physicians’ services, it is important that VHA’s 

controls over these resources provide accountability and ensure payments are 

supported by the services provided. 

Two prior OIG audits identified weaknesses in VHA’s management of parttime physician time and attendance. An audit requested by the Secretary of 

VA in 2003 reported that medical center managers did not ensure part-time 

physicians met employment obligations. VA medical centers lacked 

documented evidence of physicians’ activity for 33 percent of their 

scheduled workdays. In addition, the audit identified 11 percent of part-time 

physicians were not on duty as required, including instances where the VA 

paid part-time physicians even though they were performing surgeries on 

non-veterans at the affiliated medical school during their scheduled tour of 

duty. 

In a 2004 follow-up audit, we reported that 8 percent of part-time physicians 

scheduled for duty were not on duty, approved leave, or authorized absence. 

VA medical centers implemented many of the time and attendance controls 

in response to the 2003 audit recommendations. However, the OIG found 

that part-time physicians claimed to be on leave but the time and attendance 

system did not reflect their actual absences, changed work schedules with no 

prior written request or approval, and did not always have agreements that 

specified the amount of time allotted for clinical, administrative, research, 

and educational activities. 

VA Office of Inspector General 1 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Finding 

Review of 

Documented 

Activity 

RESULTS AND RECOMMENDATIONS 

VHA Improved Controls, but Additional Accountability 

and Oversight is Still Needed 

Since our initial audit in 2003, VHA’s increased oversight of part-time 

physician time and attendance resulted in fewer days with no evidence of VA 

activity (patient care, research, education, or administrative) decreasing from 

33 percent in 2003 to 11 percent in 2010. In addition, only 3 percent of 

part-time physicians could not be located, which is an improvement from our 

2003 and 2004 audits that identified 11 percent and 8 percent respectively. 

However, VHA’s policy no longer required written agreements for part-time 

physicians on fixed schedules. In addition, VA medical centers did not fully 

implement other controls to ensure that part-time physicians met 

employment obligations with VA. Specifically: 

 VA medical center managers did not adequately monitor the time 

part-time physicians spent on their delineated VA activities, including 

patient care workload. 

 VA medical center staff did not always follow standard operating 

procedures while performing monthly electronic reviews or semi-annual 

physical inspections to verify presence. 

 Part-time physicians and/or timekeepers did not always accurately or 

timely record tours of duty, work hours, or leave hours in the time and 

attendance system. 

Fully implemented controls can continue to enhance accountability for 

part-time physician time and attendance and strengthen assurances that all 

part-time physicians meet their employment obligations. 

We found no documented evidence to support the accomplishment of any 

VA duties for 11 percent (323 of 3,038) of the days scheduled. While 

accountability is still needed to ensure part-time physicians meet their 

employment obligations, our audit results reflect a substantial improvement 

from 2003 when we questioned 33 percent of the work days scheduled. 

According to VA Handbook 5011/12, Hours of Duty and Leave, facility 

management and supervisory officials are responsible for ensuring proper 

documentation of time and attendance for part-time physicians. The methods 

used are to be sufficiently comprehensive to assure outside reviewers that the 

part-time physician performed the required VA duty. 

VA Office of Inspector General 2 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Table 1 Part-Time Physician Workdays 

With No Documented Evidence of VA Duties Performed 

Description San 

Antonio 

Palo 

Alto Tampa Durham Totals 2003 Audit 

Part-Time Physicians 

Reviewed 30 30 30 30 120 382 

Days Scheduled for 

VA Duty 1,017 743 682 596 3,038 2,185 

Days With No 

Activity 211 20 68 24 323 730 

Percent of Days With 

No Activity 21% 3% 10% 4% 11% 33% 

Source: OIG Analysis 

The 323 days (11 percent) with no activity occurred due to two time and 

attendance issues—no evidence of VA duty and timekeeping errors. 

Table 2 Breakdown of Workdays With No Activity 

Description San 

Antonio 

Palo 

Alto Tampa Durham Totals 

Days With No Evidence 

of VA Duty 129 16 59 4 208 

Days With Timekeeping 

Errors 82 4 9 20 115 

Total Days With No 

Activity 211 20 68 24 323 

Source: OIG Analysis 

For 208 days, there was no documented evidence to support that part-time 

physicians performed their required VA duty. We limited our analysis to 

days scheduled for at least 4 hours and accepted as little as one documented 

activity—such as one progress note or one outpatient encounter—as proof of 

attendance. In some cases when none of the part-time physicians’ time could 

be accounted for, VA medical center staff could not provide an explanation. 

In other cases, staff told us that some VA activities did not always result in 

documented evidence of the work performed and cited grand rounds 

(discussing clinical cases of patients with residents or other physicians), 

inpatient continuing care, and resident supervision as examples. 

VA Office of Inspector General 3 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Locating 

Physicians 

For 115 days, timekeeping errors mistakenly reported that the physician was 

on duty. Generally, schedules were not kept current or the part-time 

physicians’ leave was not entered in the time and attendance system. For 

example, a part-time physician scheduled for Mondays worked Tuesdays 

instead. Accurate schedules are necessary to provide sufficient oversight to 

ensure part-time physicians meet their employment and patient care 

obligations. 

We located and accounted for 97 percent of 206 part-time physicians 

scheduled for VA duty that we reviewed. Only 3 percent of the part-time 

physicians (6 of 206) could not be located. This is an improvement over 

prior audit findings (11 percent in the 2003 audit and 8 percent in the 

2004 audit). 

Table 3 Locating Part-Time Physicians 

Description San 

Antonio 

Palo 

Alto Tampa Durham Totals 2004 Audit 

2003 

Audit 

Part-Time 

Physicians 

Reviewed 

76 36 37 57 206 729 448 

Not Located 2 3 0 1 6 58 50 

Percentage 

Not Located 3% 8% 0% 2% 3% 8% 11% 

Source: OIG Analysis 

Three of the six part-time physicians could not be located because their 

schedules were not accurate. The supervisor or part-time physician changed 

the biweekly schedule but they did not communicate the change to the 

timekeeper. In the other three cases, the part-time physician could not be 

located. Subsequently, two of the part-time physicians requested and 

received annual leave for the time in question. Staff did not know where the 

third part-time physician was located at the time of our review. After our site 

visit, VA medical center staff told us the physician was performing offsite 

research. 

Service 

Agreement 

Controls Were 

Limited 

In 2003, the OIG made recommendations to ensure VA part-time physicians 

are paid only for time and service actually provided. In response, VHA 

issued Directive 2003-001, Time and Attendance for Part-Time 

Physicians, which required VA medical center supervisors to establish, 

monitor, and communicate the allocation of part-time physician time. The 

Directive required written agreements concerning the employee’s 

responsibilities, including agreements on the amount of time allotted for 

VA Office of Inspector General 4 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Physicians’ Time 

Not Monitored 

Sufficiently 

clinical, administrative, research, and educational activities. In 2004, the 

OIG reported that most part-time physicians had written agreements, but 

many of the agreements did not specify the amount of time allotted for 

clinical, administrative, research, and educational activities. VHA agreed 

and stated that all part-time physicians will have a written agreement 

concerning expectations and specify the allotted time for the various 

activities. 

VHA Directive 2003-001 expired on January 31, 2008, and since then, VA 

policy only required a Memorandum of Service Level Expectations (MSLE) 

for part-time physicians on adjustable schedules. VHA officials stated that 

part-time physicians on fixed schedules were like other staff on fixed 

schedules, and a written agreement was not necessary. However, the issue 

was not related to the type of schedule, but whether VHA has adequate 

accountability over part-time physicians providing various activities needed 

to meet VHA’s needs. In response to the prior OIG audits, VHA initiated the 

annual written agreements for all part-time physicians to help determine 

staffing levels and ensure part-time physicians knew what was expected of 

them to meet their VA employment responsibilities. 

Although VHA no longer requires written agreements for part-time 

physicians on fixed schedules, all four VA medical centers reviewed had 

written tour of duty memorandums for those part-time physicians. The tour 

of duty memorandum is similar to the MSLE, outlining total hours scheduled 

per pay period and allocation of time between activities—patient care, 

research, education, or administrative. Evidence of physician time and 

attendance has improved since we examined the effectiveness of controls in 

our 2003 audit. However, VHA should require service agreements for all 

part-time physicians in order to maintain progress and promote continued 

improvement. 

VHA needs to improve the monitoring of written service agreements. 

According to VA policy, supervisors are to monitor the amount and type of 

time part-time physicians worked to ensure it is consistent with the approved 

MSLE. VA medical center managers stated they did not monitor how 

part-time physicians’ spent their time throughout the year—just that they 

worked the hours they were paid for. Supervisors at the four VA medical 

centers stated they did not monitor the activities performed because they had 

no mechanism to do so. As a result, VHA has no assurance that part-time 

physicians performed the duties as outlined in their written agreements. 

VHA management stated that the written agreements are not employment 

contracts with pay based on each activity, and it would be very difficult and 

time-consuming to track part-time physicians’ activities. We agree that these 

agreements are not employment contracts—but a tool to help ensure 

appropriate utilization of resources. This control is needed to ensure that 

VA Office of Inspector General 5 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Monthly 

Electronic 

Reviews Not 

Sufficient 

non-clinical time is not increased at the expense of other activities such as 

patient care. For example, a part-time physician’s written agreement 

allocated approximately 38 percent of time to research. Based on 

information from VA medical center staff, however, the part-time physician 

spent about 68 percent of his time on research. As a result, less time was 

devoted to other activities during that period. 

In our view, VHA could use various methods to periodically monitor parttime physicians’ activities, such as work calendars showing scheduled 

activities for part-time physicians’ or VHA’s monthly electronic monitor. 

This will help ensure VA medical centers receive the services agreed to with 

the part-time physicians or identify underutilized resources that they could 

apply to other activities. 

In 2003, the OIG recommended that VHA establish performance monitors to 

measure Veterans Integrated Service Network (VISN) and VA medical 

center enforcement of physician time and attendance. In response, VHA 

established a monthly review of electronic documentation of physician 

activity. However, VHA did not ensure VA medical centers followed 

prescribed procedures for conducting the monthly review. 

In December 2007, the Deputy Under Secretary for Health for Operations 

and Management issued standard operating procedures for validating 

part-time physician time and attendance. The procedure required VA 

medical centers to determine appropriate baseline levels of expected patient 

care workload and monitor each part-time physician’s activity in the 

electronic medical record for one complete pay period each month. 

None of the four medical centers used baseline levels to validate time and 

attendance. Three of the four VA medical centers we visited did not 

establish baselines of expected patient care workload because they were 

unaware of the specific requirement. The fourth VA medical center used the 

number of provider encounters to establish a 2-week workload baseline; 

however, they did not use these baselines to evaluate part-time 

physicians’ attendance. Instead, all four VA medical centers considered the 

part-time physician to be on duty as long as they identified at least one 

sign-on, progress note, or encounter during the 2-week pay period. 

Based on these limited procedures, the four VA medical centers reported no 

attendance issues in August, September, and October 2010. However, these 

procedures did not provide reasonable assurance that part-time physicians 

met their employment obligations. For example: 

 At one VA medical center, a written agreement showed the part-time 

physician was responsible for providing 18 clinical hours per pay period. 

Staff’s monthly review of this part-time physician documented one 

VA Office of Inspector General 6 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Semi-Annual 

Physical 

Reviews Not 

Sufficient 

Actual Hours 

Not Properly 

Recorded 

encounter during the reviewed period in October 2010, concluding the 

part-time physician met the employment obligation to the VA. 

	 At another VA medical center, one part-time physician’s baseline for a 

2-week period was a range of 27 to 33 patient encounters. The part-time 

physician had no encounters during August, September, and October 

2010; however, the medical center counted the physician as present for 

the entire pay period reviewed each month based on one system logon. 

As noted earlier, the four VA medical centers reported no attendance issues 

in August, September, and October 2010, while we identified 11 percent of 

days with no documented evidence of VA duties to validate the part-time 

physicians’ time and attendance. 

VA medical centers conducted physical reviews—verifying and 

documenting the physical presence of each part-time physician at least twice 

a year—but staff did not always follow procedures, such as selecting a 

random time for the review or using visual verification when required. For 

example: 

	 Staff at two VA medical centers told us they pick days where part-time 

physicians would be easily located (in clinics, as opposed to 

administrative or research duties). 

	 Staff at one VA medical center considered part-time physicians as 

physically verified if seen within VA grounds even though they were not 

subjects of the physical inspection at that time. 

	 Staff at one VA medical center—instead of physically searching for the 

part-time physician—routinely made phone calls to the physician to 

verify their presence. 

Standard operating procedures issued in December 2007 required VA 

medical centers to physically monitor each part-time physician, via a 

random, unannounced review at least twice a year. VA medical center staff 

at the four sites we visited did not always follow the procedure because they 

misinterpreted it or were not aware of it. 

VA medical center staff did not ensure actual hours worked by part-time 

physicians were recorded accurately and timely. In 2003, the OIG 

recommended VHA apprise all part-time physicians of their responsibilities 

regarding VA timekeeping requirements. In 2004, the OIG recommended 

VA medical center directors ensure part-time physicians request and receive 

written approval before taking leave. 

VHA implemented requirements that part-time physicians receive approval 

in writing before taking leave or changing tour schedules. However, based 

VA Office of Inspector General 7 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

on desk audits performed by VA medical centers and interviews with 

timekeepers and part-time physicians, VA medical center staff continued to 

make timekeeping errors. For example: 

	 A part-time physician failed to request leave in the time and attendance 

system for leave taken over 5 months earlier. 

	 A timekeeper posted a part-time physician’s scheduled hours even 

though the physician had reported that his actual work hours differed 

from his scheduled hours. 

	 A supervisor certified that a part-time physician worked on Wednesday 

and Thursday even though they actually worked Monday and Tuesday. 

In addition, part-time physicians on adjustable schedules did not always 

record their time and attendance daily as required, as shown in Table 4. One 

part-time physician told us that he did not record his time in the time and 

attendance system on days when he had no other reason to access the system. 

Another part-time physician stated that he was not yet familiar with the time 

and attendance system. 

According to VA policy, part-time physicians on adjustable schedules are 

required to record their time and attendance on a daily basis in the Electronic 

Subsidiary Record. It also states that timekeeping documents shall reflect 

actual hours worked. We analyzed how often part-time physicians on an 

adjustable schedule were inputting their time daily in the Electronic 

Subsidiary Record. During our 10-week review period, part-time physicians 

on adjustable schedules self-reported a total of 593 days worked in the 

Electronic Subsidiary Record. Of those, 42 percent were not recorded the 

same or next day, as shown in Table 4. 

Table 4	 Timeliness of Recording in the Electronic Subsidiary Record 

Description 

San 

Antonio 

Palo 

Alto Tampa Durham Totals 

Part-Time Physicians on 

Adjustable Schedules 5 1 8 2 16 

Days Worked, as 

Recorded in Electronic 

Subsidiary Record 

193 20 307 73 593 

Days Not Recorded 

Timely 38 4 170 39 251 

Percent of Days Not 

Recorded Timely 20% 20% 55% 53% 42% 

Source: OIG Analysis 

VA Office of Inspector General 8 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Conclusion 

Recommendations 

Management 

Comments and 

OIG Response 

VHA increased their level of accountability over time and attendance of 

part-time physicians in comparison to previous audits. VHA initiated 

effective management controls, such as time and attendance performance 

monitors, written service agreements with part-time physicians, and 

requirements to record actual hours worked. As a result, part-time 

physicians’ time and attendance improved. However, staff did not fully 

implement controls and VHA no longer required written service agreements 

for all part-time physicians. Fully implemented controls would help 

continue and enhance the improvements made by VHA in ensuring that all 

part-time physicians meet their employment obligations. 

1.	 We recommend the Under Secretary for Health reinstitute the 

requirement that all part-time physicians (including those on fixed 

schedules) who have duties other than clinical activities complete a 

written agreement detailing the approximate amount of time that will be 

spent on VHA clinical, research, education, and administrative activities. 

2.	 We recommend the Under Secretary for Health require VA medical 

center management to establish procedures to periodically monitor the 

activities of all part-time physicians to ensure consistency with written 

employment agreements. 

3.	 We recommend the Under Secretary for Health clarify procedures 

requiring staff to establish and use baseline levels to monitor part-time 

physicians’ activities for an entire pay period during the month. 

4.	 We recommend the Under Secretary for Health clarify procedures 

including documentation requirements to ensure semi-annual physical 

reviews are random and reviewers make visual verification when the 

part-time physician is at VA. 

5.	 We recommend the Under Secretary for Health require VA medical 

center management to establish oversight procedures to ensure staff 

follow the requirements in VA Handbook 5011/12 to maintain accurate 

schedules for part-time physicians. 

6.	 We recommend the Under Secretary for Health require VA medical 

center management to establish oversight procedures to ensure staff 

follow the requirements in VA Handbook 5011/12 to promptly record 

actual hours worked and leave taken by part-time physicians. 

The Under Secretary for Health agreed with our findings and 

recommendations and provided acceptable implementation plans to our 

recommendations. VHA plans to complete all corrective actions by 

March 31, 2012. We will monitor VHA’s progress and follow up on their 

implementation until all proposed actions are completed. Appendix B 

contains the full text of the Under Secretary for Health’s comments. 

VA Office of Inspector General 9 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Appendix A 

Scope and 

Methodology 

Data Analysis 

Scope and Methodology 

We conducted our audit work from November 2010 through August 2011. 

The audit focused on part-time physicians’ time and attendance controls for 

the period August 1, 2010, through March 31, 2011. We reviewed national 

policies and procedures, interviewed VHA and VISN management, and 

tested controls at four judgmentally selected VA medical centers—South 

Texas Veterans Health Care System (San Antonio, TX); Palo Alto Health 

Care System (Palo Alto, CA); James A. Haley Veterans Hospital 

(Tampa, FL); and Durham VA Medical Center (Durham, NC). At these four 

VA medical centers, we performed the following steps. 

	 Evaluated local policies and procedures related to part-time physicians’ 

time and attendance. 

	 Interviewed chiefs of staff, part-time physicians, timekeepers, 

administrative officers, compliance personnel, fiscal personnel, and VA 

medical center management. 

	 Reviewed written agreements between part-time physicians and VA 

medical centers on expectations and time allotted for activities. 

	 Reviewed signed certifications of understanding regarding VHA time 

and attendance procedures. 

	 Determined if VA medical centers conducted performance monitors 

(such as monthly monitoring of electronic documentation of time and 

attendance, and semi-annual physical reviews) according to standard 

operating procedures. 

	 Discussed absences identified in our 10-week electronic workload 

analysis of 120 randomly selected part-time physicians with staff to 

identify reasons for absences and obtain further supporting evidence, if 

available. 

	 Physically searched for 206 part-time physicians. 

As of October 2010, VA employed over 6,250 part-time physicians. The 

salary costs associated with acquiring VA part-time physicians’ services was 

approximately $660 million in FY 2010. We reviewed a random sample of 

120 out of the 465 part-time physicians employed at the four selected VA 

medical centers to determine if documented evidence validated part-time 

physicians’ attendance. We analyzed VA workload over a 10-week period 

(August 1 through October 9, 2010), limiting our analysis to days in which 

the part-time physician worked 4 or more hours. We used VA’s Personnel 

and Accounting Integrated Data system to identify part-time physicians 

employed at the VA medical centers. We obtained electronic workload 

information from Veterans Health Information Systems and Technology 

VA Office of Inspector General 10 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Reliability of 

ComputerProcessed 

Data 

Architecture (VistA). With the assistance of the OIG Data Analysis 

Division, we obtained the following data reports for the four VA medical 

centers. 

	 Time and Attendance (included schedules worked, authorized absences, 

and leave taken) 

	 Clinic Profile Report (identified clinics at each VA medical center and 

length per appointment) 

	 Anesthesia Provider Report (identified providers involved, date, and 

elapsed time) 

	 List of Operations (identified physicians involved, date, and operating 

time) 

	 Provider Encounter Counts (identified provider, date, clinic, and number 

of encounters per clinic, per day) 

	 Progress Notes (identified author, co-signer, and date) 

	 Doctor’s Orders (identified provider, date, and orders written and 

entered) 

We organized the data by VA medical center, part-time physician, and day. 

We used the time and attendance data to determine total minutes scheduled 

each day and reduced that by any leave or authorized absences. To identify 

workload, we applied data found in the anesthesia report, list of operations 

report, provider encounters report, provider progress notes report, and 

doctor’s orders report for each part-time physician on the documented day. 

To obtain a more accurate representation of attendance, we excluded days 

scheduled for less than 4 hours. For those days part-time physicians were 

scheduled for 4 hours or more, we looked for at least one piece of 

documented evidence from the reports mentioned above. 

The electronic data we obtained from VistA was limited to clinical activity 

and was not comprehensive. For days part-time physicians were scheduled 

4 hours or more with no evidence of electronic workload, we followed up 

with VA medical center staff for further supporting documentation. In some 

instances, VA medical centers were able to provide sufficient supporting 

documentation from stand-alone computer programs that varied from site to 

site. We also requested additional sources of data or explanations for 

non-clinical activities from the VA medical centers. 

To achieve the audit objective, we relied on computer-processed data 

contained in VistA. The OIG Data Analysis Division obtained 

computer-based data for time and attendance, progress notes, patient 

encounters, doctors’ orders, the list of operations, and anesthesiology reports 

from VHA’s VistA system. 

VA Office of Inspector General 11 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Compliance 

With 

Government 

Audit 

Standards 

Our review of system controls and the results of data tests showed an error 

rate that cast doubt on the data's validity. Although we found no indications 

the data was unreliable or erroneous, we did find evidence the data was 

incomplete. However, in addition to the data, we relied on other sources of 

information—such as data from stand-alone computer programs and clinic 

calendars—obtained from the VA medical centers to support the audit. 

When these data are viewed in context with other available evidence, we 

believe the opinions, conclusions, and recommendations in this report are 

valid. 

Our assessment of internal controls focused on those controls relating to our 

audit objectives. We conducted this performance audit in accordance with 

generally accepted government auditing standards. These 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 objective. We believe that the evidence obtained provides a reasonable 

basis for our findings and conclusions based on our audit objective. 

VA Office of Inspector General 12 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Appendix B Under Secretary for Health Comments 

Department of Memorandum Veterans Affairs 

Date:	 September 8, 2011 

From:	 Under Secretary for Health (10) 

Subj:	 OIG Draft Report, Follow-Up Audit of Part-Time Physician Time and 

Attendance 

To: Assistant Inspector General for Audits and Evaluations (52) 

1.	 I have reviewed the draft report and concur with the report findings and 

recommendations. 

2.	 In its report, Office of Inspector General (OIG) auditors note that the Veterans 

Health Administration (VHA) has worked diligently to ensure part-time 

physicians meet their employment obligations to the Department of Veterans 

Affairs as well as implement the VHA action plan developed to respond to 

previous recommendations from the OIG. The success of these efforts is 

evidenced in the 97 percent compliance rate that the OIG confirmed with this 

audit. 

3.	 Even with such a high compliance rate, VHA agrees that the findings in this new 

audit warrant additional study and consideration of both policy and procedure 

revisions. The attached action plan provides specifics on the actions planned to 

address the report recommendations. 

4.	 Thank you for the opportunity to review the draft report. If you have any 

questions, please contact Linda H. Lutes, Director, Management Review Service 

(10A4A4) at (202) 461-7014. 

(original signed by:) 

Robert A. Petzel, M.D. 

Attachment 

VA Office of Inspector General 13 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

VETERANS HEALTH ADMINISTRATION (VHA)
 

Action Plan
 

OIG Draft Report, Follow-Up Audit of Part-Time Physician Time and Attendance (Project 

No. 2011-00308-R5-0008), (VAIQ 7144005) 

Date of Draft Report: August 4, 2011 

Recommendations/ Status Completion 

Actions Date 

Recommendation 1. We recommend that the Under Secretary for Health reinstitute the 

requirement that all part-time physicians (including those on fixed schedules) who have 

duties other than clinical activities complete a written agreement detailing the approximate 

amount of time that will be spent on VHA clinical, research, education, and administrative 

activities. 

VHA Comments 

Concur 

The Veterans Health Administration’s (VHA) Workforce Management and Consulting (WMC) 

Office will work with all stakeholders, including its Office of Academic Affiliations (OAA), the 

Office of the Assistant Deputy Under Secretary for Health for Clinical Operations, and 

representatives from the field to update VHA Directive 2003-001, Time and Attendance for Parttime Physicians, and ensure compliance with VA Handbook 5011, Hours of Duty and Leave. 

The update will address the different circumstances involving VHA part-time physicians on flex 

tours as well as part-time physicians on fixed tours. The update will also ensure appropriate and 

flexible written agreements are completed upon employment and updated periodically to identify 

how best to reflect the scope of duties and expectations of the position. 

In Process March 31, 2012 

Recommendation 2. We recommend that the Under Secretary for Health require VA 

medical center management to establish procedures to periodically monitor the activities of 

all part-time physicians to ensure consistency with written employment agreements. 

VHA Comments 

Concur 

The WMC, OAA, and the Office of the Assistant Deputy Under Secretary for Health for Clinical 

Operations will collaborate and include other representatives from the field, as needed, to review 

and update the existing Deputy Under Secretary for Health for Operations and Management 

(DUSHOM) Standard Operating Procedures (SOP), Validation of Part-Time Physicians' 

Attendance. Appropriate monitoring and oversight activities will be considered in deliberations 

VA Office of Inspector General 14 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

to revise the SOP. The revised SOP will become part of the revised VHA Directive 2003-001 as 

described in the response to Recommendation 1. Appropriate training and education of field 

personnel will also be planned and implemented. 

In Process March 31, 2012 

Recommendation 3. Clarify procedures requiring staff to establish and use baseline levels 

to monitor part-time physicians’ activities for an entire pay period during the month. 

VHA Comments 

Concur 

The Office of the DUSHOM will provide a clarifying memorandum and SOP to Veterans 

Integrated Service Networks that will require VA medical centers to establish baseline levels to 

be used to validate time and attendance per the revised SOP. 

In Process March 31, 2012 

Recommendation 4. We recommend that the Under Secretary for Health clarify 

procedures including documentation requirements to ensure semi-annual physical reviews 

are random and reviewers make visual verification when the part-time physician is at VA. 

VHA Comments 

Concur 

Clarification of procedures and documentation requirements to ensure that semi-annual physical 

reviews are random and that reviewers make visual verification when the part-time physician is 

performing duties at VA will be addressed in the revision to the SOPs discussed in the response 

to Recommendation 2. Communication and education will be provided to the field when the 

SOP is distributed. 

In Process March 31, 2012 

Recommendation 5. We recommend that the Under Secretary for Health require VA 

medical center management to establish oversight procedures to ensure staff follow the 

requirements in VA Handbook 5011/12 to maintain accurate schedules for part-time 

physicians. 

VHA Comments 

Concur 

The WMC, OAA, the Office of the Assistant Deputy Under Secretary for Health for Clinical 

Operations, and representatives from the field will work collaboratively to revise VHA Directive 

2003-001 to ensure compliance with VA Handbook 5011. Revisions to the directive will 

VA Office of Inspector General 15 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

address the establishment of oversight procedures to ensure schedules for part-time physicians 

are accurately maintained. 

In Process March 31, 2012 

Recommendation 6. We recommend that the Under Secretary for Health require VA 

medical center management to establish oversight procedures to ensure staff follow the 

requirements in VA Handbook 5011/12 to promptly record actual hours worked and leave 

taken by part-time physicians. 

VHA Comments 

Concur 

The WMC, OAA, the Office of the Assistant Deputy Under Secretary for Health for Clinical 

Operations, and representatives from the field will work collaboratively to update VHA 

Directive 2003-001 to ensure compliance with VA Handbook 5011. The update will include 

policy and process to ensure actual hours worked and leave taken by part-time physicians are 

properly recorded. 

In Process March 31, 2012 

Veterans Health Administration 

September 2011 

VA Office of Inspector General 16 
Follow-Up Audit of VHA’s Part-Time Physician Time and Attendance 

Appendix C OIG Contact and Staff Acknowledgments
 

OIG Contact	 For more information about this report, please 

contact the Office of Inspector General at 

(202) 461-4720. 

Acknowledgments Larry Reinkemeyer, Director 

Timothy Halpin 

Patricia Hudon 

Joe Janasz 

Daniel Morris 

Dao Pham 

Lynn Scheffner 

Oscar Williams 

VA Office of Inspector General 17 
Follow-Up Audit of Part-Time Physician Time and Attendance 

Appendix D Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Health Administration
 

Veterans Benefits Administration
 

National Cemetery Administration
 

Assistant Secretaries
 

Office of General Counsel
 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report will be available in the near future on the OIG’s Web site at 

http://www.va.gov/oig/publications/reports-list.asp. This report will remain 

on the OIG Web site for at least 2 fiscal years. 

VA Office of Inspector General 18