United States Government Accountability Office

GAO Testimony 

Before the Subcommittee on Oversight 

and Investigations, Committee on 

Veterans’ Affairs, House of 

Representatives

VA HEALTH CARE 

Patient Safety Could be 

Enhanced by Improvements 

in Employment Screening 

and Physician Privileging 

Practices 

Statement of Laurie E. Ekstrand 

Director, Health Care 

For Release on Delivery

Expected at 10:00 a.m. EDT 

Thursday, June 15, 2006 

 

GAO-06-760T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

June 15, 2006

VA HEALTH CARE

Patient Safety Could be Enhanced by 

Improvements in Employment Screening 

and Physician Privileging Practices 

Highlights of GAO-06-760T, a testimony 

before the Subcommittee on Oversight 

and Investigations, Committee on

Veterans’ Affairs, House of 

Representatives 

In its March 2004 report, VA Health 

Care: Improved Screening of 

Practitioners Would Reduce Risk 

to Veterans, GAO-04-566, GAO 

made recommendations to improve 

VA’s employment screening of 

practitioners. GAO was asked to

testify today on steps VA has taken 

to improve its employment

screening requirements and VA’s 

physician credentialing and 

privileging processes because of 

their importance to patient safety. 

This testimony is based on two 

GAO reports released today that 

determined the extent to which 

(1) VA has taken steps to improve 

employment screening for

practitioners by implementing 

GAO’s 2004 recommendations, 

(2) VA facilities are in compliance

with selected credentialing and

privileging requirements for 

physicians, and (3) VA has internal 

controls to help ensure the 

accuracy of privileging information.

What GAO Recommends

In its reports released today, GAO 

recommends that VA expand its

employment screening oversight

program to include all

practitioners, provide guidance on 

collecting physician performance

information, enforce the time

frame to submit information on 

paid VA malpractice claims 

involving VA practitioners, and

instruct facilities to establish 

internal controls for physician 

privileging information. VA agreed

with the findings and conclusions 

and concurred with the 

recommendations in both reports. 

In its report released today, VA Health Care: Steps Taken to Improve

Practitioner Screening, but Facility Compliance with Screening 

Requirements Is Poor, GAO-06-544, GAO found that VA has taken steps to 

improve employment screening for practitioners, such as physicians, nurses, 

and pharmacists, by partially implementing each of four recommendations 

GAO made in March 2004. However, gaps still remain in VA’s requirements. 

For example, for the recommendation that VA check all state licenses and 

national certificates held by all practitioners, such as nurses and 

pharmacists, VA implemented the recommendation for practitioners it 

intends to hire, but has not expanded this screening requirement to include 

those currently employed by VA. In addition, VA’s implementation of another 

recommendation—to conduct oversight to help facilities comply with 

employment screening requirements—did not include all screening 

requirements, as recommended by GAO. 

In another report released today, VA Health Care: Selected Credentialing 

Requirements at Seven Medical Facilities Met, but an Aspect of Privileging 

Process Needs Improvement, GAO-06-648, GAO found at seven VA facilities 

it visited compliance with almost all selected credentialing and privileging 

requirements for physicians. Credentialing is verifying that a physician’s 

credentials are valid. Privileging is determining which health care services—

clinical privileges—a physician is allowed to provide. Clinical privileges 

must be renewed at least every 2 years. One privileging requirement—to use 

information on a physician’s performance in making privileging decisions—

was problematic 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. Further, three of the seven facilities did not submit medical 

malpractice claim information to VA’s Office of Medical-Legal Affairs within 

60 days after being notified that a claim was paid, as required by VA. This 

office uses such information to determine whether VA practitioners have 

delivered substandard care and provides these determinations to facility 

officials. When VA medical facilities do not submit all relevant information in 

a timely manner, facility officials make privileging decisions without the 

advantage of such determinations. 

VA has not required its facilities to establish internal controls to help ensure 

that physician privileging information managed by medical staff specialists—

employees who are responsible for obtaining and verifying information used 

in credentialing and privileging—is accurate. One facility GAO visited did not 

identify 106 physicians whose privileging processes 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. 

www.gao.gov/cgi-bin/getrpt?GAO-06-760T.

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. 
Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today to discuss efforts by the Department of 

Veterans Affairs (VA) to ensure that its health care practitioners provide 

safe care to veterans. Specifically, I want to discuss findings related to 

patient safety in two reports that we are releasing today. The first report 

focuses on employment screening requirements that VA medical facility 

officials must follow. Under these requirements, VA facility officials check 

the professional credentials and personal backgrounds for all practitioners

their facilities employ.1

 VA practitioners include physicians, nurses, and 

pharmacists, among others. Part of the screening process includes 

credentialing, which is the process of checking that a practitioner’s 

professional credentials, such as licensure, education, and training, are 

valid and meet VA’s requirements for employment. Our second report 

specifically examines credentialing and privileging processes intended to

ensure the safe delivery of care by VA physicians.2

 Physician privileging is 

the process for determining which health care services or clinical 

privileges, such as surgical procedures or administering anesthesia, a 

physician can provide to VA patients without supervision. These clinical 

privileges must be renewed at least every 2 years. While VA’s requirements 

cannot guarantee patient safety in health care settings, they are intended 

to minimize the chance of patients receiving care from someone who is 

incompetent or who may intentionally harm them. 

In March 2004, we reported and testified before this subcommittee on gaps 

in VA’s practitioner screening requirements.3

 We found that VA did not 

require that all of its health care practitioners with access to patients be 

thoroughly screened. In addition, we found mixed compliance with VA 

screening requirements at the medical facilities we visited. We concluded 

that the gaps in and mixed compliance with VA’s screening requirements 

created vulnerabilities that could allow VA to employ health care 

 1

GAO, 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). 

2

GAO, VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities 

Met, but an Aspect of Privileging Process Needs Improvement, GAO-06-648 (Washington,

D.C.: May 25, 2006). 

3

GAO, VA Health Care: Improved Screening of Practitioners Would Reduce Risk to 

Veterans, GAO-04-566 (Washington, D.C.: Mar. 31, 2004), and VA Health Care: Veterans at

Risk from Inconsistent Screening of Practitioners, GAO-04-625T (Washington, D.C.: 

Mar. 31, 2004). 

Page 1 GAO-06-760T
practitioners who could place patients at risk. In our 2004 report, we made 

four recommendations to address the gaps we identified in VA’s screening 

requirements and the noncompliance we found at the VA medical facilities 

we visited. VA generally agreed with our findings and conclusions and 

stated it would develop a detailed action plan to implement our 

recommendations. 

The subcommittee is interested in the progress VA has made in 

implementing our March 2004 recommendations and in efforts by VA to 

ensure that its health care practitioners are qualified and have appropriate 

backgrounds to safely deliver care to veterans. My remarks today focus on 

the extent to which (1) VA has taken steps to improve employment 

screening for practitioners by implementing the four recommendations 

made in our March 2004 report, (2) VA medical facilities are in compliance 

with VA’s employment screening requirements for health care 

practitioners, (3) VA medical facilities are in compliance with selected 

credentialing and privileging requirements for physicians, and (4) VA has 

internal controls to help ensure the accuracy of information medical 

facilities use to renew physicians’ clinical privileges. 

In carrying out this work, we reviewed VA’s policies and procedures for 

employment screening and interviewed VA headquarters officials to 

determine if the recommendations we made in March 2004 were 

implemented. We also reviewed VA policies outlining the processes for 

credentialing and privileging physicians. In addition, we visited seven VA

medical facilities for each report.4

 At each facility we visited, we reviewed 

a sample of practitioner files to determine if documentation in the files 

demonstrated compliance with the requirements in our reviews. For the 

employment screening report, we selected five employment screening 

requirements, and for the physician credentialing and privileging report, 

we selected four credentialing and five privileging requirements for 

physicians. See appendix I for the four recommendations we made in 

March 2004 and the VA screening, credentialing, and privileging 

requirements we used in our reports to measure VA medical facility 

compliance. We also identified the internal controls VA has in place for its 

privileging process and, using GAO’s standards for internal controls in the 

 4

For the employment screening report, we visited VA facilities in Fargo, North Dakota; 

Kansas City, Missouri; Miami, Florida; New Orleans, Louisiana; Salt Lake City, Utah; 

San Antonio, Texas; and Washington, D.C. For the physician credentialing and privileging 

report, we visited VA facilities in Boise, Idaho; Kansas City, Missouri; Las Vegas, Nevada; 

Lexington, Kentucky; Martinsburg, West Virginia; Miami, Florida; and San Antonio, Texas.

Page 2 GAO-06-760T
federal government, determined whether these controls are adequate.

5

 We 

performed our work from April 2005 to May 2006 in accordance with 

generally accepted government auditing standards. 

In summary, VA has taken steps to improve employment screening of its 

health care practitioners by partially implementing each of the four 

recommendations made in our March 2004 report; however, gaps still 

remain in VA’s health care practitioner screening requirements. For 

example, for our recommendation that VA check all state licenses and 

national certificates held by all practitioners, VA implemented the 

recommendation for practitioners it intends to hire, but has not expanded

this screening requirement to include those currently employed by VA. In 

addition, VA’s implementation of another recommendation—to conduct 

oversight to help facilities comply with employment screening 

requirements—did not include all types of practitioners and screening 

requirements, as we recommended. 

At the seven VA medical facilities we visited for our review of VA’s health 

care practitioner screening, we found poor compliance with four of the 

five VA screening requirements we selected for review. Based on the 

practitioner files we reviewed, we found that none of the facilities we 

visited had a compliance rate of 90 percent or more for all screening 

requirements, and VA policy requires 100 percent compliance with these 

requirements.6

At the seven VA medical facilities we visited for our review of VA’s 

physician credentialing and privileging requirements, we found 

compliance with almost all selected credentialing and privileging 

requirements. Specifically, the physician files we reviewed demonstrated 

compliance with the four selected credentialing requirements and four of 

the five privileging requirements. Compliance with a fifth privileging

requirement—to use information on a physician’s performance in making 

privileging decisions—was problematic at six of the VA medical facilities. 

At these six, officials obtained this information from their facilities’ quality 

 5

GAO, Internal Control Management and Evaluation Tool, GAO-01-1008G (Washington, 

D.C.: August 2001). 

6

A 90 percent compliance rate means that 90 percent of the health care practitioner files we 

examined at each facility provided documentation that the screening requirement had been

met in accordance with VA policy. 

Page 3 GAO-06-760T
assurance programs.7

 Use of such information in connection with 

privileging is prohibited by VA policy, and according to VA officials, this 

prohibition exists to protect the confidentiality of quality assurance 

information and to encourage physicians to participate in quality 

assurance programs. 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 physicians’ clinical 

privileges, as required. Further, three of the seven facilities did not submit 

medical malpractice claim information to VA’s Office of Medical-Legal 

Affairs within 60 days after being notified that a claim was paid, as 

required by VA. This office is responsible for forming panels of 

practitioners to determine whether VA practitioners have delivered 

substandard care. When VA medical facilities do not submit all relevant 

information in a timely manner, facility officials make privileging decisions 

without the advantage of such determinations. 

VA has not required its medical facilities to establish internal controls to 

help ensure that physician privileging information managed by medical 

staff specialists—employees who are responsible for obtaining and 

verifying the information used in credentialing and privileging—is 

accurate. One facility we visited did not identify 106 physicians whose 

privileging processes 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. This facility has since 

implemented internal controls to reduce the risk of a similar situation 

occurring in the future. During our visits to other VA facilities for the 

physicians’ credentialing and privileging report, we did not identify any 

facilities that had established internal controls to help ensure the accuracy 

of physician privileging information. 

 7

VA requires each of 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. 

Page 4 GAO-06-760T
To better ensure the safety of veterans receiving health care at VA 

facilities, in our reports we recommended that VA expand its oversight to 

include a review of VA facilities’ compliance with screening requirements 

for all types of health care practitioners, 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 enforce the requirement that 

medical facilities submit information on paid VA medical malpractice 

claims in a timely manner to VA’s Office of Medical-Legal Affairs. 

Additionally, we recommended that VA instruct its medical facilities to 

establish internal controls to ensure the accuracy of their physician 

privileging information. In commenting on drafts of these reports, VA 

agreed with our findings and conclusions and concurred with our 

recommendations. VA provided an action plan to address the three 

recommendations in the report on VA’s physician credentialing and 

privileging requirements, and stated that it will provide an action plan to 

implement the recommendations in the practitioner screening report after 

issuance of the report. 

VA operates the largest integrated health care system in the United States,

providing care to nearly 5 million veterans per year. The VA health care 

system consists of hospitals, ambulatory clinics, nursing homes, 

residential rehabilitation treatment programs, and readjustment 

counseling centers. In addition to providing medical care, VA is the largest

educator of health care professionals, training more than 28,000 medical 

residents annually, as well as other types of trainees. 

Background 

State Licenses and 

National Certificates 

VA requires its health care practitioners to have professional credentials in 

their specific professions through either state licenses or national 

certificates.8

 VA policy requires officials at its medical facilities to screen 

each applicant for positions at VA to determine whether the applicant 

possesses at least one current and unrestricted state license or an 

appropriate national certificate, whichever is applicable for the position 

sought by the applicant. VA also requires officials at its medical facilities 

to periodically verify licenses or national certificates held by health care 

 8

Not all VA practitioners, such as nursing assistants, are required to have a state license or 

a national certificate. Some practitioners, such as occupational therapists, may hold both 

national certificates and state licenses. 

Page 5 GAO-06-760T
practitioners already employed at VA. In general, for both applicants and 

employed health care practitioners, VA’s employment screening process 

proceeds in two stages. First, applicants and employed health care 

practitioners are required to disclose to VA, if applicable, their state 

licenses and national certificates. Applicants disclose their credentials to 

VA during the application process, and employed health care practitioners 

disclose credentials to VA as they expire and are renewed with the state 

licensing board or certifying organization. Second, VA facility officials are 

required to check whether the disclosed credentials are valid.

State licenses are issued by state licensing boards, whereas national 

certificates are issued by national certifying organizations, which are 

separate and independent from state licensing boards. Both state licensing 

boards and national certifying organizations establish requirements that 

practitioners must meet to be licensed or certified. Licensed practitioners

may be licensed in more than one state. “Current and unrestricted 

licenses” are licenses that are valid and in good standing in the state where 

issued. To keep a license current, practitioners must renew their licenses 

before they expire. When licensing boards discover a licensee is in 

violation of licensing requirements or established law, for example, 

abusing prescription drugs or intentionally or negligently providing poor 

quality care that results in adverse health effects, they may place 

restrictions on or revoke a license. Restrictions from a state licensing 

board can limit or prohibit a practitioner from practicing in that particular 

state. Some, but not all, state licenses are marked to indicate whether the 

licenses have had restrictions placed on them. Practitioners, such as 

respiratory and occupational therapists, who are required to have national 

certificates to work at VA, must have current and unrestricted certificates. 

National certifying organizations can restrict or revoke certificates for 

violations of the organizations’ professional standards. Generally, each 

state licensing board and national certifying organization maintains a 

database of information on restrictions, which employers can often obtain 

at no cost either by accessing the information on a board’s Web site or by 

contacting the board directly. 

Page 6 GAO-06-760T
In addition to holding valid professional credentials, when hired, health 

care practitioners are required to undergo background investigations that

verify their personal and professional histories.9

 Depending on the 

position, the extent of the background investigations for health care 

practitioners varies. For example, the minimum background investigation 

is a fingerprint-only investigation, which compares a practitioner’s 

fingerprints to those stored in criminal history databases. A traditional 

background investigation, which covers a health care practitioner’s 

personal and professional background for up to 10 years, is the most 

common type of background investigation conducted by VA on its health 

care practitioners. The traditional background investigation verifies an 

individual’s history of employment, education, and residence, and includes 

a fingerprint check against a criminal-history database. The Office of 

Personnel Management conducts background investigations for VA. To 

determine the level of background investigation required for employment, 

VA facility officials are required to complete VA Form 2280, which 

documents the level of risk posed by a particular position. 

Background Investigations 

Physician Credentialing 

and Privileging 

For physicians, VA has specific requirements that facility officials must 

follow to credential and privilege physicians. Officials must follow these 

requirements when physicians initially apply to work in VA—which is 

known as initial appointment—and then again at least every 2 years when 

physicians must apply for reappointment in order to renew their clinical 

privileges. Prior to working at VA, physicians enter into VetPro, a Webbased credentialing system VA implemented in March 2001, information 

used by VA medical facility officials in the credentialing process. For 

example, physicians enter information on their involvement in VA and 

non-VA medical malpractice claims and their medical education and 

training. For their reappointments, physicians must update this 

credentialing information in VetPro. A facility’s medical staff specialist 

then performs a data check to be sure that all required information has 

been entered into VetPro. 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. Once a physician’s credentialing information has been verified, 

 9

Executive Order 10450, April 27, 1953, requires all persons employed by federal 

departments and agencies to undergo background investigations to ensure that their 

employment is consistent with national security interests. 

Page 7 GAO-06-760T
the medical staff specialist sends the information to the physician’s 

supervisor, known as a clinical service chief.10

In addition to entering credentialing information into VetPro, physicians 

complete written requests for clinical privileges. The facility medical staff 

specialist provides a physician’s clinical service chief with the requested 

clinical privileges and information needed to complete the privileging

process, including information that indicates that the credentialing 

information entered by the physician into VetPro has been verified with 

the appropriate sources. The requested clinical privileges are reviewed by 

the 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. For reappointment only, 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 physician’s performance 

information, the clinical service chief recommends that clinical privileges 

previously granted by the facility remain the same, be reduced, or be 

revoked, and whether newly requested privileges should be added.11 The 

2-year 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. 

VA has taken steps to improve employment screening of its health care 

practitioners by partially implementing each of the four recommendations 

made in our March 2004 report; however, gaps still remain in VA’s health 

care practitioner screening requirements. To address our recommendation 

that VA facility officials contact state licensing boards and national 

certifying organizations to verify all licenses and certificates held by all VA 

health care practitioners, VA expanded its verification requirement to 

include licenses and certificates for all prospective hires but did not 

extend this requirement to include all practitioners currently employed by 

VA. For those currently employed, such as nurses and pharmacists, VA 

only required facility officials to physically inspect one license of a 

VA Has Taken Steps

to Improve 

Employment 

Screening 

Requirements, but 

Gaps Remain 

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

11Reduction of privileges may include restricting or prohibiting a physician from performing

certain procedures or prescribing certain medications. Revocation of privileges refers to 

the permanent loss of all clinical privileges at that facility. 

Page 8 GAO-06-760T
practitioner’s choosing.12 Physical inspection of a license cannot ensure 

that it is valid and without restriction, nor can it ensure that there are not 

other licenses from other states that may have restrictions. Checking all 

licenses against state records is the only way to identify practitioners with 

restricted licenses. We reviewed a draft of a VA policy that if issued in its 

current form would fully address our recommendation to require medical

facility officials to verify all state licenses and national certificates of 

currently employed health care practitioners. According to a VA official, 

this policy is expected to be issued in June 2006. 

To address our second recommendation that VA query the Department of 

Health and Human Services’ (HHS) Healthcare Integrity and Protection 

Data Bank (HIPDB) for all licensed health care practitioners that VA 

intends to hire and periodically query it for those already employed, VA in

July 2004 directed facility officials to query HIPDB for all applicants for VA 

employment. However, officials were not directed to periodically query

HIPDB for health care practitioners currently employed by VA. Officials 

told us that VA is working with HHS to develop a process whereby VA can 

electronically query HIPDB for current VA employees. Once this process is 

in place, and VA is using it to periodically query HIPDB for those currently 

employed at VA, the department will have fully implemented our 

recommendation. However, VA did not provide a time frame for 

implementing this electronic query of HIPDB. 

To address our third recommendation that VA expand the use of 

fingerprint-only background investigations for all practitioners with direct 

access to patients, VA issued a policy that required all VA medical facilities 

to begin using electronic fingerprint machines by September 1, 2005. By 

February 1, 2006, all but two facilities had obtained the equipment 

necessary to implement this requirement. 

To address our fourth recommendation concerning oversight of the 

screening requirements, VA formalized an oversight program within its 

Office of Human Resource Management to include a review of some 

aspects of the screening process for applicants and current employees. 

However, the oversight program does not ensure that facilities are 

complying with all of VA’s key screening requirements, as we 

recommended. For example, officials from the oversight program are not 

required to check personnel files to ensure that facility officials query 

 12VA Handbook 5005, pt. II, ch. 3, para. 17a(1). 

Page 9 GAO-06-760T
HIPDB and verify all health care practitioners’ licenses and certifications 

with the relevant issuing organizations. 

For the seven VA facilities we visited to determine compliance with 

employment screening requirements for practitioners, we found poor 

compliance with four of the five requirements we selected for review. Two 

of these five requirements VA implemented since our March 2004 report—

for individuals VA intends to hire, query HIPDB and use an employment 

checklist to document the completion of employment screening 

requirements. Three other employment screening requirements were longstanding—verify health care practitioners’ state licenses and national 

certificates; complete VA Form 2280, which is used to determine the 

appropriate type of background investigation needed for each health care 

practitioner job category; and conduct background investigations. In order 

to show the variability in the level of compliance among the facilities, we 

measured their performance against a compliance rate of at least 

90 percent for each of the screening requirements, even though VA policy

requires 100 percent compliance with these requirements. None of the 

facilities had a compliance rate of 90 percent or more for all screening 

requirements we reviewed. Table 1 summarizes the rate of compliance 

among the seven facilities. 

VA Facilities Did Not 

Comply with 

Employment 

Screening 

Requirements for 

Practitioners 

Page 10 GAO-06-760T
Table 1: Facilities’ Rates of Compliance with Select VA Screening Requirements, 

2005 

Source: GAO analysis of VA facility files.

Facility compliance with screening requirementsa

Facility

A

Facility

B

Facility

C

Facility

D

Facility

E

Facility

F

Facility

Screening requirements G

Conducting background investigations

Position risk level determined

(VA Form 2280) 

Querying HIPDBb

Completing employment checklist

c

Verifying license, certification, or both

Indicates a compliance rate of less than 90 percent

Indicates a compliance rate of 90 percent or greater

Notes: We considered facilities to be in compliance if they were able to provide documentation not 

available in the personnel file. Site visits to these seven VA facilities were conducted from April 2005 

through August 2005. Only salaried practitioners are represented in this table. 

a

Tested for significance at the 95 percent confidence level. 

b

Applies only to health care practitioners hired on or after October 1, 2004, and certain health care 

practitioners hired prior to this date, such as physicians and dentists. Results for this screening 

requirement cannot be generalized to the facility being reviewed because of the sample size. 

c

Applies only to health care practitioners hired on or after October 1, 2004. Results for this screening 

requirement cannot be generalized to the facility being reviewed because of the sample size. 

As shown in table 1, while two facilities performed HIPDB queries on 

individuals they intended to hire, one of these facilities completed the 

queries immediately prior to our visit and not at the time the individuals 

were hired. We also found that two facilities had created their own 

employment checklists, but had not included all of the screening 

requirements contained in the original checklist issued by VA. As a result, 

these facilities were not in compliance with VA’s requirement. 

Page 11 GAO-06-760T
We found that the physician files at the facilities we visited demonstrated 

compliance with four VA credentialing and four privileging requirements 

we reviewed.13 However, we found that there were problems complying 

with a fifth privileging requirement—to use information on a physician’s

performance in making privileging decisions. In addition, we found that 

three of the seven medical facilities we visited did not submit to VA’s 

Office of Medical-Legal Affairs information on paid VA medical 

malpractice claims within 60 days after being notified that a claim was 

paid, as required by VA policy. 

Physician Files at 

Facilities 

Demonstrated 

Compliance with 

Almost All Selected 

Credentialing and 

Privileging 

Requirements; Not All 

Facilities Submitted 

Paid Malpractice 

Claim Information in 

a Timely Manner 

Selected Physician Files at 

Facilities Demonstrated 

Compliance with Four VA

Credentialing and Four 

Privileging Requirements; 

a Fifth Privileging 

Requirement Was 

Problematic 

We found that the physician files at the facilities we visited demonstrated 

compliance with four VA credentialing and four privileging requirements 

we reviewed. For the physician files we reviewed, the VA facilities’ 

medical staff specialists contacted state licensing boards to ascertain the 

status of the state medical licenses held and disclosed by their 

physicians.14 They also queried the Federation of State Medical Boards 

(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.15 Medical staff specialists complied with the 

requirement to contact sources, such as courts of jurisdiction, to verify 

information on physicians’ involvement in medical malpractice claims, 

including ongoing claims, disclosed by physicians. Additionally, in all

cases medical staff specialists queried the National Practitioner Data Bank

 13Findings for the credentialing and privileging requirements cannot be generalized to the

facility being reviewed because of the sample size. 

14VA medical facility officials may also verify physicians’ licenses by querying a state 

licensing board’s Web site for information on the licenses. 

15VA requires facility officials to query FSMB at initial appointment only. Thereafter, VA

headquarters regularly receives reports from FSMB on any currently employed VA

physician whose name appears on FSMB’s list, indicating that disciplinary action has been 

taken against the physician’s state license. 

Page 12 GAO-06-760T
(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 also demonstrated 

compliance with four of VA’s privileging requirements. Medical staff 

specialists verified physicians’ state licenses and the information disclosed 

by physicians about their involvement in medical malpractice allegations 

or paid claims, which are both credentialing and privileging requirements. 

We also found that medical staff specialists verified that physicians had 

the necessary training and experience to deliver health care and perform 

the clinical privileges physicians requested. Additionally, after medical 

staff specialists performed their verification, clinical service chiefs 

reviewed this information, as required, along with information on 

physicians’ health status. 

While we found evidence demonstrating compliance with four of VA’s 

privileging requirements, the files we reviewed showed that there were 

problems complying with a fifth privileging requirement that is used only 

in the renewal of privileges—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, as stated in 

VA policy, physician performance information that is collected as part of a 

facility’s quality assurance program cannot be used in a facility’s 

privileging process. According to VA, the confidentiality of individual 

performance information helps ensure practitioner participation, including

that of physicians, in a medical facility’s quality assurance program by 

encouraging practitioners to openly discuss opportunities for 

improvement in practitioner practice without fear of punitive action. VA 

officials stated that quality assurance information if used outside of a 

facility’s quality assurance program could be available for other purposes, 

including litigation. However, 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. Officials at six 

medical facilities told us that they used performance 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. At the seventh medical facility, officials did not use 

individual physician performance information to renew physicians’ clinical 

privileges, as required by VA. 

Page 13 GAO-06-760T
We also included in our review a requirement that is related to the 

privileging process—medical facilities must submit to VA’s Office of 

Medical-Legal Affairs information on paid VA medical malpractice claims 

within 60 days after being notified that a claim was paid. VA’s Office of 

Medical-Legal Affairs is responsible for forming panels of practitioners to 

determine whether practitioners involved in any of these claims delivered 

substandard care to veterans and provides these determinations to facility 

officials. We found that three of the seven VA medical facilities we 

reviewed did not submit claim information to VA’s Office of Medical-Legal 

Affairs within the 60-day time frame. For example, for 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.16

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. 

Not All Facilities 

Submitted Paid 

Malpractice Claim 

Information in a Timely 

Manner 

When VA medical facilities do not submit all relevant claim information to 

the Office of Medical-Legal Affairs, determinations on substandard care 

are not available to facility officials when they make privileging decisions. 

In addition, substandard care determinations are required to be reported 

by facility officials to NPDB. When VA medical facilities do not send claim 

information in a timely manner to the Office of Medical-Legal Affairs, these 

cases, if substandard care is found, go unreported or reporting to NPDB is 

delayed. This prevents other VA and non-VA facilities where the physician

may also practice from having complete information on the physician’s 

malpractice history. 

 16As of March 31, 2006, this medical facility had sent all delinquent medical malpractice 

claim information to VA’s Office of Medical-Legal Affairs. 

Page 14 GAO-06-760T
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 processes had not been completed by facility 

officials for at least 2 years because of inaccurate information provided by

the facility’s medical staff specialist. According to facility officials, the 

medical staff specialist changed reappointment dates for some physicians

and for other physicians removed their names from VetPro, the facility’s 

credentialing database. As a result, these physicians were practicing at the 

facility without current clinical privileges. 

Once medical facility officials became aware of the problem, they 

reviewed the files of all physicians and identified 106 physicians for whom 

the privileging process had not been completed. Facility officials told us 

they did not find any problems that would have warranted the 106 

physicians’ removal from the facility’s medical staff or that placed veterans

at risk. This facility has since implemented internal controls to reduce the 

risk of a similar situation occurring in the future. During our site visits to 

other VA medical facilities for the physicians’ credentialing and privileging 

report, we did not identify any facilities that had established internal 

controls to help ensure the accuracy of the information they use to renew 

physicians’ clinical privileges. Without accurate information, VA medical 

facility officials will not know if they have failed to renew clinical 

privileges for any of their physicians.

VA’s employment screening requirements are intended to ensure the safety

of veterans receiving care by identifying practitioners who are 

incompetent or may intentionally harm veterans. In our practitioner 

screening report that we are releasing today, we continue to raise 

concerns about gaps in VA’s employment screening requirements. 

Although VA concurred with our March 2004 recommendations and took 

steps to implement them, none were fully implemented as of March 2006.

These recommendations should be fully implemented. We are also 

concerned that compliance with employment screening requirements for 

practitioners, including physicians, nurses, and pharmacists, among 

others, continues to be poor at the facilities we visited. Continuing gaps in 

VA’s employment screening requirements and mixed compliance with 

these requirements continue to place veterans at risk. 

VA Has Not 

Established Internal 

Controls to Help 

Ensure the Accuracy 

of Facilities’ 

Privileging 

Information 

Concluding 

Observations 

The other report that we are releasing today demonstrates that medical 

facilities we reviewed largely complied with VA’s physician credentialing 

and privileging requirements. However, we identified problems with the 

Page 15 GAO-06-760T
appropriate use of physician performance information in the privileging

process and the timely submission of medical malpractice information to 

VA’s Office of Medical-Legal Affairs. Additionally, VA’s lack of internal 

controls for its facilities to ensure the accuracy of physician privileging 

information raises concerns that VA is at risk for allowing physicians to 

practice with expired clinical privileges. 

Our reports include the following four recommendations that VA should 

implement to help ensure patient safety: 

• expand the human resource management oversight program to include a 

review of VA facilities’ compliance with employment screening 

requirements for all types of practitioners, 

• provide guidance to medical facilities on how to collect individual 

physician performance information in accordance with VA’s credentialing 

and privileging requirements 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 physician privileging information. 

Mr. Chairman, this concludes my prepared remarks. I will be pleased to 

answer any questions you or other members of the subcommittee may 

have. 

For further information regarding this testimony, please contact 

Laurie E. Ekstrand 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 testimony. Mary Ann Curran, 

Martha Fisher, Krister Friday, and Marcia Mann also contributed to this 

statement. 

Contacts and 

Acknowledgments 

Page 16 GAO-06-760T
Page 17 GAO-06-760T

Appendix I: March 2004 Report 

Recommendations and VA Screening, 

Credentialing, and Privileging Requirements 

In our March 2004 report, VA Health Care: Improved Screening of 

Practitioners Would Reduce Risk to Veterans, we made four 

recommendations to address the gaps we identified in VA’s employment 

screening requirements and the noncompliance we found at the four 

medical facilities we visited.1

• Expand verification of all state licenses and national certificates by 

contacting the appropriate licensing boards and national certifying 

organizations for all Department of Veterans Affairs’ (VA) health care 

practitioners. 

• Expand query of the Healthcare Integrity and Protection Data Bank 

(HIPDB)—a national data bank that contains information on health care 

practitioners involved in health care-related civil judgments and criminal 

convictions or who have had disciplinary actions taken against their 

licenses or national certificates—to include all licensed health care 

practitioners at VA facilities. 

• Conduct fingerprint-only background investigations for all VA health care 

practitioners with direct patient care access. 

• Conduct oversight of medical facilities to ensure compliance with all of 

VA’s key screening requirements. 

To measure facility compliance with VA’s employment screening 

requirements, we selected five requirements for our review.2

 We selected

two of the five requirements because in our March 2004 report we found 

that VA facilities had problems complying with these two long-standing 

requirements. We selected two other requirements because VA

implemented these since March 2004 to improve its employment screening 

of practitioners. The remaining requirement is long-standing, but is related 

to the performance of background investigations, which was a 

requirement we reviewed and found compliance with this requirement to 

be problematic in 2004. 

March 2004 Report 

Recommendations 

VA Employment 

Screening 

Requirements for 

Practitioners Selected 

for Review 

• Complete VA Form 2280, which medical facility officials must do in order

to determine the appropriate type of background investigation needed for 

each health care practitioner job category. 

• Perform a background investigation.

 1

GAO-04-566. 

2

GAO-06-544. 
• Query HIPDB. 

• Complete an employment checklist, which VA officials are to use to 

document the completion of VA screening requirements for those 

practitioners VA intends to hire. 

• Verify the status of state licenses and national certificates. 

We selected four of VA’s credentialing requirements for review because 

they are requirements that—unlike other credentialing requirements—

address information about physicians that can change or be updated with 

new information periodically.3

• Verify that all state medical licenses held by physicians are valid. 

• Query the Federation of State Medical Boards database to determine 

whether physicians had disciplinary action taken against any of their 

licenses, including expired licenses.

• Verify information provided by physicians on their involvement in medical 

malpractice claims at VA or non-VA facilities. 

• Query the National Practitioner Data Bank 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. 

We selected four privileging requirements that VA identifies as general 

privileging requirements. In addition to the four general privileging 

requirements, we selected another privileging requirement because of its 

importance in the renewal of clinical privileges because it provides clinical 

service chiefs with information on the quality of care delivered by 

individual physicians.4

VA Physician 

Credentialing 

Requirements 

Selected for Review 

VA Physician 

Privileging 

Requirements 

Selected for Review 

• Verify that all state medical licenses held by physicians are valid. 

• Verify physicians’ training and experience. 

• Assess physicians’ clinical competence and health status. 

• Consider any information provided by physicians related to medical 

malpractice allegations or paid claims, loss of medical staff membership, 

loss or reduction of clinical privileges at VA or non-VA facilities, or any 

challenges to physicians’ state medical licenses. 

 3

GAO-06-648. 

4

GAO-06-648. 

Page 18 GAO-06-760T
• Use information on physicians’ performances when making decisions 

about whether to renew physicians’ clinical privileges. 

(290540) Page 19 GAO-06-760T
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