VA Health Care: Improvements Made in Physician Privileging Policies, but Medical Facility Compliance Has Not Been Assessed
Published: 2007-11-06T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In a report issued in May 2006, GAO examined compliance with the Department of Veterans Affairs' (VA) physician credentialing and privileging requirements at seven VA medical facilities GAO visited. VA's credentialing process is used to determine whether a physician's professional credentials, such as licensure, are valid and meet VA's requirements for employment. VA's privileging process is used to determine which health care services or clinical privileges, such as surgical procedures, a VA physician is qualified to provide to veterans without supervision. Although GAO cannot generalize from its findings, GAO found that the seven facilities were complying with credentialing requirements. However, the facilities were not complying with aspects of certain privileging requirements. To better ensure that VA physicians are qualified to deliver care safely to veterans, GAO made three recommendations to improve VA's privileging of physicians. GAO was asked to testify on (1) how VA credentials and privileges physicians working in its medical facilities and (2) the extent to which VA has implemented the three recommendations made in GAO's May 2006 report that address VA's privileging requirements. To update its issued work, GAO reviewed VA's policies, procedures, and correspondence related to physician privileging and interviewed VA central office officials to determine if the recommendations made in GAO's May 2006 report were implemented.
section_title: What GAO Found
paragraphs: The Department of Veterans' Affairs (VA) has specific requirements that medical facility officials must follow to credential and privilege physicians. VA requires its medical facility officials to credential and privilege facility physicians periodically so that they can continue to work at VA. Facility officials verify the information used in the credentialing process and query certain databases that contain information on disciplinary actions that have been taken against a physician's state medical license and have information about a physician's professional competence. Each physician also must complete a written request for clinical privileges that is reviewed by the physician's supervisor who considers whether the physician has the appropriate professional credentials, training, and work experience. In addition, every 2 years, the supervisor is to consider information on a physician's performance, such as a physician's surgical complication rate, when deciding whether to renew a physician's clinical privileges. In a May 2006, GAO examined compliance with VA's physician credentialing and privileging requirements at seven VA medical facilities it visited and made three recommendations designed to improve aspects of privileging and oversight of the process. The three recommendations were (1) to 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 medical facilities' privileging process, (2) to enforce the requirement that medical facilities submit information on paid VA medical malpractice claims to VA within 60 days after being notified that the claim is paid, and (3) to instruct medical facilities to establish internal controls to ensure the accuracy of their privileging information. VA reports that it has implemented all three recommendations by establishing policy and guidance for its medical facilities. However, GAO does not know the extent of compliance with these requirements at VA medical facilities.

section_title: Letter
paragraphs: I am pleased to be here today as you discuss physician hiring practices at  medical facilities operated by the Department of Veterans Affairs (VA). VA  has over 36,000 physicians working at more than 1,300 facilities in its  health care system. To help ensure the quality of the health care these  physicians deliver and the safety of veterans, VA is responsible for  determining that its physicians have the appropriate professional  credentials and clinical experience to provide health care to VA’s patients.  To do this, VA requires physicians to undergo credentialing and  privileging. VA’s credentialing process is used to determine whether a  physician’s professional credentials, such as licensure, education, and  training, are valid and meet VA’s requirements for employment. VA’s  privileging process is used to determine which health care services or  clinical privileges, such as surgical procedures or administering  anesthesia, a VA physician is qualified to provide to veterans without  supervision. VA physicians must be credentialed and privileged when they  apply to work in VA—which is known as initial appointment—and at least  once every 2 years thereafter when they must reapply for a position on the  facility’s medical staff. These subsequent reviews are known as the  process of reappointment.
In a report we issued in May 2006, we examined compliance with select  credentialing and privileging requirements at seven VA medical facilities  we visited and made three recommendations designed to improve aspects  of privileging and oversight of the process. Although we cannot generalize  from our findings, we found that these facilities were complying with  credentialing requirements. However, they were not complying with  aspects of certain privileging requirements. For example, VA medical  facilities were not submitting information on paid medical malpractice  claims within the 60-day required time frame to VA’s office that reviews  the claims information and makes a determination about whether  physicians involved in the claims delivered substandard care to veterans.  VA generally agreed with our findings, conclusions, and recommendations.
Today, I will discuss the progress VA has made in implementing our May  2006 recommendations to address noncompliance with VA’s privileging  requirements. Specifically, I will discuss (1) how VA credentials and  privileges physicians working in its medical facilities and (2) the extent to  which VA has implemented the three recommendations made in our May  2006 report that address VA’s privileging requirements.
To perform our 2006 review, we selected four of VA’s credentialing  requirements for review because they are requirements that—unlike  others—address information about physicians that can change or be  updated with new information periodically. As a result, VA requires that  this information be verified by medical facility officials when a physician  initially applies for employment at VA and at least every 2 years thereafter.  Under the four requirements we reviewed, VA medical facility officials  must  1.  verify that all state medical licenses held by physicians are valid;  2.  query the Federation of State Medical Boards (FSMB) database to  determine whether physicians had disciplinary action taken against  any of their licenses, including expired licenses;  3.  verify information provided by physicians on their involvement in  medical malpractice claims at a VA or non-VA facility; and  4.  query the National Practitioner Data Bank (NPDB) 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.
Of the privileging requirements in VA’s credentialing and privileging  policy, we selected four requirements that VA identifies as general  privileging requirements. In addition, we selected another privileging  requirement about the use of individual performance information because  of its importance in the renewal of clinical privileges. The five VA  privileging requirements we selected were as follows:  1.  verify that all state medical licenses held by physicians are valid;  2.  verify physicians’ training and experience;  3.  assess physicians’ clinical competence and health status;  4.  consider any information provided by a physician related to medical  malpractice allegations or paid claims, loss of medical staff  membership, loss or reduction of clinical privileges at a VA or non-VA  facility, or any challenges to a physician’s state medical license; and  5.  use information on a physician’s performance when making decisions  about whether to renew the physician’s clinical privileges.
Two of the five privileging requirements—verify all state medical licenses  and consider medical malpractice information—are also VA credentialing  requirements we reviewed.
To update our work, we reviewed VA’s policies, procedures, and  correspondence related to physician privileging and interviewed VA  central office officials to determine if the recommendations we made in  our May 2006 report were implemented. We updated our issued work in  July 2007 and November 2007, and we performed all of our work in  accordance with generally accepted government auditing standards.
In summary, VA has specific requirements that medical facility officials  must follow to credential and privilege physicians. VA requires its medical  facility officials to credential and privilege facility physicians periodically  so that they can continue to work at VA. We reported in May 2006 that the  seven VA medical facilities we visited complied with the four credentialing  requirements we reviewed and all but one of the five privileging  requirements we reviewed. However, during our review, we found that  medical facility officials did not have all of the information they needed on  physicians involved in paid VA medical malpractice claims, because the  facilities had not submitted such information in a timely manner to VA’s  office that reviews the claims information and makes a determination  about whether physicians involved in the claims delivered substandard  care to veterans. We also found during our review that VA did not require  its medical facilities to establish internal controls to help ensure the  accuracy of their privileging information. Without internal controls VA  medical facility officials did not know if they properly renewed clinical  privileges, thereby allowing physicians to practice with expired clinical  privileges. Since our 2006 review, VA reports that it has implemented all  three of our recommendations to improve VA’s physician privileging  process. However, since our work in 2006 we have not visited or examined  records at facilities to determine the extent of compliance.
subsections: section_title: Background
paragraphs: 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. VA delegates decision making regarding financing,  health care service delivery, and medical facility operations to its 21  networks.
Physicians who work at VA medical facilities are required to hold at least  one current and unrestricted state medical license. Current and  unrestricted licenses are those in good standing in the states that issued  them, and licensed physicians may hold licenses from more than one state.  State medical licenses are issued by state licensing boards, which  generally establish state licensing requirements governing their licensed  practitioners. To keep licenses current, physicians must renew their  licenses before they expire and meet renewal requirements established by  state licensing boards, such as continuing education. Renewal procedures  and requirements vary by state. When state licensing boards discover  violations of licensing practices, such as the abuse of prescription drugs or  the provision of substandard care that results in adverse health effects,  they may place restrictions on licenses or revoke them. Restrictions issued  by a state licensing board can limit or prohibit a physician from practicing  in that particular state. Generally, state licensing boards maintain a  database that contains information on any restrictions or revocations of  physicians’ licenses.
section_title: VA’s Credentialing and Privileging Processes
subsections: section_title: Credentialing Process
paragraphs: When physicians apply for initial appointment, they initiate the  credentialing process by completing VA’s application, which includes  entering into VetPro—a Web-based credentialing system VA implemented  in March 2001—information used by VA medical facility officials in the  credentialing process. Among the credentialing information that VA  requires physicians enter into VetPro is information on all the state  medical licenses they have ever held, including any licenses they have held  that have expired. For their reappointments, physicians must update this  credentialing information in VetPro.
Once physicians enter their credentialing information into VetPro, a  facility’s medical staff specialist—an employee who is responsible for  obtaining and verifying the information used in the credentialing and  privileging processes—performs a data check on the information to be  sure that all required information has been entered. 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. This type of check is known as  primary source verification. For example, the medical staff specialist  contacts state licensing boards in order to verify that physicians’ state  medical licenses are valid and unrestricted.
At initial appointment only, VA requires medical staff specialists to query  FSMB, which contains information from state licensing boards. This query  enables officials to determine all the state medical licenses a physician has  ever held, including those not disclosed by a physician to VA, and whether  a physician has had any disciplinary actions taken against these licenses.  VA does not require this query at reappointment because VA headquarters  regularly receives reports from FSMB on any VA physician whose name  appears on FSMB’s list, indicating that disciplinary action has been taken  against the physician’s state medical license. When VA headquarters  receives a report from FSMB, it notifies the appropriate VA medical  facility.
VA’s credentialing process requires VA medical staff specialists to verify  medical malpractice claims at initial appointment and at reappointment.  These claims may be verified by contacting a court of jurisdiction or the  insurance company involved in the medical malpractice claims, or by  obtaining a statement of claims status from the attorney representing the  physician in the medical malpractice claim. In addition, VA requires  medical staff specialists to query NPDB, which contains reports by state  licensing boards, hospitals, and other health care entities on  unprofessional behavior on the part of physicians or adverse actions taken  against them. This query enables officials to determine whether physicians  fully disclosed to VA any involvement they might have had in paid medical  malpractice claims. Once a physician’s credentialing information has been  verified, the medical staff specialist sends the information to the  physician’s supervisor, who is known as a clinical service chief. The  clinical service chief reviews this information along with the physician’s  privileging information. Figure 1 illustrates VA’s credentialing process.
section_title: Privileging Process
paragraphs: Physicians, in addition to entering credentialing information into VetPro,  must complete a written request for clinical privileges. The facility medical  staff specialist provides a physician’s clinical service chief with the  physician’s 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. For reappointment,  documentation is required by another physician stating that the physician  is able to perform both physically and mentally the clinical privileges  requested. In addition, the medical staff specialist provides the clinical  service chief with information on medical malpractice allegations or paid  claims, loss of medical staff membership, loss or reduction of clinical  privileges, or any challenges to the physician’s state medical licenses.
The requested clinical privileges are reviewed by a 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. When deciding to recommend clinical privileges, a clinical service  chief considers whether the physician has the appropriate professional  credentials, training, and work experience to perform the privileges  requested. For reappointment only, a clinical service chief is to consider  observations of the physician’s delivery of health care to veterans, and  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 clinical  service chief’s observations and 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.
Clinical service chiefs forward their recommendations and the reasons for  the recommendations to the next level of a medical facility’s privileging  review process, which may be a professional standards board or a medical  executive committee. A medical facility professional standards board or  the medical executive committee reviews the recommendations of the  clinical service chief and recommends to the facility director whether the  physician should be appointed to the facility’s medical staff and which  clinical privileges should be granted to the physician. The 2-year time  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. The list of approved clinical privileges with the date of  approval is maintained at VA medical facilities and the initial appointment  or reappointment date is entered into VetPro. Figure 2 illustrates VA’s  privileging process.
According to VA’s policy and a VA memorandum, information concerning  individual physician performance that is used as part of the privileging  process to either reduce, revoke, or support granting clinical privileges  must be collected separately from a medical facility’s quality assurance  program. VA’s policy is based on a federal law that restricts the disclosure  of documents produced in the course of VA’s quality assurance program.  In general, documents created in connection with such a program are  confidential and may not be disclosed except in limited circumstances.  Individuals who willfully disclose documents that they know are protected  quality assurance documents are subject to fines up to $20,000. Although  the law states that it is not intended to limit the use of documents within  VA, VA’s policy expressly prohibits the use of such documents in  connection with the privileging process. VA’s use of separate information  sources for quality assurance and privileging decisions is intended to  maintain the confidential status of documents produced in connection  with quality assurance programs. According to VA, the confidentiality of  individual performance information helps ensure provider participation,  including physicians, in a medical facility’s quality assurance program by  encouraging providers to openly discuss opportunities for improvement in  provider practice without fear of punitive action.
VA has another requirement that is related to the renewal of physicians’  clinical privileges. Medical facility officials are required to submit to VA’s  Office of Medical-Legal Affairs information on paid VA malpractice claims.  This information must be submitted within 60 days after the medical  facility is notified about a paid malpractice claim. The Office of Medical- Legal Affairs is responsible for convening a panel of clinicians to  determine whether a VA facility physician involved in the claim delivered  substandard care. The Office of Medical-Legal Affairs notifies the medical  facility director of the results of its review. If it is determined that the  physician delivered substandard care to veterans, the medical facility must  report the physician to NPDB within 30 days of being notified of the  decision. VA medical facility officials also would use this determination to  decide whether to grant clinical privileges to the physician involved in the  VA medical malpractice claim.
section_title: VA Has Addressed All GAO Physician Privileging Recommendations, but Extent of Medical Facility Compliance Is Unknown
paragraphs: In our 2006 report, we found that the physician files at the seven facilities  we visited demonstrated compliance with four VA credentialing and four  privileging requirements we reviewed. 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.  We also found during our review 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. Further, VA  had not required its medical facilities to establish internal controls to help  ensure that privileging information managed by medical staff specialists is  accurate. Internal controls are important because at one facility we visited  we found 106 physicians whose privileging process had not been  completed by facility officials for at least 2 years because of inaccurate  information. As a result, these physicians were practicing at the facility  with expired clinical privileges. None of the VA medical facilities we  visited for our 2006 report had internal controls in place that would  prevent a similar situation from occurring. To better ensure that VA  physicians are qualified to deliver care safely to veterans, we  recommended that VA    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 medical facilities’ privileging process,    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 privileging information.
VA states that it has implemented all three recommendations we made in  our May 2006 report to address compliance with VA’s physician privileging  requirements by establishing policy and guidance for its medical facilities.  However, we do not know the extent of compliance with these  requirements at VA medical facilities.
VA implemented our recommendation that VA provide guidance to VA  medical facilities on how to appropriately collect information on  individual physician performance and use that information in VA’s  privileging process. Physician performance information is to be used to  assist VA medical facility clinical service chiefs in determining the  appropriate clinical privileges that should be granted based on a  physician’s clinical competence. VA implemented our recommendation by  issuing a policy on October 2, 2007, that elaborated on the sources of  physician performance information and the types of information that  could be collected outside of VA medical facilities’ quality assurance  programs. In addition, in July 2007, VA officials told us that they were in  the process of implementing online training programs on physician  performance information to help implement our recommendation. The  training will be mandatory for all VA medical facility clinical service chiefs  and medical staff leaders responsible for the assessment and oversight of  the privileging process and must be completed by January 31, 2008.
VA also implemented our recommendation that it enforce its requirement  that VA medical facilities report information on any paid VA malpractice  claims involving their physicians to VA’s Office of Medical-Legal Affairs  within 60 days after being notified of a paid claim. In June 2006, VA’s  Office of Medical-Legal Affairs began notifying network and VA medical  facility directors of delinquencies in reporting this information by the  medical facilities. If a medical facility’s delinquency in reporting extends  longer than 90 days, VA requires the Office of Medical-Legal Affairs to  inform not only network and VA medical facility directors but also VA’s  central office of the delinquency. Because VA’s Office of Medical-Legal  Affairs reviews information on paid malpractice claims involving VA  physicians to determine whether the physicians delivered substandard  care, when VA medical facilities do not submit relevant malpractice claim  information to this office, medical facility clinical service chiefs may make  privileging decisions without complete information about substandard  care provided by physicians.
Further, VA implemented our recommendation that it instruct VA medical  facilities to establish internal controls to ensure the accuracy of their  privileging information. Internal controls help ensure that VA medical  facility officials have accurate clinical privileging information and that  physicians are not practicing at the facility with expired clinical privileges.  To address our recommendation, VA first asked network directors to  report on how they tracked the privileging status of VA physicians. In  response to a VA memorandum sent on May 16, 2006, network directors  provided a report indicating that their medical facilities had one or more  mechanisms in place to identify physicians who were currently privileged  at their facilities and to track whether their privileges have expired. In  addition, VA instructed its network directors to monitor the internal  controls at their facilities that ensure that VA medical facilities have  accurate clinical privileging information and that physicians are not  practicing with expired clinical privileges.
Mr. Chairman, this concludes my prepared remarks. I will be pleased to  answer any questions you or other members of the committee may have.
section_title: Contacts and Acknowledgments
paragraphs: For further information regarding this testimony, please contact Randall B.  Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found on  the last page of this testimony. Marcia Mann, Assistant Director; Mary Ann  Curran; Christina Enders; Krister Friday; Lori Fritz; Rebecca Hendrickson;  and Jason Vassilicos also contributed to this statement.
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