VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement
Published: 2006-05-25T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Veterans Affairs (VA) is responsible for determining that over 36,000 physicians working in its facilities have the appropriate professional credentials and qualifications to deliver health care to veterans. To do this, VA credentials and privileges physicians providing care at its medical facilities. In this report, GAO determined the extent to which selected VA facilities complied with (1) four VA credentialing requirements and five VA privileging requirements and (2) a requirement to submit information on paid malpractice claims. GAO also determined (3) whether VA has internal controls to help ensure the accuracy of information used to renew clinical privileges. GAO reviewed VA's policies, interviewed VA officials, and randomly sampled 17 physician files at each of seven VA medical facilities.
section_title: What GAO Found
paragraphs: GAO found that the files reviewed at seven VA medical facilities complied with four of VA's credentialing requirements selected for review, and all but one of five privileging requirements. Credentialing is the process of verifying that a physician's professional credentials, such as state medical licenses, are valid and meet VA's requirements for employment. Privileging is the process for determining which health care services a physician is allowed to provide to veterans. For the files GAO reviewed, compliance with the fifth privileging requirement was problematic at six facilities 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. In general, VA quality assurance information is confidential, according to federal law and VA policy. According to VA officials, if quality assurance information is used outside of a facility's quality assurance program, it could be used for other purposes, including litigation. The information is protected to encourage physicians to participate in quality assurance programs by reporting and discussing adverse events to help prevent such events from occurring in the future. VA has not provided guidance to help medical facilities find ways to efficiently collect performance information outside of a facility's quality assurance program. At the seventh medical facility, officials did not use performance information to renew clinical privileges, as required. Three of the seven medical facilities did not meet VA's requirement to submit, within 60 days after being notified that the claim was paid, any information on paid VA medical malpractice claims involving facility practitioners, including physicians, to VA's Office of Medical-Legal Affairs. This office reviews the information and determines whether practitioners involved in the claims delivered substandard care, displayed professional incompetence, or engaged in professional misconduct. The office informs facilities of its determinations. When facilities do not submit all relevant VA malpractice information in a timely manner, VA medical facility officials lack complete information that would allow them to make informed decisions about the clinical privileges that their physicians should be granted. VA has not required its medical facilities to establish internal controls to help ensure that privileging information managed by medical staff specialists--who are responsible for obtaining and verifying the information used in the credentialing and privileging processes--is accurate. One facility GAO visited did not identify 106 physicians whose privileging process 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. Without accurate information on the privileges that have been granted to physicians and the dates for renewing those privileges, VA medical facility officials will not know if they have failed to renew clinical privileges for any of their physicians in accordance with VA policy.

section_title: Letter
paragraphs: The Department of Veterans Affairs (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 credentials and privileges  physicians providing care at VA medical facilities. Credentialing is the  process of verifying that a physician’s professional credentials, such as  licensure, education, and training, are valid and meet VA’s requirements  for employment. Privileging is the process for determining—based in part  on a physician’s credentials—which health care services a physician  should be allowed to provide to VA patients without supervision. These  health care services are known as a physician’s clinical privileges.  Physicians are granted initial clinical privileges when they begin their  employment at a VA medical facility. Physicians’ professional credentials  and clinical privileges must be reviewed and renewed at least every   2 years. VA’s credentialing and privileging policy describes the  information that VA medical facility officials are required to review and  verify in order to credential and grant clinical privileges to VA physicians.  In addition to the requirements outlined in VA’s credentialing and  privileging policy, medical facility officials are required to submit  information to VA headquarters on any VA physicians who are involved in  paid VA medical malpractice claims. This malpractice information is used  by VA headquarters to make decisions about the appropriateness of the  care delivered to veterans and should be used by medical facility officials  when making decisions about the clinical privileges to grant physicians.
You expressed interest in the credentialing and privileging of VA  physicians and how this helps VA ensure the delivery of safe care to  veterans. In response to your request, we (1) determined the extent to  which selected VA medical facilities complied with four of VA’s  credentialing requirements and five of VA’s privileging requirements in  relation to individual physicians, and (2) determined the extent to which  selected VA medical facilities complied with the requirement to submit  information to VA headquarters on paid VA medical malpractice claims  involving VA physicians. Also, during the course of our work, we learned  about a medical facility where inaccuracies in privileging information  resulted in 106 physicians providing care to veterans in the facility without  the required clinical privileges. According to VA officials, the individual  responsible for privileging data inappropriately changed the privileging  dates for some of these physicians to a later date in order to delay work  needed to complete the credentialing and privileging requirements on  these physicians. This led us to add to our review a reporting objective  related to internal controls. Specifically, in this report we also   (3) determined whether VA has internal controls to help ensure the  accuracy of information medical facilities use to renew physicians’ clinical  privileges.
To determine the extent to which selected VA medical facilities complied  with four of VA’s credentialing requirements and five of VA’s privileging  requirements in relation to individual physicians, we reviewed VA’s  policies to identify the requirements that VA medical facility officials must  follow when credentialing and granting clinical privileges to physicians.  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. Other VA credentialing  requirements are not subject to change or updating and are required by VA  to be verified when the physician initially applies for employment. 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 are  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 determine the extent to which selected VA medical facilities complied  with four of VA’s credentialing requirements and five of VA’s privileging  requirements, we conducted site visits to seven VA medical facilities that  were chosen based on the diversity of their size and geographic location.  The medical facilities are located in Boise, Idaho; Kansas City, Missouri;  Las Vegas, Nevada; Lexington, Kentucky; Martinsburg, West Virginia;  Miami, Florida; and San Antonio, Texas. For each of the seven medical  facilities, VA officials provided a list of medical facility physicians grouped  by their clinical specialty. Using this list, at each medical facility we  randomly selected 17 physicians and obtained files with their credentialing  and privileging information. Our sample included physicians working in  VA medical facilities full-time and part-time, through a contract, or  without direct compensation from VA. In some cases, these physicians  also worked at non-VA medical facilities. Eight of the 17 physician files at  each medical facility represent eight clinical specialties that are offered at  most VA medical facilities: anesthesiology, gastroenterology, neurology,  oncology, ophthalmology, orthopedics, radiology, and urology. Four of the  17 represent general surgery and internal medicine and 5 of the 17 had no  specialty identified on the list provided by VA. To determine whether the  files we reviewed demonstrated compliance with the four VA credentialing  requirements and VA’s privileging requirements at each of the seven VA  medical facilities, we reviewed paper copy credentialing and privileging  files for our sample of physicians to determine whether these files  included documentation demonstrating that medical facility officials had  complied with the credentialing and privileging requirements. We also  reviewed credentialing information on these physicians stored in VetPro, a  Web-based credentialing system VA implemented in March 2001. Based on  the sample of physician files we reviewed at each of the seven medical  facilities, we can discuss a medical facility’s compliance for the physician  files we reviewed; we cannot draw conclusions about the remaining  physician files at the medical facilities we visited or about the compliance  of other VA medical facilities. In collecting information on the  credentialing and privileging requirements from physician files at each  facility, we employed standard data collection techniques to ensure the  accuracy and reliability of the data used in this report.
Finally, we included in our review a requirement that is related to the  privileging process. Under this requirement, medical facility officials must  submit to VA’s Office of Medical-Legal Affairs any information on VA  practitioners, including physicians, who were involved in a paid VA  medical malpractice claim. The Office of Medical-Legal Affairs determines  whether the physicians involved in these claims delivered substandard  care to veterans. We collected information about the extent to which each  of the seven medical facilities in our review submitted malpractice  information to the Office of Medical-Legal Affairs.
To determine whether VA has internal controls to help ensure the  accuracy of information medical facilities use to renew physicians’ clinical  privileges, we interviewed the director of VA’s credentialing and  privileging program, as well as other VA headquarters and medical facility  officials. We identified the internal controls VA has in place for its  privileging process and, using GAO’s standards for internal controls in the  federal government, determined whether these controls are adequate. For  a complete description of our scope and methodology, see appendix I. We  conducted our work from July 2005 to May 2006 in accordance with  generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: 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 a license 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 result 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.
VA requires its medical facility officials to credential and privilege facility  physicians periodically in order to work at VA. VA physicians must be  credentialed and privileged prior to their initial appointment to a facility’s  medical staff and then again at least every 2 years when they must reapply  for a position on the facility’s medical staff. The latter is known as the  process of reappointment.
subsections: section_title: VA’s Credentialing Process
paragraphs: Prior to working at VA, physicians initiate the credentialing process for  their initial appointment by completing VA’s application process, which  includes entering into VetPro information used by VA medical facility  officials in the credentialing process. Among the credentialing information  that VA requires physicians enter into VetPro, for their initial appointment,  is information on all the medical licenses they have ever held and the  states where they have obtained these licenses, 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.
Medical staff specialists are required, at initial appointment and at  reappointment, to verify the status of the state medical licenses physicians  disclose to VA by listing them in VetPro. The medical staff specialists can  obtain information on the status of physicians’ state medical licenses by  accessing the information on state licensing boards’ Web sites or by  contacting the boards directly.
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 claim, 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: At the same time physicians enter credentialing information into VetPro,  they complete a written request for clinical privileges. The facility medical  staff specialist provides the physician’s clinical service chief with the  requested clinical privileges and information that indicates that the  credentialing information entered by the physician into VetPro has been  verified with the appropriate primary sources. The medical staff specialist  also provides the physician’s clinical service chief with information on the  physician’s ability to perform the clinical privileges requested, including  whether the physician has had a physical examination performed for  initial appointment. 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 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 in paper copy files 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 malpractice claims. This  information must be submitted within 60 days after being 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: Selected Physician Files at Medical Facilities Demonstrated Compliance with Four VA Credentialing and Four Privileging Requirements; a Fifth Privileging Requirement Was Problematic
paragraphs: The physician files we reviewed at the seven VA medical facilities  demonstrated compliance with the four credentialing requirements we  selected for review and four of five VA privileging requirements. The files  we reviewed showed that six of the seven medical facilities had problems  complying with a fifth privileging requirement—to use information on a  physician’s performance when renewing clinical privileges. Compliance  with that requirement was problematic largely because in their privileging  decisions facility officials used performance information obtained from  their facility quality assurance program. Information contained in  documents created in the course of a VA quality assurance program is  protected by VA policy that expressly prohibits the agency from using that  documentation in the privileging process. VA has not provided guidance to  help facilities find alternative ways to efficiently collect performance  information, outside of a facility’s quality assurance program, that could be  used in privileging decisions. At the seventh medical facility, officials did  not use performance information to renew clinical privileges, as required.
Physician files at all seven medical facilities demonstrated compliance  with the four credentialing requirements we selected for review. In all  cases, the VA facility medical staff specialists contacted state licensing  boards—a form of primary source verification—to ascertain the status of  the state medical licenses held and disclosed by their physicians. Based  on the physician files we reviewed, medical staff specialists also queried  the 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. Medical staff specialists complied with the  requirement to contact primary sources, such as courts of jurisdiction, to  verify information on involvement in medical malpractice claims,  including ongoing claims, disclosed by physicians. Additionally, in all  cases medical staff specialists queried 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 at the seven medical facilities also demonstrated  compliance with four of the five VA privileging requirements we reviewed.  We found that medical staff specialists contacted state licensing boards to  verify the status of all state medical licenses held by their physicians and  to determine whether any of these licenses had any action taken against  them. Medical staff specialists also used primary sources to verify that  physicians had the necessary training and experience to deliver health  care and perform the clinical privileges they requested. We found that after  medical staff specialists performed their verification, clinical service  chiefs reviewed this information as required, along with information on  physicians’ health status and information disclosed by the physicians  about their involvement in medical malpractice allegations or cases in  which claims were paid.
While we found evidence demonstrating compliance with four of the five  privileging requirements, the files we reviewed also showed that there  were problems complying with the fifth privileging requirement—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, the performance information cannot be collected as  part of a medical facility’s quality assurance program. Although medical  facility clinical service chiefs must use performance information in making  decisions about renewal of clinical privileges, 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.
VA’s credentialing and privileging policy states that facilities cannot use  information collected as part of a facility’s quality assurance program to  reduce or revoke the clinical privileges requested by physicians, but the  initial policy guidance was silent about the use of this information to  support granting the clinical privileges requested by physicians. Officials at  six medical facilities told us that they used quality assurance 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. In contrast, facility officials at one medical facility  did not use individual physician performance information to renew  physicians’ clinical privileges.
VA issued a directive in September 2004 and a memorandum in October  2004 which VA headquarters officials told us were intended to clarify for  medical facility officials the circumstances under which physician  performance information could not be used in the credentialing and  privileging process. The September 2004 directive explained the specific  types of information that are protected, such as information that identifies  an individual physician, and the October 2004 memorandum explained  that information on a physician’s performance that is collected as part of a  medical facility’s quality assurance program could not be used to support,  reduce, or revoke a physician’s clinical privileges. The directive and the  memorandum did not identify the ways in which medical facility officials  could efficiently collect physician performance information outside of a  facility’s quality assurance program that would provide information for  renewing physicians’ clinical privileges. According to facility officials,  collecting the same information twice—once for quality assurance and  once for privileging—is resource-intensive and limits the time they have to  address other issues.
Without guidance from VA, officials from four facilities told us that they do  not know how to collect this information in accordance with VA’s policy.  Facility officials from two other medical facilities said they believed that  they were complying with VA’s requirement because they stored  performance information in such a way that the identity of individual  physicians could not be easily retrieved. Quality assurance staff at these  two medical facilities assigned a code to each physician and filed the  performance information by assigned code rather than under an individual  physician’s name. These staff could then retrieve an individual physician’s  performance information using the code. At one facility, quality assurance  staff said their regional legal counsel told them that the confidentiality of  the information would be maintained with this type of coding system and  would allow them to use the information to renew physicians’ clinical  privileges. However, according to both VA headquarters legal counsel and  the director of VA’s credentialing and privileging program, coding quality  assurance information in this manner and using it to renew clinical  privileges could make this information available for other purposes,  including litigation, and therefore does not comply with VA policy. A VA  headquarters official told us that the medical facilities need further  education on how to collect individual physician performance information  that can be used in the renewal of physicians’ clinical privileges.
section_title: Not All Medical Facilities Submitted Paid Malpractice Claim Information in a Timely Manner
paragraphs: We found that three of the seven VA medical facilities we visited did not  comply with the requirement to submit paid VA medical malpractice claim  information in a timely manner. These facilities had not submitted  information on 52 paid medical malpractice claims that may have involved  their physicians to VA’s Office of Medical-Legal Affairs within the 60-day  required time frame for information requested as of December 2005. See  figure 3 for the number of paid VA medical malpractice claims for which  information was not submitted in a timely manner by the three facilities  from 2001 through 2005.
The Office of Medical-Legal Affairs is responsible for reviewing  information on paid VA medical malpractice claims submitted by VA  medical facilities by forming panels of clinicians to determine whether VA  practitioners, including physicians, delivered substandard care to veterans  in these claims. When VA medical facilities do not submit all relevant  claim information to the Office of Medical-Legal Affairs, facility clinical  service chiefs may make privileging decisions without the knowledge of  physician peer determinations on whether VA physicians delivered  substandard care to veterans. In addition, substandard care  determinations that are required to be reported by facility officials to the  NPDB go unreported or reporting is delayed when VA medical facilities do  not send claim information in a timely manner to the Office of Medical- Legal Affairs. This delay or lack of reporting to NPDB prevents other VA  and non-VA facilities where the physician may also practice from having  complete information on the physician’s malpractice history. For example,  at 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. 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. See  table 1 for the average number of months it took for these VA medical  facilities to submit paid VA medical malpractice claim information to VA’s  Office of Medical-Legal Affairs.
section_title: VA Has Not Established Internal Controls to Help Ensure the Accuracy of Medical Facilities’ Privileging Information
paragraphs: 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 process 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. Subsequent to our visit, this facility implemented internal  controls to reduce the risk of a similar situation occurring in the future.  During our site visits, we did not identify any medical facilities that had  established such internal controls. Without accurate information on the  privileges that have been granted to physicians and the dates for renewing  those privileges, VA medical facility officials will not know if they have  failed to renew clinical privileges for any of their physicians in accordance  with VA policy.
For at least 2 years, one VA medical facility did not identify 106 physicians  whose privileging process had not been completed by facility officials  because of inaccurate information provided by the facility’s medical staff  specialist. According to facility officials, the medical staff specialist  changed the reappointment dates on some of these physicians to a later  date in order to delay work she needed to perform to complete the  credentialing and privileging requirements on these physicians. For other  physicians, the medical staff specialist removed the physicians’ names  from the VetPro database so that the physicians would not show up on  VetPro lists as needing to be reappointed to the facility’s medical staff.  Facility officials further told us that the medical staff specialist changed  appointment dates and removed names from VetPro in order to conceal  the fact that these physicians no longer had current privileges. As a result,  these physicians were practicing at the facility without current clinical  privileges. The clinical service chiefs, members of the professional  standards board and the medical executive committee, and the facility  director were unaware that these physicians were working without  current clinical privileges, and learned of the problem only after it was  brought to their attention by an individual newly hired to help the facility’s  medical staff specialist. Medical facility officials told us that after  becoming aware of the problem, they confronted the medical staff  specialist responsible for the data inaccuracies, who then resigned.  Medical facility officials then began to check the clinical privileges of all of  their physicians and identified inaccuracies in the privileging information  for 106 physicians. After reviewing the 106 physician files, facility officials  told us they did not find any problems that would have warranted the  physicians’ removal from the facility’s medical staff or that placed veterans  at risk.
Although this medical facility did not identify any problems with the   106 physicians’ clinical privileges or with their clinical competence to  deliver care to veterans, the potential exists for problems to occur at other  VA medical facilities. During our site visits, we did not identify any  facilities that had established internal controls that would help ensure the  accuracy of the information used to renew clinical privileges. A VA  headquarters official told us that there is no requirement for VA medical  facilities to have such internal controls in place. While VA does not require  facilities to establish these internal controls, the facility that identified  inaccuracies in its privileging information subsequently implemented  internal controls to reduce the risk of a similar situation occurring in the  future. Facility officials have taken steps to help ensure that a similar  situation does not recur. For example, the facility now provides each  facility clinical service chief with a list of physicians on a quarterly basis  and asks the clinical service chiefs to verify that the listed physicians are  currently working at the medical facility and to identify those physicians  working at the facility who are not on the list. This allows medical facility  officials to know if physicians have been inappropriately deleted from  VetPro and are working at the facility without current clinical privileges.  Without internal controls such as this for their privileging information,  VA’s medical facilities may not know whether they have allowed some of  their physicians to practice with expired privileges.
section_title: Conclusions
paragraphs: VA is responsible for ensuring that its physicians are qualified to deliver  health care to veterans at VA medical facilities and has requirements in  place that medical facility officials are to use to help ensure that  physicians meet these qualifications. VA medical facilities we visited  complied with the four VA credentialing requirements we reviewed and all  but one of five privileging requirements—to use information on a  physician’s performance when renewing clinical privileges. While officials  at six of the seven facilities we visited made an attempt to comply with  VA’s requirement to use performance information, these officials deviated  from VA’s policy by collecting all or most of the performance information  through their facilities’ quality assurance programs. This occurred, in part,  because VA has not provided guidance on how to collect this information  in accordance with VA’s policy. In addition, VA medical facility officials  did not have all the information they needed on physicians involved in  paid VA medical malpractice claims, because the facilities had not  submitted such information to VA’s Office of Medical-Legal Affairs in a  timely manner. This could have placed veterans at risk of receiving care  from physicians who did not have adequate clinical skills. Finally, VA has  not required its medical facilities to establish internal controls to help  ensure the accuracy of their privileging information. Until VA requires its  medical facilities to establish internal controls to ensure the accuracy of  privileging information, facilities are at risk for allowing physicians to  practice with expired clinical privileges.
section_title: Recommendations for Executive Action
paragraphs: To better ensure that VA physicians are qualified to deliver care safely to  veterans, we recommend that the Secretary of Veterans Affairs direct the  Under Secretary for Health to take the following three actions:    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 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 privileging information.
section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report, VA agreed with our findings and  conclusions and concurred with our recommendations. VA also provided  an action plan to address the three recommendations. VA acknowledged  that we identify a challenge faced not only by VA facilities, but by all  health care facilities, to incorporate physician-specific performance  information into the credentialing and privileging processes. In addition,  VA recognized the need to improve facility compliance with submitting  information on paid VA medical malpractice claims to the Office of  Medical-Legal Affairs in a timely manner. Further, VA agreed that internal  controls are needed to ensure the accuracy of information used to renew  physicians’ clinical privileges and has begun the work necessary to  establish these internal controls at all VA facilities. VA also provided  details of actions it plans to take to implement the three recommendations  in the draft report. VA’s written comments are reprinted in appendix II.
As agreed with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days after its  date. We will then send copies of this report to the Secretary of Veterans  Affairs and other interested parties. We also will make copies available to  others upon request. In addition, the report will be available at no charge  at the GAO Web Site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me  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 report. GAO staff members who made major contributions to this  report are listed in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine the extent to which selected Department of Veterans Affairs’  (VA) medical facilities complied with VA’s credentialing and privileging  requirements, we reviewed policies, procedures, and guidance on VA’s  credentialing and privileging processes. We also interviewed the director  of VA’s credentialing and privileging program, as well as officials  responsible for credentialing and privileging at the VA medical facilities  we visited. We selected four 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  facility officials at least every 2 years. Other credentialing requirements,  such as where a physician attended medical school or previous  employment history, are not subject to change or updating and are  required by VA to be verified when the physician initially applies for  employment. The four credentialing requirements are  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 medical 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 are  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 conducted site visits to seven VA medical facilities that were chosen  based on size and geographic location. The medical facilities selected for  review were located in Boise, Idaho; Kansas City, Missouri; Las Vegas,  Nevada; Lexington, Kentucky; Martinsburg, West Virginia; Miami, Florida;  and San Antonio, Texas. For each medical facility visited, we obtained  from VA a list of physicians and their specialties. Using this list, at each  facility we randomly selected 17 physicians and obtained files with their  credentialing and privileging information. Our sample included physicians  working in VA facilities full-time and part-time, through a contract, or  without direct compensation from VA. In some cases, these physicians  also worked at non-VA medical facilities. At each facility we visited, we  selected one file from the following clinical specialties that are offered at  most VA medical facilities: anesthesiology, gastroenterology, neurology,  oncology, ophthalmology orthopedics, radiology, and urology. We also  selected two physician files from general surgery and internal medicine,  and five files from physician names that had no specialty identified on the  list provided by VA. At some facilities, we found that the physician  specialty indicated on the list provided by VA was incorrect. We replaced  these files by random selection with physician files in the specialty  needed.
To determine whether the files we reviewed demonstrated compliance  with the selected VA credentialing requirements and privileging  requirements, we compared the documentation found in our sample files  against the credentialing and privileging requirements. During our site  visits, we reviewed the documentation in VetPro and in a physician’s paper  copy credentialing file to determine whether the facility complied with  each of the four VA credentialing requirements that we reviewed. If  documentation was present either in VetPro or the paper copy file, we  determined that the medical facility complied with VA’s requirement. For  each physician, we reviewed the three most recent appointment cycles— the period from one appointment process to the next appointment  process, which occurs every 2 years. Some of the physicians in our sample  had not been through three appointment cycles. For those physicians, we  reviewed only the number of cycles that had been completed. We  documented our findings from these reviews on a data collection  instrument.
At each medical facility, we reviewed a physician’s paper copy privileging  file to determine whether the physician’s file contained documentation  that the medical facility met the five VA privileging requirements we  examined. For the fifth requirement—use of information on a physician’s  performance when making decisions about whether to renew physicians’  clinical privileges—we also interviewed facility officials, including the  facility quality assurance manager, to determine whether the facility  collected this physician performance information outside of the facility’s  quality assurance program. For some physician files we reviewed, the  physician had only been through initial appointment and therefore did not  have individual physician performance information in the privileging file.
Based on the sample of physician files we reviewed at each of the seven  medical facilities, we can discuss a medical facility’s compliance for the  physician files we reviewed; we cannot draw conclusions about the  remaining physician files at the medical facilities we visited or about the  compliance of other VA medical facilities. In collecting information on the  credentialing and privileging requirements from physician files at each  facility, we employed standard data collection techniques to ensure the  accuracy and reliability of the data used in this report, such as  interviewing medical facility officials about the accuracy and timeliness of  the information contained in the physician files we reviewed and taking  steps to have a consistent interpretation of VA’s credentialing and  privileging requirements for the physician files we reviewed at each  medical facility.
To determine the extent to which the selected VA medical facilities  complied with a requirement to submit information on paid VA medical  malpractice claims, we obtained data from VA’s Office of Medical-Legal  Affairs in Buffalo, New York to identify the VA medical facilities that were  delinquent—more than 60 days had passed since the facility was notified  that a claim had been paid—in submitting medical malpractice claim  information to this office. The data included the name of the VA medical  facility, the veteran who was named in the claim, the date the Office of  Medical-Legal Affairs was notified that a claim had been paid, and the date  the Office of Medical-Legal Affairs notified the facility that a VA medical  malpractice claim had been paid. VA’s Office of Medical-Legal Affairs  determines whether a physician who was involved in a VA medical  malpractice claim delivered substandard care to veterans, and if so, was  reported to NPDB. We interviewed officials at this office to obtain  information about VA’s process and requirements for determining if  substandard care was delivered.
To determine whether VA has internal controls to help ensure the  accuracy of medical facility information that is used to renew physicians’  clinical privileges, we interviewed the director of VA’s credentialing and  privileging program, as well as other VA officials. We identified the  internal controls VA has in place for its privileging process and used  GAO’s standards for internal controls in the federal government to  determine whether these controls were adequate. During our site visits, we  determined if any of the seven medical facilities had internal controls in  place to help ensure the accuracy of the information used to support the  renewal of clinical privileges. We conducted our work from July 2005 to  May 2006 in accordance with generally accepted government auditing  standards.
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above Marcia A. Mann, Assistant  Director; Kelly Barar; Mary Ann Curran; Martha A. Fisher; and Krister  Friday made key contributions to this report.
section_title: Related GAO Products
paragraphs: 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.
VA Health Care: Improved Screening of Practitioners Would Reduce Risk  to Veterans. GAO-04-566. Washington, D.C.: March 31, 2004.
VA Health Care: Veterans at Risk from Inconsistent Screening of  Practitioners. GAO-04-625T. Washington, D.C.: March 31, 2004.