VA Health Care: Patient Safety Could be Enhanced by Improvements in Employment Screening and Physician Privileging Practices
Published: 2006-06-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: 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. 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. 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. 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  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. 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  federal government, determined whether these controls are adequate. 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.
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  assurance programs. 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.
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.
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. 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.
subsections: section_title: State Licenses and National Certificates
paragraphs: VA requires its health care practitioners to have professional credentials in  their specific professions through either state licenses or national  certificates. 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  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.
section_title: Background Investigations
paragraphs: 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. 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.
section_title: Physician Credentialing and Privileging
paragraphs: 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 Web- based 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,  the medical staff specialist sends the information to the physician’s  supervisor, known as a clinical service chief.
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. 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.
section_title: VA Has Taken Steps to Improve Employment Screening Requirements, but Gaps Remain
paragraphs: 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  practitioner’s choosing. 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  HIPDB and verify all health care practitioners’ licenses and certifications  with the relevant issuing organizations.
section_title: VA Facilities Did Not Comply with Employment Screening Requirements for Practitioners
paragraphs: 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 long- standing—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.
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.
section_title: 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
paragraphs: We found that the physician files at the 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. 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.
subsections: section_title: Selected Physician Files at Facilities Demonstrated Compliance with Four VA Credentialing and Four Privileging Requirements; a Fifth Privileging Requirement Was Problematic
paragraphs: 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. 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. 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  (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.
section_title: Not All Facilities Submitted Paid Malpractice Claim Information in a Timely Manner
paragraphs: 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.  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.
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.
section_title: VA Has Not Established Internal Controls to Help Ensure the Accuracy of 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 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.
section_title: Concluding Observations
paragraphs: 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.
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  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.
section_title: Contacts and Acknowledgments
paragraphs: 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.
section_title: Appendix I: March 2004 Report Recommendations and VA Screening, Credentialing, and Privileging Requirements
paragraphs: 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.
subsections: section_title: March 2004 Report Recommendations
paragraphs: 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.
section_title: VA Employment Screening Requirements for Practitioners Selected for Review
paragraphs: To measure facility compliance with VA’s employment screening  requirements, we selected five requirements for our review. 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.
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.
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.
section_title: VA Physician Credentialing Requirements Selected for Review
paragraphs: 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.
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.
section_title: VA Physician Privileging Requirements Selected for Review
paragraphs: 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.
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.
Use information on physicians’ performances when making decisions  about whether to renew physicians’ clinical privileges.
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