VA Health Care: Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns
Released: 2017-11-27T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: Nearly 40,000 providers hold privileges in VHA's 170 VAMCs. VAMCs must identify and review any concerns that arise about the clinical care their providers deliver. Depending on the findings from the review, VAMC officials may take an adverse privileging action against a provider that either limits the care a provider is allowed to deliver at the VAMC or prevents the provider from delivering care altogether.

GAO was asked to review VHA processes for reviewing concerns about providers' clinical care. This report examines, among other things, selected VAMCs' (1) reviews of providers' clinical care after concerns are raised and VHA's oversight of these reviews, and (2) VAMCs' reporting of providers to the NPDB and SLBs and VHA's oversight of reporting. GAO visited a non-generalizable selection of five VAMCs selected for the complexity of services offered and variation in location. GAO reviewed VHA policies and files from the five selected VAMCs, and interviewed VHA, VISN, and VAMC officials. GAO also evaluated VHA's practices using federal internal control standards.

section_title: What GAO Found
paragraphs: Department of Veterans Affairs (VA) medical center (VAMC) officials are responsible for reviewing the clinical care delivered by their privileged providers—physicians and dentists who are approved to independently perform specific services—after concerns are raised. The five VAMCs GAO selected for review collectively required review of 148 providers from October 2013 through March 2017 after concerns were raised about their clinical care. GAO found that these reviews were not always documented or conducted in a timely manner. GAO identified these providers by reviewing meeting minutes from the committee responsible for requiring these types of reviews at the respective VAMCs, and through interviews with VAMC officials. The selected VAMCs were unable to provide documentation of these reviews for almost half of the 148 providers. Additionally, the VAMCs did not start the reviews of 16 providers for 3 months to multiple years after the concerns were identified. GAO found that VHA policies do not require documentation of all types of clinical care reviews and do not establish timeliness requirements. GAO also found that the Veterans Health Administration (VHA) does not adequately oversee these reviews at VAMCs through its Veterans Integrated Service Networks (VISN), which are responsible for overseeing the VAMCs. Without documentation and timely reviews of providers' clinical care, VAMC officials may lack information needed to reasonably ensure that VA providers are competent to provide safe, high quality care to veterans and to make appropriate decisions about these providers' privileges.

GAO also found that from October 2013 through March 2017, the five selected VAMCs did not report most of the providers who should have been reported to the National Practitioner Data Bank (NPDB) or state licensing boards (SLB) in accordance with VHA policy. The NPDB is an electronic repository for critical information about the professional conduct and competence of providers. GAO found that

selected VAMCs did not report to the NPDB eight of nine providers who had adverse privileging actions taken against them or who resigned during an investigation related to professional competence or conduct, as required by VHA policy, and

none of these nine providers had been reported to SLBs.

GAO found that officials at the selected VAMCs misinterpreted or were not aware of VHA policies and guidance related to NPDB and SLB reporting processes resulting in providers not being reported. GAO also found that VHA and the VISNs do not conduct adequate oversight of NPDB and SLB reporting practices and cannot reasonably ensure appropriate reporting of providers. As a result, VHA's ability to provide safe, high quality care to veterans is hindered because other VAMCs, as well as non-VA health care entities, will be unaware of serious concerns raised about a provider's care. For example, GAO found that after one VAMC failed to report to the NPDB or SLBs a provider who resigned to avoid an adverse privileging action, a non-VA hospital in the same city took an adverse privileging action against that same provider for the same reason 2 years later.

section_title: What GAO Recommends
paragraphs: GAO is making four recommendations, including for VA to direct VHA to require VAMCs to document reviews of providers' clinical care after concerns are raised, develop timeliness requirements for these reviews, and ensure proper VISN oversight of such reviews as well as timely VAMC reporting of providers to the NPDB and SLBs. VA concurred with GAO's recommendations and described steps it will take to implement them.

section_title: Letter
paragraphs: The Department of Veterans Affairs’ (VA) Veterans Health Administration  (VHA) operates one of the largest health care systems in the nation, and  nearly 40,000 providers hold privileges at its 170 VA medical centers  (VAMC). As in all health care delivery settings, VAMCs are responsible  for ensuring that their providers deliver safe care to patients. If a concern  about a provider’s clinical care arises at any point, it is the VAMC’s  responsibility to review the provider’s clinical care. Depending on the  nature of the concern and the findings from their review, VAMC  leadership officials may take adverse privileging actions against providers  that either limit the care they are allowed to deliver at the facility or  prevent the providers from delivering care altogether. VAMC officials are  also required to report the providers they take adverse privileging actions  against to the National Practitioner Data Bank (NPDB), which is used by  other VAMCs, non-VA hospitals, and other health care entities to obtain  information on providers with a history of substandard care and  misconduct. VAMC officials are also required to report providers to state licensing boards (SLB) when there are serious concerns about a  provider’s clinical practice. The SLB can then investigate and determine if  the provider’s license to practice medicine should be suspended,  restricted, or revoked.

Congress and VA have taken recent steps to make the adverse  privileging action process more efficient and more transparent. For  example, the Department of Veterans Affairs Accountability and  Whistleblower Protection Act of 2017 shortens the appeals process  timeframe when a VAMC proposes taking an adverse privileging action.  While these actions may shorten the time period for reviewing and  rendering a decision on taking an adverse privileging action, questions  remain about the extent to which VAMC leadership officials review  providers’ clinical care after concerns are raised and, when appropriate,  take adverse privileging actions against these providers and report them  to the NPDB or SLBs. For example, there have been recent whistleblower  complaints from VAMC providers to the U.S. Office of Special Counsel  alleging that VAMC leadership officials have not adequately reviewed and  addressed issues regarding providers’ clinical care after concerns have  been raised. According to the whistleblowers, specific providers have  delivered care in a manner that is unsafe and inconsistent with industry  standards of care, such as performing unnecessary procedures on  veterans, without adequate reviews and actions taken by VAMC  leadership.

Questions have also been raised about the extent to which VHA gives  performance pay—a component of VA provider compensation—to  providers who have had an adverse privileging action taken against them.  Performance pay is an annual lump sum payment given to providers  based on the extent to which the provider achieves specific goals in a  given fiscal year. In July 2013, we reported that providers who were the  subject of adverse actions, including adverse privileging actions, received  performance pay for the same year the actions were taken.

You asked us to review the processes VHA has in place to review  providers’ clinical care after concerns arise and the extent to which  providers receive performance pay when concerns are confirmed. In this  report, we examine  1.  VAMCs’ reviews of providers’ clinical care after concerns are raised  and VHA’s oversight of these reviews;  2.  VAMCs’ reporting of providers to the NPDB and SLBs and VHA’s  oversight of these processes; and  3.  the extent to which VAMCs give performance pay to providers who  have had an adverse privileging action taken against them.

To examine VAMCs’ reviews of providers’ clinical care after concerns are  raised, we reviewed VHA policies and guidance and interviewed relevant  VHA officials to obtain an understanding of VHA processes for these  reviews. In addition, we identified providers whose clinical care required  a review after concerns were raised at a non-generalizable selection of  five VAMCs from October 2013 through the time we completed our site  visits in March 2017. For these selected providers, we reviewed VAMC  documentation of their reviews. We selected the five VAMCs based on  the complexity of services offered and their geographic distribution. We  identified providers at each VAMC by reviewing documentation of each  VAMC’s credentialing committee meetings from fiscal year 2014 through  fiscal year 2016. During our visits, we interviewed VAMC officials, including chiefs of staff, clinical supervisors known as service chiefs, and  other officials involved in these reviews. We asked the officials to clarify  information about the documentation we received and confirm the  completeness of the list of providers we identified. Based on the  documentation and interviews, we determined the type of reviews the  selected VAMCs conducted and the extent to which the VAMCs took  adverse privileging actions against any of the identified providers. We  assessed the extent to which the selected VAMCs adhered to VHA policy  requirements for clinical care reviews and we compared these VHA  policies and the selected VAMCs’ reviews to federal internal control  standards related to monitoring and documentation. To review VHA’s  oversight of VAMCs’ clinical care reviews and adverse privileging actions,  we reviewed VHA policy for oversight responsibilities and requirements.  We also interviewed relevant VHA officials, as well as officials in VA’s  Veterans Integrated Service Networks (VISN) responsible for each of the  five selected VAMCs, about their oversight activities. We also compared  VHA’s policy and the selected VISNs’ oversight activities with federal  internal control standards related to monitoring.

To examine VAMCs’ reporting of providers to the NPDB and SLBs, we  reviewed VHA’s related policies and evaluated the extent to which the  selected VAMCs adhered to these policies. Specifically, we evaluated  the extent to which providers whose clinical care required a review or  resulted in the VAMC taking adverse privileging actions against them  from October 2013 through the time we completed our site visits in March  2017 were reported to the NPDB and the SLBs when appropriate. Our review of NPDB reporting is limited to NPDB adverse action reports,  which are reports of the adverse privileging actions VAMCs took against  providers and any providers who resigned or retired while under  investigation for a clinical care concern. Our review does not include VHA  reporting of providers for paid medical malpractice settlements or  judgements (tort claims). We reviewed VAMC documentation related to  its reporting of specific providers and interviewed VAMC officials,  including both clinical and administrative officials involved in these  reporting processes. To examine VHA’s oversight of VAMC reporting, we  reviewed VHA policies for overseeing NPDB and SLB reporting and  interviewed relevant VHA officials as well as officials in the VISNs  responsible for each of the five selected VAMCs about VISN oversight  activities. We also compared VHA’s policy for oversight responsibilities  and the selected VISNs’ oversight activities with federal internal control  standards related to monitoring.

To determine the extent to which VAMCs give performance pay to  providers who have had an adverse privileging action taken against them,  we reviewed documentation of performance pay given to providers we  identified with adverse privileging actions at the five selected VAMCs.  Specifically, for each of the providers with an adverse privileging action  who were eligible for performance pay, we reviewed documentation of  performance pay for the fiscal year in which the action was taken and for  the fiscal year prior to the action. Our performance pay analysis does not  include contract providers, because only employed providers are eligible  to receive performance pay. We also reviewed VA policy on  performance pay and interviewed relevant VHA officials, as well as VAMC  officials, about performance pay.

We conducted this performance audit from August 2016 to November  2017 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Identifying Concerns about Providers’ Clinical Care
paragraphs: As part of the credentialing and privileging process, VAMC officials are  responsible for monitoring each provider’s performance on an ongoing  basis and identifying any concerns about clinical care that may warrant  further review. VAMCs can identify concerns about providers’ clinical care  in a variety of ways, including the following:

Ongoing monitoring. VHA requires VAMCs to conduct and  document ongoing monitoring of each provider’s performance at least  twice a year through an ongoing professional practice evaluation.  During this evaluation, a provider’s performance is evaluated against  benchmarks established by VAMC leadership that define acceptable  performance, such as documenting patient visits appropriately and  achieving specific patient outcomes.

Peer review triggers. VHA has a separate process, called peer  review, that VAMCs may use to review adverse events. While  information collected as part of peer review is protected for quality  improvement purposes and may not be used to take action against a  provider, VAMCs can identify concerns about a provider’s clinical care  based on a trend of certain peer review outcomes over a specified  period of time, referred to as triggers. VHA requires VAMCs to  establish peer review triggers. An example of a peer review trigger is  when a provider has two or more episodes of patient care within a 12- month period for which a peer determined that most experienced,  competent providers would have managed the episodes differently.

Complaints or incident reports. Concerns about a provider’s clinical  care can also be identified through complaints and incident reports.  These can come from any individual with a concern, including  patients, providers, or VAMC leadership.

Tort claims. Filed or settled tort claims or malpractice claims can  raise a concern about a provider not identified through ongoing  monitoring or peer review.

section_title: Reviewing Concerns about Providers’ Clinical Care and Taking Adverse Privileging Actions
paragraphs: Once a concern about a provider’s clinical care is identified, VHA policy  and guidance establish processes for VAMC officials to use to review the  concern and determine whether an action should be taken against the  provider’s clinical privileges. VHA policy states that if allowing a provider  under review to continue delivering patient care could result in imminent  danger to veterans, VAMC officials should remove the provider from  delivering patient care through a summary suspension of privileges.  VAMC officials have flexibility to determine the most appropriate process  to use to review a provider’s clinical care depending on the specific  concerns and the situation. These processes include the following:

Focused professional practice evaluation (FPPE) for cause. This  is a prospective review of the provider’s care over a specified period  of time, during which the provider has the opportunity to demonstrate  improvement in the specific area of concern. Failure to improve could  result in further review or action.

Retrospective review. This is a review of the provider’s delivery of  patient care focused on a specific period of time in the past, a specific  area of practice, or both, based on an identified concern.

Comprehensive review. This is a more extensive retrospective  review, generally performed by a panel of experts to ensure fairness  and objectivity. In addition to reviewing the provider’s past patient  care, these reviews may also include interviews with the provider,  patients, and staff. These reviews generally result in conclusions  about whether care delivered by the provider met the standard of care  and may include recommendations about the provider’s privileges.

Once a review is completed, VAMC leadership officials and the VAMC  credentialing committee make decisions about next steps, which could  include the following: do nothing, if the review did not substantiate the concerns;  conduct further review (such as an FPPE for cause to allow the  provider an opportunity for improvement or a comprehensive review if  more information is needed); or  take an adverse privileging action, including limiting one or more  privileges (such as prescribing medication or performing a certain  procedure) or revoking all of the provider’s privileges.

If the VAMC’s credentialing committee recommends an adverse  privileging action, it is the VAMC director’s responsibility to weigh all  available information, including recommendations, and take an action.  After a permanent provider is notified of the director’s decision, the  provider can appeal the decision to the Disciplinary Appeals Board as  part of their due process rights. The adverse privileging action is  considered final once the Disciplinary Appeals Board reaches a decision  and the Deputy Under Secretary for Health executes the Board’s  decision. If a permanent provider does not make use of the offered due  process procedures within 7 days, the provider waives his or her right to  due process and the adverse privileging action is considered final.

section_title: Reporting Providers to the NPDB and SLBs
paragraphs: VHA policy requires VAMCs to alert certain entities if there are serious  concerns with regard to a provider’s clinical performance. VHA policy  assigns reporting responsibility and authority to the VAMC director, who  generally delegates the task of reporting to other VAMC officials. VHA  makes this information available to other health care entities through two  distinct reporting processes:  NPDB. Under VHA policy, VAMC directors must report to the NPDB any  adverse privileging action the facility takes that 1) affects the clinical  privileges of a provider for a period longer than 30 days and 2) is related  to professional incompetence or professional misconduct. VHA policy  requires VAMCs to submit these NPDB adverse action reports within 15  calendar days of the date the adverse privileging action is made final— that is, when all applicable internal due process procedures have been  completed and the VAMC director has signed off on the action. VAMC  directors are also required to report to the NPDB providers who resign or  retire while under investigation or in return for the VAMC not conducting  such an investigation or proceeding. To avoid any errors in the facts of  the report, the VAMC director must notify any provider who is about to be  reported to the NPDB and give the provider an opportunity to discuss the  content of the report before it is submitted.

SLBs. VHA policy requires VAMC directors to report providers—both  current and former employees—when there are serious concerns about  the providers’ clinical care to any SLB where the providers hold an active  medical license. Specifically, VHA policy requires VAMCs to report  providers who so substantially failed to meet generally accepted  standards of clinical practice as to raise reasonable concern for the safety  of patients. According to VHA policy and guidance, the SLB reporting  process should be initiated as soon as it appears that a provider’s  behavior or clinical practice fails to meet accepted standards. VAMC  officials are directed not to wait to report to SLBs until adverse privileging  actions are taken because an SLB conducts its own investigation of the  provider to determine whether licensure action is warranted. This  reporting process comprises five stages as established in VHA policy,  and VHA policy states that the process should be completed in around  100 days (see figure 1).

section_title: Performance Pay
paragraphs: Performance pay—a component of VA provider compensation—is an  annual lump sum payment based on the extent to which an individual  provider achieves specific goals. The goals may vary for providers across  VA, at the same VAMC, or within a particular specialty. VA policy  establishes minimum performance pay eligibility criteria, including being  employed by VA from July 1 through September 30 of the fiscal year  being reviewed.

section_title: Selected VAMCs’ Reviews of Providers’ Clinical Care Are Not Always Documented or Timely, and VHA Does Not Adequately Oversee These Reviews
paragraphs: Documentation frequently lacking. We found that the five selected  VAMCs collectively required reviews of 148 providers’ clinical care after  concerns were raised from October 2013 through March 2017, but VAMC  officials were unable to provide documentation that almost half of these  reviews were conducted. We found that all five VAMCs lacked at least  some documentation of the reviews they told us they conducted, and in  some cases the required reviews were not conducted at all. We also  found VHA does not adequately oversee these reviews, as discussed  later in this report.

FPPEs for cause. FPPEs for cause accounted for most of the  missing documentation of clinical care reviews, despite VHA policy  requiring VAMCs to document FPPEs for cause in the providers’ files.  Specifically, of the 112 providers for whom the selected VAMCs  required FPPEs for cause from October 2013 through March 2017,  the VAMCs were unable to provide documentation of the FPPEs for  nearly a quarter (26) of the providers. Additionally, VAMC officials  confirmed that FPPEs for cause that were required for another 21  providers were never conducted.

Other reviews. The selected VAMCs were also unable to provide  documentation of some retrospective reviews. Specifically, of the 27  providers for whom the selected VAMCs conducted a retrospective  review, 8 were missing documentation. While VHA guidance  recommends that VAMCs document these reviews, VHA policy does  not require that VAMCs document retrospective or comprehensive  reviews. VHA officials told us that they expected VAMCs to document  these types of reviews so that the information could be used to  support adverse privileging actions, if necessary. Without clearly  stated documentation requirements in VHA policy, VAMC officials  inconsistently document their results, preventing VAMC directors and  VISNs from properly evaluating the effectiveness of its retrospective  and comprehensive reviews, which are used to, among other things,  ensure patient safety. Additionally, we found that key officials from two  VAMCs were not aware of the VHA guidance and that 5 of the 8  missing retrospective reviews were from these two VAMCs.

We also found that one VAMC was missing documentation of clinical  care reviews for 12 providers who met the VAMC’s peer review  trigger. In the absence of this documentation, we were unable to  identify the type of reviews that were missing for these 12 providers.

The selected VAMCs’ failure to document reviews of providers’ clinical  care after concerns were raised is inconsistent with federal internal  control standards for monitoring and documentation, which state that  management should conduct and document separate evaluations, when  necessary. In the absence of VAMC documentation of such separate  evaluations of providers, VAMC leadership officials lack key information  needed to make decisions about whether providers’ privileges are  appropriate, and they also lack reasonable assurance that appropriate  reviews are conducted.

Reviews not always timely. We found that the five selected VAMCs’  reviews of providers’ clinical care were not always conducted in a timely  manner after concerns were raised. Specifically, of the 148 providers, the  VAMCs’ initiation of reviews of 16 providers’ clinical care was delayed by  more than 3 months, and in some cases for multiple years, after the  concern was raised. At one VAMC, service chiefs were not instructed to  conduct reviews of 14 providers until 4 to 13 months after these providers  met the VAMC’s peer review trigger. Before the service chiefs were  notified of the concerns, 3 of these providers had at least one additional  concerning episode of care—that peer reviewers judged would have been  handled differently by most experienced providers—identified through the  peer review process. As pointed out in VHA guidance, earlier  intervention could prevent additional patients from receiving substandard  care. Officials from another VAMC did not conduct retrospective reviews  on 2 providers until we requested documentation of the reviews,  approximately 3 and a half years after the credentialing committee had  initially requested a review.

While VHA officials told us that clinical care reviews should be conducted  as expeditiously as reasonably possible, VHA policy does not specify a  timeliness requirement. Allowing more time to elapse before a clinical  care review is initiated weakens the intended purpose behind clinical care  reviews and further increases risk to patient safety. Federal internal  control standards for monitoring state that management should evaluate  issues and remediate identified deficiencies in a timely manner. A  clinical care concern could represent a potential deficiency in providing  medical care, and as a result, VHA increases its risk further without  establishing a policy that sets timeframes for conducting clinical care  reviews.

VHA oversight is inadequate. We also found that VHA does not  adequately oversee VAMC reviews of providers’ clinical care after  concerns have been raised, including ensuring that these reviews are  completed and documented in a timely manner. Under VHA policy, VISNs  are responsible for overseeing the credentialing and privileging processes  at their respective VAMCs. While reviews of providers’ clinical care after  concerns are raised are a component of credentialing and privileging, we  found that the VISNs with responsibility for overseeing the selected  VAMCs through routine audits do not include these reviews in their  audits. While the standardized tool VHA requires the VISNs to use for  these audits instructs the VISNs to identify and review providers who  were on an FPPE for cause, none of the VISN officials we spoke with  described any routine oversight of FPPEs or any other reviews of  identified clinical care concerns. This may be in part because some  VISN officials are not using VHA’s standardized audit tool as required.  Officials from one VISN said they had developed their own audit tool and  officials from another VISN said that they were not conducting the audits  due to multiple instances of turnover in a key position at the VISN.  Further, VHA’s standardized audit tool does not direct the VISN to  oversee any other types of reviews of clinical care concerns, such as  retrospective or comprehensive reviews. The tool also does not require  VISN officials to look at documentation of the FPPEs for cause; instead, it  calls for reviewing credentialing committee meeting minutes. Without  reviewing documentation, VISN officials would be unable to identify the  incomplete documentation that we identified in our review. Both VHA and  VISN officials described instances of assisting VAMC officials with  reviews of providers’ clinical care after concerns had been raised, but  VHA and VISN officials told us that their involvement in these reviews is  typically consultative and not routine. (For example, the VISN may assist  by identifying providers outside of the VAMC to conduct the review.) As a  result, VHA and the VISNs are not conducting routine oversight to ensure  that VAMC reviews of providers’ clinical care after concerns are raised  are conducted appropriately, including adequately ensuring that the  reviews are completed and documented in a timely manner, in  accordance with VHA policy.

The lack of routine VHA oversight, through the VISNs, of VAMC reviews  of providers’ clinical care after concerns are raised is inconsistent with  federal internal control standards for monitoring, which state that  management should establish and operate monitoring activities. In the  absence of routine monitoring of VAMCs’ evaluations of providers after  concerns have been raised, VHA lacks reasonable assurance that  VAMCs adequately review all identified concerns about providers’ clinical  care and take appropriate privileging actions to ensure that VA is  providing safe, high quality care for veterans.

section_title: Selected VAMCs Did Not Always Report Providers to the NPDB and SLBs in Accordance with VHA Policy, and VHA Does Not Adequately Oversee This Reporting
paragraphs: NPDB and SLB reporting not completed. We found that the five  selected VAMCs did not report the majority of providers who should have  been reported to the NPDB or SLBs in accordance with VHA policy. Our  analysis shows that from October 2013 through March 2017, of the 148  providers whose clinical care required a review, the VAMCs took adverse  privileging actions against 5 providers, and another 4 providers resigned  or retired while under review but before an adverse privileging action  could be taken. However, at the time of our review, we found that the five  selected VAMCs had only reported 1 of these 9 providers to the NPDB  and none of these providers to the SLBs. Furthermore, the 1 provider  who was reported to the NPDB for an adverse privileging action was  reported 136 days after all internal VA appeals were complete, far beyond  the 15 day reporting requirement.

In addition to these nine providers, one of the selected VAMCs terminated  the services of four contract providers based on deficiencies in the  providers’ clinical performance, effectively revoking their clinical  privileges. For example, the VAMC documented that one contractor’s  services were terminated for cause related to patient abuse after only 2  weeks of work at the VAMC. A VAMC leadership official told us there was  no further documentation of whether reporting was considered or whether  any comprehensive review was conducted, despite the fact that the  VAMC credentialing committee recommended both. While VHA policy  identifies the requirements, steps, and limited fair hearing process for  reporting contract providers, these required steps were not followed, and  none of these providers were reported to the NPDB or SLB.

As a result of our audit work, in August 2017, one of the VAMCs reported  to the NPDB three of the providers who resigned or retired while under  investigation but before an adverse privileging action could be taken.

These reports were completed between 11 months and over 3 and a half  years after the providers resigned or retired. VAMC officials could not  confirm that they sent the required copies of the NPDB reports to the  appropriate SLBs.

The five selected VAMCs did report two providers to their respective  SLBs for reasons other than adverse privileging actions. In accordance  with VHA policy, these SLB reports were made after VAMC officials  determined that the providers’ behavior or clinical practice so substantially  failed to meet generally accepted standards of clinical practice as to raise  reasonable concern for the safety of patients—the standard for SLB  reporting. One of these providers could not have an adverse privileging  action taken against them because VAMC officials unintentionally allowed  the provider’s privileges to expire during a comprehensive review of the  provider’s care. The other provider reported to the SLBs was considered  for an adverse privileging action, but VAMC officials suspended the  provider instead. The provider demonstrated improvement after the  suspension.

SLB reporting not always timely. While two of the selected VAMCs had  each reported a provider, we found that in these cases the SLB reporting  process took significantly longer than the 100 day timeframe suggested in  VHA policy. Specifically, it took over 500 days for each of the two  completed reports to pass initial and comprehensive review at the VAMC,  receive concurrence from the VISN, and be submitted to the SLB. For  example, one of the two providers self-reported to the SLB the concerning  episode of care at the VAMC. However, before the VAMC submitted its  SLB report 328 days later, the SLB had completed its investigation of the  provider’s self-report and put in place an agreement that placed  restrictions and requirements on the provider’s medical license.  Subsequently, the provider successfully met the requirements of the  agreement and had all restrictions on the license removed. Officials at  two VAMCs told us the SLB reporting is more tedious or cumbersome  than the NPDB reporting process, making it difficult to complete in a  timely manner. One VAMC official commented that while completing the  process in less than a year seems reasonable, the typical timeframe for  submitting a SLB report is at least 2 years.

At the five selected VAMCs, we found that providers were not reported to  the NPDB and relevant SLBs as required because officials were generally  not familiar with or misinterpreted related VHA policies. VHA officials  commented that adverse privileging actions and clinical care concerns  rising to the level of reporting are infrequent, with officials at two VISNs  estimating that only a few occur across the facilities within their network  each year. Staff at three VAMCs commented that there has been turnover  in positions that have been delegated tasks related to reporting and one  VAMC official told us that turnover in these positions is a barrier to timely  reporting. For example, at one facility, we found that officials failed to report six providers to  the NPDB because the officials were unaware that they had been  delegated responsibility for NPDB reporting.

Officials at two of the selected VAMCs told us that VHA cannot report  contract providers to the NPDB. This assertion is inconsistent with  VHA policy.

Officials at two of the selected VAMCs were waiting to start the SLB  reporting process for providers until after all appeals had been  exhausted. This approach is inconsistent with VHA policy, which  states that the process should start within 7 days of when the  reporting standard is met. For example, for one provider who was  reported, VAMC officials unnecessarily waited 7 months for the  completion of the appeals process before they resumed the reporting  process, which ultimately took 547 days.

Officials at one VAMC did not report a provider to the NPDB or SLB  following an adverse privileging action because the SLB had found  out about the issue independently. This is inconsistent with VHA  policy for NPDB and SLB reporting, and the SLBs in other states  where the provider held a license were not alerted of concerns about  the provider’s clinical practice.

VHA oversight is inadequate. We also found that VHA and the VISNs  do not adequately oversee NPDB and SLB reporting and they cannot  ensure that VAMCs are reporting providers when required to do so by  VHA policy. While the VISNs are responsible for overseeing the  credentialing and privileging at their respective VAMCs under VHA policy,  VHA policy does not require the VISNs to oversee whether VAMCs are  reporting providers to the NPDB or SLB when warranted. As a result,  VISN officials were unaware of situations in which VAMC directors failed  to report providers to the NPDB, as evidenced by our review. In the case  of reporting processes for SLBs, VISN officials told us that they review the  evidence files to ensure, among other things, that the files are in  compliance with privacy laws. However, officials told us that the VISNs do  not oversee the reporting process to ensure that VAMC directors are  reporting all providers to the SLB who should be reported. Additionally,  VHA officials told us that they are not aware of the number of cases that  have been initiated for SLB reporting.

Further, by failing to report providers as required, VHA facilitates  providers who provide substandard care obtaining privileges at another  VAMC or a hospital outside of VA’s health care system without an  indication on their record that an adverse privileging action was taken  against them or that they resigned or retired while under investigation. For  example, we found that  two of the four contract providers whose privileges were revoked and  were not reported to the NPDB or SLBs by one VAMC continue to be  able to provide care to veterans outside of that VAMC. Specifically,  one provider whose services were terminated related to patient abuse  subsequently held privileges at another VAMC, while the other  provider belongs to a network of providers that provides care for  veterans in the community.

Seven of the 12 providers who were not reported to the NPDB or  SLBs after their privileges were revoked—through adverse privileging  actions or the termination of services on a contract—or who resigned  or retired while under investigation have current Medicare enrollment  records, indicating that they are likely practicing outside of VA and  may still be receiving federal dollars by billing for services provided to  Medicare beneficiaries.

We also identified one case where a VAMC director did not report a  provider to the NPDB or SLB after an agreement was reached that the  provider would resign, though the VAMC credentialing committee  recommended the provider’s privileges be revoked. We found that the  provider’s privileges were also revoked from a non-VA hospital in the  same city for the same reason 2 years later. The director’s decision  not to report the provider as required left patients in that community  vulnerable to adverse outcomes because problems with the provider’s  performance were not disclosed. There was no documentation of the  reasons why the VAMC director did not report the provider to the  NPDB or SLBs.

This lack of routine oversight from VHA through the VISNs of VAMCs’  reporting of providers to the NPDB and SLBs is inconsistent with federal  internal control standards for monitoring. The standards state that  management should establish and operate monitoring activities to monitor  the internal control system and appropriately remediate deficiencies on a  timely basis. Without routine monitoring of the reporting process, VHA  lacks reasonable assurance that all providers who should be reported to  the NPDB and SLBs are reported.

section_title: At Selected VAMCs, Providers with Adverse Privileging Actions Were Ineligible for Performance Pay the Year the Actions Were Taken
paragraphs: None of the five providers who had an adverse privileging action taken  against them in the period we reviewed received performance pay for the  fiscal year the action was taken because they were ineligible, per VA  policy. This is because VA policy requires providers to be employed  through the end of the fiscal year to be eligible for performance pay, and  none of the five providers we reviewed were still employed by the VAMCs  at the end of the fiscal year in which the actions were taken.

All five of the adverse privileging actions resulted from concerns about the  providers’ clinical care in previous fiscal years. Among the five providers,  two providers received performance pay in the fiscal year before their  privileges were revoked, and three providers did not. For example, one  provider’s privileges were revoked in 2015 due to concerns raised in 2014  regarding the provider’s failure to complete necessary documentation of  patient care in a timely manner. This provider did not receive credit for the  performance pay goal directly related to timely completion of  documentation, and ultimately the provider received half of the maximum  amount of performance pay for fiscal year 2014. In the case of another  provider who did not receive any performance pay for the fiscal year  before the adverse privileging action was taken, VAMC officials noted that  the provider had been removed from practice for a portion of the fiscal  year while they were reviewing the clinical care concern and thus was  unable to meet performance pay goals.

section_title: Conclusions
paragraphs: VHA is responsible for ensuring that providers at its VAMCs deliver safe  care to veterans and that concerns that may arise about providers’ clinical  care are reviewed and addressed at VHA’s 170 VAMCs. However, our  work shows that at our five selected VAMCs, reviews of concerns about  providers’ clinical care were not always documented or conducted in a  timely manner and VAMCs had not reported the majority of providers they  should have reported to the NPDB or SLBs. This is concerning for several  reasons. First, without documentation of the reviews of these concerns  about providers’ clinical care, VAMC leadership officials may not have the  information they need to make decisions about whether a provider’s  privileges at the VAMC are appropriate. Second, if VAMCs do not  document that they have reviewed provider’s clinical care after concerns  have been raised, VHA lacks reasonable assurance that the VAMCs are  adequately addressing such concerns or that VAMCs are limiting or  revoking providers’ privileges when necessary. Third, if these reviews are  not conducted in a timely manner and providers continue to deliver  potentially substandard care, VHA may be increasing the risk that  veterans will receive unsafe care at VAMCs. Finally, VAMCs’ failure to  report providers to the NPDB and SLBs, as required under VHA policy,  makes it possible for providers to obtain privileges at other VAMCs or  non-VA health care entities without disclosing the problems with their past  performance. In effect, this can help shield the providers from  professional accountability outside of VA’s health care system.

Further, VHA’s inadequate oversight of these processes calls into  question the extent to which VAMCs are held accountable for ensuring  that veterans receive safe, high quality care. As our review shows, the  VISNs responsible for overseeing the five selected VAMCs do not  routinely oversee VAMC reviews of providers’ clinical care after concerns  are raised to ensure that these reviews are completed in accordance with  VHA policies; nor do the VISNs oversee the VAMCs to ensure that all  providers that should be reported are reported to the NPDB and SLBs.  Until VHA strengthens its oversight of these processes, veterans may be  at increased risk of receiving unsafe care through the VA health care  system.

section_title: Recommendations for Executive Action
paragraphs: We are making the following four recommendations to VA:  The Under Secretary for Health should specify in VHA policy that reviews  of providers’ clinical care after concerns have been raised should be  documented, including retrospective and comprehensive reviews.  (Recommendation 1)

The Under Secretary for Health should specify in VHA policy a timeliness  requirement for initiating reviews of providers’ clinical care after a concern  has been raised. (Recommendation 2)

The Under Secretary for Health should require VISN officials to oversee  VAMC reviews of providers’ clinical care after concerns have been raised,  including retrospective and comprehensive reviews, and ensure that  VISN officials are conducting such oversight with the required  standardized audit tool. This oversight should include reviewing  documentation in order to ensure that these reviews are documented  appropriately and conducted in a timely manner. (Recommendation 3)

The Under Secretary for Health should require VISN officials to establish  a process for overseeing VAMCs to ensure that they are reporting  providers to the NPDB and SLBs, and are reporting in a timely manner.  (Recommendation 4)

section_title: Agency Comments
paragraphs: We provided a draft of this report to VA for comment. In its written  comments, which are reproduced in Appendix I, VA agreed with our  conclusions and concurred with our recommendations. In its comments,  VA stated that VHA plans to revise existing policy to require  documentation of reviews of providers’ clinical care after concerns have  been raised and to establish expected timeframes for completing such  reviews. VA estimates that it will complete these actions by September  2018. VA also stated that VHA will update the standardized audit tool  used by the VISNs so that it directs them to oversee reviews of providers’  clinical care after concerns have been raised and to ensure timely  reporting to the NPDB and SLBs. According to VA, the revised tool will  also facilitate aggregate reporting by VISNs to identify trends and issues.  VA estimates that it will complete these actions by October 2018.

As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the appropriate  congressional committees, the Secretary of Veterans Affairs, and the  Under Secretary for Health. In addition, the report will be available at no  charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  Sharon M. Silas at (202) 512-7114 or silass@gao.gov or Randall B.  Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs can be found on  the last page of this report. GAO staff who made major contributions to  this report are listed in appendix II.

section_title: Appendix I: Comments from the Department of Veterans Affairs

section_title: Appendix II: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Marcia A. Mann (Assistant  Director), Kaitlin M. McConnell (Analyst-in-Charge), and Summar C.  Corley made major contributions to this report. Also contributing were  Krister Friday, Jacquelyn Hamilton, Vikki Porter, and Brienne Tierney.

Fast facts: The Department of Veterans Affairs requires its medical centers to review a doctor’s care if quality or safety concerns arise. If VA medical center officials decide a doctor should no longer provide care to veterans, they are required to inform hospitals and other health care entities by reporting to a national database and to the states where the doctor is licensed.

However, at the 5 VA medical centers we reviewed, we found that these reviews were not always timely. We also found that VA officials did not report 8 of the 9 doctors who should have been reported.

We recommended VA improve oversight of clinical care reviews and reporting.

Question-summary annotations: questions: question: What are the department of Veterans Affairs medical center responsible for reviewing?
answer: Department of Veterans Affairs (VA) medical center (VAMC) officials are responsible for reviewing the clinical care delivered by their privileged providers—physicians and dentists who are approved to independently perform specific services—after concerns are raised.
child_questions: question: What did GAO find in their review of five VAMCs?
answer: GAO found that these reviews were not always documented or conducted in a timely manner.

question: What issues did the GAO find with the VHA?
answer: GAO found that VHA policies do not require documentation of all types of clinical care reviews and do not establish timeliness requirements. GAO also found that the Veterans Health Administration (VHA) does not adequately oversee these reviews at VAMCs through its Veterans Integrated Service Networks (VISN), which are responsible for overseeing the VAMCs.
child_questions: question: What are the dangers of lacking documentation and timely reviews?
answer: Without documentation and timely reviews of providers' clinical care, VAMC officials may lack information needed to reasonably ensure that VA providers are competent to provide safe, high quality care to veterans and to make appropriate decisions about these providers' privileges.

questions: question: What problem did the GAO find with VAMCs?
answer: GAO also found that from October 2013 through March 2017, the five selected VAMCs did not report most of the providers who should have been reported to the National Practitioner Data Bank (NPDB) or state licensing boards (SLB) in accordance with VHA policy.
child_questions: question: What is the purpose of the NPDB?
answer: The NPDB is an electronic repository for critical information about the professional conduct and competence of providers.

question: How is the NPDB relevant to this issue?
answer: The NPDB is an electronic repository for critical information about the professional conduct and competence of providers. GAO found that

questions: question: What did the GOA find in their investigation of the VAMCs?
answer: GAO found that officials at the selected VAMCs misinterpreted or were not aware of VHA policies and guidance related to NPDB and SLB reporting processes resulting in providers not being reported. GAO also found that VHA and the VISNs do not conduct adequate oversight of NPDB and SLB reporting practices and cannot reasonably ensure appropriate reporting of providers.
child_questions: question: What was consequently uncovered about the VISNs?
answer: GAO also found that VHA and the VISNs do not conduct adequate oversight of NPDB and SLB reporting practices and cannot reasonably ensure appropriate reporting of providers.
child_questions: question: What did the GOA find as a consequence of these oversights?
answer: As a result, VHA's ability to provide safe, high quality care to veterans is hindered because other VAMCs, as well as non-VA health care entities, will be unaware of serious concerns raised about a provider's care.

question: What specific issues have been identified from the lack of reporting?
answer: For example, GAO found that after one VAMC failed to report to the NPDB or SLBs a provider who resigned to avoid an adverse privileging action, a non-VA hospital in the same city took an adverse privileging action against that same provider for the same reason 2 years later.

questions: question: How prevalent are VAMC privileges?
answer: Nearly 40,000 providers hold privileges in VHA's 170 VAMCs.

question: What is the responsibility of the VAMCs?
answer: VAMCs must identify and review any concerns that arise about the clinical care their providers deliver.
child_questions: question: What actions may the VAMCs take?
answer: Depending on the findings from the review, VAMC officials may take an adverse privileging action against a provider that either limits the care a provider is allowed to deliver at the VAMC or prevents the provider from delivering care altogether.

questions: question: What was GAO asked to review regarding the VHA?
answer: GAO was asked to review VHA processes for reviewing concerns about providers' clinical care.
child_questions: question: What did the GAO report conclude?
answer: This report examines, among other things, selected VAMCs' (1) reviews of providers' clinical care after concerns are raised and VHA's oversight of these reviews, and (2) VAMCs' reporting of providers to the NPDB and SLBs and VHA's oversight of reporting.

question: How did the GAO complete this assessment of the VHA?
answer: GAO visited a non-generalizable selection of five VAMCs selected for the complexity of services offered and variation in location. GAO reviewed VHA policies and files from the five selected VAMCs, and interviewed VHA, VISN, and VAMC officials.
child_questions: question: What investigative techniques were used?
answer: GAO reviewed VHA policies and files from the five selected VAMCs, and interviewed VHA, VISN, and VAMC officials. GAO also evaluated VHA's practices using federal internal control standards.