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

Letter

Background

Identifying Concerns about Providers’ Clinical Care

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.

Reviewing Concerns about Providers’ Clinical Care and Taking Adverse Privileging Actions

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.

Reporting Providers to the NPDB and SLBs

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).

Performance Pay

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.

Selected VAMCs’ Reviews of Providers’ Clinical Care Are Not Always Documented or Timely, and VHA Does Not Adequately Oversee These Reviews

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.

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

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.

At Selected VAMCs, Providers with Adverse Privileging Actions Were Ineligible for Performance Pay the Year the Actions Were Taken

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.

Conclusions

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.

Recommendations for Executive Action

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)

Agency Comments

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.

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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.

Appendix I: Comments from the Department of Veterans Affairs

Appendix II: GAO Contacts and Staff Acknowledgments

GAO Contacts

Staff Acknowledgments

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.