Clinical contracts at VA are used to acquire the services of clinical personnel, such as physicians, pharmacists, and nurses. These contracts can be used to fill vacancies for clinicians in specialties that are difficult to recruit, supplement existing VAMC capacity by providing additional clinicians in high-volume areas where VA also manages a staff of its own employees, or fill critical staffing vacancies on a long- or short-term basis. Clinical contracting at VA is governed by two sets of regulations—the FAR and VAAR—that contain general requirements for all VA acquisitions. The FAR contains government-wide regulations and establishes uniform policies and procedures used by all executive branch federal agencies for their acquisitions. VA supplements the FAR with the VAAR to establish uniform policies and procedures for all VA acquisitions of supplies and services. In addition to the VAAR, VA provides guidance to its acquisition workforce in the form of policy directives and handbooks. Both acquisition and clinical staff at VA work together to plan, execute, and monitor clinical contracts at VA. On the acquisition side, COs are responsible for planning, awarding, and administering contracts on behalf of the federal government. Each CO is able to obligate federal funds up to a specified limit and a CO must formally approve all clinical contracts at VA. Common tasks of a CO include developing acquisition planning documents used to begin a clinical contract, conducting market research to determine pricing and availability for a clinical contract, and completing the formal competitive or non-competitive solicitation process for contracts. Each CO works within a network contracting office and is overseen by managers within that office who report directly to VA Central Office. There are 21 network contracting offices throughout VA’s health care system that manage all the contracting activities of a single VISN. Two types of VAMC staff have monitoring responsibilities for clinical contracts—CORs and medical directors. For each VA clinical contract, the CO responsible for the contract designates a COR at the VAMC to help develop the clinical contract and monitor the contract provider’s performance once the provider begins work. Common tasks delegated to the COR include providing input on the performance requirements for the clinical contract, determining how the contract provider’s performance will be measured and monitoring performance once work has begun, validating the contract provider’s invoices to ensure their accuracy, managing contract modifications, and assisting the CO in resolving any issues that may arise with the contract provider. At VA, CORs are commonly administrative personnel responsible for managing the operations of a specialty care line at a VAMC—such as primary care, surgery, etc.—where the contractor will be working. Medical directors in various specialty care lines often assist CORs in monitoring contract provider performance because CORs lack the expertise to evaluate a contract provider’s clinical abilities. Medical directors are responsible for overseeing the clinical care provided by all providers within a specialty care line, including VA-employed and contract clinicians. Medical directors use existing VA processes, including the credentialing and privileging process, to monitor contract providers. This clinical monitoring includes an initial assessment of the clinician’s competency during the first 90 days after the contract provider begins working at a VA facility and typically includes evaluations in several areas—such as patient care, clinical knowledge, and interpersonal communication skills. Upon successful completion of the initial competency evaluation, medical directors monitor contract providers through ongoing evaluations of their performance according to the specific performance standards used to evaluate all clinicians working at VA within their specialty. Medical directors provide the results of these initial and ongoing evaluations to the COR and work with the COR to resolve any issues that may arise as a result of a contract provider’s clinical performance. CORs are responsible for maintaining the official record of the contract provider’s performance and providing official performance assessments to the CO. VA Central Office has primary responsibility for overseeing network contracting offices and manages clinical contracting activities through the VHA Procurement and Logistics Office. There are five primary offices within the VHA Procurement and Logistics Office that are responsible for overseeing various aspects of clinical contracting activities and report to VHA’s Deputy Chief Procurement Officer. (See fig. 1.) Medical Sharing Office. The Medical Sharing Office is responsible for providing guidance to network contracting offices regarding the content and structure of solicitations for clinical contracts and for reviewing several types of clinical contracts. The Medical Sharing Office reviews solicitations of all competitive clinical contracts valued at over $1.5 million, all non-competitive clinical contracts valued at over $500,000, and all organ transplant contracts. All Medical Sharing Office reviews are conducted before a solicitation is issued to ensure that all the necessary provisions are in place prior to any competition or award. Procurement Operations Office. The Procurement Operations Office is responsible for providing ongoing guidance and monitoring of the COR population at VA. The Procurement Operations Office conducts reviews of COR files and publishes a COR newsletter. Procurement Audit Office. The Procurement Audit Office is responsible for ensuring compliance with VA policies and procedures related to contracting. This office conducts internal compliance audits of contracts, including clinical contracts, once they are executed to ensure that all required documentation was included in the final contract and audits the activities of network contracting offices and SAOs to ensure their compliance with VA policies and regulations. Procurement Policy Office. The Procurement Policy Office is responsible for providing guidance to VA’s acquisition workforce in network contracting offices and SAOs. This office produces and updates standard operating procedures for CORs and COs. Service Area Offices. SAOs are the regional contract management entities created to oversee the activities of the 21 network contracting offices and the COs and supervisors that work within them. VHA created three SAOs—East, West, and Central—to manage the contracting activities of six to eight VISNs each. SAOs review solicitations for most clinical contracts during their initial stages to ensure that all necessary provisions are in place prior to any competition or award. We found that all 12 contracts we reviewed from the four VAMCs we visited contained performance requirements consistent with VA acquisition policy. However, we found that 10 of the 12 contracts we reviewed lacked detailed descriptions of contractors’ performance requirements in one or more of the six categories we assessed. We analyzed the content of these contracts using six performance requirement categories we established through reviews of the VAAR, VA policies, and the standards of the leading hospital accreditation organization. (See fig. 2) We also found that the level of detail in contract performance requirements contained in the 12 contracts we reviewed varied both by the type of contract—CBOC contract, specialty care contract, or temporary clinical provider contract—and by the six performance requirement categories we assessed. (See table 1.) The CBOC contracts we reviewed were the most detailed, followed by specialty care contracts and temporary clinical provider contracts. CBOC contracts. Contracts for CBOCs generally contained the most detailed performance requirements. For example, all four of the CBOC contracts we reviewed had complete performance requirements for three of the six applicable categories—the type of provider or care, clinical practice standards, and medical record documentation. However, two of the four CBOC contracts—at the Minneapolis and Seattle VAMCs— lacked detail in one or more of the performance requirement categories we reviewed. For example, the Seattle VAMC CBOC contract was the only CBOC contract we reviewed that did not include a required set of operating hours for the contracted facility, which was a component we assessed within the access to care category. Specialty care contracts. The amount of detail in performance requirements within specialty care contracts varied across our four selected VAMCs. Overall, performance requirements in these contracts lacked specificity in key categories. For example, two of our selected specialty care contracts—for the Seattle and Minneapolis VAMCs—were for the services of cardiothoracic surgeons and had very similar results in our review, except for their descriptions of performance requirements within the clinical practice standards category. For this category, the Seattle VAMC cardiothoracic contract had detailed performance requirements, but the Minneapolis VAMC cardiothoracic contract did not contain a statement describing the provider’s responsibilities for the reporting of and response to adverse events and patient complaints, a component we assessed within the clinical practice standards category.In addition, the Nashville VAMC specialty care contract for the services of a psychiatrist had limited detail because it did not contain requirements for the clinical contractor’s privileges to be renewed at the beginning of each new contract term, and received a partial rating in the medical record documentation category because the contract did not contain performance requirements for the timely entry of information into VA’s electronic medical record. Temporary clinical provider contracts. We found that temporary clinical provider contracts included the least detailed performance requirements among the three contract types we reviewed. For example, the Lebanon VAMC temporary clinical provider contract for a gynecologist was missing descriptions of requirements for providers to undergo VA’s credentialing and privileging process, comply with The Joint Commission requirements that apply to gynecology, and enter relevant data into veterans’ electronic medical records. These specific requirements are components of three separate categories we reviewed—credentialing and privileging, clinical practice standards, and medical record documentation. In addition, the Seattle VAMC temporary clinical provider contract for a pharmacist was missing information on contractor requirements related to both the clinical practice standards and medical record documentation categories. According to VA officials, temporary clinical provider contracts are often written using a format that is designed to allow for shorter and faster contract award timeframes; however, this shorter format likely contributed to less complete performance requirement statements in the contracts we reviewed. We also found the level of detail in contract performance requirements varied significantly by performance requirement category, with a majority of reviewed contracts missing some component of the credentialing and privileging performance requirement category. Credentialing and privileging.