VA Health Care: Selected Credentialing Requirements at Seven	 
Medical Facilities Met, but an Aspect of Privileging Process	 
Needs Improvement (25-MAY-06, GAO-06-648).			 
                                                                 
The Department of Veterans Affairs (VA) is responsible for	 
determining that over 36,000 physicians working in its facilities
have the appropriate professional credentials and qualifications 
to deliver health care to veterans. To do this, VA credentials	 
and privileges physicians providing care at its medical 	 
facilities. In this report, GAO determined the extent to which	 
selected VA facilities complied with (1) four VA credentialing	 
requirements and five VA privileging requirements and (2) a	 
requirement to submit information on paid malpractice claims. GAO
also determined (3) whether VA has internal controls to help	 
ensure the accuracy of information used to renew clinical	 
privileges. GAO reviewed VA's policies, interviewed VA officials,
and randomly sampled 17 physician files at each of seven VA	 
medical facilities.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-648 					        
    ACCNO:   A54725						        
  TITLE:     VA Health Care: Selected Credentialing Requirements at   
Seven Medical Facilities Met, but an Aspect of Privileging	 
Process Needs Improvement					 
     DATE:   05/25/2006 
  SUBJECT:   Health care personnel				 
	     Hiring policies					 
	     Internal controls					 
	     Malpractice (medical)				 
	     Noncompliance					 
	     Personnel qualifications				 
	     Physicians 					 
	     Quality assurance					 
	     Reporting requirements				 
	     Veterans' medical care				 
	     Health policies					 

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GAO-06-648

     

     * Results in Brief
     * Background
          * VA's Credentialing Process
          * Privileging Process
     * Selected Physician Files at Medical Facilities Demonstrated
     * Not All Medical Facilities Submitted Paid Malpractice Claim
     * VA Has Not Established Internal Controls to Help Ensure the
     * Conclusions
     * Recommendations for Executive Action
     * Agency Comments and Our Evaluation
     * GAO Contact
     * Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

Report to the Chairman, Committee on Veterans' Affairs, House of
Representatives

United States Government Accountability Office

GAO

May 2006

VA HEALTH CARE

Selected Credentialing Requirements at Seven Medical Facilities Met, but
an Aspect of Privileging Process Needs Improvement

GAO-06-648

Contents

Letter 1

Results in Brief 5
Background 7
Selected Physician Files at Medical Facilities Demonstrated Compliance
with Four VA Credentialing and Four Privileging Requirements; a Fifth
Privileging Requirement Was Problematic 15
Not All Medical Facilities Submitted Paid Malpractice Claim Information in
a Timely Manner 18
VA Has Not Established Internal Controls to Help Ensure the Accuracy of
Medical Facilities' Privileging Information 21
Conclusions 22
Recommendations for Executive Action 23
Agency Comments and Our Evaluation 23
Appendix I Scope and Methodology 25
Appendix II Comments from the Department of Veterans Affairs 29
Appendix III GAO Contact and Staff Acknowledgments 33
Related GAO Products 34

Table

Table 1: Average Number of Months Taken by Three VA Medical Facilities to
Submit VA Medical Malpractice Claim Information to VA's Office of
Medical-Legal Affairs (as of December 2005) 20

Figures

Figure 1: Steps Taken in VA's Physician Credentialing Process 10
Figure 2: Steps Taken in VA's Physician Privileging Process 13
Figure 3: Medical Malpractice Claim Information Not Submitted by Three VA
Medical Facilities to the Office of Medical-Legal Affairs within 60 Days
19

Abbreviations

FSMB Federation of State Medical Boards NPDB National Practitioner Data
Bank VA Department of Veterans Affairs

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separately.

United States Government Accountability Office

Washington, DC 20548

May 25, 2006

The Honorable Steve Buyer Chairman Committee on Veterans' Affairs House of
Representatives

Dear Mr. Chairman:

The Department of Veterans Affairs (VA) has over 36,000 physicians working
at more than 1,300 facilities in its health care system. To help ensure
the quality of the health care these physicians deliver and the safety of
veterans, VA is responsible for determining that its physicians have the
appropriate professional credentials and clinical experience to provide
health care to VA's patients.1 To do this, VA credentials and privileges
physicians providing care at VA medical facilities. Credentialing is the
process of verifying that a physician's professional credentials, such as
licensure, education, and training, are valid and meet VA's requirements
for employment. Privileging is the process for determining-based in part
on a physician's credentials-which health care services a physician should
be allowed to provide to VA patients without supervision.2 These health
care services are known as a physician's clinical privileges. Physicians
are granted initial clinical privileges when they begin their employment
at a VA medical facility. Physicians' professional credentials and
clinical privileges must be reviewed and renewed at least every 2 years.3
VA's credentialing and privileging policy describes the information that
VA medical facility officials are required to review and verify in order
to credential and grant clinical privileges to VA physicians. In addition
to the requirements outlined in VA's credentialing and privileging policy,
medical facility officials are required to submit information to VA
headquarters on any VA physicians who are involved in paid VA medical
malpractice claims. This malpractice information is used by VA
headquarters to make decisions about the appropriateness of the care
delivered to veterans and should be used by medical facility officials
when making decisions about the clinical privileges to grant physicians.

1We have performed other work related to this subject. See Related GAO
Products listed at the end of this report.

2Health care services could include, for example, surgical procedures and
administering anesthesia.

3Physicians' clinical privileges are also reviewed whenever a physician
requests that a health care service be added or removed from the list of
approved clinical privileges. This may occur before the 2-year renewal
period.

You expressed interest in the credentialing and privileging of VA
physicians and how this helps VA ensure the delivery of safe care to
veterans. In response to your request, we (1) determined the extent to
which selected VA medical facilities complied with four of VA's
credentialing requirements and five of VA's privileging requirements in
relation to individual physicians, and (2) determined the extent to which
selected VA medical facilities complied with the requirement to submit
information to VA headquarters on paid VA medical malpractice claims
involving VA physicians. Also, during the course of our work, we learned
about a medical facility where inaccuracies in privileging information
resulted in 106 physicians providing care to veterans in the facility
without the required clinical privileges. According to VA officials, the
individual responsible for privileging data inappropriately changed the
privileging dates for some of these physicians to a later date in order to
delay work needed to complete the credentialing and privileging
requirements on these physicians. This led us to add to our review a
reporting objective related to internal controls. Specifically, in this
report we also (3) determined whether VA has internal controls to help
ensure the accuracy of information medical facilities use to renew
physicians' clinical privileges.

To determine the extent to which selected VA medical facilities complied
with four of VA's credentialing requirements and five of VA's privileging
requirements in relation to individual physicians, we reviewed VA's
policies to identify the requirements that VA medical facility officials
must follow when credentialing and granting clinical privileges to
physicians. We selected four of VA's credentialing requirements for review
because they are requirements that-unlike others-address information about
physicians that can change or be updated with new information
periodically. As a result, VA requires that this information be verified
by medical facility officials when a physician initially applies for
employment at VA and at least every 2 years thereafter. Other VA
credentialing requirements are not subject to change or updating and are
required by VA to be verified when the physician initially applies for
employment.4 Under the four requirements we reviewed, VA medical facility
officials must

           1. verify that all state medical licenses held by physicians are
           valid;
           2. query the Federation of State Medical Boards (FSMB) database to
           determine whether physicians had disciplinary action taken against
           any of their licenses, including expired licenses;
           3. verify information provided by physicians on their involvement
           in medical malpractice claims at a VA or non-VA facility; and
           4. query the National Practitioner Data Bank (NPDB) to determine
           whether a physician was reported to this data bank because of
           involvement in VA or non-VA paid medical malpractice claims,
           display of professional incompetence, or engagement in
           professional misconduct.

Of the privileging requirements in VA's credentialing and privileging
policy, we selected four requirements that VA identifies as general
privileging requirements. In addition, we selected another privileging
requirement about the use of individual performance information because of
its importance in the renewal of clinical privileges. The five VA
privileging requirements we selected are

           1. verify that all state medical licenses held by physicians are
           valid;
           2. verify physicians' training and experience;
           3. assess physicians' clinical competence and health status;
           4. consider any information provided by a physician related to
           medical malpractice allegations or paid claims, loss of medical
           staff membership, loss or reduction of clinical privileges at a VA
           or non-VA facility, or any challenges to a physician's state
           medical license; and
           5. use information on a physician's performance when making
           decisions about whether to renew the physician's clinical
           privileges.

4Physicians may also possess credentials that VA does not require to work
in a VA facility, such as a Drug Enforcement Administration certificate,
which allows a physician practicing outside of a VA facility to prescribe
controlled substances. If a physician does have these other credentials,
then VA requires medical facility officials to verify these credentials
since they may change or be updated periodically.

Two of the five privileging requirements-verify all state medical licenses
and consider medical malpractice information-are also VA credentialing
requirements we reviewed.

To determine the extent to which selected VA medical facilities complied
with four of VA's credentialing requirements and five of VA's privileging
requirements, we conducted site visits to seven VA medical facilities that
were chosen based on the diversity of their size and geographic location.
The medical facilities are located in Boise, Idaho; Kansas City, Missouri;
Las Vegas, Nevada; Lexington, Kentucky; Martinsburg, West Virginia; Miami,
Florida; and San Antonio, Texas. For each of the seven medical facilities,
VA officials provided a list of medical facility physicians grouped by
their clinical specialty. Using this list, at each medical facility we
randomly selected 17 physicians and obtained files with their
credentialing and privileging information. Our sample included physicians
working in VA medical facilities full-time and part-time, through a
contract,5 or without direct compensation from VA. In some cases, these
physicians also worked at non-VA medical facilities. Eight of the 17
physician files at each medical facility represent eight clinical
specialties that are offered at most VA medical facilities:
anesthesiology, gastroenterology, neurology, oncology, ophthalmology,
orthopedics, radiology, and urology. Four of the 17 represent general
surgery and internal medicine and 5 of the 17 had no specialty identified
on the list provided by VA. To determine whether the files we reviewed
demonstrated compliance with the four VA credentialing requirements and
VA's privileging requirements at each of the seven VA medical facilities,
we reviewed paper copy credentialing and privileging files for our sample
of physicians to determine whether these files included documentation
demonstrating that medical facility officials had complied with the
credentialing and privileging requirements. We also reviewed credentialing
information on these physicians stored in VetPro, a Web-based
credentialing system VA implemented in March 2001. Based on the sample of
physician files we reviewed at each of the seven medical facilities, we
can discuss a medical facility's compliance for the physician files we
reviewed; we cannot draw conclusions about the remaining physician files
at the medical facilities we visited or about the compliance of other VA
medical facilities. In collecting information on the credentialing and
privileging requirements from physician files at each facility, we
employed standard data collection techniques to ensure the accuracy and
reliability of the data used in this report.

5VA medical facilities can contract with local or national companies in
order to obtain physician services.

Finally, we included in our review a requirement that is related to the
privileging process. Under this requirement, medical facility officials
must submit to VA's Office of Medical-Legal Affairs any information on VA
practitioners, including physicians, who were involved in a paid VA
medical malpractice claim. The Office of Medical-Legal Affairs determines
whether the physicians involved in these claims delivered substandard care
to veterans.6 We collected information about the extent to which each of
the seven medical facilities in our review submitted malpractice
information to the Office of Medical-Legal Affairs.

To determine whether VA has internal controls to help ensure the accuracy
of information medical facilities use to renew physicians' clinical
privileges, we interviewed the director of VA's credentialing and
privileging program, as well as other VA headquarters and medical facility
officials. We identified the internal controls VA has in place for its
privileging process and, using GAO's standards for internal controls in
the federal government, determined whether these controls are adequate.7
For a complete description of our scope and methodology, see appendix I.
We conducted our work from July 2005 to May 2006 in accordance with
generally accepted government auditing standards.

                                Results in Brief

The physician files we reviewed at the seven VA medical facilities
demonstrated compliance with the four credentialing requirements we
reviewed and four of the five privileging requirements. The files we
reviewed showed that compliance with the fifth privileging requirement-to
use information on a physician's performance in making privileging
decisions-was problematic at six of the seven VA medical facilities we
visited. At these six medical facilities, officials obtained this
information from their facility's quality assurance program. In general,
information that is collected as part of VA's quality assurance program is
confidential according to federal law, and VA by policy prohibits the use
of such information in connection with privileging. This information is
protected, in large part, to encourage physicians to participate in
quality assurance programs by reporting and discussing openly the causes
of adverse patient events to help prevent such events from occurring in
the future. According to VA officials, if quality assurance information is
used outside of a facility's quality assurance program, it could be
available for other purposes, including litigation. VA has not provided
guidance to help medical facilities find alternative ways to efficiently
collect performance information, outside of a facility's quality assurance
program, that could be used in the renewal of clinical privileges. At the
seventh medical facility, officials did not use performance information to
renew clinical privileges, as required.

6In this report, determinations of substandard care may also include
determinations of professional incompetence or professional misconduct.

7GAO, Internal Control Management and Evaluation Tool, GAO-01-1008G
(Washington, D.C.: August 2001).

Three of the seven medical facilities we visited did not meet the
requirement to submit, within 60 days, information on paid VA medical
malpractice claims involving their practitioners, including physicians, to
VA's Office of Medical-Legal Affairs. This office reviews the claims
information and makes a determination of whether practitioners, including
physicians, involved in the claims delivered substandard care to veterans.
If it is determined that the physician delivered substandard care to
veterans, the medical facility must report the physician to NPDB. When VA
medical facilities do not submit all relevant information to the Office of
Medical-Legal Affairs in a timely manner, facility officials make
privileging decisions without the advantage of determinations on whether
VA physicians delivered substandard care. In addition, substandard care
determinations that are required to be reported to the NPDB go unreported
or reporting is delayed when VA medical facilities do not send information
in a timely manner to the Office of Medical-Legal Affairs. This delay or
lack of reporting to NPDB prevents other VA and non-VA facilities where
the physician may also practice from having complete information on the
physician's medical malpractice history.

VA has not required its medical facilities to establish internal controls
to help ensure that privileging information managed by medical staff
specialists-employees responsible for obtaining and verifying the
information used in the credentialing and privileging processes-is
accurate. One facility we visited did not identify 106 physicians whose
privileging process had not been completed by facility officials for at
least 2 years because of inaccurate information provided by the facility's
medical staff specialist. As a result, these physicians were practicing at
the facility without current clinical privileges. Subsequent to our visit,
this facility implemented internal controls to reduce the risk of a
similar situation occurring in the future. During our site visits, we did
not identify any medical facilities that had established such internal
controls. Without accurate information on the privileges that have been
granted to physicians and the dates for renewing those privileges, VA
medical facility officials will not know if they have failed to renew
clinical privileges for any of their physicians in accordance with VA
policy.

To better ensure that VA physicians are qualified to deliver care safely
to veterans, we recommend that VA provide guidance to medical facilities
on how to collect individual physician performance information in
accordance with VA's credentialing and privileging policy to use in the
renewal of physicians' clinical privileges, and that VA enforce the
requirement that medical facilities submit information on paid VA medical
malpractice claims to VA's Office of Medical-Legal Affairs within 60 days
after being notified that the claim is paid. Additionally, we recommend
that VA instruct its medical facilities to establish internal controls to
ensure the accuracy of their privileging information. In commenting on a
draft of this report, VA agreed with our findings and conclusions and
concurred with our recommendations. VA also provided an action plan to
address the three recommendations.

                                   Background

Physicians who work at VA medical facilities are required to hold at least
one current and unrestricted state medical license. Current and
unrestricted licenses are those in good standing in the states that issued
them, and licensed physicians may hold licenses from more than one state.
State medical licenses are issued by state licensing boards, which
generally establish state licensing requirements governing their licensed
practitioners.8 To keep a license current, physicians must renew their
licenses before they expire and meet renewal requirements established by
state licensing boards, such as continuing education. Renewal procedures
and requirements vary by state. When state licensing boards discover
violations of licensing practices-such as the abuse of prescription drugs
or the provision of substandard care-that result in adverse health
effects, they may place restrictions on licenses or revoke them.
Restrictions issued by a state licensing board can limit or prohibit a
physician from practicing in that particular state. Generally, state
licensing boards maintain a database that contains information on any
restrictions or revocations of physicians' licenses.

8State licenses are issued by offices in states, territories, or the
District of Columbia, collectively referred to as state licensing boards.

VA requires its medical facility officials to credential and privilege
facility physicians periodically in order to work at VA. VA physicians
must be credentialed and privileged prior to their initial appointment to
a facility's medical staff and then again at least every 2 years when they
must reapply for a position on the facility's medical staff. The latter is
known as the process of reappointment.

VA's Credentialing Process

Prior to working at VA, physicians initiate the credentialing process for
their initial appointment by completing VA's application process, which
includes entering into VetPro information used by VA medical facility
officials in the credentialing process. Among the credentialing
information that VA requires physicians enter into VetPro, for their
initial appointment, is information on all the medical licenses they have
ever held and the states where they have obtained these licenses,
including any licenses they have held that have expired. For their
reappointments, physicians must update this credentialing information in
VetPro.

Once physicians enter their credentialing information into VetPro, a
facility's medical staff specialist-an employee who is responsible for
obtaining and verifying the information used in the credentialing and
privileging processes-performs a data check on the information to be sure
that all required information has been entered. In general, the medical
staff specialist at each VA medical facility manages the accuracy of
VetPro's credentialing data. The medical staff specialist verifies, with
the original source of the information, the accuracy of the credentialing
information entered by the physicians. This type of check is known as
primary source verification. For example, the medical staff specialist
contacts state licensing boards in order to verify that physicians' state
medical licenses are valid and unrestricted.

Medical staff specialists are required, at initial appointment and at
reappointment, to verify the status of the state medical licenses
physicians disclose to VA by listing them in VetPro. The medical staff
specialists can obtain information on the status of physicians' state
medical licenses by accessing the information on state licensing boards'
Web sites or by contacting the boards directly.

At initial appointment only, VA requires medical staff specialists to
query FSMB, which contains information from state licensing boards. This
query enables officials to determine all the state medical licenses a
physician has ever held, including those not disclosed by a physician to
VA, and whether a physician has had any disciplinary actions taken against
these licenses. VA does not require this query at reappointment because VA
headquarters regularly receives reports from FSMB on any VA physician
whose name appears on FSMB's list, indicating that disciplinary action has
been taken against the physician's state medical license. When VA
headquarters receives a report from FSMB, it notifies the appropriate VA
medical facility.

VA's credentialing process requires VA medical staff specialists to verify
medical malpractice claims at initial appointment and at reappointment.
These claims may be verified by contacting a court of jurisdiction or the
insurance company involved in the medical malpractice claim, or by
obtaining a statement of claims status from the attorney representing the
physician in the medical malpractice claim. In addition, VA requires
medical staff specialists to query NPDB, which contains reports by state
licensing boards, hospitals, and other health care entities on
unprofessional behavior on the part of physicians or adverse actions taken
against them. This query enables officials to determine whether physicians
fully disclosed to VA any involvement they might have had in paid medical
malpractice claims.9 Once a physician's credentialing information has been
verified, the medical staff specialist sends the information to the
physician's supervisor, who is known as a clinical service chief.10 The
clinical service chief reviews this information along with the physician's
privileging information. Figure 1 illustrates VA's credentialing process.

9NPDB includes information on medical malpractice claims that are paid,
but does not include information on ongoing claims.

10Clinical services may include surgery, medicine, and radiology.

Figure 1: Steps Taken in VA's Physician Credentialing Process

Note: This credentialing process takes place at VA medical facilities.

Privileging Process

At the same time physicians enter credentialing information into VetPro,
they complete a written request for clinical privileges. The facility
medical staff specialist provides the physician's clinical service chief
with the requested clinical privileges and information that indicates that
the credentialing information entered by the physician into VetPro has
been verified with the appropriate primary sources. The medical staff
specialist also provides the physician's clinical service chief with
information on the physician's ability to perform the clinical privileges
requested, including whether the physician has had a physical examination
performed for initial appointment. For reappointment, documentation is
required by another physician stating that the physician is able to
perform both physically and mentally the clinical privileges requested. In
addition, the medical staff specialist provides the clinical service chief
with information on medical malpractice allegations or paid claims, loss
of medical staff membership, loss or reduction of clinical privileges, or
any challenges to the physician's state medical licenses.

The requested clinical privileges are reviewed by a clinical service
chief, who recommends whether a physician should be appointed or
reappointed to the facility's medical staff and which clinical privileges
should be granted. When deciding to recommend clinical privileges, a
clinical service chief considers whether the physician has the appropriate
professional credentials, training, and work experience to perform the
privileges requested. For reappointment only, a clinical service chief is
to consider observations of the physician's delivery of health care to
veterans, and VA's policy requires that information on a physician's
performance, such as a physician's surgical complication rate, be used
when deciding whether to renew a physician's clinical privileges. Based on
the clinical service chief's observations and the physician's performance
information, the clinical service chief recommends that clinical
privileges previously granted by the facility remain the same, be reduced,
or revoked, and whether newly requested privileges should be added.11

Clinical service chiefs forward their recommendations and the reasons for
the recommendations to the next level of a medical facility's privileging
review process, which may be a professional standards board or a medical
executive committee.12 A medical facility professional standards board or
the medical executive committee reviews the recommendations of the
clinical service chief and recommends to the facility director whether the
physician should be appointed to the facility's medical staff and which
clinical privileges should be granted to the physician. The 2-year time
period for renewal of clinical privileges and reappointment to the medical
staff begins on the date that the privileges are approved by the medical
facility's director. The list of approved clinical privileges with the
date of approval is maintained in paper copy files at VA medical
facilities and the initial appointment or reappointment date is entered
into VetPro. Figure 2 illustrates VA's privileging process.

11Reduction of privileges may include restricting or prohibiting a
physician from performing certain procedures or prescribing certain
medicines. Revocation of privileges refers to the permanent loss of all
clinical privileges at that facility.

12At some VA medical facilities, the professional standards board and the
medical executive committee represent the medical staff, have the same
members, and perform the same functions so are considered to be one
committee. If the committees are separate, the professional standards
board is generally comprised of three to five physician peers and the
medical executive committee is generally comprised of all facility
clinical service chiefs.

Figure 2: Steps Taken in VA's Physician Privileging Process

Note: This privileging process takes place at VA medical facilities.

According to VA's policy and a VA memorandum, information concerning
individual physician performance that is used as part of the privileging
process to either reduce, revoke, or support13 granting clinical
privileges must be collected separately from a medical facility's quality
assurance program.14 VA's policy is based on a federal law that restricts
the disclosure of documents produced in the course of VA's quality
assurance program.15 In general, documents created in connection with such
a program are confidential and may not be disclosed except in limited
circumstances.16 Individuals who willfully disclose documents that they
know are protected quality assurance documents are subject to fines up to
$20,000. Although the law states that it is not intended to limit the use
of documents within VA, VA's policy expressly prohibits the use of such
documents in connection with the privileging process. VA's use of separate
information sources for quality assurance and privileging decisions is
intended to maintain the confidential status of documents produced in
connection with quality assurance programs. According to VA, the
confidentiality of individual performance information helps ensure
provider participation, including physicians, in a medical facility's
quality assurance program by encouraging providers to openly discuss
opportunities for improvement in provider practice without fear of
punitive action.

VA has another requirement that is related to the renewal of physicians'
clinical privileges. Medical facility officials are required to submit to
VA's Office of Medical-Legal Affairs information on malpractice claims.
This information must be submitted within 60 days after being notified
about a paid malpractice claim. The Office of Medical-Legal Affairs is
responsible for convening a panel of clinicians to determine whether a VA
facility physician involved in the claim delivered substandard care. The
Office of Medical-Legal Affairs notifies the medical facility director of
the results of its review. If it is determined that the physician
delivered substandard care to veterans, the medical facility must report
the physician to NPDB within 30 days of being notified of the decision. VA
medical facility officials also would use this determination to decide
whether to grant clinical privileges to the physician involved in the VA
medical malpractice claim.

13Support granting clinical privileges means that the clinical privileges
previously held by the physician will be maintained as well as adding
newly requested clinical privileges.

14VA requires its medical facilities to have a quality assurance program.
In general, the VA quality assurance program consists of specified
systematic health care reviews carried out by or for VA for the purpose of
improving the quality of medical care or the utilization of health care
resources in VA facilities. See 38 C.F.R. S: 17.500 (2005). These programs
collect data on various clinical process and outcome measures involving
physicians and other types of practitioners. The measures may include a
surgeon's complication rate or a physician's prescribing of medications.
Medical facility officials use these measures to look for undesirable
patterns and trends in performance.

1538 U.S.C. S: 5705 (2000).

16See Department of Veterans Affairs, VHA Handbook 1100.19 (Mar. 6, 2001).

Selected Physician Files at Medical Facilities Demonstrated Compliance with Four
    VA Credentialing and Four Privileging Requirements; a Fifth Privileging
                          Requirement Was Problematic

The physician files we reviewed at the seven VA medical facilities
demonstrated compliance with the four credentialing requirements we
selected for review and four of five VA privileging requirements. The
files we reviewed showed that six of the seven medical facilities had
problems complying with a fifth privileging requirement-to use information
on a physician's performance when renewing clinical privileges. Compliance
with that requirement was problematic largely because in their privileging
decisions facility officials used performance information obtained from
their facility quality assurance program. Information contained in
documents created in the course of a VA quality assurance program is
protected by VA policy that expressly prohibits the agency from using that
documentation in the privileging process. VA has not provided guidance to
help facilities find alternative ways to efficiently collect performance
information, outside of a facility's quality assurance program, that could
be used in privileging decisions. At the seventh medical facility,
officials did not use performance information to renew clinical
privileges, as required.

Physician files at all seven medical facilities demonstrated compliance
with the four credentialing requirements we selected for review. In all
cases, the VA facility medical staff specialists contacted state licensing
boards-a form of primary source verification-to ascertain the status of
the state medical licenses held and disclosed by their physicians.17 Based
on the physician files we reviewed, medical staff specialists also queried
the FSMB database as required to obtain additional information on the
status of physicians' medical licenses, including those that may not have
been disclosed by physicians. Medical staff specialists complied with the
requirement to contact primary sources, such as courts of jurisdiction, to
verify information on involvement in medical malpractice claims, including
ongoing claims, disclosed by physicians. Additionally, in all cases
medical staff specialists queried NPDB to identify those physicians who
have been involved in paid medical malpractice claims, including any
physicians who failed to disclose involvement in such claims.

17VA medical facility officials may also perform primary source
verification of physicians' licenses by querying a state licensing board's
Web site for information on the licenses.

The physician files at the seven medical facilities also demonstrated
compliance with four of the five VA privileging requirements we reviewed.
We found that medical staff specialists contacted state licensing boards
to verify the status of all state medical licenses held by their
physicians and to determine whether any of these licenses had any action
taken against them. Medical staff specialists also used primary sources to
verify that physicians had the necessary training and experience to
deliver health care and perform the clinical privileges they requested. We
found that after medical staff specialists performed their verification,
clinical service chiefs reviewed this information as required, along with
information on physicians' health status and information disclosed by the
physicians about their involvement in medical malpractice allegations or
cases in which claims were paid.

While we found evidence demonstrating compliance with four of the five
privileging requirements, the files we reviewed also showed that there
were problems complying with the fifth privileging requirement-to use
information on a physician's performance in making privileging decisions.
VA requires that during the renewal of a physician's clinical privileges,
VA clinical service chiefs use information on a physician's performance to
support, reduce, or revoke the clinical privileges the physician has
requested. However, the performance information cannot be collected as
part of a medical facility's quality assurance program. Although medical
facility clinical service chiefs must use performance information in
making decisions about renewal of clinical privileges, VA has not provided
guidance on how facility officials can obtain such information in
accordance with VA policy-that is, outside of a quality assurance program.

VA's credentialing and privileging policy states that facilities cannot
use information collected as part of a facility's quality assurance
program to reduce or revoke the clinical privileges requested by
physicians, but the initial policy guidance was silent about the use of
this information to support granting the clinical privileges requested by
physicians. Officials at six medical facilities told us that they used
quality assurance information to support the granting of clinical
privileges requested by their physicians, but collected all or most of
this information through facility quality assurance programs. In contrast,
facility officials at one medical facility did not use individual
physician performance information to renew physicians' clinical
privileges.

VA issued a directive in September 2004 and a memorandum in October 2004
which VA headquarters officials told us were intended to clarify for
medical facility officials the circumstances under which physician
performance information could not be used in the credentialing and
privileging process. The September 2004 directive explained the specific
types of information that are protected, such as information that
identifies an individual physician, and the October 2004 memorandum
explained that information on a physician's performance that is collected
as part of a medical facility's quality assurance program could not be
used to support, reduce, or revoke a physician's clinical privileges. The
directive and the memorandum did not identify the ways in which medical
facility officials could efficiently collect physician performance
information outside of a facility's quality assurance program that would
provide information for renewing physicians' clinical privileges.
According to facility officials, collecting the same information
twice-once for quality assurance and once for privileging-is
resource-intensive and limits the time they have to address other issues.

Without guidance from VA, officials from four facilities told us that they
do not know how to collect this information in accordance with VA's
policy. Facility officials from two other medical facilities said they
believed that they were complying with VA's requirement because they
stored performance information in such a way that the identity of
individual physicians could not be easily retrieved. Quality assurance
staff at these two medical facilities assigned a code to each physician
and filed the performance information by assigned code rather than under
an individual physician's name. These staff could then retrieve an
individual physician's performance information using the code. At one
facility, quality assurance staff said their regional legal counsel told
them that the confidentiality of the information would be maintained with
this type of coding system and would allow them to use the information to
renew physicians' clinical privileges. However, according to both VA
headquarters legal counsel and the director of VA's credentialing and
privileging program, coding quality assurance information in this manner
and using it to renew clinical privileges could make this information
available for other purposes, including litigation, and therefore does not
comply with VA policy. A VA headquarters official told us that the medical
facilities need further education on how to collect individual physician
performance information that can be used in the renewal of physicians'
clinical privileges.

  Not All Medical Facilities Submitted Paid Malpractice Claim Information in a
                                 Timely Manner

We found that three of the seven VA medical facilities we visited did not
comply with the requirement to submit paid VA medical malpractice claim
information in a timely manner.18 These facilities had not submitted
information on 52 paid medical malpractice claims that may have involved
their physicians to VA's Office of Medical-Legal Affairs within the 60-day
required time frame for information requested as of December 2005.19 See
figure 3 for the number of paid VA medical malpractice claims for which
information was not submitted in a timely manner by the three facilities
from 2001 through 2005.

18At the time of our review, the remaining four VA facilities did not have
any medical malpractice claim information that had not been submitted
within VA's 60-day time frame.

19VA medical malpractice claims may involve physicians or another type of
licensed health care practitioner, such as a nurse.

Figure 3: Medical Malpractice Claim Information Not Submitted by Three VA
Medical Facilities to the Office of Medical-Legal Affairs within 60 Days

Note: We considered claim information submitted 14 days after the 60-day
time frame to be on time, while information submitted 15 or more days
after the 60-day time frame, we considered to be delinquent.

The Office of Medical-Legal Affairs is responsible for reviewing
information on paid VA medical malpractice claims submitted by VA medical
facilities by forming panels of clinicians to determine whether VA
practitioners, including physicians, delivered substandard care to
veterans in these claims.20 When VA medical facilities do not submit all
relevant claim information to the Office of Medical-Legal Affairs,
facility clinical service chiefs may make privileging decisions without
the knowledge of physician peer determinations on whether VA physicians
delivered substandard care to veterans. In addition, substandard care
determinations that are required to be reported by facility officials to
the NPDB go unreported or reporting is delayed when VA medical facilities
do not send claim information in a timely manner to the Office of
Medical-Legal Affairs. This delay or lack of reporting to NPDB prevents
other VA and non-VA facilities where the physician may also practice from
having complete information on the physician's malpractice history. For
example, at one facility we visited, we found that from 2001 through 2005,
information on 21 of the facility's 26 paid medical malpractice claims had
not been submitted within the 60-day time frame to VA's Office of
Medical-Legal Affairs.21 Moreover, on average this medical facility took
30 months to submit information to VA's Office of Medical-Legal Affairs,
whereas the other two facilities averaged about 5 months to submit
information. See table 1 for the average number of months it took for
these VA medical facilities to submit paid VA medical malpractice claim
information to VA's Office of Medical-Legal Affairs.

20The panel must include at least one reviewer who is a member of the
profession of the practitioner under review.

Table 1: Average Number of Months Taken by Three VA Medical Facilities to
Submit VA Medical Malpractice Claim Information to VA's Office of
Medical-Legal Affairs (as of December 2005)

                 Average number of months to submit information on VA medical
                                      malpractice claims
Calendar year           Facility A          Facility B          Facility C 
2001                             4                  57                   3 
2002                             3                  47                   6 
2003                             9                  34                   7 
2004                             6                   3                   4 
2005                             3                   3                   6 

Source: GAO analysis of VA data.

21As of March 31, 2006, this medical facility had sent all delinquent
medical malpractice claims to VA's Office of Medical-Legal Affairs.

VA Has Not Established Internal Controls to Help Ensure the Accuracy of Medical
                      Facilities' Privileging Information

VA has not required its medical facilities to establish internal controls
to help ensure that privileging information managed by medical staff
specialists is accurate. One facility we visited did not identify 106
physicians whose privileging process had not been completed by facility
officials for at least 2 years because of inaccurate information provided
by the facility's medical staff specialist. As a result, these physicians
were practicing at the facility without current clinical privileges.
Subsequent to our visit, this facility implemented internal controls to
reduce the risk of a similar situation occurring in the future. During our
site visits, we did not identify any medical facilities that had
established such internal controls. Without accurate information on the
privileges that have been granted to physicians and the dates for renewing
those privileges, VA medical facility officials will not know if they have
failed to renew clinical privileges for any of their physicians in
accordance with VA policy.

For at least 2 years, one VA medical facility did not identify 106
physicians whose privileging process had not been completed by facility
officials because of inaccurate information provided by the facility's
medical staff specialist. According to facility officials, the medical
staff specialist changed the reappointment dates on some of these
physicians to a later date in order to delay work she needed to perform to
complete the credentialing and privileging requirements on these
physicians. For other physicians, the medical staff specialist removed the
physicians' names from the VetPro database so that the physicians would
not show up on VetPro lists as needing to be reappointed to the facility's
medical staff. Facility officials further told us that the medical staff
specialist changed appointment dates and removed names from VetPro in
order to conceal the fact that these physicians no longer had current
privileges. As a result, these physicians were practicing at the facility
without current clinical privileges. The clinical service chiefs, members
of the professional standards board and the medical executive committee,
and the facility director were unaware that these physicians were working
without current clinical privileges, and learned of the problem only after
it was brought to their attention by an individual newly hired to help the
facility's medical staff specialist. Medical facility officials told us
that after becoming aware of the problem, they confronted the medical
staff specialist responsible for the data inaccuracies, who then resigned.
Medical facility officials then began to check the clinical privileges of
all of their physicians and identified inaccuracies in the privileging
information for 106 physicians. After reviewing the 106 physician files,
facility officials told us they did not find any problems that would have
warranted the physicians' removal from the facility's medical staff or
that placed veterans at risk.

Although this medical facility did not identify any problems with the 106
physicians' clinical privileges or with their clinical competence to
deliver care to veterans, the potential exists for problems to occur at
other VA medical facilities. During our site visits, we did not identify
any facilities that had established internal controls that would help
ensure the accuracy of the information used to renew clinical privileges.
A VA headquarters official told us that there is no requirement for VA
medical facilities to have such internal controls in place. While VA does
not require facilities to establish these internal controls, the facility
that identified inaccuracies in its privileging information subsequently
implemented internal controls to reduce the risk of a similar situation
occurring in the future. Facility officials have taken steps to help
ensure that a similar situation does not recur. For example, the facility
now provides each facility clinical service chief with a list of
physicians on a quarterly basis and asks the clinical service chiefs to
verify that the listed physicians are currently working at the medical
facility and to identify those physicians working at the facility who are
not on the list. This allows medical facility officials to know if
physicians have been inappropriately deleted from VetPro and are working
at the facility without current clinical privileges. Without internal
controls such as this for their privileging information, VA's medical
facilities may not know whether they have allowed some of their physicians
to practice with expired privileges.

                                  Conclusions

VA is responsible for ensuring that its physicians are qualified to
deliver health care to veterans at VA medical facilities and has
requirements in place that medical facility officials are to use to help
ensure that physicians meet these qualifications. VA medical facilities we
visited complied with the four VA credentialing requirements we reviewed
and all but one of five privileging requirements-to use information on a
physician's performance when renewing clinical privileges. While officials
at six of the seven facilities we visited made an attempt to comply with
VA's requirement to use performance information, these officials deviated
from VA's policy by collecting all or most of the performance information
through their facilities' quality assurance programs. This occurred, in
part, because VA has not provided guidance on how to collect this
information in accordance with VA's policy. In addition, VA medical
facility officials did not have all the information they needed on
physicians involved in paid VA medical malpractice claims, because the
facilities had not submitted such information to VA's Office of
Medical-Legal Affairs in a timely manner. This could have placed veterans
at risk of receiving care from physicians who did not have adequate
clinical skills. Finally, VA has not required its medical facilities to
establish internal controls to help ensure the accuracy of their
privileging information. Until VA requires its medical facilities to
establish internal controls to ensure the accuracy of privileging
information, facilities are at risk for allowing physicians to practice
with expired clinical privileges.

                      Recommendations for Executive Action

To better ensure that VA physicians are qualified to deliver care safely
to veterans, we recommend that the Secretary of Veterans Affairs direct
the Under Secretary for Health to take the following three actions:

           o  provide guidance to medical facilities on how to collect
           individual physician performance information in accordance with
           VA's credentialing and privileging policy to use in medical
           facilities' privileging processes,
           o  enforce the requirement that medical facilities submit
           information on paid VA medical malpractice claims to VA's Office
           of Medical-Legal Affairs within 60 days after being notified that
           the claim is paid, and
           o  instruct medical facilities to establish internal controls to
           ensure the accuracy of their privileging information.

           In commenting on a draft of this report, VA agreed with our
           findings and conclusions and concurred with our recommendations.
           VA also provided an action plan to address the three
           recommendations. VA acknowledged that we identify a challenge
           faced not only by VA facilities, but by all health care
           facilities, to incorporate physician-specific performance
           information into the credentialing and privileging processes. In
           addition, VA recognized the need to improve facility compliance
           with submitting information on paid VA medical malpractice claims
           to the Office of Medical-Legal Affairs in a timely manner.
           Further, VA agreed that internal controls are needed to ensure the
           accuracy of information used to renew physicians' clinical
           privileges and has begun the work necessary to establish these
           internal controls at all VA facilities. VA also provided details
           of actions it plans to take to implement the three recommendations
           in the draft report. VA's written comments are reprinted in
           appendix II.

           As agreed with your office, unless you publicly announce its
           contents earlier, we plan no further distribution of this report
           until 30 days after its date. We will then send copies of this
           report to the Secretary of Veterans Affairs and other interested
           parties. We also will make copies available to others upon
           request. In addition, the report will be available at no charge at
           the GAO Web Site at http://www.gao.gov .

           If you or your staff have any questions about this report, please
           contact me at (202) 512-7101 or [email protected] . Contact points
           for our Offices of Congressional Relations and Public Affairs may
           be found on the last page of this report. GAO staff members who
           made major contributions to this report are listed in appendix
           III.

           Sincerely yours,

           Laurie E. Ekstrand Director, Health Care

           To determine the extent to which selected Department of Veterans
           Affairs' (VA) medical facilities complied with VA's credentialing
           and privileging requirements, we reviewed policies, procedures,
           and guidance on VA's credentialing and privileging processes. We
           also interviewed the director of VA's credentialing and
           privileging program, as well as officials responsible for
           credentialing and privileging at the VA medical facilities we
           visited. We selected four credentialing requirements for review
           because they are requirements that-unlike others-address
           information about physicians that can change or be updated with
           new information periodically. As a result, VA requires that this
           information be verified by facility officials at least every 2
           years. Other credentialing requirements, such as where a physician
           attended medical school or previous employment history, are not
           subject to change or updating and are required by VA to be
           verified when the physician initially applies for employment. The
           four credentialing requirements are

                        1. verify that all state medical licenses held by
                        physicians are valid;
                        2. query the Federation of State Medical Boards
                        (FSMB) database to determine whether physicians had
                        disciplinary action taken against any of their
                        licenses, including expired licenses;
                        3. verify information provided by physicians on their
                        involvement in medical malpractice claims at a VA or
                        non-VA medical facility; and
                        4. query the National Practitioner Data Bank (NPDB)
                        to determine whether a physician was reported to this
                        data bank because of involvement in VA or non-VA paid
                        medical malpractice claims, display of professional
                        incompetence, or engagement in professional
                        misconduct.

           Of the privileging requirements in VA's credentialing and
           privileging policy, we selected four requirements that VA
           identifies as general privileging requirements. In addition, we
           selected another privileging requirement about the use of
           individual performance information because of its importance in
           the renewal of clinical privileges. The five VA privileging
           requirements we selected are

                        1. verify that all state medical licenses held by
                        physicians are valid;
                        2. verify physicians' training and experience;
                        3. assess physicians' clinical competence and health
                        status;
                        4. consider any information provided by a physician
                        related to medical malpractice allegations or paid
                        claims, loss of medical staff membership, loss or
                        reduction of clinical privileges at a VA or non-VA
                        facility, or any challenges to a physician's state
                        medical license; and
                        5. use information on a physician's performance when
                        making decisions about whether to renew the
                        physician's clinical privileges.

           Two of the five privileging requirements-verify all state medical
           licenses and consider medical malpractice information-are also VA
           credentialing requirements.

           We conducted site visits to seven VA medical facilities that were
           chosen based on size and geographic location. The medical
           facilities selected for review were located in Boise, Idaho;
           Kansas City, Missouri; Las Vegas, Nevada; Lexington, Kentucky;
           Martinsburg, West Virginia; Miami, Florida; and San Antonio,
           Texas. For each medical facility visited, we obtained from VA a
           list of physicians and their specialties. Using this list, at each
           facility we randomly selected 17 physicians and obtained files
           with their credentialing and privileging information. Our sample
           included physicians working in VA facilities full-time and
           part-time, through a contract, or without direct compensation from
           VA. In some cases, these physicians also worked at non-VA medical
           facilities. At each facility we visited, we selected one file from
           the following clinical specialties that are offered at most VA
           medical facilities: anesthesiology, gastroenterology, neurology,
           oncology, ophthalmology orthopedics, radiology, and urology. We
           also selected two physician files from general surgery and
           internal medicine, and five files from physician names that had no
           specialty identified on the list provided by VA. At some
           facilities, we found that the physician specialty indicated on the
           list provided by VA was incorrect. We replaced these files by
           random selection with physician files in the specialty needed.

           To determine whether the files we reviewed demonstrated compliance
           with the selected VA credentialing requirements and privileging
           requirements, we compared the documentation found in our sample
           files against the credentialing and privileging requirements.
           During our site visits, we reviewed the documentation in VetPro
           and in a physician's paper copy credentialing file to determine
           whether the facility complied with each of the four VA
           credentialing requirements that we reviewed. If documentation was
           present either in VetPro or the paper copy file, we determined
           that the medical facility complied with VA's requirement. For each
           physician, we reviewed the three most recent appointment
           cycles-the period from one appointment process to the next
           appointment process, which occurs every 2 years. Some of the
           physicians in our sample had not been through three appointment
           cycles. For those physicians, we reviewed only the number of
           cycles that had been completed. We documented our findings from
           these reviews on a data collection instrument.

           At each medical facility, we reviewed a physician's paper copy
           privileging file to determine whether the physician's file
           contained documentation that the medical facility met the five VA
           privileging requirements we examined. For the fifth
           requirement-use of information on a physician's performance when
           making decisions about whether to renew physicians' clinical
           privileges-we also interviewed facility officials, including the
           facility quality assurance manager, to determine whether the
           facility collected this physician performance information outside
           of the facility's quality assurance program. For some physician
           files we reviewed, the physician had only been through initial
           appointment and therefore did not have individual physician
           performance information in the privileging file.

           Based on the sample of physician files we reviewed at each of the
           seven medical facilities, we can discuss a medical facility's
           compliance for the physician files we reviewed; we cannot draw
           conclusions about the remaining physician files at the medical
           facilities we visited or about the compliance of other VA medical
           facilities. In collecting information on the credentialing and
           privileging requirements from physician files at each facility, we
           employed standard data collection techniques to ensure the
           accuracy and reliability of the data used in this report, such as
           interviewing medical facility officials about the accuracy and
           timeliness of the information contained in the physician files we
           reviewed and taking steps to have a consistent interpretation of
           VA's credentialing and privileging requirements for the physician
           files we reviewed at each medical facility.

           To determine the extent to which the selected VA medical
           facilities complied with a requirement to submit information on
           paid VA medical malpractice claims, we obtained data from VA's
           Office of Medical-Legal Affairs in Buffalo, New York to identify
           the VA medical facilities that were delinquent-more than 60 days
           had passed since the facility was notified that a claim had been
           paid-in submitting medical malpractice claim information to this
           office.1 The data included the name of the VA medical facility,
           the veteran who was named in the claim, the date the Office of
           Medical-Legal Affairs was notified that a claim had been paid, and
           the date the Office of Medical-Legal Affairs notified the facility
           that a VA medical malpractice claim had been paid. VA's Office of
           Medical-Legal Affairs determines whether a physician who was
           involved in a VA medical malpractice claim delivered substandard
           care to veterans, and if so, was reported to NPDB. We interviewed
           officials at this office to obtain information about VA's process
           and requirements for determining if substandard care was
           delivered.

           To determine whether VA has internal controls to help ensure the
           accuracy of medical facility information that is used to renew
           physicians' clinical privileges, we interviewed the director of
           VA's credentialing and privileging program, as well as other VA
           officials. We identified the internal controls VA has in place for
           its privileging process and used GAO's standards for internal
           controls in the federal government to determine whether these
           controls were adequate. During our site visits, we determined if
           any of the seven medical facilities had internal controls in place
           to help ensure the accuracy of the information used to support the
           renewal of clinical privileges. We conducted our work from July
           2005 to May 2006 in accordance with generally accepted government
           auditing standards.

           Laurie E. Ekstrand at (202) 512-7101 or [email protected]

           In addition to the contact named above Marcia A. Mann, Assistant
           Director; Kelly Barar; Mary Ann Curran; Martha A. Fisher; and
           Krister Friday made key contributions to this report.

           VA Health Care: Steps Taken to Improve Practitioner Screening, but
           Facility Compliance with Screening Requirements Is Poor.
           GAO-06-544 . Washington, D.C.: May 25, 2006.

           VA Health Care: Improved Screening of Practitioners Would Reduce
           Risk to Veterans. GAO-04-566 . Washington, D.C.: March 31, 2004.

           VA Health Care: Veterans at Risk from Inconsistent Screening of
           Practitioners. GAO-04-625T . Washington, D.C.: March 31, 2004.

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                       Agency Comments and Our Evaluation

Appendix I: Scope and Methodology 

1We considered claim information submitted 14 days after the 60-day time
frame to be on time, while information submitted 15 or more days after the
60-day time frame, we considered to be delinquent. At the time of our
review, four of the seven facilities did not have any medical malpractice
claim information that had not been submitted within VA's 60-day time
frame.

Appendix II: Comments from the Department of Veterans Affairs

Appendix III: GAO Contact and Staff Acknowledgments

                                  GAO Contact

                                Acknowledgments

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Highlights of GAO-06-648 , a report to the Chairman, Committee on
Veterans' Affairs, House of Representatives

May 2006

VA HEALTH CARE

Selected Credentialing Requirements at Seven Medical Facilities Met, but
an Aspect of Privileging Process Needs Improvement

The Department of Veterans Affairs (VA) is responsible for determining
that over 36,000 physicians working in its facilities have the appropriate
professional credentials and qualifications to deliver health care to
veterans. To do this, VA credentials and privileges physicians providing
care at its medical facilities. In this report, GAO determined the extent
to which selected VA facilities complied with (1) four VA credentialing
requirements and five VA privileging requirements and (2) a requirement to
submit information on paid malpractice claims. GAO also determined (3)
whether VA has internal controls to help ensure the accuracy of
information used to renew clinical privileges. GAO reviewed VA's policies,
interviewed VA officials, and randomly sampled 17 physician files at each
of seven VA medical facilities.

What GAO Recommends

GAO recommends that VA provide guidance to its medical facilities on how
to collect physician performance information in accordance with VA's
policy that can be used to renew clinical privileges, enforce the timely
submission of VA medical malpractice information, and instruct facilities
to establish internal controls for privileging information. VA concurred
with the

findings and recommendations and provided an action plan to implement the
three recommendations.

GAO found that the files reviewed at seven VA medical facilities complied
with four of VA's credentialing requirements selected for review, and all
but one of five privileging requirements. Credentialing is the process of
verifying that a physician's professional credentials, such as state
medical licenses, are valid and meet VA's requirements for employment.
Privileging is the process for determining which health care services a
physician is allowed to provide to veterans. For the files GAO reviewed,
compliance with the fifth privileging requirement was problematic at six
facilities because officials used performance information when renewing
clinical privileges but collected all or most of this information through
their facility's quality assurance program. This is prohibited under VA
policy. In general, VA quality assurance information is confidential,
according to federal law and VA policy. According to VA officials, if
quality assurance information is used outside of a facility's quality
assurance program, it could be used for other purposes, including
litigation. The information is protected to encourage physicians to
participate in quality assurance programs by reporting and discussing
adverse events to help prevent such events from occurring in the future.
VA has not provided guidance to help medical facilities find ways to
efficiently collect performance information outside of a facility's
quality assurance program. At the seventh medical facility, officials did
not use performance information to renew clinical privileges, as required.

Three of the seven medical facilities did not meet VA's requirement to
submit, within 60 days after being notified that the claim was paid, any
information on paid VA medical malpractice claims involving facility
practitioners, including physicians, to VA's Office of Medical-Legal
Affairs. This office reviews the information and determines whether
practitioners involved in the claims delivered substandard care, displayed
professional incompetence, or engaged in professional misconduct. The
office informs facilities of its determinations. When facilities do not
submit all relevant VA malpractice information in a timely manner, VA
medical facility officials lack complete information that would allow them
to make informed decisions about the clinical privileges that their
physicians should be granted.

VA has not required its medical facilities to establish internal controls
to help ensure that privileging information managed by medical staff
specialists-who are responsible for obtaining and verifying the
information used in the credentialing and privileging processes-is
accurate. One facility GAO visited did not identify 106 physicians whose
privileging process had not been completed by facility officials for at
least 2 years because of inaccurate information provided by the facility's
medical staff specialist. As a result, these physicians were practicing at
the facility without current clinical privileges. Without accurate
information on the privileges that have been granted to physicians and the
dates for renewing those privileges, VA medical facility officials will
not know if they have failed to renew clinical privileges for any of their
physicians in accordance with VA policy.
*** End of document. ***