VA Health Care: Patient Safety Could be Enhanced by Improvements 
in Employment Screening and Physician Privileging Practices	 
(15-JUN-06, GAO-06-760T).					 
                                                                 
In its March 2004 report, "VA Health Care: Improved Screening of 
Practitioners Would Reduce Risk to Veterans," GAO-04-566, GAO	 
made recommendations to improve VA's employment screening of	 
practitioners. GAO was asked to testify today on steps VA has	 
taken to improve its employment screening requirements and VA's  
physician credentialing and privileging processes because of	 
their importance to patient safety. This testimony is based on	 
two GAO reports released today that determined the extent to	 
which (1) VA has taken steps to improve employment screening for 
practitioners by implementing GAO's 2004 recommendations, (2) VA 
facilities are in compliance with selected credentialing and	 
privileging requirements for physicians, and (3) VA has internal 
controls to help ensure the accuracy of privileging information. 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-760T					        
    ACCNO:   A54724						        
  TITLE:     VA Health Care: Patient Safety Could be Enhanced by      
Improvements in Employment Screening and Physician Privileging	 
Practices							 
     DATE:   06/15/2006 
  SUBJECT:   Background investigations				 
	     Health care personnel				 
	     Hiring policies					 
	     Internal controls					 
	     Personnel qualifications				 
	     Physicians 					 
	     Professional licenses				 

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GAO-06-760T

     

     * Background
          * State Licenses and National Certificates
          * Background Investigations
          * Physician Credentialing and Privileging
     * VA Has Taken Steps to Improve Employment Screening Requireme
     * VA Facilities Did Not Comply with Employment Screening Requi
     * Physician Files at Facilities Demonstrated Compliance with A
          * Selected Physician Files at Facilities Demonstrated Complian
          * Not All Facilities Submitted Paid Malpractice Claim Informat
     * VA Has Not Established Internal Controls to Help Ensure the
     * Concluding Observations
     * Contacts and Acknowledgments
     * March 2004 Report Recommendations
     * VA Employment Screening Requirements for Practitioners Selec
     * VA Physician Credentialing Requirements Selected for Review
     * VA Physician Privileging Requirements Selected for Review
     * 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

Testimony

Before the Subcommittee on Oversight and Investigations, Committee on
Veterans' Affairs, House of Representatives

United States Government Accountability Office

GAO

For Release on Delivery Expected at 10:00 a.m. EDT

Thursday, June 15, 2006

VA HEALTH CARE

Patient Safety Could be Enhanced by Improvements in Employment Screening
and Physician Privileging Practices

Statement of Laurie E. Ekstrand

Director, Health Care

GAO-06-760T

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today to discuss efforts by the Department of
Veterans Affairs (VA) to ensure that its health care practitioners provide
safe care to veterans. Specifically, I want to discuss findings related to
patient safety in two reports that we are releasing today. The first
report focuses on employment screening requirements that VA medical
facility officials must follow. Under these requirements, VA facility
officials check the professional credentials and personal backgrounds for
all practitioners their facilities employ.1 VA practitioners include
physicians, nurses, and pharmacists, among others. Part of the screening
process includes credentialing, which is the process of checking that a
practitioner's professional credentials, such as licensure, education, and
training, are valid and meet VA's requirements for employment. Our second
report specifically examines credentialing and privileging processes
intended to ensure the safe delivery of care by VA physicians.2 Physician
privileging is the process for determining which health care services or
clinical privileges, such as surgical procedures or administering
anesthesia, a physician can provide to VA patients without supervision.
These clinical privileges must be renewed at least every 2 years. While
VA's requirements cannot guarantee patient safety in health care settings,
they are intended to minimize the chance of patients receiving care from
someone who is incompetent or who may intentionally harm them.

In March 2004, we reported and testified before this subcommittee on gaps
in VA's practitioner screening requirements.3 We found that VA did not
require that all of its health care practitioners with access to patients
be thoroughly screened. In addition, we found mixed compliance with VA
screening requirements at the medical facilities we visited. We concluded
that the gaps in and mixed compliance with VA's screening requirements
created vulnerabilities that could allow VA to employ health care
practitioners who could place patients at risk. In our 2004 report, we
made four recommendations to address the gaps we identified in VA's
screening requirements and the noncompliance we found at the VA medical
facilities we visited. VA generally agreed with our findings and
conclusions and stated it would develop a detailed action plan to
implement our recommendations.

1GAO, 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).

2GAO, VA Health Care: Selected Credentialing Requirements at Seven Medical
Facilities Met, but an Aspect of Privileging Process Needs Improvement,
GAO-06-648 (Washington, D.C.: May 25, 2006).

3GAO, VA Health Care: Improved Screening of Practitioners Would Reduce
Risk to Veterans, GAO-04-566 (Washington, D.C.: Mar. 31, 2004), and VA
Health Care: Veterans at Risk from Inconsistent Screening of
Practitioners, GAO-04-625T (Washington, D.C.: Mar. 31, 2004).

The subcommittee is interested in the progress VA has made in implementing
our March 2004 recommendations and in efforts by VA to ensure that its
health care practitioners are qualified and have appropriate backgrounds
to safely deliver care to veterans. My remarks today focus on the extent
to which (1) VA has taken steps to improve employment screening for
practitioners by implementing the four recommendations made in our March
2004 report, (2) VA medical facilities are in compliance with VA's
employment screening requirements for health care practitioners, (3) VA
medical facilities are in compliance with selected credentialing and
privileging requirements for physicians, and (4) VA has internal controls
to help ensure the accuracy of information medical facilities use to renew
physicians' clinical privileges.

In carrying out this work, we reviewed VA's policies and procedures for
employment screening and interviewed VA headquarters officials to
determine if the recommendations we made in March 2004 were implemented.
We also reviewed VA policies outlining the processes for credentialing and
privileging physicians. In addition, we visited seven VA medical
facilities for each report.4 At each facility we visited, we reviewed a
sample of practitioner files to determine if documentation in the files
demonstrated compliance with the requirements in our reviews. For the
employment screening report, we selected five employment screening
requirements, and for the physician credentialing and privileging report,
we selected four credentialing and five privileging requirements for
physicians. See appendix I for the four recommendations we made in March
2004 and the VA screening, credentialing, and privileging requirements we
used in our reports to measure VA medical facility compliance. We also
identified the internal controls VA has in place for its privileging
process and, using GAO's standards for internal controls in the federal
government, determined whether these controls are adequate.5 We performed
our work from April 2005 to May 2006 in accordance with generally accepted
government auditing standards.

4For the employment screening report, we visited VA facilities in Fargo,
North Dakota; Kansas City, Missouri; Miami, Florida; New Orleans,
Louisiana; Salt Lake City, Utah; San Antonio, Texas; and Washington, D.C.
For the physician credentialing and privileging report, we visited VA
facilities in Boise, Idaho; Kansas City, Missouri; Las Vegas, Nevada;
Lexington, Kentucky; Martinsburg, West Virginia; Miami, Florida; and San
Antonio, Texas.

In summary, VA has taken steps to improve employment screening of its
health care practitioners by partially implementing each of the four
recommendations made in our March 2004 report; however, gaps still remain
in VA's health care practitioner screening requirements. For example, for
our recommendation that VA check all state licenses and national
certificates held by all practitioners, VA implemented the recommendation
for practitioners it intends to hire, but has not expanded this screening
requirement to include those currently employed by VA. In addition, VA's
implementation of another recommendation-to conduct oversight to help
facilities comply with employment screening requirements-did not include
all types of practitioners and screening requirements, as we recommended.

At the seven VA medical facilities we visited for our review of VA's
health care practitioner screening, we found poor compliance with four of
the five VA screening requirements we selected for review. Based on the
practitioner files we reviewed, we found that none of the facilities we
visited had a compliance rate of 90 percent or more for all screening
requirements, and VA policy requires 100 percent compliance with these
requirements.6

At the seven VA medical facilities we visited for our review of VA's
physician credentialing and privileging requirements, we found compliance
with almost all selected credentialing and privileging requirements.
Specifically, the physician files we reviewed demonstrated compliance with
the four selected credentialing requirements and four of the five
privileging requirements. Compliance with a fifth privileging
requirement-to use information on a physician's performance in making
privileging decisions-was problematic at six of the VA medical facilities.
At these six, officials obtained this information from their facilities'
quality assurance programs.7 Use of such information in connection with
privileging is prohibited by VA policy, and according to VA officials,
this prohibition exists to protect the confidentiality of quality
assurance information and to encourage physicians to participate in
quality assurance programs. VA has not provided guidance to help medical
facilities find alternative ways to efficiently collect performance
information, outside of a facility's quality assurance program, that could
be used in the renewal of clinical privileges. At the seventh medical
facility, officials did not use performance information to renew
physicians' clinical privileges, as required. Further, three of the seven
facilities did not submit medical malpractice claim information to VA's
Office of Medical-Legal Affairs within 60 days after being notified that a
claim was paid, as required by VA. This office is responsible for forming
panels of practitioners to determine whether VA practitioners have
delivered substandard care. When VA medical facilities do not submit all
relevant information in a timely manner, facility officials make
privileging decisions without the advantage of such determinations.

5GAO, Internal Control Management and Evaluation Tool, GAO-01-1008G
(Washington, D.C.: August 2001).

6A 90 percent compliance rate means that 90 percent of the health care
practitioner files we examined at each facility provided documentation
that the screening requirement had been met in accordance with VA policy.

VA has not required its medical facilities to establish internal controls
to help ensure that physician privileging information managed by medical
staff specialists-employees who are responsible for obtaining and
verifying the information used in credentialing and privileging-is
accurate. One facility we visited did not identify 106 physicians whose
privileging processes had not been completed by facility officials for at
least 2 years because of inaccurate information provided by the facility's
medical staff specialist. As a result, these physicians were practicing at
the facility without current clinical privileges. This facility has since
implemented internal controls to reduce the risk of a similar situation
occurring in the future. During our visits to other VA facilities for the
physicians' credentialing and privileging report, we did not identify any
facilities that had established internal controls to help ensure the
accuracy of physician privileging information.

7VA requires each of 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.

To better ensure the safety of veterans receiving health care at VA
facilities, in our reports we recommended that VA expand its oversight to
include a review of VA facilities' compliance with screening requirements
for all types of health care practitioners, provide guidance to medical
facilities on how to collect individual physician performance information
in accordance with VA's credentialing and privileging policy to use in the
renewal of physicians' clinical privileges, and enforce the requirement
that medical facilities submit information on paid VA medical malpractice
claims in a timely manner to VA's Office of Medical-Legal Affairs.
Additionally, we recommended that VA instruct its medical facilities to
establish internal controls to ensure the accuracy of their physician
privileging information. In commenting on drafts of these reports, VA
agreed with our findings and conclusions and concurred with our
recommendations. VA provided an action plan to address the three
recommendations in the report on VA's physician credentialing and
privileging requirements, and stated that it will provide an action plan
to implement the recommendations in the practitioner screening report
after issuance of the report.

                                   Background

VA operates the largest integrated health care system in the United
States, providing care to nearly 5 million veterans per year. The VA
health care system consists of hospitals, ambulatory clinics, nursing
homes, residential rehabilitation treatment programs, and readjustment
counseling centers. In addition to providing medical care, VA is the
largest educator of health care professionals, training more than 28,000
medical residents annually, as well as other types of trainees.

State Licenses and National Certificates

VA requires its health care practitioners to have professional credentials
in their specific professions through either state licenses or national
certificates.8 VA policy requires officials at its medical facilities to
screen each applicant for positions at VA to determine whether the
applicant possesses at least one current and unrestricted state license or
an appropriate national certificate, whichever is applicable for the
position sought by the applicant. VA also requires officials at its
medical facilities to periodically verify licenses or national
certificates held by health care practitioners already employed at VA. In
general, for both applicants and employed health care practitioners, VA's
employment screening process proceeds in two stages. First, applicants and
employed health care practitioners are required to disclose to VA, if
applicable, their state licenses and national certificates. Applicants
disclose their credentials to VA during the application process, and
employed health care practitioners disclose credentials to VA as they
expire and are renewed with the state licensing board or certifying
organization. Second, VA facility officials are required to check whether
the disclosed credentials are valid.

8Not all VA practitioners, such as nursing assistants, are required to
have a state license or a national certificate. Some practitioners, such
as occupational therapists, may hold both national certificates and state
licenses.

State licenses are issued by state licensing boards, whereas national
certificates are issued by national certifying organizations, which are
separate and independent from state licensing boards. Both state licensing
boards and national certifying organizations establish requirements that
practitioners must meet to be licensed or certified. Licensed
practitioners may be licensed in more than one state. "Current and
unrestricted licenses" are licenses that are valid and in good standing in
the state where issued. To keep a license current, practitioners must
renew their licenses before they expire. When licensing boards discover a
licensee is in violation of licensing requirements or established law, for
example, abusing prescription drugs or intentionally or negligently
providing poor quality care that results in adverse health effects, they
may place restrictions on or revoke a license. Restrictions from a state
licensing board can limit or prohibit a practitioner from practicing in
that particular state. Some, but not all, state licenses are marked to
indicate whether the licenses have had restrictions placed on them.
Practitioners, such as respiratory and occupational therapists, who are
required to have national certificates to work at VA, must have current
and unrestricted certificates. National certifying organizations can
restrict or revoke certificates for violations of the organizations'
professional standards. Generally, each state licensing board and national
certifying organization maintains a database of information on
restrictions, which employers can often obtain at no cost either by
accessing the information on a board's Web site or by contacting the board
directly.

Background Investigations

In addition to holding valid professional credentials, when hired, health
care practitioners are required to undergo background investigations that
verify their personal and professional histories.9 Depending on the
position, the extent of the background investigations for health care
practitioners varies. For example, the minimum background investigation is
a fingerprint-only investigation, which compares a practitioner's
fingerprints to those stored in criminal history databases. A traditional
background investigation, which covers a health care practitioner's
personal and professional background for up to 10 years, is the most
common type of background investigation conducted by VA on its health care
practitioners. The traditional background investigation verifies an
individual's history of employment, education, and residence, and includes
a fingerprint check against a criminal-history database. The Office of
Personnel Management conducts background investigations for VA. To
determine the level of background investigation required for employment,
VA facility officials are required to complete VA Form 2280, which
documents the level of risk posed by a particular position.

Physician Credentialing and Privileging

For physicians, VA has specific requirements that facility officials must
follow to credential and privilege physicians. Officials must follow these
requirements when physicians initially apply to work in VA-which is known
as initial appointment-and then again at least every 2 years when
physicians must apply for reappointment in order to renew their clinical
privileges. Prior to working at VA, physicians enter into VetPro, a
Web-based credentialing system VA implemented in March 2001, information
used by VA medical facility officials in the credentialing process. For
example, physicians enter information on their involvement in VA and
non-VA medical malpractice claims and their medical education and
training. For their reappointments, physicians must update this
credentialing information in VetPro. A facility's medical staff specialist
then performs a data check to be sure that all required information has
been entered into VetPro. In general, the medical staff specialist at each
VA medical facility manages the accuracy of VetPro's credentialing data.
The medical staff specialist verifies, with the original source of the
information, the accuracy of the credentialing information entered by the
physicians. Once a physician's credentialing information has been
verified, the medical staff specialist sends the information to the
physician's supervisor, known as a clinical service chief.10

9Executive Order 10450, April 27, 1953, requires all persons employed by
federal departments and agencies to undergo background investigations to
ensure that their employment is consistent with national security
interests.

In addition to entering credentialing information into VetPro, physicians
complete written requests for clinical privileges. The facility medical
staff specialist provides a physician's clinical service chief with the
requested clinical privileges and information needed to complete the
privileging process, including information that indicates that the
credentialing information entered by the physician into VetPro has been
verified with the appropriate sources. The requested clinical privileges
are reviewed by the clinical service chief, who recommends whether a
physician should be appointed or reappointed to the facility's medical
staff and which clinical privileges should be granted. For reappointment
only, VA's policy requires that information on a physician's performance,
such as a physician's surgical complication rate, be used when deciding
whether to renew a physician's clinical privileges. Based on the
physician's performance information, the clinical service chief recommends
that clinical privileges previously granted by the facility remain the
same, be reduced, or be revoked, and whether newly requested privileges
should be added.11 The 2-year period for renewal of clinical privileges
and reappointment to the medical staff begins on the date that the
privileges are approved by the medical facility's director.

VA Has Taken Steps to Improve Employment Screening Requirements, but Gaps Remain

VA has taken steps to improve employment screening of its health care
practitioners by partially implementing each of the four recommendations
made in our March 2004 report; however, gaps still remain in VA's health
care practitioner screening requirements. To address our recommendation
that VA facility officials contact state licensing boards and national
certifying organizations to verify all licenses and certificates held by
all VA health care practitioners, VA expanded its verification requirement
to include licenses and certificates for all prospective hires but did not
extend this requirement to include all practitioners currently employed by
VA. For those currently employed, such as nurses and pharmacists, VA only
required facility officials to physically inspect one license of a
practitioner's choosing.12 Physical inspection of a license cannot ensure
that it is valid and without restriction, nor can it ensure that there are
not other licenses from other states that may have restrictions. Checking
all licenses against state records is the only way to identify
practitioners with restricted licenses. We reviewed a draft of a VA policy
that if issued in its current form would fully address our recommendation
to require medical facility officials to verify all state licenses and
national certificates of currently employed health care practitioners.
According to a VA official, this policy is expected to be issued in June
2006.

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

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

To address our second recommendation that VA query the Department of
Health and Human Services' (HHS) Healthcare Integrity and Protection Data
Bank (HIPDB) for all licensed health care practitioners that VA intends to
hire and periodically query it for those already employed, VA in July 2004
directed facility officials to query HIPDB for all applicants for VA
employment. However, officials were not directed to periodically query
HIPDB for health care practitioners currently employed by VA. Officials
told us that VA is working with HHS to develop a process whereby VA can
electronically query HIPDB for current VA employees. Once this process is
in place, and VA is using it to periodically query HIPDB for those
currently employed at VA, the department will have fully implemented our
recommendation. However, VA did not provide a time frame for implementing
this electronic query of HIPDB.

To address our third recommendation that VA expand the use of
fingerprint-only background investigations for all practitioners with
direct access to patients, VA issued a policy that required all VA medical
facilities to begin using electronic fingerprint machines by September 1,
2005. By February 1, 2006, all but two facilities had obtained the
equipment necessary to implement this requirement.

To address our fourth recommendation concerning oversight of the screening
requirements, VA formalized an oversight program within its Office of
Human Resource Management to include a review of some aspects of the
screening process for applicants and current employees. However, the
oversight program does not ensure that facilities are complying with all
of VA's key screening requirements, as we recommended. For example,
officials from the oversight program are not required to check personnel
files to ensure that facility officials query HIPDB and verify all health
care practitioners' licenses and certifications with the relevant issuing
organizations.

12VA Handbook 5005, pt. II, ch. 3, para. 17a(1).

    VA Facilities Did Not Comply with Employment Screening Requirements for
                                 Practitioners

For the seven VA facilities we visited to determine compliance with
employment screening requirements for practitioners, we found poor
compliance with four of the five requirements we selected for review. Two
of these five requirements VA implemented since our March 2004 report-for
individuals VA intends to hire, query HIPDB and use an employment
checklist to document the completion of employment screening requirements.
Three other employment screening requirements were long-standing-verify
health care practitioners' state licenses and national certificates;
complete VA Form 2280, which is used to determine the appropriate type of
background investigation needed for each health care practitioner job
category; and conduct background investigations. In order to show the
variability in the level of compliance among the facilities, we measured
their performance against a compliance rate of at least 90 percent for
each of the screening requirements, even though VA policy requires 100
percent compliance with these requirements. None of the facilities had a
compliance rate of 90 percent or more for all screening requirements we
reviewed. Table 1 summarizes the rate of compliance among the seven
facilities.

Table 1: Facilities' Rates of Compliance with Select VA Screening
Requirements, 2005

Notes: We considered facilities to be in compliance if they were able to
provide documentation not available in the personnel file. Site visits to
these seven VA facilities were conducted from April 2005 through August
2005. Only salaried practitioners are represented in this table.

aTested for significance at the 95 percent confidence level.

bApplies only to health care practitioners hired on or after October 1,
2004, and certain health care practitioners hired prior to this date, such
as physicians and dentists. Results for this screening requirement cannot
be generalized to the facility being reviewed because of the sample size.

cApplies only to health care practitioners hired on or after October 1,
2004. Results for this screening requirement cannot be generalized to the
facility being reviewed because of the sample size.

As shown in table 1, while two facilities performed HIPDB queries on
individuals they intended to hire, one of these facilities completed the
queries immediately prior to our visit and not at the time the individuals
were hired. We also found that two facilities had created their own
employment checklists, but had not included all of the screening
requirements contained in the original checklist issued by VA. As a
result, these facilities were not in compliance with VA's requirement.

 Physician Files at Facilities Demonstrated Compliance with Almost All Selected
 Credentialing and Privileging Requirements; Not All Facilities Submitted Paid
                Malpractice Claim Information in a Timely Manner

We found that the physician files at the facilities we visited
demonstrated compliance with four VA credentialing and four privileging
requirements we reviewed.13 However, we found that there were problems
complying with a fifth privileging requirement-to use information on a
physician's performance in making privileging decisions. In addition, we
found that three of the seven medical facilities we visited did not submit
to VA's Office of Medical-Legal Affairs information on paid VA medical
malpractice claims within 60 days after being notified that a claim was
paid, as required by VA policy.

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

We found that the physician files at the facilities we visited
demonstrated compliance with four VA credentialing and four privileging
requirements we reviewed. For the physician files we reviewed, the VA
facilities' medical staff specialists contacted state licensing boards to
ascertain the status of the state medical licenses held and disclosed by
their physicians.14 They also queried the Federation of State Medical
Boards (FSMB) database, as required, to obtain additional information on
the status of physicians' medical licenses, including those that may not
have been disclosed by physicians.15 Medical staff specialists complied
with the requirement to contact sources, such as courts of jurisdiction,
to verify information on physicians' involvement in medical malpractice
claims, including ongoing claims, disclosed by physicians. Additionally,
in all cases medical staff specialists queried the National Practitioner
Data Bank (NPDB) to identify those physicians who have been involved in
paid medical malpractice claims, including any physicians who failed to
disclose involvement in such claims. The physician files also demonstrated
compliance with four of VA's privileging requirements. Medical staff
specialists verified physicians' state licenses and the information
disclosed by physicians about their involvement in medical malpractice
allegations or paid claims, which are both credentialing and privileging
requirements. We also found that medical staff specialists verified that
physicians had the necessary training and experience to deliver health
care and perform the clinical privileges physicians requested.
Additionally, after medical staff specialists performed their
verification, clinical service chiefs reviewed this information, as
required, along with information on physicians' health status.

13Findings for the credentialing and privileging requirements cannot be
generalized to the facility being reviewed because of the sample size.

14VA medical facility officials may also verify physicians' licenses by
querying a state licensing board's Web site for information on the
licenses.

15VA requires facility officials to query FSMB at initial appointment
only. Thereafter, VA headquarters regularly receives reports from FSMB on
any currently employed VA physician whose name appears on FSMB's list,
indicating that disciplinary action has been taken against the physician's
state license.

While we found evidence demonstrating compliance with four of VA's
privileging requirements, the files we reviewed showed that there were
problems complying with a fifth privileging requirement that is used only
in the renewal of privileges-to use information on a physician's
performance in making privileging decisions. VA requires that during the
renewal of a physician's clinical privileges, VA clinical service chiefs
use information on a physician's performance to support, reduce, or revoke
the clinical privileges the physician has requested. However, as stated in
VA policy, physician performance information that is collected as part of
a facility's quality assurance program cannot be used in a facility's
privileging process. According to VA, the confidentiality of individual
performance information helps ensure practitioner participation, including
that of physicians, in a medical facility's quality assurance program by
encouraging practitioners to openly discuss opportunities for improvement
in practitioner practice without fear of punitive action. VA officials
stated that quality assurance information if used outside of a facility's
quality assurance program could be available for other purposes, including
litigation. However, VA has not provided guidance on how facility
officials can obtain such information in accordance with VA policy-that
is, outside of a quality assurance program. Officials at six medical
facilities told us that they used performance information to support the
granting of clinical privileges requested by their physicians, but
collected all or most of this information through facility quality
assurance programs. At the seventh medical facility, officials did not use
individual physician performance information to renew physicians' clinical
privileges, as required by VA.

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

We also included in our review a requirement that is related to the
privileging process-medical facilities must submit to VA's Office of
Medical-Legal Affairs information on paid VA medical malpractice claims
within 60 days after being notified that a claim was paid. VA's Office of
Medical-Legal Affairs is responsible for forming panels of practitioners
to determine whether practitioners involved in any of these claims
delivered substandard care to veterans and provides these determinations
to facility officials. We found that three of the seven VA medical
facilities we reviewed did not submit claim information to VA's Office of
Medical-Legal Affairs within the 60-day time frame. For example, for one
facility we visited, we found that from 2001 through 2005, information on
21 of the facility's 26 paid medical malpractice claims had not been
submitted within the 60-day time frame to VA's Office of Medical-Legal
Affairs.16 Moreover, on average this medical facility took 30 months to
submit information to VA's Office of Medical-Legal Affairs, whereas the
other two facilities averaged about 5 months to submit information.

When VA medical facilities do not submit all relevant claim information to
the Office of Medical-Legal Affairs, determinations on substandard care
are not available to facility officials when they make privileging
decisions. In addition, substandard care determinations are required to be
reported by facility officials to NPDB. When VA medical facilities do not
send claim information in a timely manner to the Office of Medical-Legal
Affairs, these cases, if substandard care is found, go unreported or
reporting to NPDB is delayed. This prevents other VA and non-VA facilities
where the physician may also practice from having complete information on
the physician's malpractice history.

16As of March 31, 2006, this medical facility had sent all delinquent
medical malpractice claim information to VA's Office of Medical-Legal
Affairs.

    VA Has Not Established Internal Controls to Help Ensure the Accuracy of
                      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 processes had not been completed by facility
officials for at least 2 years because of inaccurate information provided
by the facility's medical staff specialist. According to facility
officials, the medical staff specialist changed reappointment dates for
some physicians and for other physicians removed their names from VetPro,
the facility's credentialing database. As a result, these physicians were
practicing at the facility without current clinical privileges.

Once medical facility officials became aware of the problem, they reviewed
the files of all physicians and identified 106 physicians for whom the
privileging process had not been completed. Facility officials told us
they did not find any problems that would have warranted the 106
physicians' removal from the facility's medical staff or that placed
veterans at risk. This facility has since implemented internal controls to
reduce the risk of a similar situation occurring in the future. During our
site visits to other VA medical facilities for the physicians'
credentialing and privileging report, we did not identify any facilities
that had established internal controls to help ensure the accuracy of the
information they use to renew physicians' clinical privileges. Without
accurate information, VA medical facility officials will not know if they
have failed to renew clinical privileges for any of their physicians.

                            Concluding Observations

VA's employment screening requirements are intended to ensure the safety
of veterans receiving care by identifying practitioners who are
incompetent or may intentionally harm veterans. In our practitioner
screening report that we are releasing today, we continue to raise
concerns about gaps in VA's employment screening requirements. Although VA
concurred with our March 2004 recommendations and took steps to implement
them, none were fully implemented as of March 2006. These recommendations
should be fully implemented. We are also concerned that compliance with
employment screening requirements for practitioners, including physicians,
nurses, and pharmacists, among others, continues to be poor at the
facilities we visited. Continuing gaps in VA's employment screening
requirements and mixed compliance with these requirements continue to
place veterans at risk.

The other report that we are releasing today demonstrates that medical
facilities we reviewed largely complied with VA's physician credentialing
and privileging requirements. However, we identified problems with the
appropriate use of physician performance information in the privileging
process and the timely submission of medical malpractice information to
VA's Office of Medical-Legal Affairs. Additionally, VA's lack of internal
controls for its facilities to ensure the accuracy of physician
privileging information raises concerns that VA is at risk for allowing
physicians to practice with expired clinical privileges.

Our reports include the following four recommendations that VA should
implement to help ensure patient safety:

           o  expand the human resource management oversight program to
           include a review of VA facilities' compliance with employment
           screening requirements for all types of practitioners,
           o  provide guidance to medical facilities on how to collect
           individual physician performance information in accordance with
           VA's credentialing and privileging requirements to use in medical
           facilities' privileging processes,
           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 physician privileging information.

           Mr. Chairman, this concludes my prepared remarks. I will be
           pleased to answer any questions you or other members of the
           subcommittee may have.

           Contacts and Acknowledgments
		   
		   For further information regarding this testimony, please contact
           Laurie E. Ekstrand 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 testimony.
           Mary Ann Curran, Martha Fisher, Krister Friday, and Marcia Mann
           also contributed to this statement.

           Appendix I: March 2004 Report Recommendations and VA Screening,
                       Credentialing, and Privileging Requirements

           In our March 2004 report, VA Health Care: Improved Screening of
           Practitioners Would Reduce Risk to Veterans, we made four
           recommendations to address the gaps we identified in VA's
           employment screening requirements and the noncompliance we found
           at the four medical facilities we visited.1

           March 2004 Report Recommendations
		   
		   o  Expand verification of all state licenses and national
           certificates by contacting the appropriate licensing boards and
           national certifying organizations for all Department of Veterans
           Affairs' (VA) health care practitioners.
           o  Expand query of the Healthcare Integrity and Protection Data
           Bank (HIPDB)-a national data bank that contains information on
           health care practitioners involved in health care-related civil
           judgments and criminal convictions or who have had disciplinary
           actions taken against their licenses or national certificates-to
           include all licensed health care practitioners at VA facilities.
           o  Conduct fingerprint-only background investigations for all VA
           health care practitioners with direct patient care access.
           o  Conduct oversight of medical facilities to ensure compliance
           with all of VA's key screening requirements.

           VA Employment Screening Requirements for Practitioners Selected 
		   for Review
		   
		   To measure facility compliance with VA's employment screening
           requirements, we selected five requirements for our review.2 We
           selected two of the five requirements because in our March 2004
           report we found that VA facilities had problems complying with
           these two long-standing requirements. We selected two other
           requirements because VA implemented these since March 2004 to
           improve its employment screening of practitioners. The remaining
           requirement is long-standing, but is related to the performance of
           background investigations, which was a requirement we reviewed and
           found compliance with this requirement to be problematic in 2004.

           o  Complete VA Form 2280, which medical facility officials must do
           in order to determine the appropriate type of background
           investigation needed for each health care practitioner job
           category.
           o  Perform a background investigation.
           o  Query HIPDB.
           o  Complete an employment checklist, which VA officials are to use
           to document the completion of VA screening requirements for those
           practitioners VA intends to hire.
           o  Verify the status of state licenses and national certificates.

           VA Physician Credentialing Requirements Selected for Review
		   
		   We selected four of VA's credentialing requirements for review
           because they are requirements that-unlike other credentialing
           requirements-address information about physicians that can change
           or be updated with new information periodically.3

           o  Verify that all state medical licenses held by physicians are
           valid.
           o  Query the Federation of State Medical Boards database to
           determine whether physicians had disciplinary action taken against
           any of their licenses, including expired licenses.
           o  Verify information provided by physicians on their involvement
           in medical malpractice claims at VA or non-VA facilities.
           o  Query the National Practitioner Data Bank to determine whether
           a physician was reported to this data bank because of involvement
           in VA or non-VA paid medical malpractice claims, display of
           professional incompetence, or engagement in professional
           misconduct.

           VA Physician Privileging Requirements Selected for Review
		   
		   We selected four privileging requirements that VA identifies as
           general privileging requirements. In addition to the four general
           privileging requirements, we selected another privileging
           requirement because of its importance in the renewal of clinical
           privileges because it provides clinical service chiefs with
           information on the quality of care delivered by individual
           physicians.4
	
           o  Verify that all state medical licenses held by physicians are
           valid.
           o  Verify physicians' training and experience.
           o  Assess physicians' clinical competence and health status.
           o  Consider any information provided by physicians related to
           medical malpractice allegations or paid claims, loss of medical
           staff membership, loss or reduction of clinical privileges at VA
           or non-VA facilities, or any challenges to physicians' state
           medical licenses.
           o  Use information on physicians' performances when making
           decisions about whether to renew physicians' clinical privileges.

           GAOï¿½s Mission
		   
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1 GAO-04-566 .

2 GAO-06-544 .


3 GAO-06-648 .

4 GAO-06-648 .

(290540)

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www.gao.gov/cgi-bin/getrpt? GAO-06-760T .

To view the full product, including the scope

and methodology, click on the link above.

For more information, contact Laurie E. Ekstrand at (202) 512-7101 or
[email protected].

Highlights of GAO-06-760T , a testimony before the Subcommittee on
Oversight and Investigations, Committee on Veterans' Affairs, House of
Representatives

June 15, 2006

VA HEALTH CARE

Patient Safety Could be Enhanced by Improvements in Employment Screening
and Physician Privileging Practices

In its March 2004 report, VA Health Care: Improved Screening of
Practitioners Would Reduce Risk to Veterans,  GAO-04-566, GAO made
recommendations to improve VA's employment screening of practitioners. GAO
was asked to testify today on steps VA has taken to improve its employment
screening requirements and VA's physician credentialing and privileging
processes because of their importance to patient safety. This testimony is
based on two GAO reports released today that determined the extent to
which (1) VA has taken steps to improve employment screening for
practitioners by implementing GAO's 2004 recommendations, (2) VA
facilities are in compliance with selected credentialing and privileging
requirements for physicians, and (3) VA has internal controls to help
ensure the accuracy of privileging information.

What GAO Recommends

In its reports released today, GAO recommends that VA expand its
employment screening oversight program to include all practitioners,
provide guidance on collecting physician performance information, enforce
the time frame to submit information on paid VA malpractice claims
involving VA practitioners, and instruct facilities to establish internal
controls for physician privileging information. VA agreed with the
findings and conclusions and concurred with the recommendations in both
reports.

In its report released today, VA Health Care: Steps Taken to Improve
Practitioner Screening, but Facility Compliance with Screening
Requirements Is Poor, GAO-06-544, GAO found that VA has taken steps to
improve employment screening for practitioners, such as physicians,
nurses, and pharmacists, by partially implementing each of four
recommendations GAO made in March 2004. However, gaps still remain in VA's
requirements. For example, for the recommendation that VA check all state
licenses and national certificates held by all practitioners, such as
nurses and pharmacists, VA implemented the recommendation for
practitioners it intends to hire, but has not expanded this screening
requirement to include those currently employed by VA. In addition, VA's
implementation of another recommendation-to conduct oversight to help
facilities comply with employment screening requirements-did not include
all screening requirements, as recommended by GAO.

In another report released today, VA Health Care: Selected Credentialing
Requirements at Seven Medical Facilities Met, but an Aspect of Privileging
Process Needs Improvement, GAO-06-648, GAO found at seven VA facilities it
visited compliance with almost all selected credentialing and privileging
requirements for physicians. Credentialing is verifying that a physician's
credentials are valid. Privileging is determining which health care
services-clinical privileges-a physician is allowed to provide. Clinical
privileges must be renewed at least every 2 years. One privileging
requirement-to use information on a physician's performance in making
privileging decisions-was problematic because officials used performance
information when renewing clinical privileges, but collected all or most
of this information through their facility's quality assurance program.
This is prohibited under VA policy. Further, three of the seven facilities
did not submit medical malpractice claim information to VA's Office of
Medical-Legal Affairs within 60 days after being notified that a claim was
paid, as required by VA. This office uses such information to determine
whether VA practitioners have delivered substandard care and provides
these determinations to facility officials. When VA medical facilities do
not submit all relevant information in a timely manner, facility officials
make privileging decisions without the advantage of such determinations.

VA has not required its facilities to establish internal controls to help
ensure that physician privileging information managed by medical staff
specialists-employees who are responsible for obtaining and verifying
information used in credentialing and privileging-is accurate. One
facility GAO visited did not identify 106 physicians whose privileging
processes had not been completed by facility officials for at least 2
years because of inaccurate information provided by the facility's medical
staff specialist. As a result, these physicians were practicing at the
facility without current clinical privileges.
*** End of document. ***