VA Health Care: Physician Peer Review Identifies Quality of Care Problems
but Actions to Address Them Are Limited (Letter Report, 07/07/95,
GAO/HEHS-95-121).

Pursuant to a congressional request, GAO examined the relationship
between problem identification and problem resolution in the Department
of Veterans Affairs' (VA) physician peer review process, focusing on:
(1) how the results of VA peer review are being used in disciplining
physicians with performance problems; (2) the impediments to effective
peer review; and (3) whether VA is taking action against physicians who
are not performing in accordance with professional standards.

GAO found that: (1) actions taken by VA to address quality of care
problems are often limited to undocumented discussions with the
physicians involved; (2) there is generally no record of the extent to
which quality of care problems are addressed or the actions taken to
deal with the problems identified; (3) VA is developing practice
guidelines and using peer review to help reduce heavy reliance on
professional judgement in peer review; and (4) VA medical centers are
not reporting many actions taken against physicians to the National
Practitioner Data Bank because of their restrictive reporting
procedures.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-95-121
     TITLE:  VA Health Care: Physician Peer Review Identifies Quality of 
             Care Problems but Actions to Address Them Are
             Limited
      DATE:  07/07/95
   SUBJECT:  Patient care services
             Veterans benefits
             Veterans hospitals
             Physicians
             Internal controls
             Reporting requirements
             Documentation
             Personnel evaluation
             Evaluation methods
             Quality assurance
IDENTIFIER:  HHS National Practitioner Data Bank
             
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Cover
================================================================ COVER


Report to Ranking Minority Member, Committee on Veterans' Affairs,
U.S.  Senate

JULY 1995

VA HEALTH CARE - PHYSICIAN PEER
REVIEW IDENTIFIES QUALITY OF CARE
PROBLEMS BUT ACTIONS TO ADDRESS
THEM ARE LIMITED

GAO/HEHS-95-121

Physician Peer Review


Abbreviations
=============================================================== ABBREV

  HHS - Department of Health and Human Services
  TCIS - Tort Claim Information System
  VA - Department of Veterans Affairs

Letter
=============================================================== LETTER


B-254062

July 7, 1995

The Honorable John D.  Rockefeller IV
Ranking Minority Member
Committee on Veterans' Affairs
United States Senate

Dear Senator Rockefeller: 

Peer review--physicians reviewing the work of other physicians--is a
crucial element in ensuring that quality medical care is provided to
patients.  When used appropriately, peer review can result in both
immediate and long-term improvements in patient care.  However, when
used inappropriately, it can prevent the detection of poorly
performing practitioners and cause severe quality of care problems
for patients.  An essential element of peer review is management
support for actions recommended by the peer review process.  Without
such support, peer review is a meaningless activity because no action
is taken on the peer reviewers' recommendations. 

In response to your request, we have examined the relationship
between problem identification and problem resolution as it pertains
to the Department of Veterans Affairs (VA) physician peer review. 
Specifically you asked (1) how the results of VA peer review are
being used in the process of reprivileging and disciplining
physicians with performance problems; (2) what are the impediments to
effective peer review; and (3) whether VA was taking action to
identify, follow up on, and report to state medical boards and the
National Practitioner Data Bank on the actions of those physicians
who are not performing in accordance with professional standards. 

Our review was conducted at VA's Central Office and six VA medical
centers during the period January 1994 through March 1995.  At each
location we (1) reviewed peer review policies, procedures, and
documentation; (2) examined quality assurance files; and (3)
interviewed physicians involved in the peer review process.  We also
examined malpractice claims paid on behalf of physicians at these
medical centers.  The quality assurance data that we reviewed are
considered confidential and privileged under the provisions of Title
38, U.S.C.  5705.  Thus, we are not incorporating in this report any
examples of cases that VA peer reviewers believed an experienced,
competent practitioner would have handled differently.  However,
these examples will be provided to you under separate cover.  Further
details on our scope of work and methodology are contained in
appendix I. 

Our review was conducted in accordance with generally accepted
government auditing standards. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

The peer review process at the six medical centers that we visited
has enabled the facilities to identify potential quality of care
problems.  However, actions taken by VA clinical service chiefs to
address these problems were often limited to undocumented discussions
with the physicians involved.  Further, there was generally no record
of the extent to which quality of care problems were addressed or
what, if any, action was taken to deal with the problems identified. 
As a result, corrective actions, if taken, cannot be identified and
trends cannot be established to point the way for improvement. 

Peer review in both VA and non-VA facilities is a highly subjective
process that places heavy reliance on professional judgment.  While
experts recognize that some element of professional judgment will
always be present in peer review, the development of practice
guidelines and use of peer review by committee can help to reduce it. 
VA has begun to develop its own practice guidelines, and some VA
medical centers are using the committee approach to peer review. 

By establishing restrictive procedures for reporting to the National
Practitioner Data Bank, VA medical centers are not reporting to the
Data Bank many of the malpractice payments made on behalf of
physicians, dentists, and other licensed health care practitioners or
the adverse actions\1 taken against physicians' and other
practitioners' clinical privileges.  Failure to make such reports can
result in practitioners who have provided patients with less than
optimal care being allowed to (1) leave VA employment with no record
of having been involved in a malpractice claim or an adverse action
or (2) remain in the VA system without any indication on their record
that problems may exist with their performance. 


--------------------
\1 An adverse action is one that results in a reduction, revocation,
or suspension of a physician, dentist, or other health care
practitioner's clinical privileges, licensure, or membership in a
professional society.  An adverse action is based on a professional
review of a practitioner's professional competence or conduct. 


   BACKGROUND
------------------------------------------------------------ Letter :2

VA employs approximately 10,000 physicians in its 158 medical
centers.  To help ensure that the care these physicians provide meets
accepted professional standards, VA uses several systems to monitor
and evaluate physician practice.  These systems include surgical case
review, external peer review, credentialing and privileging,
malpractice claim analysis, and occurrence screens.\2 An integral
part of VA's process is physician peer review--physicians evaluating
the medical care provided by other physicians. 

Peer review in VA is used by medical centers to determine if
practitioner care is less than optimal and is initiated when an
occurrence screen identifies potential quality of care problems. 
Peer review is also used to establish the basis for the granting of
privileges to physicians and to examine malpractice claims made
against health care professionals in the medical center.  No
disciplinary action is taken against a physician's privileges after a
peer review following an occurrence screen.  This is because quality
assurance information, such as occurrence screen peer review data, is
confidential and cannot be used in disciplinary proceedings. 
However, peer review findings can be used by medical center
management to initiate a formal investigation of a physician's
performance or conduct after which disciplinary action can be taken. 

VA guidance, issued in April 1994, presents various methods for
conducting peer review but does not mandate a specific peer review
technique.  Specifically, the guidance discusses the disadvantages of
the single reviewer approach and presents three types of multiple
reviewer techniques:  (1) committee review, (2) multiple independent
review, and (3) discussion to consensus.  At the six medical centers
we visited, two methods of peer review were being utilized:  multiple
independent review and committee review.  (See app.  II for a
discussion of these approaches.)

Regardless of the approach used, the result of any peer review is an
evaluation of the care provided by a practitioner and a preliminary
determination as to how, in the reviewer's opinion, other physicians
would have handled the case.  Cases rated as a level 1 (most
experienced, competent practitioners would handle case similarly)
usually receive no further action.  Cases rated as a level 2 (most
experienced, competent practitioners might handle the case
differently) or a level 3 (most experienced, competent practitioners
would handle the case differently) receive a supervisory review by
the responsible clinical service chief, such as the chief of surgery. 

All physicians and dentists employed by VA are subject to privileging
procedures.  Privileging is the process by which a practitioner is
granted permission by the institution to provide medical or other
patient care services within defined limits on the basis of an
individual's clinical competence as determined by peer references. 
Privileging is done at the time of employment and every 2 years
thereafter.  However, a physician's privileges can be examined at any
time if a question about his or her performance or competence is
raised. 

The National Practitioner Data Bank was created under Title IV of
Public Law 99-660, the Health Care Quality Improvement Act of 1986. 
The act calls for (1) insurance companies and certain self-insured
health care entities to report malpractice payments made for the
benefit of a physician, dentist, or other licensed health care
practitioner to the Data Bank and (2) hospitals and other authorized
health care entities, licensing boards, and professional societies to
report professional review actions relating to possible incompetence
or improper professional conduct adversely affecting the clinical
privileges, licensure, or membership in a professional society of a
practitioner for longer than 30 days to the Data Bank. 

The intent of the act is to improve the quality of medical care by
encouraging physicians, dentists, and other health care practitioners
to identify and discipline those who engage in unprofessional
behavior and to restrict the ability of incompetent physicians,
dentists, and other health care practitioners to move from state to
state without disclosure or discovery of their previous damaging or
incompetent performance.  The Data Bank acts as a clearinghouse for
information about licensed practitioners' paid malpractice claims and
adverse actions on licensure, clinical privileges, and professional
society membership.  It has two main functions:  (1) responding to
queries about practitioners from authorized health care entities and
hospitals and (2) collecting and storing adverse actions and
malpractice payment information. 

Although the act does not require VA medical centers to participate
in the Data Bank, it directs the Secretary of Health and Human
Services (HHS) to enter into a memorandum of understanding with the
Administrator of the Veterans Administration (now VA) to apply the
reporting requirements of the act to health care facilities under
VA's jurisdiction.  Accordingly, a memorandum of understanding was
signed in November 1990, followed by interpretive rules effective
October 1991. 


--------------------
\2 An occurrence screen is the professional review of cases involving
adverse outcomes to identify opportunities for improvement of care. 


   PEER REVIEW PROCESS IDENTIFIES
   QUALITY OF CARE PROBLEMS
------------------------------------------------------------ Letter :3

VA's physician peer review process is identifying cases needing
management attention at the six medical centers that we visited. 
Specifically, in fiscal year 1993, peer reviewers at these locations
reviewed a total of 563 cases referred from the occurrence screen
process involving potential quality of care problems.  In 373 of
these cases, peer reviewers decided that most experienced, competent
practitioners would have handled the case similarly; in 136 cases,
the peer reviewers believed that most experienced, competent
practitioners might have handled the case differently; and in 54
cases, the peer reviewers believed that most experienced, competent
practitioners would have handled the case differently. 

Each of the VA medical centers that we visited uses occurrence
screens to identify potential physician performance problems that may
warrant a peer review.  Under this process, cases are screened
against a predetermined list of criteria, usually by nurses.  Those
cases that involve one or more of the occurrences will be reviewed to
identify possible problems in patient care.  Occurrences that are
reviewed include, but are not limited to, the following: 

  readmittance within 10 days of an inpatient stay;

  readmittance within 3 days of an outpatient visit;

  return to special care unit, such as intensive care;

  return to operating room; and

  death. 

Any case for which the occurrence screen results show that a
potential quality of care problem may exist is referred to the
cognizant service chief for medical peer review.  Table 1 shows, by
medical center, how the peer reviewers rated the 563 cases. 



                           Table 1
           
             Classification of Occurrence Screen
                   Cases by Peer Reviewers

                               Level   Level   Level
VA medical center                  1       2       3   Total
----------------------------  ------  ------  ------  ------
A                                 49      11       1      61
B                                 65      64      19     148
C                                 75      14       3      92
D                                 51       9       0      60
E                                 37      21      14      72
F                                 96      17      17     130
============================================================
Total                            373     136      54     563
------------------------------------------------------------

      ACTION TAKEN BY SERVICE
      CHIEFS ON PEER REVIEW
      FINDINGS
---------------------------------------------------------- Letter :3.1

VA guidance governing peer review of potential quality of care
problems identified through occurrence screens states that when peer
review indicates that practitioner care is less than optimal, the
cases are sent to the service chief for a determination regarding
corrective action.  The actions chosen by the service chief will be
communicated in writing to the chief of staff and the occurrence
screen program coordinator.  If no action is considered necessary, a
notation to that effect should be made by the service chief. 
However, VA guidance does not explicitly state the extent to which
(1) discussions with a practitioner should be documented or (2) the
reasons for no action being taken should be justified.  As a result,
the worksheets provided to the occurrence screen coordinator
generally contained no elaboration on the action taken.  Of the 50
cases we reviewed where peer reviewers believed that most
experienced, competent practitioners would have handled the case
differently than the physician under review, 32 resulted in a
discussion with the physician, 4 resulted in no action, 8 resulted in
a policy change, and 6 resulted in counseling.\3

Table 2 shows how the service chiefs at the medical centers we
visited dealt with cases that their peer reviewers believed most
experienced, competent practitioners would have handled differently. 



                           Table 2
           
            Actions Taken on Cases Peer Reviewers
               Believed That Most Experienced,
              Competent Practitioners Would Have
                     Handled Differently

                      Number
                          of                  Policy
                       level                       /
                           3              No  proced
                      cases\  Discus  action     ure  Counse
VA medical center          a    sion   taken  change    ling
--------------------  ------  ------  ------  ------  ------
A                          2       1       0       1       0
B                         15      10       1       2       2
C                          3       2       0       0       1
D                          0       0       0       0       0
E                         16      12       1       1       2
F                         14       7       2       4       1
============================================================
Total                     50      32       4       8       6
------------------------------------------------------------
\a These numbers refer to the occurrence screen peer review cases we
reviewed.  The numbers in table 1 refer to all the occurrence screen
peer review cases completed at each medical center we visited. 

Service chiefs clearly favored a discussion of problems over any
other type of action.  But in 32 of the 50 level 3 cases in which a
discussion took place, when we asked for documentation about what was
actually discussed with the practitioner about the peer review
findings or what, if any, corrective actions were agreed upon, we
were told by staff that they could not find information in either the
occurrence screen worksheets or minutes of the service meetings. 
Further, in the 4 cases we reviewed in which no action was taken by a
service chief on peer reviewers' findings, there was no indication in
the occurrence screen worksheets as to why a decision to take no
action was justified. 

VA regulations require cases meeting the occurrence screen criteria
to be entered into an ongoing occurrence screen database, which is
reviewed and analyzed regularly to identify patterns that may be
problematic.  However, when actions taken by the service chiefs are
not being documented for future reference, corrective actions, if
taken, cannot be identified and trends cannot be established to point
the way for improvement. 

In 14 cases, evidence was present that action was taken on the peer
reviewer's findings.  Specifically, in 8 cases, medical center
management revised certain policies and procedures to ensure that the
problems identified by peer reviewers would not recur.  In 6 cases,
physicians were provided counseling on the basis of the peer
reviewer's findings and a record of the incident was placed in the
physician's privileging file.  The incidents triggering formal
counseling included inappropriate medical management of a patient
with diabetes; failure to diagnose, monitor, and treat patients;
failure to communicate resuscitation plans for a terminally ill
patient; failure to monitor patient response to medication and take
appropriate action; and failure to assess a patient and order the
correct dose of medication. 


--------------------
\3 For purposes of this report, a discussion consists of a notation
in the occurrence screen worksheets indicating that a discussion was
held in a staff meeting, with a practitioner, with a resident, with
an attending practitioner, or in an educational conference.  However,
no details of any of these discussions were provided.  Counseling
includes actions specified in the occurrence screen worksheets as
counseled practitioner (without documentation); formal counseling
(letter sent to file); and referral of case for administrative
investigation or review. 


      IMPEDIMENTS TO EFFECTIVE
      PEER REVIEW
---------------------------------------------------------- Letter :3.2

Experts believe that a significant impediment to effective peer
review is the inherent subjectivity involved in determining whether a
potential quality of care problem exists.  The development of
practice guidelines that peer reviewers can use to make performance
judgments is one method suggested by experts to reduce the
subjectivity.  For example, practice guidelines could reduce the
tendency on the part of some peer reviewers to focus on the effect of
a bad patient outcome rather than whether the standard of care was
met. 

In a 1992 Journal of the American Medical Association article, an
official in VA's Office of Quality Management stated that the
development of practice guidelines would be a great aid to improve
peer review.  In a corroborating article, the physician writing about
peer review states that peer judgments regarding appropriateness of
care are strongly influenced by perceived outcomes.\4 This suggests
that the standard of care is often unclear to reviewers.  Practice
guidelines are being developed with increasing frequency in both VA
and the medical community as a whole.  However, at least one expert
does not believe that it will be possible to design guidelines that
will take into account every possible factor that might constitute an
exception to the standard.\5

Other experts note a tendency of some reviewers to give consistently
more lenient or harsh ratings than do others.  For example, some
suggest that only acknowledged experts should be asked to review the
care provided by other practitioners.  In their opinion,

     "picking skilled physician-reviewers may be the central and
     critical step.  Simply choosing a peer physician may not be the
     best strategy; rather, identifying an expert in both the
     condition under study and in quality assessment purposes and
     techniques may be required."\6

At the six medical centers we visited, we found that classification
of peer review findings is a highly subjective activity because no
systemwide clinical criterion exists for peer reviewers to determine
whether physicians would or would not have performed in the same
manner as the physician under review.  As indicated above, such a
situation is not unique to VA and will be resolved only when a
complete set of practice guidelines is used routinely.  Until such
criteria are generally available, a case that might be a level 1 in
VA medical center A might be a level 3 in VA medical center F. 
Levels assigned to cases may also vary among the specialty services
within the medical center. 


--------------------
\4 Caplan, Robert A., and others, "Effect of Outcome on Physician
Judgments of Appropriateness of Care," Journal of the American
Medical Association, Vol.  265, No.  15 (1991), pp.  1957-1960. 

\5 Chassin, Mark R., "Standards of Care in Medicine," Inquiry, Vol. 
25 (1988), pp.  437-453. 

\6 Brook, Robert H., and Kathleen N.  Lohr, "Monitoring Quality of
Care in the Medicare Program," Journal of the American Medical
Association, Vol.  258, No.  21 (1987), p.  3138. 


      PHYSICIAN PERCEPTIONS OF THE
      PEER REVIEW PROCESS IN VA
      ARE MIXED
---------------------------------------------------------- Letter :3.3

The degree to which the concept of peer review is accepted or
embraced by physicians depends to a great extent on how the results
of peer review are utilized by medical center management.  Although
we found differences among services within medical centers, four of
the six VA medical centers we visited are using peer review primarily
to evaluate physician performance and identify physicians who may
have contributed to adverse patient outcomes.  This approach is
resulting in negative perceptions of the peer review process and is
impeding its acceptance among physicians.  At these facilities,
several physicians questioned the usefulness of the peer review
process and did not view it as having an important role in
identifying opportunities for improving care. 

These physicians contend that peer review duplicates other quality
assurance monitors.  For example, the medical service units at each
of the VA medical centers we visited hold morbidity and mortality
conferences to discuss all deaths and clinical complications that
occurred during the week preceding the meeting.  Some of these cases
are later selected for peer review.  But, according to physicians
involved in peer review, the peer reviews do not identify any issues
that are not identified and discussed in the morbidity and mortality
conferences. 

Physicians also told us that peer review committee findings have more
credibility than the findings of a single peer reviewer because the
subjectivity inherent in determining quality of care is reduced. 
Other benefits of the committee approach include identifying the
underlying problem that led to an adverse outcome and greater
physician acceptance of peer review.  Physicians told us that by
focusing on the identification of system issues, they are better able
to identify the underlying cause of an adverse outcome and prevent it
from occurring again. 

Physicians who are members of peer review committees also told us
that the anonymity associated with peer review committees allows them
to be open and honest in their evaluations.  Officials from one VA
medical center that switched from using a single reviewer to a peer
review committee stated that the number of cases rated level 2 or 3
rose when they began using a peer review committee.  Specifically,
during the first 5 months of 1994, the committee assigned more level
3 designations to cases than did individual reviewers in all of 1993. 
At another medical center that began using peer review committees,
the number of cases rated level 2 or 3 by a committee increased by
more than 60 percent. 


   VA IS UNDERREPORTING
   MALPRACTICE PAYMENTS TO THE
   DATA BANK
------------------------------------------------------------ Letter :4

The Health Care Quality Improvement Act of 1986 requires that all
malpractice claims paid on the behalf of a practitioner be reported
to the Data Bank.  However, under rules setting forth VA's policy for
participation in the Data Bank, VA will file a report with the Data
Bank regarding any malpractice payment for the benefit of a
physician, dentist, or other licensed practitioner only when the
director of the facility at which the act or omission occurred
affirms the conclusion of a peer review panel\7 that payment was
related to substandard care, professional incompetence, or
professional misconduct.\8

Thus, before reporting a practitioner to the Data Bank after a
malpractice payment is made, VA is in effect requiring the peer
review panel to make a determination that either the standard of care
was not met or that a practitioner was guilty of professional
incompetence or misconduct.  Adherence to these procedures results in
VA medical centers' not reporting to the Data Bank all malpractice
payments made on behalf of their practitioners. 

The process followed by VA medical centers to deal with malpractice
claims is as follows:  Within 30 days of a claim being filed, the
appropriate VA district counsel notifies the medical center involved
in providing the medical care identified in the allegations that a
claim has been filed.  Medical center personnel then conduct a peer
review to determine if the appropriate standards of care were met. 
These standards can relate to any part of the system (for example,
hospital, outpatient care, equipment, systems in place, and
practitioners).  The medical center forwards the results of the peer
review along with a copy of the Tort Claim Information System data
and a copy of the patient's medical record to both the Armed Forces
Institute of Pathology\9 and the appropriate VA district counsel. 
Upon receipt of the results of the initial peer review, the district
counsel can make a request for the medical opinion of an external
expert.  Finally, the VA district counsel can settle or deny a claim. 

If a payment is made on the claim, the responsible medical center
director will convene a second peer review panel to determine if an
identifiable licensed health care practitioner is involved in the
case.  During this review, a determination is made as to whether the
acts or omission of the practitioners in relation to the patient
injury for which the settlement or judgment was made constituted care
that did not meet generally accepted standards of professional
competence or conduct.  The recommendations of this panel should
determine whether the practitioner involved in the incident is
reported to the Data Bank.  However, before approving the report, the
director will notify the practitioner to be reported and provide him
or her with an opportunity to discuss the situation with appropriate
medical center officials, including the director. 

At the six medical centers we visited, we reviewed 53 paid claim
files in which the claim alleged that an adverse patient outcome was
caused by a licensed practitioner(s).  We found that it was possible
to determine the practitioner(s) associated with the adverse patient
outcome in each of the 53 claims.  However, only four of these
individuals were reported to the Data Bank.  The remaining
practitioners were not reported for a variety of reasons, including
determination by the panel that the standard of care was met (13);
inability to identify the practitioner responsible for the patient
(3); problem was considered to be a system failure (4); belief that
the resident rather than the attending physician was to blame for the
incident (3); patient was at fault (2); no evidence of misconduct,
negligence, or malpractice (6); panel split on the need to report
(1); and practitioner behavior was not clearly outside the standards
of practice (1).  Further, from October 28, 1991, to September 30,
1994, only 73 practitioners from 1,047 paid claims for all VA medical
centers were reported to the Data Bank.  (See app.  III.)

In his response to this report, VA's Under Secretary for Health
stated that there is not necessarily an identifiable practitioner
associated with every malpractice claim because (1) malpractice
claims involving VA are filed against the United States of America
and typically do not name practitioners, (2) payments made are on
behalf of care provided at a VA facility, and (3) the act or omission
for which payment was made is not necessarily practitioner- related. 
The Under Secretary concluded that (1) the VA peer review process is
necessary to determine if there is an identifiable licensed health
care provider for whom it can be said that payment was made and (2)
only if there is an identifiable practitioner can it be said that the
payment was on his or her behalf. 

We agree that malpractice claims are filed against the United States
of America and not against individual practitioners.  We found,
however, that identifying practitioners involved in a malpractice
claim and on whose behalf it can be said payment was made is not
difficult.  Our review of 558 malpractice claims involving VA that
were paid during fiscal years 1992 and 1993 shows that 422, or 76
percent, involved claims in which it was alleged that an adverse
patient outcome was caused by a licensed practitioner(s).  Of these
practitioners, 409 were physicians. 


--------------------
\7 In November 1994, VA issued a directive indicating that a director
may not overturn the conclusion of a peer review panel. 

\8 Private sector malpractice insurance entities are required to
report to the Data Bank the names of practitioners on whose behalf a
payment has been made in response to a settlement or adjudication of
a claim.  There is no assessment of whether the standards of care
have been met. 

\9 The Armed Forces Institute of Pathology began trending tort claims
for VA in October 1992.  The Institute analyzes the data to determine
where problem areas may exist.  It issued the first of its periodic
reports to VA in April 1994. 


   VA IS NOT REPORTING ADVERSE
   PRIVILEGING ACTIONS TO THE DATA
   BANK
------------------------------------------------------------ Letter :5

Under its memorandum of understanding with HHS, VA has agreed to
report to the Data Bank through state licensing boards any action
that for longer than 30 days reduces, restricts, suspends, or revokes
the clinical privileges of a physician or dentist due to incompetence
or improper professional conduct.  However, regardless of the length
of time an individual's privileges have been affected, VA will not
report adverse actions, including suspensions lasting longer than 30
days, to the Data Bank until all internal appeals have been
satisfied.  Such a policy is not required by the act and can delay
reporting for a considerable time.  For example, one VA medical
center we visited suspended the privileges of two physicians in 1993
and terminated their employment in 1994.  One of these physicians was
reinstated in March 1995 with a formal reprimand.  As of April 4,
1995, the other was still involved in the internal appeals process. 
Neither has been reported to the Data Bank. 

VA's privileging process includes, among other things, evaluation of
a physician's relevant experience and current competence.  It also
includes consideration of any information related to medical
malpractice allegations or judgments, loss of medical staff
membership, loss or reduction of clinical privileges, or challenges
to licensure.  In addition, the evaluation must be determined using
evidence of an individual's current competence.  Initial privileging
is done at the time of employment and every 2 years thereafter. 
However, a physician's privileges can be examined at any time if the
situation requires it; for example, when there is a question of
physician competency or professional conduct. 

From October 28, 1991, through September 30, 1994, nine medical
centers reported 11 adverse actions to the Data Bank.  However, our
analysis shows that the adverse reporting rate for VA medical centers
is lower than the adverse reporting rate of community hospitals.  For
example, in California, VA has 4,008 beds and reported 2 adverse
actions for an average reporting rate of 0.50 reports per 1,000 beds. 
Conversely, community hospitals in California have 105,270 beds and
reported 390 adverse actions for an average reporting rate of 3.7
reports per 1,000 beds.  (See app.  IV for a complete reporting
comparison by state.)

The Under Secretary for Health, in responding to this report, stated
that VA reporting rates are not comparable with community hospital
rates because VA practitioners are employees of VA, not independent
entrepreneurs.  The Under Secretary believes that through appropriate
supervision, service chiefs at the medical centers are identifying
problems and through supervision and progressive discipline, if
necessary, issues are handled before formal privileging actions
occur.  Conversely, in a community hospital, practitioners are not
typically employees of the organization, and the formal privileging
review process is the only legitimate process for review.  The Under
Secretary noted, however, that VA policy requires that licensed
health care practitioners who leave VA employment while under
investigation be reported to the Data Bank immediately. 

Service chiefs at the medical centers we visited told us that they
use formal and informal processes to deal with physicians who have
performance problems.  Formal procedures require due process hearings
that (1) take time to administer, (2) require much documentation, and
(3) involve extensive understanding of the regulations and guidelines
governing such actions.  For example, in fiscal years 1993 and 1994,
action was taken to officially remove three physicians at the medical
centers we visited.  The time involved from the initiation of
disciplinary action to ultimate removal ranged from 5-1/2 months to a
little over 1 year.  Reasons for the varying time frames include
complexity of the issues involved (such as professional misconduct
versus quality of care), multiple independent peer reviews necessary
in two cases and not in the other, and the extent to which the
physicians fought the disciplinary actions.  In each case, the
physician's privileges were restricted for more than 30 days;
however, only one of the three cases was reported to the Data Bank. 
VA policy requires that the appeals process be completed before any
case is reported to the Data Bank, and these physicians had appealed
the suspension and revocation of their privileges and the termination
of their employment. 

Service chiefs at the medical centers we visited also used an
informal process to remove physicians who had performance problems. 
However, the effect is that physicians who may have performance
problems are not reported to the Data Bank.  Further, one service
chief told us that he tends to hire part-time physicians to avoid
having to adhere to the formal procedures for dealing with problem
physicians.  The following is an example of a situation that resulted
in the removal of a problem physician through informal means. 

A service chief reduced a physician's privileges and personally
supervised the physician for 6 months to determine the physician's
competence level.  The service chief concluded that the physicians'
medical skills did not improve during the time of observation and
recommended to the physician that he resign.  The physician took this
advice and resigned from the medical center.  But no documentation of
restricted privileges or other problems appeared in the physician's
credentialing and privileging file. 


   CONCLUSIONS
------------------------------------------------------------ Letter :6

Although physician peer review is performed at the VA medical centers
that we visited and cases of questionable quality of care are
identified, actions taken by service chiefs as the result of peer
review findings are seldom made a matter of record in peer review
files.  Such information could allow management to track the
performance of practitioners over time and help ensure that any
pattern of less than optimal care is quickly identified. 
Documentation also establishes the degree to which management
addressed the issues raised by peer reviewers.  From an
organizational perspective, this establishes accountability on the
part of service chiefs, increases practitioner awareness of the
importance that the medical center places on the delivery of quality
care, and is a good risk-management tool because it requires managers
to go on record as to how a potential problem was addressed. 

By establishing restrictive Data Bank reporting procedures, VA has
shielded its physicians from the professional accountability that is
required of private sector practitioners.  In so doing, VA could be
facilitating the delivery of substandard care outside the VA health
care system by allowing practitioners with poor performance records
to leave its employment with no record of having been involved in a
malpractice claim or an adverse action.  Conversely, failure to
report also allows some physicians who provide patients with less
than optimal care to remain in the VA system without any indication
on their record that problems may exist with their performance. 


   RECOMMENDATIONS
------------------------------------------------------------ Letter :7

We recommend that the Secretary of Veterans Affairs direct the Under
Secretary for Health to

  require service chiefs to fully document all discussions held with
     practitioners involved in cases that peer reviewers conclude
     that most experienced, competent practitioners might or would
     have handled differently, and

  revise the criteria now being used by medical centers to report VA
     practitioners to the National Practitioner Data Bank so that
     they are more consistent with the reporting practices now used
     in the private sector. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

VA's Under Secretary for Health concurred with our recommendation
that service chiefs fully document all discussions held with
practitioners and stated that VA will reinforce, on a systemwide
basis, the requirement that service chiefs must fully document
appropriate actions taken in response to peer review conclusions. 
The Under Secretary also concurred in principle with our
recommendation relating to reporting to the National Practitioner
Data Bank.  While he does not believe that a change in policy is
needed for the reporting of malpractice payments, he does agree that
more timely reporting of initial summary suspensions of physician
privileges lasting longer than 30 days is an option.  In this regard,
he said that a group of knowledgeable program staff will explore all
policy options and report their recommendations to him by the end of
September 1995. 

Under VA's current procedures, the postpayment peer review is made to
determine if there is an identifiable licensed health care
practitioner responsible for a breach in care.  The Under Secretary
stated that effective May 19, 1995, these reviews will be completed
outside of the medical center for which payment was made (for
example, in another medical center).  This is an interim measure, and
VA is in the process of pursuing peer review options that are
external to the VA system, such as utilization of the clinical
reviewers participating in VA's External Peer Review Program. 

We disagree with the Under Secretary's contention that no policy
change is needed with respect to the reporting of malpractice
payments.  VA's policy of reporting only those malpractice payments
involving practitioners who have been determined to have breached the
standard of care remains more restrictive than required under Public
Law 99-660.  The law requires only that all malpractice payments made
on behalf of a physician or licensed health care practitioner be
reported to the Data Bank.  In addition, the law states that payment
of a claim should not be construed as creating a presumption that
medical malpractice has occurred.  Thus, any post-payment peer review
need only determine that the payment was for the benefit of a
practitioner, not that it results from a breach in care. 

We also believe that reporting initial summary suspensions rather
than only final actions should be viewed as more than an option. 
VA's memorandum of understanding with HHS clearly states that it will
report to the Data Bank any action that for longer than 30 days
reduces, restricts, suspends, or revokes the clinical privileges of a
physician or dentist due to incompetence or improper professional
conduct. 


---------------------------------------------------------- Letter :8.1

As arranged with your office, unless you publicly announce its
contents earlier, we plan no further distribution of this report
until 30 days from its issue date.  At that time, copies will be sent
to appropriate congressional committees; the Secretary of Veterans
Affairs; the Director, Office of Management and Budget; and other
interested parties.  We will also make copies available to others
upon request. 

If you have questions on this report, please contact James Carlan,
Assistant Director, Federal Health Care Delivery Issues, on (202)
512-7120.  Other staff contributing to this report were team
coordinators Patrick Gallagher and Patricia Jones and team members
Deena M.  El-Attar, Barbara Mulliken, and George Bogart. 

Sincerely yours,

David P.  Baine
Director, Federal Health Care
 Delivery Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

To accomplish our review, we interviewed VA's medical inspector and
officials in VA's Professional Affairs Office, Quality Management
Planning and Evaluation Office, Office of Personnel and Labor
Relations, and Office of General Counsel.  The objective of these
interviews was to obtain information on (1) the role of peer review
in evaluating physicians and reporting to the National Practitioner
Data Bank and state licensing boards and (2) how VA's Tort Claim
Information System (TCIS) was developed and is being utilized.  We
also visited six VA medical centers\10 selected on the basis of the
number of paid malpractice claims made on behalf of these facilities. 
At each location, we (1) interviewed quality assurance personnel,
physicians who served as peer reviewers, and service chiefs to obtain
their perspectives on the peer review process and (2) reviewed
policies and procedures for peer review quality assurance programs,
minutes of any meetings that dealt with potential quality of care
issues, and documentation pertaining to 191 peer reviews made as a
result of an occurrence screen.  We also reviewed peer review
documentation for 80 tort claims paid and pending for practitioners
in 1992 and 1993 at the six medical centers we visited.  In addition,
we obtained the Armed Forces Institute of Pathology\11 analysis of VA
tort claim information for fiscal year 1993 for all VA medical
centers and reviewed HHS information on VA's participation in
reporting to the Data Bank. 


--------------------
\10 We visited four university affiliated medical centers: 
Cleveland, Ohio; Houston, Texas; Hines, Illinois; and St.  Louis,
Missouri.  And we visited two nonuniversity affiliated medical
centers:  Martinsburg, West Virginia, and Fayetteville, North
Carolina. 

\11 The Armed Forces Institute of Pathology is a triservice
organization "sponsored" by the Army Surgeon General's Office.  The
three Department of Defense services--Army, Navy, Air Force--are
required to report all malpractice claims to the Institute.  VA has
an agreement with this organization wherein the Institute will
analyze all VA medical malpractice cases referred to it and report
its findings back to VA. 


TYPES OF PEER REVIEW CONDUCTED IN
THE MEDICAL CENTERS WE VISITED
========================================================== Appendix II

Under the multiple independent reviewer approach, which is being used
at the Cleveland, Hines, and Martinsburg medical centers, physicians
selected by the service chief individually review the work of a
colleague within the same service; for example, surgeons review the
work of other surgeons.  During this review, the medical records
associated with a case are examined and any physicians or others
involved in the case may be interviewed.  Each peer reviewer
independently evaluates the quality of care involved in the case and
makes a preliminary determination as to how, in his or her opinion,
other physicians would have handled the case.  In those cases where
the service chief and a peer reviewer disagree, the service chief's
opinion will prevail.  The service chief also determines the extent
to which follow-up action will be taken on the case. 

The Fayetteville, Houston, and St.  Louis medical centers use a
committee approach to peer review.  While each committee is
multidisciplinary and comprised of elected or appointed
representatives from the major medical services such as surgery and
medicine, each committee conducts peer reviews somewhat differently. 
In Fayetteville, the peer review committee, which consists of all the
service chiefs, performs the peer review as a group and determines
what action to take.  The Houston peer review committee selects
individual members of the peer review committee to review cases and
present their findings to the entire committee for discussion and
level determination.  While the committee makes the final peer review
level determination, the service chiefs determine what action to
take.  In St.  Louis, all service level peer reviews are submitted to
a Quality Assurance/Quality Improvement Committee, which then
performs another peer review to validate the original review.  The
committee has the final decision-making authority regarding the level
assigned and will often recommend what action should be taken and
then follow up to ensure that the recommended action occurs. 


ADVERSE ACTION AND MALPRACTICE
PAYMENT REPORTS SUBMITTED TO THE
DATA BANK, BY VA MEDICAL CENTER
(OCT.  28, 1991-SEPT.  30, 1994)
========================================================= Appendix III

                                              Advers  Malpra
                                                   e   ctice
                                              action  paymen
                                                   s      ts
                                              report  report
VA medical center                                 ed      ed
--------------------------------------------  ------  ------
Phoenix, Arizona                                  --       2
Little Rock, Arkansas                             --       3
Livermore, California                             --       1
Long Beach, California                             1       1
San Diego, California                             --       2
California clinics                                 1       2
Denver, Colorado                                  --       1
Grand Junction, Colorado                           1       1
Bay Pines, Florida                                --       1
Gainesville, Florida                              --       1
Danville, Illinois                                --       1
Hines, Illinois                                   --       1
North Chicago, Illinois                           --       4
Lexington, Kentucky                               --       2
New Orleans, Louisiana                            --       1
Togus, Maine                                      --       1
Bedford, Massachusetts                            --       1
Boston, Massachusetts                             --       1
Battle Creek, Michigan                            --       2
Minneapolis, Minnesota                            --       3
Biloxi, Mississippi                               --       1
Poplar Bluff, Missouri                            --       1
St. Louis, Missouri                               --       1
Fort Harrison, Montana                            --       2
Manchester, New Hampshire                         --       1
East Orange, New Jersey                            1      --
Lyons, New Jersey                                  1       1
Albuquerque, New Mexico                           --       2
Bronx, New York                                    1      --
Fayetteville, North Carolina                      --       1
Chillicothe, Ohio                                 --       1
Dayton, Ohio                                      --       1
Muskogee, Oklahoma                                --       1
Portland, Oregon                                  --       1
Roseburg, Oregon                                  --       2
Altoona, Pennsylvania                              2       2
Erie, Pennsylvania                                --       1
Pittsburgh, Pennsylvania                          --       2
Wilkes-Barre, Pennsylvania                        --       1
Providence, Rhode Island                           1      --
Fort Meade, South Dakota                          --       1
Mountain Home, Tennessee                          --       1
Amarillo, Texas                                   --       1
Dallas, Texas                                     --       1
Houston, Texas                                     1      --
San Antonio, Texas                                --       1
Temple, Texas                                     --       1
Waco, Texas                                        1      --
Richmond, Virginia                                --       1
Salem, Virginia                                   --       1
Spokane, Washington                               --       1
Tacoma, Washington                                --       1
Walla Walla, Washington                           --       1
Milwaukee, Wisconsin                              --       1
Huntington, West Virginia                         --       2
Martinsburg, West Virginia                        --       1
Undesignated                                      --       4
============================================================
Total                                             11      73
------------------------------------------------------------

VA AND COMMUNITY HOSPITAL ADVERSE
ACTION REPORTING RATES PER 1,000
BEDS
========================================================== Appendix IV

This appendix presents a comparison of VA's and community hospitals'
reported adverse actions per 1,000 hospital beds.  This analysis
shows that VA hospitals are not reporting at the same rate as other
hospitals in the same state.  The analysis used information from an
HHS Inspector General's report that concluded that most hospitals are
underreporting to the Data Bank.  VA's adverse action reports are
from its first 3 years' participation in the Data Bank, October 28,
1991, through September 30, 1994.  The community hospitals' adverse
action reports are from the first 3-1/2 years of the Data Bank's
operation, September 1, 1990, through December 31, 1993.  Only nine
VA medical centers in seven states reported adverse actions. 
Hospitals in all states reported adverse actions. 



                           Table IV.1
            
            VA and Community Hospital Adverse Action
                 Reporting Rates per 1,000 Beds


                        Report  Report          Report  Report
                Number    s to   s per  Number    s to   s per
                    of    Data   1,000      of    Data   1,000
State             beds    Bank    beds    beds    Bank    beds
--------------  ------  ------  ------  ------  ------  ------
Alabama          1,471       0    0.00  23,574      33     1.4
Alaska               0       0    0.00   1,909       6     3.1
Arizona            770       0    0.00  13,629      94     6.9
Arkansas           927       0    0.00  13,328      24     1.8
California       4,008       2    0.50  105,27     390     3.7
                                             0
Colorado           534       1    1.87  13,691      90     6.6
Connecticut        569       0    0.00  14,238      25     1.8
Delaware           150       0    0.00   2,808      11     3.9
District of        580       0    0.00   7,527      61     8.1
 Columbia
Florida          2,388       0    0.00  63,415     174     2.7
Georgia          1,450       0    0.00  36,334      91     2.5
Hawaii               0       0    0.00   4,274       6     1.4
Idaho              118       0    0.00   4,045       6     1.5
Illinois         2,789       0    0.00  57,343      84     1.5
Indiana            841       0    0.00  26,143      90     3.4
Iowa               603       0    0.00  17,009      30     1.8
Kansas             871       0    0.00  15,477      52     3.4
Kentucky           916       0    0.00  19,052      43     2.3
Louisiana          855       0    0.00  23,980      35     1.5
Maine              272       0    0.00   6,083      23     3.8
Maryland           987       0    0.00  19,982      70     3.5
Massachusetts    1,942       0    0.00  31,973      55     1.7
Michigan         1,486       0    0.00  39,913     116     2.9
Minnesota          801       0    0.00  24,019      35     1.5
Mississippi        809       0    0.00  17,577      19     1.1
Missouri         1,159       0    0.00  29,455      56     1.9
Montana            153       0    0.00   4,742      10     2.1
Nebraska           399       0    0.00  10,292      30     2.9
Nevada             124       0    0.00   4,144      35     8.5
New Hampshire      108       0    0.00   4,831      17     3.5
New Jersey       1,297       2    1.54  37,796     117     3.1
New Mexico         449       0    0.00   6,867      17     2.5
New York         4,784       1    0.21  102,03     210     2.1
                                             6
North Carolina   1,375       0    0.00  30,151      52     1.7
North Dakota       119       0    0.00   5,213      11     2.1
Ohio             1,626       0    0.00  51,701     149     2.9
Oklahoma           424       0    0.00  15,100      50     3.3
Oregon             639       0    0.00  10,153      38     3.7
Pennsylvania     3,149       2    0.64  66,298     116     1.8
Rhode Island       156       1    6.41   4,301       9     2.1
South Carolina     579       0    0.00  15,166      29     1.9
South Dakota       506       0    0.00   5,450       4     0.7
Tennessee        1,840       0    0.00  29,420      37     1.3
Texas            3,601       2    0.56  79,982     190     2.4
Utah               305       0    0.00   5,641      20     3.6
Vermont            120       0    0.00   2,290       6     2.6
Virginia         1,298       0    0.00  29,349     124     4.2
Washington         813       0    0.00  15,735      88     5.6
West Virginia      772       0    0.00  10,590      18     1.7
Wisconsin        1,103       0    0.00  23,971      50     2.1
Wyoming            283       0    0.00   3,026       8     2.6
--------------------------------------------------------------
