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Improvements in Employment Screening and Physician Privileging 
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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: 

GAO Highlights: 

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

Why GAO Did This Study: 

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 Found: 

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. 

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. 

[Hyperlink, http://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 ekstrandl@gao.gov. 

[End of Section] 

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.[Footnote 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.[Footnote 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.[Footnote 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. 

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.[Footnote 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.[Footnote 5] We performed our work 
from April 2005 to May 2006 in accordance with generally accepted 
government auditing standards. 

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.[Footnote 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.[Footnote 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. 

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. 

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.[Footnote 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. 

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.[Footnote 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.[Footnote 10] 

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.[Footnote 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.[Footnote 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. 

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. 

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. 

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

[See PDF for image] 

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. 

[A] Tested for significance at the 95 percent confidence level. 

[B] Applies 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. 

[C] Applies 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. 

[End of figure] 

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.[Footnote 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.[Footnote 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.[Footnote 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. 

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.[Footnote 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. 

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: 

* expand the human resource management oversight program to include a 
review of VA facilities' compliance with employment screening 
requirements for all types of practitioners, 

* 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, 

* 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: 

* 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 ekstrandl@gao.gov. 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. 

[End of section] 

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.[Footnote 17] 

March 2004 Report Recommendations: 

* 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. 

* 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. 

* Conduct fingerprint-only background investigations for all VA health 
care practitioners with direct patient care access. 

* 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.[Footnote 
18] 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. 

* 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. 

* Perform a background investigation. 

* Query HIPDB. 

* 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. 

* 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.[Footnote 19] 

* Verify that all state medical licenses held by physicians are valid. 

* Query the Federation of State Medical Boards database to determine 
whether physicians had disciplinary action taken against any of their 
licenses, including expired licenses. 

* Verify information provided by physicians on their involvement in 
medical malpractice claims at VA or non-VA facilities. 

* 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.[Footnote 20] 

* Verify that all state medical licenses held by physicians are valid. 

* Verify physicians' training and experience. 

* Assess physicians' clinical competence and health status. 

* 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. 

* Use information on physicians' performances when making decisions 
about whether to renew physicians' clinical privileges. 

FOOTNOTES 

[1] GAO, 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). 

[2] GAO, 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). 

[3] GAO, 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). 

[4] For 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. 

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

[6] A 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. 

[7] VA 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. § 
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. 

[8] Not 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. 

[9] Executive 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. 

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

[11] Reduction 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. 

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

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

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

[15] VA 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. 

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

[17] GAO-04-566. 

[18] GAO-06-544. 

[19] GAO-06-648. 

[20] GAO-06-648. 

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