VA Health Care:

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

GAO-06-648: Published: May 25, 2006. Publicly Released: Jun 15, 2006.

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

GAO found that the files reviewed at seven VA medical facilities complied with four of VA's credentialing requirements selected for review, and all but one of five privileging requirements. Credentialing is the process of verifying that a physician's professional credentials, such as state medical licenses, are valid and meet VA's requirements for employment. Privileging is the process for determining which health care services a physician is allowed to provide to veterans. For the files GAO reviewed, compliance with the fifth privileging requirement was problematic at six facilities because officials used performance information when renewing clinical privileges but collected all or most of this information through their facility's quality assurance program. This is prohibited under VA policy. In general, VA quality assurance information is confidential, according to federal law and VA policy. According to VA officials, if quality assurance information is used outside of a facility's quality assurance program, it could be used for other purposes, including litigation. The information is protected to encourage physicians to participate in quality assurance programs by reporting and discussing adverse events to help prevent such events from occurring in the future. VA has not provided guidance to help medical facilities find ways to efficiently collect performance information outside of a facility's quality assurance program. At the seventh medical facility, officials did not use performance information to renew clinical privileges, as required. Three of the seven medical facilities did not meet VA's requirement to submit, within 60 days after being notified that the claim was paid, any information on paid VA medical malpractice claims involving facility practitioners, including physicians, to VA's Office of Medical-Legal Affairs. This office reviews the information and determines whether practitioners involved in the claims delivered substandard care, displayed professional incompetence, or engaged in professional misconduct. The office informs facilities of its determinations. When facilities do not submit all relevant VA malpractice information in a timely manner, VA medical facility officials lack complete information that would allow them to make informed decisions about the clinical privileges that their physicians should be granted. VA has not required its medical facilities to establish internal controls to help ensure that privileging information managed by medical staff specialists--who are responsible for obtaining and verifying the information used in the credentialing and privileging processes--is accurate. One facility GAO visited did not identify 106 physicians whose privileging process had not been completed by facility officials for at least 2 years because of inaccurate information provided by the facility's medical staff specialist. As a result, these physicians were practicing at the facility without current clinical privileges. Without accurate information on the privileges that have been granted to physicians and the dates for renewing those privileges, VA medical facility officials will not know if they have failed to renew clinical privileges for any of their physicians in accordance with VA policy.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: VA has issued guidance to VA medical facilities on how to appropriately collect information on individual physician performance and use that information in VA's privileging process. In addition, VA has completed training for credentialers at all its medical facilities on provider-specific profiles to be used at the time of reappraisal and privileging. VA's Office of Quality and Performance launched three new online training programs on 7/13/2007. This training requires participants to enter their names and facility location so that lists can be developed to determine completion of the training. Training for the three new programs (Medical Staff Leadership and Medical Staff Performance Profiles--Parts I and II) was completed on January 31, 2008. VA reported that over 3,200 staff took each of the 3 modules.

    Recommendation: To better ensure that VA physicians are qualified to deliver care safely to veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to provide guidance to medical facilities on how to collect individual physician performance information in accordance with VA's credentialing and privileging policy to use in medical facilities' privileging processes.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Implemented

    Comments: In June 2006, VA's Office of Medical-Legal Affairs began notifying network and VA medical facility directors of delinquencies in reporting this information by the medical facilities. If a medical facility's delinquency in reporting extends longer than 90 days, VA requires the Office of Medical-Legal Affairs to inform not only network and VA medical facility directors but also VA headquarters of the delinquency. Because VA's Office of Medical-Legal Affairs reviews information on paid malpractice claims involving VA physicians to determine whether the physicians delivered substandard care, when VA medical facilities do not submit relevant malpractice claim information to this office, medical facility clinical service chiefs may make privileging decisions without complete information about substandard care provided by physicians.

    Recommendation: To better ensure that VA physicians are qualified to deliver care safely to veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: VA implemented our recommendation by first asking network directors to report on how they tracked the privileging status of VA physicians. In response to a VA memorandum sent on May 16, 2006, network directors provided a report indicating that their medical facilities had one or more mechanisms in place to identify physicians who were currently privileged at their facilities and to track whether their privileges have expired. In addition, VA instructed its network directors to monitor the internal controls at their facilities that ensure that VA medical facilities have accurate clinical privileging information and that physicians are not practicing with expired clinical privileges.

    Recommendation: To better ensure that VA physicians are qualified to deliver care safely to veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to instruct medical facilities to establish internal controls to ensure the accuracy of their privileging information.

    Agency Affected: Department of Veterans Affairs

 

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