DOD Health Care:

Actions Needed to Help Ensure Full Compliance and Complete Documentation for Physician Credentialing and Privileging

GAO-12-31: Published: Dec 15, 2011. Publicly Released: Dec 15, 2011.

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What GAO Found

 

DOD and the military services—Army, Navy, and Air Force—each establish requirements for reviewing physician credentials and competence, but the military services’ requirements are in some cases inconsistent with DOD’s requirements and each other’s. For example, DOD requires disclosure and primary source verification of all state medical licenses a physician has ever held; Navy only requires these steps for licenses held during the previous 10 years. Inconsistencies also exist between DOD’s and the services’ requirements for the use of and primary source verification of certain clinical competence and practice history documents. Such differences may result in MTF noncompliance with requirements that DOD deems important. They may also create challenges for ensuring that all requirements are met for physicians from one military service who are working at an MTF managed by another service. Furthermore, DOD lacks a systematic process to address inconsistencies across requirements, to coordinate revisions to the requirements, and to achieve its goal of standardizing physician credentialing and privileging requirements across the MHS.

 

The five Army MTFs GAO examined did not fully comply with certain Army physician credentialing and privileging requirements. For 34 of the 150 credentials files GAO reviewed, the MTF had not documented proper verification of every state medical license the physician ever held at the time the MTF granted privileges; 7 of these 34 credentials files lacked this documentation for the physician’s only current medical license. In addition, credentials files did not consistently contain documents required to support the physician’s clinical competence, including peer recommendations and performance assessments; 14 files were missing required peer recommendations and 21 files were missing required performance assessments. Further, MTFs were not consistently documenting follow-up conducted on peer recommendations, as required. When required documents were present, they sometimes lacked required information. For example, performance assessments did not consistently contain data to support the assessment, even when an MTF’s form specifically prompted for it. MTFs also lacked a systematic process for compiling and analyzing performance data. Finally, while MTFs usually complied with Army’s requirement to search physicians’ malpractice history, files often lacked information needed to determine if the MTF had documented a complete practice history, as required.

 

Army oversight processes and requirements were insufficient to assure that its MTFs fully complied with requirements and documented complete information to support credentialing and privileging decisions. Army oversight of individual MTFs’ privileging decisions was insufficient to identify the instances of noncompliance and incomplete documentation that GAO observed during its review of credentials files at five selected Army MTFs. In particular, Army lacks a process for reviewing individual MTFs’ credentials files to identify these issues, as do Navy and Air Force. Moreover, weaknesses in Army requirements contributed to noncompliance and incomplete documentation. For example, MTFs did not consistently document follow-up on peer recommendations, in part because existing requirements do not clearly delineate responsibilities for documenting follow-up. Further, Army lacks requirements for documenting certain types of information—such as information on significant MTF deliberations—needed to support credentialing and privileging decisions.

Why GAO Did This Study

The process of credentialing and privileging is central to ensuring that physicians who work in DOD military treatment facilities (MTF) have the appropriate credentials and clinical competence. After an Army physician allegedly shot and killed 13 people at Fort Hood in November 2009, GAO was asked to examine DOD’s physician credentialing and privileging requirements and whether MTFs are fully complying with those requirements. GAO examined the extent to which: (1) DOD ensures that physician credentialing and privileging requirements are consistent across the Military Health System (MHS), (2) Army MTFs are complying with Army’s physician credentialing and privileging requirements, and (3) Army’s existing oversight and physician credentialing and privileging requirements are sufficient to assure compliance and complete documentation. GAO reviewed DOD and service-level requirements and interviewed DOD and military service officials. Because Army has the largest staff of medical personnel, GAO reviewed a nongeneralizable sample of 150 physician credentials files—selected to include a variety of specialties—and interviewed staff at five Army MTFs selected based on size and location.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To help ensure that the military services' requirements for physician credentialing and privileging are consistent across the MHS, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Surgeons General of the military services to establish a DOD-wide process to identify and address existing inconsistencies between DOD's and the military services' physician credentialing and privileging requirements, including those inconsistencies we identified in this report.

    Agency Affected: Department of Defense

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To help ensure that the military services' requirements for physician credentialing and privileging are consistent across the MHS, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Surgeons General of the military services to establish a DOD-wide process to coordinate all current and future efforts to revise physician credentialing and privileging requirements.

    Agency Affected: Department of Defense

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to coordinate individual MTFs' efforts to establish mechanisms to collect and analyze data to evaluate physician performance and support performance assessments.

    Agency Affected: Department of Defense

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to clarify requirements for how MTFs document follow-up on peer recommendations, including who is responsible for documenting follow-up and where that documentation should be filed.

    Agency Affected: Department of Defense

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to clarify requirements for the information that physicians need to provide in their curriculum vitae (CV) so that MTFs can identify unaccounted for periods in practice history, as well as how MTFs should document explanations of any unaccounted for periods.

    Agency Affected: Department of Defense

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to establish requirements for MTFs to document significant events that occur during the review of a credentials file, including which types of significant events should be documented, who is responsible for documenting significant events, and where that documentation should be filed.

    Agency Affected: Department of Defense

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to establish a process to ensure that relevant information from the DPDB is documented in the credentials file.

    Agency Affected: Department of Defense

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To assure that MTFs are fully complying with DOD's and the military services' requirements for physician credentialing and privileging and implementing these requirements appropriately, the Secretary of Defense should direct the Surgeons General of the military services to establish and implement an oversight process to conduct reviews of a sample of credentials files to identify and address areas of noncompliance and incomplete documentation.

    Agency Affected: Department of Defense

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

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