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VA has policies to ensure that physicians have appropriate qualifications and clinical abilities through the processes of credentialing, privileging, and continuous monitoring of performance. Results of a VA investigatory report in 2008 cited deficiencies in the Marion, Illinois, VA medical center's (VAMC) credentialing and privileging processes and oversight of its surgical program. This report examines VA's policies and guidance to help ensure that information about physician qualifications and performance is accurate and complete, VAMCs' compliance with selected VA credentialing and privileging policies, and their implementation of VA policies to continuously monitor performance. The Government Accountability Office (GAO) reviewed VA's policies, interviewed VA officials, and reviewed a judgmental sample of 30 credentialing and privileging files at each of six VAMCs that GAO visited. GAO selected the files to ensure inclusion of highly paid specialties, newly hired physicians, and other physician characteristics. GAO selected the judgmental sample of six VAMCs based on geographic balance and other factors.

VA's policies and guidance on credentialing, privileging, and continuous monitoring help ensure the collection of accurate and complete information about physician professional qualifications, clinical abilities, and clinical performance. These policies and guidance address or exceed relevant accreditation standards. Following events at the Marion VAMC, VA made policy changes to allow VAMCs to collect more complete and timely information on physician licensure, malpractice, and disciplinary actions. GAO did not find problems at the six VAMCs visited that mirrored the extent of those reported by investigators at the Marion VAMC. However, GAO found that VAMC staff did not consistently follow VA's credentialing and privileging policy requirements selected for review. GAO selected requirements that must be verified each time a physician goes through the credentialing process and must be recorded in VA's Web-based credentialing database. For example, 29 of the 180 credentialing and privileging files reviewed lacked proper verification of state medical licensure. In addition, the VAMCs did not identify instances when physicians appeared to have omitted required information on their applications. For example, GAO identified 21 files where required malpractice information was not disclosed by physicians and was not detected by VAMCs. GAO identified several of these cases in an external database of malpractice settlements and judgments that VAMCs should review. Finally, VA policies lacked sufficient internal controls, such as specifying how compliance should be assessed, to identify and correct problems with VAMCs' noncompliance with credentialing and privileging policies. The six VAMCs GAO visited also exhibited gaps in implementing VA policies and guidance to continuously monitor physician performance. All six VAMCs either failed to document the collection of physician performance information or collected data that were insufficient to adequately gauge performance. In addition, despite VA guidance, confusion over the proper usage of protected physician performance information persisted at the VAMCs GAO visited. Four of the six VAMCs inappropriately used protected information in privileging decisions--a violation of VA policy that may result in public disclosure and render some privileging decisions subject to challenge.

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Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs 1. In order to improve oversight of credentialing, privileging, and continuous monitoring processes at VAMCs, the Secretary of Veterans Affairs should direct the Under Secretary for Health to require Veterans Integrated Service Network (VISN) directors to develop a formal oversight process to systematically review credentialing and privileging files and the information used to support reprivileging of physicians for compliance with VA policies and document results of reviews and corrective actions at least annually. The oversight process should include feedback to VAMC officials about the proper use of legally protected performance information, if necessary. In order to close the feedback loop, the oversight process should describe a method of follow up to measure whether VAMCs corrected identified weaknesses.
Closed - Implemented
VA issued in October 2012 VHA Directive 2012-030, Credentialing of Health Care Professionals, and VHA Handbook 1100.19, Credentialing and Privileging, which state that the Network chief medical officers (CMO) are responsible for oversight of the credentialing and privileging process for the facilities within their networks. The policies specify that networks will use a standardized assessment tool when completing oversight activities. The revised handbook also includes additional detail regarding the proper use of legally protected performance information.
Department of Veterans Affairs 2. In order to improve oversight of credentialing, privileging, and continuous monitoring processes at VAMCs, the Secretary of Veterans Affairs should direct the Under Secretary for Health to update VetPro to more effectively display physician credentialing information. Specifically, VA should improve the display of verified information on VetPro's summary tables and simplify and clarify questions related to malpractice and licensure.
Closed - Not Implemented
VA is in the process of moving all records from VetPro, its current credentialing system, to CCQAS the credentialing system currently used by the Department of Defense. This recommendation to modify VetPro is no longer applicable.
Department of Veterans Affairs 3. In order to improve oversight of credentialing, privileging, and continuous monitoring processes at VAMCs, the Secretary of Veterans Affairs should direct the Under Secretary for Health to collect more information about state medical boards' policies on the release of information, and consider amending VA policy to not require written verification for states that do not provide additional information in addition to what is available by phone or on the state boards' Web sites.
Closed - Implemented
VA's Office of Quality and Performance completed a survey in December 2009 of the 70 State medical boards, 52 State nursing boards, and 52 State dental boards seeking information as to whether or not they would respond to written requests for additional information. VA reports that the survey found that only 17 percent of the medical boards will respond to a request for information concerning open or pending information, and almost 59 percent of the medical boards charge for verification of information that is already on their Web sites. Because of the results of the survey, VA plans to discontinue the requirement for written verification of licensure.

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