Selected Physician Files at Medical Facilities Demonstrated Compliance with Four VA Credentialing and Four Privileging Requirements; a Fifth Privileging Requirement Was Problematic

The physician files we reviewed at the seven VA medical facilities  demonstrated compliance with the four credentialing requirements we  selected for review and four of five VA privileging requirements. VA has not provided guidance to  help facilities find alternative ways to efficiently collect performance  information, outside of a facility’s quality assurance program, that could be  used in privileging decisions. At the seventh medical facility, officials did  not use performance information to renew clinical privileges, as required. However, the performance information cannot be collected as  part of a medical facility’s quality assurance program. Officials at  six medical facilities told us that they used quality assurance 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. However, according to both VA headquarters legal counsel and  the director of VA’s credentialing and privileging program, coding quality  assurance information in this manner and using it to renew clinical  privileges could make this information available for other purposes,  including litigation, and therefore does not comply with VA policy. VA Has Not Established Internal Controls to Help Ensure the Accuracy of Medical 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 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. VA medical facilities we visited  complied with the four VA credentialing requirements we reviewed and all  but one of five privileging requirements—to use information on a  physician’s performance when renewing clinical privileges. Recommendations for Executive Action

To better ensure that VA physicians are qualified to deliver care safely to  veterans, we recommend that the Secretary of Veterans Affairs direct the  Under Secretary for Health to take the following three actions:    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,    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 privileging information. The four credentialing requirements are  1.  verify that all state medical licenses held by physicians are valid;  2.  query the Federation of State Medical Boards (FSMB) database to  determine whether physicians had disciplinary action taken against  any of their licenses, including expired licenses;  3.  verify information provided by physicians on their involvement in  medical malpractice claims at a VA or non-VA medical facility; and  4.  query the National Practitioner Data Bank (NPDB) 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. In collecting information on the  credentialing and privileging requirements from physician files at each  facility, we employed standard data collection techniques to ensure the  accuracy and reliability of the data used in this report, such as  interviewing medical facility officials about the accuracy and timeliness of  the information contained in the physician files we reviewed and taking  steps to have a consistent interpretation of VA’s credentialing and  privileging requirements for the physician files we reviewed at each  medical facility. We interviewed officials at this office to obtain  information about VA’s process and requirements for determining if  substandard care was delivered. VA Health Care: Improved Screening of Practitioners Would Reduce Risk  to Veterans.
Why GAO Did This Study

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.

What GAO Found

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.