Because VAMCs generally have discretion in which of  these processes they choose to use to respond to an adverse event,  different VAMCs may choose different processes in response to  experiencing similar adverse events. According to VHA policy, VAMCs can use both protected and  nonprotected processes concurrently or consecutively as long as  protected and nonprotected processes and data collection are kept  separate. For example, if a provider meets a VAMC’s  peer review triggers by receiving three peer review level of care ratings of  3—meaning that the most experienced, competent providers would have  managed the cases differently—within a 12-month period, then VAMC  officials would be prompted to conduct a detailed assessment of the  provider’s care, and address concerns about the provider’s ability to  deliver safe, quality patient care by conducting an FPPE. The FPPE is a time-limited period during which medical staff  leadership assesses the provider’s professional performance and ability  to improve. VA and VHA Monitoring Responsibilities

There are several VA and VHA organizational components that are  involved in monitoring VAMCs’ adverse events and related processes. The VA OIG Office of Healthcare Inspections  inspects individual health care issues and performs quality program  assistance reviews of VAMC operations. VAMCs Did Not Adhere to Certain Policy Elements of the Protected Peer Review Process, and Monitoring by VHA Is Limited

		VAMCs Did Not Adhere to Certain Policy Elements of the Protected Peer Review Process

According to VHA’s protected peer review policy, and supported by  federal internal control standards for risk assessment and information and  communications, VHA’s protected peer review policy requirements should  ensure that identified patient safety risks are mitigated and lead to  organizational improvements and optimal patient outcomes. Moreover, the delayed establishment of the peer review  triggers by some VAMCs may have resulted in missed opportunities to  identify providers who posed a risk to patient safety and to conduct an  FPPE, which would have allowed any warranted action to be taken  against the provider. Officials from the VISNs that  oversee the four VAMCs we visited told us they monitor VAMCs’  protected peer review processes through quarterly data monitoring and  annual site visits, as required by VHA’s protected peer review policy. However, VISNs, VHA, and VA OIG have not monitored whether  the triggers have actually been implemented. Because neither VHA’s Office of Risk Management nor VA OIG review  whether peer review triggers have been implemented, VHA cannot  provide reasonable assurance that VAMCs are using the triggers as a risk  assessment tool as intended. VAMC’s Adherence to the FPPE Process Is Unclear Due to Gaps in Policy Addressing Documentation Requirements; VHA Does Not Routinely Monitor Nonprotected Processes

		Gaps in Policy Create Lack of Clarity as to How VAMCs Are to Document the FPPE Process; Requirements for AIBs Generally Are Clear

FPPEs. VHA’s FPPE policy provides a general definition of an FPPE, that it can  be used for cause (when a question arises regarding a provider’s ability to  provide safe, quality patient care), that the criteria for the FPPE should be  defined by the VAMC in advance, and that the results of the FPPE must  be documented in the provider’s profile. However, there are gaps in  VHA’s policy regarding how these evaluations should be documented and  what information should be included, which limited our ability to assess  VAMCs’ adherence to the FPPE policy. Officials from the VAMCs we visited were generally aware that FPPEs  can be used to address concerns about the quality of a provider’s care;  are time limited; and are not disciplinary, but could ultimately be used to  take adverse action against a provider, if necessary. The fourth VAMC initially provided us with documentation of one  FPPE, including a completed template identifying the clinical service  involved, the method of evaluation, the evaluator’s findings, and the  service chief’s conclusions; and several documents, each with  focused professional practice evaluation labeled at the top, specifying  the medical records evaluated for the FPPE and the evaluator’s  comments on each case. This disagreement illustrates that even within the same  facility the interpretation of VHA’s policy on FPPEs differs, which can  lead to potentially inappropriate use. Gaps in VHA’s policy on FPPE documentation requirements create a lack  of clarity and therefore may affect VAMCs’ ability to appropriately  document the evaluation of providers’ skills, support any actions initiated,  and track provider-specific FPPE-related incidents over time. VHA Does Not Routinely Monitor Nonprotected Processes

FPPEs. The VISN Chief Medical Officer is  responsible for oversight of the credentialing and privileging process of  the VAMCs within the VISN. Although officials at the four VAMCs we reviewed  generally understood the protected peer review process, we found that  none of these four VAMCs adhered to all four VHA protected peer review  policy elements selected for review, such as completing peer reviews  within required time frames and sending the required peer-reviewed  cases to the peer review committee for further assessment. As such, VHA  may be missing opportunities for improvements both in the practice of  individual providers and organizationally. Inadequate documentation of the FPPE process may result in VAMC  officials being unable to take adverse action against a provider when  necessary. To address protected peer review process requirements, we recommend  that the Secretary of Veterans Affairs direct the Under Secretary for  Health to ensure that VAMCs send all required initial peer reviews (level of care  2 and 3) to the peer review committee; ensure VAMCs’ peer review committees complete final peer reviews  within 120 calendar days; provide clear guidance and assistance on the purpose, development,  and implementation of peer review triggers; and  require VAMCs to periodically provide data on peer review triggers,  including the number of providers that have exceeded the triggers as  part of the protected peer review data VAMCs report to VISNs on a  quarterly basis.
Why GAO Did This Study

Adverse events--clinical incidents that may pose the risk of injury to a patient as the result of a medical intervention, rather than the patient's underlying health condition--can occur in all health care delivery settings. VAMCs can use one or more of the protected (confidential and nonpunitive) and nonprotected processes to evaluate the role of individual providers in adverse events. GAO was asked to review the extent to which processes used to respond to adverse events are carried out across VAMCs. In this report, GAO examined (1) VAMCs' adherence to VHA's protected peer review process, and the extent to which VHA monitors this process, and (2) VAMCs' adherence to VHA's nonprotected processes and the extent to which VHA monitors these processes. To conduct this work, GAO visited four VAMCs selected for variation in size, complexity of surgeries typically performed, and location. GAO reviewed VHA policies and federal internal control standards and analyzed data from the four selected VAMCs. GAO also interviewed VHA and VA OIG officials, as well as officials from VISNs of the four selected VAMCs.

What GAO Found

The Department of Veterans Affairs (VA) medical centers GAO visited did not adhere to certain policy elements of the protected peer review process, and monitoring by VA's Veterans Health Administration (VHA) is limited. According to policy issued by VHA, protected peer review may be used by VA medical centers (VAMC) when there is a need to determine whether a provider's actions associated with an adverse event were clinically appropriate--that is, whether another provider with similar expertise would have taken similar action. Despite VAMC officials' general understanding of the protected peer review process, none of the VAMCs GAO visited adhered to all four protected peer review policy elements selected for review, including the timely completion of reviews, and the timely development of peer review triggers that signal the need for further review of a provider's care. Failure of VAMCs to adhere to the protected peer review policy elements may result in missed opportunities to identify providers who pose a risk to patient safety. Veterans Integrated Service Networks (VISN), responsible for oversight of VAMCs, monitor VAMCs' protected peer review processes through quarterly data submissions and annual site visits. A VHA official said that VHA monitors the process by reviewing and analyzing the aggregated quarterly data submitted by VAMCs through the VISNs. The VA Office of the Inspector General (OIG) also conducts oversight of the protected peer review process as part of a larger review of VAMCs' operations. While the VISNs and VA OIG have reviewed VAMCs establishment of peer review triggers to prompt further review of a provider's care, neither they nor VHA has monitored their implementation. As such, VHA cannot provide reasonable assurance that VAMCs are using the peer review triggers as intended, as a risk assessment tool. This weakens VAMCs' ability to ensure they are identifying providers that are unable to deliver safe, quality patient care.
VAMCs' adherence to the nonprotected focused professional practice evaluation (FPPE) process is unclear due to gaps in VHA's policy on documentation requirements, and VHA does not routinely monitor nonprotected processes. An FPPE for cause is a time-limited evaluation during which the VAMC assesses the provider's professional competence when a question arises regarding the provider's ability to provide safe, quality patient care. Information collected through the FPPE can be used to inform adverse actions, such as limiting the provider's scope of care. Although VAMC officials were generally aware of the FPPE process, there are gaps in VHA's policy regarding how these evaluations should be documented and what information should be included, which limited GAO's ability to assess VAMCs' adherence to the process. For example, one VAMC provided GAO with documentation labeled as an FPPE and identified by the service chief as an FPPE; however, the quality manager said a formal FPPE was not conducted and that the documentation was actually part of a protected peer review. These differing views illustrate that, even within the same facility, gaps in VHA's policy on documenting FPPEs create a lack of clarity and opportunities for misinterpretation and inappropriate use. Moreover, the gaps in VHA's policy may hinder VAMCs' ability to appropriately document the evaluation of a provider's skills, support any actions initiated, and track provider-specific incidents over time. There is no routine monitoring of FPPEs for cause by VHA, VISNs, or VA OIG.

What GAO Recommends

GAO recommends that VA take action to ensure VAMCs adhere to certain elements of the peer review policy, require VAMCs to report data on implementation of peer review triggers, and develop more specific policy to help guide the FPPE process, including documentation requirements. In its written comments, VA generally concurred with GAO's conclusions and recommendations.