Medical directors use existing VA processes, including the  credentialing and privileging process, to monitor contract providers. Reviewed Contracts Included Performance Requirements, but Lacked Complete Detail Needed to Hold Contractors Accountable in Some Cases

We found that all 12 contracts we reviewed from the four VAMCs we  visited contained performance requirements consistent with VA  acquisition policy. For this category, the  Seattle VAMC cardiothoracic contract had detailed performance  requirements, but the Minneapolis VAMC cardiothoracic contract did not  contain a statement describing the provider’s responsibilities for the  reporting of and response to adverse events and patient complaints, a component we assessed within the clinical practice standards category.In addition, the Nashville VAMC specialty care contract for the services of  a psychiatrist had limited detail because it did not contain requirements  for the clinical contractor’s privileges to be renewed at the beginning of  each new contract term, and received a partial rating in the medical  record documentation category because the contract did not contain  performance requirements for the timely entry of information into VA’s  electronic medical record. Type of provider or care. Business processes. Absent available tools, such as standard templates for common types of  contracts—including those for CBOCs, specialty care, and temporary  clinical providers—VA cannot reasonably ensure that critical requirements  for contract providers’ performance are consistently included in VA clinical  contracts and are standardized across VAMCs. CORs Reported that Heavy Workloads and Inadequate Training Make It Difficult to Effectively Monitor Contract Providers’ Performance

During our review of 12 clinical contracts at four VAMCs, CORs reported  two challenges that may compromise VA’s monitoring of contractors’  performance—the heavy workload associated with the COR position and  the lack of adequate training for CORs. Most CORs at the four VAMCs we  visited reported that they had other primary duties—including managing  staff—that required them to approach their COR responsibilities as a  collateral duty. The majority of these  CORs said that one of their greatest challenges is not having adequate  time to fulfill their COR duties and responsibilities and that the demands  of their primary positions prevented them from fully monitoring clinical  contractors’ performance. We found that VA’s current guidance related to COR responsibilities does  not include any information on how VAMCs are to determine the  feasibility of whether a COR’s workload—including both COR and primary  position responsibilities—will allow them to carry out their tasks as CORs  for monitoring contract provider performance. Included little information on monitoring responsibilities. VA officials told us that, while the Procurement Operations Office sets  a goal to review COR files from two network contracting offices each  month, since implementing the program in March 2013 these reviews  have been completed in only four network contracting offices and  none of these four offices have received feedback on the outcomes of  these reviews as of August 2013. Without a  robust monitoring system in place, VA cannot reasonably assure that all  CORs in all VAMCs are maintaining the proper records of their efforts to  monitor the activities of clinical contractors caring for veterans. While VA has undertaken efforts to provide supplemental  training to CORs on clinical contracts, this additional training fails to  address how CORs should monitor clinical contracts and instead focuses  on the development of contracts. Finally, VA Central Office currently provides limited oversight of clinical  contract monitoring activities. Recommendations for Executive Action

To improve the monitoring and oversight of clinical contracts, we  recommend that the Secretary of Veterans Affairs direct the Under  Secretary for Health to take the following five actions:
Develop and disseminate tools, such as standard templates, for the  most common types of clinical contracts in VA’s health care system. Appendix I: Objectives, Scope and Methodology

This appendix describes the information and methods we used to  examine: (1) the extent to which the Department of Veterans Affairs (VA)  establishes complete performance requirements for clinical contractors;  (2) the extent to which VA clinical contracts include clear and measurable  performance standards for assessing whether or not clinical contractors  met the acceptable quality levels defined in selected contracts;   (3) challenges VA staff encounter in monitoring clinical contractors’  performance; and (4) the extent to which VA Central Office provides  oversight of VA staff responsible for monitoring clinical contracts. To identify VAMCs for our site visits, we:
Selected VAMCs that were located in different Veterans Integrated  Service Networks (VISN) to ensure that our selected VAMCs varied in  their geographic locations and reported to different VISN management  officials;
Ensured that our selected VAMCs had a variety of active clinical  contracts in place to allow for a variety of COR perspectives on  clinical contractor monitoring; and
Selected at least one VAMC from each of VA’s three Service Area  Offices (SAO)—the regional contract management entities created to  oversee the activities of the 21 network contracting offices and the  contracting officers (CO) and supervisors that work within them. We also verified these  categories with officials from the Medical Sharing Office, Procurement  Operations Office, and Procurement Audit Office to ensure they were an  accurate reflection of performance requirements that should be included  in VA clinical contracts.
Why GAO Did This Study

VA must frequently contract with non-VA health care providers so that clinical providers are available to meet veterans' health care needs. While recent studies have disclosed problems with VA's development of contracts for clinical services, there has been little scrutiny of how VA monitors and evaluates the care contract providers give to veterans.
GAO was asked to review VA's efforts to monitor clinical contractors working in VA facilities. This report examines the extent to which VA establishes complete performance requirements for contract providers, challenges VA staff encounter in monitoring contract providers' performance, and the extent to which VA oversees VAMC staff responsible for monitoring contract providers.
GAO reviewed VA acquisition regulations and other guidance. In addition, GAO visited four VAMCs that varied in geographic location and selected a nongeneralizable sample of three types of clinical contracts from each of the four VAMCs to review. GAO discussed how VAMC and VISN staff monitor and oversee these contracts and reviewed contract monitoring documentation.

What GAO Found

All 12 contracts GAO reviewed from the four Department of Veterans Affairs' (VA) medical centers (VAMC) visited contained performance requirements consistent with VA acquisition policy. However, the performance requirements lacked detail in six categories: type of provider or care; credentialing and privileging; clinical practice standards; medical record documentation; business processes; and access to care. GAO identified these categories from reviews of VA acquisition regulations, VA policies, and hospital accreditation standards; and VA officials verified that these six categories were an accurate reflection of performance requirements that should be in VA clinical contracts. GAO found, for example, one VAMC cardiothoracic contract that had detailed performance requirements while another VAMC's cardiothoracic contract did not contain a statement describing the contract provider's responsibilities for reporting and responding to adverse events and patient complaints. GAO also found that contracting officials lack tools, such as standard templates, that provide examples of the performance requirements that should be included in common types of clinical contracts. Such tools would help ensure consistency in requirements across contracts.
Contracting officer's representatives (COR) cited two main challenges in monitoring contract providers' performance--too little time to monitor clinical contractors' performance effectively and inadequate training. Most of the 40 CORs at the four VAMCs in GAO's review said that their clinical contract monitoring duties were a collateral duty and that they had other primary responsibilities, such as serving as a business manager or administrative officer for a specialty clinic within the VAMC. GAO found that, on average, each of these 40 CORs spent about 25 percent of their time monitoring an average of 12 contracts. CORs said the demands of their primary positions at times prevented them from fully monitoring contract providers' performance. Further, VA's current guidance related to COR responsibilities does not include any information on how VAMCs are to determine the feasibility of whether a COR's workload--including both COR and primary position responsibilities--will allow them to carry out their tasks as CORs for monitoring contract provider performance. GAO also found that current VA COR training programs focus on contracts that buy goods, not clinical services, and include little information on monitoring responsibilities. CORs questioned the usefulness of the COR training VA uses to prepare them for monitoring clinical contracts.
VA Central Office conducts limited oversight of COR and contract monitoring activities. VA Central Office reviews of COR clinical contractor monitoring activities are limited to a small number of annual file reviews that focus on verifying the presence of required documentation only and do not assess the quality of CORs' monitoring activities. Since implementing the program in March 2013 these reviews have been conducted in 4 of 21 network contracting offices and as of August 2013 none of the 4 offices has received feedback on these reviews. Without a robust monitoring system, VA cannot ensure that all CORs in its VAMCs are properly monitoring, evaluating, and documenting the performance of contract providers caring for veterans.

What GAO Recommends

GAO recommends that VA develop and disseminate standard templates that provide examples of performance requirements for clinical contracts, revise guidance for CORs to include workload information, modify COR training, and improve the monitoring and oversight of clinical contracts. VA concurred with GAO's recommendations.