Reviewing Concerns about Providers’ Clinical Care and Taking Adverse Privileging Actions

Once a concern about a provider’s clinical care is identified, VHA policy  and guidance establish processes for VAMC officials to use to review the  concern and determine whether an action should be taken against the  provider’s clinical privileges. Once a review is completed, VAMC leadership officials and the VAMC  credentialing committee make decisions about next steps, which could  include the following: do nothing, if the review did not substantiate the concerns;  conduct further review (such as an FPPE for cause to allow the  provider an opportunity for improvement or a comprehensive review if  more information is needed); or  take an adverse privileging action, including limiting one or more  privileges (such as prescribing medication or performing a certain  procedure) or revoking all of the provider’s privileges. We found that the five selected  VAMCs collectively required reviews of 148 providers’ clinical care after  concerns were raised from October 2013 through March 2017, but VAMC  officials were unable to provide documentation that almost half of these  reviews were conducted. We also  found VHA does not adequately oversee these reviews, as discussed  later in this report. Specifically, of the 112 providers for whom the selected VAMCs  required FPPEs for cause from October 2013 through March 2017,  the VAMCs were unable to provide documentation of the FPPEs for  nearly a quarter (26) of the providers. Specifically, of the 148 providers, the  VAMCs’ initiation of reviews of 16 providers’ clinical care was delayed by  more than 3 months, and in some cases for multiple years, after the  concern was raised. As a  result, VHA and the VISNs are not conducting routine oversight to ensure  that VAMC reviews of providers’ clinical care after concerns are raised  are conducted appropriately, including adequately ensuring that the  reviews are completed and documented in a timely manner, in  accordance with VHA policy. In the  absence of routine monitoring of VAMCs’ evaluations of providers after  concerns have been raised, VHA lacks reasonable assurance that  VAMCs adequately review all identified concerns about providers’ clinical  care and take appropriate privileging actions to ensure that VA is  providing safe, high quality care for veterans. Selected VAMCs Did Not Always Report Providers to the NPDB and SLBs in Accordance with VHA Policy, and VHA Does Not Adequately Oversee This Reporting

NPDB and SLB reporting not completed. However, at the time of our review, we found that the five  selected VAMCs had only reported 1 of these 9 providers to the NPDB  and none of these providers to the SLBs. One of these providers could not have an adverse privileging  action taken against them because VAMC officials unintentionally allowed  the provider’s privileges to expire during a comprehensive review of the  provider’s care. Officials at one VAMC did not report a provider to the NPDB or SLB  following an adverse privileging action because the SLB had found  out about the issue independently. We also found that VHA and the VISNs  do not adequately oversee NPDB and SLB reporting and they cannot  ensure that VAMCs are reporting providers when required to do so by  VHA policy. We found that the  provider’s privileges were also revoked from a non-VA hospital in the  same city for the same reason 2 years later. This lack of routine oversight from VHA through the VISNs of VAMCs’  reporting of providers to the NPDB and SLBs is inconsistent with federal  internal control standards for monitoring. Conclusions

VHA is responsible for ensuring that providers at its VAMCs deliver safe  care to veterans and that concerns that may arise about providers’ clinical  care are reviewed and addressed at VHA’s 170 VAMCs. However, our  work shows that at our five selected VAMCs, reviews of concerns about  providers’ clinical care were not always documented or conducted in a  timely manner and VAMCs had not reported the majority of providers they  should have reported to the NPDB or SLBs. Finally, VAMCs’ failure to  report providers to the NPDB and SLBs, as required under VHA policy,  makes it possible for providers to obtain privileges at other VAMCs or  non-VA health care entities without disclosing the problems with their past  performance. As our review shows, the  VISNs responsible for overseeing the five selected VAMCs do not  routinely oversee VAMC reviews of providers’ clinical care after concerns  are raised to ensure that these reviews are completed in accordance with  VHA policies; nor do the VISNs oversee the VAMCs to ensure that all  providers that should be reported are reported to the NPDB and SLBs. In its comments,  VA stated that VHA plans to revise existing policy to require  documentation of reviews of providers’ clinical care after concerns have  been raised and to establish expected timeframes for completing such  reviews.
Why GAO Did This Study

Nearly 40,000 providers hold privileges in VHA's 170 VAMCs. VAMCs must identify and review any concerns that arise about the clinical care their providers deliver. Depending on the findings from the review, VAMC officials may take an adverse privileging action against a provider that either limits the care a provider is allowed to deliver at the VAMC or prevents the provider from delivering care altogether.
GAO was asked to review VHA processes for reviewing concerns about providers' clinical care. This report examines, among other things, selected VAMCs' (1) reviews of providers' clinical care after concerns are raised and VHA's oversight of these reviews, and (2) VAMCs' reporting of providers to the NPDB and SLBs and VHA's oversight of reporting. GAO visited a non-generalizable selection of five VAMCs selected for the complexity of services offered and variation in location. GAO reviewed VHA policies and files from the five selected VAMCs, and interviewed VHA, VISN, and VAMC officials. GAO also evaluated VHA's practices using federal internal control standards.

What GAO Found

Department of Veterans Affairs (VA) medical center (VAMC) officials are responsible for reviewing the clinical care delivered by their privileged providers—physicians and dentists who are approved to independently perform specific services—after concerns are raised. The five VAMCs GAO selected for review collectively required review of 148 providers from October 2013 through March 2017 after concerns were raised about their clinical care. GAO found that these reviews were not always documented or conducted in a timely manner. GAO identified these providers by reviewing meeting minutes from the committee responsible for requiring these types of reviews at the respective VAMCs, and through interviews with VAMC officials. The selected VAMCs were unable to provide documentation of these reviews for almost half of the 148 providers. Additionally, the VAMCs did not start the reviews of 16 providers for 3 months to multiple years after the concerns were identified. GAO found that VHA policies do not require documentation of all types of clinical care reviews and do not establish timeliness requirements. GAO also found that the Veterans Health Administration (VHA) does not adequately oversee these reviews at VAMCs through its Veterans Integrated Service Networks (VISN), which are responsible for overseeing the VAMCs. Without documentation and timely reviews of providers' clinical care, VAMC officials may lack information needed to reasonably ensure that VA providers are competent to provide safe, high quality care to veterans and to make appropriate decisions about these providers' privileges.
GAO also found that from October 2013 through March 2017, the five selected VAMCs did not report most of the providers who should have been reported to the National Practitioner Data Bank (NPDB) or state licensing boards (SLB) in accordance with VHA policy. The NPDB is an electronic repository for critical information about the professional conduct and competence of providers. GAO found that
selected VAMCs did not report to the NPDB eight of nine providers who had adverse privileging actions taken against them or who resigned during an investigation related to professional competence or conduct, as required by VHA policy, and
none of these nine providers had been reported to SLBs.
GAO found that officials at the selected VAMCs misinterpreted or were not aware of VHA policies and guidance related to NPDB and SLB reporting processes resulting in providers not being reported. GAO also found that VHA and the VISNs do not conduct adequate oversight of NPDB and SLB reporting practices and cannot reasonably ensure appropriate reporting of providers. As a result, VHA's ability to provide safe, high quality care to veterans is hindered because other VAMCs, as well as non-VA health care entities, will be unaware of serious concerns raised about a provider's care. For example, GAO found that after one VAMC failed to report to the NPDB or SLBs a provider who resigned to avoid an adverse privileging action, a non-VA hospital in the same city took an adverse privileging action against that same provider for the same reason 2 years later.

What GAO Recommends

GAO is making four recommendations, including for VA to direct VHA to require VAMCs to document reviews of providers' clinical care after concerns are raised, develop timeliness requirements for these reviews, and ensure proper VISN oversight of such reviews as well as timely VAMC reporting of providers to the NPDB and SLBs. VA concurred with GAO's recommendations and described steps it will take to implement them.