System of Records (SOR)

29VA11 - Physician, Dentist and Supervisory Nurse Professional Standards Board Action File-VA

System location:
Department of Medicine and Surgery (11B), Veterans Administration Central Office, Washington, DC 20420.

Categories of individuals covered by the system:
Physicians, dentists, supervisory nurses and physician's assistants, appointed under 38 USC, chapter 73, currently or formerly employed at a VA health care facility.

Categories of records in the system:
Personnel forms and correspondence pertaining to promotions, reassignments, transfers, proficiency ratings physical examinations, etc., all of which are duplicated in the employee's official personnel folder. This system also contains board action folders for former employees who cannot be re-employed without approval of the Chief Medical Director.

Authority for maintenance of the system:
Title 38, United States Code, Chapter 73, Section 4108.

Routine uses of records maintained in the system, including categories of users and the purposes of such uses:

1. In the event that a system of records maintained by this agency to carry out its functions indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and whether arising by general statute or particular program statute, or by regulation, rule or order issued pursuant thereto, the relevant records in the system of records may be referred, as a routine use, to the appropriate agency, whether Federal, State, local or foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute, or rule, regulation or order issued pursuant thereto.
2. A record from this system of records may be disclosed to a Federal agency, in response to its request, in connection with the hiring or retention of an employee, the issuance of a security clearance, the reporting of an investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency's decision on the matter.
3. A record from this system of records may be disclosed as a `routine use' to a Federal, State or local agency maintaining civil, criminal or other relevant information, such as current licenses, if necessary to obtain information relevant to an agency decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or other health, educational or welfare benefits.
4. All of the information contained in this system of records is used for official purposes of the Veterans Administration; all such uses of the information are compatible with the purpose for which the information was collected.
5. Disclosure may be made to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.
6. Disclosure may be made to NARA (National Archives and Records Administration) GSA (General Services Administration) in records management inspections conducted under authority of 44 U.S.C. 2904 and 2906.
7. Records from this system of records may be disclosed to a Federal Agency or to a State or local government licensing board and/ or to the Federation of State Medical Boards or a similar nongovernment entity which maintains records concerning individuals' employment histories or concerning the issuance, retention or revocation of licenses, certifications, or registration necessary to practice an occupation, profession or specialty, in order for the Agency to obtain information relevant to an Agency decision concerning the hiring, retention or termination of an employee or to inform a Federal Agency or licensing boards or the appropriate nongovernment entities about the health care practices of a terminated, resigned or retired health care employee whose professional health care activity so significantly failed to conform to generally accepted standards of professional medical practice as to raise reasonable concern for the health and safety of patients in the private sector or from another Federal Agency. These records may also be disclosed as part of an ongoing computer matching program to accomplish these purposes.
8. Relevant information from this system of records may be disclosed to the National Practitioner Data Bank and/or State Licensing Board in the State(s) in which a practitioner is licensed, in which the VA facility is located, and/or in which an act or omission occurred upon which a medical malpractice claim was based when VA reports information concerning: (1) Any payment for the benefit of a physician, dentist, or other licensed health care practitioner which was made as the result of a settlement or judgment of a claim of medical malpractice if an appropriate determination is made in accordance with agency policy that payment was related to substandard care, professional incompetence or professional misconduct on the part of the individual; (2) a final decision which relates to possible incompetence or improper professional conduct that adversely affects the clinical privileges of a physician or dentist for a period longer than 30 days; or, (3) the acceptance of the surrender of clinical privileges or any restriction of such privileges by a physician or dentist either while under investigation by the health care entity relating to possible incompetence or improper professional conduct, or in return for not conducting such an investigation or proceeding. These records may also be disclosed as part of a computer matching program to accomplish these purposes.
9. Relevant information from this system of records may be disclosed to the National Practitioner Data Bank or to a State or local government licensing board which maintains records concerning the issuance, retention or revocation of licenses, certifications, or registrations necessary to practice an occupation, profession or specialty when under the following circumstances, through a peer review process that is undertaken pursuant to VA policy, negligence, professional incompetence, responsibility for improper care, and/or professional misconduct has been assigned to a physician or licensed or certified health care practitioner: (1) On any payment in settlement (or partial settlement) of, or in satisfaction of a judgment in, a medical malpractice action or claim; or, (2) on any final decision that adversely affects the clinical privileges of a physician or practitioner for a period of more than 30 days. These records may also be disclosed as part of a computer matching program to accomplish these purposes.

Policies and practices for storing, retrieving, accessing, retaining, and disposing of records in the system:

Storage:
Paper documents.

Retrievability:
Alphabetically by name.

Safeguards:

Physical Security:
Access to VA working space and medical record storage areas is restricted to VA employees on a `need to know' basis. Generally, VA file areas are locked after normal duty hours and are protected from outside access by the Federal Protective Service. Employee file records and file records of public figures or otherwise sensitive medical record files are stored in separate locked files. Strict control measures are enforced to ensure that disclosure is limited to a `need to know' basis.

Retention and disposal:
Disposed of three years after date of last service with the VA. Board action folders of former employees who cannot be re-employed without approval of the Chief Medical Director are reviewed periodically. Those folders no longer requiring approval of the Chief Medical Director are interfiled with the regular board actions folders. Destruction of records accomplished by either shredding or burning.

System manager(s) and address:
Chairman Special Boards, Department of Medicine and Surgery (11B), Veterans Administration Central Office, Washington, DC 20420.

Notification procedure:
Physicians, dentists and supervisory nurses seeking information concerning the existence and content of a board action folder pertaining to themselves must submit a written request or apply in person to the system manager.

Record access procedures:
Physicians, dentists and supervisory nurses seeking information regarding access to and contesting of VA Board Action Folders may write, call or visit the system manager.

Contesting record procedures:
(See Record Access Procedures above.)

Record source categories:
VA health care facilities official personnel folders.

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