This is the accessible text file for GAO report number GAO-08-271T 
entitled 'VA Health Care: Improvements Made in Physician Privileging 
Policies, but Medical Facility Compliance Has Not Been Assessed' which 
was released on November 6, 2007. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as part 
of a longer term project to improve GAO products' accessibility. Every 
attempt has been made to maintain the structural and data integrity of 
the original printed product. Accessibility features, such as text 
descriptions of tables, consecutively numbered footnotes placed at the 
end of the file, and the text of agency comment letters, are provided 
but may not exactly duplicate the presentation or format of the printed 
version. The portable document format (PDF) file is an exact electronic 
replica of the printed version. We welcome your feedback. Please E-mail 
your comments regarding the contents or accessibility features of this 
document to Webmaster@gao.gov.

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

United States Government Accountability Office:
GAO: 

Testimony:
Before the Committee on Veterans' Affairs, U.S. Senate: 

For Release on Delivery: 
Expected at 9:30 a.m. EST: 
Tuesday, November 6, 2007: 

VA Health Care: 

Improvements Made in Physician Privileging Policies, but Medical 
Facility Compliance Has Not Been Assessed: 

Statement of Randall B. Williamson:
Acting Director, Health Care: 

GAO-08-271T: 

GAO Highlights: 

Highlights of GAO-08-271T, a testimony before the Committee on 
Veterans’ Affairs, U.S. Senate. 

Why GAO Did This Study: 

In a report issued in May 2006, GAO examined compliance with the 
Department of Veterans Affairs’ (VA) physician credentialing and 
privileging requirements at seven VA medical facilities GAO visited. 
VA’s credentialing process is used to determine whether a physician’s 
professional credentials, such as licensure, are valid and meet VA’s 
requirements for employment. VA’s privileging process is used to 
determine which health care services or clinical privileges, such as 
surgical procedures, a VA physician is qualified to provide to veterans 
without supervision. Although GAO cannot generalize from its findings, 
GAO found that the seven facilities were complying with credentialing 
requirements. However, the facilities were not complying with aspects 
of certain privileging requirements. To better ensure that VA 
physicians are qualified to deliver care safely to veterans, GAO made 
three recommendations to improve VA’s privileging of physicians. GAO 
was asked to testify today on (1) how VA credentials and privileges 
physicians working in its medical facilities and (2) the extent to 
which VA has implemented the three recommendations made in GAO’s May 
2006 report that address VA’s privileging requirements. To update its 
issued work, GAO reviewed VA’s policies, procedures, and correspondence 
related to physician privileging and interviewed VA central office 
officials to determine if the recommendations made in GAO’s May 2006 
report were implemented. 

What GAO Found: 

VA has specific requirements that medical facility officials must 
follow to credential and privilege physicians. VA requires its medical 
facility officials to credential and privilege facility physicians 
periodically so that they can continue to work at VA. Facility 
officials verify the information used in the credentialing process and 
query certain databases that contain information on disciplinary 
actions that have been taken against a physician’s state medical 
license and have information about a physician’s professional 
competence. Each physician also must complete a written request for 
clinical privileges that is reviewed by the physician’s supervisor who 
considers whether the physician has the appropriate professional 
credentials, training, and work experience. In addition, every 2 years, 
the supervisor is to consider information on a physician’s performance, 
such as a physician’s surgical complication rate, when deciding whether 
to renew a physician’s clinical privileges. 

In a May 2006, GAO examined compliance with VA’s physician 
credentialing and privileging requirements at seven VA medical 
facilities it visited and made three recommendations designed to 
improve aspects of privileging and oversight of the process. The three 
recommendations were to 

* 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 
process, 

* enforce the requirement that medical facilities submit information on 
paid VA medical malpractice claims to VA 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. 

VA reports that it has implemented all three recommendations by 
establishing policy and guidance for its medical facilities. However, 
GAO does not know the extent of compliance with these requirements at 
VA medical facilities. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.GAO-08-271T]. For more information, contact 
Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov. 

[End of section] 

Mr. Chairman and Members of the Committee: 

I am pleased to be here today as you discuss physician hiring practices 
at medical facilities operated by the Department of Veterans Affairs 
(VA). VA has over 36,000 physicians working at more than 1,300 
facilities in its health care system. To help ensure the quality of the 
health care these physicians deliver and the safety of veterans, VA is 
responsible for determining that its physicians have the appropriate 
professional credentials and clinical experience to provide health care 
to VA's patients. To do this, VA requires physicians to undergo 
credentialing and privileging. VA's credentialing process is used to 
determine whether a physician's professional credentials, such as 
licensure, education, and training, are valid and meet VA's 
requirements for employment. VA's privileging process is used to 
determine which health care services or clinical privileges, such as 
surgical procedures or administering anesthesia, a VA physician is 
qualified to provide to veterans without supervision. VA physicians 
must be credentialed and privileged when they apply to work in VA--
which is known as initial appointment--and at least once every 2 years 
thereafter when they must reapply for a position on the facility's 
medical staff. These subsequent reviews are known as the process of 
reappointment. 

In a report we issued in May 2006, we examined compliance with select 
credentialing and privileging requirements at seven VA medical 
facilities we visited and made three recommendations designed to 
improve aspects of privileging and oversight of the process. Although 
we cannot generalize from our findings, we found that these facilities 
were complying with credentialing requirements. However, they were not 
complying with aspects of certain privileging requirements.[Footnote 1] 
For example, VA medical facilities were not submitting information on 
paid medical malpractice claims within the 60-day required time frame 
to VA's office that reviews the claims information and makes a 
determination about whether physicians involved in the claims delivered 
substandard care to veterans. VA generally agreed with our findings, 
conclusions, and recommendations. 

Today, I will discuss the progress VA has made in implementing our May 
2006 recommendations to address noncompliance with VA's privileging 
requirements. Specifically, I will discuss (1) how VA credentials and 
privileges physicians working in its medical facilities and (2) the 
extent to which VA has implemented the three recommendations made in 
our May 2006 report that address VA's privileging requirements. 

To perform our 2006 review, we selected four of VA's credentialing 
requirements for review because they are requirements that--unlike 
others--address information about physicians that can change or be 
updated with new information periodically. As a result, VA requires 
that this information be verified by medical facility officials when a 
physician initially applies for employment at VA and at least every 2 
years thereafter. Under the four requirements we reviewed, VA medical 
facility officials must: 

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 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. 

Of the privileging requirements in VA's credentialing and privileging 
policy, we selected four requirements that VA identifies as general 
privileging requirements. In addition, we selected another privileging 
requirement about the use of individual performance information because 
of its importance in the renewal of clinical privileges. The five VA 
privileging requirements we selected were as follows: 

1. verify that all state medical licenses held by physicians are valid; 

2. verify physicians' training and experience; 

3. assess physicians' clinical competence and health status; 

4. consider any information provided by a physician related to medical 
malpractice allegations or paid claims, loss of medical staff 
membership, loss or reduction of clinical privileges at a VA or non-VA 
facility, or any challenges to a physician's state medical license; 
and: 

5. use information on a physician's performance when making decisions 
about whether to renew the physician's clinical privileges. 

Two of the five privileging requirements--verify all state medical 
licenses and consider medical malpractice information--are also VA 
credentialing requirements we reviewed. 

To update our work, we reviewed VA's policies, procedures, and 
correspondence related to physician privileging and interviewed VA 
central office officials to determine if the recommendations we made in 
our May 2006 report were implemented. We updated our issued work in 
July 2007 and November 2007, and we performed all of our work in 
accordance with generally accepted government auditing standards. 

In summary, VA has specific requirements that medical facility 
officials must follow to credential and privilege physicians. VA 
requires its medical facility officials to credential and privilege 
facility physicians periodically so that they can continue to work at 
VA. We reported in May 2006 that the seven VA medical facilities we 
visited complied with the four credentialing requirements we reviewed 
and all but one of the five privileging requirements we reviewed. 
However, during our review, we found that medical facility officials 
did not have all of the information they needed on physicians involved 
in paid VA medical malpractice claims, because the facilities had not 
submitted such information in a timely manner to VA's office that 
reviews the claims information and makes a determination about whether 
physicians involved in the claims delivered substandard care to 
veterans. We also found during our review that VA did not require its 
medical facilities to establish internal controls to help ensure the 
accuracy of their privileging information. Without internal controls VA 
medical facility officials did not know if they properly renewed 
clinical privileges, thereby allowing physicians to practice with 
expired clinical privileges. Since our 2006 review, VA reports that it 
has implemented all three of our recommendations to improve VA's 
physician privileging process. However, since our work in 2006 we have 
not visited or examined records at facilities to determine the extent 
of compliance. 

Background: 

VA operates the largest integrated health care system in the United 
States, providing care to nearly 5 million veterans per year. The VA 
health care system consists of hospitals, ambulatory clinics, nursing 
homes, residential rehabilitation treatment programs, and readjustment 
counseling centers. VA delegates decision making regarding financing, 
health care service delivery, and medical facility operations to its 21 
networks. 

Physicians who work at VA medical facilities are required to hold at 
least one current and unrestricted state medical license. Current and 
unrestricted licenses are those in good standing in the states that 
issued them, and licensed physicians may hold licenses from more than 
one state. State medical licenses are issued by state licensing boards, 
which generally establish state licensing requirements governing their 
licensed practitioners.[Footnote 2] To keep licenses current, 
physicians must renew their licenses before they expire and meet 
renewal requirements established by state licensing boards, such as 
continuing education. Renewal procedures and requirements vary by 
state. When state licensing boards discover violations of licensing 
practices, such as the abuse of prescription drugs or the provision of 
substandard care that results in adverse health effects, they may place 
restrictions on licenses or revoke them. Restrictions issued by a state 
licensing board can limit or prohibit a physician from practicing in 
that particular state. Generally, state licensing boards maintain a 
database that contains information on any restrictions or revocations 
of physicians' licenses. 

VA's Credentialing and Privileging Processes: 

Credentialing Process: 

When physicians apply for initial appointment, they initiate the 
credentialing process by completing VA's application, which includes 
entering into VetPro--a Web-based credentialing system VA implemented 
in March 2001--information used by VA medical facility officials in the 
credentialing process. Among the credentialing information that VA 
requires physicians enter into VetPro is information on all the state 
medical licenses they have ever held, including any licenses they have 
held that have expired. For their reappointments, physicians must 
update this credentialing information in VetPro. 

Once physicians enter their credentialing information into VetPro, a 
facility's medical staff specialist--an employee who is responsible for 
obtaining and verifying the information used in the credentialing and 
privileging processes--performs a data check on the information to be 
sure that all required information has been entered. In general, the 
medical staff specialist at each VA medical facility manages the 
accuracy of VetPro's credentialing data. The medical staff specialist 
verifies, with the original source of the information, the accuracy of 
the credentialing information entered by the physicians. This type of 
check is known as primary source verification. For example, the medical 
staff specialist contacts state licensing boards in order to verify 
that physicians' state medical licenses are valid and unrestricted. 

At initial appointment only, VA requires medical staff specialists to 
query FSMB, which contains information from state licensing boards. 
This query enables officials to determine all the state medical 
licenses a physician has ever held, including those not disclosed by a 
physician to VA, and whether a physician has had any disciplinary 
actions taken against these licenses. VA does not require this query at 
reappointment because VA headquarters regularly receives reports from 
FSMB on any VA physician whose name appears on FSMB's list, indicating 
that disciplinary action has been taken against the physician's state 
medical license. When VA headquarters receives a report from FSMB, it 
notifies the appropriate VA medical facility. 

VA's credentialing process requires VA medical staff specialists to 
verify medical malpractice claims at initial appointment and at 
reappointment. These claims may be verified by contacting a court of 
jurisdiction or the insurance company involved in the medical 
malpractice claims, or by obtaining a statement of claims status from 
the attorney representing the physician in the medical malpractice 
claim. In addition, VA requires medical staff specialists to query 
NPDB, which contains reports by state licensing boards, hospitals, and 
other health care entities on unprofessional behavior on the part of 
physicians or adverse actions taken against them. This query enables 
officials to determine whether physicians fully disclosed to VA any 
involvement they might have had in paid medical malpractice 
claims.[Footnote 3] Once a physician's credentialing information has 
been verified, the medical staff specialist sends the information to 
the physician's supervisor, who is known as a clinical service 
chief.[Footnote 4] The clinical service chief reviews this information 
along with the physician's privileging information. Figure 1 
illustrates VA's credentialing process. 

Figure 1: Steps Taken in VA's Physician Credentialing Process: 

[See PDF for image] 

This figure is a flow chart of the steps taken in VA's Physician 
Credentialing process. The following data is depicted: 

Initial appointment and reappointment: 
Medical staff specialist gives physician access to VetPro; 

Initial appointment: 
Physician enters information into VetPro that includes: 
* All state medical licenses including expired licenses; 
* Any involvement in paid or settled medical malpractice claims; 

Reappointment: 
Physician updates information stored in VetPro from initial 
appointment. 

Initial appointment and reappointment: 
Medical staff specialist checks completeness of VetPro information; 
Performs primary source verification of VetPro information; 
Queries FSMB (only at initial appointment); 
Queries NPDB; 
Sends VetPro information to clinical service chief. 

Initial appointment and reappointment: 
Clinical service chief reviews information sent by the medical staff 
specialist and considers it along with the physician’s privileging 
information. 

Source: GAO analysis of VA credentialing policy. 

[End of figure] 

Privileging Process: 

Physicians, in addition to entering credentialing information into 
VetPro, must complete a written request for clinical privileges. The 
facility medical staff specialist provides a physician's clinical 
service chief with the physician's requested clinical privileges and 
information needed to complete the privileging process, including 
information that indicates that the credentialing information entered 
by the physician into VetPro has been verified with the appropriate 
sources. For reappointment, documentation is required by another 
physician stating that the physician is able to perform both physically 
and mentally the clinical privileges requested. In addition, the 
medical staff specialist provides the clinical service chief with 
information on medical malpractice allegations or paid claims, loss of 
medical staff membership, loss or reduction of clinical privileges, or 
any challenges to the physician's state medical licenses. 

The requested clinical privileges are reviewed by a clinical service 
chief, who recommends whether a physician should be appointed or 
reappointed to the facility's medical staff and which clinical 
privileges should be granted. When deciding to recommend clinical 
privileges, a clinical service chief considers whether the physician 
has the appropriate professional credentials, training, and work 
experience to perform the privileges requested. For reappointment only, 
a clinical service chief is to consider observations of the physician's 
delivery of health care to veterans, and VA's policy requires that 
information on a physician's performance, such as a physician's 
surgical complication rate, be used when deciding whether to renew a 
physician's clinical privileges. Based on the clinical service chief's 
observations and the physician's performance information, the clinical 
service chief recommends that clinical privileges previously granted by 
the facility remain the same, be reduced, or be revoked, and whether 
newly requested privileges should be added.[Footnote 5] 

Clinical service chiefs forward their recommendations and the reasons 
for the recommendations to the next level of a medical facility's 
privileging review process, which may be a professional standards board 
or a medical executive committee.[Footnote 6] A medical facility 
professional standards board or the medical executive committee reviews 
the recommendations of the clinical service chief and recommends to the 
facility director whether the physician should be appointed to the 
facility's medical staff and which clinical privileges should be 
granted to the physician. The 2-year time period for renewal of 
clinical privileges and reappointment to the medical staff begins on 
the date that the privileges are approved by the medical facility's 
director. The list of approved clinical privileges with the date of 
approval is maintained at VA medical facilities and the initial 
appointment or reappointment date is entered into VetPro. Figure 2 
illustrates VA's privileging process. 

Figure 2: Steps Taken in VA's Physician Privileging Process: 

[See PDF for image] 

This figure is a flow chart of the steps taken in VA's Physician 
Privileging process. The following data is depicted: 

Initial appointment and reappointment: 

Physician completes written request for specific clinical privileges; 

Medical staff specialist sends physician’s clinical privilege request 
to clinical service chief with information that includes: 
* verification of credentialing information; 
* verification of physician’s training and experience; 
* assessment of physician’s clinical competence and health status; 

Clinical service chief reviews information sent by medical staff 
specialist and recommends whether physician should be appointed and the 
clinical privileges that should be granted, then sends the 
documentation and recommendation to the facility’s professional 
standards board/medical executive committee; 
(For reappointment only: Clinical service chief also reviews 
information on physician’s performance); 

Professional standards board/medical executive committee reviews 
information and recommends whether physician should be appointed and 
the clinical privileges that should be granted, then sends 
documentation and recommendation to facility director; 

Facility director makes final decision to approve a physician’s 
appointment or reappointment and recommends clinical privileges. 

Source: GAO analysis of VA privileging policy. 

[End of figure] 

According to VA's policy and a VA memorandum, information concerning 
individual physician performance that is used as part of the 
privileging process to either reduce, revoke, or support[Footnote 7] 
granting clinical privileges must be collected separately from a 
medical facility's quality assurance program.[Footnote 8] VA's policy 
is based on a federal law that restricts the disclosure of documents 
produced in the course of VA's quality assurance program.[Footnote 9] 
In general, documents created in connection with such a program are 
confidential and may not be disclosed except in limited 
circumstances.[Footnote 10] Individuals who willfully disclose 
documents that they know are protected quality assurance documents are 
subject to fines up to $20,000. Although the law states that it is not 
intended to limit the use of documents within VA, VA's policy expressly 
prohibits the use of such documents in connection with the privileging 
process. VA's use of separate information sources for quality assurance 
and privileging decisions is intended to maintain the confidential 
status of documents produced in connection with quality assurance 
programs. According to VA, the confidentiality of individual 
performance information helps ensure provider participation, including 
physicians, in a medical facility's quality assurance program by 
encouraging providers to openly discuss opportunities for improvement 
in provider practice without fear of punitive action. 

VA has another requirement that is related to the renewal of 
physicians' clinical privileges. Medical facility officials are 
required to submit to VA's Office of Medical-Legal Affairs information 
on paid VA malpractice claims. This information must be submitted 
within 60 days after the medical facility is notified about a paid 
malpractice claim. The Office of Medical-Legal Affairs is responsible 
for convening a panel of clinicians to determine whether a VA facility 
physician involved in the claim delivered substandard care. The Office 
of Medical-Legal Affairs notifies the medical facility director of the 
results of its review. If it is determined that the physician delivered 
substandard care to veterans, the medical facility must report the 
physician to NPDB within 30 days of being notified of the decision. VA 
medical facility officials also would use this determination to decide 
whether to grant clinical privileges to the physician involved in the 
VA medical malpractice claim. 

VA Has Addressed All GAO Physician Privileging Recommendations, but 
Extent of Medical Facility Compliance Is Unknown: 

In our 2006 report, we found that the physician files at the seven 
facilities we visited demonstrated compliance with four VA 
credentialing and four privileging requirements we reviewed.[Footnote 
11] However, we found that there were problems complying with a fifth 
privileging requirement--to use information on a physician's 
performance in making privileging decisions. We also found during our 
review that three of the seven medical facilities we visited did not 
submit to VA's Office of Medical-Legal Affairs information on paid VA 
medical malpractice claims within 60 days after being notified that a 
claim was paid, as required by VA policy. Further, VA had not required 
its medical facilities to establish internal controls to help ensure 
that privileging information managed by medical staff specialists is 
accurate. Internal controls are important because at one facility we 
visited we found 106 physicians whose privileging process had not been 
completed by facility officials for at least 2 years because of 
inaccurate information. As a result, these physicians were practicing 
at the facility with expired clinical privileges. None of the VA 
medical facilities we visited for our 2006 report had internal controls 
in place that would prevent a similar situation from occurring. To 
better ensure that VA physicians are qualified to deliver care safely 
to veterans, we recommended that VA: 

* 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 
process, 

* 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. 

VA states that it has implemented all three recommendations we made in 
our May 2006 report to address compliance with VA's physician 
privileging requirements by establishing policy and guidance for its 
medical facilities. However, we do not know the extent of compliance 
with these requirements at VA medical facilities. 

VA implemented our recommendation that VA provide guidance to VA 
medical facilities on how to appropriately collect information on 
individual physician performance and use that information in VA's 
privileging process. Physician performance information is to be used to 
assist VA medical facility clinical service chiefs in determining the 
appropriate clinical privileges that should be granted based on a 
physician's clinical competence. VA implemented our recommendation by 
issuing a policy on October 2, 2007, that elaborated on the sources of 
physician performance information and the types of information that 
could be collected outside of VA medical facilities' quality assurance 
programs. In addition, in July 2007, VA officials told us that they 
were in the process of implementing online training programs on 
physician performance information to help implement our recommendation. 
The training will be mandatory for all VA medical facility clinical 
service chiefs and medical staff leaders responsible for the assessment 
and oversight of the privileging process and must be completed by 
January 31, 2008. 

VA also implemented our recommendation that it enforce its requirement 
that VA medical facilities report information on any paid VA 
malpractice claims involving their physicians to VA's Office of 
Medical-Legal Affairs within 60 days after being notified of a paid 
claim. In June 2006, VA's Office of Medical-Legal Affairs began 
notifying network and VA medical facility directors of delinquencies in 
reporting this information by the medical facilities. If a medical 
facility's delinquency in reporting extends longer than 90 days, VA 
requires the Office of Medical-Legal Affairs to inform not only network 
and VA medical facility directors but also VA's central office of the 
delinquency. Because VA's Office of Medical-Legal Affairs reviews 
information on paid malpractice claims involving VA physicians to 
determine whether the physicians delivered substandard care, when VA 
medical facilities do not submit relevant malpractice claim information 
to this office, medical facility clinical service chiefs may make 
privileging decisions without complete information about substandard 
care provided by physicians. 

Further, VA implemented our recommendation that it instruct VA medical 
facilities to establish internal controls to ensure the accuracy of 
their privileging information. Internal controls help ensure that VA 
medical facility officials have accurate clinical privileging 
information and that physicians are not practicing at the facility with 
expired clinical privileges. To address our recommendation, VA first 
asked network directors to report on how they tracked the privileging 
status of VA physicians. In response to a VA memorandum sent on May 16, 
2006, network directors provided a report indicating that their medical 
facilities had one or more mechanisms in place to identify physicians 
who were currently privileged at their facilities and to track whether 
their privileges have expired. In addition, VA instructed its network 
directors to monitor the internal controls at their facilities that 
ensure that VA medical facilities have accurate clinical privileging 
information and that physicians are not practicing with expired 
clinical privileges. 

Mr. Chairman, this concludes my prepared remarks. I will be pleased to 
answer any questions you or other members of the committee may have. 

Contacts and Acknowledgments: 

For further information regarding this testimony, please contact 
Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this testimony. Marcia Mann, Assistant 
Director; Mary Ann Curran; Christina Enders; Krister Friday; Lori 
Fritz; Rebecca Hendrickson; and Jason Vassilicos also contributed to 
this statement. 

[End of section] 

Footnotes: 

[1] GAO, VA Health Care: Selected Credentialing Requirements at Seven 
Medical Facilities Met, but an Aspect of Privileging Process Needs 
Improvement, GAO-06-648 (Washington, D.C.: May 25, 2006), and VA Health 
Care: Patient Safety Could be Enhanced by Improvements in Employment 
Screening and Physician Privileging Practices, GAO-06-760T 
(Washington, D.C.: June 15, 2006). 

[2] State licenses are issued by offices in states, territories, or the 
District of Columbia, collectively referred to as state licensing 
boards. 

[3] NPDB includes information on medical malpractice claims that are 
paid, but does not include information on ongoing claims. 

[4] Clinical services may include surgery, medicine, and radiology. 

[5] Reduction of privileges may include restricting or prohibiting a 
physician from performing certain procedures or prescribing certain 
medicines. Revocation of privileges refers to the permanent loss of all 
clinical privileges at that facility. 

[6] At some VA medical facilities, the professional standards board and 
the medical executive committee represent the medical staff, have the 
same members, and perform the same functions so are considered to be 
one committee. If the committees are separate, the professional 
standards board generally consists of three to five physician peers and 
the medical executive committee generally consists of all facility 
clinical service chiefs. 

[7] Support granting clinical privileges means that the clinical 
privileges previously held by the physician will be maintained and 
newly requested clinical privileges will be added. 

[8] VA requires its medical facilities to have a quality assurance 
program. In general, the VA quality assurance program consists of 
specified systematic health care reviews carried out by or for VA for 
the purpose of improving the quality of medical care or the utilization 
of health care resources in VA facilities. See 38 C.F.R. § 17.500 
(2005). These programs collect data on various clinical process and 
outcome measures involving physicians and other types of practitioners. 
The measures may include a surgeon's complication rate or a physician's 
prescribing of medications. Medical facility officials use these 
measures to look for undesirable patterns and trends in performance. 

[9] 38 U.S.C. § 5705 (2000). 

[10] See Department of Veterans Affairs, VHA Handbook, 1100.19 
(Washington, D.C.: Mar. 6, 2001). 

[11] Findings for the credentialing and privileging requirements cannot 
be generalized to the facility being reviewed because of the sample 
size. 

[End of section] 

GAO's Mission: 

The Government Accountability Office, the audit, evaluation, and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the performance 
and accountability of the federal government for the American people. 
GAO examines the use of public funds; evaluates federal programs and 
policies; and provides analyses, recommendations, and other assistance 
to help Congress make informed oversight, policy, and funding 
decisions. GAO's commitment to good government is reflected in its core 
values of accountability, integrity, and reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each 
weekday, GAO posts newly released reports, testimony, and 
correspondence on its Web site. To have GAO e-mail you a list of newly 
posted products every afternoon, go to [hyperlink, http://www.gao.gov] 
and select "E-mail Updates." 

Order by Mail or Phone: 

The first copy of each printed report is free. Additional copies are $2 
each. A check or money order should be made out to the Superintendent 
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 
more copies mailed to a single address are discounted 25 percent. 
Orders should be sent to: 

U.S. Government Accountability Office: 
441 G Street NW, Room LM: 
Washington, DC 20548: 

To order by Phone: 
Voice: (202) 512-6000: 
TDD: (202) 512-2537: 
Fax: (202) 512-6061: 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 

Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]: 
E-mail: fraudnet@gao.gov: 
Automated answering system: (800) 424-5454 or (202) 512-7470: 

Congressional Relations: 

Gloria Jarmon, Managing Director, JarmonG@gao.gov: 
(202) 512-4400: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7125: 
Washington, DC 20548: 

Public Affairs: 

Chuck Young, Managing Director, youngc1@gao.gov: 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, DC 20548: