Report Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of VHA facilities’ selected medical staff privileging program requirements. The report describes related findings from healthcare inspections performed at 36 VHA medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff and reviews of clinical and administrative processes. The OIG reviewers evaluated meeting minutes and other relevant documents.

The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses with focused professional practice evaluation criteria, reprivileging decision processes, ongoing professional practice evaluations, processes for recommending continuing privileges, timely completion of and required signatures for provider exit review forms, and state licensing board reporting.

The OIG issued six recommendations, including three repeat recommendations related to:

• minimum specialty criteria for focused professional evaluations,

• inclusion of service-specific criteria in ongoing professional practice evaluations, and

• use of professional practice evaluation results in executive committee recommendations to continue licensed independent practitioners’ privileges.