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Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities

Report Information

Issue Date
Report Number
20-00827-126
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Medical Staff Privileging Credentialing
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted an inspection to assess VA medical facilities’ compliance and processes regarding Veterans Health Administration (VHA) policies for reporting healthcare professionals to state licensing boards (SLBs) and the National Practitioner Data Bank (NPDB). The OIG found widespread noncompliance with SLB and NPDB reporting processes applied by facilities to healthcare professionals whose conduct or competence led to separation from employment. Failure to comply with reporting policies leaves SLBs and recipients of NPDB information unaware of a healthcare professional’s practice deficiencies and ultimately violates an important VA commitment to protect the health of veterans and the public. Moreover, the OIG found a lack of programmatic oversight of compliance with SLB and NPDB reporting processes. For a majority of cases involving separated healthcare professionals, facility directors failed to follow mandatory processes for reporting healthcare professionals to SLBs. The OIG identified SLB reporting noncompliance was related to staff misunderstanding policy and poor facility processes. In 15 of 35 physician or dentist cases appealing a separation from employment, facility directors failed to submit NPDB reports as required by federal regulation and VHA policy. Conflicting language in VHA policies, misunderstanding of policies, and poor facility processes contributed to the failures. VHA SLB and NPDB reporting policies did not assign programmatic oversight to ensure facility leaders’ compliance with SLB and NPDB reporting processes. The lack of programmatic oversight contributed to the failure of VHA leaders to detect and intervene upon facility noncompliance. The OIG made four recommendations to the Under Secretary for Health regarding ensuring SLB and NPDB reporting compliance and programmatic oversight as well as aligning NPDB policy with federal regulation.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Under Secretary for Health reviews the State Licensing Board reporting processes at the facility level to ensure compliance with Veterans Health Administration policy, identifies noncompliance, and takes action as warranted.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures that the National Practitioner Data Bank facility reporting practices align with federal regulations and Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Under Secretary for Health instructs facility directors to submit National Practitioner Data Bank reports regarding physicians and dentists consistent with Veterans Health Administration policy.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures programmatic oversight of facility State Licensing Board and National Practitioner Data Bank reporting processes.