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Title page 1
Contents 3
Highlights 2
Letter 6
Background 11
Reviewing VHA Providers' Clinical Care Concerns and Taking Adverse Privileging Actions When Necessary 12
Reporting VHA Providers to the NPDB and SLBs After Clinical Care Concerns are Substantiated 13
Selected Facilities Did Not Consistently Adhere to VHA Review and Reporting Policies, Limited Training Reported as Factor 18
Selected Medical Facilities Did Not Consistently Adhere to VHA Policy When Conducting Quality Reviews and Reporting Providers with... 18
Selected Medical Facilities Faced Challenges Meeting VHA's Suggested Time Frames for Review and Reporting Processes of Providers with... 25
VHA Oversight of Reviews and Reporting of Providers with Clinical Care Concerns Is Limited 28
Conclusions 33
Recommendations for Executive Action 34
Agency Comments 35
Appendix I: Number of VHA Providers Included in GAO's Review 37
Appendix II: Selected VHA Medical Facility Adherence to NPDB Reporting Requirements in VHA Policy for Malpractice Claims 38
Appendix III: Selected VHA Medical Facility Adherence to SLB and NPDB Reporting Requirements in VHA Policy 40
Appendix IV: Seven Provider Cases from Selected VHA Medical Facilities Where SLB and NPDB Reporting Was Not Initiated 45
Appendix V: Comments from the Department of Veterans Affairs 47
Appendix VI: GAO Contacts and Staff Acknowledgments 51
Figure 1. VHA Process for Determining NPDB Reporting for Adverse Privileging Actions, January 2020-July 2024 15
Figure 2. VHA Process for Determining SLB Reporting, January 2020-July 2024 17
Figure 3. Example of Updated Veterans Health Administration (VHA) Tracker Data Fields for Reporting to State Licensing Boards 29
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