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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

Tables 3

Table 1. Number of VHA Providers with a Potential Clinical Care Concern from January 2020-July 2024 that GAO Reviewed at Five Selected... 37

Table 2. Five Selected Medical Facilities' Adherence to VHA Policy for Malpractice Claims for a Sample of 67 VHA Providers, January 2020-July 2024 39

Table 3. Five Selected Medical Facilities' Adherence to VHA Policy for Three State Licensing Board (SLB) Reports for Three VHA Providers,... 41

Table 4. Five Selected Medical Facilities' Adherence to VHA Policy for 25 State Licensing Board (SLB) Reports for 24 VHA Providers,... 42

Table 5. Four Selected Medical Facilities' Adherence to VHA Policies for Nine Proposed Adverse Privileging Actions for Eight VHA Providers,... 44

Figures 4

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