STATEMENT OF
DR. GERALD CROSS
PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
November 6, 2007
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Good morning, Mr. Chairman and members of the Committee.  Thank you for the opportunity to come here today to discuss VA's Credentialing and Privileging and its impact on current events at the Marion VA health care facility.  I am accompanied by Ms. Kate Enchelmayer, our Director of Quality Standards, Dr. Peter Almenoff, Director of Veterans Integrated Service Network 15, and Dr. George Maish, Chief of Surgery, Lebanon, Pennsylvania, VA Medical Center.  

Credentialing
Credentials are a person's educational, training, experience, current competence, health status, certification and licensure documents.  The Department of Veterans Affairs' (VA) standardized electronic credentialing program, VetPro, is used system-wide to document the credentials of health care providers.  VA realizes that accurate credentialing is a cornerstone to ensuring qualified health care providers come into the system.  In addition to the credentialing done on every licensed provider, the process of privileging that provider to administer care within the scope of his license and clinical competence and within the medical center's supporting capability remains an essential part of the initial processing that must be completed before the provider begins his duties within the Veterans Health Administration (VHA).  This process is completed on initial appointment and at a minimum of every two years thereafter, before transfer from another medical facility, or whenever the provider requests an addition to his privileges. 

The Credentialing Officer at a medical center obtains primary source information on all credentials.  This is accomplished by direct contact with the entity providing the education, training, certification, licensure or registration.  Information submitted by an individual health care practitioner is verified with that entity.  This includes confirming the practitioner's answers to 17 supplemental/attestation questions specific to denial, surrender, revocation and termination of a credential, privileges, and medical society affiliation, as well as felony charges and any convictions.  If a provider's license required for the position within VHA has ever been revoked or surrendered for cause (i.e., for reasons of substandard care, professional misconduct, or professional incompetence), that provider is not eligible for employment in VHA unless that license has been fully restored.  The practitioner also is required to possess at least one full, active, current, and unrestricted license to practice.

In addition, VA uses other flagging systems during the credentialing process and the determination of suitability for employment.  These include the National Practitioner Data Bank -Health Integrity and Protection Bank (NPDB-HIPDB), the Disciplinary Alerts Service of the Federation of State Medical Board (FSMB), the Health and Human Services Office of Inspector General List of Excluded Individuals and Entities (LEIE), the National Agency Check and Inquiry (NACI), and the Special Agreement Check (SAC) (fingerprint check).  The NPDB is queried for reports of malpractice payments or adverse actions against clinical privileges by another entity.  The HIPDB. which is a national data collection program for the reporting and disclosure of certain final adverse actions taken against health care practitioners, providers, and suppliers, is queried.  Moreover, VA continuously monitors physician licensure for any disciplinary or untoward activity with the FSMB.   VA also queries the LEIE, which is a database maintained by the Office of the Inspector General at the Department of Health and Human Services that lists all individuals and entities that are currently excluded from participation in Medicare, Medicaid and all other Federal health care programs.

The NACI is the basic and minimum background investigation generally required on all new Federal employees.  It consists of a National Agency Check (NAC) of OPM's Security/Suitability Investigations Index (SII); the Defense Clearance and Investigations Index (DCII); the FBI Identification Division's name and fingerprint files; as well as written inquiries and searches of records covering specific areas of a person's background during the past five years. Those inquiries are sent to current and past employers, schools attended, references, and local law enforcement authorities. 

Providers as well as all applicants are subject to a pre-employment background investigation.  The SAC, an OPM investigation tool is a fingerprint based criminal history check that is processed through the FBI. 

Clinical Privileging (Privileges)
In VA, a health care provider licensed for independent practice is given "privileges" that cover the breadth of their area of clinical practice. Specifically, these privileges are permissions to perform the individual procedure(s).  These requested procedures are recommended by the executive committee of the medical staff and approved by the medical center director in accordance with medical center bylaws.  Clinical privileges are focused on provider clinical practice and are medical center-specific, provider-specific, and within the scope of the provider's licensure, training, experience and competency, medical/clinical knowledge and provider health status (as it relates to the individual's ability to perform the requested clinical privileges).  Consideration is also given to any information related to medical malpractice allegations or judgments, loss of medical staff membership, and loss or reduction in clinical privileges. 

Clinical privileges are granted for a period not to exceed two years at which time they must be re-evaluated and reissued.  Re-privileging begins with the licensed health care provider applying through VetPro, updating all credentials/certification information, provision of peer references, and, again, answering the 17 supplemental/attestation questions.  The service chief assesses updated information that mirrors items reviewed for the provider's initial appointment.  The service chief, along with the credentialing officer, then recommends which privileges should be granted/re-granted to the executive committee of the medical staff which is chaired by the medical center Chief of Staff.  The executive committee evaluates the materials to determine if medical/clinical knowledge and clinical competence are adequately demonstrated to support re-credentialing and the granting of the requested privileges.  A final recommendation is then submitted to the medical center director who is the authority to grant privileges. 

National Surgical Quality Improvement Program (NSQIP)
NSQIP gathers aggregate data from surgical outcomes to determine whether there are significant deviations in mortality and morbidity rates for surgical procedures.  Since the beginning of Fiscal Year 2007, this information is assembled on a quarterly basis.  Prior to that time, the information had been gathered yearly.  It was decided that NSQIP would be a better tool if the data were gathered more frequently.  This was reinforced when our NSQIP data was evaluated after the onset of this new timing.

In response to an elevated ratio of observed to expected surgical deaths during the first two quarters of Fiscal Year 2007, a NSQIP team conducted an on site visit at the Marion, IL VAMC.  This was conducted as part of the NSQIP ongoing program of surveillance of surgical mortality.  The site visit was conducted in August 2007. 

Following a full and comprehensive investigation of the elevated ratio of mortality at the Marion VAMC, the Director took immediate action to ensure the safety of patients until the completion of the investigation.  All in-patient surgery at the Marion VAMC requiring general anesthesia was discontinued immediately.  Veterans requiring surgery with general anesthesia were referred to other VAMCs or, if necessary, to non-VA hospitals. VA's Under Secretary of Health (USH) directed the VA Office of Medical Inspector (OMI) to conduct an on site visit.  On September 5-6, 2007, the OMI conducted a visit at the Marion VAMC and confirmed significant issues regarding surgical quality and operation and raised issues regarding the management environment at the medical center in general.  That report is anticipated to be completed in the near future.  The USH requested the VA Office of the Inspector General (OIG) to conduct an on-site visit.  Those findings are not final at this time.  To date, five members of the Marion VAMC staff have been reassigned to non-clinical areas away from the medical center or placed on administrative leave. 

VA promptly notified Congress of the initial finding identified by VA's ongoing assessment and review processes.  VA continues to be responsive to Congressional inquiries, to the extent possible, considering ongoing investigations.

CONCLUSION
Mr. Chairman, VA has multiple tools in place for assessing and evaluating health care and they are working, as in this case, to identify irregularities and correct them.  These tools are part of the ongoing processes that are used in not only revealing the positive but also the vulnerabilities and deficiencies in VA's health care system.   VA acknowledges these findings and seeks to actively address the challenges they present.  Moreover, the lessons learned are disseminated to health care providers throughout our health care system.

Mr. Chairman, this concludes my statement.  At this time I would be pleased to answer any questions that you may have.