Healthcare Inspection VISN Summary Report: Evaluation of Practitioner Credentialing and Privileging for Fiscal Years 2023 to 2024

Veterans Health Administration (VHA) administers healthcare services through a nationwide network of 18 regional systems referred to as Veterans Integrated Service Networks (VISNs). This Office of Inspector General (OIG) report describes the results of a VISN-level oversight evaluation of credentialing and privileging processes at facilities within the VISNs. The OIG inspected VISNs 7, 8, 12, 15, 20, and 23 from December 5, 2022, through February 14, 2024. Specifically, the OIG determined whether VISNs complied with the following requirements:
   •    Senior strategic business partners, VISN human resources officers, and chief medical officers review licensure information for practitioners with a history of adverse licensure actions
   •    Practitioners with equivalent specialized training and similar privileges complete professional practice evaluations for solo and two-deep practitioners and facilities’ chiefs of staff
   •    VISN directors and privacy officers review evidence files for state licensing board reporting
   •    Chief medical officers review each facility annually and oversee credentialing and privileging processes
 

The OIG issued four recommendations for improvement:
   •    External practitioners with equivalent training and similar privileges complete timely evaluations for
      o    Solo and two-deep practitioners
      o    Facility chiefs of staff
   •    Review of state licensing board reporting processes for compliance with VHA policy
   •    The Chief Medical Officer oversees facilities’ annual self-assessment and ensures responses reflect accurate data