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Military Health Care: Improved Procedures and Monitoring Needed to Ensure Provider Qualifications and Competence

GAO-22-104668 Published: Aug 11, 2022. Publicly Released: Aug 11, 2022.
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Fast Facts

After concerns about the quality of servicemembers' health care arose in 2014, Congress put the Defense Health Agency in charge of administering DOD's medical facilities. This includes ensuring individual providers are qualified and competent to deliver high-quality care.

Four selected medical facilities and the agency didn't always adhere to the agency's clinical quality management procedures. For example, they didn't always review patient safety events—which harmed or could have harmed patients—in the required timeframes.

We recommended that the agency clarify its procedures for monitoring provider qualifications and competence.

military ID tags and a stethoscope on an American flag

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What GAO Found

The Defense Health Agency is responsible for ensuring the quality and safety of health care delivered by individual providers at its military medical treatment facilities. However, GAO found that four selected facilities and the Defense Health Agency did not always adhere to the agency's clinical quality management procedures in part because they were unclear.

  • Credentialing and privileging. GAO reviewed documentation for 100 providers from four selected facilities and found that the facilities did not always adhere to the Defense Health Agency's procedures for credentialing and privileging—the process of verifying that a provider has the appropriate qualifications and abilities to deliver specific health care services. For example, for about one-sixth of providers reviewed, the facilities did not verify all medical licenses before granting privileges. Additionally, for almost half of the providers reviewed, the facilities did not obtain clinical references from appropriate individuals such as the program director, as required. GAO found this was partly due to the procedures being unclear about which providers must have clinical references.
  • Focused evaluations of concerns. The four selected facilities collectively conducted 20 focused evaluations to address clinical performance concerns raised about individual providers. GAO's review showed that these facilities did not always adhere to requirements. For example, for about half of these evaluations, facilities did not document the metrics for evaluating whether providers adequately addressed the concerns raised. GAO found that nonadherence was due in part to unclear procedures, such as inconsistent terminology for these evaluations.
  • Patient safety events that resulted in compensation. GAO found that the Defense Health Agency did not always adhere to its own requirements for reviewing patient safety events. Patient safety events, such as the misdiagnosis of a life-threatening condition, can involve compensation because of the potential for patient harm. The four selected facilities had 12 such events that resulted in compensation to patients or their families. Specifically, the Defense Health Agency's reviews of nine of these events exceeded the required time limits for those reviews. Also, the Defense Health Agency did not report providers involved in those nine events to a national database as required.

GAO also found that the Defense Health Agency did not sufficiently monitor facilities' adherence to its clinical quality management procedures. As of May 2022, the Defense Health Agency monitored adherence to some credentialing and privileging requirements by running database reports on expired credentials, but did not monitor adherence to other requirements, such as certain performance evaluations. Defense Health Agency officials told GAO they have developed plans to monitor facilities' documentation of focused evaluations and patient safety events, but had not yet implemented these plans.

Why GAO Did This Study

Since 2014, Congress and the Department of Defense (DOD) have taken steps intended to strengthen patient safety in the Military Health System. As part of those efforts, Congress mandated that the Defense Health Agency, an agency within DOD, be responsible for the military departments' administration of facilities. This responsibility includes ensuring individual providers are qualified and competent to deliver safe, high quality care to patients.

Congress included a provision in statute for GAO to review the Defense Health Agency's clinical quality management procedures. This report addresses facilities' and the Defense Health Agency's adherence to these procedures and the Defense Health Agency's monitoring of facilities' adherence. GAO reviewed documentation from four facilities selected to obtain variation in location and military department. Additionally, GAO reviewed the Defense Health Agency's clinical quality management procedures and interviewed relevant Defense Health Agency officials about these procedures and related monitoring efforts. GAO also evaluated the procedures and monitoring efforts using federal internal control standards.


GAO is making two recommendations, to the Defense Health Agency to (1) clarify its clinical quality management procedures and (2) conduct monitoring to better ensure facilities adhere to these procedures. DOD concurred with both recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Defense Health Agency The Director of the Defense Health Agency should revise the procedures manual for clinical quality management to better ensure requirements are clear and specific. Revisions should

  • clarify whether clinical references are required for providers whose privileges are being renewed.
  • specify how far in advance of privileging an MTF is allowed to verify licenses and query the NPDB and List of Excluded Individuals and Entities.
  • specify that MTF staff must document their consideration of information that raises concerns during the credentialing and privileging process.
  • clarify requirements for FPPEs for cause, including clear distinctions between requirements that apply to initial FPPEs and those that apply to FPPEs for cause.
  • specify how DHA defines commencing and completing a PCE review and how MTFs should document these milestones in DOD's centralized healthcare risk management database.

(Recommendation 1)

DOD concurred with this recommendation. DOD has taken some steps to clarify requirements, including publishing interim guidance requiring MTFs to report FPPEs for cause to DHA. DHA plans to update its implementation guidance in the short term and revise its procedures manual in the longer term. As of February 2024, DOD estimates completion of planned actions in response to this recommendation in July 2025.
Defense Health Agency The Director of the Defense Health Agency should implement monitoring of clinical quality management procedures at MTFs and ensure that the monitoring approach includes

  • an assessment of MTF adherence to credentialing and privileging, FPPE for cause, and PCE review procedures.
  • a process for obtaining and evaluating information about all patient safety events that resulted in compensation and require DHA review.

(Recommendation 2)

Open – Partially Addressed
DOD concurred with this recommendation. As of February 2024, DHA has taken steps to improve its monitoring of MTF adherence to certain clinical quality management procedures, including credentialing and privileging and FPPE for cause. For example, DHA provided documentation of modifying its credentialing database to improve MTF adherence to license verification requirements. DHA also provided documentation of a May 2023 memo instructing MTFs to upload documentation of FPPEs for cause so that DHA officials can conduct monthly monitoring and periodic audits. However, DHA has not implemented planned actions to improve its monitoring of patient safety events that could potentially result in compensation (i.e. PCEs), including events for which a payment has not been made and events involving an active-duty death or disability payment. In February 2024, DHA estimated completing its planned actions for monitoring adherence to these procedures in September 2024.

Full Report

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Agency evaluationsHealth careMilitary health careMilitary treatment facilitiesPatient carePerformance monitoringQuality assuranceSafetyQuality of careDatabase management systems