VA Health Care:

VA's Patient Injury Control Program Not Effective

HRD-87-49: Published: May 18, 1987. Publicly Released: May 21, 1987.

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Pursuant to a congressional request, GAO reviewed the effectiveness of the patient injury control function in the Veterans Administration's (VA) quality assurance program.

At the nine centers GAO visited, it found that: (1) the patient injury control program was not effective in preventing the recurrence of unexpected deaths and surgical complications; (2) in fiscal year (FY) 1985, VA medical centers reported about 85,000 incidents involving patient injuries, but did not report more serious injuries because of staff disincentives, lack of central oversight, and inadequate reporting guidelines; (3) VA referred only 36 percent of the incidents requiring investigation to the medical inspector; (4) VA did not compare data on patient incidents over time because it thought that it would take care of the incidents on a case-by-case basis or by other quality assurance activities; and (5) an occurrence screening program would complement the incident-reporting program.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: The VA manual has been revised in accordance with this recommendation.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to revise the VA manual to reflect accurately the requirements of the federal regulations and revise statistical reporting requirements to correspond to the incident reporting categories in the revised manual.

    Agency Affected: Veterans Administration

  2. Status: Closed - Implemented

    Comments: VA provided software for occurrence screening and patient incident reporting. VA also revised its manual. Additionally, the Office of Quality Assurance provided guidance on conducting the trending and analysis, and handbooks and instructional guides were developed and distributed to the field.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to develop guidelines that identify the data to be gathered and analyzed for trends and provide guidance on conducting the trending and analysis.

    Agency Affected: Veterans Administration

  3. Status: Closed - Implemented

    Comments: VA implemented this recommendation by revising its manual, MP-1, part 1.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to revise the VA manual to reflect current practice in regard to investigating unexpected deaths, which requires: (1) a three-member board investigation only for deaths the facility director decides to investigate; or (2) submission to the medical inspector of appropriate explanatory documentation so that he will have a basis for requiring an investigation if, after reviewing the documentation, he disagrees with the facility director's decision to investigate.

    Agency Affected: Veterans Administration

  4. Status: Closed - Implemented

    Comments: VA implemented this recommendation by revising its manual, MP-1, part 1.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to reemphasize to the medical centers what incidents are required to be investigated, and that all investigations reports are to be forwarded to the medical inspector.

    Agency Affected: Veterans Administration

  5. Status: Closed - Implemented

    Comments: VA implemented this recommendation by revising its manual, MP-1, part 1.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to clarify which incidents are reportable by revising VA Manual MP-1 to incorporate all reportable incidents listed in the applicable federal regulations.

    Agency Affected: Veterans Administration

  6. Status: Closed - Implemented

    Comments: VA has implemented this recommendation by revising its manual, MP-1, part 1.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to emphasize to all medical center staff: (1) the importance of incident reporting as a means to ensure that VA provides quality health care; and (2) that federal regulations must be followed.

    Agency Affected: Veterans Administration

  7. Status: Closed - Implemented

    Comments: A computerized comparison of FY 1987 and FY 1988 Semiannual Reports of Patient Incidents has been produced and reviewed. Weaknesses in reporting were discussed at the Regional QA Managers Meeting in March 1989. Representatives from the Office of QA and Medical Inspector have met to identify potential concerns regarding analysis and trending. This process will continue on a routine basis.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to require the medical inspector to analyze and trend VA program data to determine if individual medical centers are not reporting patient incidents or are having problems providing quality care.

    Agency Affected: Veterans Administration

 

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