VA Health Care:

The Quality of Care Provided by Some VA Psychiatric Hospitals Is Inadequate

HRD-92-17: Published: Apr 22, 1992. Publicly Released: Apr 22, 1992.

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Pursuant to a congressional request, GAO reviewed quality assurance programs at Department of Veterans Affairs (VA) psychiatric hospitals.

GAO found that: (1) none of the four VA psychiatric hospitals visited are effectively collecting and using the kind of quality assurance data needed to demonstrate that their psychiatric programs fully meet patients' psychiatric needs, primarily because VA has not defined requirements for evaluating psychiatric programs, and nurses and physicians in two hospitals are not documenting the reasons why they place patients under restraints and seclusion; (2) hospital staff in two VA hospitals were not timely correcting quality assurance problems identified through patient incident reports; (3) unnecessary deaths occur in VA hospitals because medical staff do not use available quality assurance data to correct identified problems; (4) VA and non-VA hospitals' quality assurance programs are similar; and (5) quality-of-care problems resulting in complications or death occurred in both VA and non-VA hospitals.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: Significant effort has been made to clarify expectations for medical center directors' performance in various quality assurance mechanisms. Conference calls have been held and will continue to be held discussing the need to ensure premortem and postmortem analyses for unexpected deaths.

    Recommendation: The Secretary of Veterans Affairs should require the Chief Medical Director to hold each hospital director responsible for making certain that all committees, service chiefs, and other users of quality assurance information conduct premortem and postmortem analyses on unexpected deaths and those that occur within 24 hours of admission, determine the cause of any differences between the two analyses, and take action where appropriate.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Implemented

    Comments: Actions such as the revisions to the Patient Incident Reporting (PIR) system, including the automation and national "roll-up" of PIR data with other risk management information such as surgical complications, will provide the ultimate resolution of this recommendation.

    Recommendation: The Secretary of Veterans Affairs should require the Chief Medical Director to hold each hospital director responsible for making certain that all committees, service chiefs, and other users of quality assurance information thoroughly examine the cause and related circumstances surrounding unexpected deaths that occur in the hospital, those that occur within 24 hours of admission, and those that occur in specific clinical diagnoses at a higher than expected rate and correct any quality-of-care problems identified as being a possible factor in the deaths.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: A survey of restraint and seclusion use was performed and issued in September 1996. Follow-up calls to discuss results and responsibilities then occurred with Medical Center directors.

    Recommendation: The Secretary of Veterans Affairs should require the Chief Medical Director to hold each hospital director and appropriate psychiatric staff responsible for accurately documenting incidents of restraints and seclusion and reasons why patients are remaining in the hospital beyond their commitment period.

    Agency Affected: Department of Veterans Affairs

  4. Status: Closed - Implemented

    Comments: VA revised its manual (M2, part X, dated June 29, 1993) to define expectations for treatment planning, evaluation of goals, and program reviews.

    Recommendation: The Secretary of Veterans Affairs should require the Chief Medical Director to define the meaning of the term "treatment goal," provide guidance to hospital directors on how such goals should be evaluated, and ensure that program reviews are conducted in each hospital to evaluate the attainment of those goals.

    Agency Affected: Department of Veterans Affairs

  5. Status: Closed - Implemented

    Comments: VA has begun to monitor the quality of medical and surgical care for 17 discharge diagnoses and surgical procedures, including most of the types of cases GAO was concerned about. Additionally, criteria for mental health care are being developed. As part of a multiyear effort to empower VAMC clinicians in the evaluation of care, there has been a national training program in clinical indicators.

    Recommendation: The Secretary of Veterans Affairs should require the Chief Medical Director to hold each hospital director responsible for making certain that all committees, service chiefs, and other users of quality assurance information analyze patient incident data over time and take corrective action on any identified problems.

    Agency Affected: Department of Veterans Affairs

 

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