VA Health Care:
Adequacy of Resident Supervision Is Not Assured, but Plans Could Improve Oversight
GAO-03-625: Published: Jul 2, 2003. Publicly Released: Jul 2, 2003.
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The Department of Veterans Affairs (VA) provides graduate medical education (GME) to as many as one-third of U.S. resident physicians, but oversight responsibilities spread across VA's organizational components and multiple affiliated hospitals and medical schools could allow supervision problems to go undetected or uncorrected. GAO was asked to examine VA's procedures for (1) monitoring VA medical centers' adherence to VA's requirements for resident supervision, (2) using evaluations of supervision by GME accrediting bodies and residents, and (3) using information about resident supervision drawn from VA's programs for monitoring the quality and outcomes of patient care.
VA cannot assure that the resident physicians who provide care in its facilities receive adequate supervision because its procedures for monitoring supervision are insufficient. VA does not know whether medical centers have adopted VA's national requirements for supervision of residents' diagnosis, treatment, or discharge of patients. VA officials require a review of only one specific requirement that is intended to ensure availability of supervision when a supervising physician does not need to be in the operating or procedural suite while a resident performs a diagnostic or therapeutic procedure. Four of 11 network officials we interviewed had not conducted this review, and the requirement at one medical center in one of these four networks was less stringent than VA's national requirement. To obtain more complete information about adherence to its national supervision requirements, VA plans to have external peer reviewers examine documentation of supervision in patients' medical records. VA's plans for this review have not been finalized. For example, as of May 2003, VA had not decided whether reviewers would examine records from VA's new outpatients. Without records from new patients, reviewers will not be able to assess documentation of residents' supervision during a veteran's first outpatient visit. To improve its oversight, VA is making efforts to obtain information from accrediting bodies and residents about the quality of resident supervision. For example, VA has taken steps to obtain direct access to letters from accrediting bodies that contain evaluations of the GME programs in which its medical centers participate. To solicit feedback from residents, VA implemented a national survey, but was unable to send this survey to a representative sample of residents from each VA medical center because it does not have a complete central list of its residents. VA is taking action to obtain this information. In addition, VA uses information from its broader programs for monitoring the quality and outcomes of patient care, such as its patient safety and surgical quality improvement programs, to identify and correct problems with resident supervision. Information from these programs has served as the basis for corrective actions by VA officials.
Recommendations for Executive Action
Status: Closed - Implemented
Comments: During fiscal year 2005, VA took steps to improve adherence to its requirements for resident supervision as GAO recommended. For example, VA created a national performance measure for resident supervision based on a random sampling methodology. This performance measure assessed the timeliness of documentation of resident supervision and held facilities accountable for their progress in this area. As another example, VA implemented mandatory procedures for VA facility, network, and headquarters officials to monitor adherence to VA's requirements for the supervision of medical residents.
Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to take steps to improve VA's oversight of the supervision of residents by ensuring that all VA medical centers that provide GME adopt and adhere to the requirements for resident supervision established in VA's handbook.
Agency Affected: Department of Veterans Affairs
Status: Closed - Not Implemented
Comments: The Department of Veterans Affairs (VA) has indicated that it no longer plans to implement this recommendation.
Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to take steps to improve VA's oversight of the supervision of residents by ensuring that external peer review of documentation of resident supervision includes examination of records from VA's new outpatients.
Agency Affected: Department of Veterans Affairs