VA Health Care:

Actions in Response to VA's 1989 Mortality Study

HRD-91-26: Published: Nov 27, 1990. Publicly Released: Nov 27, 1990.

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Pursuant to a congressional request, GAO reviewed the Department of Veterans Affairs' (VA) actions to address a June 1989 report about quality-of-care problems associated with deaths in several VA medical centers during fiscal year (FY) 1986, focusing on whether VA: (1) appropriately conducted its follow-up validation methodology; (2) completed the follow-up as described in the mortality study; (3) took proper actions as a result of the follow-up; and (4) needed to take other actions to ensure that it identifies quality-of-care problems and takes corrective actions.

GAO found that: (1) VA used an appropriate methodology to identify and follow up on deaths associated with quality-of-care problems, and completed most of the actions it planned to assess the significance of the mortality study findings; (2) VA was still analyzing deaths that occurred in psychiatric centers in FY 1989 to determine if there were any significant differences between the quality of care provided in psychiatric facilities and that provided at other VA medical centers; (3) although VA took specific actions to follow up on its mortality study, it did not use the information it obtained from individual medical centers to improve systemwide operations; and (4) VA failure to disseminate all pertinent information to all medical centers could result in a duplication of effort and the lost opportunity to share data that could help to prevent similar problems from occuring at other medical centers.

Matters for Congressional Consideration

  1. Status: Closed - Implemented

    Comments: Committee staff stated that continuing discussions with VA officials regarding this issue have been held as part of the broader quality of health care issue.

    Matter: As part of its continuing oversight of VA health care issues, the Senate Committee on Veterans' Affairs may wish to discuss with the Secretary of Veterans Affairs the results of VA efforts to compare the quality of care provided in medical and surgical units in primarily psychiatric hospitals with that provided in medical and surgical acute care hospitals.

  2. Status: Closed - Implemented

    Comments: Committee staff stated that continuing discussions with VA officials regarding this issue have been held as part of the broader quality of health care issue.

    Matter: As part of its continuing oversight of VA health care issues, the Senate Committee on Veterans' Affairs may wish to discuss with the Secretary of Veterans Affairs the need for central office staff to review the results of future quality assurance studies for possible systemwide applications and disseminate appropriate information to all medical centers.

 

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