VA Health Care:

Medical Centers Are Not Correcting Identified Quality Assurance Problems

HRD-93-20: Published: Dec 30, 1992. Publicly Released: Dec 30, 1992.

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Pursuant to a congressional request, GAO reviewed the Department of Veterans Affairs' (VA) administration of medical centers, focusing on: (1) inadequate reporting and investigation of patient incidents; and (2) VA failure to properly document the supervision of resident physicians.

GAO found that: (1) four of the five medical centers visited underreported patient incidents involving deaths and medication errors; (2) none of the medical centers consistently documented whether attending physicians provided supervision to all resident physicians who performed surgical procedures or provided medical care; (3) medical center personnel were not following established criteria concerning incident reporting, completing required investigations of serious incidents in a timely manner, or strictly enforcing policies and procedures that require all attending physicians to document their involvement in patient cases; (4) VA has issued detailed procedures to all medical centers on how they should verify physician credentials; (5) VA has enhanced its monitoring by having regional office personnel visit each center to verify that the procedures are being followed; and (6) VA has added compliance with credentialing requirements as a standard in every medical center director's performance contract.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: VA has not made the specific changes that GAO recommended. However, it has made major changes in its medical center program structure and initiated several efforts designed to monitor and assess the quality of health care. Over the past 2 years, VA has implemented its Veterans Integrated Service Network (VISN), which is tasked with the responsibility for ensuring the quality of patient care to 22 networks that manage VA's 159 medical centers. In addition, since November 1991, VA has systematically collected information on patient care quality, including incidents which adversely affect patients. VA also established an External Peer Review Program, performed by an outside contractor, that measures the quality of care, processes, and outcomes in VA patients. VA's Resident Supervision Oversight and Steering Committee developed several instruments, including a monitoring tool for resident supervision. Information will be reviewed locally and reported to regional and central offices.

    Recommendation: The Secretary of Veterans Affairs should instruct the Under Secretary for Health to require central and regional offices to establish a review program that targets specific quality assurance areas, such as patient incidents and supervision of residents, for extensive review and followup.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Implemented

    Comments: VA disagreed that regional inspection teams should be implemented. However, VA reorganized its medical center structure under the VISN concept and has initiated efforts designed to monitor and assess the quality of health care. Under its detailed plans for the VISN concept, VA adopted several guiding principles and proposed several actions, both taken and planned, which are consistent with the intent of this recommendation. GAO believes that these actions should result in continued improvement in the quality of care provided by VA medical centers.

    Recommendation: The Secretary of Veterans Affairs should instruct the Under Secretary for Health to require regional directors to have inspection teams ensure that every medical center in their region is complying with quality assurance requirements and that problems GAO and the Inspector General identified have been corrected.

    Agency Affected: Department of Veterans Affairs


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