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Highlights

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.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs 1. 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.
Closed - Implemented
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.
Department of Veterans Affairs 2. 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.
Closed - Implemented
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.

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