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.
Recommendations for Executive Action
|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.|
|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.|