STATEMENT OF DR. JOHN H. MATHER
ASSISTANT INSPECTOR GENERAL
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE SUBCOMMITTEE ON HEALTH,
COMMITTEE ON VETERANS' AFFAIRS,
UNITED STATES HOUSE OF REPRESENTATIVES
OVERSIGHT HEARING ON
THE VETERANS HEALTH ADMINISTRATION'S
RISK MANAGEMENT PROGRAM AND
ITS OFFICE OF MEDICAL INSPECTOR
October 8, 1997
Mr. Chairman and Members of the Subcommittee, I appreciate the opportunity to appear today to discuss the Veterans Health Administration's policy and performance in the area of risk management, and the mission, role, and organizational structure of its Office of Medical Inspector (OMI), as it relates to both risk management and the OMI's other responsibilities.
1. Office of Inspector General (OIG) Role
The Office of Inspector General (OIG) has a mandate to provide independent oversight of the Department of Veterans Affairs. The OIG is accountable to both Congress and the Department in carrying out its mission to promote economy, efficiency, and effectiveness in VA operations; to detect and prevent fraud, waste, and abuse in VA programs; and to monitor VA's medical quality-assurance programs. In carrying out its mission, one of the OIG's primary goals is to help management succeed in its effort to reinvent government; that is, to build a government that works better and costs less for the benefit of today's and tomorrow's veterans and taxpayers. This goal speaks to the very essence of the OIG mission--and unites us with Department management and Congress as we strive together to ensure that quality services are delivered to veterans in a cost effective, efficient, and timely manner.
2. OIG Monitoring of Quality Assurance
In the mid-1980s, a perception developed that, at least in the area of having proficiency in the formal implementation of the healthcare quality assurance (QA) process, VA was lagging. The General Accounting Office (GAO) reported, "VA Has Not Fully Implemented Its Health Care Quality Assurance Systems, " in June 1985, followed immediately by a U.S. House of Representatives report entitled "Patients At Risk: A Study Of Deficiencies In the Veterans Administration Medical Quality Assurance Program" Both reports were very critical of VA's formal QA programs and processes.
The GAO similarly criticized the VA Central Office's Office of the Medical Inspector (OMI) established to oversee quasi-legal and quasi-medical aspects of VA, mainly VA's patient injury control program, patient abuse, and practitioner licensing sanctions. VA's Medical Inspector office, which had been established within the Veterans Health Administration (VHA) in response to an apparent lack of effective central oversight and medical investigator capacity, was felt to require substantial revision in the GAO report, "VA's Patient Injury Control Program Not Effective."
It is consistent with the broad charter of VA's IG--mainly the obligation to monitor the economy, efficiency, and effectiveness of the Department's programs and activities--to oversee VA healthcare and QA activities. Nonetheless, after substantial debate, Congress decided to provide emphasis in this area for VA's IG.
The first specific attempt at such a focus through the OIG was in Public Law 99-166, "The Veterans' Administration Health-Care Amendments of 1985," which mandated that "The Inspector General of the Veterans' Administration shall allocate sufficient resources including sufficient personnel with the necessary skills and qualifications to enable the Inspector General to monitor the [healthcare] quality assurance program." Eventually the Congress was to extend this legislation and, in the "Veterans Benefits and Services Act of 1988", Public Law 100-322. It was more fully elaborated that VA should "upgrade and expand the activities of the Veterans' Administration's Office of Inspector General in overseeing, monitoring, and evaluating the operations of the Department of Medicine and Surgery's [VHA's] quality-assurance programs and activities and its Medical Inspector office so as to provide the Chief Medical Director [Under Secretary for Health], the Administrator [Secretary], and the Congress with clear and objective assessments of the effectiveness of those programs and operations, including ensuring such numbers of, and such skills and training on the part of, employees assigned to the Office of Inspector General as are necessary to carry out such oversight, monitoring, and evaluation effectively."
3. OIG Organizational Focus: Office of Healthcare Inspections
In 1988, VA's IG established a support Division within its Policy, Planning, and Resources Office known as the Quality Assurance Review Division (QARD). This Division was staffed in 1989. In 1991, coincident with the continuing and, indeed, increasing prominence of QA and oversight of health care systems, the QARD was upgraded to a full VA OIG "office," co-equal organizationally with its Office of Audit and Office of Investigations. This Office is named the Office of Healthcare Inspections (OHI).
The OHI fulfills for the IG the primary focus for general oversight and monitoring of VHA's quality-assurance activities and programs, and oversight of the VHA's OMI. These broad responsibilities are ongoing and become most specific as regards program evaluations, Hotline inspections, and the development of a new Quality Program Assistance (QPA) review.
a. General Oversight
i. Oversight of VA's QA Programs
Oversight of VA's QA programs at all levels, particularly its VACO/VHA Quality Assurance Office (now named, Office of Performance and Quality) was specifically mandated by Congress. OHI attempts to meet this mandate in two general ways. In individual case reviews, a facility's QA programs are routinely assessed, and generally commented upon in conjunction with OHI hotline inspections. Second, OHI understands that VACO/VHA coordinates several nationwide QA programs. These include its "Occurrence Screening Program," "The Patient Incident Reporting System," "Tort Claims Analysis," "Patient Satisfaction Survey Program, " "Utilization Management Program," "Cardiac Surgery Review Program," and the "External Peer Review Program."
OHI, in its oversight capacity has reviewed the strengths and weaknesses of many of these programs, such as the "Evaluation of the Veterans Health Administration's Patient Satisfaction Survey Program." This was followed by an "Evaluation of the Veterans Health Administration's Quality Improvement Checklist (QUIC) Program," and "Evaluation Of The Patient Representative Program." Its most recent report of
a VACO/VHA directed QA program is a review of the "External Peer Review Program."
Earlier this year, OHI initiated an evaluation of VHA's quality assurance program at the request of the Senate Veterans' Affairs Committee (SVAC). This review will encompass and conduct:
OHI is in the midst of this review which will include a review of VHA's risk management program. It is anticipated that this will be completed early in 1998.
ii.Oversight of the Office of Medical Inspector
VHA's Office of Medical Inspector (OMI) was established in 1980. This office serves as an internal medicolegal oversight office for VHA, and in some sense might be considered a precursor to OHI. However, it is distinguished from the OIG's OHI, in that OMI is internal to VHA. OHI, being an OIG component, is external to the VHA. This distinction, which, unfortunately, has been a repeated cause of confusion, even to those familiar with VA, might be further explained by the analogy that the OMI serves as an internal overseer and "troubleshooter" for VHA and reports to the Under Secretary for Health (USH): while OHI is an external overseer of health care activities, reporting, through the Inspector General, to the Department's Secretary and Congress. These different reporting relationships provide the OHI with the assurance of an independence of its investigations that the OMI cannot always have. VHA's current operating philosophy is that the USH should have the opportunity to have available internal oversight mechanisms as a "troubleshooter" including an office configured as OMI, for a health care system the size of VHA.
The above notwithstanding, Public Law 100-322 provides OIG with a specific directive to oversee the OMI. This task has been approached in several ways. Initially, case reviews conducted by OMI are reviewed by OHI prior to final closure. In so reviewing the OMI's work, and having the imprimatur of final closure, both the quality and rigor of that Office's case reviews could be assessed, and hence the OMI overseen. Likewise, this means of oversight provided OHI with a sense of the issues and controversies current within VHA. Second, as OHI evolved, the approach of publishing a detailed summary report on the activities, needs, strengths, and weaknesses of OMI was added to OHI's oversight efforts of OMI, and this is discussed later.
b. Specific Oversight
i. Program Evaluations
More under the auspices of the IG Act than under Public Law 100-322 which focuses specifically on VA's quality assurance programs, review of VHA clinical programs other than strictly its QA programs, has been a continuing OHI activity. At the forefront of such program reviews are current critical issues in veterans health care. These include the Department's response to veterans who become ill after service in the Persian Gulf, provision of health care to an ever increasing number of female veterans in a healthcare system largely designed to serve male veterans, and a review of VA's handling of the new, but extremely expensive and, toxic, high surveillance anti-schizophrenic drug clozapine. In addition to the topics receiving medical and public attention, there are ongoing issues in veterans health care for which VA has developed programs, and which OHI inspected. These include VA's programs addressing such issues as homelessness, domiciliary care, ambulatory care, Advance Directives and the impact of downsizing substance abuse rehabilitation programs. It is anticipated that such programmatic reviews will continue, these being perennial health care issues which require oversight, and which are integral to a large health care system.
ii. Hotline Inspections
To fulfill the OIG organizational charge of identifying waste, fraud, and abuse in the agency, VA's OIG, like most Federal OIGs, maintains a "hotline." This "hotline" is an "800 number," and an address which is prominently displayed in VA facilities (medical and non-medical), and listed in local telephone directories and more recently can be accessed on the OIG Internet. On the order of 20,000 hotline contacts yearly are made to VA's OIG. A large portion of these contacts are clinical or QA related and hence OHI has found itself involved in numerous hotline cases. Additionally, Congressional constituent referrals, White House case referrals, and cases prominently highlighted in the media are often assigned hotline status. While the majority of these cases must be referred to VHA for primary review, many are referred to OMI--thus reinforcing the need for OHI oversight of VHA. However, as a means of independent verification of VHA's work, and due to its status as a clinical oversight body independent of VHA, OHI also independently inspects approximately 100 hotline cases yearly. Most of OHI's hotline cases have very high profiles. Through OHI's performance of hotline reviews, oversight data is obtained in the form of independent verification of the quality and rigor of VHA's review of such cases. These inspections often give some insight into the effectiveness of a VAMC's risk management program. OHI is currently conducting a review of all hotline cases for Fiscal Years 1993 through 1995 from which it is expected that some profiles and patterns will emerge.
Also, OHI provides technical assistance to OIG's audit and criminal investigative branches. OHI provides technical assistance in clinical fields such as medicine, nursing, social work, respiratory therapy, nutrition, and clinical pharmacy to auditors and investigators not trained in those areas. OHI technical assistance has led, on occasion, to identification of clinical, i.e., non-audit and non-criminal, quality assurance issues, which may then be reported under OHI cover.
iii. Quality Program Assistance (QPA) Review
It has become apparent that OHI should "inspect" VHA's hospital facilities and inspect individual VAMC's QA programs, on-site, without the crisis atmosphere or adversarial nature that may accompany a hotline inspection. To meet this need, OHI is pioneering a system of proactive review.
OHI hopes to develop and implement a program of comprehensive medical center reviews which includes an assessment of the medical care and provides VHA managers with independent, objective findings which will assist them in improving the efficiency and effectiveness of their operations. The principles guiding the QPA program development are: healthcare remains, at its core, the interaction of professionals (providers) with clients (patients); the program should focus on broad general indicators of healthcare quality; inspections should be direct and consider historic data only secondarily; the process should not be duplicative of other internal or external review programs; the inspections should be undertaken by generalist healthcare inspectors; the process should use standard instruments, which might eventually allow results to be compared from center-to-center; and the process should be cost effective.
The program of QPA reviews was begun in early 1995 and after an initial pilot, six facilities were visited to further refine the process through late 1996. After a careful review of the experience gained from those early endeavors, a final prototype was devised with the advice of some VISN clinical managers, and was tested at six VAMCs at the end of fiscal year 1997. If, after a final thorough evaluation, it is concluded that this is a "value added" process, then it is projected that the QPA reviews will become fully operational in 1998.
4. OHI/OIG Oversight of VHA's Risk Management Policy
The general purpose of a risk management policy in healthcare facilities and healthcare systems is to have program and operational requirements, which have a fundamental orientation towards prevention of errors in the provision of personal medical services. Hence it is expected that an effective risk management program will:
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Reviewed/Updated Date: November 10, 2009