Combined Assessment Program Summary Report - Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2014

Report Information

Issue Date
Report Number
14-00378-208
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) completed an evaluation of Veterans Health Administration medical facilities’ quality management programs. OIG conducted this review at 57 Veterans Health Administration medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2013, through September 30, 2014. Facility senior managers reported that they supported their quality management programs and actively participated through being involved in committees, mentoring teams, and reviewing meeting minutes and reports. We identified opportunities for improvement in the areas of peer review, teledermatology, utilization management, review of resuscitation events, blood usage review, and surgical oversight and made seven recommendations.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinical managers complete improvement actions related to peer review and report the completion to the Peer Review Committee and that the Peer Review Committee submits quarterly reports to the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that the Medical Executive Committee documents approval when telemedicine services are received or provided.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinical managers reassess observation criteria and/or utilization when the conversion rate from observation to admission was greater than the allowed percent.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinicians complete reviews of inpatients’ continuing stays.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirement for an interdisciplinary committee to review individual resuscitation episodes and for facilities to collect resuscitation data.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that transfusion committees meet at least quarterly; include clinical representation from Medicine, Surgical, and Anesthesia Services; and review all required elements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirements for Surgical Work Groups to meet monthly, include the Chief of Staff as a member, monitor surgical performance improvement activities, and review National Surgery Office reports.