Report Summary

Title: Combined Assessment Program Summary Report - Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2012
Report Number: 12-01480-183
Issue Date: 4/25/2013
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CAP Reviews
Release Type: Unrestricted
Summary: OIG completed an evaluation of quality management (QM) in Veterans Health Administration (VHA) facilities for fiscal year 2012. The purposes of the evaluation were to determine whether VHA facilities had comprehensive, effective QM programs designed to monitor patient care activities and coordinate improvement efforts and whether VHA facility senior managers actively supported QM efforts and appropriately responded to QM results. OIG conducted this review at 54 facilities during Combined Assessment Program reviews performed from October 1, 2011, through
September 30, 2012, and identified three areas where VHA facilities needed to improve compliance. OIG recommended that facility directors and Patient Safety Officers sit on the high-level committees that review QM results, that completed corrective actions related to peer review be reported to the Peer Review Committee, and that Focused Professional Practice Evaluations for newly hired licensed independent practitioners be initiated and completed and that the results be reported to the Medical Executive Committee.