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Combined Assessment Program Summary Report – Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2013

Report Information

Issue Date
Report Number
13-00054-148
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purposes of the review were to determine whether Veterans Health Administration facilities had comprehensive, effective quality management programs designed to monitor patient care activities and coordinate improvement efforts and whether facility senior managers actively supported quality management efforts and appropriately responded to quality management results. OIG performed this review at 58 Veterans Health Administration medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2012, through September 30, 2013. All 58 facilities had established QM programs and performed ongoing reviews and analyses of mandatory areas. OIG identified opportunities for improvement in the areas of peer review, utilization management, electronic health record scanning, review of resuscitation events, and blood usage review.

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 Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that completed improvement actions related to protected peer review are reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facility observation bed processes are guided by comprehensive policies and that usage is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that reviews of inpatients’ continuing stays are consistently completed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ scanning processes are guided by comprehensive policies, that medical information is properly scanned into patients’ electronic health records, and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirements for thorough review of individual resuscitation episodes.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ transfusion committees meet at least quarterly; include clinical representation from Medicine, Surgical, and Anesthesia Services; and review all required elements.