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Evaluation of the Quality, Safety, and Value Program in Veterans Health Administration Facilities Fiscal Year 2016

Report Information

Issue Date
Report Number
16-03743-193
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
National Healthcare Review
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General completed a healthcare evaluation of Veterans Health Administration medical facilities’ quality, safety, and value programs. The purpose of the evaluation was to determine whether Veterans Health Administration facilities complied with selected requirements related to quality, safety, and value activities. We conducted this review at 28 Veterans Health Administration medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2015 through March 31, 2016. All 28 facilities had established quality, safety, and value programs and performed ongoing reviews and analyses of mandatory areas. We identified system weaknesses in five areas and recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers and facility senior managers, reinforce requirements for: Facility clinical managers to evaluate licensed independent practitioners’ ongoing professional performance regularly according to the frequency established by facility policy; Facility clinical managers to implement the improvement actions recommended by the Peer Review Committee; Facility Utilization Managers to complete at least 75 percent of all required reviews and designated Physician Utilization Management Advisors to document their review decisions in the Veterans Health Administration’s utilization management database; Facility Patient Safety Managers to enter all patient incidents into the Veterans Health Administration’s web-based patient incident database, complete the minimum number of root cause analyses each fiscal year, provide feedback about the root cause analyses findings to the individuals or departments who reported the incidents, and submit patient safety reports to facility leaders at least annually; Facility committees and teams to consistently implement and evaluate corrective actions from quality, safety, and value activities.

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 Network and facility senior managers, ensure clinical managers evaluate licensed independent practitioners’ ongoing professional performance regularly according to the frequency required by facility policy.
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 Network managers and facility senior managers, ensure clinical managers implement the improvement actions recommended by the Peer Review Committee.
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 Network and facility senior managers, ensure Utilization Managers complete at least 75 percent of all required reviews and designated Physician Utilization Management Advisors document their review decisions in the Veterans Health Administration’s utilization management database.
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 Network and facility senior managers, ensure Patient Safety Managers enter all patient incidents into the Veterans Health Administration’s web-based patient incident database, complete the minimum number of root cause analyses, provide feedback about the root cause analyses findings to the individuals or departments who reported the incidents, and submit patient safety reports to facility leaders at least annually.
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 Network and facility senior managers, ensure committees and teams consistently implement and evaluate corrective actions from quality, safety, and value activities.