OIG conducted a healthcare inspection of the peer review process for quality management at the Huntington VA Medical Center (facility), Huntington, WV. We identified concerns while conducting a Combined Assessment Program review of the facility, which included an evaluation of Peer Review Committee activities. We found that in the cases we evaluated that were referred for peer review peer reviewers did not consistently address and document a comprehensive exploration of possible event causes. We also found (1) incomplete Peer Review Committee oversight of initial peer reviews; (2) an inappropriate but otherwise qualified individual conducted initial peer reviews; (3) that an individual was uncomfortable about conducting a peer review; and (4) that a peer reviewer conducting an initial review lacked qualifications required of a peer relative to the episode of care under review. We recommended that the Facility Director ensure peer reviewers identify and evaluate surgical and non-surgical clinical events, service-level committees adhere to the Veterans Health Administration’s peer review directive when conducting initial peer reviews and consider ensuring secondary reviews of all such cases, the Peer Review Committee provide final Level of Care assignments in writing for all cases brought before it, that service chiefs select peer reviewers to conduct initial peer reviews and that peer review processes provide means for peer reviewers to withdraw when uncomfortable about conducting reviews, that initial peer reviewers possess the qualifications required of peers relative to the episode of care under review and that all identified cases are reviewed and the initial peer review is repeated for those cases not conducted in compliance with the Veterans Health Administration’s peer review directive.