Report Summary

Title: Improved Governance Would Help Patient Advocates Better Manage Veterans’ Healthcare Complaints
Report Number: 21-00510-105 Download
Issue Date: 3/24/2022
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Audits and Evaluations
Report Type: Audit
Release Type: Unrestricted

The Patient Advocacy Program helps advance the Veterans Health Administration’s (VHA) efforts to improve customer service, support veterans’ access to quality care, and provide a mechanism to resolve healthcare issues. Patient advocates document veterans’ concerns, communicate the resolution, provide follow up and feedback, and identify trends for potential opportunities to improve medical facilities. In FY 2020, VHA tracked about 162,000 serious complaints in its patient advocate tracking systems.

The OIG conducted this audit to determine whether VHA patient advocates resolved serious complaints on time and as required in that year. The audit also assessed whether VHA Patient Advocacy Program leaders effectively used program data to identify and address pervasive healthcare issues for veterans.

The audit found that VHA lacked adequate governance of the Patient Advocacy Program. VHA did not effectively issue and implement adequate policies, monitor complaint practices, and provide guidance to medical facility directors responsible for local program management. This inadequacy in governance contributed to patient advocates and other program leaders not fully complying with requirements for managing complaints in FY 2020.

According to an OIG survey, patient advocates and patient advocate supervisors at 17 percent of reviewed medical facilities did not always enter complaints into a patient advocate tracking system as required. Although the data indicated that patient advocates generally closed serious complaints on time, the OIG found that they did not always adhere to the documentation requirements to show full complaint resolution. In addition, there was inadequate monitoring at the local, regional, and national program levels.

VA concurred with the OIG’s three recommendations to the under secretary for health to review and update program policy; implement controls for regular, documented reviews of records; and provide guidance to medical facility directors to ensure they fulfill program management duties.