Report Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration (VHA) facilities’ quality, safety, and value (QSV) programs. This report describes findings from healthcare inspections performed at 45 medical facilities during fiscal year 2021 that focused on facility committees responsible for QSV oversight functions, systems redesign and improvement programs, protected peer reviews of clinical care, and medical center surgical programs.

Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses with protected peer review and facility surgical work groups and issued three recommendations for

• peer review committee documentation of individual improvement actions for Level 3 peer reviews,

• surgical work groups that meet at least monthly with consistent attendance by required members, and

• surgical work groups’ monthly review of surgical deaths.