Comprehensive Healthcare Inspection Summary Report: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, Fiscal Year 2021

Report Information

Issue Date
Report Number
22-00818-03
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

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.

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)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility peer review committees recommend improvement actions for Level 3 peer reviews.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility surgical work groups meet monthly and core members consistently attend meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility surgical work groups consistently review surgical deaths.