Combined Assessment Program Summary Report Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010

The purposes of the evaluation were to determine whether VHA facilities had comprehensive, effective QM programs designed to monitor patient care activities and coordinate improvement efforts and whether VHA facility senior managers actively supported QM efforts and appropriately responded to QM results. To improve operations, we recommended that VHA reinforce requirements for: (1) comprehensive utilization management programs; (2) thorough review of individual resuscitation episodes and trending of aggregate data; and (3) life support training policies, monitoring, and actions. We also recommended that facility senior managers review the mortality data provided to them in Inpatient Evaluation Center reports and take actions as appropriate when negative trends are identified.