Combined Assessment Program Summary Report – Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2011

OIG completed an evaluation of the management of Veterans Health Administration (VHA) medical facilities’ quality management (QM) programs. 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. OIG conducted this review at 54 facilities during Combined Assessment Program reviews performed from October 1, 2010, through September 30, 2011, and identified six areas with opportunities for improvement. OIG recommended that VHA reinforce requirements for facility senior managers to actively participate in the review of well-integrated QM/performance improvement results; Peer Review Committees to submit quarterly reports to their Medical Executive Committees; completed corrective actions related to peer review to be reported to the Peer Review Committee; electronic health records (EHR) committees to provide oversight and analyze EHR quality and unauthenticated documentation at least quarterly and to include all services in EHR quality reviews; routine monitoring of EHR entries for inappropriate copy and paste use and quarterly reporting to the EHR committee; and all facilities with acute inpatient beds to have documented plans addressing patients who must be held in temporary bed locations and overflow locations.