Healthcare Inspection Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2007

The evaluation was conducted to determine whether VHA facilities had comprehensive, effective quality management (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. Although all 46 facilities reviewed had established comprehensive QM programs and performed ongoing reviews and analyses of mandatory areas, two facilities had significant weaknesses. Senior managers at all facilities reported that they support and actively participate in their QM programs. However, senior managers needed to continue to strengthen QM programs by improving compliance in adverse event disclosure, utilization management (UM), National Patient Safety (NPS) Goals, patient flow, and action item implementation and evaluation.