Healthcare Inspection Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2009

The evaluation was conducted to determine whether Veterans Health Administration (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 44 facilities reviewed had established comprehensive QM programs and performed ongoing reviews and analyses of mandatory areas, 4 facilities had significant weaknesses. Senior managers at all facilities reported that they support their QM programs and actively participate. To improve operations, we recommended that VHA reinforce requirements for: A systematic approach to planning, delivering, measuring, and improving health care, which includes tracking open action items. Peer review timeliness, action documentation, trend analyses, and reports to the Medical Executive Committee. Defining staff who need life support training, systematically tracking training status, and taking appropriate actions when needed training is not maintained. Systematic review processes of the quality of medical record entries. Documented plans addressing the delivery of services to patients held in temporary bed locations and non-admitted patients placed in overflow locations.