Summary

Department of Veterans Affairs (VA) medical centers have had mixed success in resolving the quality assurance deficiencies noted by GAO and the Inspector General in earlier audits. Problems persist in reporting and investigating patient incidents and in documenting the supervision of residents. As a result, VA still cannot accurately analyze unexpected or unfavorable incidents involving patient care and recommend corrective action. Moreover, it still does not know whether its residents are being properly supervised. These problems continue because medical center personnel are not adhering to applicable policies and procedures. Further, VA's central office and regional offices are not adequately monitoring medical center efforts to correct these problems. On the other hand, recent VA initiatives in credentialing physicians have greatly improved medical center compliance with policies and procedures. VA is undertaking several systemwide initiatives to bolster its quality assurance programs, such as peer review of the quality of care being delivered at medical centers. Success, however, depends on VA ensuring that medical centers correct any problems identified through these initiatives.

GAO found that: (1) four of the five medical centers visited underreported patient incidents involving deaths and medication errors; (2) none of the medical centers consistently documented whether attending physicians provided supervision to all resident physicians who performed surgical procedures or provided medical care; (3) medical center personnel were not following established criteria concerning incident reporting, completing required investigations of serious incidents in a timely manner, or strictly enforcing policies and procedures that require all attending physicians to document their involvement in patient cases; (4) VA has issued detailed procedures to all medical centers on how they should verify physician credentials; (5) VA has enhanced its monitoring by having regional office personnel visit each center to verify that the procedures are being followed; and (6) VA has added compliance with credentialing requirements as a standard in every medical center director's performance contract.