Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Summary Report 

Evaluation of Quality Management in 

Veterans Health Administration Facilities 

Fiscal Year 2010 

Report No. 10-00415-90 February 16, 2011

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations: 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

Contents 

Page

Executive Summary ........................................................................................................ i

Introduction .......................................................................................................... 1

Summary .......................................................................................................................... 1 

Background ...................................................................................................................... 1

Scope and Methodology .................................................................................................. 2

Inspection Results ............................................................................................... 4 

Issue 1: Facility Quality Management and Performance Improvement Programs .......... 4 

A. Program Areas ........................................................................................................ 4

B. Data Management ................................................................................................... 8

Issue 2: Senior Managers’ Support for Quality Management and Performance 

Improvement Efforts ........................................................................................................ 8

Conclusions ...................................................................................................................... 9

Recommendations .......................................................................................................... 10

Comments ...................................................................................................................... 10 

Appendixes 

A. Under Secretary for Health Comments .................................................................... 11

B. OIG Contact and Staff Acknowledgments ............................................................... 15

C. Report Distribution................................................................................................... 16

VA Office of Inspector General 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

Executive Summary 

Introduction 

The Department of Veterans Affairs, Office of Inspector General (OIG), Office of 

Healthcare Inspections completed an evaluation 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. 

The OIG conducted this review at 55 VA medical facilities during Combined Assessment 

Program reviews performed across the country from October 1, 2009, through 

September 30, 2010. 

Results and Recommendations 

Although all 55 facilities had established comprehensive QM programs and performed 

ongoing reviews and analyses of mandatory areas, 4 facilities had significant weaknesses. 

To improve operations, we recommended that VHA reinforce requirements for: 

• Comprehensive utilization management programs 

• Thorough review of individual resuscitation episodes and trending of aggregate 

data 

• 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. 

Comments 

The Under Secretary for Health concurred with the findings and recommendations. The 

implementation plans are acceptable, and we will follow up until all actions are 

completed. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General i 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 1 

Introduction 

Summary 

The Department of Veterans Affairs, Office of Inspector General (OIG), Office of 

Healthcare Inspections completed an evaluation 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. 

VHA program officials had issued clarifications and initiated corrective actions that 

addressed the recommendations made in our seven previous QM evaluation reports. 

During fiscal year (FY) 2010, we reviewed 55 facilities during Combined Assessment 

Program (CAP) reviews performed across the country. Although all 55 facilities had 

established comprehensive QM programs and performed ongoing reviews and analyses 

of mandatory areas, 4 facilities had significant weaknesses. These four facilities needed 

more effective structures to ensure systematic quality review, analysis, and problem 

identification and resolution. The four facilities’ CAP reports provide details of the 

findings, recommendations, and action plans.1,2,3,4

Facility senior managers reported that they support their QM programs and actively 

participate through involvement in committees and by reviewing meeting minutes and 

reports. 

Background 

Leaders of health care delivery systems are under pressure to achieve better 

performance.5

 As such, they must commit to relentless self-examination and continuous 

improvement.6

 The 2009 Baldrige Health Care Criteria for Performance Excellence

state that an effective health care system depends on the measurement and analysis of 

 

1 Combined Assessment Program Review of the Memphis VA Medical Center, Memphis, Tennessee (Report 

No. 10-00046-32, November 22, 2010). 

2 Combined Assessment Program Review of the El Paso VA Health Care System, El Paso, Texas (Report 

No. 10-01876-252, September 21, 2010). 

3 Combined Assessment Program Review of the Carl Vinson VA Medical Center, Dublin, Georgia (Report 

No. 10-00045-207, July 26, 2010). 

4 Combined Assessment Program Review of the Providence VA Medical Center, Providence, Rhode Island (Report 

No. 10-01158-190, July 13, 2010). 

5

 James L. Reinertsen, MD, et al., Seven Leadership Leverage Points for Organization-Level Improvement in Health 

Care, 2d ed., Cambridge, MA, Institute for Healthcare Improvement, 2008. 6

 Anne Gauthier, et al., Toward a High Performance Health System for the United States, The Commonwealth Fund, 

March 2006. 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 2 

quality and performance. The Joint Commission (JC) describes QM and performance 

improvement (PI) as continuous processes that involve measuring the functioning of 

important processes and services and, when indicated, identifying and implementing 

changes that enhance performance. 

Since the early 1970s, VA has required its health care facilities to operate comprehensive 

QM programs to monitor the quality of care provided to patients and to ensure 

compliance with selected VA directives and accreditation standards. External, private 

accrediting bodies, such as The JC, require accredited organizations to have 

comprehensive QM programs. The JC conducts triennial surveys at all VHA medical 

facilities; however, the current survey process does not focus on those standards that 

define many requirements for an effective QM program. Also, external surveyors 

typically do not focus on VHA requirements. 

Public Laws 99-1667

 and 100-3228 require the VA OIG to oversee VHA QM programs 

at every level. The QM program review has been a consistent focus during OIG CAP 

reviews since 1999. 

Scope and Methodology 

We performed this review in conjunction with 55 CAP reviews of VA medical facilities 

conducted from October 1, 2009, through September 30, 2010. The facilities we visited 

represented a mix of facility size, affiliation, geographic location, and Veterans Integrated 

Service Networks (VISNs). Our review focused on facilities’ FYs 2009 and 2010 QM 

activities. The OIG generated an individual CAP report for each facility. For this report, 

we analyzed the data from the individual facility CAP QM reviews to identify 

system-wide trends. 

The OIG revises the QM review guide each year to reflect changes in relevant VHA and 

external requirements. To the extent possible, we compared our findings from FY 2010 

CAPs with the findings cited in our FY 2009 report.9

 

To evaluate QM activities, we interviewed facility directors, chiefs of staff, and QM 

personnel, and we reviewed plans, policies, and other relevant documents. Some of the 

areas reviewed did not apply to all VHA facilities because of differences in functions or 

frequencies of occurrences; therefore, denominators differ in our reported results. 

 

7

 Public Law 99-166, Veterans’ Administration Health-Care Amendments of 1985, December 3, 1985, 99 Stat. 941, 

Title II: Health-Care Administration, Sec. 201–4. 

8

 Public Law 100-322, Veterans’ Benefits and Services Act of 1988, May 20, 1988, 102 Stat. 508–9, Sec. 201. 9 Healthcare Inspection – Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal 

Year 2009 (Report No. 09-00069-161, June 2, 2010). 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 3 

For the purpose of this review, we defined a comprehensive QM program as including 

the following program areas: 

• Adverse event disclosure 

• Medical record quality reviews and copy and paste function monitoring 

• Medication reconciliation monitoring 

• Mortality analyses 

• Operative and other invasive procedures reviews 

• Patient complaints management 

• Patient flow and system redesign 

• Patient safety analyses and annual reporting 

• Peer review management 

• QM and PI committees, activities, and teams 

• Reviews of resuscitation episodes and life support training 

• Utilization management (UM) 

To evaluate monitoring and improvement efforts in each of the program areas, we 

assessed whether VHA facilities used a series of data management process steps. These 

steps are consistent with JC standards and included: 

• Gathering and critically analyzing data 

• Comparing the data analysis results with established goals or targets 

• Identifying specific corrective actions when results did not meet goals 

• Implementing and evaluating actions until problems were resolved or 

improvements were achieved 

In past QM reports, we included a review of physician credentialing and privileging in 

this evaluation. However, in July we published a separate report on this topic.10 

We used 95 percent as the general level of expectation for performance in the areas 

discussed above. In making recommendations, we considered improvement compared 

with past performance and ongoing activities to address weak areas. For those areas 

listed above that are not mentioned further in this report, we found neither any 

noteworthy positive elements to recognize nor any reportable deficiencies. 

We conducted the review in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

 

10 Healthcare Inspection – Evaluation of Physician Credentialing and Privileging in Veterans Health Administration 

Facilities (Report No. 10-02381-185, July 6, 2010).
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 4 

Inspection Results 

Issue 1: Facility Quality Management and Performance 

Improvement Programs 

A. Program Areas 

Although all 55 facilities had comprehensive QM/PI programs, 4 facilities had significant 

weaknesses. All facilities had established senior-level committees with responsibility for 

QM/PI, and all had chartered teams that worked on various PI initiatives, such as 

improving patient flow throughout the organization and managing medications. 

UM. VHA implemented a standardized system-wide UM approach in 2005.11 We found 

that all facilities had implemented a process where nurses reviewed a sample of acute 

care admissions and continued stay days against established criteria (for example, 

severity of illnesses and intensity of treatments). However, we found that cases not 

meeting criteria were consistently referred to physician advisors at only 34 (69 percent) 

of 49 facilities. This is a decrease from 79 percent in our 2009 report. UM reviewers 

collaborated daily with others responsible for patient management and/or patient flow at 

49 (94 percent) of 52 facilities. In addition, we found that there was a defined 

communication process between UM reviewers and physician UM advisors at 

43 (88 percent) of 49 facilities. 

We reviewed training for both UM reviewers and physician UM advisors. We found that 

50 facilities had a standardized process for determining inter-rater reliability and that 

44 (88 percent) of them had trained and tested all their UM reviewers. The physician 

UM advisors received training related to the physician advisor role at 82 percent 

(42 of 51) of facilities. 

Although this program area has undergone significant changes over the past 5 years, the 

requirements have been stable during the past year. Therefore, we recommended that 

VHA re-emphasize these requirements and monitor for compliance. 

Reviews of Resuscitation Episodes and Life Support Training. VHA requires that 

facilities review each episode of care where resuscitation was attempted—both on an 

individual basis and in the aggregate—for the purpose of identifying problems, analyzing 

trends, and benchmarking to identify opportunities to improve both process and 

outcomes.12 We found that 50 (94 percent) of 53 facilities gathered data that measured 

processes in responding to resuscitation episodes. The following required items should 

 

11 VHA Directive 2005-040, Utilization Management Policy, September 22, 2005. Reissued as VHA 

Directive 2010-021, Utilization Management Program, May 14, 2010. 12 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility 

Cardiopulmonary Resuscitation Committees, October 17, 2008. 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 5 

be addressed: (1) errors or deficiencies in technique, (2) malfunctioning equipment, and 

(3) delays in initiating cardiopulmonary resuscitation (CPR). We found that about 

90 percent of facilities included these items in their reviews. These results represent a 

decrease from our FY 2009 review. Therefore, we recommended that VHA re-emphasize 

the requirements for thorough review of individual resuscitation episodes and trending of 

aggregate data. 

VHA expects that each facility will have a policy that defines the staff who need to have 

current CPR or Advanced Cardiac Life Support (ACLS) training, a mechanism to ensure 

compliance, and consequences if needed training is not maintained.13 Only 

29 (54 percent) of 54 facilities’ staff complied with the CPR and/or ACLS training 

required by their policies, which is the same result in our FY 2009 report. Furthermore, 

only 2 (8 percent) of the facilities not in compliance had taken appropriate actions to 

correct the situation. Additionally, we found that the required annual review of all 

facility policies related to the training of staff and performance of CPR was done at 

51 (93 percent) of 55 facilities. 

We discussed these results with the responsible program official who told us that VHA is 

planning a standardized CPR and ACLS training program and a standardized tracking 

mechanism. In our FY 2009 report, we recommended that VHA re-emphasize 

compliance with these requirements. Because performance in FY 2010 was still below 

expectations and to encourage VHA to implement the planned training and tracking 

program, we again recommended that VHA re-emphasize compliance with these 

requirements and that facility directors ensure compliance with facility policy, which 

includes tracking training status and taking appropriate action when needed training is not 

maintained. 

Mortality Analyses. Since 1998, VHA has required that managers thoroughly analyze 

mortality data. The Inpatient Evaluation Center (IPEC) provides reports to each facility 

that include mortality data adjusted in various ways. We found that facility senior 

managers reviewed IPEC mortality data at 88 percent (42 of 48) of facilities. While 

VHA has not required that IPEC reports be reviewed, we believe the information is 

useful in alerting senior managers to mortality trends. We recommended that VHA 

require facility senior managers to review the mortality data provided to them in IPEC 

reports and take actions as appropriate when negative trends are identified. 

QM and PI Committees. VHA requires facilities to have an organized, systematic 

approach to planning, delivering, measuring, and improving health care.14 Committee 

discussions about QM reviews and decisions about problem areas must be recorded in 

meeting minutes. We found that 50 (91 percent) of 55 facilities used a standardized 

 

13 VHA Directive 2008-008, Cardiopulmonary Resuscitation (CPR) and Advanced Cardiac Life Support (ACLS) 

Training for Staff, February 6, 2008. 14 VHA Directive 2009-043, Quality Management System, September 11, 2009. 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 6 

format for meeting minutes. This represents an improvement from 89 percent in our 

FY 2009 report. Busy committees need methods to keep track of open items, and facility 

senior managers need methods to keep track of all the major committees’ activities. 

Eighty-five percent (47 of 55) of facilities used a standardized mechanism to assist with 

tracking open action items, which is an increase from 64 percent in our FY 2009 report. 

Although improvement is noted, performance did not meet expectations. In our FY 2009 

report, we recommended that VHA re-emphasize compliance with these requirements, 

which was accomplished at a national conference in June. Therefore, we did not make a 

recommendation but will continue to review. 

Peer Review Management. VHA requires that facilities have consistent processes for 

peer review.15 Peer review can result in improvements in patient care by revealing areas 

for improvement in individual providers’ practices. We found opportunities for 

improvement in several areas. Forty-seven (85 percent) of 55 facilities’ Peer Review 

Committees (PRCs) submitted quarterly reports to their Medical Executive Committees, 

which is an increase from 80 percent in our FY 2009 report. When peer reviews were not 

completed within the required timeframes, extensions by the facility director were 

documented as required at 13 (54 percent) of 24 facilities. When peer reviews resulted in 

actions, the PRC received the documented results of the actions at 35 (73 percent) of 

48 facilities, which is about the same as the 76 percent in our FY 2009 report. 

In our FY 2009 report, we recommended that VHA re-emphasize compliance with these 

requirements, which was accomplished at a national conference in June. Therefore, we 

did not make a recommendation but will continue to review. 

Medical Record Copy and Paste Function Monitoring. VHA requires that facilities have 

policies that address medical record copy and paste functions and that they monitor for 

inappropriate use.16 VHA’s computerized medical record provides a remarkable tool for 

documenting patient care. However, one of the potential pitfalls is the ease with which 

text can be copied from one note and pasted into another. Only 46 (84 percent) of the 

55 facilities had a process to monitor inappropriate use of the copy and paste functions. 

This result represents an increase compared with 72 percent in our FY 2009 report. VHA 

re-emphasized compliance with these requirements at a national conference in August. 

Therefore, we did not make a recommendation but will continue to review. 

Patient Flow and System Redesign. The JC requires facilities to have a documented plan 

addressing patients who must be held in temporary bed locations, such as the emergency 

department. We found such plans at 46 (94 percent) of 49 facilities, which is an 

improvement from 90 percent in our FY 2009 report. VHA re-emphasized compliance 

with these requirements at a national conference in June. Therefore, we did not make a 

recommendation but will continue to review. 

 

15 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 16 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 7 

Adverse Event Disclosure. VHA facilities have an obligation to disclose adverse events 

to patients who have been harmed in the course of their care, for example, as a result of 

significant medication errors.17 Two types of disclosure are defined—clinical and 

institutional. Clinical disclosures may be documented in ordinary progress notes. 

Institutional disclosures require a consultation with Regional Counsel, a family 

conference, and a note indicating that the patient or family member was informed of his 

or her right to file a tort claim or a claim for increased benefits. 

Disclosure was considered for patients who experienced events resulting in Level 3 peer 

reviews at 90 percent (46 of 51) of facilities. Similarly, 86 percent (31 of 36) of facilities 

considered disclosure for patients who experienced events that resulted in serious adverse 

outcomes related to surgical procedures. Overall, institutional disclosure was 

appropriately considered by 94 percent (45 of 48) of facilities. VHA requires that facility 

directors receive a written report regarding the disclosure of adverse events at least 

annually, and we found such a report at 43 (88 percent) of 49 facilities. VHA is in the 

process of revising the directive and re-emphasized compliance with these requirements 

at a national conference in April. Therefore, we did not make a recommendation. 

Medication Reconciliation Monitoring. This topic is a national patient safety goal that 

requires each facility to maintain a list of all medications each patient takes, regardless of 

the source. This list must be reviewed at key points during each patient’s care, such as 

admission, transfer, and discharge. Any duplications, omissions, or potentially hazardous 

combinations must be addressed or reconciled. We found evidence that medications 

were consistently reconciled upon admission at most facilities. However, upon transfer 

into or out of facilities, we found evidence of complete medication lists at only 91 percent 

(50 of 55) of facilities, which is a slight increase from 88 percent in our FY 2009 report. 

Also, we found that medications were consistently reconciled upon discharge at only 

92 percent (48 of 52) of facilities. This result represents a slight decrease from our 

FY 2009 review. VHA is in the process of creating a directive and re-emphasized 

compliance with these requirements at national conferences in April, June, and August. 

Therefore, we did not make a recommendation. 

Operative and Other Invasive Procedures Reviews. The JC requires the monitoring of 

operative and other invasive procedures performed outside of the operating room setting. 

Numbers and complications from these procedures, including those using moderate 

sedation, should be reported to an organization-wide venue. We found that 

47 (92 percent) of 51 facilities reviewed the data to identify trends and reported to an 

organization-wide committee. VHA is creating a directive to address infrastructure, 

oversight, and reporting for ambulatory surgery and moderate sedation processes. 

Therefore, we made no recommendation but will continue to review. 

 

17 VHA Directive 2008-002, Disclosure of Adverse Events to Patients, January 18, 2008. 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 8 

B. Data Management 

We evaluated monitors in all the QM/PI program areas reviewed by assessing whether 

VHA facilities followed a series of data management process steps that are described on 

page 3 of this report and in The JC’s Improving Organizational Performance standards. 

We found that improvement is needed in the following area. 

Identifying, Implementing, and Evaluating Actions. Facility managers must use the 

information from data analysis to identify corrective actions, implement the actions, and 

evaluate them to determine whether they achieved the expected results. According to the 

Institute for Healthcare Improvement, the leaders of successful organizations do not 

accept action plans passively but often send management teams back to develop more 

robust solutions.18 We found that facility managers did not consistently assure 

implementation of recommended corrective actions or evaluate the effectiveness of the 

interventions. Only 47 (85 percent) of 55 facilities indicated that they had a standardized 

mechanism to assist with tracking open action items. 

We found inadequate identification, implementation, and evaluation of corrective actions 

when results did not meet goals in the following eight program areas 

(range 55–81 percent): 

• Peer review management 

• Patient complaints management 

• Patient safety analyses 

• Operative and other invasive 

procedures reviews 

• Medication reconciliation 

monitoring 

• Reviews of resuscitation episodes 

• Medical record copy and paste 

function monitoring 

• UM 

These results indicate that facility managers must do a better job of identifying corrective 

actions from QM and PI reviews and effectively implementing and evaluating them. This 

area continues to be challenging for VHA, and we have noted similar results in all of our 

annual QM reports. VHA re-emphasized compliance with these requirements at a 

national conference in June. Therefore, we did not make a recommendation but will 

continue to review. 

Issue 2: Senior Managers’ Support for Quality Management 

and Performance Improvement Efforts 

Facility directors are responsible for their QM programs, and senior managers’ 

involvement is essential to the success of ongoing QM and PI efforts. “The era when 

quality aims could be delegated to ‘quality staff,’ while the executive team works on 

 

18 Reinertsen, p. 10. 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 9 

finances, facility plans, and growth, is over.”19 During our interviews, all senior 

managers voiced strong support for QM and PI efforts. They stated that they were 

involved in QM and PI in the following ways: 

• Chairing or attending leadership or executive-level committee meetings 

• Reviewing meeting minutes 

• Chairing the PRC (chiefs of staff) 

• Reviewing patient safety analyses 

• Coaching system redesign patient flow initiatives 

QM program coordinators generally agreed that their senior managers supported the 

program. One hundred percent of QM program coordinators rated facility directors 

involved or highly involved in QM and PI compared with 91 percent for chiefs of staff 

and 81 percent for physicians. We noted some gaps in program continuity when key QM 

and patient safety staff vacancies were not filled expeditiously, and interim coverage was 

inadequate. 

Senior managers stated that methods to ensure that actions to address important patient 

care issues were successfully executed included delegating tracking to QM and patient 

safety personnel, reviewing meeting minutes, and using web-based tracking logs. 

VHA’s High Performance Development Model20 states that managers should 

demonstrate their commitment to customer service by being highly visible and accessible 

to all customers. We asked facility directors and chiefs of staff whether they visited the 

patient care areas of their facilities, and all responded affirmatively. Seventy-nine 

percent of them stated that they visited clinical areas at least weekly. VHA has not stated 

any required frequency for senior managers to visit the clinical areas of their facilities. 

Therefore, we made no recommendation. 

Conclusions 

Although all 55 facilities we reviewed during FY 2010 had established comprehensive 

QM programs and performed ongoing reviews and analyses of mandatory areas, 

4 facilities had significant weaknesses. Facility senior managers reported that they 

support their QM and PI programs and are actively involved. However, they need to 

ensure that the requirements that were re-emphasized at national meetings in 2010 are 

being fully complied with in their facilities. 

VHA, VISN, and facility senior managers need to continue to strengthen QM and PI 

programs through increased compliance with existing requirements for UM, thorough 

reviews of resuscitation episodes, and life support training. In addition, VHA should 

 

19 Reinertsen, p. 12. 

20 VHA, High Performance Development Model, Core Competency Definitions, January 2002. 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 

VA Office of Inspector General 10 

require facility senior managers to review the mortality data provided to them in IPEC 

reports and take actions as appropriate when negative trends are identified. 

Recommendations 

Recommendation 1: We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, re-emphasize the requirements for 

facilities to have a comprehensive UM program and monitor compliance. 

Recommendation 2: We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, re-emphasize the requirements for 

thorough review of individual resuscitation episodes and trending of aggregate data. 

Recommendation 3: We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, re-emphasize the requirements to 

define staff who need life support training, systematically track training status, and take 

appropriate actions when needed training is not maintained. 

Recommendation 4: We recommended that the Under Secretary for Health, in 

conjunction with VISN senior managers, require that facility senior managers review the 

mortality data provided to them in IPEC reports and take actions as appropriate when 

negative trends are identified. 

Comments 

The Under Secretary for Health concurred with the recommendations and provided 

implementation plans with target completion dates. The Office of the Deputy Under 

Secretary for Health for Operations and Management (DUSHOM) will issue 

memorandums to the field re-emphasizing the requirements for facilities to have 

comprehensive UM programs; to do thorough reviews of individual resuscitation 

episodes and trend aggregate data; and to define staff who need life support training, 

systematically track training status, and take appropriate actions when needed training is 

not maintained. Each VISN will certify to the DUSHOM that reviews of these areas with 

their facilities have been completed. Also, the DUSHOM will issue a memorandum to 

VISN directors to ensure that facility senior managers review IPEC mortality data and 

document the review in appropriate committee minutes. The full text of the comments is 

shown in Appendix A (beginning on page 11). The Under Secretary for Health’s 

comments and implementation plans are responsive to the recommendations. We will 

continue to follow up until all actions are completed. 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010

Appendix A 

Under Secretary for Health Comments 

VA Office of Inspector General 11 

Department of 

Veterans Affairs Memorandum

Date: Jan 26, 2011 

From: Under Secretary for Health (10) 

Subject: OIG Combined Assessment Program Summary Report Draft 

Report, Evaluation of Quality Management in Veterans 

Health Administration Facilities Fiscal Year 2010 

(VAIQ 7068593)

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report and concur with all four of the 

recommendations. Attached is the Veterans Health Administration’s 

corrective action plan for the report’s recommendations. 

2. Thank you for the opportunity to review the draft report. If you have 

any questions, please contact Linda H. Lutes, Director, Management 

Review Service (10B5) at (202) 461-7014. 

(original signed by:) 

Robert A. Petzel, M.D. 

Attachment 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010

VETERANS HEALTH ADMINISTRATION (VHA) 

Action Plan 

OIG Draft Report, Evaluation of Quality Management in Veterans 

Health Administration Facilities Fiscal Year (FY) 2010 

(VAIQ 7068593) 

Date of Draft Report: December 17, 2010 

Recommendations/ Status Completion 

Actions Date 

OIG Recommendations

Recommendation 1. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, 

re-emphasize the requirements for facilities to have a comprehensive UM 

program and monitor compliance. 

VHA Comments

Concur 

The Office of the Deputy Under Secretary for Health for Operations and 

Management (DUSHOM) will issue a memorandum to the field 

re-emphasizing the requirements for facilities to have a comprehensive 

Utilization Management (UM) program and to monitor compliance. 

This Office of Inspector General (OIG) summary report rolls up the 

findings from individual FY 2010 OIG Combined Assessment Program 

(CAP) reviews that have identified the need for improvement of specific 

facilities regarding UM. For each of the areas for improvement identified 

in a relevant CAP review, the Veterans Integrated Service Network (VISN) 

Director is responsible for reinforcing that these issues have been reviewed 

with the particular medical center, and that action plans have been 

completed or timelines have been established for their completion. Each 

VISN Director will certify to the DUSHOM by March 1, 2011, that the 

reviews with facilities in the VISN have been completed. 

In Process March 31, 2011 

Recommendation 2. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, 

VA Office of Inspector General 12 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010

re-emphasize the requirements for thorough review of individual 

resuscitation episodes and trending of aggregate data. 

VHA Comments

Concur 

The DUSHOM will issue a memorandum to the field re-emphasizing 

requirements for thorough review of individual resuscitation episodes and 

trending of aggregate data. In general, VHA requires that facilities review 

each episode of care where resuscitation was attempted—both on an 

individual basis and in the aggregate—to detect problems, analyze trends, 

and benchmark to identify opportunities to improve both the process and 

outcomes. The DUSHOM will specifically address the following identified 

issues: 

• Errors or deficiencies in technique; 

• Malfunctioning equipment; and 

• Delays in initiating cardiopulmonary resuscitation (CPR). 

This OIG summary report rolls up the findings from individual FY 2010 

OIG CAP reviews that have identified the need for improvement of specific 

facilities regarding individual resuscitation episodes and trending of 

aggregate data. For each of the areas for improvement identified in a 

relevant CAP review, each VISN Director is responsible for reinforcing 

that these issues have been reviewed with the particular medical center, and 

that action plans have been completed or timelines have been established 

for their completion. Each VISN will certify to the DUSHOM by 

March 1, 2011, that the reviews with facilities in each VISN have been 

completed. 

In Process March 31, 2011 

Recommendation 3. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, 

re-emphasize the requirements to define staff who need life support 

training, systematically track training status, and take appropriate actions 

when needed training is not maintained. 

VHA Comments

Concur 

The DUSHOM will issue a memorandum to the field re-emphasizing the 

requirements to define staff who need life support training, systematically 

VA Office of Inspector General 13 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010

VA Office of Inspector General 14 

track training status, and take appropriate actions when needed training is 

not maintained. 

This OIG summary report rolls up the findings from individual FY 2010 

OIG CAP reviews that have identified the need for improvement regarding 

training. For each of these areas for improvement identified in a relevant 

CAP review, each VISN Director is responsible for reinforcing that these 

issues have been reviewed with the particular medical center, and that 

action plans have been completed or timelines have been established for 

their completion. Each VISN Director will certify to the DUSHOM by 

March 1, 2011, that each area of improvement has been reviewed with 

facilities. 

In Process March 31, 2011 

Recommendation 4. We recommended that the Under Secretary for 

Health, in conjunction with VISN senior managers, require that facility 

senior managers review the mortality data provided to them in IPEC reports 

and take actions as appropriate when negative trends are identified. 

VHA Comments

Concur 

The DUSHOM will issue a memorandum to the VISNs explaining this OIG 

report and findings. The memorandum will require that VISN Directors 

ensure that facility senior managers review the IPEC mortality data, and 

document the review in appropriate committee minutes. Also, the 

DUSHOM will require that: 

• When the mortality indicator is red for the first quarter, the VISN 

Director will work with the appropriate facility to develop an action 

plan, and monitor implementation until performance is stabilized and 

performance is within the expected range. 

• IPEC Mortality statistics and any required action plans will be 

discussed and documented (at a minimum) at the VISN quarterly 

Quality Council meeting. 

• IPEC Mortality data will be discussed in each Network Director’s 

quarterly review with the DUSHOM, and action plans for level 2 

and 3 “at risk” facilities will be tracked through IPEC. 

In Process March 31, 2011 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact Julie Watrous, R.N., M.S. 

Director, Combined Assessment Program 

Acknowledgments Jennifer Christensen 

Donna Giroux 

David Griffith 

Elaine Kahigian 

Cathleen King 

Jennifer Kubiak 

Karen Moore 

Glen Pickens 

Reba Ransom 

Wilma Reyes 

Virginia Solana 

Karen Sutton 

Judith Thomas 

Roberta Thompson 

Mary Toy 

Ann Ver Linden 

Cheryl Walker 

Marilyn Walls 

Toni Woodard 

Susan Zarter 

VA Office of Inspector General 15 
Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010

Appendix C 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

Office of Quality and Performance 

National Center for Patient Safety 

Office of General Counsel 

Office of Medical Inspector 

Veterans Integrated Service Network Directors (1–23) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 16