VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events
Published: 2015-07-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Adverse events are incidents that pose a risk of injury to a patient as the result of a medical intervention or the lack of an appropriate intervention. VAMCs use the RCA process to identify and evaluate systems or processes that caused an adverse event, recommend changes to prevent the event's recurrence, and determine whether implemented changes were effective.
GAO was asked to review VA's processes and procedures for responding to adverse events. In this report, GAO examined (1) the extent to which VAMCs used the RCA process to respond to adverse events and (2) how VHA oversees the RCA process and uses information from the process to make system-wide improvements. To conduct this work, GAO reviewed VHA policy and guidance documents, analyzed VHA data on RCAs completed from fiscal years 2010 through 2014, and interviewed officials from NCPS—the VHA office responsible for monitoring RCA data. GAO also analyzed local RCA data and interviewed officials from four VAMCs selected to provide variation in factors such as complexity and location.
section_title: What GAO Found
paragraphs: To address adverse events, Department of Veterans Affairs (VA) medical centers (VAMC) completed 18 percent fewer root cause analyses (RCA) in fiscal year 2014 compared to fiscal year 2010, and the Veterans Health Administration (VHA) has not analyzed the reasons for the decrease. VHA's National Center for Patient Safety (NCPS) officials told GAO they were aware of the decrease, but were not certain why the number of completed RCAs had decreased over time, especially in light of a 7 percent increase in reports of adverse events over the same time period. NCPS officials suggested several potential factors that could contribute to the decrease, including VAMCs' use of processes other than RCAs to address adverse events. However, NCPS is unaware of how many VAMCs use these other processes or their results. VHA's lack of analysis is inconsistent with federal internal control standards which state that agencies should compare data to analyze relationships and take appropriate actions. Because NCPS has not conducted an analysis of the relationship between the decrease in RCAs and possible contributing factors, it is unclear whether the decrease indicates a negative trend in patient safety at VAMCs or a positive one. In addition, without understanding the extent to which VAMCs use alternative processes and their results, NCPS has limited awareness of what VAMCs are doing to address the root causes of adverse events.
NCPS oversees the RCA process by monitoring VAMC compliance, and develops system-wide patient safety initiatives informed by RCA data. NCPS monitors each VAMC's compliance with requirements by reviewing RCA database information and conducting site visits. NCPS uses RCA information to inform system-wide patient safety initiatives, such as Patient Safety Alerts and Advisories—urgent notifications sent to VAMCs that describe a safety issue and include instructions and due dates for implementing actions to prevent recurrence.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA (1) analyze the declining number of completed RCAs, including identifying the contributing factors and taking appropriate actions, and (2) determine the extent to which VAMCs are using alternative processes to address adverse events, and collect information on their results. VA concurred with GAO's recommendations.

section_title: Letter
paragraphs: The Department of Veterans Affairs’ (VA) Veterans Health Administration  (VHA) operates one of the largest integrated health care delivery systems  in the United States. In fiscal year 2014, it provided health care services  to about 5.8 million veterans, a 14 percent increase from fiscal year 2009.  VHA’s health care system includes 150 VA medical centers (VAMC)  nationwide that offer a variety of outpatient, residential, and inpatient  services.
Adverse events—incidents that pose a risk of injury to a patient as the  result of a medical intervention or the lack of an appropriate intervention,  such as a missed or delayed diagnosis—occur in all health care settings,  including VAMCs. Adverse events may not always be attributable to an  error made by a provider, and can be due to systems vulnerabilities or  process failures. VHA requires that its VAMCs take appropriate action to  report and evaluate adverse events, which can include conducting a root  cause analysis (RCA)—a process to identify and evaluate systems or  processes that caused an adverse event, recommend changes to prevent  the event’s recurrence, and determine whether implemented changes  were effective. Information gleaned through an RCA may be used to  make system or process changes within a specific VAMC or VHA’s health  care system more broadly.
You asked us to review VA’s processes and procedures for responding to  adverse events that occur within its health care system. We previously  reported on the processes VAMCs can use to examine a clinician’s  actions as they relate to an adverse event.RCA process, which may be used to assess whether a systems or  process issue caused an adverse event. Specifically, this report examines  (1) the extent to which VAMCs used the RCA process to respond to  adverse events and (2) how VHA oversees the RCA process and uses  information from the process to make system-wide improvements.
In this report, we examine the  To determine the extent to which VAMCs used the RCA process to  respond to adverse events, we reviewed and analyzed VHA data on the  total number of RCAs completed across VHA during the past 5 fiscal  years (2010 through 2014), as well as the extent to which those RCAs  were required and whether individual VAMCs met VHA’s RCA  requirements. We reviewed VHA policy and guidance and interviewed  officials from VHA’s National Center for Patient Safety (NCPS)—the VHA  office responsible for monitoring RCA data—to identify RCA  requirements. We also interviewed NCPS officials to obtain their views on  trends we identified in the data. We evaluated VHA’s actions with respect  to identified trends within the context of federal internal control standards,  as documented in GAO’s Standards for Internal Control in the Federal  Government.  We also reviewed documentation on VHA’s centralized  RCA reporting system, and we spoke with NCPS officials about how RCA  data are collected and documented, and any limitations to the data. We  determined that these data were sufficiently reliable for our purposes.
GAO, Internal Control: Standards for Internal Control in the Federal Government,  GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999). selected sites), geographic location, and VAMC complexity level. For the  selected VAMCs, we analyzed VHA data on the RCAs conducted at each  VAMC from fiscal year 2010 through fiscal year 2014 to provide  illustrative examples of how the RCA process is conducted at the local  level. We interviewed officials from the selected VAMCs responsible for  convening, participating in, and approving RCAs to determine how they  implemented the RCA process.
To determine how VHA oversees the RCA process and uses information  from the process to make system-wide improvements, we reviewed VHA  policy and guidance documents and interviewed NCPS officials. We also  reviewed documentation of the results of NCPS analyses related to  RCAs. For the four selected VAMCs, we interviewed patient safety  officers from the associated Veterans Integrated Service Networks  (VISN), process, and disseminating information regarding system-wide  improvements.   to obtain information about their role in overseeing the RCA  We conducted this performance audit from November 2014 to July 2015  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: VHA’s National Patient Safety Improvement Handbook identifies key staff  involved in the RCA process, establishes minimum requirements for  conducting RCAs, and outlines the RCA process.
VISNs are regional systems of care that oversee the day-to-day functions of VAMCs that  are within their network. Each VAMC is assigned to one of VA’s 21 VISNs.
subsections: section_title: Key VHA Staff Involved in the RCA Process
paragraphs: Within VHA, NCPS supports the RCA process VHA-wide as part of its  broader efforts to reduce and prevent inadvertent harm to patients as a  result of their care. NCPS staff categorize and analyze RCA data, and  provide training and education for VAMCs on the RCA process.  According to VHA policy, NCPS is also responsible for disseminating  important information learned from RCAs to VAMCs. NCPS reports to the  Assistant Deputy Under Secretary for Health for Quality, Safety, and  Value, but also works with other VHA offices, including the Office of the  Deputy Under Secretary for Health for Operations and Management,  which directs operations at the VISN and VAMC levels. At the VISN level,  patient safety officers may provide additional oversight of the RCA  process and disseminate information from NCPS to the VAMCs within  their networks. Each VAMC has a patient safety manager who facilitates  the RCA process at the local level.
section_title: RCA Requirements
paragraphs: An RCA may be required by VHA policy if a VAMC’s initial review of an  adverse event finds that there is a risk to the safety of veterans, based on  the severity of the event and its likelihood of recurrence. VHA requires  that each VAMC complete a minimum of eight RCAs each fiscal year,  four of which must be on individual adverse events. The other four RCAs  can be a combination of individual RCAs and aggregated RCAs, the latter  of which review a group of similar adverse events to identify common  causes and actions to prevent future occurrences. VHA requires that  VAMCs conduct aggregated RCAs on three types of adverse events— falls, adverse drug events, and missing patients—to the extent that they  occur in a given year. All RCA-related information is required to be  entered into VHA’s centralized RCA reporting system—WebSPOT, a  software application within VHA’s Patient Safety Information System.  WebSPOT is the means by which RCA information is provided to NCPS  and to VISN patient safety officers.
Information obtained through the RCA process is protected and  confidential, according to federal law, and cannot be used to inform an  adverse action or privileging action against a provider. Therefore, the  RCA process is referred to as a protected process.
section_title: RCA Process
paragraphs: VAMCs use the RCA process to examine whether a systems or process  issue caused an adverse event. Figure 1 provides an overview of the  RCA process at VAMCs.
Adverse event occurs. The RCA process at a VAMC begins with the  recognition of an adverse event. At the VAMC, the patient safety manager  receives information from VAMC staff about an adverse event that occurs  at the VAMC. To determine if an RCA is required, the patient safety  manager evaluates the event using VHA’s safety assessment code matrix  to score the severity of the event and its likelihood of recurrence on a  scale of 1 (lowest risk) to 3 (highest risk). As directed by VHA policy,  adverse events with a score of 3 always require an RCA. VAMCs have  discretion in determining whether to conduct RCAs on adverse events  with scores of 1 or 2.
VAMC conducts RCA. After determining the need for an RCA, the  VAMC director convenes a multidisciplinary team of VAMC staff to  identify root causes and actions to be taken with associated outcome  measures. VHA policy states that those staff directly involved in the  adverse event cannot participate on the RCA team; however, the RCA  team may interview these staff as part of its investigation to obtain their  perspectives on the event that occurred and suggestions for preventing  its recurrence.
The RCA team is required to develop a report, which includes a  description and flowchart of the adverse event, identifies one or more root  causes, and includes actions to be taken with associated outcome  measures. Actions describe VAMC-level changes to reduce or eliminate  future occurrences of similar adverse events. Each action is also required  to have at least one outcome measure—a specific, quantifiable, and time- bound means by which responsible staff can determine the extent to  which the action has been taken to address the root cause. For example,  in the case of an overdose of an anesthesia medication from a pump that  held an unsafe amount of medication, the action might be to use a  different type of pump that holds less medication and prevents an  accidental overdose; an outcome measure might be to measure patient  outcomes 1 year later to ensure that no such overdoses occurred.
Leadership reviews/approves. Upon completion of the RCA report, the  RCA team presents its findings to VAMC leadership. The completed RCA  report is required to be signed by the VAMC director within 45 days of the  determination of the need for an RCA.signature is the date the RCA is considered complete. The patient safety  manager then submits the completed report to NCPS through WebSPOT.
The date of the director’s  VAMC implements RCA actions. After an RCA report is submitted to  NCPS, patient safety managers follow up with VAMC staff on the  implementation of identified actions, and, after implementation, evaluate  the effectiveness of those actions in addressing the identified root causes.
Patient safety managers also update WebSPOT with the actual  implementation date of each action. If a VAMC does not implement an  action, the patient safety manager can indicate in WebSPOT that the  action was not implemented and the reason why. VAMCs may not  implement certain actions identified by the RCA team for several reasons,  including funding constraints and other unforeseen complications, like  building design limitations. After implementation, patient safety  managers update WebSPOT to add any comments associated with  implementation, as well as information about the effectiveness of each  action in addressing identified root causes on a five-point scale from  “much worse” to “much better.” In fiscal year 2014, VAMCs most  commonly rated RCA actions as having made the related system or  process “better” or “much better.”
Upon receipt of a completed RCA report, NCPS staff categorize key  aspects, such as the type of adverse event, location of the event,  corrective actions, and outcome measures. NCPS staff also categorize  RCA actions according to an action strength hierarchy of stronger,  intermediate, or weaker. (See table 1 for descriptions of stronger,  intermediate, and weaker actions.) NCPS recommends using stronger or  intermediate actions to the extent possible to improve the likelihood that  actions will remove human error from processes and be more successful  in addressing the root causes of an adverse event. About two-thirds   (68 percent) of all actions resulting from RCAs in fiscal year 2014 were  categorized as stronger or intermediate.
section_title: VAMCs Completed Fewer RCAs Each Year from Fiscal Year 2010 through Fiscal Year 2014, but VHA Has Not Analyzed the Reasons for the Decrease
paragraphs: Total completed RCAs (both individual and aggregated) at VAMCs  decreased in each of the past 5 fiscal years. Overall, from fiscal years  2010 through 2014, the total number of RCAs completed at VAMCs  decreased by 18 percent—from 1,862 in fiscal year 2010 to 1,523 in fiscal  year 2014. (See fig. 2.) Individual RCAs accounted for 88 percent of the  decrease during this time period.
VHA’s NCPS officials told us they are not certain why the number of  completed RCAs has decreased over time, especially in light of an  increase in reports of adverse events over the past 5 fiscal years.  Specifically, our analysis of adverse event reports in WebSPOT shows  that they increased by 7 percent in the past 5 fiscal years (from 109,951  in fiscal year 2010 to 117,136 in fiscal year 2014). An increase in reports  does not necessarily mean that there should also be an increase in the  number of RCAs conducted, as it is possible that the safety assessment  code score was not high enough to require an RCA, giving the VAMC the  discretion to address the adverse event through other available  processes. However, NCPS officials told us they have not conducted an  analysis to determine the contributing factors to the decrease. Without  further analysis, it is unclear whether an increase in adverse event reports  at the same time that the number of completed RCAs is decreasing is a  cause for concern. NCPS’s lack of analysis is not consistent with federal  internal control standards, which state that control activities should  include comparisons and assessments of different sets of data so that  analyses of the relationships can be made and appropriate actions  taken.
NCPS officials told us they were aware of the decrease in completed  RCAs, but have not conducted an analysis of the decrease because it is  difficult to determine causal relationships between many possible  contributing factors. Although they have not conducted an analysis,  NCPS officials suggested possible contributing factors to the decrease in  completed RCAs, including: (1) a change in the culture of safety at  VAMCs; (2) VAMCs using alternative processes to address adverse  events in place of RCAs; and (3) an increasing number of VAMCs  conducting the minimum of four individual RCAs each fiscal year.
Change in the culture of safety at VAMCs. NCPS officials  stated that they have observed a change in the culture of safety in  recent years in which staff feel less comfortable reporting adverse   Officials added that this change  events than they did previously.is reflected in NCPS’s periodic survey on staff perceptions of  safety; specifically, 2014 scores showed decreases from 2011 on  questions measuring staff’s overall perception of patient safety, as  well as decreases in perceptions of the extent to which staff work  in an environment with a nonpunitive response to error. As  previously noted, however, the number of adverse event reports  has been increasing, despite NCPS officials’ observation of a  change in the culture of safety.
VAMCs’ use of alternative processes. NCPS officials told us  that VAMCs sometimes choose alternative processes, such as  those based on Lean methods, to address adverse events when  an RCA is not required. However, VHA is unaware how many  VAMCs use these alternative processes. From fiscal year 2009  through fiscal year 2014, VHA trained over 20,000 staff on the use  of Lean methods, but an official from the VA Center for Applied  Systems Engineering—the VHA office that conducted the  trainings—told us VHA has not conducted any follow-up to  determine how these methods are being applied at VAMCs. The  official added that, after training, it is up to VAMC leadership to  implement Lean methods in their VAMCs, and that the Center for  Applied Systems Engineering began working with NCPS about a  year ago to begin aligning the RCA process with Lean methods.  The lack of follow-up on the use of alternative processes is not  consistent with standards for internal control. Without information  on the extent to which VAMCs are using alternative processes like  Lean methods in place of RCAs, NCPS has limited awareness of  the extent to which VAMCs are addressing the root causes of  adverse events.
Three of the four VAMCs in our review completed fewer RCAs in  fiscal year 2014 compared to fiscal year 2010. Officials at one of  these VAMCs told us the reason they had completed fewer RCAs  was because the VAMC director supported the use of a Lean  method to understand and act on the root cause of an adverse  event when an RCA was not required. Officials at this VAMC also  told us that they thought their Lean method was sometimes more  appropriate for reviewing low-severity events because it yielded  similar results to an RCA and allowed for a broader, more  complete view of the issue being examined. NCPS officials told us  they support VAMCs’ use of these alternative processes when  appropriate, but acknowledged loss of information as the results of  these processes are not required to be entered into WebSPOT, or  otherwise shared with NCPS.
Increasing numbers of VAMCs conducting the minimum of   4 individual RCAs each fiscal year. NCPS officials told us they  were aware that by setting a requirement in 2007 that VAMCs  conduct a minimum of 4 individual RCAs each fiscal year, VAMCs  that had previously completed many more than 4 might decrease  the number of individual RCAs they completed over time. Our  analysis of RCA data shows that from fiscal years 2010 through  2014, the number of VAMCs completing more than 4 individual  RCAs declined by 8 percent (from 135 to 124 VAMCs). In  addition, the number of VAMCs completing exactly 4 individual  RCAs in this time period more than doubled, from 4 VAMCs in  fiscal year 2010 to 10 VAMCs in fiscal year 2014. All 10 of these  VAMCs completed more than 4 individual RCAs in fiscal year  2010, with totals ranging from 5 to 14 individual RCAs. Officials  stated that the selection of 4 individual RCAs as a minimum (as  well as the selection of 8 as a minimum total of individual and  aggregated RCAs), was arbitrary but seemed reasonable. They  expressed concern that raising the annual individual RCA  minimum requirement may result in lower-quality RCAs.
Because NCPS has not conducted an analysis to understand the  relationship between the decrease in RCAs and possible contributing  factors, such as the increase in adverse event reports and use of  alternative processes, it is unclear whether the decrease indicates a  negative trend in patient safety at VAMCs or a positive one. For example,  the decrease can indicate a negative trend of VAMCs not reporting  severe adverse events that would require RCAs, or a positive trend  reflecting fewer severe adverse events occurring. Moreover, without  complete information on the extent to which VAMCs are using alternative  processes to address the root causes of adverse events and the results  of those processes, NCPS lacks important data that may be helpful in  better identifying trends and system-wide patient safety improvement  opportunities.
section_title: VHA Oversees the RCA Process by Monitoring VAMC Compliance, and Develops System- Wide Patient Safety Initiatives Informed by RCA Data
paragraphs: NCPS and VISN patient safety officers oversee the RCA process by  monitoring each VAMC’s compliance with RCA requirements, including  by reviewing RCA information in WebSPOT and conducting site visits.
Reviewing RCA information in WebSPOT. NCPS conducts  quarterly reviews of RCA information in WebSPOT to monitor  VAMCs’ progress toward meeting annual RCA requirements.  NCPS monitors, for example, each VAMC’s progress toward  completing the required number of individual and aggregated  RCAs for the fiscal year. Our analysis of WebSPOT data shows  that, from fiscal year 2010 through fiscal year 2014, almost all  VAMCs completed the minimum number of RCAs required each  year: an average of 98 percent of VAMCs completed four or more  individual RCAs, and an average of 96 percent of VAMCs  completed eight or more total RCAs. NCPS officials told us that  their review of WebSPOT information also provides insight into the  effectiveness of a VAMC’s RCA process. NCPS submits quarterly  reports of VAMCs’ progress to the Deputy Under Secretary for  Health for Operations and Management.
NCPS officials told us that when they find that a VAMC has not  met the annual requirement for the number of completed RCAs,  they may contact the VAMC’s patient safety manager to ask if  barriers to the RCA process exist. Officials said that, in one such  instance, the patient safety manager at a VAMC that had not  completed the required number of RCAs told NCPS that the  medical center director was not supportive of the RCA process.  According to NCPS officials, in situations such as this they may  then contact the VAMC’s leadership to remind them of the  importance of completing RCAs and of the benefits to the entire  system of having complete information in WebSPOT, and to offer  their assistance. VISN patient safety officers we spoke with told us  that they also monitor VAMCs’ compliance with RCA requirements  through reviews of RCA information in WebSPOT, and by meeting  with VAMC patient safety managers.
Conducting site visits to VAMCs. NCPS officials said they may  conduct a site visit to provide consultation and feedback to a  VAMC that appears to be encountering challenges in meeting  RCA requirements, such as completing individual RCAs within   45 days. NCPS site visits can also include an examination of other  aspects of the RCA process, including reviewing a sample of  RCAs to examine the assignment of safety assessment scores,  the strength of corrective actions, and the implementation status  of the actions. Officials stated that the 12 to 20 site visits they  conduct each year are the most valid way for them to verify the  implementation of RCA actions because they provide NCPS with  the ability to observe implemented activities and the effectiveness  of RCA-based improvements. NCPS officials told us that they visit  VAMCs at the request of the VAMC director or as participants in a  visit made by other VHA offices, including the Deputy Under  Secretary for Health for Operations and Management. In  addition to NCPS, patient safety officers at three of the four VISNs  in our review told us that they also conduct annual site visits to  some or all VAMCs in their networks to assess implementation of  RCA actions and to consult with VAMC patient safety managers.
In addition to monitoring compliance, NCPS uses RCA information to  inform system-wide initiatives to improve patient safety. Not all initiatives  are based solely on RCAs, but officials told us that RCAs are a  contributing factor to NCPS’s larger patient safety improvement efforts.  Officials told us that they focus their initiatives on problems that pose the  greatest risk to patients or are the most prevalent in VA’s health care  system, such as suicide. Officials explained that their choice of which  initiative to pursue is determined by what will have the greatest impact on  a problem. Examples of NCPS’s initiatives include Patient Safety Alerts  and Advisories, topic summaries, and Clinical Team Training.
Patient Safety Alerts and Advisories. Patient Safety Alerts and  Advisories are urgent notifications sent to VAMCs that contain a  description of a safety issue, instructions for implementing actions  to prevent recurrence of the problem, and due dates for  completion of actions. NCPS officials told us that alerts and  advisories can come from several sources, including reports from  VAMCs, other VHA offices, and medical device manufacturers.  Patient Safety Alerts and Advisories are developed by NCPS and  then issued by the VHA Deputy Under Secretary for Health for  Operations and Management. For example, VHA issued a Patient  Safety Alert after a patient in a VAMC behavioral health unit  hanged himself from an air conditioning vent. The RCA team  recommended a structural change to the vents to prevent  recurrence, which VHA then required to be implemented at all  VAMCs. NCPS also tracks the date that VAMCs completed  implementation of actions. From fiscal year 2010 through fiscal  year 2014, NCPS has developed 57 alerts and 7 advisories.
Topic summaries. Officials told us that NCPS may issue an RCA  topic summary if they identify a trend in adverse events or RCAs  in WebSPOT. An RCA topic summary provides background  context for the relevant adverse event, discusses root causes that  were identified through the RCAs conducted, and describes  corrective actions taken by VAMCs. For example, NCPS officials  told us that after their review of RCAs identified a trend in adverse  events caused by the misidentification of patients, they  determined that system-wide improvements were needed. NCPS  prepared topic summaries on misidentification related to  specimens and transporting patients, as well as a guidance  document on patient wristbands, which included best practices for  VAMCs. NCPS officials told us topic summaries are distributed to  VAMCs as part of the agenda for monthly conference calls that  NCPS conducts with patient safety staff at VAMCs and VISNs,  and that they are also made available through NCPS’s internal  website and via e-mail. From fiscal year 2010 through fiscal year  2014, NCPS has issued 12 topic summaries.
NCPS may also determine the need for a topic summary on the  basis of requests for WebSPOT searches from VAMC and VISN  patient safety staff interested in knowing whether RCAs have  been conducted for similar adverse events at other VAMCs.
NCPS officials estimated that they conduct about 200 such  searches annually, and that these searches provide VAMC and  VISN staff with information on similar adverse events, such as the  corrective actions identified at other locations to address the  adverse event. According to officials, NCPS may determine  through these searches that several locations are encountering  similar patient safety issues, prompting the preparation of a topic  summary.
Clinical Team Training. NCPS implemented Clinical Team  Training for surgical teams in 2007 following analysis of RCA  information in WebSPOT that found communication failure to be a  root cause or contributing factor in 75 percent of the more than  7,000 RCAs reviewed. The objective of Clinical Team Training is  to enhance teamwork and overcome obstacles to effective  communication across professional boundaries. The training  curriculum includes 2 months of preparation by the VAMC; a day- long onsite learning session consisting of lectures, group  interaction, and videos; and quarterly interviews of the clinical  team to assess training implementation. One study found that  surgical mortality decreased 11 percent more in VAMCs that  received Clinical Team Training compared to those that had not   NCPS officials told us they have expanded Clinical  received it. Team Training beyond surgical teams, and have provided this  training, for example, to teams in emergency departments,  intensive care units, and inpatient behavioral health units.
Julia Neily et al., “Association between Implementation of a Medical Team Training  Program and Surgical Mortality,” Journal of the American Medical Association, vol. 304,  no. 15 (2010).
section_title: Conclusions
paragraphs: RCAs are an important tool for VAMCs to identify the systems or  processes that contributed to an adverse event, and implement actions to  address them. They are also an important contributor to NCPS initiatives  to improve patient safety across VA’s health care system. It is unclear  whether the 18 percent decrease in total RCAs completed from fiscal year  2010 to fiscal year 2014 is a negative trend reflecting less reporting of  serious adverse events, or a positive trend reflecting fewer serious  adverse events that would require an RCA. VHA has not, as would be  consistent with federal internal control standards, conducted an analysis  to determine the relationship between data showing a decrease in RCAs  and factors that may be contributing to this trend, including VAMCs use of  alternative processes, such as Lean methods, when RCAs are not  required. Although the choice to use alternative processes may be  appropriate, NCPS is not aware of the extent to which these processes  are used, the types of events being reviewed, or the changes resulting  from them. Without analyzing the reasons for declining RCAs, and  understanding the extent that VAMCs use alternative processes and their  results, NCPS has limited awareness of what VAMCs are doing to  address the root causes of adverse events. Moreover, the lack of  complete information may result in missed opportunities to identify  needed system-wide patient safety improvements.
section_title: Recommendations for Executive Action
paragraphs: To ensure that appropriate steps are being taken to address the root  causes of adverse events within VHA, the Secretary of Veterans Affairs  should direct the Under Secretary for Health to take the following two  actions:
Conduct an analysis of the declining number of completed RCAs  within the VA health care system, including identifying contributing  factors, and take appropriate actions to address them.
Determine the extent to which VAMCs are using alternative processes  to address the root causes of adverse events when an RCA is not  required, and collect information from VAMCs on the number and  results of those alternative processes.
section_title: Agency Comments
paragraphs: We provided a draft of this report to VA for comment. In its written  comments, reproduced in appendix I, VA generally agreed with our  conclusions and concurred with our recommendations. In its comments,  VA also provided information on an initial analysis it had conducted, as  well as its plans for implementing each recommendation, with an  estimated completion date of November 2015.
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If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at draperd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix II.
section_title: Appendix I: Comments from the Department of Veterans Affairs
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Janina Austin, Assistant Director;  Jennie F. Apter; Frederick K. Caison; Christine Davis; Kaitlin McConnell;  Vikki L. Porter; Emily Wilson; and Malissa G. Winograd made key  contributions to this report.