Comprehensive Healthcare Inspection Summary Report: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, Fiscal Year 2020

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration facilities’ quality, safety, and value (QSV) programs. This evaluation examined committee processes for QSV oversight functions, protected peer reviews of clinical care, utilization management, and patient safety.This report describes QSV-related findings from healthcare inspections performed at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG reviewers evaluated meeting minutes, protected peer reviews, root cause analyses, annual patient safety reports, and other relevant documents. The results in this report are a snapshot of Veterans Health Administration performance at the time of the fiscal year 2020 OIG reviews.The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses in various key QSV functions, noted repeat findings from the fiscal year 2018 and 2019 QSV evaluations, and issued four recommendations related to the• implementation of action items recommended by committees responsible for QSV oversight,• peer review of all applicable suicide deaths,• inclusion of required processes in root cause analyses, and• implementation and monitoring of action items resulting from root cause analyses.