Clipping 3, From 1985 - VA has not fully implemented Its Healthcare Quality Assurance Program

Report GAO/HRD-85-57 was filed in response to requests made in 1983 and 1984 by the chairman and ranking minority members of the Committee on Veterans Affairs, US Senate. - GAO Reports to The Committee Veterans’ Affair United States Senate. “VA has not fully implemented Its Healthcare Quality Assurance Program, GAO/HRD-85-57, June 27, 1985.   This report surfaces problems with infection control some 25 years before some many veterans were infected with debilitating and life-threatening diseases. 

The cover letter in the report states:

“In response to the December 21, 1983, request from the previous Chairman and the September 6, 1984, request he made jointly with the Ranking Minority Member, we have reviewed the Veterans Administration's (VA's) systems and procedures for assuring the provision of quality health care.  This report discusses (1) the extent to which the VA medical centers we visited had implemented quality assurance programs and (2) the roles of and processes used by other VA organizations in assuring quality of care. We did not evaluate the effectiveness of VA's programs and therefore do not comment on the quality of health care provided.”

The review covered internal quality programs and VA oversight of those programs.  Infection control reviews were a part of continuous monitoring function, 1 of 5 mandatory functions.

“Infection control review determines the trend and extent of hospital-related infections, proposes corrective actions, when appropriate, and should ensure that exposure to such infection is minimized.” Chapter 2 page 6

The GAO visited 13 VA medical centers.  None fully met the requirements of the VA’s quality program.  Compliance issues were recorded as a misinterpretation of the requirements and the perceived low need for review and analysis. Chapter 2 page 10, None of the medical centers performed all five of the required functions of the quality assurance plans.  Continuous Monitoring was specifically noted.  Again, infection control fell under that function.

The report reflects issues with high-level VA oversight as well.  The projected number of reviews to “ascertain the quality of health care” and to actually assess the effectiveness of each medical center’s internal quality had fallen short since 1977.  The goal was 60 reviews, the annual average was 44. Page iv

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