(:ornmit,tee on , U.S. Senate -___._ l_l_,__._ -...____........... I- _-.-_ __-- . ..-.. - .-------. ^ ---__. ,Yovc~rrrt,t~r VA HEALTH CARE I!)!)0 Actions in Response to VA’s 1989 Mortality Study llIlllllIlll ll 142716 ----- __..-----pI--- (;Ao,/‘IIHI)-!)I-~~i I -.--. “. .*l*“““l”l.“._.--_-_.- ..-,--- Humau Resources Divisiou B-241910 November 27,199O The Honorable Alan Cranston Chairman, Committee on Veterans’ Affairs United States Senate Dear Mr. Chairman: As requested in your June 16, 1989, letter, we have reviewed the actions that the Department of Veterans Affairs (VA) has taken to address quality-of-care problems associatedwith deaths in several VA medical centers during fiscal year 1986. Specifically, in a June 1989 report, VA stated that 44 of its 172 medical centers had higher-than-expected mor- tality rates in one or more diagnostic categories(for example, cancer or severeheart disease)in that period. Further, “likely” quality-of-care problems were found in 90 casesin which deaths occurred. VA said it would conduct follow-up activities to determine to what extent such problems exist in its medical centers and what actions will be taken to correct them. You requested that we monitor and review VA’S follow-up actions, specif- ically determining whether . the validation methodology for the follow-up is appropriate, l the follow-up is completed as described in the mortality study, l the actions taken as a result of the follow-up are proper, and l other actions may be neededto ensure that the probable causesof death resulting from quality-of-care problems are identified and corrective actions taken. We briefed your staff on the results of our work on July 9, 1990. This report summarizesthat information and provides an update of certain VA activities through October 31, 1990. Our work’s scopeand method- ology are discussedin appendix I. In June 1989, at the direction of the Chief Medical Director, VA’S Office Background of Quality Assurance published a report concerning deaths in VA medical centers during fiscal year 1986. The report showed that 44 of VA’S 172 medical centers had higher-than-expected mortality rates in one or more Page 1 GAO/HRB91-26 VA’s 1999 Mortdty Study B-241910 diagnostic categories.’ In the aggregate, 3,050 deaths occurred in these medical centers2 in those diagnostic categories, whereas only 2,098 deaths would have been anticipated. Staff from VA’s Medical District Ini- tiated Peer Review Organizations (MEDIPROS) reviewed 1,77 13of these cases according to preestablished criteria and referred 473 cases from 43 hospitals to MEDIPRO physicians for review. These physicians deter- mined that 90 cases had “likely” quality-of-care problems. Almost half of these cases (38 of 90) occurred in six primarily psychiatric hospitals. The remaining were identified as having occurred in 16 medical centers providing primarily medical and surgical acute care. In its report, VA stated that, among other things, the following actions would be taken to assess the significance of the aforementioned data: . Require each medical center to comment on MEDIPRO decisions and pro- vide both the central office and MEDIPRO a summary of corrective actions to be taken to address issues raised. l Require MEDIPRO and central office personnel to review and approve the medical centers’ responses and corrective action plans. . Analyze mortality cases not available at the time the original study was published and report in a supplement the findings and corrective actions taken. . Validate the original study methodology. . Monitor the care in the medical and surgical wards of primarily psychi- atric facilities to determine if there are any significant differences between this care and that provided at other VA medical facilities. A complete statement of the actions VA planned to take to address the study findings is contained in appendix II. has used an appropriate methodology to identify and follow up on Results in Brief VA deaths associated with quality-of-care problems. Further, most of the actions it planned to take to assess the significance of the mortality 1These diagnostic categories were severe heart disease; metabolic, electrolyte disorder; cancer; ortho- pedic conditions; cerebravascular disease; gastrointestinal disease; low-risk heart disease; pulmonary disease; renal and urologic disease; and follow-up and after-care. 2Although the June 1989 mortality report identified 44 hospitals with higher than expected mortality rates, the report included data from only 43. Data from the 44th hospital were analyzed as part of the follow-up actions. “VA selected 2,417 of the 3,050 mortality cases for MEDIPRO review. Of the cases selected, 273 were found to involve deaths after discharge or erroneous coding and were eliminated from the study, and 373 pertinent records were unavailable; thus, 1,771 cases were ultimately reviewed. Page 2 GAO/HRD-91-26 VA’s 1989 Mortality Study --- B-241910 --..- study findings have been completed. But VA is still analyzing deaths that occurred in psychiatric centers in fiscal year 1989, to determine if there are any significant differences between the quality of care provided in psychiatric facilities and that provided at other VA medical centers. VA’S completed actions are as follows: . Each medical center has commentedon the MEDIPROdecisionsand has provided a summary of any corrective actions taken to resolve the issuesraised. . MEDIPRO and central office personnel have reviewed and commentedon each medical center’s corrective action plan. . MEDIPROpersonnel have reviewed mortality casesnot available for review when the original study was conducted. Actions yet to be completed are: l The original study methodology is being examined, and a final report is expected to be iss,uedin March 1991. l MEDIPRO staff are reviewing deaths that occurred in fiscal year 1989 in seven4psychiatric hospitals that had high mortality rates in 1986 to determine the extent to which quality-of-care problems are occurring. Preliminary data indicate that at least four of the sevenpsychiatric hos- pitals continue to have deaths with possible quality-of-care problems at rates higher than the comparable mortality rate in medical and surgical acute care hospitals. Assessmentsof the quality of care provided in the psychiatric facilities involved are in process. Although VA has taken specific actions to follow up on its mortality study, it has not used the information it obtained from individual med- ical centers to improve systemwide operations. For example, at least five medical centers were known to have problems implementing their “Do Not Resuscitate” procedures,6and each developedits own revisions to correct the situations encountered,This issue may have systemwide applicability. But the central office did not disseminate the data to all of its medical centers, The result may be duplication of effort and a lost ‘The review of previously unavailable casesidentified anotherthree “likely” problemcasesin a SW- enth psychiatric hospital. %ocedures written to clarify matterssuch asthe extent to which emergencymeasureswill be insti- tuted if a patient’s condition warrants, who hasthe authority to makesuchdecisions,and what factors must enter into thosedecisions. Page 8 GAO/HiUbW26 VA’s 1888 Mortality Study - 5241910 opportunity to share data that could prevent similar problems from occurring at other medical centers. The Committee should consider discussing with VA the results of actions that are still underway and the need to disseminate information that has systemwide applicability. VA used physician peers (MEDIPRO) from outside the involved medical VA Used a Generally centers to examine each mortality case selected for review, determine Accepted Methodology potential quality-of-care problems, and evaluate the appropriateness of to Identify Quality-of- corrective actions taken. This peer review technique is consistent with methods used in the private sector to evaluate medical care. It is based Care Problems on a fundamental medical community premise that physicians are best qualified to review and judge the clinical activities of other physicians. VA initiated MEDIPRO in 1985 on a limited basis and, by 1986, had expanded it to include all districts in the system. Its purpose was to pro- vide a mechanism for physician peers to evaluate the quality of care and utilization of resources in VA medical centers. Clinically active VA physi- cians from hospitals within each of VA'S 27 districts were selected to serve on district boards, which analyzed data to identify potential quality-of-care problems in VA medical centers.” VA used MEDIPRO for the mortality study and its follow-up because it had experience in con- ducting multi-facility medical record reviews and was external to the facilities being reviewed. MEDIPROSserved a function similar to that played by Peer Review Orga- nizations (PROS) in the private sector. PROSare congressionally mandated private organizations established to ensure that services furnished through Medicare are necessary, appropriate, and of high quality. VA medical centers have completed all of the follow-up efforts they were VA Actions Are Being required to take as a result of the June 1989 study. VA'S central office Conducted as Planned and MEDIPROSare in the process of conducting their intended follow-up efforts. MEDIPROScompleted their reviews of cases that were not avail- able when the original study was performed; every VA medical center that had deaths attributed to quality-of-care problems commented on ” MEDIPRO decisions and provided a summary of any proposed corrective 'As of April 1, 1990,VA abolishedits district offices and, as of October 1990, had not determined what peer review structure will be employed. Page4 B241910 actions to the cognizant MEDIPRO and to the central office; and the med- ical centers’ corrective action plans were reviewed and evaluated by cognizant MEDIPROS. Disagreements bet,ween medical centers and MEDIPROS about the quality of care provided in individual cases were referred to panels appointed by central office officials. VA’S central office, however, has not completed its planned study to determine whether there are differences between the quality of care furnished in medical and surgical wards of primarily psychiatric facili- ties and that provided to medical and surgical patients in other VA med- ical centers. MEDIPROS are reviewing deaths that occurred in fiscal year 1989 in psychiatric hospitals previously found to have quality-of-care problems to determine if such problems continue to occur at rates higher than that experienced in acute care VA facilities in 1986 (3.7 percent). These MEDIPROS will also report their conclusions about the quality of care provided at locations in which deaths occurred that had related quality-of-care problems. VA hopes to complete this process by December 15, 1990. The following sections discuss what VA is doing in each area in which follow-up action was planned. Patient Records From January to November 1989, MEDIPRO staff reviewed patient Unavailable During records in 627 mortality cases that had been identified in the original statistical study as occurring at higher-than-expected rates, but, for Original Survey Were various reasons, were not in the final report.7 Of these cases, 104 did not Reviewed meet the staff’s screening criteria and were referred to MEDIPRO physi- cians for further review. These physicians concluded that 21 cases had “likely” quality-of-care problems, thus increasing the total number of problem cases to 111. VA intends to publish a supplement to the mor- tality study to describe these additional findings and the results of its review of deaths that occurred in the seven psychiatric hospitals in fiscal year 1989. This supplement is expected to be published by March 1991. 7These follow-up steps were begun at the time the published study report was being finalized. Of the patient records not reviewed in time for the report’s publication, 267 were located in one hospital that was delayed in starting its review; 94 were from two hospitals that expanded the scope of their review; and the other 266 were from various hospitals that did not have the patient records available immediately. Page 5 GAO/H&D91-26 VA’s1989Mortality Study B241910 Medical Centers Every medical center in which MEDIPRO alleged that a quality-of-care Commented on MEDIPRO problem existed commented on the MEDIPRO findings. Not all agreed with the MEDIPRO’S findings; therefore, some took no corrective action. Of the Findings, but Not All Took 111 cases involving “likely” quality-of-care problems, the medical cen- Corrective Actions ters agreed with MEDIPRO findings in 78 cases and disagreed in 33. The latter were sent for review to VA’S central office, which upheld the MEDIPRO’S decisions in 22 cases. Medical centers submitted corrective action plans, which, in most cases, the cognizant MEDIPRO approved, to address problems identified in 81 of the 111 cases. In the remaining 30 cases, medical centers took no correc- tive actions: in 15 cases, officials disagreed with the MEDIPRO’S findings; in 11 cases, all of the involved physicians had left the medical center and center officials believed no further action was necessary; and in 4 cases, the hospital had no evidence that the recommended actions had been taken. In cases where there was disagreement, VA central office officials told us that no corrective action by the medical center will be required. Specifically, they stated that staff in each of the affected facilities have already reviewed the case data several times to determine if any corrective action was necessary. In the opinion of these officials, any requirement to review the cases again would be superfluous. In many instances, medical centers took more than one action to correct, a problem: 63 actions involved medical center policy and procedure changes, 34 related to increased use of occurrence screening! 48 involved additional training or education, 13 involved individual coun- seling with the provider, and 12 involved physician reassignment. In 9 of the 81 cases, hospital officials believe that the corrective action taken ivas not effective, and further problem-solving activity is in progress. In 10 cases, the medical centers took various corrective actions even though the involved physicians had left the medical centers. Appendix IV summarizes the corrective actions taken at each medical center. sOne of several elements in a VA medical center’s quality assurance program. It involves a review of patient records by trained personnel, who use designated criteria to identify occurrences that represent deviations from normal procedures or expected outcomes. Once identified during the review of a medical record, the occurrence is evaluated through a peer review of physicians, who determine whether the care given was appropriate and met acceptable medical standards. Page 6 GAO/HRB91-26 VA’s 1989 Mortality Study B241910 VA Is Validating the The chief of staff at VA’S Hines Medical Center is examining the original Methodology Used in the study methodology through a VA central office-funded research project. He has submitted several status reports to the central office covering Original Mortality Study the period July 1989 to August 1990 and expects to issue a final report to the central office in March 1991. Psychiatric Case In its June 1989 report, VA stated that it would monitor the care pro- Monitoring Is in Progress vided in medical and surgical wards in primarily psychiatric facilities to determine whether it differs significantly from that provided at other VA medical facilities. As of October 1990, this action had not been com- pleted, but VA officials hope to complete the analysis by December 15, 1990. To meet its follow-up commitment, VA is examining all deaths that occurred in fiscal year 1989 at the seven psychiatric facilities that were determined to have quality-of-care problems in 1986. Cases with such problems are being identified using a process similar to that employed by MEDIPRO to review deaths that occurred in fiscal year 1986, and a rate of cases with quality-of-care problems is being computed. As the case analysis is completed, the 1989 data are being compared to aggregate data developed by VA for all VA acute care hospitals (3.7 percent). Prelim- inary data from six of the seven psychiatric facilities examined show that at one center, 14 percent of the mortalities have related quality-of- care problems. Three centers have quality-of-care problems ranging from 6.7 to 6.9 percent of the death cases reviewed;g one psychiatric center has a rate comparable to acute medical and surgical facilities, 3.9 percent; and one center has a rate lower than such facilities, 2.9 percent. VA regional offices are analyzing data describing the corrective actions taken by the medical centers to resolve any problems identified. Fur- ther, each MEDIPRO board that analyzed mortality cases has been tasked with drawing conclusions about the quality of care provided at the facil- ities and making recommendations regarding the need for further moni- toring and other activities. This approach is consistent with a recommendation made in December 1989 by a committee of central office and medical center personnel appointed by the former Associate Deputy Chief Medical Director to gDeath cases at two medical centers have been reviewed by one physician. VA central office officials have directed the cognizant region to assign a second physician to review the problem cases. When the second review is complete, the problem rates may be lower than the preliminary data indicate (0.0 and 6.3 percent). Page 7 GAO/HRB91-26 VA’s 1999 Mortality Study B-241910 review mortality cases in psychiatric hospitals that had “likely” quality- of-care problems. The committee reviewed 36 cases MEDIPRO identified as having such problems in six psychiatric medical centerslo and deter- mined that death was preventable in 12 cases. It also concluded that 30 cases had one or more quality-of-care problems: 25 cases had delays in diagnosis; 15, drug usage problems; and 8, a delay in or omission of referral or consultation. The committee recommended that VA conduct future studies to compare the quality of care in psychiatric facilities with that in other VA facilities. medical centers have identified quality-of-care problems and initiated VA Needs to Better VA corrective actions that could have had systemwide applicability. But Disseminate VA'S central office did not use the experience gained in these centers as a Information to Medical means of improving care throughout the system. According to central office officials, medical centers provided information about the Centers problems and proposed corrective actions. However, data were not suffi- ciently detailed to allow a determination to be made as to whether the problems may exist systemwide and whether the actions taken to address them could have universal applicability. Central office per- sonnel also stated that no effort was made to obtain additional informa- tion from the medical centers because, at the time, no consideration was being given to the potential systemwide applicability of the data. For example, a medical center pharmacist team developed a drug usage evaluation plan for several therapeutic drugs that, among other things, specified procedures for when and how to use theophyllinell for thera- peutic use in the emergency room. This and other drug usage protocols were presented at a national pharmacists’ meeting, and many attendees requested copies. However, these guidelines were not communicated to other VA medical centers. VA traditionally has delegated operational decision-making to its medical center directors. As a result, central office personnel are generally reluc- tant to act in ways that might suggest they are attempting to direct the medical centers’ activities. Thus, in discussing the potential systemwide applicability of some of the changes made at individual medical centers, central office quality assurance officials stated that they had not consid- ered the possibility of wider applicability of these changes. The officials loThe special review had already begun before the follow-up identified a seventh psychiatric hospital with problem cases. * lA drug used for treating certain bronchial conditions. Page 8 GAO/HRD-91-26 VA’s 1989 Mortality Study &241910 stated, however, that in the future they will consider disseminating data with potential systemwide applicability. Patients in VA psychiatric facilities should benefit if VA (1) completes, as Conclusions planned, its comparison of the differences between care provided on medical and surgical units in primarily psychiatric hospitals with that furnished in medical and surgical acute care centers and (2) takes appropriate action to resolve any problems identified. Statistical data derived from the original study indicated that, in 1986, mortality rates and quality-of-care problems were higher in psychiatric facilities than in other acute care hospitals. Preliminary data on 1989 deaths in psychi- atric facilities indicate that these problems still exist. Until the MEDIPROS complete their analysis, serious questions about the quality of care pro- vided on medical and surgical units of psychiatric facilities will remain. VA's central office could have made more extensive use of the informa- tion that MEDIPROSand medical centers developed as part of the mor- tality study and its follow-up. MEDIPROS' review of mortality cases identified some quality-of-care problems with possible systemwide applicability. If these problems and their corresponding corrective actions had been communicated throughout the VA medical system, indi- vidual medical centers might have identified similar problems and used effective corrective responses developed elsewhere. More importantly, initiating these corrective actions systemwide could have helped assure more uniform care for all VApatients. As part of its continuing oversight of VA health care issues, the Com- Matters for mittee may wish to discuss with the Secretary Consideration by the Committee l the results of VA'S efforts to compare the quality of care provided in medical and surgical units in primarily psychiatric hospitals with that provided in medical and surgical acute care hospitals and . the need for central office staff to review the results of future quality assurance studies for possible systemwide applications and disseminate appropriate information to all medical centers. As agreed with your office, we did not obtain written comments on this report from VA, but did discuss its contents with Office of Quality Assur- ance officials. Their comments have been incorporated, where appropriate. Page 9 GAO/HRD91-26 VA’s 1989 Mortality Study We are distributing this report to VA and to interested congressional com- mittees and members. We will also make.copies available to others upon request. If we can provide any further assistance, please call me at (202) 276-6207. Other major contributors to this report are listed in appendix V. Sincerely yours, David P. Baine Director, Federal Health Care Delivery Issues Page 10 GAO/HRD-91.26VA’s 1989Mortality Study P8ge 11 GAO/HRD-91-28VA’s1989Mortality Study contents Letter 1 Appendix I 14 Scopeand Methodology Appendix II 15 Review of Mortality in VA Medical Centers- Planned Actions Appendix III 16 Results of Death Cases Examined by MEDIPROsand Central Office Reviewers Appendix IV 18 Medical Center Corrective Actions Appendix V 20 Major Contributors to This Report Abbreviations MEDIPRO Medical District Initiated Peer Review Organization PRO Peer Review Organization VA Department of Veterans Affairs VHS&RA Veterans Health Services and Research Administration Page 12 GAO/HRD-91-26 VA’s 1989 Mortality Study Page 13 GAO/HRD-91-26VA’s1989Mortality Study Appendix I Scopeand Methodology In this monitoring effort, we relied on the work of district MEDIPROSand did not evaluate their decisions or conclusions. Our objective was to determine whether problems were addressed, corrective actions were taken, and any lessons were learned that could be applied to medical centers systemwide. We periodically met with quality assurance staff in VA'S central office to obtain an update on their follow-up activities. We also reviewed VA med- ical center correspondence that discussed follow-up actions, examined data aggregated by central office quality assurance staff about correc- tive actions taken in each medical center, and analyzed questionnaires completed by medical center officials describing corrective actions taken and submitted to MEDIPRO and central office staff. To determine the ade- quacy of hospitals’ corrective actions, we talked with medical center directors, quality assurance coordinators, chiefs of staff, or other appro- priate VA personnel and obtained documents that included the policy revisions made and described education or training provided. Our work was performed between August 1989 and October 1990 at VA headquar- ters in Washington, DC., in accordance with generally accepted goven- ment auditing standards. Page14 GAO/HRDBl-26 VA’8 19S9 Mortal&y Study Apbendix II Review of Mortality in VA Medical Centers- Plmed Actions 1, Medical centers will report the following information for each case that was assessed by two peer reviewers as having a likely quality-of- care problem: l Whether the case was previously reviewed by the facility’s quality assurance program and, if so, the outcome of that review. l Whether the medical center agrees with the findings of the review and, if not, the reasons for its disagreement. . The proposed corrective actions to address the issues raised by the case. 2. The medical centers’ responses will be reviewed by the MEDIPROboards and VA'S central office. 3. Medical record reviews of a number of cases that were targeted by the mortality rate analysis were not completed in time to be included in the report. A supplement will present the results of these medical record reviews and a description of all corrective actions resulting from them. 4. Monitoring of the care provided in the medical and surgical wards of primarily psychiatric facilities will be conducted through a number of Veterans Health Services and Research Administration (VHS&RA) quality assurance mechanisms, such as MEDIPROand, where appropriate, site visits by central office clinical and administrative officials. This moni- toring will determine: . Whether there are significant differences between the quality of medical and surgical care provided at primarily psychiatric medical facilities and that provided at other VA medical facilities. l If so, what actions should be taken to improve the care at primarily psy- chiatric facilities. 5. A VHS&RA study will be conducted to determine the validity of the statistical methodology described in part I of VA'S mortality study as a mechanism for identifying possible quality-of-care problems. Upon com- pletion of this study, VHS&RA will decide whether regularly scheduled mortality rate analyses would be a useful addition to existing quality assurance activities. Page 15 GAO/HRD-91-26 VA’s 1989 Mortality Study Appendix III Results of Death Casesl!kunined by MEDIPROs and Central Office Reviewers Number of cases Original Foltfyi Number of - study hospitals Total -_-_II__- Cases reviewed bv MEDIPRO staff 1,771 627 2,398 44 Cases referred to MEDIPRO physicians for invdepth review 473 104 577 44 Cases _ .__... that MEDIPRO believes have “likely” quality-of-care problems - ..-._-_-__---- -- 90 21 111 --.-27 Cases that medical centers agreed have quality-of-care problems __-- ---. 78 l_---- 23 Cases referred tocentral office because medical centers disputed MEDIPRO findings __l_-_- 33 --.--- 16 Cases for which central office reviewers concurred with MEDIPROfindings that _.-_.-quality-of-care ..--.---______ problems existed ._I_ 22 14 Remaindera 11 6 ‘In eight cases,the panels agreed with medical centers that no quality-of-care problem had occurred; in two cases, records were unavailable; and in one case, the panel could not determine from the records if a problem had occurred. Page 16 GAO/HRD-91-26VA’s 1989Mortality Study Page 17 GAO/HRD91-26VA’s1989Mortality Study Appendix IV Medical Center Corrective Actions Corrective action taken Number of Occurrence Individual Addltional Policy Facility cases screening counseling training change Othep Albany, NY .-._.._-- 1 1 ----.-..-.. 1 Asheville, NC 2 2 Atlanta, GA 3 2 1 --.__ ~-.._..~ Battle Creek, Ml ..-.--- 12 12 12 12 12 Chillicothe,OH~ .’ 2 2 2 2 Columbra.SC 1 1 Dayton; OH 6 5 2 1 5 ----..-.- 6 ---- -.-- ._.-.~. Denver, CO 8 3 3 2 Durham, NC 2 Fayetteville, NC .. -_-.. 1 1 1 Houston, TX 10 9 9 Iowa Crty, IA 1 1 Leavenworth, KS 3 3 3 2 Lebanon: PA ._-. --.- 3 3 3 Loma Linda, CA 10 2 IO Mar&, IN -. 5 5 5 Mountain Home, TN 1 New Orleans, LA 3 3 2 --_- ---. ~-... ..- Oklahoma City, OK -- -~ .--.---. .- -..-_- 1 1 1 1 Phoenrx, AZ .- 1 -1 Saksbury, NC San Juan, PR St. Louis, MC- Tuskegee, AL 6 6 6 6 __l_----.-. -- -. Waco, TX 5 Walla Walla, WA - ___ --l____._~ _---- Washington, DC 4 _._- 111 34 13 48 53 ____-.- -.. .~~35 Totals Page 18 GAO/H&D91-26 VA’s 1989Mortality Study Appendix lv Medleal Center Chrective Actions Examples of corrective actions and other comments ____-.- Pokey changed to require all car&%a~e~s .I. . ..__.--_--__ and-dehstobe-reviewed. -_-._--- --..--..----. A respirator was placed in the emergency room. ___-- Staff trained to better.document mortality case review. .______ __-.- .----~-~ The medtcal center disagreed with .-. MEDIPRO’s ..--~ decision in one case. The medical center and MEDIPRO now review all deaths concurrently. Laboratory and radiology are staffed 24 hours. Nurses were instructed to prepare better documentation, The “Do Not Resuscitate” ~__-.- policy was revised. Physicians presented case to the mortality and morbidity committee and conducted a literature review on infections. Medical center implemented new “Do-Not%&us%ate” po~y%a~ty&sursnc&taff?now reviews all autopsy reports. In one case, the chief of surgery discussed the need for adequate documentation with surgeons. ____-. One case is now the subject of a lawsuit, Policy involved: following up on use of anticoagulation drugs, monitoring of blood pressure drops during surgery, and monrtoring of oxygen tank gauges. ----~ No actions taken In response to these cases-becausethemedicalcenter disagreed with MEDIPRO’s conclusions. Further, VA review substantiated the medical center’s position ..-....- ^...- that I__^___no____._._ problem - ..-- had occurred. -. .----.~----.~--~---. ..__~.__-.--.. .....--- ~-__ ----~~- The need for adequate documentation was discussed. Medical center noted that by the time of the follow-up review, all the involved residents had left. However, the medical center admissions okcy was changed to requrre an attending physician to see all new admissions within 24 hours of admission, seven days a week. Also, R rgh dosages of theophylline are now monttored; a strong drug usage education program was started; and surgery patients now have cardiac workup. X-ray results are now reported more promptly. --. Use of four antibiotics is now monitored and discussed in staff training. Medical staff received refresher training in medical center’s “Do Not Resuscitate” policy. -..- _____~---.--.-----.- Medical center rewrote its “Do Not Resuscitate” policy. Medical staff recerved instruction in treating severe cardiac cases. No correctrve actions were taken because.medical cknterbidnotasreethataquaiity-of-care problem had occurred. Continuing education now given for nurses’ documentation of emergency situations and physicians’ documentation of progress notes before surgery. Also, glucometers were placed in wards. Medical center now reviews all autopsy reports. __.______~ --......-.. --~ Continuing education was furnished on how to recognize acute medical problems in debilitated elderly patients, particularly at time of transfer from other facilities. No action-taken because the medical staff involved, including the chief of staff, had left the medical center. Staff education on case workup, management, treatment, and need for better documentation enforced. Medrcal staff were Instructed in improved dia nosis and treatment of ulcer surgery and were directed to improve their consultation with surgical staff. Results of test reports are now .~~~ 8.lled more promptly. -- _~.~. _~~_..... The medical center developed new “Do Not Resuscitate” policy and improved its reporting of lab and X-ray test results to physicians. Also, weekly mortality and morbidity reviews ..~-~ have been _ improved. ..- -~~~.-.....-. Medical center documentation of mortality review was improved. No other actions were taken because medical center disagreed with MEDIPRO in all five cases _~~~~~~~ ~~~ Critical lab results are now reported by telephone. A consulting spectatist~providedstaff withc<minuingeducation in diagnosis and treatment of stroke patients. ,. Medical center cauld not locate documentation indicating-/f actions were~&%enTG<ne case%%oEas taken in remaining three cases because medical center disagreed with MEDIPRO findings. aOther corrective actions taken include increased use of resources, such as patient mclitoring equip. ment; improved or faster procedures, such as reporting lab results; and modified quality assurance procedures, such as more thorough reviews of all mortality cases. Some of these examples are described in the last column of this table. Page 19 GAO/HRD-91-26VA’s1989Mortality Study k&pendix V ’ Major Contributors to This Report JamesA. Carlan, Assistant Director, (202) 708-4228 Human Resources Lawrence L. Moore, Evaluator-in-Charge Division, Washin&on, DC, Y (101359) Page 20 GAO/HID-91-26 VA’s 1989Mortality Study ![ .^.. I. ..--... -_.---.-..--.._ -__“-.---________ Orttt~ritlg Illf’orrtl;it,iort I I.S. (h*nt~rid Ac~oitrit.ing Ofl’ict~ I’.(). IhJX M)l5 (;ait ht~rslmrg, MI) 20877 Orttt~rs may also btb ptac~~d by calling (202) 275-6241. r. __,,, _., -___-” ,..._--_. .__.__ .^___ _ __ ._ .___ _ ,“. .,. ,. -_-..- --..- ..-. ..--.---...-...... I .l.““l-* .I- --I_- -- ___... --.- l”.“l..-_-.-._-““l-.- . . --.-- ..--.-.- -_..-.-- .._.... .._,_. -._._.“m I.” 1.1-.1”....-..-..----
VA Health Care: Actions in Response to VA's 1989 Mortality Study
Published by the Government Accountability Office on 1990-11-27.
Below is a raw (and likely hideous) rendition of the original report. (PDF)