VA Health Care

Actions in Response to VA's 1989 Mortality Study Gao ID: HRD-91-26 November 27, 1990

Pursuant to a congressional request, GAO reviewed the Department of Veterans Affairs' (VA) actions to address a June 1989 report about quality-of-care problems associated with deaths in several VA medical centers during fiscal year (FY) 1986, focusing on whether VA: (1) appropriately conducted its follow-up validation methodology; (2) completed the follow-up as described in the mortality study; (3) took proper actions as a result of the follow-up; and (4) needed to take other actions to ensure that it identifies quality-of-care problems and takes corrective actions.

GAO found that: (1) VA used an appropriate methodology to identify and follow up on deaths associated with quality-of-care problems, and completed most of the actions it planned to assess the significance of the mortality study findings; (2) VA was still analyzing deaths that occurred in psychiatric centers in FY 1989 to determine if there were any significant differences between the quality of care provided in psychiatric facilities and that provided at other VA medical centers; (3) although VA took specific actions to follow up on its mortality study, it did not use the information it obtained from individual medical centers to improve systemwide operations; and (4) VA failure to disseminate all pertinent information to all medical centers could result in a duplication of effort and the lost opportunity to share data that could help to prevent similar problems from occuring at other medical centers.


Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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