For  example, its National Surgical Quality Improvement Program (NSQIP)  examines postoperative outcomes. Accrediting bodies have not been  sending these letters to participating institutions. For example, as of May  2003, VA had not decided whether reviewers would examine records from  VA’s new outpatients. VA Does Not Determine Whether VA Medical Centers’ Policies Are Consistent with Its National Requirements for Resident Supervision

VA does not know whether all its medical centers have adopted policies  that are consistent with the specific requirements in its resident  supervision handbook for the supervision of residents’ diagnosis,  treatment, and discharge of patients. We found that the requirement of a medical  center in one of the four networks that had not conducted this review was  less stringent than the requirement in VA’s handbook for supervision of  diagnostic and therapeutic procedures. VA’s Plans to Use External Peer Review to Monitor Documentation of Supervision Have Not Been Finalized

To obtain more complete information about the extent to which its  requirements for supervision are being followed, VA has begun to test its  plans to monitor adherence through external peer review of the  documentation of supervision. Without a sample of records from new  patients, it will not be possible to assess adherence to VA’s requirement  for supervisory involvement during a veteran’s first outpatient visit. VA Is Acting to Obtain Information about Supervision from Accrediting Bodies and Residents

VA is making efforts to obtain consistent access to information provided  by accrediting bodies and residents about the quality of resident  supervision in VA medical centers. VA headquarters also developed  a survey to obtain feedback from residents, but cannot send it to a random  sample of residents because VA does not have a complete list of its  residents. VA Uses Its Programs for Monitoring Patient Care to Identify and Correct Problems with Resident Supervision

VA headquarters, network, and medical center officials use information  from VA’s programs for monitoring the quality and outcomes of patient  care to identify and correct problems with resident supervision. In addition to reviewing NSQIP reports,  headquarters officials who oversee VA’s surgical services monitor the  frequency with which supervising physicians are in the operating or  procedural suite when residents perform surgeries. Conclusions

VA cannot assure that the residents who provide care in its facilities  receive adequate supervision because its current procedures for  monitoring supervision are insufficient. Recommendations for Executive Action

We recommend that the Secretary of Veterans Affairs direct the Under  Secretary for Health to take steps to improve VA’s oversight of the  supervision of residents by    ensuring that all VA medical centers that provide GME adopt and adhere  to the requirements for resident supervision established in VA’s handbook  and    ensuring that external peer review of documentation of resident  supervision includes examination of records from VA’s new outpatients.
Why GAO Did This Study

The Department of Veterans Affairs (VA) provides graduate medical education (GME) to as many as one-third of U.S. resident physicians, but oversight responsibilities spread across VA's organizational components and multiple affiliated hospitals and medical schools could allow supervision problems to go undetected or uncorrected. GAO was asked to examine VA's procedures for (1) monitoring VA medical centers' adherence to VA's requirements for resident supervision, (2) using evaluations of supervision by GME accrediting bodies and residents, and (3) using information about resident supervision drawn from VA's programs for monitoring the quality and outcomes of patient care.

What GAO Found

VA cannot assure that the resident physicians who provide care in its facilities receive adequate supervision because its procedures for monitoring supervision are insufficient. VA does not know whether medical centers have adopted VA's national requirements for supervision of residents' diagnosis, treatment, or discharge of patients. VA officials require a review of only one specific requirement that is intended to ensure availability of supervision when a supervising physician does not need to be in the operating or procedural suite while a resident performs a diagnostic or therapeutic procedure. Four of 11 network officials we interviewed had not conducted this review, and the requirement at one medical center in one of these four networks was less stringent than VA's national requirement. To obtain more complete information about adherence to its national supervision requirements, VA plans to have external peer reviewers examine documentation of supervision in patients' medical records. VA's plans for this review have not been finalized. For example, as of May 2003, VA had not decided whether reviewers would examine records from VA's new outpatients. Without records from new patients, reviewers will not be able to assess documentation of residents' supervision during a veteran's first outpatient visit. To improve its oversight, VA is making efforts to obtain information from accrediting bodies and residents about the quality of resident supervision. For example, VA has taken steps to obtain direct access to letters from accrediting bodies that contain evaluations of the GME programs in which its medical centers participate. To solicit feedback from residents, VA implemented a national survey, but was unable to send this survey to a representative sample of residents from each VA medical center because it does not have a complete central list of its residents. VA is taking action to obtain this information. In addition, VA uses information from its broader programs for monitoring the quality and outcomes of patient care, such as its patient safety and surgical quality improvement programs, to identify and correct problems with resident supervision. Information from these programs has served as the basis for corrective actions by VA officials.