According to VHA policy, NCPS is also responsible for disseminating  important information learned from RCAs to VAMCs. RCA Process

VAMCs use the RCA process to examine whether a systems or process  issue caused an adverse event. Adverse event occurs. Overall, from fiscal years  2010 through 2014, the total number of RCAs completed at VAMCs  decreased by 18 percent—from 1,862 in fiscal year 2010 to 1,523 in fiscal  year 2014. 2.) VHA’s NCPS officials told us they are not certain why the number of  completed RCAs has decreased over time, especially in light of an  increase in reports of adverse events over the past 5 fiscal years. NCPS’s lack of analysis is not consistent with federal  internal control standards, which state that control activities should  include comparisons and assessments of different sets of data so that  analyses of the relationships can be made and appropriate actions  taken. However, VHA is unaware how many  VAMCs use these alternative processes. Because NCPS has not conducted an analysis to understand the  relationship between the decrease in RCAs and possible contributing  factors, such as the increase in adverse event reports and use of  alternative processes, it is unclear whether the decrease indicates a  negative trend in patient safety at VAMCs or a positive one. Moreover, without  complete information on the extent to which VAMCs are using alternative  processes to address the root causes of adverse events and the results  of those processes, NCPS lacks important data that may be helpful in  better identifying trends and system-wide patient safety improvement  opportunities. VHA Oversees the RCA Process by Monitoring VAMC Compliance, and Develops System- Wide Patient Safety Initiatives Informed by RCA Data

NCPS and VISN patient safety officers oversee the RCA process by  monitoring each VAMC’s compliance with RCA requirements, including  by reviewing RCA information in WebSPOT and conducting site visits. In addition to monitoring compliance, NCPS uses RCA information to  inform system-wide initiatives to improve patient safety. Patient Safety Alerts and  Advisories are urgent notifications sent to VAMCs that contain a  description of a safety issue, instructions for implementing actions  to prevent recurrence of the problem, and due dates for  completion of actions. The RCA team  recommended a structural change to the vents to prevent  recurrence, which VHA then required to be implemented at all  VAMCs. Without analyzing the reasons for declining RCAs, and  understanding the extent that VAMCs use alternative processes and their  results, NCPS has limited awareness of what VAMCs are doing to  address the root causes of adverse events. Recommendations for Executive Action

To ensure that appropriate steps are being taken to address the root  causes of adverse events within VHA, the Secretary of Veterans Affairs  should direct the Under Secretary for Health to take the following two  actions:
Conduct an analysis of the declining number of completed RCAs  within the VA health care system, including identifying contributing  factors, and take appropriate actions to address them. Determine the extent to which VAMCs are using alternative processes  to address the root causes of adverse events when an RCA is not  required, and collect information from VAMCs on the number and  results of those alternative processes.
Why GAO Did This Study

Adverse events are incidents that pose a risk of injury to a patient as the result of a medical intervention or the lack of an appropriate intervention. VAMCs use the RCA process to identify and evaluate systems or processes that caused an adverse event, recommend changes to prevent the event's recurrence, and determine whether implemented changes were effective.
GAO was asked to review VA's processes and procedures for responding to adverse events. In this report, GAO examined (1) the extent to which VAMCs used the RCA process to respond to adverse events and (2) how VHA oversees the RCA process and uses information from the process to make system-wide improvements. To conduct this work, GAO reviewed VHA policy and guidance documents, analyzed VHA data on RCAs completed from fiscal years 2010 through 2014, and interviewed officials from NCPS—the VHA office responsible for monitoring RCA data. GAO also analyzed local RCA data and interviewed officials from four VAMCs selected to provide variation in factors such as complexity and location.

What GAO Found

To address adverse events, Department of Veterans Affairs (VA) medical centers (VAMC) completed 18 percent fewer root cause analyses (RCA) in fiscal year 2014 compared to fiscal year 2010, and the Veterans Health Administration (VHA) has not analyzed the reasons for the decrease. VHA's National Center for Patient Safety (NCPS) officials told GAO they were aware of the decrease, but were not certain why the number of completed RCAs had decreased over time, especially in light of a 7 percent increase in reports of adverse events over the same time period. NCPS officials suggested several potential factors that could contribute to the decrease, including VAMCs' use of processes other than RCAs to address adverse events. However, NCPS is unaware of how many VAMCs use these other processes or their results. VHA's lack of analysis is inconsistent with federal internal control standards which state that agencies should compare data to analyze relationships and take appropriate actions. Because NCPS has not conducted an analysis of the relationship between the decrease in RCAs and possible contributing factors, it is unclear whether the decrease indicates a negative trend in patient safety at VAMCs or a positive one. In addition, without understanding the extent to which VAMCs use alternative processes and their results, NCPS has limited awareness of what VAMCs are doing to address the root causes of adverse events.
NCPS oversees the RCA process by monitoring VAMC compliance, and develops system-wide patient safety initiatives informed by RCA data. NCPS monitors each VAMC's compliance with requirements by reviewing RCA database information and conducting site visits. NCPS uses RCA information to inform system-wide patient safety initiatives, such as Patient Safety Alerts and Advisories—urgent notifications sent to VAMCs that describe a safety issue and include instructions and due dates for implementing actions to prevent recurrence.

What GAO Recommends

GAO recommends that VA (1) analyze the declining number of completed RCAs, including identifying the contributing factors and taking appropriate actions, and (2) determine the extent to which VAMCs are using alternative processes to address adverse events, and collect information on their results. VA concurred with GAO's recommendations.