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Review of Veterans’ Access to Mental Health Care
Review of Veterans’ Access to Mental Health Care
Source: U.S. Department of Veterans Affairs, Office of Inspector General
Congress and the VA Secretary requested the OIG determine how accurately the Veterans Health Administration records wait times for mental health services for both new patients and established patients visits and if the wait time data VA collects is an accurate depiction of the veteran’s ability to access those services. VHA policy requires all first-time patients referred to or requesting mental health services receive an initial evaluation within 24 hours and a more comprehensive diagnostic and treatment planning evaluation within 14 days. The primary goal of the initial 24-hour evaluation is to identify patients with urgent care needs and to trigger hospitalization or the immediate initiation of outpatient care when needed.
One method VHA uses to monitor access to mental health services is to calculate patients’ waiting times by measuring the elapsed days from the desired dates of care to the dates of the treatment appointments. Medical facility schedulers must enter the correct desired dates of care in the system to ensure the accuracy of this measurement. VHA’s goal is to see patients within 14 days of the desired dates of care.
VHA does not have a reliable and accurate method of determining whether they are providing patients timely access to mental health care services. VHA did not provide first-time patients with timely mental health evaluations and existing patients often waited more than 14 days past their desired date of care for their treatment appointment. As a result, performance measures used to report patient’s access to mental health care do not depict the true picture of a patient’s waiting time to see a mental health provider.
The Under Secretary for Health concurred with the OIG’s findings and recommendations and stated VHA is unequivocally committed to providing Veterans the best care possible.
+ Full Report (PDF)
Audit of VHA’s Homeless Providers Grant and Per Diem Program
Audit of VHA’s Homeless Providers Grant and Per Diem Program (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
We conducted this audit to determine whether community agencies receiving funds from the Grant and Per Diem Program (GPDP) are providing services to homeless veterans as agreed upon in their grant agreements or authorized changes of scope. We also examined whether program funding is effectively aligned with program priorities. We found the VHA GPDP provided services to homeless veterans and had successfully assisted veterans to live independently in safe and affordable permanent housing. However, an incomplete grant application evaluation process; a lack of program safety, security, health, and welfare standards; and an inconsistent monitoring program impacted the program’s effectiveness. As a result, VHA did not ensure homeless veterans consistently received the supportive services agreed to in approved grants. In addition, funding was not effectively aligned with program goals. We recommended strengthening the grant application and evaluation process by publishing policies and standards, updating the inspection checklists, and implementing procedures to ensure grant providers had the capability to deliver services. The Under Secretary for Health concurred with our findings and recommendations and provided appropriate action plans.
+ Full Report (PDF)
America’s Women Veterans: Military Service History and VA Benefit Utilization Statistics
America’s Women Veterans: Military Service History and VA Benefit Utilization Statistics (PDF)
This comprehensive report chronicles the history of women in the military and as Veterans, profiles the characteristics of women Veterans in 2009, illustrates how women Veterans in 2009 utilized some of the major benefits and services offered by the Department of Veterans Affairs (VA), and discusses the future of women Veterans in relation to VA. The goal of this report is to gain an understanding of who our women Veterans are, how their military service affects their post-military lives, and how they can be better served based on these insights.
Message from the Secretary of Veterans Affairs on Veterans Day 2011
Message from the Secretary of Veterans Affairs on Veterans Day 2011
Source: U.S. Department of Veterans Affairs (Eric K. Shinseki)
Generation after generation—from Bunker Hill and Bennington to Baghdad and Abbottabad—protected, defended, and preserved the principles and ideals that define our democracy. Across that remarkable sweep of history, today’s America was shaped at Lexington and Concord, Antietam and Gettysburg, in the skies over Midway, on the beaches of Normandy, in winter’s grip at Chosin Reservoir, in the heat of Ia Drang Valley, from the Persian Gulf into Afghanistan and Iraq by those who wore our Nation’s uniforms. Over twenty-two million living Veterans today embody our exceptional character and values as a people—each a line in our Nation’s history, but together many chapters towards today’s future.
The Department of Veterans Affairs fulfills its obligation to serve Veterans, their families, and survivors of the fallen by living a set of core values defining who we are as an organization: Integrity, Commitment, Advocacy, Respect, and Excellence—I CARE. Veterans trust that we will live these values, every day, in our medical facilities, our benefits offices, and our national cemeteries. And VA is committed to serving them. We are privileged to provide the very best in compassionate and quality care and services, delivered by our more than 300,000 employees.
VA Posts Online List of Ships Associated with Presumptive Agent Orange Exposure
VA Posts Online List of Ships Associated with Presumptive Agent Orange Exposure
Source: U.S. Department of Veterans Affairs
Veterans who served aboard U.S. Navy and Coast Guard ships operating on the waters of Vietnam between January 9, 1962, and May 7, 1975, may be eligible to receive Department of Veterans Affairs (VA) disability compensation for 14 medical conditions associated with presumptive exposure to Agent Orange.
An updated list of U.S. Navy and Coast Guard ships confirmed to have operated on Vietnam’s inland waterways, docked on shore, or had crewmembers sent ashore, has been posted at http://www.publichealth.va.gov/exposures/agentorange/ to assist Vietnam Veterans in determining potential eligibility for compensation benefits.“Posting of the ships list is an important recognition of the sacrifices U.S. Navy and Coast Guard Veterans made for this Nation,” said Secretary of Veterans Affairs Eric K. Shinseki. “It provides an easier path for Veterans who served in Vietnam to get the benefits and services they are entitled to under the law.”
VA presumes herbicide exposure for any Veteran with duty or visitation within the country of Vietnam or on its inland waterways during the Vietnam era. Comprehensive information about the 14 recognized illnesses under VA’s “presumption” rule for Agent Orange is also located on the webpage.In practical terms, Veterans with qualifying Vietnam service who develop a disease associated with Agent Orange exposure need not prove a medical link between their illnesses and their military service. This presumption simplifies and speeds up the application process for benefits.
VA Publishes Social Media Policy
VA Publishes Social Media Policy
Source: U.S. Department of Veterans Affairs
The Department of Veterans Affairs (VA) announced today the release of a policy directive regarding the secure use of Web-based collaboration and social media tools. The policy allows the Department and its employees to leverage emerging platforms that enhance communication, stakeholder outreach, and information exchange as the Department transforms itself into a 21st Century organization attuned to the needs of Veterans of all generations.
“Veterans should have consistent and convenient access to reliable VA information real time using social media —whether on a smartphone or a computer,” said Secretary of Veterans Affairs Eric K. Shinseki. “They also should be able to communicate directly with appropriate VA employees electronically.”
The policy, “VA Directive 6515: Use of Web-Based Collaboration Technologies,” encourages the adoption and use of social media by VA employees. It provides workplace boundaries and establishes the Department’s philosophy for communication: VA is open and transparent, and VA is willing and able to engage and collaborate with its many stakeholders online.
“This isn’t about using social media because it’s cool or because it’s a fad,” said VA Director of Online Communications Brandon Friedman. “It’s about getting the right information to the right Veteran at the right time. This policy sets us on a path toward changing how we talk—and listen—to Vets.”
VA began launching social media sites in 2009 and the Department has over 100 Facebook pages, more than 50 Twitter feeds, two blogs, a YouTube channel, and a Flickr page. VA’s Facebook pages have a combined subscribership of over 293,000 fans—with the Department’s main page reaching over 138,000. On Twitter, VA has a combined followership of over 53,000—with the Department’s main feed reaching over 22,000. VA has posted over 300 videos on YouTube and over 9,000 photos on Flickr, which have been viewed over a combined 1.1 million times. In November 2010, VA launched its first blog, VAntage Point, which distinguishes itself from other government blogs by actively soliciting guest pieces from both employees and the public. By the end of the year, the Department expects to have an active Facebook page and Twitter feed for all 152 VA Medical Centers.
+ VA Directive 6515 (Social Media Policy) (PDF)
+ Directory of VA Social Media Sites
Review of Alleged Unauthorized Access to VA Systems
Review of Alleged Unauthorized Access to VA Systems (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
The Office of Inspector General evaluated the allegations that certain contractors, without proper security clearances, gained unauthorized access to VA systems and networks and whether VA was providing adequate oversight to ensure the contractor is meeting VA information security requirements. We substantiated the allegations that the contractor did not comply with VA information security policies for accessing mission critical systems and networks. Specifically, contractor personnel: improperly shared user accounts when accessing VA networks and systems; did not readily initiate actions to terminate accounts of separated employees; and did not obtain appropriate security clearances or complete security training for access to VA systems and networks. Also, VA has not implemented oversight to ensure the contractor complies with VA information security policies and procedures, making sensitive data at risk of inappropriate disclosure or misuse. We recommend the Assistant Secretary for Information and Technology monitor contractor user accounts and terminate those for separated employees; ensure contractor personnel are vetted and trained prior to accessing VA systems; request a modification the contract to reflect higher level personnel security requirements; and review the contractor’s current system security controls and practices to ensure compliance with VA requirements. The Department agreed with our findings and recommendations.
Audit of Veteran-Owned and Service Disabled Veteran-Owned Small Business Programs
Audit of Veteran-Owned and Service Disabled Veteran-Owned Small Business Programs (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
We audited VA’s Veteran-Owned Small Business (VOSB) and Service-Disabled Veteran-Owned Small Business (SDVOSB) programs to assess whether businesses met program and contract eligibility requirements and VA provided effective management oversight. We found that VA awards ineligible businesses at least 1,400 VOSB and SDVOSB contracts valued at $500 million, annually. Moreover, VA will award $2.5 billion to ineligible businesses over the next 5 years if it does not strengthen contracting officer oversight and business verification procedures. Seventy-six percent of the reviewed businesses were ineligible to participate in the programs or to receive the contracts. They received $46.5 million in awards, including $26.7 million in Recovery Act contracts. VA’s FY 2010 socioeconomic goal accomplishment data may also be overstated by 3 to 17 percent due to awards made to ineligible businesses. We recommended VA implement comprehensive program controls to ensure awards are not made to ineligible businesses and improve adherence to Federal and VA regulations. The Under Secretary for Health, the Office of Small and Disadvantaged Business Utilization, and the Office of Acquisition, Logistics, and Construction agreed with our findings. The planned actions are acceptable, and we will follow up on their implementation.
Healthcare Inspection Review of Facility Capabilities Where Veterans Received Complex Surgical Care
Healthcare Inspection Review of Facility Capabilities Where Veterans Received Complex Surgical Care (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
OIG conducted a retrospective review to characterize where seven complex and intermediate surgical procedures were performed at VHA facilities and at non-VHA facilities through fee basis arrangements prior to VHA’s release of Directive 2010-018, Facility Infrastructure Requirements To Perform Standard, Intermediate, Or Complex Surgical Procedures, on May 6, 2010. We found that VHA facilities had appropriate infrastructure to support surgeries performed. Although some surgeries were performed at VHA facilities with designations of lower complexity than required by the Directive, these surgeries were performed prior to the publication of the Directive, and we identified no adverse patient outcomes clearly attributable to facility infrastructure. We also found that VHA referred complex surgeries to non-VHA facilities with sufficient capabilities to support the surgeries performed. OIG made no recommendations.
Healthcare Inspection Evaluation of Community Based Outpatient Clinics Fiscal Year 2010
Healthcare Inspection Evaluation of Community Based Outpatient Clinics Fiscal Year 2010 (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
The purpose was to evaluate selected activities, assessing whether the community based outpatient clinics (CBOCs) are operated in a manner that provides veterans with consistent, safe, high-quality health care. CBOCs overall appear to be providing a quality of care that is not substantially different from parent VA medical centers. The CBOCs generally met Veterans Health Administration (VHA) directives and guidelines.
Overall, we found no statistically significant differences between VA-staffed and contract CBOCs performance measure estimated compliance rates. However, estimated VA CBOC compliance rates were slightly higher in VA-staffed CBOCs than in contract CBOCs. Rural contract CBOCs had a higher mean compliance rate than VA-staffed CBOCs, and urban CBOCs average compliance rates were higher for VA-staffed; but, neither was statistically significant. We found the following areas that needed improvement. We found that (a) only 41 (87 percent) of 47 CBOCs complied with the required cardiopulmonary resuscitation training; (b) 12 (26 percent) of the 47 CBOCs did not monitor, collect, or analyze hand hygiene data on a routine basis; (c) 9 (19 percent) CBOCs did not consistently secure patients’ personal identifiable information (PII); (d) VHA used 4 different pricing models to compensate for mental health (MH) services at the 18 contract CBOCs; and (e) Primary Care Management Module (PCMM) Coordinators were not effectively managing primary care provider (PCP) assignments, which resulted in 9 (50 percent) of 18 contract CBOCs having patients assigned to more than one PCP. To improve operations, we recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers: (1) emphasize the requirements to define staff that need life support training, systematically track training status, and take appropriate action when training is not maintained; (2) monitor, collect, and analyze hand hygiene data; (3) secure and protect patients’ PII; (4) review MH pricing models to determine the most effective compensation for MH services to be implemented in CBOC contracts; and (5) ensure that the PCMM is effectively managed by the Facility Director in conjunction with the PCMM Coordinator to minimize the assignment of patients to more than one PCP.
Healthcare Inspection — Post Traumatic Stress Disorder Counseling Services at Vet Centers
Healthcare Inspection — Post Traumatic Stress Disorder Counseling Services at Vet Centers (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
The purpose of our inspection was to assess the quality of Readjustment Counseling Service (RCS) Vet Centers’ post traumatic stress disorder (PTSD) counseling services to determine: (1) how Vet Centers screen clients for PTSD, (2) if documentation of clients’ treatment is in compliance with policy, and (3) if providers are trained to provide PTSD counseling services according to policy. We found that RCS Vet Center counselors utilized appropriate tools to screen clients for PTSD. Client treatment case file documentation improved from our FY 2009 report. Staff training also improved. Approximately 85 percent of Vet Center providers had attended RCS’ required training on PTSD, and 53 percent of the providers had attended Veterans Health Administration-sponsored PTSD training. In addition, some Vet Center providers received supplemental training in Evidence-Based Therapy (EBT), and most Vet Centers were providing EBT to PTSD clients. Although RCS made improvement from our previous review, we found that the Team Leaders were not consistently providing supervision and consultation to the Vet Center providers in accordance with RCS policy. We recommended that the Under Secretary for Health, in conjunction with the RCS Chief Officer: Ensure that Vet Center Team Leaders perform monthly provider’s record reviews, and provide supervision and consultation to providers in compliance with RCS policy. Ensure that corrective action is taken when supervision and consultation issues are identified through the annual clinical quality reviews.
Audit of the VHA’s Office of Rural Health
Audit of the VHA’s Office of Rural Health (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
The Office of Inspector General conducted this audit to assess whether the Veterans Health Administration’s Office of Rural Health (ORH) effectively planned and managed $533 million allocated to improve access and quality of care for veterans residing in rural areas during FYs 2009 and 2010. The Veterans Health Administration needs to strengthen the management of rural health care funding to ensure that rural health projects meet ORH’s mission of improving access and quality of care for rural veterans. Specifically, we found ORH did not adequately manage the use of fee funds and the proposal selection process. Additionally, ORH did not monitor project obligations and performance measures. This occurred because of a lack of financial controls, the absence of policies and procedures to ensure staff followed management directives, and inadequate communication with key stakeholders. Also, ORH lacked a project monitoring system, procedures to monitor performance measures, and a process to assess rural health needs. As a result, ORH lacked reasonable assurance that its use of $273.3 million (51percent) of the $533 million in funding received during FYs 2009 and 2010 improved access and quality of care for veterans residing in rural areas. We recommended the Under Secretary for Health implement financial controls, establish management policies and procedures, and implement an effective communication plan. We also recommended the Under Secretary establish a project monitoring system, establish procedures to monitor performance measures, and reassess the FY 2012 budget for ORH to align planned use of resources to their greatest rural health needs. The Under Secretary for Health agreed with our finding, recommendations. We consider these planned actions acceptable, and will follow up on their implementation.
Review of VBA’s Pension Management Centers
Review of VBA’s Pension Management Centers (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
We conducted this review to determine if the Veterans Benefits Administration’s (VBA) Pension Management Centers (PMCs) ensure that pensioners receive timely benefit payments. We also assessed the implementation of prior recommendations from OIG’s FY 2007 audit of VBA’s Pension Maintenance Program. PMCs assumed processing responsibilities for live and death pension applications and Dependency and Indemnity Compensation in FY 2008 and 2009, respectively. This change increased the claims processing workload significantly at the PMCs. We found VBA did not process original death pension claim benefits timely because PMCs were not adequately prepared to process additional claims added to their workload from VA Regional Offices in FYs 2008 and 2009. In addition, VBA did not process Internal Revenue Service and Social Security Administration Income Verification Matches (IVM) timely, which resulted in overpayments. Lastly, VBA’s PMC performance measures in the Performance and Accountability Report do not adequately measure all the work processed. VBA has taken sufficient measures to address prior OIG recommendations. We identified an opportunity for VBA to ensure IVM actions are processed timely that can potentially save $205 million in overpayments. We recommended establishment of an operational plan to ensure PMCs efficiently and effectively manage the workload. VBA also needs to establish timeliness performance standards for completing Income Verification Matches to reduce overpayments, and to modify the Performance and Accountability Report performance measures to reflect the current workload and ensure transparency over actual performance. The Acting Under Secretary for Benefits agreed with our report findings and recommendations and plans to complete all corrective actions by November 30, 2011.
Combined Assessment Program Summary Report Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities
Combined Assessment Program Summary Report Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
The purpose of this review was to re-evaluate the extent Veterans Health Administration (VHA) mental health (MH) providers consistently developed suicide prevention safety plans (SPSPs) for patients assessed to be at high risk for suicide. We evaluated SPSP practices at 45 facilities during Combined Assessment Program reviews conducted from January 1 through September 30, 2010. VHA facilities recognized the importance of developing comprehensive, timely SPSPs for high-risk patients. Additionally, VHA issued appropriate timeframes for initiating SPSPs. However, despite VHA’s efforts to comply with suicide prevention program requirements, problems with SPSP development continue to occur. We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that MH providers develop and document timely SPSPs that meet all applicable criteria.
Combined Assessment Program Summary Report Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities
Combined Assessment Program Summary Report Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
The purposes of the evaluation were to determine whether facilities: (1) complied with local and selected Veterans Health Administration (VHA) standards for reusable medical equipment (RME) sterilization and high-level disinfection, (2) provided and documented annual training for employees who perform RME reprocessing activities, and (3) assessed and documented annual competencies for employees who perform RME reprocessing activities. We evaluated RME processes at 45 VHA medical facilities during Combined Assessment Program reviews conducted from January 1 through September 30, 2010. We identified six areas that needed improvement. We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensures that: (1) standard operating procedures (SOPs) be current, consistent with manufacturers’ instructions, and located within the reprocessing areas; (2) employees consistently follow SOPs, supervisors monitor compliance, and annual training and competency assessments be completed and documented; (3) flash sterilization be used only in emergent situations, supervisors monitor compliance, and managers assess and document annual competencies for employees who perform flash sterilization; (4) appropriate personal protective equipment be donned before entering and worn in decontamination areas; (5) ventilation systems be inspected and filters changed quarterly in all reprocessing areas and that temperature and humidity levels be monitored and maintained within acceptable ranges in sterile storage areas; and (6) processes for consistent internal oversight of RME activities be established to ensure senior management involvement.
Healthcare Inspection Radiation Safety in Veterans Health Administration Facilities
Healthcare Inspection Radiation Safety in Veterans Health Administration Facilities (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
We evaluated program oversight and quality assurance processes for diagnostic and therapeutic radiation procedures at Veterans Health Administration (VHA) facilities. The review focused on four areas associated with the greatest potential for harm to veterans—radiation therapy (RT), computed tomography (CT), fluoroscopy, and nuclear medicine. To evaluate RT care, we queried 32 VHA facilities about processes pertaining to physician peer review and conducted onsite inspections at 26 facilities. To evaluate CT, fluoroscopy, and nuclear medicine procedures, we reviewed VHA documents and interviewed VHA radiology and nuclear medicine leaders. VHA has disseminated information in an effort to reduce CT dose variability, but we found no oversight of actual doses being delivered. Our review of patients with the highest cumulative radiation doses from CT scans found that neither patients nor providers had data about cumulative radiation exposure available to them at the time of clinical decision making. We also found that patients were not informed that CT scans may cause cancer. VHA has been developing guidance regarding the use of fluoroscopy. In nuclear medicine, VHA monitors data provided by all facilities and proficiency assessments are accomplished annually.
We recommended that the Under Secretary for Health: (1) clarify the current expectations for frequency of physician peer review in RT, (2) develop a process for monitoring delivered radiation dose to ensure that patients do not receive excessive doses from CT scans, (3) develop risk-based criteria for informed consent prior to CT scans, (4) plan for the development of a mechanism by which patients and providers have information about prior radiation exposure available to them at the time of clinical decision making, and (5) ensure that the fluoroscopy handbook is implemented.
Audit of the Veterans Service Network
Audit of the Veterans Service Network (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
We conducted an audit of VETSNET to determine whether: effective controls have been implemented to address previously identified program governance deficiencies; schedule, cost, and performance goals for the program have been met; and effective change controls have been implemented to support the planning, testing, and implementation of the VETSNET suite of applications.
Since 1996, VA has been working to consolidate compensation and pension benefits processing into a single replacement system, called the Veterans Service Network (VETSNET). VA has addressed prior program governance deficiencies by establishing oversight groups, risk management processes, and software development gate reviews to provide greater visibility and control of VETSNET program activities. Despite these improvements, VETSNET faces the continuing challenge of managing competing mandates and new systems initiatives that have repeatedly changed the scope and direction of the program.
These changes have adversely impacted achieving schedule, cost, and performance goals over the life of the VETSNET program. Specifically, work to meet original program objectives has been delayed and consolidation of compensation and benefits processing has been extended by nearly 5 years since 2006. In 2006, the total cost projection for VETSNET was $151 million through 2009. In 2009, VA reported a revised cost estimate of $308 million through 2012, more than two times the previous amount. Planned system functionality enhancements also remain unaddressed.
Moreover, the competing priorities have resulted in changing business requirements, necessitating additional software releases to meet those requirements. Because software change controls and testing have not been adequate to ensure proper system functionality, software rework and rollback of installation packages have been required to correct defects, and planned functionality enhancements have been delayed.
We recommend the Assistant Secretary, Office of Information and Technology, clarify goals, align resources, and establish a schedule for accomplishing the goals of VETSNET in the near term. We also recommend that improved processes be implemented to address software development deficiencies. The Assistant Secretary for Information and Technology and the Acting Under Secretary for Benefits agreed with our findings and recommendations. The OIG will monitor implementation of the action plans.
Combined Assessment Program Summary Report Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010
Combined Assessment Program Summary Report Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2010 (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General
The purposes of the evaluation were to determine whether VHA facilities had comprehensive, effective QM programs designed to monitor patient care activities and coordinate improvement efforts and whether VHA facility senior managers actively supported QM efforts and appropriately responded to QM results. To improve operations, we recommended that VHA reinforce requirements for: (1) comprehensive utilization management programs; (2) thorough review of individual resuscitation episodes and trending of aggregate data; and (3) life support training policies, monitoring, and actions. We also recommended that facility senior managers review the mortality data provided to them in Inpatient Evaluation Center reports and take actions as appropriate when negative trends are identified.
