Why GAO did this study. Since 2014, Congress and the Department of Defense (DOD) have taken steps intended to strengthen patient safety in the Military Health System. As part of those efforts, Congress mandated that the Defense Health Agency, an agency within DOD, be responsible for the military departments’ administration of facilities. This responsibility includes ensuring individual providers are qualified and competent to deliver safe, high quality care to patients. Congress included a provision in statute for GAO to review the Defense Health Agency's clinical quality management procedures. This report addresses facilities’ and the Defense Health Agency’s adherence to these procedures and the Defense Health Agency’s monitoring of facilities’ adherence. GAO reviewed documentation from four facilities selected to obtain variation in location and military department. Additionally, GAO reviewed the Defense Health Agency’s clinical quality management procedures and interviewed relevant Defense Health Agency officials about these procedures and related monitoring efforts. GAO also evaluated the procedures and monitoring efforts using federal internal control standards. What GAO recommends. GAO is making two recommendations, to the Defense Health Agency to (1) clarify its clinical quality management procedures and (2) conduct monitoring to better ensure facilities adhere to these procedures. DOD concurred with both recommendations.
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