Fundamentals of Quality Reviews

10. Fundamentals of Quality Reviews

Introduction

This topic contains information about IQRs, including

• fundamentals of quality reviews
• misclassified errors
• deselections
• grace period for IQRs
• error narratives
• required elements
• multiple error citations, and
• use of error question and descriptors
• definition of cascading, and
• avoiding the cascade effect.

Change Date

September 23, 2025

7.10.a. Fundamentals of Quality Reviews

The fundamentals of quality review are listed below.

• Perform a comprehensive review and analysis of all elements of processing the specific claim, issue, transaction, task, or EP.
• All associated actions processed (or that should have been processed) with the transaction pulled in QMS are under review, including work items and concurrent EPs and are subject to error citation.
• The standard for an error is where the decision made rises to the level of a clear and unmistakable error (CUE) or a clear violation of current regulations or directives.
• The QRT is required to follow all guidance on citing errors provided by P&F Service Quality and Oversight Staff. This includes guidance delivered via the P&F Quality and Oversight Mailbox.
• The QRT must provide a regulation citation, manual reference, or other appropriate reference to support every error call, regardless of the type of quality review.
• Personal feelings should not enter into the error call. The only consideration is what the evidence shows and how it should be applied to the appropriate reference.

7.10.b. Misclassified Errors

Errors will not be removed on reconsideration merely because the error was misclassified on the appropriate checklist or due to insufficient supporting references. Removing known errors on cases on the mandated random sample is contrary to sound quality control principles and provides stakeholders with inaccurate data.

Note: This process will not affect the employee’s right to ask for an additional reconsideration using the local reconsideration procedures.

7.10.c. Deselections

To ensure a statistically valid sample, every effort will be made to perform a quality review on all cases identified either via QMS.

PA&I provides claim numbers to QMS based upon specific system transactions by individual. Therefore, generally, there should be an actionable transaction appropriate for quality review.

In rare instances, when a review may not be appropriate, the QRS will propose to deselect the case if there is no other alternative.

The deselected case will be forwarded via QMS to the QRT coach (or appropriate designee) for verification and final deselection approval.

Example: On a VSR award transaction, it is discovered that, prior to a QRT review, the claim was subsequently returned by the authorization activity and regenerated by a different VSR. That transaction should be deselected. A valid review is not possible as there is no verifiable measure for the VSR under review for this action.

Reference: For more information on deselections, see the QMS User Guide in the QRT SharePoint site.

7.10.d. Grace Period for IQRs

The QRT will have a 30-calendar day grace period for any new manual changes before citing local critical errors. For benefits administered by PMCs, the grace period is counted as 30 calendar days after the relevant information is published in CPKM. This does not include minor grammatical changes or relocation.

An error noted prior to the expiration of the 30-calendar day grace period should be recorded as a comment to ensure the employee is made aware of the change and a correction to the case will be required. However, the employee will not be cited for a critical quality error.

Example: A manual change is published on October 1, 2020, with a Key Changes document showing new manual guidance and changes. The grace period includes the next 30 calendar days. Critical errors will be cited on or after October 31, 2020, for any errors relevant to this specific citation.

7.10.e. Error Narratives: Required Elements

Every error narrative must include

• a statement of the
• error, and
• facts, and
• supporting references.

The table below describes each of the required error narrative elements.

Scroll sideways to see the full table.

7.10.f. Error Narratives: Multiple Error Citations

If multiple errors are cited, each error should be discussed independent from the others. Each error should include the three elements of a narrative as noted in the previous block.

7.10.g. Error Narratives: Use of Error Question and Descriptors

Reviews completed in QMS should not include a reference to the question or descriptor. The checklist questions and/or descriptors may be adjusted; therefore, the order of the descriptors in QMS may change.

QMS has built in functionality to sort the user selections for error trend analysis purposes.

7.10.h. Definition: Cascading

Cascading is the result of citing multiple errors based upon the same basis, or root cause.

7.10.i. Avoiding the Cascade Effect

Once the QRS has determined the root cause of an error, no other errors should be cited as a natural result of the initial root cause error.

Once the root cause error has been identified, the QRS should review the claim as if the decision in error were correct, when reviewing the remainder of the claim.

All errors associated with a decision should be captured on the appropriate checklist. Accuracy rates will be provided by VBA approved reporting systems.

Example 1:

• Veterans Pension is improperly granted because there was no war time service, but the income calculation and effective date are otherwise correct.
• Once the QRS has determined that the root cause of the error is the improper grant of pension due to lack of war time service, the QRS should continue to review the decision as if the grant were correct. In this case, only a single error should be cited for the improper grant of pension. The QRS would be incorrect to cite additional errors based upon the income calculation and effective date. Per the scenario, the income calculation and effective date were correct based upon the evidence of record. The income calculation and effective date are not in error based solely upon the fact that the grant of pension itself was improper.

Example 2:

• A VSR generates the wrong effective date for a dependent which results in an incorrect notification letter.
• The VSR would be called for one error for the incorrect effective date. The subsequent error (incorrect notification letter) would not be called because it was caused by and the direct result of the original effective date error.