Overview

4. Fundamentals of Quality Reviews

Introduction

This topic contains information on the fundamentals of quality reviews, including

• overview
• misclassified errors
• deselections
• grace period for IQRs
• error narratives: required elements
• error narratives: multiple error citations
• error narratives: use of error question and descriptors
• definition of cascading
• avoiding the cascade effect
• expanded reviews
• enhanced sampling, and
• interim guidance

Change Date

August 23, 2024

3.A.4.a. Overview

The fundamentals of a quality review are listed below.

• Perform a comprehensive review and analysis of all elements of processing the specific claim, issue, transaction, task, or end product (EP).
• 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 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 must not enter into the error call. The only consideration is what the evidence shows and how it should be applied to the appropriate reference.

3.A.4.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 reference. Removing known errors on cases on the mandated random sample is contrary to sound quality control principles and provides stakeholders with inaccurate data.

Notes:

• In these cases, the error will be upheld, but reclassified in the QMS database to reflect the most appropriate classification.
• This process will not affect the employee’s right to ask for an additional reconsideration using the local reconsideration procedures.

3.A.4.c. Deselections

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

The Office of Performance Analysis and Integrity (PA&I) provides claim numbers to QMS based upon specific system transactions by individuals. 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.

Examples of incorrect deselection reasons include deselecting because the QRS is not trained in the review type, the transaction is already authorized or second signed, or there's a large number of issues on the IQR.

Examples of proper deselections include deselecting because the documents associated to the transaction under review are no longer viewable to the QRS (for example, the rating decision, award, or correspondence).

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

References: For more information on

• deselections, see the QMS User Guide
• proper deselection scenarios, see M21-4, Chapter 6, Topic 4.c.

3.A.4.d. Grace Period for IQRs

QRT will have a 30-calendar day grace period for any substantive procedural changes in the M21 series of manuals before citing deficiencies as critical errors. The grace period is counted as 30-calendar days after the relevant Veterans Affairs (VA) Key Changes document is published. This does not include minor grammatical changes or relocation. The QRS must ensure that the specific block being cited was subject to substantive change before applying a grace period. An error noted prior to the expiration of the 30-calendar day grace period should be recorded on the checklist 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 quality error.

Instructions for indicating these errors on the appropriate checklist are found in M21-5, Chapter 3, Section A.5.c.

Example: VA Key Changes document showing new manual guidance is published on January 22, 2024, so the grace period includes the next 30 calendar days. Errors will be cited on or after February 21, 2024, for any errors relevant to the specific citation.

Notes:

• Guidance issued through other means, such as interim guidance or guidance issued by the Office of Administrative Review (OAR) that contains specific claim processing instructions, does not warrant a grace period unless specifically provided by OAR. DROCs may not locally determine if a grace period is warranted.
• DROCs may ask for an extension of a grace period, when applicable, by contacting OAR at vbawasoarqualitytrn@va.gov.

3.A.4.e. Error Narratives: Required Elements

Every error narrative must include

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

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

Scroll sideways to see the full table.

3.A.4.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 M21-5, Chapter 3, Section A.4.e.

3.A.4.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 as they appear in QMS may change.

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

3.A.4.h. Definition: Cascading

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

3.A.4.i. Avoiding the Cascade Effect

Once the QRS has determined the root cause of an error, the QRS should cite no other errors 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 was correct, when reviewing the remainder of the claim.

QRS should capture all errors associated with a decision. VBA approved reporting systems will provide accuracy rates.

Examples:

• Service connection (SC) is improperly granted because there was no event in service, but the assigned evaluation and effective date are otherwise correct.
• Once the QRS has determined that the root cause of the error is the improper grant of SC due to lack of an event in 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 SC. The QRS would be incorrect to cite additional errors based upon the assigned evaluation and effective date. Per the scenario, the evaluation assigned and effective date were correct based upon the evidence of record. The assigned evaluation and effective date are not in error based solely upon the fact that the grant of SC itself was improper.
• SC is improperly granted because there was no event in service. Additionally, the assigned evaluation and effective date are incorrect based upon the evidence of record.
• Once the QRS has determined that the grant of SC was improper, the QRS should continue to review the decision as if the grant were correct. In this example, the assigned evaluation was incorrect based upon evidence of record, so a separate error should be cited for the incorrect evaluation. Similarly, the effective date was incorrect based upon the evidence of record, so the error for an incorrect effective date should be cited as well.
• 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.

3.A.4.j. Expanded Reviews

Expanded sample sizes based on the amount set forth in the national performance standards for each position will be reviewed for quality purposes if a routine review of an employee’s work demonstrates the need for quality improvement.

Note: Effective October 1, 2020, expanded reviews are not applicable to VSRs and RVSRs. Effective January 1, 2021, expanded reviews are not applicable to DROs. However, management retains the option to select below threshold employees for an enhanced sample, as noted in M21-5, Chapter 3, Section A.4.k.

Note: After reviewing all local quality data for an employee, the QRT supervisor will initiate a request to the DROC Manager (DROCM) or designee for an expanded review due to a demonstrated deficiency in quality.

Important: Approval for the requested expanded review will come from the DROCM or designated appointee. Expanded reviews must be established in the appropriate VBA system.

Reference: For more information on expanded reviews, see the QMS User Guide.

3.A.4.k. Enhanced Sampling

Management may use enhanced sampling if a routine review of a VSR, RVSR, or DRO's work demonstrates the need for quality improvement.

Note: After reviewing all local quality data for an employee, the QRT supervisor will initiate a request to the DROC Manager (DROCM) or designee for an enhanced sample review due to a demonstrated deficiency in quality.

Important: Approval for the requested enhanced sample will come from the DROCM or designated appointee. Enhanced sample reviews must be established in the appropriate VBA system.

3.A.4.l. Interim Guidance

VBA Central Office interim guidance supersedes the instructions found in M21-1 or other VA procedural references for quality review purposes. While the interim guidance is in effect, quality errors should be cited in instances where claims processors clearly do not follow the interim procedures correctly.

This includes citing systems compliance errors for incorrectly utilizing (or failing to properly add) corporate flashes or special issue indicators not listed as critical errors in M21-4, Chapter 6, Appendix A.d and e, but that are required by the interim procedures.

Interim procedures documents located on the Compensation Service website or other VA-maintained websites may be used as a valid reference for the error citation.

Note: Interim guidance must be implemented immediately. Grace periods will not apply to interim guidance unless one is specifically provided by OFO or OAR.