Full Report link at: Summary Report Number 10-03237-41
Healthcare Inspection Review of Quality of Care at a VA Medical Center
Report Number 10-03237-41, 12/9/2010 | Full Report (PDF)
Summary:
The VA Office of Inspector General, Office of Healthcare Inspections conducted an inspection to assess the quality of a veteran’s care at a VA Medical Center (the medical center) and to determine if the events leading to the veteran’s death were connected to any issues with the quality of care. Our review identified three areas that the medical center could improve on. Specifically, the medical center needs to ensure smooth transitions when there are changes in veterans’ providers and/or care settings. The medical center also needs to improve internal communications between providers and external communications with veterans and other parts of the VA system to ensure that significant information is communicated timely and with individuals who have a need to know. Lastly, the medical center needs to review the procedures of the Disruptive Behavior Committee to ensure clear and consistent messages about patient risk and to promote patient-centered solutions when risks are identified.
We recommended that medical center leadership: (1) review, and revise as needed, its policies and procedures for providing case management for veterans who have complex medical and psychosocial issues; (2) review its policies and practices to ensure effective communication with veterans when there are changes in their providers or care settings; (3) work with Veterans Health Administration (VHA) leaders to identify ways, within existing privacy laws, to improve sharing between VHA and Veterans Benefits Administration of information about unusual events impacting services; and, (4) review the policies and practices of the Disruptive Behavior Committee and implement procedures to ensure that risks are communicated timely and consistently and conveyed with a patient-centered focus.
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