Healthcare Inspection – Quality and Coordination of Care Concerns at Three Veterans Integrated Service Network 11 Facilities

At the request of Congresswoman Jackie Walorski, the Office of Inspector General Office of Healthcare Inspections conducted an evaluation in response to allegations relating to access and quality issues at the Northern Indiana Health Care System, Fort Wayne, IN, affecting a patient who ultimately died by suicide after a self-inflicted gunshot wound. We determined that, although the outcome may have been the same for this patient, there were several missed opportunities where the patient’s care and the effectiveness of VA’s system processes could have been improved. Communication breakdowns and providers’ failures to review information available in the patient’s electronic health record during care transitions compromised the patient’s mental health and primary care and diminished the benefits associated with the VA’s electronic health record system. The advantages of comprehensive access to health records and exchange of health information, key features of the system, were not consistently and effectively utilized. We found an absence of oversight in facilitating the continuum of this patient’s care. We found no indication that VA providers analyzed the patient’s multiple suicide risk factors. Further, although Veterans Health Administration has extensive policy specifications to help ensure a patient’s mental health course is comprehensively and continuously monitored, in the totality of this case, the policy was more abstract than applied. We made 14 recommendations.