Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Ann Arbor Healthcare System, Ann Arbor, Michigan

Report Information

Issue Date
Report Number
14-04391-162
VISN
State
Michigan
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General conducted a review of the VA Ann Arbor Healthcare System’s Community Based Outpatient Clinics (CBOCs) and other outpatient clinics to evaluate for safe, consistent, and high-quality health care. The review evaluated the clinics’ compliance with selected VHA requirements for alcohol use disorder, human immunodeficiency virus (HIV) screening, and outpatient documentation. We also randomly selected the Jackson VA Clinic, Michigan Center, MI, as a representative site and evaluated the environment of care on January 13, 2015. OIG noted opportunities for improvement and made 13 recommendations in the following focused review areas: Alcohol Use Disorder, HIV Screening, and Environment of Care.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Jackson VA Outpatient Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees at the Jackson VA Outpatient Clinic receive the required training on hazardous materials.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Jackson VA Outpatient Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that fire drills are performed every 12 months at the Jackson VA Outpatient Clinic.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closet at the Jackson VA Outpatient Clinic is maintained according to information technology safety and security standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Jackson VA Outpatient Clinic receive regular information/updates on their responsibilities in emergency response operations.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Jackson VA Outpatient Clinic participate in scheduled emergency management training and exercises.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.