OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Healthcare Inspection - Management of Disruptive Patient Behavior at VA Medical Facilities
Report Number: 11-02585-129 Download
Issue Date: 3/7/2013
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

OIG conducted a review to assess how VA medical facilities manage patients who display disruptive and violent behaviors. We found that VHA facilities vary significantly in how they identify and manage disruptive patient behavior, especially in regards to defining disruptive behavior, documenting incidents and interventions, and employing interventions to prevent and/or minimize the risk of further incidents. We also found significant delays in facilities’ assignments of Category I Patient Record Flags, which are intended to alert VHA employees to patient behavior that may pose an immediate threat to other patients, facility employees, and visitors. We recommended that the Under Secretary for Health ensure that VHA program officials provide guidance on what constitutes disruptive behavior and establish common terminology for VHA facilities, develop guidelines for what information facilities should document about disruptive incidents and where this information should be documented, and provide guidance to VHA facilities on collecting and analyzing data on disruptive incidents. We also recommended that the Under Secretary for Health consider implementing a national reporting system or data collection template for disruptive patient incidents and ensure that VHA facilities implement procedures to improve the timeliness of assigning Category I PRFs to alert VHA employees to patients who may pose an immediate threat. The Under Secretary for Health agreed with the findings and recommendations and provided acceptable improvement plans.