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Combined Assessment Program Summary Report – Evaluation of Moderate Sedation in Veterans Health Administration Facilities

Report Information

Issue Date
Report Number
13-01743-192
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG completed an evaluation of moderate sedation in Veterans Health Administration (VHA) facilities. The purpose of the evaluation was to determine whether VHA facilities used safe processes for the provision of moderate sedation that complied with selected requirements. OIG conducted this review at 44 facilities during Combined Assessment Program reviews performed from October 1, 2011, through September 30, 2012, and identified three areas where VHA facilities needed to improve compliance. OIG recommended that clinicians consistently document all required elements of comprehensive pre-procedure assessments; that when there is a provider change, clinicians consistently document that the patient was informed of and agreed to the change; and that clinicians consistently discharge moderate sedation patients appropriately and safely.

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 the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently document all required elements of comprehensive pre-sedation assessments and that facilities monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that when there is a provider change, clinicians consistently document that the patient was informed of and agreed to the change and that facilities monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently discharge MS patients appropriately and safely and that facilities monitor compliance.