Clinical Assessment Program Review of the Boise VA Medical Center, Boise, Idaho

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the Boise VA Medical Center. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; and Management of Disruptive/Violent Behavior. During the review, OIG provided crime awareness training to 119 employees. OIG identified system certain weaknesses in Environment of Care Committee documentation of environment of care deficiencies, the facility’s policy for ensuring correct surgery and invasive procedures, Community Nursing Home Oversight Committee meeting frequency and representation, Community Nursing Home Review Team annual reviews, and community nursing home cyclical visits. As a result of the findings, OIG could not gain reasonable assurance that: (1) facility documentation of environment of care rounds deficiencies consistently includes a comprehensive analysis of the findings, (2) facility policy for ensuring correct surgery and invasive procedures includes all Veterans Health Administration required elements for the timeout checklist, and (3) there is effective oversight and management of the community nursing home program. OIG made recommendations for improvement in the following three focused review areas: (1) Environment of Care, (2) Moderate Sedation, and (3) Community Nursing Home Oversight.