Report Summary

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided at the Atlanta 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; Management of Disruptive/Violent Behavior; and Mental Health Residential Rehabilitation Treatment Program. OIG also followed up on recommendations from the previous Combined Assessment Program and Community Based Outpatient Clinic and Primary Care Clinic reviews and provided crime awareness briefings to 344 employees. As a result of the findings, OIG could not gain reasonable assurance that: (1) Clinical managers effectively monitor the professional competency of providers, peer reviewers assess important aspects of care, and physician advisors’ input is considered when making utilization management decisions; (2) Facility leaders address environmental deficiencies and maintain a clean and safe environment in patient care areas; (3) The facility has a comprehensive anticoagulation therapy management program; (4) Clinicians always safely transfer patients from the facility; (5) Glucometers are always clean; (6) The facility has an effective program to prevent and manage disruptive/violent behavior; (7) Facility leadership implemented and maintained processes to ensure care for patients with pressure ulcers and positive alcohol screens. OIG made recommendations for improvement in the following six review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Coordination of Care: Inter-Facility Transfers; (5) Diagnostic Care: Point-of-Care Testing; and (6) Management of Disruptive/Violent Behavior. OIG made a repeat recommendation in Pressure Ulcer Prevention and Management and in Alcohol Use Disorder.