Report Summary

Title: Healthcare Inspection – Administrative Summary – Review of Post-Traumatic Stress Disorder Consult Management, Battle Creek VA Medical Center, Battle Creek, Michigan
Report Number: 16-04991-387 Download
Issue Date: 9/29/2017
City/State: Battle Creek, MI
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type:
Release Type: Unrestricted

OIG conducted a healthcare inspection to assess allegations made regarding the management of outpatient post-traumatic stress disorder (PTSD) consults by the PTSD Clinical Team (PCT) at Battle Creek VA Medical Center (facility), Battle Creek, MI.

Specifically the complainant alleged:

• Between May and July 2016, consults were improperly designated as complete although a PCT provider had not evaluated the patient.

• A mental health provider used computer-based and written psychological testing as a substitution for evaluations.

• Staff psychologists were unproductive.

We substantiated that some PCT consults were improperly identified as completed between May 1 and July 30, 2016. We substantiated that four of the five identified patients had PCT consults inappropriately designated as complete roughly between May 1 and July 30, 2016. In spring 2016, PCT managers changed their assessment process to include multiple clinic visits rather than a single one. The change caused confusion relating to when a consult was considered complete. We reviewed the care of all patients who received a PCT consult between January 1 and March 31, 2016, before the process change, and between May 1 and July 30, 2016, after the process change. We found 37 of the 111 (33 percent) consults were marked as completed prior to the assessment process with a provider. However, we did not find any of the patients suffered adverse clinical impact. We confirmed that PCT managers decided to return the PCT consult process to its previous operation prior to our site visit in August 2016. In that the consult scheduling process was corrected and we found no adverse impact to patients, we made no recommendation.

We did not substantiate a mental health provider used computer-based and written psychological testing as a substitution for an evaluation or that psychologists had nonproductive work hours during the new scheduling process.

We made no recommendations.