Comprehensive Healthcare Inspection Program Review of the John D. Dingell VA Medical Center, Detroit, Michigan

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the John D. Dingell VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation, and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 53 employees. The facility has generally stable executive leadership and active engagement with employees and patients to improve satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to improve perceptions of the facility through active stakeholder engagement). OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results identified multiple organizational risk factors. The senior leadership team was knowledgeable about selected SAIL metrics and should continue to take considerable actions to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 2-star rating. OIG noted findings in four of the six areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Chief of Staff, Nurse Executive, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Review of credentialing and privileging data (2) Medication Management: Anticoagulation Therapy • Patient education specific for newly prescribed anticoagulant medications • Employee competency assessments (3) Environment of Care • Environment of care rounds attendance • Damaged furnishings in patient care areas • Panic alarm testing • Radiation shield and apron integrity inspection and testing • Annual inspection of radiology equipment • Interdisciplinary Safety Inspection Team training (4) Long-Team Care: Community Nursing Home Oversight • Cyclical clinical visits