Alleged Interference and Failure to Comply with the Pain Management Directive and the Opioid Safety Initiative at the VA Northern Indiana Health Care System, Fort Wayne, Indiana

Report Information

Issue Date
Report Number
17-05835-165
VISN
State
Indiana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of confidential allegations that system leaders interfered with primary care providers’ opioid prescribing practices; requirements specified in Veterans Health Administration’s (VHA) Pain Management directive were not followed; and system leaders failed to meet all the goals of VHA’s Opioid Safety Initiative Update. The OIG substantiated that on four occasions the Chief of Staff interfered with primary care providers’ opioid prescribing practices. The OIG determined that patients did not have identifiable adverse clinical outcomes; however, the continuation of patients’ opioids may have prolonged their dependence on opioids. Providers also reported experiencing pressure by the Chief of Staff related to opioid prescribing practices. The OIG substantiated that the system did not follow all requirements in VHA Directive 2009-053, Pain Management. Further, not all providers used the required opioid risk assessment tools for patients on long-term opioid therapy. The OIG found that system leaders were not in compliance with the system’s policy related to veteran requests to change providers. The system met six out of nine goals outlined in VHA’s Opioid Safety Initiative Update. The OIG made one recommendation to the VISN 10 Director related to the ethics of a system leader interfering with the opioid prescribing practices of primary care providers and 11 recommendations to the System Director related to the Pain Management Committee, pain assessments, annual evaluation of compliance with the Pain Management Strategy, tertiary pain rehabilitation programs, stepped care education and training, the pain management team, opioid risk assessment tools, veteran requests to change providers, prescription drug monitoring program reports, and opioid and benzodiazepine tapering protocols.

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)
The Veteran Integrated Service Network 10 Director ensures a case consult is made to Veterans Health Administration’s National Center for Ethics to consider whether the Chief of Staff used the position of authority in a manner intended to induce a patient management action which would have otherwise not been taken and, if so, whether the Chief of Staff’s conduct comports with a proper ethical standard.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director verifies that the Pain Management Committee is providing oversight and monitoring of pain management activities as required by Veterans Health Administration policy and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director ensures monitoring of the quality of pain assessments and the effectiveness of pain management interventions and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director develops and implements a process to evaluate the success of meeting the goals of the Veterans Health Administration National Pain Management Strategy on a regular basis, at least yearly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director establishes a formal transfer process for tertiary, interdisciplinary pain rehabilitation program referrals as required by Veterans Health Administration’s stepped care model for pain management.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director evaluates the educational programs offered to providers related to pain management and opioid safety to determine if the programs meet the intent of the Veterans Health Administration Pain Management Strategy for standardizing training and competencies and ensure that providers attend regularly.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director ensures that the pain management team is operational as required by Veterans Health Administration.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director ensures that the system policy is followed for providers to routinely review an opioid risk assessment for patients on long-term opioid therapy and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director verifies compliance with the system’s pain management policy regarding patients’ requests to change providers and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director makes certain that primary care providers are utilizing the prescription drug monitoring program as required by Veterans Health Administration when prescribing opioid medication and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director ensures that primary care providers receive education on safe and effective Veterans Integrated Service Network tapering programs for patients using the combination of benzodiazepines and opioids and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northern Indiana Health Care Director ensures that providers receive education on tapering programs for patients on high-risk opioids and monitors compliance.