Report Summary

Title: Comprehensive Healthcare Inspection of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
Report Number: 19-00012-51 Download
Issue Date: 1/14/2020
City/State: Indianapolis, IN
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Richard L. Roudebush VA Medical Center, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, areas of focus included Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations.

The leadership team was relatively new, having worked together for about four months as of the week of the OIG’s visit. Selected survey scores related to employee satisfaction and patient experience were generally better than the VHA average but revealed some opportunities for improvement. The OIG reviewed accreditation agency findings, sentinel events, adverse patient event disclosures, patient safety indicator data, and identified organizational risk factors. Leaders were generally knowledgeable about selected Strategic Analytics for Improvement and Learning metrics but should continue to act to sustain and improve performance of measures contributing to the facility’s “3-star” quality rating.

The OIG issued 13 recommendations for improvement:

(1) Quality, Safety, and Value

• Peer Review Committee summary reports

• Interdisciplinary review of utilization management data

• Review of relevant literature in root cause analyses

• Resuscitative episode reviews

• Implementation and monitoring of corrective actions

(2) Medical Staff Privileging

• Focused professional practice evaluation processes

(3) Environment of Care

• Wheelchair maintenance

(4) Medication Management: Controlled Substances Inspections

• Controlled substances inspection report reviews

• Signatures for controlled substances waste

• Override report reviews

(5) Geriatric Care: Antidepressant Use among Elderly

• Patient/caregiver education

• Medication reconciliation

(6) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up

• Women Veterans Health Committee membership composition