Comprehensive Healthcare Inspection of the Ann Arbor VA Medical Center in Michigan

Report Information

Issue Date
Report Number
20-01266-117
VISN
10
State
Michigan
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Ann Arbor VA Medical Center and multiple outpatient clinics in Michigan and Ohio. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Privileging; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The medical center executive leadership team appeared stable. All positions were permanently assigned and only the assistant director had been in the role for less than a year. Employee survey items revealed that leaders appeared to have created a positive workplace environment where employees felt safe bringing forth issues and concerns. Patient experience survey data indicated satisfaction with inpatient care provided and highlighted opportunities to improve veterans’ experiences in the outpatient settings. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued nine recommendations for improvement in five areas: (1) Quality, Safety, and Value • Improvement action implementation (2) Medical Staff Privileging • Ongoing professional practice evaluations • Provider exit reviews (3) Mental Health • Suicide safety plans • Staff training (4) Women’s Health • Women Veterans Health Committee structure and reporting (5) High-Risk Processes • Daily cleaning schedule • Storage and reprocessing areas temperature and humidity • Staff continuing education

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 Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures action items are fully implemented when problems or opportunities for improvement are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that practitioners with similar training and privileges complete ongoing professional practice evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that Provider Exit Review Forms are completed within seven business days of licensed independent practitioners’ departure from the medical center.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention coordinators complete suicide prevention safety plans within the required time frame and include contact information for professional agencies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete annual suicide prevention refresher training
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Women Veterans Health Committee meets regularly, appoints required members who consistently attend meetings, and reports to executive leaders.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures the Chief of Sterile Processing Services enforces the endoscopy clinic reprocessing area’s daily cleaning schedule.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that temperature and humidity ranges are monitored and maintained in the Sterile Processing Services main supply room and endoscopy clinic reprocessing area.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all staff who reprocess reusable medical equipment receive monthly continuing education.