Clinical Assessment Program Review of the VA Portland Health Care System, Portland, Oregon

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided at the VA Portland Health Care System. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; and Management of Disruptive/Violent Behavior. OIG also provided crime awareness briefings to 208 employees. OIG identified certain system weaknesses in utilization management; general safety and environmental cleanliness; anticoagulation processes; transfer documentation; moderate sedation policy, processes, and competency assessment; Community Nursing Home Oversight Committee representation and processes; management of disruptive/violent behavior training; and training of facility nursing expert panel members. As a result of this review, OIG could not gain reasonable assurance that: (1) the facility consistently performs all required utilization management reviews, (2) the facility completes all fire drills and ensures patient equipment is clean, (3) clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications, (4) clinicians document all required elements for the patient transfer process, (5) the facility documents required elements related to moderate sedation and ensures training is in place, (6) the facility provides oversight for the community nursing home program, and (7) the facility effectively trains employees to manage disruptive or violent behavior and ensures all members of the facility nursing expert panel receive the required training. OIG made recommendations for improvement in the following seven review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Coordination of Care: Inter-Facility Transfers; (5) Moderate Sedation; (6) Community Nursing Home Oversight; and (7) Management of Disruptive/Violent Behavior. OIG made a repeat recommendation in Nurse Staffing related to nursing expert panel training.