Clinical Assessment Program Review of the White River Junction VA Medical Center, White River Junction, Vermont

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the White River Junction VA Medical Center. 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 154 employees. OIG identified certain system weaknesses in the quality, safety, and value program; anticoagulation policies and processes; transfer documentation; moderate sedation care; community nursing home oversight; and management of disruptive and violent behavior. As a result of the findings, OIG could not gain reasonable assurance that: 1. Facility leadership is involved in high-level oversight and decision-making by the Quality Management Board. 2. Clinical managers reviewed Ongoing Professional Practice Evaluation data to monitor trends in practice and patient outcomes. 3. The facility maintains effective oversight of utilization management processes. 4. The facility prioritizes patient safety improvement by conducting root cause analyses as required. 5. Clinical employees and leadership provide safe anticoagulation care. 6. Clinicians provide informed consent and communicate important information to other health care team members through the electronic health record when they transfer patients from the facility. 7. Providers and other clinical employees provide safe moderate sedation care. 8. The facility monitors the community nursing home program and assures the effective oversight of care of patients in these settings. 9. The facility has processes and procedures in place to prevent, reduce, and manage disruptive/violent behavior. OIG made recommendations for improvement in the following six review areas: (1) Quality, Safety, and Value; (2) Medication Management: Anticoagulation Therapy; (3) Coordination of Care: Inter-Facility Transfers; (4) Moderate Sedation; (5) Community Nursing Home Oversight; and (6) Management of Disruptive/Violent Behavior.