Clinical Assessment Program Review of the Aleda E. Lutz VA Medical Center, Saginaw, Michigan

The VA Office of Inspector General (OIG) conducted an evaluation of the Aleda E. Lutz VA Medical Center. This included reviews 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 provided crime awareness briefings to 252 employees. OIG identified certain system weaknesses in credentialing and privileging; utilization management; general safety; anticoagulation processes; transfer documentation; point-of-care testing processes; moderate sedation processes and training; Community Nursing Home Oversight Committee representation, annual reviews, and clinical visits; and management of disruptive or violent behavior processes and training. As a result of the findings, OIG could not gain reasonable assurance that: (1) Ongoing Professional Practice Evaluation data and utilization management data are reviewed; (2) Medications in carts are secured from unauthorized access; (3) Clinicians obtain all required laboratory results after initiating anticoagulants, document all required elements for patient transfers, and take and document all actions required in response to test results; (4) The facility documents required elements for moderate sedation and ensures training is in place; (5) The facility provides community nursing home program oversight and ensures annual and cyclical clinical visits of nursing homes; (6) The facility minimizes disruptive/violent behavior and trains employees to manage this behavior; (7)Clinicians inform patients about Patient Record Flags and the right to request to amend/appeal, and the Chief of Staff/designee approves Orders of Behavioral Restriction. OIG made recommendations for improvement in all eight review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Coordination of Care: Inter-Facility Transfers; (5) Diagnostic Care: Point-of-Care Testing; (6) Moderate Sedation; (7) Community Nursing Home Oversight; and (8) Management of Disruptive/Violent Behavior.