Clinical Assessment Program Review of the Michael E. DeBakey VA Medical Center, Houston, Texas

The VA Office of Inspector General (OIG) evaluated the quality of care delivered at the Michael E. DeBakey 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 also provided crime awareness briefings to 171 employees. OIG identified certain system weaknesses in utilization management; environmental cleanliness; anticoagulation processes and staff competency; employee competencies for point-of-care testing; community nursing home committee representation, annual reviews, and cyclical monthly documentation; and establishment of an Employee Threat Assessment Team and employee training for management of disruptive/violent behavior. As a result of the findings, OIG could not gain reasonable assurance that: 1. Facility managers effectively monitor the documentation of physician advisors’ decisions in the required database. 2. Facility managers maintain clean floors and patient rolling equipment and ensure damaged patient rolling equipment is repaired. 3. The facility reviews quality assurance data for the anticoagulation management program, clinicians obtain all required laboratory testing prior to initiating anticoagulants, and employees involved in the anticoagulant program complete competency assessments. 4. The facility develops and implements employee competencies for glucometer point-of care testing and assesses competencies annually. 5. Facility managers ensure required disciplines participate in Community Nursing Home Oversight Committee functions, monitor the community nursing home program, and assure the safe care of patients in those homes. 6. The facility has an Employee Threat Assessment Team, and employees receive training to reduce and prevent disruptive behaviors. OIG made recommendations for improvement in the following six review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Diagnostic Care; (5) Community Nursing Home Oversight; and (6) Management of Disruptive/Violent Behavior.