Comprehensive Healthcare Inspection of the Ann Arbor VA Medical Center

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