Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021

Submitting OIG:

Department of Veterans Affairs OIG

Report Description:

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report highlights the results of a focused evaluation of Veterans Health Administration (VHA) facilities’ care coordination programs related to inter-facility patient transfers. The report describes findings from healthcare inspections performed at VHA medical facilities during fiscal year 2021. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG found general compliance with some of the selected care coordination requirements. However, the OIG identified weaknesses with and issued four recommendations related to the • existence of facility policies for inter-facility transfers, • monitoring and evaluation of inter-facility transfers, • transmission of patients’ active medication lists and advance directives to receiving facilities, and • communication between nurses at sending and receiving facilities.

Date Issued:

Thursday, September 15, 2022

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

22-00815-232

Component, if applicable:

Veterans Health Administration

Location(s):

Agency-Wide

Type of Report:

Review

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

View Document:

Attachment	Size
VAOIG-22-00815-232.pdf	1.53 MB

Additional Details Link:

https://www.va.gov/oig/pubs/VAOIG-22-00815-232.pdf

Recommendation Number	Recommendation Status	Significant Recommendation
1	Open	Yes
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures medical facility directors make certain that a written policy is in place and implemented for the safe, appropriate, orderly, and timely transfer of patients.
2	Open	Yes
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures chiefs of staff and associate directors of patient care services monitor and evaluate all transfers as part of Veterans Health Administration’s Quality Management Program.
3	Open	Yes
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff ensure that transferring providers send patients’ active medication lists and copies of advance directives to receiving facilities during inter-facility transfers.
4	Open	Yes
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff and associate directors of patient care services ensure nurse-to-nurse communication occurs during the inter-facility transfer process.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

Yes

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures medical facility directors make certain that a written policy is in place and implemented for the safe, appropriate, orderly, and timely transfer of patients.

Open

Yes

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures chiefs of staff and associate directors of patient care services monitor and evaluate all transfers as part of Veterans Health Administration’s Quality Management Program.

Open

Yes