Clinical Assessment Program Review of the VA Northern Indiana Health Care System, Fort Wayne, Indiana

The VA Office of Inspector General (OIG) evaluated the quality of care delivered at the VA Northern Indiana Health Care System. 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 53 employees. OIG identified certain system weaknesses in utilization management; environmental cleanliness; anticoagulation processes and competency assessment; transfer data collection and documentation; re-evaluations prior to moderate sedation procedures; community nursing home clinical visits; disruptive behavior program implementation, processes, and training; and credentialing and privileging. As a result of the findings, OIG could not gain reasonable assurance that: (1) Physician advisors provide input for utilization management decisions. (2) The facility maintains clean bed frames. (3) The facility has a comprehensive anticoagulation therapy management program. (4) The facility has effective processes for the safe transfer of patients. (5) Clinicians re-evaluate patients prior to moderate sedation procedures. (6) The facility monitors and assures the safe care of patients in the community nursing home program by conducting clinical visits. (7) The facility effectively manages disruptive/violent behavior incidents, and employees receive training to reduce and prevent disruptive behaviors. (8) The facility has an effective process for approving another facility’s physicians for teledermatology services and obtaining professional practice evaluation data for telemedicine providers. OIG made recommendations for improvement in the following seven review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Coordination of Care; (5) Moderate Sedation; (6) Community Nursing Home Oversight; and (7) Management of Disruptive/Violent Behavior. OIG made repeat recommendations from the previous Combined Assessment Program review in Quality Management.