Comprehensive Healthcare Inspection Program Review of the VA Ann Arbor Healthcare System, Michigan

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Ann Arbor Healthcare System (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 124 employees. The Facility has a relatively new executive leadership team that appears stable and actively engaged with employees and patients. The executive leaders support efforts related to patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to maintain care and performance of selected SAIL metrics likely contributing to the current “4-Star” rating. The OIG noted findings in three of the eight areas of clinical operations reviewed and issued three recommendations that are attributable to the Director, Chief of Staff, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluations (2) Environment of Care • Environment of care rounds attendance (3) Medication Management: Controlled Substances (CS) Inspection Program • Reconciliation of CS dispensing and return of stock