Comprehensive Healthcare Inspection of the Aleda E. Lutz VA Medical Center in Saginaw, Michigan

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Aleda E. Lutz VA Medical Center and multiple outpatient clinics in Michigan. 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; 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’s executive leadership team appeared stable, although two of the four positions had been filled for less than one year at the time of the OIG’s virtual review. Selected employee satisfaction survey results indicated opportunities for the Associate Director for Patient Care Services to improve workplace perceptions and for the Chief of Staff to support an environment where employees felt less moral distress. Patient experience survey scores reflected lower female satisfaction ratings than VHA averages. The inspection team reviewed accreditation agency findings, sentinel events, and disclosures of adverse patient events but did not find any substantial organizational risk factors. Executive leaders spoke in depth about actions taken during the previous 12 months to maintain or improve employee satisfaction and patient experiences. Leaders were knowledgeable about data used by Strategic Analytics for Improvement and Learning models.The OIG issued nine recommendations in five areas:(1) Quality, Safety, and Value• Improvement action implementation(2) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit review forms(3) Care Coordination• Goals of care conversations(4) Women’s Health• Women veterans health committee attendance(5) High-Risk Processes• Standard operating procedures• Staff training• Competency assessments