Comprehensive Healthcare Inspection of the John D. Dingell VA Medical Center in Detroit, Michigan

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 John D. Dingell VA Medical Center in Detroit, which includes multiple outpatient clinics in Michigan. The inspection covers key clinical and administrative processes 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’s executive leadership team appeared stable, with one of the five positions permanently filled for four months at the time of the OIG’s virtual review. Employee survey results revealed opportunities for the Associate Director for Patient Care Services to improve staff satisfaction and reduce moral distress. Patient experience surveys revealed opportunities for leaders to improve patient satisfaction. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any significant concerns. Leaders were knowledgeable selected data used in Strategic Analytics for Improvement and Learning models and should continue to sustain and improve performance.The OIG issued five recommendations for improvement in three areas:(1) Medical Staff Privileging• Provider exit review process(2) Mental Health• Suicide prevention training completion(3) Women’s Health• Women veterans health committee membership• Women veterans program manager responsibilities• Designated maternity care coordinator