The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Minneapolis VA Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home (CNH) Oversight. OIG provided crime awareness briefings to 26 employees.The facility has generally stable executive leadership and active engagement with employees and patients to maintain high satisfaction scores. Organizational leadership supports patient safety, quality care, and other positive outcomes. The senior leadership team was knowledgeable of insightful and important metrics that reflect upon their leadership qualities and activities taken to improve or sustain performance of selected metrics. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors.OIG noted findings in the six areas of clinical operations reviewed and issued 18 recommendations. The identified areas with deficiencies are:(1) QSV• Implementation of Peer Review Committee actions• Completion of utilization management reviews and documentation of decisions• Annual patient safety report• Committee meeting minutes(2) Medication Management: Anticoagulation Therapy• Inclusion of required elements in facility policy• Quality assurance data• Staff competency assessments(3) Coordination of Care: Inter-Facility Transfers• Inclusion of required elements in facility policy• Documentation for inter-facility transfers(4) EOC• EOC rounds frequency and attendance• Mental health unit staff and Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Moderate Sedation• History and physical examination and pre-sedation assessment components• Provision and documentation of informed consent • Performance of timeouts(6) Long-Term Care: CNH Oversight • Oversight committee participation• Monthly cyclical clinical visits
Minneapolis, MN
United States
