Comprehensive Healthcare Inspection of the VA Northern Indiana Health Care System in Marion

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 VA Northern Indiana Health Care System, which includes a campus in Fort Wayne and Marion, and multiple outpatient clinics in Indiana. 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 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 leaders had worked together for nine months at the time of the OIG’s virtual review. Employee survey data indicated that leaders had created a positive workplace environment where employees felt safe bringing forth issues and concerns. Patient experience surveys highlighted opportunities to improve satisfaction in the inpatient and outpatient settings. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the healthcare system had disclosed 114 adverse events to patients and their families. Leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to sustain and improve performance.The OIG issued 20 recommendations for improvement in five areas:(1) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit review forms• State licensing board reporting(2) Medication Management• Aberrant behavior risk assessments• Urine drug testing• Informed consent(3) Mental Health• Follow-up visits• Suicide prevention safety plans• Suicide prevention training(4) Women’s Health• Gynecological care coverage• Women veterans health committee attendance(5) High-Risk Processes• Annual risk analysis• Daily cleaning schedule• Staff training and continuing education• Competency assessments