Federal Reports

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 Central Alabama Veterans 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; Environment of Care; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 194 employees.The facility has generally stable executive leadership and ongoing processes to improve employee and patient satisfaction. 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. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected SAIL metrics, particularly Quality of Care and Efficiency metrics likely contributing to the current 3-star rating.OIG noted findings in four of the six areas of clinical operations reviewed and issued seven recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Ongoing Professional Practice Evaluation data review(2) Coordination of Care: Inter-Facility Transfers• Informed consent and required transfer documentation(3) Environment of Care• Attendance of Environment of Care rounds• Locked mental health unit Interdisciplinary Safety Inspection Team training(4) Post-Traumatic Stress Disorder Care• Completion of suicide risk assessments• Referral for and completion of diagnostic evaluations

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 Robert J. Dole VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 96 employees.The facility has generally stable executive leadership to support patient safety and quality care. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and SAIL results did not identify any substantial organizational risk factors. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care, overall employee satisfaction, and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 3-star ranking.OIG noted findings in the six areas of clinical operations reviewed and issued 14 recommendations. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Senior-level committee for quality, safety, and value functions• Physician Utilization Management Advisors’ documentation of decisions(2) Medication Management: Anticoagulation Therapy• Collecting, analyzing, and reporting quality assurance data• Employee competency assessments(3) Coordination of Care: Inter-Facility Transfers• Transfer data collection and reporting• Resident supervision and staff/attending physician countersignatures(4) Environment of Care• Environment of care rounds attendance• Panic alarm testing(5) High Risk Processes: Moderate Sedation• Pre-sedation airway and post-procedure pain level assessments(6) Long-Term Care: Community Nursing Home Oversight• Oversight committee meeting requirements• Integration into the facility quality improvement program• Annual reviews• Cyclical clinical visits

To watch a short video regarding the findings of this report, please click the link below.

This review is part of a series of hospital compliance reviews. Using computer matching, data mining, and data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2015, Medicare paid hospitals $163 billion, which represents 46 percent of all fee-for-service payments for the year.