Federal Reports

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 Maine Healthcare System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The leadership team appeared stable, with all the positions permanently assigned. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Patient experience survey results highlighted opportunities to improve female veterans’ satisfaction in inpatient and outpatient settings. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued eleven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Systems redesign and improvement program process• Peer review quarterly summaries• Surgical work group attendance(2) Care Coordination• Patient transfer policy• Patient transfer monitoring and evaluation• Informed consent• Transfer form completion• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee attendance• Disruptive Behavior Reporting System• Staff training

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate a patient’s mental health care at the VA Portland Health Care System (facility) including care coordination, administrative actions following the patient’s death, and non-VA community care procedures. The OIG also evaluated VA Palo Alto Health Care System (VA Palo Alto) posttraumatic stress disorder residential rehabilitation treatment program (RRTP) processes.Facility staff made reasonable efforts to accommodate the patient’s treatment preferences, completed safety planning, and conducted required military sexual trauma screening and care. Facility leaders and staff did not assign a Mental Health Treatment Coordinator (MHTC) or establish a policy as required. Facility staff did not review the patient’s high risk for suicide patient record flag timely or ensure the facility’s High Risk Review Workgroup approved flag inactivation, inadequately managed the patient’s flag, and failed to assess suicide risk following the patient’s Veterans Crisis Line call.The OIG identified Veterans Health Administration (VHA) policy and suicide behavior reporting guidance inconsistencies and facility leaders did not follow VHA staff-specific guidance. Facility staff did not complete a behavioral health autopsy timely.VA Palo Alto RRTP staff did not complete the patient’s screening within VHA expectations and did not accept patient self-referrals. RRTP staff appropriately considered the patient’s service animal request. However, inconsistent with VHA policy, RRTP policy included additional admission requirements for the service animal.The OIG made two recommendations to the Under Secretary for Health related to suicide behavior and overdose report staff-specific guidance and RRTP admission decision timeframe expectations; three recommendations to the Facility Director related to MHTC policy and assignment, suicide behavior and overdose report staff-specific guidance, and behavioral health autopsy report timeliness; and two recommendations to the VA Palo Alto Director related to aligning facility RRTP procedures and assistance dog policies with VHA requirements.

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 Maine Healthcare System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The leadership team appeared stable, with all the positions permanently assigned. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Patient experience survey results highlighted opportunities to improve female veterans’ satisfaction in inpatient and outpatient settings. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued eleven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Systems redesign and improvement program process• Peer review quarterly summaries• Surgical work group attendance(2) Care Coordination• Patient transfer policy• Patient transfer monitoring and evaluation• Informed consent• Transfer form completion• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee attendance• Disruptive Behavior Reporting System• Staff training