Comprehensive Healthcare Inspection of the Battle Creek VA Medical Center in 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 Battle Creek VA Medical Center and multiple outpatient clinics in Michigan. 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. Three of four executive team members were serving in an acting capacity at the time of the OIG’s review. Employee survey results revealed opportunities for the Associate Director for Patient Care Services to improve staff satisfaction. Patient experience survey data highlighted various opportunities to improve satisfaction. The OIG’s review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued 11 recommendations for improvement in six areas: (1) Quality, Safety, and Value • Recommendation, implementation, and monitoring of action items • Interdisciplinary review of utilization management data (2) Medical Staff Privileging • Provider exit review forms (3) Medication Management • Pain management committee processes (4) Mental Health • Patient follow-up visits (5) Women’s Health • Women veterans health committee membership and attendance • Women veterans program manager duties • Designated maternity care coordinator (6) High-Risk Processes • Standard operating procedures • Staff training • Competency assessments