Comprehensive Healthcare Inspection Program Review of the Battle Creek VA Medical Center, Michigan

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 Battle Creek 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 (QSV); Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. Two of four Facility leadership positions were filled by interim staff at the time of the OIG’s on-site visit. On April 1, 2018, the Chief of Staff assumed the Acting Director role, and the Chief of Dentistry took over responsibilities as the Acting Chief of Staff. The OIG noted that Facility leaders appear to be actively engaged with employees and were working to improve inpatient satisfaction scores. Organizational leaders support efforts related to patient safety, quality care, and other positive outcomes (such as initiating processes and plans to achieve and maintain positive perceptions of the Facility through active stakeholder engagement). The OIG did not identify any substantial organizational risk factors. Three of the four leaders were knowledgeable while the Acting Chief of Staff was still becoming familiar with selected Strategic Analytics for Improvement and Learning (SAIL) metrics due to the limited time in the role. The leaders should take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the current “2-Star” rating. The OIG noted findings in two of the clinical operations reviewed and issued three recommendations that are attributable to the Acting Director and Acting Chief of Staff. The identified areas with deficiencies are: (1) QSV • Required utilization management reviews (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluations