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

Report Information

Issue Date
Report Number
22-04112-125
VISN
10
State
Indiana
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of 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 the Fort Wayne and Marion VA Medical Centers, multiple outpatient clinics in Indiana, and an outpatient clinic in Ohio. This evaluation focused on five key operational areas:
•    Leadership and organizational risks
•    Quality, safety, and value
•    Medical staff privileging
•    Environment of care
•    Mental health (suicide prevention initiatives)

The OIG issued 10 recommendations for improvement in three areas:
1.    Medical staff privileging
•    Focused Professional Practice Evaluation time frames
•    Privileges based on Ongoing Professional Practice Evaluation activities

2.    Environment of care
•    Corrugated containers
•    Clean and free of dust and soiling
•    Clean patient care areas
•    Expired commercial products
•    Clean and dirty equipment storage
•    Walls allow thorough cleaning
•    Inpatient Mental Health Unit over-the-door alarm testing

3.    Mental health
•    Comprehensive Suicide Risk Evaluation completion

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs define the time frames for Focused Professional Practice Evaluations.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation activities

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff remove corrugated containers from patient care areas.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff keep storerooms clean and free of visible dust and soiling.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures Environmental Management Services staff keep patient care areas clean.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services ensures staff remove expired commercial products from patient care areas.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff store clean and dirty equipment separately.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff maintain walls to allow for thorough cleaning.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Associate Director ensures staff test over-the-door alarms in the Inpatient Mental Health unit per the manufacturer’s recommendations.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.