On January 12, 2015, the Office of Inspector General (OIG) of the U.S. Department of Veterans Affairs (Office of Healthcare Inspections) issued a report regarding what it deems to be its review of selected patient care activities to determine whether the Community Based Outpatient Clinics (CBOCs) and other outpatient clinics (OOCs) provide safe, consistent, and high-quality health care.
The review specifically limited its evaluation to the clinics’ compliance with selected requirements for alcohol use disorder, human immunodeficiency virus (HIV) screening, and outpatient documentation. The OIG further limited its evaluation by randomly selecting only the Mobile Outpatient Clinic in Alabama as a representative site, and by limiting its evaluation to the care environment on October 20, 2014.
The Official Review Results
The report states, “We conducted four focused reviews and had no findings for the Outpatient Documentation review. However, we made recommendations for improvement ..”
The report provides some very limited findings: 22 of 104 employees (21%) had not received training by December 1, 2013 regarding the new label elements and safety data sheet format; staff did not complete diagnostic assessments for 7 of 36 patients (19%) who had positive alcohol use screens; 10 of 36 RN Care Managers (28%) did not receive motivational interview training within 12 months of appointment to Patent Aligned Care Teams; 6 of 39 licensed independent providers (16%) did not receive health coaching training within 12 months of appointment to Patient Aligned Care Teams; the facility did not have a Lead HIV Clinician; the facility had no policy or procedure for HIV testing; the facility did not have a policy in place for communication of HIV test results; written patient educational materials were not utilized prior to or at the time of informed consent for HIV testing; clinicians did not provide HIV testing to 31 of 37 patients (84%); and, clinicians did not document informed consent for HIV testing for three of four patients.
The VA reports that the overall new primary care patient average wait time in days for the Veterans Health Administration for Fiscal Year 2014 is in the mid-20s, but varies widely by facility and by month (for Biloxi, the average wait time was 51.9 days in both January and February 2014 but was 29.8 days in September; for Mobile, the average wait time in March 2014 was 11.4 days but was 19.4 in January).
After carefully reading the entire report, we are left asking why the “review” was undertaken in the first place if it was so narrowly performed, and what useful insights system-wide can be gleaned from the results? Can the review results be extrapolated and interpreted so that we can understand the problems existing throughout the VA health care outpatient system and what needs to be done to address the numerous problems and shortcomings that continue to harm VA beneficiaries?
Nonetheless, it is clear from the very limited findings reported for the Mobile Outpatient Clinic in Alabama as of October 20, 2014 that there are serious problems and issues with the services being provided in the limited areas evaluated: alcohol use disorder and HIV screening.
If you or a loved one were injured as a result of medical negligence at a VA outpatient facility, you should promptly consult with a VA medical malpractice claim lawyer in your U.S. state who may investigate your VA medical malpractice claim for you and represent you in a medical malpractice claim involving the VA, if appropriate.
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