VA Health Care:

VA Medical Centers Need to Improve Monitoring of High-Risk Patients

HRD-94-27: Published: Dec 10, 1993. Publicly Released: Jan 11, 1994.

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Pursuant to a congressional request, GAO reviewed the Department of Veterans Affairs' (VA) procedures for locating patients missing from its medical facilities, focusing on: (1) whether patients leaving VA facilities without authorization is a pervasive problem; (2) how many VA patients are unaccounted for; (3) whether VA patient reporting and search procedures are effective; and (4) the extent that VA investigates patient disappearances.

GAO found that: (1) high-risk patients leaving VA treatment facilities without staff authorization is a significant problem at some VA medical centers; (2) VA medical centers are not taking sufficient steps to preclude high-risk patients from leaving their treatment facilities; (3) physicians and nurses at these centers are not consistently assessing a patient's potential for leaving without authorization; (4) although VA medical centers are implementing several methods to monitor the whereabouts of their high-risk patients, their monitoring activities are limited; (5) patient monitoring is hampered by the lack of medical center staff and medical center policies that grant patients special privileges; (6) 5 VA medical centers conducted 966 searches for psychiatric and other high-risk patients that left their treatment facilities without permission from October 1990 through September 1992; (7) 957 of these patients were unharmed, 3 were dead, and 5 were unaccounted for; (8) most of the patients that VA classifies as high risk are psychiatric cases, and the majority of these individuals voluntarily admit themselves to VA facilities; and (9) VA has implemented a new search directive that requires each medical center to have a detailed plan that meets minimum criteria for the identification, search, and location of patients who leave treatment facilities without permission.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: The Associate Chief Medical Director for Operations emphasized the importance of this recommendation in a June 3, 1994, VHA conference call and an August 29, 1994, memorandum to all facility directors. Nursing Service also addressed this recommendation in a March 1994 conference call.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to emphasize to medical center management and staff the importance of identifying and closely monitoring high-risk patients with a propensity to leave a treatment area or facility without staff knowledge or permission.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Implemented

    Comments: VHA asked facilities representing urban, rural, psychiatric, and general medical and surgical groups to submit information on how high-risk patients are identified. VHA central office staff reviewed and compiled this information. It was attached to the Associate Chief Medical Director's August 29, 1994, memorandum to all medical center directors.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to identify successful approaches taken by medical centers to more effectively monitor the activities of high-risk patients while in the facility or on facility grounds and disseminate this information to medical centers systemwide.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: VHA conducted policy reviews that met the intent of this recommendation between January and April 1993. As incidents involving missing patients are reported through the Patient Incident Reporting program, regional quality assurance staff review that particular facility's missing patient policy to ensure compliance with the Central Office directive. This activity is an ongoing effort and no additional actions are planned.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that medical centers have incorporated the provisions of the VA central office's September 1992 search directive in their local policies and procedures and are adhering to them.

    Agency Affected: Department of Veterans Affairs

  4. Status: Closed - Implemented

    Comments: Staff of the Office of the Associate Chief Medical Director for Operations, with assistance from the Central Region, the Medical Information Resources Management Office, and the Hines Information Systems Center, developed a Missing Patient Register. The system was alpha and beta tested in the Central Region and scheduled for nationwide installation into the Decentralized Hospital Computer Program (DHCP). The registry has automated screening features that will alert a VA medical center when a patient reported as missing presents to any facility for treatment. Registering a veteran for inpatient or outpatient care will automatically trigger a search of the missing patient registry systemwide.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to require medical centers from which a patient has left without staff permission and is unaccounted for to disseminate information on that patient to other VA facilities and veterans' organizations in the area that, in coordination with the VA facility, establish local programs for locating missing patients.

    Agency Affected: Department of Veterans Affairs


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