Comprehensive Healthcare Inspection of the Bay Pines VA Healthcare System in Florida

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 Bay Pines Healthcare System and eight outpatient clinics in Florida. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; High-Risk Processes: Management of Disruptive and Violent Behavior. When the team conducted this inspection, the executive team had worked together for nine months. All staff were permanently assigned. Employee survey responses demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected and discrimination was not tolerated. However, responses also highlighted opportunities to reduce staff feelings of moral distress at work. Patient experience survey data implied satisfaction with the care provided. Further, the OIG found that selected survey results for female respondents were generally more favorable than those for female VHA patients nationally. The OIG identified an opportunity to strengthen the tracking of sentinel events that warrant institutional disclosure. Executive leaders were knowledgeable within their scope of responsibilities about selected VHA data used by the Strategic Analytics for Improvement and Learning models. The OIG issued five recommendations for improvement in four areas: (1) Leadership and Organizational Risks • Disclosure of adverse events (2) Quality, Safety, and Value • Surgical work group processes (3) Mental Health • Suicide prevention training (4) High-Risk Processes • Disruptive behavior committee attendance • Patient notification