Comprehensive Healthcare Inspection of the Memphis VA Medical Center in Tennessee

Submitting OIG:

Report Description:

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Memphis VA Medical Center in Tennessee. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center prevention initiatives) Survey results highlighted opportunities for executive leaders to improve patient satisfaction. The OIG issued six recommendations for improvement in two areas: 1. Medical staff privileging • Ongoing Professional Practice Evaluation processes 2. Environment of care • Patient care area inspections • Biohazard signage • Area designations • Video recording

Date Issued:

Tuesday, February 14, 2023

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

21-03310-54

Component, if applicable:

Veterans Health Administration

Location(s):

Memphis, TN

United States

Tupelo, MS

United States

Jonesboro, AR

United States

Holly Springs, MS

United States

Savannah, TN

United States

Jackson, TN

United States

Dyersburg, TN

United States

West Helena, AR

United States

Type of Report:

Inspection / Evaluation

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

View Document:

Attachment	Size
VAOIG-21-03310-54.pdf	4.17 MB

Additional Details Link:

https://www.va.gov/oig/pubs/VAOIG-21-03310-54.pdf

Recommendation Number	Recommendation Status	Significant Recommendation
1	Open	Yes
The Chief of Staff determines any additional reasons for noncompliance and makes certain that service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
2	Open	Yes
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs’ recommendations to continue licensed independent practitioners’ privileges are based, in part, on Ongoing Professional Practice Evaluation data.
03	Open	No
The Medical Center Director determines any additional reasons for noncompliance and makes certain the Comprehensive Environment of Care Coordinator or designee schedules and ensures completion of environment of care inspections in patient care areas at the required frequency or maintains documentation to support pandemic-related postponement.
3	Open	Yes
The Medical Center Director determines any additional reasons for noncompliance and makes certain the Comprehensive Environment of Care Coordinator or designee schedules and ensures completion of environment of care inspections in patient care areas at the required frequency or maintains documentation to support pandemic-related postponement.
4	Open	Yes
The Medical Center Director determines the reasons for noncompliance and ensures staff post signage in all areas where biohazards are present.
5	Open	Yes
The Medical Center Director determines the reasons for noncompliance and ensures the Chief of Police, Privacy Officer, and chiefs of programs identify medical center areas as a treatment, secure, personal, or other area.
6	Open	Yes
The Medical Center Director determines the reasons for noncompliance and ensures leaders comply with VHA requirements for signage and camera-recording, based on area designations.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

Yes

The Chief of Staff determines any additional reasons for noncompliance and makes certain that service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

Open

Yes

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs’ recommendations to continue licensed independent practitioners’ privileges are based, in part, on Ongoing Professional Practice Evaluation data.

Open

The Medical Center Director determines any additional reasons for noncompliance and makes certain the Comprehensive Environment of Care Coordinator or designee schedules and ensures completion of environment of care inspections in patient care areas at the required frequency or maintains documentation to support pandemic-related postponement.