Comprehensive Healthcare Inspection of the Providence VA Medical Center in Rhode Island

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 Providence VA Medical Center and multiple outpatient clinics in Massachusetts and Rhode Island. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It 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; and High-Risk Processes: Management of Disruptive and Violent Behavior. The medical center’s executive team had worked together for over seven months at the time of the OIG virtual site visit. The Director was the newest member of the executive team and had served in the role since June 2020. The other team members had been in their positions for more than two years. Employee survey data revealed opportunities for the Chief of Staff and Director to improve feelings of servant leadership and reduce moral distress at work, respectively. Patient experience survey data indicated satisfaction with the care provided. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scope of responsibilities about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance. The OIG issued three recommendations for improvement in two areas: (1) Quality, Safety, and Value • Systems Redesign and Improvement Program • Surgical work group (2) Care Coordination • Nurse-to-nurse communication