Comprehensive Healthcare Inspection of the Tennessee Valley Healthcare System in Nashville

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 Tennessee Valley Healthcare System, which includes the Nashville VA Medical Center, the Alvin C. York VA Medical Center (Murfreesboro), and multiple outpatient clinics in Kentucky and 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 suicide prevention initiatives) The OIG issued eight recommendations for improvement in four areas: 1. Leadership and organizational risks • Institutional disclosures 2. Quality, safety, and value • Peer review processes • Patient safety events 3. Medical staff privileging • Focused and Ongoing Professional Practice Evaluation processes • Privileging reviews 4. Environment of care • Environmental risks for suicide

Date Issued:

Tuesday, May 16, 2023

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

21-03312-114

Component, if applicable:

Veterans Health Administration

Location(s):

Nashville, TN

United States

Murfreesboro, TN

United States

Athens, TN

United States

Bowling Green, KY

United States

Clarksville, TN

United States

Columbia, TN

United States

Cookeville, TN

United States

Dover, TN

United States

Gallatin, TN

United States

Hopkinsville, KY

United States

McMinnville, TN

United States

Chattanooga, TN

United States

Harriman, TN

United States

Arnold Air Force Base, TN

United States

Type of Report:

Review

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

View Document:

Attachment	Size
VAOIG-21-03312-114.pdf	2.14 MB

Additional Details Link:

https://www.va.gov/oig/publications/report-summary.asp?id=5280

Recommendation Number	Recommendation Status	Significant Recommendation
01	Open	No
The Executive Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
02	Open	No
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff complete final peer reviews within 120 calendar days or approves a written extension request.
04	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs use Focused Professional Practice Evaluation criteria that are defined in advance and accepted by the practitioners.
05	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews professional practice evaluations for licensed independent practitioners’ privileging requests and documents the review in meeting minutes.
06	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for reprivileging decisions.
07	Open	No
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluations completed by practitioners with similar training and privileges.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

The Executive Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

Open

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff complete final peer reviews within 120 calendar days or approves a written extension request.

Open

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs use Focused Professional Practice Evaluation criteria that are defined in advance and accepted by the practitioners.

Open

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews professional practice evaluations for licensed independent practitioners’ privileging requests and documents the review in meeting minutes.