Comprehensive Healthcare Inspection of the VA Boston Healthcare System in Massachusetts

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 VA Boston Healthcare System and multiple outpatient clinics in Massachusetts. The inspection covers key clinical and administrative processes that are 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; 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 system’s executive leadership team appeared stable, with all positions permanently assigned. Leaders had worked together for over six years. Selected employee satisfaction survey responses demonstrated satisfaction with leaders and maintenance of an environment where staff felt respected and discrimination was not tolerated. Patient experience survey data indicated satisfaction with the care provided. Executive leaders were able to speak in depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance. The inspection team reviewed accreditation agency findings and did not identify any substantial organizational risk factors. However, the OIG identified deficiencies with institutional disclosures of adverse events. The OIG issued eight recommendations for improvement in four areas: (1) Leadership and Organizational Risks • Institutional disclosures (2) Quality, Safety, and Value • Peer review process (3) Mental Health • Suicide risk screening (4) Care Coordination • Patient transfer policy • Monitoring and evaluation of patient transfers • Transfer forms • Medication list transmission • Nurse-to-nurse communication