Comprehensive Healthcare Inspection of the VA Finger Lakes Healthcare System in Bath, New York

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 Finger Lakes Healthcare System, which includes two medical center campuses—Bath and Canandaigua—and multiple outpatient clinics in New York and Pennsylvania. The inspection covered 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 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. At the time of the inspection, system leaders had worked together for approximately three months. The OIG reviewed employee satisfaction survey results and concluded that averages from selected leadership questions were similar to or lower than VHA averages. Patient experience survey data showed that patients were generally satisfied with their outpatient care but less happy with their inpatient care than VHA patients nationally. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the OIG identified a vulnerability in staffing challenges at the Canandaigua VA Medical Center. System leaders were knowledgeable within their scope of responsibilities about selected VHA data used in Strategic Analytics for Improvement and Learning models, and should continue taking actions to sustain and improve performance. The OIG issued six recommendations for improvement in three areas: (1) Mental Health • Suicide safety plan training (2) Care Coordination • Patient transfer monitoring and evaluation • Advance directive sent to receiving facility • Nurse-to-nurse communication (3) High-Risk Processes • Disruptive behavior committee meeting attendance • Staff training