Comprehensive Healthcare Inspection of the VA Hudson Valley Health Care System in Montrose, 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 Hudson Valley Health Care System in Montrose, New York. The inspection covered key clinical and administrative processes that are associated with promoting quality care, focusing on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. At the time of the review, the healthcare system’s leaders had worked together for one year, with the Director, Associate Director for Patient Care Services, and Chief of Staff serving since May 2020, December 2015, and August 2019, respectively. The Associate Director was appointed in December 2020 and also covered the open assistant director position. Employee survey scores for the healthcare system were lower than the VHA averages, although scores for most leaders were generally similar to or higher than VHA and healthcare system averages. Outpatient satisfaction survey results generally reflected higher care ratings than VHA averages. However, they also highlighted opportunities to improve patient perceptions of inpatient care, as well as outpatient providers and access to outpatient services. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors but position turnover in the Quality Management Service was noted as an area of vulnerability. Executive leaders were very knowledgeable about selected data used in Strategic Analytics for Improvement and Learning measures. The OIG issued seven recommendations for improvement in three areas: (1) Quality, Safety, and Value • Protected peer review process (2) Care Coordination • Inter-facility transfer policy and documentation • Nurse-to-nurse communication (3) High Risk Processes • Staff training