Comprehensive Healthcare Inspection of the West Palm Beach VA Medical Center in Florida

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 West Palm Beach VA Medical Center. 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 OIG review, the leadership team had worked together for just over two months. All positions were permanently assigned. Employee survey results identified opportunities for improvement but also reflected an environment where staff felt respected and discrimination was not tolerated. Patient survey results, while generally more positive than VHA averages, also highlighted opportunities to improve male inpatient experiences and female patients’ access to routine specialty care appointments. Executive leaders were knowledgeable about selected medical center Strategic Analytics for Improvement and Learning metrics but lacked understanding of community living center metrics. The OIG issued two recommendations for improvement in two areas: (1) Quality, Safety, and Value • Surgical work group attendance (2) High-Risk Processes • Prevention and management of disruptive behavior training