Comprehensive Healthcare Inspection of the Atlanta VA Health Care System in Decatur, Georgia

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 Atlanta VA Health Care System and multiple outpatient clinics in Georgia. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The healthcare system leaders were relatively new to their positions and had been working together as a team for less than two months. Employee and patient survey results were generally worse than the VHA averages, indicating multiple opportunities for leaders to improve employee and patient satisfaction. The OIG noted concerns with the healthcare system’s under-reporting of sentinel events and medication administration processes in the inpatient mental health unit. Although leaders were generally knowledgeable about VHA data and/or system-level factors contributing to specific poorly performing measures, these leaders have opportunities to improve quality of care and efficiency. The OIG issued 23 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Committee processes • Protected peer reviews • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Medication Management • Aberrant behavior risk assessments • Urine drug testing • Informed consent (4) Mental Health • Outreach activities • Staff training (5) Women’s Health • Women’s health primary care providers • Women veterans health committee membership (6) High-Risk Processes • Storage area temperature and humidity • Staff training (7) Incidental Finding • Bar code medication administration processes