Comprehensive Healthcare Inspection of the Central Alabama Veterans Health Care System in Montgomery

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 Central Alabama Veterans Health Care System and multiple outpatient clinics in Alabama and Georgia. The inspection covers key clinical and administrative processes 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 executive leadership team had vacancies in four of the five key positions. The director, associate director for patient care services, and associate director roles had been vacant for at least six months; the chief of staff position had been vacant for two years. The Deputy Director was the only permanently-assigned leader. Employee satisfaction and patient experience survey scores were generally lower than VHA averages. Executive leaders were generally knowledgeable about facility Strategic Analytics for Improvement and Learning (SAIL) measures, but lacked understanding of Community Living Center SAIL measures. The OIG issued 30 recommendations for improvement in eight areas: (1) Quality, Safety, and Value • Peer review processes • Utilization management processes • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Environmental cleanliness (4) Medication Management • Behavior risk assessment • Concurrent therapy • Urine drug testing • Informed consent • Patient follow-up • Pain committee (5) Mental Health • Patient follow-up • Staff training (6) Care Coordination • Goals of care conversations (7) Women’s Health • Women Veterans Health Committee • Quality data monitoring (8) High-Risk Processes • Annual risk analysis • Airflow testing • Staff training