Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center in Augusta, Georgia

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Charlie Norwood VA Medical Center and multiple outpatient clinics in Georgia and South Carolina. 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 executive leadership team had worked together for seven months at the time of the OIG’s visit. Survey results revealed opportunities for the Director to improve employee satisfaction. Survey data also indicated that patients were somewhat satisfied with their care. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial risk factors. However, the OIG identified significant concerns with equipment purchased and corresponding lack of full implementation. Executive leaders were able to speak knowledgeably about actions taken during the previous 12 months to maintain or improve performance. Leaders were also knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models. The OIG issued 20 recommendations for improvement in five areas: (1) Quality, Safety, and Value • Committee processes • Peer review • Root cause analyses (2) Medical Staff Privileging • Exit review process (3) Environment of Care • Environmental safety and cleanliness • Information protection (4) Women’s Health • Gynecological care coverage • Women’s health providers and clinical liaison (5) High-Risk Processes • Standard operating procedures • Risk analysis • Equipment storage • Staff training