Comprehensive Healthcare Inspection Program Review of the VA New York Harbor Healthcare System, New York, New York

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA New York Harbor Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Mental Health (MH) Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 135 employees. The facility has generally stable executive leadership with demonstrated cohesiveness and active engagement with employees and patients. Organizational leaders support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. OIG noted findings in five of the clinical operations reviewed and issued 14 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Review of ongoing professional practice evaluation data (2) Medication Management: Anticoagulation Therapy • Collection and reporting of quality assurance data • Patient education specific for newly prescribed anticoagulant medications • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Transfer data analyzing and reporting • Documentation of acute patient transfers to other facilities • Communication with accepting facility (4) EOC • EOC rounds attendance • Panic alarm in the locked MH unit • Risk assessment of locked MH unit electric or mechanical beds • MH Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Moderate Sedation • Reporting and trending of reversal agents and adverse events • Performance of history and physical examinations and pre-sedation assessments • Documentation of informed consent