Comprehensive Healthcare Inspection Summary Report for Fiscal Year 2019

This Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered by Veterans Health Administration facilities. The report covers key processes that are associated with promoting quality care, and focuses on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma (MST) Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Operations and Management of Emergency Departments and Urgent Care Centers. The Office of Inspector General (OIG) noted that 88 percent of facility leaders were assigned permanently at the 43 VA facilities visited in fiscal year 2019. These facility leaders generally appeared engaged in quality activities, felt supported by network leaders, were aware of employee/patient satisfaction improvement efforts, and actively addressed recommendations for improvement. However, the OIG found opportunities for some facilities to improve their Strategic Analytics for Improvement and Learning ratings. The OIG issued 32 recommendations for improvement across eight areas: (1) Quality, Safety, and Value • Peer review processes • Cardiopulmonary resuscitation committee processes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluations (3) Environment of Care • Emergency resource and asset inventory review (4) Medication Management • Controlled substances inspection report review • Limitations to perform balance adjustments • Monthly physical controlled substances inspections • Override report review (5) Mental Health • MST issues, services, and initiatives communicated to leaders • Mandatory MST training (6) Geriatric Care • Patient and/or caregiver education • Medication reconciliation (7) Women’s Health • Committee membership and activities • Cervical cancer screening data tracking (8) High-Risk Processes • Operating hours, staffing, support services, and directional signage