Comprehensive Healthcare Inspection of Veterans Integrated Service Network 4: VA Healthcare, Pittsburgh, Pennsylvania

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the leadership performance and oversight by the Veterans Integrated Service Network (VISN) 4, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; and Medication Management: Controlled Substances Inspections. The OIG conducted this unannounced visit while concurrent inspections of the following VISN 4 facilities were also performed—Coatesville VA Medical Center and VA Butler Healthcare. The VISN’s executive leadership team appeared stable, with the deputy director, chief medical officer, and quality management officer serving together for the past 16 months. Selected survey scores related to employee satisfaction were consistently better than VHA averages. The VISN averages for selected patient experience survey questions were similar to VHA averages. The VISN leaders appeared actively engaged with employees and patients and were working to sustain and further improve satisfaction. The VISN executive leaders seemed to support efforts to improve and maintain quality care. Review of access metrics and clinician vacancies did not identify any substantial organizational risk factors. The VISN leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center metrics and should continue to take actions to sustain and improve performance of measures contributing to the current SAIL ratings. The OIG issued two recommendations for improvement: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Establishment of a VISN emergency management committee