Comprehensive Healthcare Inspection of the Carl Vinson VA Medical Center, Dublin, Georgia

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Carl Vinson VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Care; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results; and High-Risk Processes: Emergency Department/Urgent Care Center Operations. The facility’s leadership team was not stable, with vacancies for director and chief of staff. Employee satisfaction and patient experience surveys results were similar to or lower than VHA averages. The OIG’s review of institutional disclosures identified an opportunity to ensure timely notification to patients and accurately maintain information and data on disclosures. The leaders should continue to take actions to improve care and performance of measures contributing to the Strategic Analytics for Improvement and Learning “3-star” and community living center “1-star” quality ratings. The OIG issued 22 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary utilization management data reviews • Root cause analyses • Resuscitative episode reviews (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Privileging action reporting to National Practitioner Data Bank (3) Environment of Care • Panic alarm testing (4) Medication Management • Reconciliation of dispensing and return of stock • Verification of hard copy prescriptions • Monthly controlled substances inventory verification • Medication override process (5) Mental Health • Communication of issues, services, and initiatives to leadership • Military sexual trauma training (6) Geriatric Care • Patient/caregiver education and understanding of medications (7) Women’s Health • Designated women’s health medical director/clinical champion • Women Veterans Health Committee processes • Cervical cancer screening data tracking process • Patient notification of abnormal results (8) High-risk Processes • Backup call schedule for urgent care center providers