Comprehensive Healthcare Inspection of the Chillicothe VA Medical Center in Ohio

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Chillicothe VA Medical Center and multiple outpatient clinics in Ohio. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Privileging; 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 medical center’s executive leadership team appeared stable. At the time of the virtual site visit, leaders had worked together for almost two months, while some had served in their roles for more than a year. Employee survey data revealed opportunities for the Chief of Staff to improve satisfaction in the workplace. Patients generally appeared happy with their care. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were able to speak in depth about actions taken during the previous 12 months to maintain or improve employee satisfaction and patient experiences. Leaders were knowledgeable within their scope of responsibilities about data and/or factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures.The OIG issued 12 recommendations for improvement in six areas:(1) Quality, Safety, and Value• Peer review summary reports• Root cause analysis processes(2) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit review forms(3) Medication Management• Pain management committee processes(4) Mental Health• Suicide prevention training(5) Women’s Health• Women veterans health committee membership and attendance(6) High-Risk Processes• Standard operating procedures• Airflow directional devices• Staff training and competency