Comprehensive Healthcare Inspection of the Cincinnati 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 Cincinnati VA Medical Center and multiple outpatient clinics in Kentucky, Indiana, and Ohio. The inspection covers key clinical and administrative processes that are 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.Three of the medical center’s four executive leadership positions were occupied by acting staff. The Associate Director, the only permanently assigned leader, had been in the position for less than one year at the time of the OIG virtual review. Survey results revealed opportunities for the acting Chief of Staff to improve employee attitudes toward the workplace. Survey data also indicated that patients were generally satisfied with the care provided. However, gender-specific results highlighted opportunities to improve experiences in the inpatient and patient-centered medical home settings. The OIG identified concerns related to the identification of sentinel events and institutional disclosures. Leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and actions taken during the previous 12 months to maintain and improve performance.The OIG issued 16 recommendations for improvement in five areas:(1) Quality, Safety, and Value• Committee processes• Peer review processes• Root cause analyses(2) Medical Staff Privileging• Professional practice evaluations• Provider exit reviews(3) Mental Health• Suicide safety plans(4) Women’s Health• Designated women’s health providers• Women veterans health committee membership(5) High-Risk Processes• Standard operating procedures• CensiTrac® instrument tracking system• Eyewash station testing• Staff training