Comprehensive Healthcare Inspection of the Dayton 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 Dayton VA Medical Center and multiple outpatient clinics in Ohio and Indiana. 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.The executive leadership team had worked together for five weeks at the time of the OIG’s inspection. The team faced multiple challenges, including responding to the COVID-19 pandemic and beginning the electronic health record modernization. Although leaders have opportunities to improve veteran experiences, most survey results for women veterans were generally better than those for female patients nationally. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial risks, although the OIG noted a repeat finding from the previous comprehensive healthcare inspection visit related to completion of all required focused professional practice elements. Leaders were able to speak knowledgeably about selected data used in Strategic Analytics for Improvement and Learning models and actions taken to maintain or improve performance.The OIG issued 10 recommendations for improvement in five areas:(1) Medical Staff Privileging• Professional practice evaluations• Provider exit reviews(2) Medication Management• Committee oversight(3) Mental Health• Follow-up visits• Patient safety plans(4) Care Coordination• Treatment plan referral and review(5) Women’s Health• Collateral duties