Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia

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 Hunter Holmes McGuire VA Medical Center and associated outpatient clinics in Virginia. The inspection covered key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.When the team conducted this inspection, the medical center’s leaders had worked together in their positions for 19 months. Employee survey results highlighted opportunities to improve employee attitudes toward leaders and the workplace, and reduce staff feelings of moral distress. Patient survey results identified opportunities to improve care experiences. Review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify substantial organizational risk factors. The executive leaders spoke knowledgeably within their scope of responsibilities about VHA data and factors contributing to poorly performing quality and efficiency measures.The OIG issued nine recommendations for improvement in three areas:(1) Quality, Safety, and Value• Tracking of improvement capabilities and projects• Peer review processes• Surgical death reviews(2) Care Coordination• Inter-facility transfer monitoring and evaluation• Transfer form completion• Medical record transmission(3) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training