This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the James A. Haley Veterans' Hospital, covering leadership, organizational risks, and key processes associated with promoting quality care. For this inspection, areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations.The facility’s leadership team had been working together for almost seven months, although several had served in their positions for years. Selected survey scores related to employee satisfaction with the facility’s leaders and patient experience survey data revealed scores related to satisfaction with the facility were similar to or better than the VHA averages. The OIG did not identify any substantial organizational risks. The leaders who were permanently assigned were knowledgeable within their scope of responsibility about selected SAIL and SAIL CLC metrics but the leadership team should continue to take actions to sustain and improve performance measures contributing to the SAIL “4-star” and CLC “2-star.”The OIG issued seven recommendations for improvement in the following areas:(1) Medical Staff Privileging• Focused professional practice evaluation (including for cause) processes• Ongoing professional practice evaluation(2) Medication Management: Controlled Substances Inspections• Monthly reviews of automatic dispensing cabinet override reports(3) Mental Health: Military Sexual Trauma Follow-up and Staff Training• MST training(4) Geriatric Care: Antidepressant Use among the Elderly• Patient/caregiver education and understanding of medications• Medication reconciliation(5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up• Women Veterans Health Committee core membership
Tampa, FL
United States
