Comprehensive Healthcare Inspection of the Miami VA Healthcare System in Florida

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 Miami VA Healthcare System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on 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.The system’s executive leadership team appeared stable, with the exception of the associate director for patient care services position. The position had been vacant since April 2019 and was filled by two different interim staff. Employee satisfaction survey data was generally positive. However, scores for the associate director for patient care services role reflected opportunities to improve staff feelings toward leaders and the workplace. Patient experience survey data indicated overall satisfaction with the care provided, but also revealed concerns with specialty care services. 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 knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued five recommendations for improvement in two areas:(1) Care Coordination• Patient transfer monitoring and evaluation• Transfer documentation• Medication list transmission(2) High-Risk Processes• Staff training